All differences p < 0.001 except: bleed Ð 6 month follow-up p= 0.05; death Ð 6 months p=0.52, NS. In multivariate logistic modeling, odds ratios (ORs) for recurrent VTE in 6 months: CONCLUSION: Patients with PE (versus DVT) were less likely to be Latino, more likely to be African-American, and more likely to have cardiopulmonary disease or recent surgery. Recurrent VTE manifested as PE was strongly associated with an initial diagnosis of PE, and conversely, recurrent DVT was strongly associated with an initial diagnosis of DVT. Coupled with recent data indicating that the prevalence of factor V-Leiden among patients with PE is significantly lower compared to patients with DVT, our findings suggest that there are undefined genetic or acquired factors that effect the phenotypic expression of VTE. complications after specific kinds of surgeries has been intensely studied, few studies have compared the 3-month incidence of VTE after different surgeries. METHODS: We analyzed the California linked discharge records of 2,159,747 patients hospitalized between Jan 1, 1991 and Oct 1, 1996 who underwent one of 75 selected surgical procedures on the first or second hospital day, and determined the 3 month incidence of rehospitalization for VTE. Data were stratified by age ( > 65 and < 65) and malignancy (present within 6 months or absent). A multivariate model was developed to compare the 3 month incidence of VTE using inguinal hernia repair (ICD-9-CM = 53.0) as the referent surgery, adjusting for age, sex, presence of malignancy, Charlson Index > 1, race (Asian vs. non-Asian), and prior VTE ( < 6 mo.). RESULTS: The table below shows the VTE incidence in a analysis restricted to age > 65 yrs, no cancer, > 10,000 procedures. In a logistic model that included all surgeries, parameters significantly associated with VTE included age > 65 (OR = 1.5, CI 1.4 ± 1.6), malignancy (OR = 2. (83%) returned questionnaires. Mean patient age was 42 years, 17% were female, 71% were white, and 66% were gay. In bivariate tests, general communication (r = 0.12, p = 0.003), ADH dialogue (r = 0.19, p < 0.001), overall satisfaction (r = 0.10, p = 0.01), willingness to recommend (r = 0.12, p = 0.006) and MD trust (r = 0.10, p = 0.01) were significantly associated with ADH. MCS (r= 0.226, p < 0.001), PCS (r = 0.160, p < 0.001), and age (r= 0.16, p = 0.0003) were significantly associated with ADH. Blacks reported worse ADH than whites (p < 0.05). In multivariable models, after controlling for MCS, age, and race, ADH dialogue was the only variable significantly associated with ADH (R2 = 0.12, p = 0.001). CONCLUSION: Only ADH dialogue was independently associated with adherence. Optimizing patients' ADH probably requires detailed and specific information gathering and problem solving directed at specific dosing times and/or specific medications. These data do not appear to be an automatic biproduct of good general MD-PT communication. The Surgeon General's Report on Oral Health highlights the inadequate oral health care provided to the vulnerable population of homebound older adults. Cost of dental care and transportation challenges serve as major barriers to dental care in this population. We sought to examine the impact of removing both cost and transportation barriers on dental care utilization in urban homebound older adults. METHODS: 225 older adults participating in a home and community based waiver program and/or a home-delivered meals program were invited to receive free nutritional and oral health assessments. Individuals with both poor oral health and nutritional needs were offered free dental care including free transportation. A dental hygienist and nurse coordinator made appointments on behalf of patients, provided appointment reminders and arranged transportation. RESULTS: Mean age of participants was 81.6. 81% were female, 53% were African American. Of 159 subjects who completed both nutritional and oral health assessments, one-third were eligible for free dental intervention and transportation. Of those offered free dental care, 80% agreed to receive care. Of those who agreed to receive care, 14% did not keep any dental appointments, 19% kept some of their dental appointments but did not complete their dental intervention, 67% fully completed their dental interventions. The only significant barrier to completing the recommended dental intervention was depression score (p=.03). Even when functional status and Mini Mental State Examination scores were adjusted in the model, depression remained an independent predictor for not completing the recommended dental care visits. CONCLUSION: When cost and transportation difficulties are removed as barriers to dental care, it is possible to complete needed dental interventions in a significant number homebound adults. Public policy changes would be needed to provide an infrastructure to facilitate this process. Depression remains an independent risk factor for incomplete interventions. PURPOSE: To avoid erroneous results in the estimation of the sensitivity and specificity of diagnostic tests, it