Diana Tisnado

Several studies in the 1980s suggested that mortality rates for patients hospitalized with the acquired immunodeficiency syndrome (AIDS) were lower in hospitals that cared for greater numbers of AIDS patients. We sought to determine whether this observation persisted in the mid-1990s in California. We performed an analysis of hospital discharge data for 7,901 adults discharged with human immunodeficiency virus (HIV) or AIDS-related diagnoses from all acute care hospitals (n = 333) in California during 1994. The main outcome measure was in-hospital mortality, adjusted for severity of illness, comorbidity, prior hospitalizations, and other patient and hospital characteristics. Among 7,901 persons hospitalized with AIDS, the unadjusted inpatient mortality was 9.0%. The adjusted mortality rate varied significantly (P <0.0001) from 12.4% among institutions with the lowest quartile of AIDS experience to 10.3%, 6.3%, and 7.6% by quartile of greater AIDS experience. Increasing severity of illness, comorbidity, and previous hospitalizations were also significant predictors of increased mortality. Sex, race, and insurance status were not associated with hospital mortality. Hospital mortality for AIDS patients was greater among less experienced hospitals. The difference in mortality rate was equivalent to more than four additional deaths per 100 patients with AIDS admitted to the least experienced hospitals. This finding was not explained by severity of illness, comorbidity, or other case-mix variables.

Introduction: Tongan-Americans face severe disparities in health including diabetes, cardiovascular disease, and cancer. Educational disparities also affect health opportunities and well-being, influencing health status and community capacity to address disparities. Few resources have been identified within the Tongan-American community to address these concerns. The Tongan American Health Professionals Association (TAHPA) was conceived to identify and develop health and health career resources for the Tongan community. Through TAHPA, the Tongan-American community is utilizing a communityempowerment approach to address disparities and well-being. Methods: TAHPA was formed in 2008 through the leadership of individuals with a vision of a healthier Tongan-American community. TAHPA's purpose was to inspire and empower the Tongan-American community by developing an organization of Tongan-American health care professionals and pre-professionals, celebrating their accomplishments, and ...

Objective: We describe the development of a community and academic research partnership, share reflections on processes for collaborations, and identify key factors for establishing strong and effective relationships to foster high-quality research. Background: A community-based participatory research (CBPR) effort evaluating a community-based patient navigation program assisting Chamorro women to access breast cancer services in Southern California served as the foundation for the development of the community-academic partnership. Methods: Using a CBPR approach focusing on active involvement of community members, organizational representatives, and academic researchers in all aspects of research process, faculty from a research university and a local community-based organization were brought together to build a partnership. Community and academic partners engaged in a series of meetings where dialogue focused on developing and nurturing trust and shared values, respect for communit...

ObjectivesCancer “survivorship” is a distinct and important aspect of the cancer experience. More research is needed about survivorship care in underserved populations such as Latinas. This study examined issues of breast cancer survivorship care among Latinas to understand their experiences and needs, to inform the design of future programs.Design and SampleSix English‐ and six Spanish‐language focus groups were conducted, with a nonprobability sample. About 74 Latinas who varied in terms of characteristics including stage, time since diagnosis, and English proficiency were recruited through support groups, health fairs, and promotoras.MeasuresA semi‐structured question guide was used to examine experiences with follow‐up care, barriers, and meaning associated with breast cancer survivorship.ResultsResults indicate numerous gaps and unmet needs in Latinas' survivorship care experiences, including problems with finances, continuity of care, unmet needs for information, and sympt...

218 Background: Although known to provide more efficient end-of-life cancer care, the quality of VA’s end of life cancer care is unknown. We used Cancer Quality ASSIST to evaluate supportive care comprehensively in a national sample. Methods: We measured ASSIST QIs addressing symptoms, communication, treatment toxicities, and complications among 719 Veterans with a 2008 registry diagnosis of stage IV colorectal (37%), pancreatic (30%), or lung cancer (33%). We abstracted records from diagnosis for 3 years or until death among eligible Veterans (lived >= 30 days following diagnosis with >= 1 VA hospitalization or >=2 VA outpatient visits). We determined patient-level overall and individual QI scores (%delivered/appropriate care) and confirmed reliability on a 5% sample, retaining 39 of 42 QIs. Results: Most Veterans were older (mean 66 years) male (97%), and white (68%) with 20% African American, and 3% Hispanic. 85% had >=1 hospitalization and 93% died. Overall, subjects...

