Several individual symptoms correlated strongly and statistically significantly with longer measures of the same concept, like the MOS-HIV Health Survey. Overall, no one method is clearly superior; different individual symptoms were better measured using different methods. Studies are needed to develop a measure of symptoms commonly experienced by HIV-infected people. Medical College of Wisconsin, Milwaukee, WI PURPOSE: Women have been found to overestimate breast cancer risk. Perceptions are more accurate in higher educated and more numerate women. The objectives of this study are to evaluate the association between African-American (AA) race and breast cancer risk perceptions. METHODS: We assessed 5-year and Lifetime Risk Perceptions of AA and Caucasian women recruited from a primary care clinic. Actual risk was calculated using the Gail Model. Error in estimation (EE) was defined as perceived risk minus calculated risk. The following categories were defined. Under-estimators had an error of < À10%, Accurate Estimators had an error of > À10% but < 10%, Moderate Over-estimators had an error of > 10% and < 30%, High Overestimators had an error of > 30% and < 50%, Extreme Over-estimators had an error of > 50%. Nonparametric statistics were used to compare EE between groups. RESULTS: There were 254 subjects. Sixty-eight percent (68%) were Caucasian, 30% AA, and 2% other. AA were younger (mean of 55 yrs vs. 58 years, p = 0.03), of lower income (84% vs. 35% of Caucasians < $20,000/year, p < 0.0001), had lower Rapid Estimate of Adult Literacy in Medicine (REALM) scores (mean 53 vs. 65, p < 0.0001), and less likely to answer a set of three numeracy questions correctly (11% vs. 55%, p < 0.0001), compared to Caucasians. The calculated mean lifetime and five-year risk of AA women was lower than Caucasian women (lifetime risk: 5.5% vs. 9.7%, p < 0.0001, five-year risk: 0.89% vs. 1.8%, p < 0.0001). In univariate analyses, race, age, and reading level were not associated with accurate risk perception. A trend of increased accuracy of lifetime and five-year risk with higher numeracy was found (p = 0.08). The table shows error in estimation stratified by race (*p-values > 0.05 using a chi-square test). CONCLUSION: In a primary care population, AA women had similar levels of accurate breast cancer risk estimation as Caucasian women, despite lower education and numeracy levels. Both populations could benefit from education to improve the accuracy of risk estimation. PURPOSE: Deciding on anticoagulating the oldest-old (OO)with atrial fibrillation (AF)with warfarin is an increasingly common problem for general internists. Age is an important risk factor not only for AF, but also for stroke in patients with AF. In addition, other risk factors for stroke in AF, such as hypertension (HBP)and diabetes (DM), also increase with age. Though anticoagulation(AC)has been shown to be effective in preventing strokes in some patients with AF, these studies cover only short periods and include few OO. Also, contraindications and side effects of AC are greater in the OO, the fastest growing segment of the population. METHODS: A cost-effectiveness analysis was developed using 3 Markov states: 1ife without stroke, life with stroke residuals and death. Quality-adjusted life expectancy (QALE) was calculated for each state. Baseline probabilities and rates were obtained from systematic reviews and age-adjusted. Based on self-report, women were categorized into three subgroups Ð current, past, and never drinkers. A drinker was defined as someone who drank moderately ( < 2 drinks/day). Depression was evaluated by using the Geriatric Depression Scale (low score indicating less depression) and Social Networks were defined by using the Lubben Social Network Scale (higher score indicating worse social network). RESULTS: When compared to past drinkers, current drinkers are less likely to carry a previous diagnosis of depression, score low on the depression scale, and take antidepressants. Current users are more similar to never users for these measures. CONCLUSION: Women who currently drink a moderate amount of alcohol are less likely to be depressed and more likely to have a stronger social network than women who are past or never users. Questions regarding possible confounders and why past users quit using alcohol may be answered after analyzing a recent questionnaire describing this cohort's pattern of alcohol use. PURPOSE: Public health departments have traditionally provided episodic safety net services to the uninsured. Increasingly, these providers have taken up the role of providing primary care clinical preventive services as well, particularly to racial/ethnic minority populations. To assess the association of race/ethnicity and other patient and system characteristics with receipt of preventive health care services by low-income women, we studied patients cared for through the Los Angeles-County-Department of Health Services(LAC-DHS) Primary Care Network. METHODS: We sampled patients receiving primary care services at 50 facilities to represent all patients in care throughout the LAC-DHS Primary Care Network. 