METHODS: We surveyed patients and physicians at 7 medical centers in 4 states (NC,GA,FL,VT). For the patient questionnaire, a trained research assistant administered a 112-item survey that included questions pertaining to demographics, health status, functional status (SF-36), and spirituality assessment (SWB scale). Patients were also asked to express their preferences regarding physician involvement in their religious/spiritual life. The physician questionnaire was administered to residents and primary care practitioners through the mail. Descriptive statistics were tabulated. RESULTS: Two hundred ninety-nine patients and 444 physicians were surveyed. Patients' ages ranged from 19 to 86 years. Fifty six percent were male, 46%were African ± American, 51%white, and 63%belonged to Protestant denominations. Fifty three percent had annual incomes of $20,000 or less. Of the physicians, 45%were practicing physicians and 55%were residents/fellows. Seventy three percent were internists and 21%family practitioners. Forty five percent of physicians were of Protestant denominations. Twenty percent of patients wanted their their physicians to pray with them during a routine office visit, but only 5%of physicians wanted to pray with their patients under the same circumstances. However, 55%of physicians said they would pray with their patients during a routine office visit if the patients requested. If patients were hospitalized and near death, 52%wanted their physicians to pray with them compared to 26%of physicians who felt this appropriate. This number increases to 77%of physicians if a patient requests such prayer behavior. CONCLUSION: Patients' preferences for prayer in medical settings increases in settings associated with more severe illness. Physicians' willingness to engage in prayer with patients rises in a parallel manner but does not match the level of patients' desires unless prayer by a patient is requested. These data suggest that patients should communicate their feelings about prayer to their doctor if they truly desire their physician' s participation. PURPOSE: Alcohol is known to affect HIV risk behaviors and adherence to antiretroviral medications, but its prevalence among HIV-infected persons and effective screening approaches are less well described. Our objective was to determine the prevalence of a history of alcohol problems in patients entering primary care for HIV infection and to assess the positive predictive value of the CAGE questionnaire for alcohol abuse or dependence. METHODS: Between 7/97 and 10/00, HIV-infected patients presenting to a multidisciplinary clinic for evaluation and linkage to primary care were assessed for alcohol problems using the standard threshold of 2 or more positive responses to the CAGE questionnaire. The predictive value of the CAGE was evaluated by administering the CIDI-SAM, an interview for DSM-IV lifetime diagnoses of alcohol abuse and dependence, to a sample of those with a positive CAGE screening test. RESULTS: Among the 715 patients who spoke English or Spanish, mean age was 38.6 years; 70%were male; 50%were Black, 25%Latino, 23%White, 2%other. Primary HIV risk factors were injection drug use 47%, heterosexual 37%, and men who have sex with men 16%. Most (673/715, 94%) were evaluated for alcohol problems: 41%(279/673) had a positive CAGE screening test (2+); 7%(47/673) had 0 or 1+ CAGE scores, but were deemed to have had an alcohol problem by physician clinical judgment. Of the 326 patients with reports of alcohol problems, 116 underwent a diagnostic interview: 80%(93/116) met DSM-IV criteria for diagnosis of lifetime alcohol dependence, 14%(16/116) for lifetime alcohol abuse, and 6%(7/ 116) did not meet criteria for either diagnosis. In the group of patients with 2 or more positive responses to the CAGE questionnaire (n = 102), 95%(97/102) met DSM-IV criteria for alcohol dependence or abuse. In the group not identified by the CAGE but by clinical judgment (n=14), 86%(12/14) met the same criteria. CONCLUSION: Nearly half of patients presenting for HIV care in an urban clinic had a history of past or present alcohol problems, and the positive predictive value of the CAGE questionnaire was 95%for lifetime diagnoses of alcohol abuse or dependence. Given the prevalence of alcohol problems in this population, the potential impact of such problems on treatment, and the high predictive value of this simple screening tool, alcohol screening should be routinely implemented for all patients initiating HIV medical care. PURPOSE: Previous research suggests that diabetic patients with low literacy have lower disease-specific knowledge. We sought to examine the prevalence of low literacy among high-risk diabetic patients and determine if literacy level affects the change in