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OBJECTIVE: The aims of the study were to demonstrate a method for developing rehabilitation service areas and to compare service areas based on postacute care rehabilitation admissions to service areas based on acute care hospital admissions. DESIGN: We conducted a secondary analysis of 2013–2014 Medicare records for older patients in Texas (N = 469,172). Our analysis included admission records for inpatient rehabilitation facilities, skilled nursing facilities, long-term care hospitals, and home health agencies. We used Ward’s algorithm to cluster patient ZIP Code Tabulation Areas based on which facilities patients were admitted to for rehabilitation. For comparison, we set the number of rehabilitation clusters to 22 to allow for comparison to the 22 hospital referral regions in Texas. Two methods were used to evaluate rehabilitation service areas: intraclass correlation coefficient and variance in the number of rehabilitation beds across areas. RESULTS: Rehabilitation service areas had a higher intraclass correlation coefficient (0.081 vs. 0.076) and variance in beds (27.8 vs. 21.4). Our findings suggest that service areas based on rehabilitation admissions capture has more variation than those based on acute hospital admissions. CONCLUSIONS: This study suggests that the use of rehabilitation service areas would lead to more accurate assessments of rehabilitation geographic variations and their use in understanding rehabilitation outcomes.

Heart failure (HF) is one of the leading causes of hospitalization and readmissions. Our study aimed to examine racial disparities in heart failure patients including onset, mortality, length of stay (LOS), direct costs, and readmission rates. This is a secondary data analysis. We analyzed the risk-adjusted inpatient data of all patients admitted with HF to one health academic center. We compared five health outcomes among three racial groups (white, black, and Hispanic). There were 1006 adult patients making 1605 visits from 10/01/2011 to 09/30/2015. Most black patients were admitted in younger age than other racial groups which indicates the needs for more public health preventions. With risk adjustments, the racial differences in LOS and readmission rates remain. We stratified health outcomes by race/ethnic and type of HF. The findings suggest that further studies to uncover underlying causes of these disparities are necessary. Using risk-adjusted hospitalization data allows for comparisons of quality of care across three racial groups. The study suggests that more prevention and protection services are needed for African American patients with heart failure.

Objective To examine geographic and facility variation in cognitive and motor functional outcomes after postacute inpatient rehabilitation in patients with stroke. Design Retrospective cohort design using Centers for Medicare and Medicaid Services (CMS) claims files. Records from 1209 rehabilitation facilities in 298 hospital referral regions (HRRs) were examined. Patient records were analyzed using linear mixed models. Multilevel models were used to calculate the variation in outcomes attributable to facilities and geographic regions. Setting Inpatient rehabilitation units and facilities. Participants Patients (N=145,460) with stroke discharged from inpatient rehabilitation from 2006 through 2009. Intervention Not applicable. Main Outcome Measures Cognitive and motor functional status at discharge measured by items in the CMS Inpatient Rehabilitation Facility–Patient Assessment Instrument. Results Variation profiles indicated that 19.1% of rehabilitation facilities were significantly below the mean functional status rating (mean ± SD, 81.58±22.30), with 221 facilities (18.3%) above the mean. Total discharge functional status ratings varied by 3.57 points across regions. Across facilities, functional status values varied by 29.2 points, with a 9.1-point difference between the top and bottom deciles. Variation in discharge motor function attributable to HRR was reduced by 82% after controlling for cluster effects at the facility level. Conclusions Our findings suggest that variation in motor and cognitive function at discharge after postacute rehabilitation in patients with stroke is accounted for more by facility than geographic location.

Ethnic enclaves may be protective for health. This study investigates the effects of neighborhood co-ethnic density on problem drinking among older Mexican American men. Probability sample of 2,086 community-dwelling Mexican Americans aged 75 or older drawn in 2004–2005 residing in communities in Arizona, California, Colorado, New Mexico and Texas. Problem drinking was found among 15.3 % of men (n = 350). For each percent increase in neighborhood percent Mexican American, men had 2 % lower odds of problem drinking [odds ratio (OR) 0.98; P < 0.05]. U.S. born men had lower odds of problem drinking (OR 0.40; P < 0.05) compared with foreign born men, while English language use was associated with greater odds of problem drinking (OR 2.14; P < 0.05). Older Mexican American men in neighborhoods with low levels of co-ethnic density, the foreign born, and those with English language facility had an increased likelihood of problem drinking.

