BREAST CANCER SCREENING IN AMERICAN SAMOAN WOMEN. S. Mishra 1 , F. Hubbell 1 , P. Luce 2 ; 1 University of California, Irvine, CA; 2 National Office of Samoan Affairs, Carson, CA PURPOSE: Little is known about breast cancer screening practices or predictors of age-specific screening for Samoan women. We determine population-based estimates of utilization of clinical breast exam (CBE) and mammography by Samoan women and examine predictors of recent age-specific utilization of screening exams. METHODS: Through systematic, random sampling procedures, we identified and interviewed 720 adult (!30 years) Samoan women residing in American Samoa, Hawaii, and Los Angeles. Multivariate logistic regressions were performed to determine independent predictors for recent age-specific screening RESULTS: Only 55.6% of women (!30 years) had ever had a CBE and 32.9% of women (!40 years) had ever had a mammogram. Furthermore, only 24.4% and 22.4% of Samoan women (!40 years) residing in Hawaii and Los Angeles, respectively, had an age-specific mammogram within the prior year. Independent predictors of age-specific CBE screening included age, education, health insurance, ambulatory visit, and being a resident of Hawaii or Los Angeles; and those for mammography included ambulatory visit and awareness of screening guidelines. CONCLUSION: Population-based estimates of age-specific breast cancer screening among Samoan women are lower than nation objectives and those reported for other minorities. Targeted efforts that address doctor patient communication on preventative behavior, improved access to health care services (especially in American Samoa), and focused educational awareness programs are needed to improve the dismal screening rates observed in this indigenous population. PURPOSE: Controversy exists on whether postmenopausal hormone replacement therapy (HRT) can lessen or avert cognitive impairment that may lead to dementia. The purpose of this study is to examine the association of HRT use and impaired cognition. METHODS: Postmenopausal women (n=1403) participating in the population-based Beaver Dam Eye Study and the Epidemiology of Hearing Loss Study in Beaver Dam, Wisconsin were included in these analyses. Data were from the 10-year follow-up for the eye study and the concurrent 5-year follow-up for the hearing study (1998 ± 2000) . HRT use was assessed by questionnaire and confirmed by participants' presentation of prescribed medications at the eye examination. Cognitive impairment is defined as less than 24 points, or 80%, on the minimental status exam, or doctor-diagnosed Alzheimer's disease. Odds ratios were obtained from logistic regression models. RESULTS: The average age of the women was 69 years (range 53 to 97). Twenty-five percent of participants were current HRT users. The average age of current users was 65 years; the average age of non-users was 72 years. More current users completed high school than nonusers, 91% and 78%, respectively. In preliminary analyses, the overall prevalence of cognitive impairment was 6%. HRT users were less likely to be cognitively impaired than non-users (5.7% vs 0.5%, p = 0.0003). After adjusting for age, education, and depression (as measured by Short Form-36 mental health subscale), the odds of being cognitively impaired were not statistically significantly different for HRT users versus non-users (OR = 0.40; 95% CI = 0.14 ± 1.15, p = 0.09). CONCLUSION: These preliminary analyses suggest that postmenopausal HRT use may be associated with a slighter lower odds of having impaired cognition. However, this association may be marking selection bias, as the relationship is no longer statistically significant after adjusting for the confounding effects of age, education, and depression. Longitudinal studies, adequately controlling for these confounders, are needed to determine the effect of HRT use on cognition. PURPOSE: Assessing patient satisfaction with care received is important to measure as it is a primary goal of providers and clinic practices. Studies done, to date, have been limited in that most measure patient satisfaction with experiences related to medical student education and have been retrospective in design. We designed a prospective study to find the differences in patient satisfaction with outpatient care provided by continuity clinic resident physicians compared to satisfaction with care provided directly by faculty physicians in the same practice. METHODS: During one week in June 2000, 1107 adult and pediatric clinic patients completed a patient satisfaction questionnaire following their visit, during which the patient was either seen by the faculty member or by the resident physician