has been recommended that a broad spectrum of disease be represented in the study population when evaluating the efficacy of a test. However, the actual effect of severity of disease on these indexes has not been evaluated on a clinically relevant population. The objective of this study was to assess the effect of the severity of disease on the diagnostic performance of a positive PPD and upper lobe disease on chest radiograph (defined as infiltrates and/or consolidation above the third rib posteriorly) for the diagnosis of pulmonary tuberculosis (TB). METHODS: Seventy five patients with positive sputum culture for TB and 75 subjects who were considered at risk of TB but whose sputum tested negative for TB were identified from the hospital's TB registry. Patients were divided into two groups, severe disease and non-severe disease according to the presence or absence of specific criteria that are known to be associated with worse clinical outcomes. Patients with TB were classified as having severe disease if the sputum smear tested positive for acid-fast bacilli. Patients without TB (most of which had pneumonia) were classified as having severe disease if they were older than 65 years of age, had a temperature greater than 408C, or had pleural effusion on chest radiograph. The sensitivity and specificity of a positive PPD and upper lobe disease were determined independently among the group of patients with severe and non-severe disease. RESULTS: The sensitivity of upper lobe disease for the diagnosis of TB was 41.6% and 21.6% among those with severe and non-severe disease respectively (P = 0.03). The specificity of this radiologic finding increased from 77.2% among patients with severe disease to 94.7% among those with non-severe disease (P = 0.05). Conversely, the sensitivity of PPD was lower among those with severe disease (22.2%) compared to those with nonsevere disease (42.0%, P = 0.05). The specificity of PPD was not statistically significantly different among this two groups (100.0% vs 89.0%, severe vs non severe disease respectively; P = 0.10). CONCLUSION: The spectrum of disease significantly modified the sensitivity and specificity of a positive PPD and upper lobe disease on chest radiograph for the diagnosis of TB. Interestingly, the effect of the severity of disease was not in the same direction in the two tests evaluated. This potential source of error in measuring test performance should be considered when translating the results of research studies to the clinical practice. Variables (and beta weights) negatively (p05) associated: age in decades (À0.9), being female (À2), being employed, retired, homemaker or student (À0.89) compared to being unemployed, having friends who provide encouragement when faced with a difficult situation (À.76), and frequency of physical problems interfering with social activities (À.26). Family CAGE, race, marital status, education level, having a close friend, losing a friend or relative, frequency of contact with those closest to you, self-report number of visits to a doctor in the past year were not significantly associated with AUDIT score. CONCLUSION: The associations presented do not necessarily suggest causality. As expected, being male, younger, having friends who are problem drinkers, and higher CAGE scores had the highest association with AUDIT scores. Counter to our a priori predictions, frequency of participating in spiritual activities and having a friend willing to help were associated with higher AUDIT scores. Interestingly, frequency of emotional problems is positively associated with AUDIT scores while frequency of physical problems is inversely associated. Also unexpected was the lack of association between Family CAGE and AUDIT score. Further investigation may help explain these unexpected findings. Patients were asked about their preference for first seeing their PCP or a specialist for 3 clinical scenarios and the health problem for which they sought medical care on the day on which they were surveyed. To identify the independent predictors of preferring to see a specialist, we combined patients' responses to the 3 scenarios and health problem and performed a multiple logistic regression, adjusted for clustering at the patient level using the Huber-White method. We also performed analyses separately for each of the 3 scenarios and the presenting health problem. RESULTS: The proportion of patients who preferred to see a specialist first for the 3 scenarios was 13% for chest pain, 15% for knee pain, 11% for a rash, and was 8% for the presenting health problem. In the multivariable analysis, blacks were less likely than whites to prefer a specialist (OR=0.45, p < 0.0001). Compared to those with fee-for-service insurance, those with VA coverage and Medicaid insurance were less likely to prefer a specialist (OR=0.55, p=0.04 and OR=0.42, p=0.01, respectively). Those who preferred a specialist had less trust in their PCP (OR=1.6, p < 0.0001), had less confidence in their PCP's ability to diagnose and treat their problem (OR=2.6, p < 0.0001), were more certain