To examine and describe regional variation in outcomes for persons with stroke receiving inpatient medical rehabilitation.Retrospective cohort design.Inpatient rehabilitation units and facilities contributing to the Uniform Data System for Medical Rehabilitation from the United States.Patients (N=143,036) with stroke discharged from inpatient rehabilitation during 2006 and 2007.Not applicable.Community discharge, length of stay (LOS), and discharge functional status ratings (motor, cognitive) across 10 geographic service regions defined by the Centers for Medicare and Medicaid Services (CMS).Approximately 71% of the sample was discharged to the community. After adjusting for covariates, the percentage discharged to the community varied from 79.1% in the Southwest (CMS region 9) to 59.4% in the Northeast (CMS region 2). Adjusted LOS varied by 2.1 days, with CMS region 1 having the longest LOS at 18.3 days and CMS regions 5 and 9 having the shortest at 16.2 days.Rehabilitation outcomes for persons with stroke varied across CMS regions. Substantial variation in discharge destination and LOS remained after adjusting for demographic and clinical characteristics.

Substantial research shows that increased Hispanic neighborhood concentration is associated with several beneficial health outcomes including lower adult mortality, better self-rated health, and fewer respiratory problems. Literature on the relationship of Hispanic composition and depressive symptoms is more equivocal. In addition, few studies have directly investigated hypothesized mechanisms of this relationship. This study uses data from a probability sample of 1238 Mexican-descent adults living in 48 neighborhoods in Texas City, Texas. Multilevel regression models investigate whether Hispanic neighborhood composition is associated with fewer depressive symptoms. This study also investigates whether social support, perceived discrimination, and perceived stress mediate or moderate the relationship, and whether results differ by primary language used at home. We find that individuals living in high Hispanic composition neighborhoods experience fewer depressive symptoms than individuals in low Hispanic composition neighborhoods. In addition, we find that these beneficial effects only apply to respondents who speak English. Social support, perceived discrimination, and perceived stress mediate the Hispanic composition–depressive symptoms relationship. In addition, discrimination and stress moderate the relationship between Hispanic composition and depressive symptoms. Our findings support theories linking higher neighborhood Hispanic composition and better mental health, and suggest that Spanish language use, social support, discrimination and stress may play important roles in the Hispanic composition–depressive symptoms relationship.

Background. Hispanics diagnosed with cutaneous melanoma are more likely to present at advanced stages but the reasons for this are unknown. We identify census tracts at high risk for late stage melanoma diagnosis (LSMD) and examine the contextual predictors of LSMD in California, Texas, and Florida. Methods. We conducted a cross-sectional study using geocoded state cancer registry data. Using hierarchical multilevel logistic regression models we estimated ORs and 95% confidence intervals for the impact of socioeconomic, Hispanic ethnic concentration, index of dissimilarity, and health resource availability measures on LSMD. Results. We identified 12,493 cases. In California, late stage cases were significantly more likely to reside within census tracts composed mostly of Hispanics and immigrants. In Texas, LSMD was associated with residence in areas of socioeconomic deprivation and a higher proportion of immigrants. In Florida, living in areas of low education attainment, high levels of poverty, and a high percentage of Hispanic residents was significantly associated with LSMD. Residential segregation did not independently affect LSMD. Conclusion. The influence of contextual predictors on LSMD varied in magnitude and strength by state, highlighting both the cosegregation of social adversity and poverty and the complexity of their interactions.

Well-designed electronic health records (EHRs) must integrate a variety of accurate information to support efforts to improve quality of care, particularly equity-in-care initiatives. This case study provides insight into the challenges those initiatives may face in collecting accurate race, ethnicity, and language (REAL) information in the EHR. We present the experience of an academic medical center strengthening its EHR for better collection of REAL data with funding from the EHR Incentive Programs for meaningful use of health information technology and the Texas Medicaid 1115 Waiver program. We also present a plan to address some of the challenges that arose during the course of the project. Our experience at an academic medical center can provide guidance about the likely challenges similar institutions may expect when they implement new initiatives to collect REAL data, particularly challenges regarding scope, personnel, and other resource needs.