knowledge or average hemoglobin AIC (HBAIC) after a comprehensive intervention to improve diabetes care. METHODS: Using a well-validated literacy instrument, the Rapid Estimate of Adult Literacy in Medicine (REALM), we screened 91 diabetic patients who were referred for enrollment in a comprehensive, pharmacist-based diabetes care program in a university internal medicine clinic. The intervention involved direct verbal teaching, simple diagrams, and phone-based follow-up to help patients better manage their blood sugar levels. We obtained diabetes knowledge scores and HBAIC values at entry and after 3 ± 4 month follow-up. We then analyzed the effect of literacy level on change in knowledge and HBAIC from baseline to follow-up using nonparametric Wilcoxon rank sum tests. RESULTS: Mean age of subjects was 58 (range 27 ± 87); 63%were female, 65%were African ± American, and 38%completed high school. Average duration of disease was 9years (range 0 ± 35). Low literacy, defined as a reading level below 9th grade (REALM < 61) was present in 78%of patients (32%grade 3 or below, 22% grade 4 ± 6, 24%grad 7 or 8). The effect of literacy on the response to the intervention is shown in the Table. CONCLUSION: Low literacy is extremely common among high-risk adult patients with diabetes. Our intervention improved knowledge and outcomes for patients with high and low literacy, but the effect was greater for patients with higher literacy. To prevent disparities in health outcomes, specific interventions to assist low literacy patients should be developed. We prospectively evaluated patients with any viral symptoms (temp > 1008F, headache, fatigue, sore throat, myalgias, night sweats, rash, oral ulcers, or diarrhea) and any risk for HIV infection (sex or drug use) in the prior two months. Primary infection was defined as ELISA negative and RNA positive; chronic infection was defined as ELISA/Western Blot positive and RNA positive. RESULTS: 1010 patients who presented to the UCC with viral symptoms were screened. Of 413 interested and eligible patients, 375 (91%) enrolled and had antibody and RNA testing. HIV infection was diagnosed in 9 (2.4%, 95%CI: 1.1%, 4.5%). Primary infection was diagnosed in 4 (1.1%, 95%CI: 0.3%, 2.7%) and chronic infection in 5 (1.3%, 95%CI: 0.4%, 3.0%). Fever was associated with a higher prevalence of primary HIV infection (7.0%, OR = 24.8, p < 0.0001). Symptoms associated with a higher prevalence of chronic HIV were oral ulcers (5.7%, OR = 6.8, p = 0.018) and diarrhea (4.2%, OR = 12.3, p = 0.0047). The four patients with chronic HIV and available CD4 counts all had very advanced disease (CD4 < 50/uL). CONCLUSION: Undiagnosed primary and advanced chronic HIV infection are prevalent in patients presenting with viral illness to an urban urgent care clinic. Testing for both should be recommended for these patients. PURPOSE: Coronary artery calcium (CAC), a marker of coronary artery disease (CAD), may be detected and quantified using electron beam computed tomography (EBCT). Proposals have been made to use the CAC score to guide cholesterol-lowering therapy, but the costs and benefits of this strategy have not been quantified. We performed a cost-effectiveness analysis to determine whether measurement of CAC with EBCT is a cost-effective method of targeting patients for cholesterol-lowering drug therapy. METHODS: A Markov model was constructed to estimate the incremental cost-effectiveness, over 10 years, of five different strategies:``Treat none, ''``Treat all, ''or test with EBCT and treat if the CAC score is greater than 0 (``Test and treat>0"), 100 (``Test and treat>100"), or 400 (``Test and treat>400"). Overall rates of CAD events were based on Framingham risk equations. Distributions of CAC scores given risk factors were calculated from the literature. Summary relative risks for CAD events in each of four CAC score strata (0, 1 ± 100, 101 ± 400, > 400) were calculated with a random-effects model using data obtained from meta-analysis of articles identified through a systematic search of the literature. Therapy with HMG-CoA Reductase Inhibitors (STATINS) was assumed to reduce CAD event rate by 31%. Cost data were derived from literature review. Two base-case analyses were performed. Case 1 was a 50 year old man with low density lipoprotein cholesterol (LDL) of 175, high-density lipoprotein cholesterol level (HDL) of 45, and no other CAD risk factors. In Case 1, STATINS would not be recommended according to the National Cholesterol Education Program II (NCEP II) guidelines. Case 2 was the same 50 year old man with high cholesterol, but also Stage I hypertension, for whom STATINS would be recommended by NCEP II. RESULTS: Meta-analysis: Four studies met inclusion criteria. Relative risks (with 95%confidence