about their diagnosis (OR = 1.4, p < 0.0001), and perceived the health problem as being more serious (OR = 1.2, p = 0.02). Non-significant predictors included age, gender, employment, education, income, managed care insurance, health status and several attitudes including perceived susceptibility to illness, entitlement and assertiveness. These results were similar across the 3 scenarios and the presenting health problem. CONCLUSION: Controlling for other sociodemographic characteristics, health beliefs and attitudes, blacks were much less likely to prefer care from a specialist. Though blacks have generally had worse access to care, lower quality of medical care, and worse health outcomes, their satisfaction with medical care has not consistently been lower than that of whites. Our results support the hypothesis that differences in expectations for care might explain this incongruity and raise the question about whether differences in expectations might contribute to disparities in health care quality and outcomes. PURPOSE: Most providers say that they withhold protease inhibitors (PIs) from HIV-infected patients whom they believe will be non-adherent. We hypothesized that this prescribing attitude might influence patients' access to PIs and sought to determine whether this prescribing attitude explained why African Americans tend to receive PIs later than whites. METHODS: In the HIV Cost and Services Utilization Study (HCSUS), we prospectively studied a nationally representative sample of HIV-infected patients (n=2864) and their providers in the U.S. We examined data for those with completed provider and patient surveys (398 providers taking care of 1892 patients (66% of original patient cohort)). We asked providers whether they prescribe PIs to patients whom they believe will be non-adherent. Patients were followed over a 2-year period and were asked at baseline and both follow-up surveys whether and when they began using PIs. Using parametric survival models, we determined the impact of providers' PI prescribing attitude on time to first PI use and on racial differences in time to first PI use. RESULTS: Contrary to our hypothesis, having a provider who considers adherence before prescribing PIs (More Restrictive) predicted earlier PI use, adjusting for provider characteristics only (e.g. HIV knowledge and type of specialty) (p = 0.01). However, providers' PI prescribing attitude was not associated with time to PI use after additionally adjusting for patient CD4 count, symptoms, age, gender, HIV risk factor, education, income, insurance and perceived access to care. After adjusting for patient and provider characteristics, the median time to first PI use was 74.2 days later for African Americans than for whites (p = 0.001). This racial difference in time to PI use was similar for an individual with a More or Less Restrictive provider (adjusted racial difference in time to PI use was 74.7 and 73.3 days respectively, p > 0.20). CONCLUSION: Providers' PI prescribing attitude was not associated with patients' access to PIs. African Americans received PIs later than whites, but providers' PI prescribing attitude did not explain this racial disparity. Future studies will need to examine whether other patient or provider characteristics better explain why African Americans receive PIs later than whites. PURPOSE: Though blacks have greater mortality rates than whites, it is not known which diseases contribute most to this disparity. We examined mortality rates as well as years of potential life lost (YPLL), which is a more sensitive measure of loss of life due to premature death. METHODS: To examine nationally representative samples of adults in the U.S., we used data from the 1986 , 1988 and 1990 for participants greater than age 25 with corresponding National Death Index data on each cohort through 1995. YPLL was calculated as the difference between the age at death and the maximum years that a person could have lived, which we set at age 85. Mortality rates and YPLL due to all and specific causes of death were calculated for blacks and whites and standardized to the age, sex, and educational distribution of the total U.S. population. We then calculated the percent contribution of racial differences in YPLL from specific causes of death to racial differences in YPLL from all-cause mortality. RESULTS: Adjusted for age and sex only, YPLL due to all-cause mortality was 0.62 years/ person greater for blacks than for whites, averaging across the 3 NHIS cohorts. However, this disparity disappeared after adjusting for education in addition to age and sex (black-white difference was À0.08 years/person). Age and sex-adjusted YPLL was greater among blacks compared to whites for all of the specific causes of death that we examined and for all 3 NHIS cohorts. The contribution of specific causes of death to the racial disparity in YPLL was 25.6% for infections, 14.0% for cancer, 6.1% for diabetes, 4.6% for stroke, 4.0% for ischemic heart disease, 3.3% for renal disease, 3.1% for lung disease, and 4.0% for accidents, homicides, and