© 2014 Center for Migration Studies of New York. All rights reserved. One-fourth of deportees from the United States are parents of US-citizen children. We do not know how separation from families affects remigration among deportees, who face high penalties given unlawful reentry. We examined how family separation affects intent to remigrate among Salvadoran deportees. The majority of deportees with children in the United States were also separated from their spouse, and the vast majority had US-citizen children. Family separation was the single most important factor affecting intent to remigrate. We interpret these findings in light of immigration policy debates.

Objectives: To describe the growth of the Hispanic population in the Midwest states of the United States, to present disability levels in older Mexican and non-Mexican-origin Midwest Hispanics by place of birth and poverty status, and compare disability levels among older Midwest Hispanics with those among Southwest Hispanics as well as non-Hispanics Whites and African Americans in each region. Method: Population data come from decennial U.S. Census Bureau surveys. Disability data for adults ≥ 50 years old come from the 2008 American Community Survey. Results: The Hispanic population in the Midwest has tripled since 1980 and now constitutes 6.6% of the entire Midwest population. Older Midwest Hispanics are somewhat younger, have a higher male–female ratio, and are more likely to be born outside the continental United States than Southwest Hispanics. In the Midwest, foreign-born Mexican American men report the lowest disability levels. Foreign-born Hispanic women of non-Mexican origin report the highest disability levels. Overall, older Hispanics have intermediate disability levels relative to non-Hispanic Whites and African Americans. Midwest Hispanics report less disability than Southwest Hispanics. Discussion: There is substantial heterogeneity in late-life disability among Midwest Hispanics, which may be related to place of birth and of origin. Future research is needed to examine age at immigration and health selection as potential reasons for low disability levels among foreign-born Mexican American men.

Research indicates that neighborhood context can have a significant effect on the health of older adults. The evidence suggests that there may be physical health benefits afforded to Mexican Americans living in ethnically homogenous neighborhoods, despite the relatively high economic risk in such neighborhoods, but few studies have considered the effect of neighborhood ethnic density on mental health outcomes in older adults. This study evaluated the association between neighborhoods with a high proportion of Mexican Americans and depressive symptoms in very old Mexican Americans. Hierarchical linear modeling was used to examine data from Wave 5 (2004/05) of the Hispanic Established Populations for the Epidemiologic Study of the Elderly. Subjects included 1,875 community-dwelling Mexican Americans aged 75 and older living in 386 neighborhoods in five states in the southwestern United States (Arizona, California, Colorado, New Mexico, Texas). Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (α=0.88). Results showed that, in very old men, there was a significant negative association between percentage of Mexican Americans in the neighborhood and depressive symptoms (P=.01). In women, the direction of the association was the same, but the effect was not significant. These findings suggest that the proportion of Mexican Americans in the neighborhood matter more for very old Mexican American men than women. Further research may inform screening and treatment for depressive symptoms based on differences in neighborhood composition. Recommendations include culturally customized programs that offer older Mexican Americans greater mobility and access to programs and opportunities in culturally identifiable neighborhoods.

The objective of this study was to examine the total life expectancy (TLE), frailty-free life expectancy (FFLE), frailty life expectancy (FLE), pre-frailty life expectancy (PFLE), and frailty free-disability life expectancy. Data are from an 18-year prospective cohort study of 2438 non-institutionalized Mexican American aged 67 years and older from the Hispanic Established Population for the Epidemiological Study of the Elderly (1995/96–2004/05). Frailty was defined as meeting two or more of the following: unintentional weight loss of > 10 pounds, weakness, self-reported exhaustion, and slow walking speed. Total life expectancy and frailty-free life expectancy were estimated using the interpolation of Markov chain method. At baseline, 54.4% participants were non-frail, 32.8% were pre-frail, and 15.8% were frail. For men, the TLE at age 67 was 15.5 years, the FFLE was 6.5 years, the PFLE was 5.4 years, and the FLE was 3.6 years. For women, the TLE at age 67 was 17.5 years, the FFLE was 6.5 years, the PFLE was 6.5 years, and the FLE was 4.5 years. For men, frailty free-disability LE was 2.7 years and with disability was 1.1 years. For women, frailty free-disability LE was 2.5 years and with disability was 2.1 years. For men, pre-frailty free-disability LE was 5.1 years and with disability was 0.4 years. For women, pre-frailty free-disability LE was 6.0 years and with disability was 0.8 years. This study showed that at every age, women had fewer years in non-frailty state and more years of LE in pre-frail state, frail state, and with disability.