Samoans experience among the worst five-year breast cancer survival rates in the U.S., largely due to late stage diagnosis. There is great potential for screening interventions to reduce cancer mortality among Samoans. This paper examines the effectiveness of a culturally and linguistically tailored breast cancer education workshop for Samoan and other Pacific Islander women in Southern California. Educational workshops were conducted in churches, homes, and the Samoan National Nurses Association office to Pacific Islander women. Effectiveness was assessed using pre- and post-tests. Self-administered questionnaires queried participants about demographics, access, personal or family breast cancer history, screening knowledge and behaviors, and plans to obtain screening (n=495). Participants were predominantly Samoan, with 57% reporting they were ≥40 years of age. At pre-test, half of the participants did not know how to perform Breast Self Examination (BSE), 40% never had a Clinical ...

Patient-reported data may provide valuable information for oncology quality measurement. We evaluated applying patient-reported data from the Cancer Care Outcomes Research and Surveillance Consortium national study to quality indicators addressing supportive oncology domains. We analyzed surveys including validated instruments for symptoms and care planning from 4,174 patients newly diagnosed with lung or colorectal cancer. We adapted existing supportive oncology indicators for use with patient-reported data from Cancer Quality-ASSIST and the American Society of Clinical Oncology Quality Oncology Practice Initiative. Where feasible, we examined indicators using medical record data for comparison purposes. Using patient-reported data, the percentage of patients meeting indicator criteria for screening ranged from 74% (significant depressive symptoms) to 93% (pain, nausea/vomiting). The percentage meeting indicator criteria for symptom treatment ranged from 73% (significant depressive...

Stage at diagnosis and survival for breast cancer varies significantly with patients’ race/ethnicity, raising concerns that delayed diagnosis and variations in treatment may contribute to poorer outcomes for vulnerable populations. – 9] In addition, studies have documented disparities in the treatment and outcomes of non-White patients with breast cancer. – 7,10] In contrast, in this issue of Cancer Investigation, Issel et al. (see pp. 497–504) report that women with breast cancer in Hawaii received the same treatment regardless of their race/ ethnicity. A number of mechanisms have been hypothesized for the observed disparities by the race/ethnicity in processes and outcomes of care. Most acknowledge that race/ethnicity are largely social constructs that are associated with differential social and economic position in society as well as other characteristics such as culture and language resulting in certain groups facing financial and nonfinancial barriers to access to care. Financial barriers include health insurance coverage and the means to pay for out-of-pocket expenses. Nonfinancial barriers include patient characteristics such as education, health literacy, patient preferences and cultural beliefs, limited English proficiency, and social status or stigma; characteristics of the health services delivery system such as distance from facilities; and problems with patientprovider interactions such as cultural barriers, differences in communication and decision-making style, and unconscious or overt racism. Hawaii provides a fascinating laboratory for examining racial and ethnic disparities and the role of barriers to access. Hawaii is unique in the United States because it has almost universal health insurance coverage for all of its residents. In contrast to the mainland, where currently 16 percent are uninsured, during the years in which Issel’s study took place, 96 percent of Hawaiians had health insurance coverage due to the near-universal health insurance system that has been in place for 30 years. In addition, Hawaii, with its majority of ‘‘minority’’ groups (according to 2000 population estimates, 24 percent of the population of Hawaii is Caucasian), is well versed in the issues of multiculturalism. Women who do not have insurance are diagnosed at a later stage, are less likely to receive appropriate treatment, and are more likely to die of their disease than women who have health care coverage. Access to mammography appears to account for much, if not all, of the variation in stage at diagnosis of breast cancer attributable to race. Women who receive their medical care through the Department of Defense, and, therefore, have to access care, demonstrate no difference in stage between Caucasian, African American, and Hispanic women diagnosed with breast cancer. Taken in the context of these studies, the findings reported by Issel et al. suggest that much of variation in treatment and outcomes across women of different race/ethnicity that has been reported in prior studies is likely to be explained by some patients’ limited access to the health care system because of being uninsured or underinsured. However, not all problems in the quality of cancer care can be explained by financial barriers to care. Disparities in breast cancer screening rates and survival have been noted among certain Asian and Pacific Islander groups to be influenced by lack of knowledge, gender roles, feelings about family obligations, fatalism, and distrust of Western medicine. Hawaii’s health insurance system has been in place since 1974, yet diagnosis at a more advanced stage and Dr. Malin is supported by a CI-10 Damon Runyon-Lilly Clinical Investigator Award from the Damon Runyon Cancer Research Foundation. Address correspondence to Jennifer L. Malin, M.D., Ph.D., UCLA Division of General Internal Medicine-Health Services Research, 911 Broxton Ave., Los Angeles, CA 90095-1736, USA; Fax: (310) 7940732; E-mail: jmalin@mednet.ucla.edu