suicides combined. An analysis of mortality rates revealed similar results, with the exception that cancer contributed most to the racial disparities in mortality (22.6%) followed by infectious diseases (14.6%). For deaths due to infections, the black-white mortality rate difference was more pronounced in those younger than 60 years old compared to those 60 years or older (6.0 vs. 0.6 deaths/10,000 person-years, respectively). In contrast, the racial disparity for deaths due to cancer was much greater in those age60 years than in those age < 60 years (black-white mortality difference=20.2 vs. 3.5 deaths/10,000 person-years, respectively). CONCLUSION: YPLL was greater among blacks than whites, though differences in socioeconomic status (using education as a proxy) appear to account for this disparity. Mortality rates and YPLL yielded slightly different results because YPLL accounts for the age at death and racial disparities in death due to infections were more pronounced at younger ages as compared to deaths from cancer. Future efforts to reduce the racial disparity in mortality may have the greatest impact if focused on infectious diseases and cancer, which we found contributed the most to the difference in YPLL and mortality rates between blacks and whites. OBJECTIVES: Multiple studies indicate that patient compliance with cardiovascular medications is poor. One possible explanation is that patients perceive medication use as difficult. The goal of this study was to assess characteristics of patients who found medication use difficult, including the physician-patient relationship, health beliefs, and socioeconomic factors. METHODS: We prospectively surveyed 273 White and African American patients who underwent nuclear imaging studies graded as positive for cardiac ischemia at 5 VA hospitals (Houston, Atlanta, St. Louis, Pittsburgh, and Durham). Of these, 33 (12.1%) patients rated medication use as difficult. Difficulty was assessed by asking patients``How bothersome is it for you to take your pills for chest pain, chest tightness, or angina as prescribed?'' RESULTS: Patients who found medication use difficult were less likely than those who did not find it difficult to agree that they were satisfied with their current treatment (59.4% vs. 77.0% respectively, P = 0.03) and that their doctors used words they could understand (68.8% vs. 88.3%, P=0.003). Among patients who found medication use difficult, there were also trends towards having less trust in their doctor's judgement about their medical care (78.8% vs. 87.5%, P = 0.17) and feeling that they were less able to get to know their doctor (59.4% vs. 70.6%, P = 0.20). There were no differences between patients who found medication use difficult and those who did not in the perception that their doctors were well qualified to manage their medical problems ( (SD 10.4) ]. In addition, 35/50 faculty and residents that provide DM care in the clinic completed physician surveys. Variables were coded as pt, provider or system barriers if 30% or > of respondents endorsed an item as a problem some or all of the time. Provider and system barriers were also identified from chart review when 30% or > of data was missing. RESULTS: Thirty-five (35) variables and 63 barriers to DM care were identified. Pt barriers (25.3%)included adherence with medication, glucose monitoring, diet and exercise. Noncompliance with appointments was affected by transportation, childcare, and work-related issues. Costs of care, pt literacy, lack of family support and other pt priorities were also cited as pt barriers. Provider barriers (45.2%)included knowledge of/agreement with ADA guidelines, reimbursement issues, prescribing uncertainty, and provider perceptions of pts with DM. System barriers (33.3%) included lack of insurance, DM care costs, reimbursement problems, lack of DM educators/nutritionists, poor record-keeping, difficulty obtaining lab data and provider communication issues. Chart review documented: HBA1c -67%, UA -52%, urine microalbumin -20%, total cholesteral -23.5%, LDL -11.8%, foot exam -25%,funduscopic exam -19%, influenza and pneumonia vaccine -18% and 7%, respectively. CONCLUSION: We found that provider and system barriers outweighed patient barriers to DM care in this high-risk population. In addition to pt empowerment, DM improvement programs must address provider and system obstacles that impede optimal DM management. Further clarification of specific barriers and their impact on diabetes care is needed, particulary in AA, underinsured and/or high-risk populations. Adult patients who had been cared for by the same physicians for more than 3 months and who had at least 4 visits during this period, were selected for this study. The patient trust of physician ratings were obtained by self-administered questionnaires, the Trust in Physician Scale ( modified by the Stanford Trust Study Group). In addition to patient trust, we obtained a General Trust Scale (Yamagishi, Japan), patients' demographic data, the lengths of the patientphysician relationships, the reasons for the patients' choice of physicians. 