Objectives. We tested the data artifact hypothesis regarding the Hispanic mortality advantage by investigating whether and to what degree this advantage is explained by Hispanic origin misclassification on US death certificates. Methods. We used the National Longitudinal Mortality Study, which links Current Population Survey records to death certificates for 1979 through 1998, to estimate the sensitivity, specificity, and net ascertainment of Hispanic ethnicity on death certificates compared with survey classifications. Using national vital statistics mortality data, we estimated Hispanic age-specific and age-adjusted death rates, which were uncorrected and corrected for death certificate misclassification, and produced death rate ratios comparing the Hispanic with the non-Hispanic White population. Results. Hispanic origin reporting on death certificates in the United States is reasonably good. The net ascertainment of Hispanic origin is just 5% higher on survey records than on death certificates. Corrected age-adjusted death rates for Hispanics are lower than those for the non-Hispanic White population by close to 20%. Conclusions. The Hispanic mortality paradox is not explained by an incongruence between ethnic classification in vital registration and population data systems.

Assimilation and acculturation have long been recognized as important though complex correlates of change in health risk profiles of immigrants and the resulting ethnic populations(1,2). The standard model that dominates research on acrulruration and health suggests that new immigrant populations typicdlly have a set of risk profiles that are distinctive from those of the population of the host society in which they have settled. These differences may reflect a combination of influences, including the maintenance of culturally distinctive behaviours characteristic of the country of origin; the distinctive influences of the immigration experience itself, including disruption of personal networks and exposure to discrimination; and the correlation of the decision to migrate across national boundaries with distinctive personal characteristics. Time spent in the host society — measured in years, and sometimes generations, among the descendents of immigrants — tends to erode these differences. Social epidemiologists frequently turn to the variables of time and, where relevant, linguistic change — the adoption of the language of the destination society — as correlates of changes in social and behavioural risk profiles away from those characteristic of the immigrant group itself, and towards those characteristic of segments of the broader population of the country of destination(1,3–5). Recently, increased anention has been given in the social epidemiology literature to the influence of the social-spatial context of health. In particular, a growing literature investigates variation in local social environments with respect to variables such as quality of food supply, local modelling of healthy diets and personal habits, stressfulness of daily living and encouragement of physical activity(6-10). In the context of the social scientific study of immigrant incorporation, this emphasis is concordant with a well-documented relationship linking ethnic residential enclaves with the maintenance and intergenerational transmission of ethnic-specific cultures(11-13). Drawing on these broader social science research findings, epidemiologists have investigated the hypothesis that ethnic concentration of immigrant-derived populations in neighbourhoods is associated with the maintenance of group-specific social behavioural practices that influence health outcomes. The Mexican-American population of the USA provides a particularly noteworthy case for the investigation of the effects of residential concentration on health. Compared with non-Hispanic whites, Mexican-Americans have lower mortality rates from all causes, and from leading causes including CVD and cancers at most common sites(13-18). Mexican-American mortality rates are consistently reported to be lower for immigrants than they are for Mexican-Americans born in the USA13,15,17-19). That mortality rates are lower for a Mexican-American population that is on average socia-economically disadvantaged has been described as an epidemiological paradox(20,21). One of the leading hypotheses about the better than expected health and mortality outcomes for Mexican-Americans, as well as the apparently poorer outcomes for US-born Mexican-Americans compared with immigrants from Mexico, points to protective aspecrs of health-related behaviours among immigrants, including healthier diets, lower rates of smoking, substance and alcohol use, and higher rates of physical activity(13,16,21,22). Indeed, studies of acculturation have documented a relationship between acculturation and less healthy lifestyles in the Mexican origin population, although effects of acculturation are not entirely negative. Notably, both health-care access and use of screening improves with greater acculturation. A small but growing number of studies have examined the hypothesis that a high concentration of Mexican populations in residential communities is associated with better health outcomes. To date, results have been mixed. Some studies report evidence of lower mortality, lower chronic disease morbidity, better mental health and higher self-rated health(23-31). Others report weak, contradicrory or null results(13,32,33). In the present study we investigate the relationship between ethnic residential concentration of Mexican-Americans and dietary intake. Specifically, we investigate the hypothesis that there is a strong relationship between ethnic concentration, e.g. residence in a barrio community, and types of foods consumed. This hypothesis has a high degree of plausibility, because a high level of ethnic concentration in a local community creates a context for the supply of ethnic-specific food products and for the modelling of dietary practices. The Mexican-American population lives in very diverse residential settings, ranging from homogeneous ethnic environments in near-border areas in the south-west, to neighbourhoods throughout the USA where they are highly integrated with no n-Hispanics. Do dietary practices among Mexican-Americans in different neighbourhood settings differ in ways that suggest that integration with other groups leads to deterioration of dietary practices that help explain the increaSing rates of chronic disease prevalence among more acculturated Hispanics?