intervals) for CAD events were 1.0 (reference), 3.9 (1.7 ± 8.8), 7.9 (2.5 ± 24.4), and 9.9 (2.8 ± 34.6), given CAC scores of 0, 1 ± 100, 101 ± 400, or > 400, respectively. Cost-effectiveness analysis: In each case, the``Test and treat ''strategies were more costeffective than the``Treat all ''strategy. This result held true while the cost of EBCT was less than $2400 (base case $400/scan), and the cost of STATINS was more than $150/year (base case $849.84/year). It was also insensitive to reasonable variation of other parameters, including the cost of CAD events, overall risk of events, relative risk given CAC score stratum, relative risk reduction with STATINS, and distribution of CAC scores. The``Test and treat > 400'' strategy failed by extended dominance in both cases. In Case 1, the incremental cost-effectiveness ratios (C/E' s) of all``Test and treat ''strategies, though lower than``Treat all,'' were greater than 300,000 $/life-year compared with``Treat none'' (the NCEP II recommendation). Given a reasonable C/E threshold of 50,000 $/life-year, this result was also insensitive to variation of parameters. In Case 2, the C/E of``Treat all'' (the NCEP II recommendation), in comparison to the``Test and treat > 0'' strategy, was 1,600,000 $/life-year. The per-year cost of STATINS would have to be less than $160/year, or the cost of EBCT greater than $2400, in order to make the NCEP II standard (``Treat all'') cost-effective or dominant in comparison to the optimal`T est and treat'' strategy. Note that the NCEP II standard (``Treat all'') in comparison with`T reat none'' also did not meet reasonable C/E standards, consistent with a recent costeffectiveness analysis of STATINS for primary prevention of CAD (Ann Intern Med 2000;132:769 ± 779). CONCLUSION: Screening of patients with EBCT who would not otherwise qualify for cholesterol-lowering therapy, based on NCEP II guidelines, does not meet reasonable costeffectiveness guidelines. On the other hand, using EBCT to identify patients at very low risk for CAD events among patients who would otherwise be treated with STATINS may be a costeffective strategy in selected patient populations. Research on the utilization of screening mammography for women has consistently shown that women are not taking advantage of recommended screening services. Most of the research on breast cancer screening has utilized retrospective crossectional survey designs, convenience samples and has not controlled for important confounding variables. These studies have limited themselves to describing characteristics of patients who do not get screened or listing patient-reported reasons for underutilization. Studies have implicated cost, insurance status and socioeconomic status as strong predictors of who will follow through with screening. METHODS: Randomized, unblinded, controlled interventional design. Consecutive clinic attendees who were > 40 years of age and eligible for a screening mammogram were enrolled in the study (N = 334). Patients were randomized within resident patient panels to be offered free screening mammograms or to be offered mammograms without mention of cost. Residents used a standardized script to offer all elegible patients a mammogram. Those who agreed were given appointments prior to leaving the clinic. The hypothesis was that those patients who were assigned to receive a free mammogram would be more likely to follow through with their mammogram appointment. RESULTS: Baseline characteristics between the control and intervention group were similar. Overall compliance rates were similar for both groups. Fifty four percent of the control group and 63%of the intervention group completed mammograms. This difference was not significant (chi square = 2.88; p = .237). Black women were 23% less likely than their non-black counterpoints to complete the mammogram (p = .069). There was no association between completion of mammogram and age, education, family history of breast cancer or type of insurance. CONCLUSION: Offering free screening mammograms and eliminating many of the known barriers to screening was not sufficient in this population to encourage compliance with screening mammography. PURPOSE: Low health literacy, a hidden obstacle to adequate health care, has significant impact on health services utilization. We set out to determine the association between health literacy of medical inpatients and subsequent emergency room visits, and hospital readmissions. METHODS: The study is a prospective cohort study with 3 months of follow-up, and took place in the medical service of an urban, teaching, hospital in Providence, Rhode Island. Patients admitted to the medical service at Rhode Island Hospital were eligible to participate in the study. A total of 293 hospitalized patients were approached over a seven week period for participation in the study, of which 161 (55%) completed the instrument. Patients who agreed to participate completed the short version of the Test of Functional Health Literacy in Adults (sTOFHLA), which was administered by a bilingual research assistant. RESULTS: Of the participants, 54%were female, and the mean age was 59 years old. 126 (78%) of the participants scored in the adequate health literacy range, which was defined as a score of 23 ± 36 (maximum score = 36). 