1,288adult females were interviewed for a response rate of 80%. The sample was racially and ethnically diverse-63% Latina/Hispanic, 22% white, 13% African American,1% Asian/Pacific Islander and 1% Mixed race/Other. We measured receipt of the following tests and services: Pap smear within 3 years, mammogram within 2 years among women age 50 years and older, flu shot among women at risk, and cardiovascular disease testing and counseling among women at risk. We used bivariate and multivariate logistic regression analyses to assess the association of patient characteristics (age, race/ethnicity, education, income, immigration status, health insurance status, health status) and system characteristics (type of facility-comprehensive health center, personal health center, hospital outpatient clinic and public/private partnership clinic) with receipt of preventive health care services by low-income women within a publicly funded health care system. RESULTS: Eighty-eight percent of women had undergone cervical cancer screening within 3 years and 82% of women age 50 years and older had undergone breast cancer screening within 2 years, with the highest rates of screening among Latina patients. Among women at increased risk for morbidity and mortality associated with influenza 41 % had received a flu shot within one year. For women at increased risk for cardiovascular disease 91 % had undergone cholesterol screening within 3 years, 82% had been counseled about the importance of exercise, 86% about nutrition and healthy eating and 46% about tobacco use. In multivariate regression analyses Latinas remained the most likely to have undergone cervical and breast cancer screening and among women at risk for influenza African Americans were the most likely to have received a flu shot. CONCLUSION: For low-income women who are able to gain access to a large urban publicly funded health care system for their primary care needs their level of receipt of preventive health care is comparable or better than that of women in other healthcare settings, although shortcomings remain. PURPOSE: Studies have demonstrated that people seek emergency department services for a variety of reasons, including not being able to otherwise access needed health care. To assess the use of emergency department services(emergent and non-emergent) by low-income patients with a regular source of care we interviewed a sample of patients who received their medical care through a large public health system. METHODS: We performed a stratified cross sectional study utilizing probability sampling techniques and survey methods. We sampled patients receiving primary care services through the Los Angeles County Department of Health Services Primary Care Network. 1819 adults were successfully interviewed for a response rate of 80%. The sample was racially, and ethnically diverse. We used bivariate and multivariate logistic regression analyses to assess the association of patient characteristics including insurance status and use of primary care services with visits ( 1 or more) to the emergency department within the preceding 12 months. RESULTS: Twenty-eight percent of the adults in this sample had made one or more visits to an Emergency Department for medical treatment within the preceding 12 months. Almost half of those who had used emergency department services reported that they felt their medical problem was an emergency (49%),but a substantial number of patients sought emergency care for financial reasons(10%) and ease of accessibility to needed medical care (12%). Multivariate analyses revealed that patient characteristics associated with a greater likelihood of having used emergency department services included being white, poor health status, having Medicaid rather than being uninsured, and having delayed seeking needed medical care. CONCLUSION: Patients within a publicly funded medical system have high rates of emergency department use. Type of health insurance and whether people had delayed receiving needed medical care during the preceding year were associated with use of emergency department services. Thus, access and barriers to needed medical care are related to use of emergency department services for emergent and non-emergent medical care. PURPOSE: Conflicting study results regarding the role of intranasal steroids in patients with rhinosinusitis create a dilemma for clinicians. Using a double-blind, randomized, placebocontrolled methodology, we examined whether the addition of an