The Hispanic population in Texas has increased numerically faster than any other racial or ethnic group in the past 2 decades. If these trends continue, Texas is likely to become a Hispanic majority state by 2040. Despite this change in the ethnic composition of the state, few have researched the travel behaviors of Hispanics. Logistic regression models and the 2006 American Community Survey Public Use Microdata Sample for Texas were used to explore carpooling on the journey to work among Hispanics and Hispanic immigrants in comparison with non-Hispanic whites. Influences of socioeconomic, occupational, and geographic characteristics on the propensity to carpool on the journey to work were disaggregated to test if differences in carpooling use between Hispanics and non-Hispanic whites remain. Differences in carpool use based on immigrant status were investigated. It was found that differences in carpool use remain between Hispanic and non-Hispanic whites, even accounting for socioeconomic status, occupation, and location if immigrant status is not considered. However, in accounting for immigrant status, no differences were found in carpool use between native-born Hispanics and non-Hispanic whites, while differences remain for Hispanic immigrants. Findings suggest that in the absence of improvements in the socioeconomic status of native-born Hispanics and with increased immigration, carpooling is likely to increase as a result of changes in ethnic composition.

Since the mid-1990s the United States has enacted a series of laws that make it easier to deport noncitizens. Drawing on findings from interviews with a random sample of 300 Salvadoran deportees, we examine how family relations, ties, remittance behavior, and settlement experiences are disrupted by deportation, and how these ties influence future migration intentions. We find that a significant number of deportees were long-term settlers in the United States. Many had established work histories and had formed families of their own. These strong social ties in turn influence the likelihood of repeat migration to the United States.

Previous research on the relationship between diet and acculturation among Hispanics has produced inconsistent results. This study examined the association between diet, country of birth, and a language acculturation scale among Mexican-American women.The study used a cross-sectional design with data from the 2000 National Health Interview Survey and its Cancer Control Module. The module was administered to one adult per household and included 17 dietary intake questions.Subjects were 1,245 nonpregnant women of Mexican descent between 25 and 64 years of age residing in the United States who were interviewed in their homes.Least-squares regression with sampling weights and adjustment of standard errors for survey design effects was used to estimate the associations between country of birth, language acculturation, and percent energy from fat, intake of fiber, and intake of fruits and vegetables, with statistical control for age, education, and marital status.In multivariate models, US-born women consumed fewer grams of fiber per day (beta=-2.44; P0.01) and a larger percentage of energy from fat (beta=2.06; P0.01) than Mexican-born women. Greater English language use was associated with decreased consumption of fiber (P0.01), and a decline in fruit and vegetable intake with a greater decline for US-born (P0.10).Acculturation is associated with several unfavorable dietary changes. Women who were born in the United States are at greater risk of declining dietary quality compared to Mexican-born women, and US-born English-speaking women have more unfavorable dietary profiles. Research and public health education concerning dietary intake should consider both country of birth and language.

This study assessed contextual risks for polydrug use in a triethnic sample (non-Hispanic white, African American, Hispanic) of young women with a low income. For the current analysis, a total of 712 young women aged 18 to 31 years who sought care in state-funded family planning clinics in southeast Texas from December 2001 to May 2003 participated in the survey. The main outcome of the study was the number of illicit drugs (including marijuana, MDMA [ecstasy], crack cocaine, and other hard drugs) used in the last 12 months. Of the 712 subjects, 198 (28%) reported using illicit drugs in the past 12 months. Neighborhood socioeconomic status was significantly associated with drug use in a bivariate model. The proportion of women living in the most advantaged neighborhoods who reported drug use was more than twice that of women living in the most disadvantaged neighborhoods. However, the significance of neighborhood socioeconomic status was eliminated after controlling for ethnicity or for personal network characteristics in a multivariate ordinal logistic regression model. In contrast, in multivariate models, personal network indicators, such as a larger number of monthly contacts with friends (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.11, 1.56) and a larger number of friends who used illicit drugs (OR = 1.47, 95% CI = 1.33, 1.62) were associated with increased drug use. In addition, not being currently married (vs. being married) (OR = 2.73, 95% CI = 1.44, 5.16) was associated with a larger number of drugs used in the last 12 months. In conclusion, we found that neighborhood socioeconomic status was not directly associated with more drug use when controlling for ethnicity or for personal network characteristics. Personal networks may mediate the relationships between neighborhood and drug use. Strategies to reduce polydrug use should target personal networks where friends use illicit drugs.