year 1 through 4. The data was collected from 5 primary care clinics; pediatrics, internal medicine and a combined medicine/ pediatric clinic. Four clinics were in community practices and one clinic was an academic hospital based practice. The questionnaire comprised of 26 questions addressing service characteristics of the office staff, provider and facility. Ten questions assessed satisfaction of care provided by the doctor. Differences in results for faculty vs. resident patients were analyzed for the entire set of collected responses, as well as for each clinic. RESULTS: 1772 total patients were seen during the study week. Sixty-three percent of the questionnaires were completed (1107); 824 from faculty patients and 283 from visits with the resident. 42% of the faculty patients and 24% of the resident patients saw the doctor they wanted to see on the day of the visit. 67% of the faculty patients and 60% of the residents patients``strongly agreed'' that the resident answered questions in a way the patient could understand. 52% of faculty patients and 43% of the resident patients indicated that the time spent with the physician was``excellent''. 62% of the faculty patients rated thoroughness of the exam as excellent versus 50% of the resident visits.47% of the faculty visits and 36% of the resident visits rated the care received overall as``excellent''. All differences reached statistical significance with p < 0.05. A similar distribution of small differences, all indicating better satisfaction with care by faculty occurred in all 5 participating practices. CONCLUSION: Patients were more satisfied with care received by faculty as compared with residents. Difficulty for the residents patients to schedule an appointment with their physician of choice is an important barrier to improving patient satisfaction. Overall access to and use of HIV care is lower for Hispanics than for whites, but little is known about how these vary within the diverse Hispanic population in the US. We examined access to, use of, and unmet need for care among HIV+ Hispanics according to level of acculturation, language in which subjects chose to complete surveys, citizenship status, gender, education and insurance status among the 415 Hispanic patients (15% of all subjects) in the HIV Costs and Services Utilization Study (HCSUS). METHODS: HCSUS is a nationally representative study of HIV-infected persons in care. Weights were used to adjust for sampling, multiplicity, and non-response. Standard errors were corrected for the multistage sampling design. Use of care was measured in four dimensions: ambulatory care, emergency care, hospital care and mental health services. Overall access was measured with a six-item scale (alpha = 0.72) asking about urgent care, emergency care, hospital care, clinic location, costliness of services, and access to specialists. Unmet need for care was measured by five items asking about foregone medical care due to: inability to get time off work, being too sick to seek care, lack of transportation, needing to care for someone else, or insufficient money to pay for care. All results reported are significant at a p < 0.05 level. RESULTS: In separate multivariate analyses controlling for CD4 count, Hispanics who were US citizens reported greater use of emergency care (Odds Ratio [OR]=1.92), hospital care (OR=2.59) and mental health services (OR=1.92) than non-citizens. Hispanics who were more acculturated (OR=1.76), who completed an English-language survey (OR=2.43), who were US citizens (OR=1.85), who were more educated (OR=1.93) and who were insured (OR=3.54) reported greater access to care. Women reported less use of ambulatory care (OR=0.66) and mental health services (OR=0.63) and worse overall access (OR=0.63) than men. Women were more likely to report unmet need for medical care (OR=2.17) than men (due to any reason of the five reasons asked about). CONCLUSION: Significant variation exists among HIV+ Hispanics in access to and use of care by language preference, acculturation, citizenship status and gender. Interventions to improve access for Hispanics should prioritize those Hispanics in greatest need. University of Pittsburgh, Pittsburgh, PA PURPOSE: Community-acquired pneumonia (CAP) is the leading infectious disease cause of death in the United States. Although risk factors for short-term mortality are widely studied, there is very little data on the risk factors for long-term mortality after surviving CAP. The aim of this study is to examine the predictors of long-term mortality after initial CAP. METHODS: This analysis was a follow-up of the 4 United States sites of the Pneumonia Patient Outcomes Research Team (PORT) prospective, multicenter cohort study. Baseline demographic and clinical data, including comorbid illnesses, laboratory and radiology results, were obtained for all patients. Long-term mortality was determined using the National Death Index. Patients were enrolled between October 1991 and March 1994, and mortality information was obtained up to December 1998. Charlson's comorbidity scale was used to assign a comorbidity score for preexisting comorbid conditions and age. All patients who died within 90-days of enrollment were excluded from the analysis in order to study the long-term mortality of those surviving after the acute illness. Statistical modeling included the use of Kaplan ± Meier survival plots and the log rank test for categorical variables, and univariate Cox proportional hazard modeling for continuous variables. Any variable that was statistically significant (p 0.05) was then entered into a step-wise forward multivariate Cox proportional hazard model. RESULTS: Of the 1555 subjects enrolled at the 4 U.S. centers, 1419 subjects survived past 90days after enrollment. Of those patients 472 (33.3%) died by December 1998. During the first year after enrollment 29.2% of patients died, in the second year 19.1%, third year 16.1%, fourth year 10.0% and !fifth year 25.4%. Significant baseline predictors of long-term mortality were being DNR (hazard ratio 2.1 with 95% confidence interval of 1.5 ± 2.9), poor nutritional status (1.9, 1.3 ± 2.8), pleural effusion (1.4, 1.1 ± 1.8), steroid use (1.6, 1.3 ± 2.1), nursing home residence (10.1, 3.2 ± 32.1), Charlson's score of 1 or 2 (2.5, 1.6 ± 4.0), Charlson's score 3 or 4 (5.8, 3.9 ± 8.9), and a Charlson's score !5 (14.6, 10 ± 21.5). Significant protective factors against mortality included !college education (0.6, 0.5 ± 0.8), female gender (0.7, 0.6 ± 0.8), and the symptom of fever (0.7, 0.6 ± 0.9). CONCLUSION: This study demonstrates that there is a significant long-term mortality burden after CAP, and that age, education, gender, comorbidity, nutritional status and nursing home status are important predictors of long-term mortality after CAP. PURPOSE: Although studies of tea consumption and mortality among healthy adults report conflicting results, the effect of tea consumption on patients with acute myocardial infarction is unknown. METHODS: In a prospective cohort study, we followed 1935 patients (601 women and 1334 men) hospitalized with a confirmed acute myocardial infarction between 1989 and 1994 at 45 community hospitals and tertiary care centers in the United States, as part of the Determinants of Myocardial Infarction Onset Study. During hospitalization, participants reported their usual intake of caffeinated tea during the year prior to infarction to trained interviewers. We excluded 35 patients with missing information on tea intake. We analyzed survival through 1995 using Cox proportional hazards regression, controlling for age, sex, body-mass index, previous myocardial infarction, diabetes, hypertension, education, income, current and former smoking, alcohol use, regular exertion, acute infarct complications, previous medication use, and receipt of thrombolytic therapy. RESULTS: Of the 1900 eligible patients, 1019 consumed no tea, 615 consumed less than 2 cups daily (moderate use), and 266 consumed 2 or more cups daily (heavy use). Heavy tea drinkers were older, less obese, and more likely to be female than non-drinkers, but their sociodemographic and clinical characteristics were otherwise similar. During a median followup of 3.8 years, a total of 313 patients (16%) died. Compared to non-drinkers, total mortality was lower among moderate tea drinkers (hazard ratio 0.78; 95% confidence interval (CI), 0.60 ± 1.01) and heavy tea drinkers (hazard ratio 0.65; 95% CI, 0.44 ± 0.97; p for trend = 0.01). When modeled continuously, the hazard ratio for each additional daily cup of tea was 0.89 (95% CI, 0.78 ± 1.01). The effect of tea was similar in men and women, in younger and older patients, and for total and cardiovascular mortality. Controlling for coffee intake did not change the results. CONCLUSION: Self-reported tea consumption during the year prior to acute myocardial infarction is associated with improved survival following infarction. PURPOSE: With recent changes in the financing of health care, home care patients may be discharged from home care prematurely, placing them at risk for adverse outcomes. Little is known about what happens to patients after home care discharge. We examined the frequency of adverse outcomes within 3 months of home care discharge, and identified factors associated with their occurrence. METHODS: Patients admitted to a single