intranasal steroid to conventional antibiotic therapy speeds the recovery of patients with recurrent acute rhinosinusitis. METHODS: Ninety-five (95) patients, ages 18 or older, presenting with acute rhinosinusitis and a previous history of recurrent sinusitis or chronic rhinitis were enrolled from 22 primary care and otolaryngology practices nationwide. Either plain film sinus radiograph or nasal endoscopy supported the diagnosis of sinusitis for all patients. Patients with a history of chronic bacterial sinusitis, previous sinus surgery, and recent intranasal steroid or antibiotic use were excluded. Subjects were randomized to receive either 2 puffs of fluticasone proprionate (n = 47) or saline nasal spray (n = 48) in each nostril once daily for 21 days. All patients received 2 puffs of oxymetazoline hydrochloride in each nostril twice daily for 3 days initially and cefuroxime axetil 250 mg twice daily for 10 days. Patients recorded their daily symptom status in a diary during the 3-week treatment phase. Telephone follow-up was conducted at 10, 21, and 56 days after enrollment; 88 patients (92.6%) completed all telephone follow-up. The primary endpoint was time to clinical success over the 8-week follow-up period (defined a priori as cured or much improved). RESULTS: Patients using the regimen which included fluticasone propionate achieved higher rates of clinical success, 93% versus 74% in the placebo group (p = 0.009 by Chi-square test). The relative benefit increase was 26% with the inclusion of fluticasone to the regimen and the absolute benefit increase was 19%; the number needed to treat to achieve one additional treatment success was 6. Fluticasone-treated patients improved significantly more rapidly (median days to clinical success was 9.5 and 6.0 days, respectively; p = 0.012 by log rank test). Other covariates, including specialty vs. primary care study site, age, number of comorbidities, gender, race, recent upper respiratory infection, or history of allergy, were tested using a Cox proportional hazards model, but only the inclusion of fluticasone to antibiotic and decongestant therapy significantly influenced the clinical outcomes. CONCLUSION: The addition of a 3-week course of fluticasone propionate to oxymetazoline (3 days) and antimicrobial therapy with cefuroxime (10 days) improves clinical success rates and accelerates recovery of patients with a history of either chronic rhinitis or recurrent sinusitis who present for treatment of acute rhinosinusitis. PURPOSE: Disadvantaged populations are often the last to benefit from innovation, including quality improvement (QI) programs for depression. Public sector clinics may not have the resources to implement and maintain QI programs and QI programs designed for private patients may not address needs, treatment preferences, and resources available to depressed, indigent patients. Careful needs assessment can help formulate objectives of QI for such populations, but assessment may be limited by the fact that such populations have little prior exposure to appropriate treatments. We present the development of a unique approach that demonstrates respect for indigent patients and their providers by employing market research strategies to rigorously assess their preferences for and barriers to depression care, as the first step to developing a tailored QI program. METHODS: We conducted literature reviews of existing primary care depression interventions and reviewed methods for understanding patient treatment preferences, including the use of market research methods for assessing consumer preferences. Key informant interviews were conducted with 4 principal investigators of depression treatment interventions. RESULTS: The reviews indicated that few existing QI studies for depression explicitly incorporate assessment of and respect for patient treatment preferences in intervention design. Further, valid methods for assessing patient and provider preferences for and barriers to depression care have not been systematically applied to treatment interventions for the poor. Market research techniques including conjoint analysis surveys have been validated and used to design appealing and acceptable consumer products and services. Because market research methods, such as conjoint analysis, have not been commonly used in developing health services interventions, especially in populations with little treatment experience, we have developed an iterative process for assessing and validating patient and provider preferences and barriers to care. The method includes 4 phases: 1.) patient and provider focus groups, 2.) a market research survey (using conjoint analysis) 3.) a pilot depression intervention in which patient preferences, barriers to care, and opportunities for treatment are identified and results from step 2 are