This study tested the hypothesis that neighborhood deprivation will be associated with lower levels of serum carotenoids in comparison with wealthy residential areas.Cross-sectional, nationally representative survey data were used to assess the relationship between neighborhood level socioeconomic status and serum carotenoids.Seventeen thousand two participants aged 17 years and older from the Third National Health and Nutrition Examination Survey were linked with 1990 census data.Serum levels of lycopene, beta-carotene, alpha-carotene, lutein/zeaxanthin, and beta-cryptoxanthin.Multivariate linear regression was used to model the association of serum carotenoids and neighborhood deprivation, which is a summary index of 11 indicators for tract level socioeconomic status. Adjustments are made for individual level age, sex, years of education, household income, employment, race/ethnicity, body mass index, serum cotinine, alcohol use, physical activity, and serum cholesterol.Multivariate analysis revealed a negative and statistically significant association between high levels of neighborhood deprivation and beta-carotene (beta=-2.98 microg/dL [-0.06 micromol/L], P=0.00), alpha-carotene (beta=-1.28 microg/dL [-0.02 micromol/L], P=0.0001), lutein/zeaxanthin (-1.69 microg/dL [-0.03 micromol/L], P=0.00, beta-cryptoxanthin (beta=-1.34 microg/dL [-0.02 micromol/L], P0.0001), and total carotenoids (beta=-8.20 microg/dL, P=0.0001). Lycopene was not related to neighborhood deprivation. Adjusted mean levels of carotenoids for high deprivation neighborhoods were lower than neighborhoods with low deprivation: beta-carotene=8.72 microg/dL [0.16 micromol/L] vs 20.64 microg/dL [0.38 micromol/L], alpha-carotene=0.44 microg/dL [0.008 micromol/L] vs 5.56 microg/dL [0.10 micromol/L], lutein/zeaxanthin=13.79 microg/dL [0.24 micromol/L] vs 20.55 microg/dL [0.36 micromol/L], beta-cryptoxanthin=4.57 microg/dL [0.08 micromol/L] vs 9.93 microg/dL [0.18 micromol/L], lycopene=22.07 microg/dL [0.41 micromol/L] vs 25.63 microg/dL [0.48 micromol/L], and total=49.56 microg/dL vs 82.36 microg/dL.Neighborhood deprivation was associated with lower serum levels of carotenoids. There was a substantial disparity between low deprivation and high deprivation residential areas with respect to fruit and vegetable intake.

The current recommendation is that pancreatic resections be performed at hospitals doing10 pancreatic resections annually.To evaluate the extent of regionalization of pancreatic resection and the factors predicting resection at high-volume centers (10 cases/year) in Texas.Using the Texas Hospital Inpatient Discharge Public Use Data File, we evaluated trends in the percentage of patients undergoing pancreatic resection at high-volume centers (10 cases/year) from 1999 to 2004 and determined the factors that independently predicted resection at high-volume centers.A total of 3,189 pancreatic resections were performed in the state of Texas. The unadjusted in-hospital mortality was higher at low-volume centers (7.4%) compared to high-volume centers (3.0%). Patients resected at high-volume centers increased from 54.5% in 1999 to 63.3% in 2004 (P = 0.0004). This was the result of a decrease in resections performed at centers doing less than five resections/year (35.5% to 26.0%). In a multivariate analysis, patients who were75 (OR = 0.51), female (OR = 0.86), Hispanic (OR = 0.58), having emergent surgery (OR = 0.39), diagnosed with periampullary cancer (OR = 0.68), and living75 mi from a high-volume center (OR = 0.93 per 10-mi increase in distance, P0.05 for all OR) were less likely to be resected at high-volume centers. The odds of being resected at a high-volume center increased 6% per year.Whereas regionalization of pancreatic resection at high-volume centers in the state of Texas has improved slightly over time, 37% of patients continue to undergo pancreatic resection at low-volume centers, with more than 25% occurring at centers doing less than five per year. There are obvious demographic disparities in the regionalization of care, but additional unmeasured barriers need to be identified.