home care agency between April and September 2000 were invited to participate in the study. We collected data by chart review and telephone interview. We followed patients for 3 months after home care discharge and collected information on 5 adverse outcomes: death, readmission to home care, nursing home placement, emergency room use, and hospitalization. As potential correlates of adverse outcomes, we analyzed patient demographics, reason for home care, dependency in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), cognitive function, depression, number of medications, caregiver support, and living alone. We developed a logistic regression model for adverse outcomes within 3 months of home care discharge. RESULTS: Of 217 eligible patients, 180 (83%) agreed to participate in interviews. To date, 155 have been discharged from home care (85% remained home, 13% were hospitalized, and 2% were transferred to hospice). We obtained 3-month outcomes on 108 (84%) of the 129 patients who remained at home after home care discharge. Of these patients, 60% were female, 78% were white, 74% were !65 years of age (mean age 74 years), and 72% had Medicare or Medicare managed care as their primary insurance. The median home care length of stay was 23 days. At the time of home care discharge, 57% had ! 1 ADL dependency; 95% had ! 1 IADL dependency; 37% lived alone; and 16% had no caregiver. The most common diagnoses were congestive heart failure (25%), chronic pulmonary disease (28%), diabetes (28%) and cancer (30%). Within 3 months of home care discharge, 34 patients (32%) had one or more adverse outcomes: 5% died, 4% were readmitted to home care, 26% had an emergency room visit, and 15% were hospitalized. Patients with ! 1 ADL dependency were more likely to have an adverse outcome compared to those with no ADL dependency (42% vs. 17%, p = 0.007). In a multivariable model including patient age and sex, factors associated with adverse outcomes within 3 months of home care discharge were ! 1 ADL dependency (Adjusted Odds Ratio 3.9 [95% CI: 1.3, 11.5]) and a history of cancer (4.7 [1.7, 12.9] ). CONCLUSION: Home care patients are at substantial risk for adverse outcomes within 3 months of home care discharge. Those with functional dependence or cancer are at highest risk. Further research is necessary to determine whether additional home care services would prevent adverse outcomes in these high risk patients. To determine if Enhanced QTc Dispersion occurs in ischemia during pharmacologic stress testing. This may serve as a non-invasive method to detect ischemia in patients suspected of having CAD. BACKGROUND: QTdispersion (Qtd), defined as the interlead variability in QT intervals on a 12 lead surface electrocardiogram (EKG) reflects regional inhomogeneity of ventricular repolarisation. Increased QTd has been reported in patients with ischemic heart disease (IHD) during exercise and after myocardial infarction (MI). Pharmacological coronary vasodilatation is known to alter regional myocardial blood flow. However, the effect of redistribution of coronary blood flow during pharmacological coronary vasodilatation on myocardial function is unclear. We hypothesized that increased disparity of myocardial blood flow can lead to nonhomogenous regional ventricular repolarisation. METHODS: We examined the effect of pharmacologic coronary vasodilatation on QTd in 81 subjects who received dypiridamole during myocardial stress imaging study (imaging). Patients with history of MI in the past 2 weeks, electrolyte imbalance, cardiac arrhythmia, long QT syndrome, those on pro-arrhythmia agents were excluded. Routine EKGs were performed at rest (0 Mts) and peak stress ( 7 ± 9 Mts after dipyridamole infusion). All EKGs were interfaced to a personal computer equipped with a digitizing tablet consisting of a magnifier used to enhance the accuracy of measurements. QT intervals were measured in all 12 leads and corrected for heart rate (QTc) using Bazett's formula. Intra & interpersonal variations were minimized by repeated blinded measurements. Patients were divided into three groups based on clinical probability and the results of the myocardial perfusion scan. 25 subjects with high pre-test probability for IHD and high risk reversible defects on imaging (reversible group) were compared with 33 other subjects with low clinical probability and normal imaging study (``normal'' group). 12 patients with low risk fixed defects on imaging and variable probability (``fixed'' group) were also studied. Mean Qtcd values at rest and during pharmacologic stress testing were compared in each group. Statistical analysis was done using t test. Results are expressed in mean+ SD.