validated, and 4.) indepth qualitative interviews with patients and providers. For all phases of the design depressed patients from the general internal medicine clinic are identified using waiting room screening. Focus groups were held with depressed patients to inform the design of the conjoint analysis survey. Of 86 patients in the general internal medicine clinic screened for focus groups, 26 (36%) had current depressive disorders, 23 patients were eligible to participate in focus groups, and 15 (65% of those eligible) did so. The mean age of focus group participants was 52 (SD = 8.9); 14 of 15 were female; 73% had less than 6 years of education; and all were Spanish speaking. Only one participant reported prior treatment for depression. Patients preferred counseling as the first line treatment for depression, but would consider antidepressants if recommended by a caregiver. A majority preferred group over individual counseling. Patients preferred to receive treatment at the primary care clinic, but from a mental health specialist rather than a primary care provider. Patients reported that their lack of knowledge regarding depression and its treatment and their fear of treatment costs were the main reasons that they had not sought care. In the second phase, 175 depressed patients are recruited to complete a conjoint analysis survey. In this technique, key attributes of a proposed product and possible variations (called``levels'') of the attributes are defined. Hypothetical products with variations of the defined attributes are rated or ranked by patients according to their preferences. Conjoint analysis then determines the relative importance consumers attach to each of the attributes and the utilities they attach to each variation or level of the attributes. We assess the validity of conjoint analysis for determining preferences for and barriers to depression care by comparing survey results with actual treatment choices and barriers to care following a limited depression intervention. Finally, indepth qualitative interviews developed with a medical anthropologist are used to complement quantitative data gathered during the pilot intervention. CONCLUSION: Previous QI programs for depression in primary care have generally not included systematic assessment of patient and provider preferences for and barriers to care in their design. Rather than making assumptions about the needs of providers and consumers in disadvantaged settings, researchers should rigorously assess the preferences of those most affected by a planned QI intervention. A rational and respectful approach for assessing patient and provider preferences using market research methods is proposed for developing and adapting health care QI interventions for disadvantaged populations. PURPOSE: To use anti-Xa activity to monitor enoxaparin dosing in the following patient types: greater than 65 years old, with a creatnine clearance less than 30ml/min and in morbid obesity. To develop a weight adjusted dosing method for patients over 65 years old and for patients with a creatnine clearance less than 30mls/min. METHODS: All patients were dosed by their physician using 1mg/kg sub-cutaneous every 12 hours. Peak anti-Xa activity was obtained 3 ± 5 hours after the third dose, trough activity was obtained just prior to the dose. Anti-Xa activity was measured using Dioagnostica Strago instrumentation. aPTT was obtained simultaneously. RESULTS: Thirty-eight patients were involved in the evaluation. Thirty-six peak levels and 17 trough levels were obtained. Thirteen patients greater than 65 years old were able to be evaluated. All values are mean: age 77, Scr 1.29mg/dl, CrCl 42ml/min, peak anti-Xa 1.3IU/ml. aPTT was prolonged in the vast majority of patients who had anti-Xa activity > 1.0IU/ml. One patient experienced a major hemorrhage. CONCLUSION: Doses of 1mg/kg of enoxaparin in elderly patients, especially females, seems to produce higher than expected peak anti-Xa activity. This can result from a decrease in renal function and an altered volume of distribution. As a follow-up to this evaluation we developed a weight-adjusted dosing method for enoxaparin in our elderly patients. We realize anti-Xa acitvity is only one of several pharmacologic properties of enoxaprin. PURPOSE: Self-reports of chronic diseases and general measures of health status predict use of health services but it is not established how well they predict mortality or hospitalization. We developed the Seattle Index of Co-morbidity (SIC) using self-reported chronic illnesses and tested its ability to predict mortality and hospitalizations among general outpatients. METHODS: Using data from the Ambulatory Care Quality Improvement Project (ACQUIP), we conducted a prospective cohort study of patients from GIM clinics at 7 VA medical centers.