Objectives. We sought to determine whether mortality rates among immigrant and US-born Hispanic young adults were higher or lower compared with non-Hispanic Whites. We also sought to identify which causes of death accounted for the differences in mortality rates between groups. Measures. We used Texas and California vital registration data from 1999 to 2001 linked to 2000 census denominators. We calculated cause-specific, indirectly standardized rates and ratios and determined excess/deficit calculations comparing mortality rates among US- and foreign-born Hispanic men and women with rates among non-Hispanic White men and women. Results. Mortality rates were substantially lower among Hispanic immigrant men (standardized mortality ratio [SMR]=0.79) and women (SMR=0.59) than among non-Hispanic White men and women. Most social and behavioral and chronic disease causes in Texas and California other than homicide were noteworthy contributors to this pattern. Mortality rates among US-born Hispanics were similar to or exceeded those among non-Hispanic Whites (male SMR=1.17, female SMR=0.91). Conclusions. Mortality rates among younger Hispanic immigrants in Texas and California were lower than rates among non-Hispanic Whites. This pattern was not observed among US-born Hispanics, however.

The aim of this report is to present key findings from the Hispanic Established Populations for the Epidemiological Studies of the Elderly. This unique study began in 1993–1994 with 3050 Mexican–Americans aged 65 years or older who lived in California, Arizona, New Mexico, Colorado and Texas (USA). The subsequent four waves of data collection span 11 years and interviews will be conducted again in the Spring of 2007. Although this population has been observed to have lower than expected mortality rates, they continue to suffer from chronic health problems and disability to the same extent as other racial and ethnic groups. In addition, they are at higher risk for inappropriate medication use and inadequate health insurance coverage. The implications for clinical practice and future research are discussed.

We explore the association between racial composition of couples—that is, whether they are interracial or homogamous—and the psychological distress of their members, as measured in a screening scale for non-specific psychological distress. We use a pooled 1997–2001 National Health Interview Survey sample of the married and cohabiting population of the United States. We compare the odds of distress for interracial vs. same race married/cohabiting adults. There are several key findings. Interracial marriage is associated with increases in severe distress for Native American men, white women, and for Hispanic men and women married to non-white spouses, compared to endogamous members of the same groups. Higher rates of distress are observed for intermarried persons with African American or Native American husbands or wives, and for women with Hispanic husbands. Lower socioeconomic status explains approximately half of the increased distress experienced by white women, while higher socioeconomic status partially suppresses increases in distress for Hispanic men and women.

Objective. This article documents the patterns of white-nonwhite differences in nonspecific psychological distress and explores how acculturation characteristics, social class, marital status, and chronic illness mediate or moderate these differences for eight racial/ethnic populations in the United States. Methods. We analyze data from a five-year pool of the National Health Interview Survey (NHIS) collected between 1997 and 2001 (N=162,032) and employ multivariate regression techniques to explore level of psychological distress of various ethnic groups relative to non-Hispanic whites. Results. Nonwhite populations exhibit variable base-line differences in psychological distress compared to non-Hispanic whites; however, adjusted estimates show that African Americans and Mexicans have lower levels of distress while distress scores for “other Hispanics,” Asians, and Cubans exhibit statistically similar levels. The highest distress occurs for Puerto Ricans. Interaction models reveal chronic sources of stress (e.g., poverty, chronic illness, nonmarriage) are even more taxing on psychological health of high-risk groups or have weaker relationships to stress for other groups. Conclusions. This study reveals the need for capturing ethnic variation in studies of mental health. Social class, acculturation, marital status, and chronic illness cannot fully explain white-nonwhite differences in psychological distress.