35 (22%) patients scoring in the marginal health literacy range (17 ± 22), and those scoring in the inadequate range (0 ± 16) were combined into one group as low health literacy. Three months after discharge from the hospital, the hospital computer records were reviewed for the main outcomes-number of emergency room visits and hospital readmissions. There were 22 emergency room visits in the 126 patients with adequate literacy and 15 emergency room visits in the 35 patients with low health literacy (mean number of emergency room visits 0.17 (95%CI 0.082 ± 0.267) vs. 0.43 (95%CI 0.092 ± 0.765), p = 0.04). Patients with low health literacy had 2.5 times more visits to the emergency room than patients with adequate literacy. There were 52 hospital readmissions in the 126 patients with adequate literacy and 25 readmissions in the 35 patients with low health literacy (mean number of readmissions 0.413 (95%CI 0.237 ± 0.589) vs. 0.714 (95%CI 0.346 ± 1.083), p = 0.12). CONCLUSION: In our study of a medical inpatient population, patients with low health literacy had an increased number of emergency room visits within three months of discharge when compared to patients with adequate health literacy. Future studies should be focused on interventions aimed at patients with low health literacy to improve health services utilization. Higher * 10.5% 8.4% À2.1% (À3.5%, À0.7%) À1.1% (À2.5%, +0.4% Lower ** 9.6% 8.5% À1.1% (À1.6%, À0.5%) * Higher literacy is !9th level (n=19); ** Lower literacy is < 9th grade (n=72) ACCESS TO CARE ISSUES IN A PUBLIC HOSPITAL URGENT CARE CLINIC. S. Prock 1 , H. Batal 1 , S. Majeres 1 , L. Lasater 1 , R. Lundgren 2 , J. Adams 1 , P. Mehler 1 ; 1 Denver Health Medical Center, Denver, CO; 2 Colorado Prevention Center, Denver, CO PURPOSE: To describe access to care issues in a population of patients seeking care at a public hospital urgent care clinic. METHODS: 20%of patients presenting to the Denver Health Medical Center urgent care clinic (UCC) between June 15 and August 11, 2000 were randomly approached to participate in a pre-visit interview, offered in both English and Spanish. Patients were asked standardized questions regarding physical and mental health, their reasons for accessing care in the UCC, barriers to health care, history of prior Emergency Department (ED) and UCC usage, reasons for delaying health care, chronic medical conditions, and prior receipt of preventive health services. Study patients' charts and admission records were abstracted for the number of prior visits and documentation of receipt of preventive health services at our institution, ethnicity, age, gender, and insurance status. Data were analyzed using multiple logistic regression. RESULTS: There were 1006 patients surveyed with a refusal rate of 20.3%. The study patients did not differ from the total population who accessed care during this time period in regards to age, insurance status, ethnicity, or gender. A regular source of care, other than an ED or UCC, was identified by only 37.1%of patients. Those patients with insurance were 1.7 times more likely to note a regular source of health care (p = 0.0046) than those without insurance or those on the state indigent care discount program. Hispanic (p = 0.0075) and black (p = 0.04) patients were more likely than white patients to note a regular source of health care. Older patients (p < 0.0001)and female patients (p < 0.0001) were also more likely to report a regular source of health care. Patients accessing care in the UCC were likely to have delayed accessing care, 71%had been sick for more than two days, with 49%noting that their current medical problem had been present for a week or longer. Those patients without insurance or on the state indigent care program were more likely to report a delay in seeking care (p = 0.0279). Among those who delayed care for more than two days, 26.4%reported that a lack of insurance contributed to their delay. CONCLUSION: Patients presenting to a public hospital urgent care clinc often delay care and often do not have a regular source of health care. Having a regular source of care was associated with age, gender, ethnicity, and insurance status. Patients without insurance were more likely to report delaying health care.