275 patients answered the questionnaire to rate 11 different physicians during their visits. Multiple regression analysis was used for this study. RESULTS: The Trust in Physician scale (5 Likert scales: 1 = totally disagree to 5 = totally agree) were transformed to a 0 to 100 scale, and it showed high internal consistency (Cronbach's alpha = .82) for Japanese patients. Mean scores of male and female were 86.3 (SD: 10.3) and 85.9 (SD: 10.5) respectively. The Trust in Physician scores were strongly associated with the General Trust scores (p = .017), the reasons for the patients' choices (p = .037) and the satisfaction with care (p < .001) after adjusted by patient characteristics. However,the Trust in Physician scores were not statistically associated with gender, age, education levels and the lengths of the relationships. CONCLUSION: The patient trust, a measure of the health care seeking behaviors, was associated with the societal trust in general in our study. In addition, the patient trust was a useful concept to assess the relationship between patient and physician, especially the satisfaction with care. Normal range (18.5 ± 24.9 kg/m 2 ) was the referent category in the analyses. RESULTS: Participants had a mean age of 54.6 years (SD=5.6); 69% were white, 29% were black and 94% were male. The distribution of BMI was: < 18.5 kg/m 2 (n=16, 1.3%), 18.5 ± 24.9 kg/m 2 (n = 254, 20%), 25 ± 29.9 kg/m 2 (n = 531, 42%), 30 ± 34.9 kg/m 2 (n = 308, 25%), 35 ± 39.9 kg/m 2 (n = 112, 8.9%) and > = 40 kg/m 2 (n = 32, 2.6%). Mean SF-36 subscale scores for the sample were lower than U.S. norms by a mean of À18.7 points (range: À32.9 on Role-Physical to À3.5 on Mental Health). After adjusting for covariates, individuals with BMI > = 40 kg/m 2 had significantly lower scores compared with normal weight individuals on the Role-Physical ( = À18.8, p=0.008), Vitality ( = À12.5, p=0.001) and Social Functioning ( = À9.3, p=0.017) subscales ( represents the deviation in mean score from the referent BMI group (3.9 vs. 2.8) than their male counterparts. Of the 652 calls during the study, female patients called more frequently than male patients (p < .001), and female patients generated more total calls than male patients (p < .001). Also, female physicians had significantly more calls and callers than male physicians did (p < .001). Physician age, specialty, and years in practice did not affect calling rate. CONCLUSION: Compared to male physicians, female physicians experience more demand for on-call service. In addition to slower advancement, factors intrinsic to their practice may contribute to higher reported job stress among female physicians. Physician gender may be an important factor when considering severity adjustments to determine reimbursement schedules.`W E'RE JINXED!'' -ARE RESIDENT'S FEARS FOUNDED? A.C. Ahn 1 , B. Nallamothu 2 , S.K. Saint 2 ; 1 Massachusetts General Hospital, Jamaica Plain, MA; 2 University of Michigan, Ann Arbor, MI PURPOSE: Many house officers believe that there is bad kharma bestowed on them when supportive remarks are expressed during call days. Remarks such as``Hope you have a great call!'' or``Hope you have no more admissions!'' are interpreted as ill-fortuned greetings that may do more harm than good. The purpose of this study is to determine whether this fear of being``jinxed'' is based on objective findings or mere psychological superstition. METHODS: We performed a randomized controlled trial using senior medical residents at 2 university-affiliated hospitals. On the morning of a call day, each resident was randomized by selecting either a Jinx (``You will have a great call day!'') or No Jinx message (i.e. blank form) from a collection of unlabeled envelopes. Primary outcomes measured included the number of total admissions and hours of sleep for each resident, and the subjective level of difficulty of the resident's call day (on a scale from 1 to 5 with 1 being easiest and 5 the most difficult). Some residents were randomized more than once during a call month. Student t-tests assessed for differences in outcomes between the Jinx and No Jinx groups, with robust variance estimates used to adjust for the effects of clustering at the resident level. RESULTS: Thirty-three Jinxes and 36 No Jinxes were performed on 30 residents. No statistically significant differences were seen between the 2 groups in important baseline characteristics such as a priori level of superstition or admitting service (i.e., general medical service, cardiology service). Relative to those in the No Jinx group, residents who were jinxed had significantly fewer admissions (5.1 versus 6.2;P=0.021), more hours of sleep (3.8 versus 2.9; P=0.034), and a lower subjective level of difficulty (2.9 versus 2.5;P=0.040) during their call day. CONCLUSION: There is no evidence that offering encouraging remarks to residents on a call day``jinxes'' them. Therefore, such remarks may be given safely to residents without fear of causing more admissions or less sleep, or worsening a call day's level of difficulty.