BACKGROUND Hispanics in the United States have a 33% lower age-adjusted incidence of cancer and a 38% lower cancer mortality rate compared with non-Hispanic whites. This may be secondary to health behaviors that vary with residential and economic assimilation. The authors investigated whether cancer incidence among Hispanics increased with residential and economic assimilation into mainstream culture. METHODS Data from the Surveillance, Epidemiology, and End Results program (SEER) and the U.S. Census Bureau were used to compare cancer incidence rates and rate ratios as a function of percentage of Hispanics and income of Hispanics in a census tract. Type of cancer was identified with a site recode variable in the SEER data set. Cases with in situ prostate and cervical carcinoma were excluded. Hispanic ethnicity in SEER was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract, age at diagnosis, and stratification by gender. RESULTS The incidence of breast, colorectal, and lung carcinoma among Hispanics increased as the percentage of Hispanics in the census tract decreased and as tract Hispanic income increased. For example, there was a 39% reduction in breast carcinoma and a 38% reduction in male colorectal carcinoma when the Hispanic population in high-density Hispanic neighborhoods in the lowest income quartile was contrasted to Hispanics living in tracts with the lowest total percentage of Hispanics in the highest income quartile. CONCLUSIONS The lower cancer rates among Hispanics relative to non-Hispanic whites in the United States may dissipate as Hispanics become more assimilated into the mainstream society. Cancer 2005. © 2005 American Cancer Society.

PURPOSE: To determine whether neighborhood characteristics are associated with self-rated health in older Mexican Americans. METHODS: Epidemiologic data on 3050 older Mexican Americans residing in the southwestern United States during 1993 and 1994 were merged with 1990 US Census data. All subjects were matched to one of 210 census tracts (neighborhoods). Multilevel ordinal logit models were used to examine relationships between self-rated health and individual- and neighborhood-level variables. RESULTS: After adjusting for individual characteristics, older Mexican Americans were more likely to rate their health poorer if they lived in neighborhoods that were economically disadvantaged, less populated by other Hispanics, or located within 50 miles of the US-Mexico border. In addition, residence in a border community moderated the relationship between self-rated health and neighborhood economic disadvantage. The effect of neighborhood economic disadvantage on poorer self-rated health was two to three times stronger for subjects living near the border region than subjects living further away from the border. CONCLUSIONS: This study demonstrates the importance of considering several dimensions of neighborhood context, especially for Mexican Americans. Residence in a border community and neighborhood economic disadvantage were important predictors of poorer self-rated health status. In addition, older Mexican Americans experience a health benefit from living in neighborhoods populated with other Hispanics.

Background Recent reports show substantial geographic variation in postacute health care spending. Little is known about variation in functional outcomes after postacute rehabilitation for patients with hip fracture. We examined variation in mobility and self-care after hip fracture rehabilitation across inpatient rehabilitation facilities (IRFs), hospital referral regions (HRRs) and states. Methods Retrospective cohort study using data from the Centers for Medicare and Medicaid Services (CMS) from 2006 to 2009. Study sample included 149,258 records from patients 66 years and older at 1,166 IRFs located within 292 HRRs and across 50 states. Hip fracture cases were defined by CMS impairment group codes (08.11, 08.12). Hierarchical generalized linear models were used to assess discharge mobility and self-care functional status, adjusting for individual patient characteristics and the random effect of IRFs, HRRs, and states. Results Variation in discharge mobility status as assessed by the intraclass correlation percentage (ICC%) was 8.8% across IRFs, 4.0% across HRRs, and 1.8% across states. For self-care, the ICCs were 10.2% across IRFs, 4.8% across HRRs, and 2.4% across states. The range of discharge mobility scores (maximum functional status rating to minimum functional status rating) showed a 9.6-point difference for IRFs, 6.5 for regions, and 2.6 for states. Range of discharge self-care scores were 13.1 for IRFs, 6.8 for HRRs, and 3.4 for states. Conclusion Variation in functional status following postacute hip fracture rehabilitation appears to occur primarily at the level of facilities rather than geographic location.

Objective: In a test of the relationships between sexual touching before puberty and later incarcerations during adolescence and adulthood, two theoretical models were examined. These models focus on examination of crime from the developmental origins of criminals and the adaptive and maladaptive outcomes of early experiences. Method: Data were taken from the National Health and Social Life Survey to study the sexual touching and social origin variables in childhood and incarceration variable during teen years. The sample was a stratified, random sample of 3,362 adults (18 to 59 years of age) throughout the United States. Results: Data support inferences from the two interrelated models. Respondents reporting touching before puberty were significantly more likely to experience incarceration. They were also more likely to engage in behaviors as teenagers that were associated with an increased probability of jailing. Such behaviors include sexual promiscuity and early departure from the parental family. Conclusions: These findings are consistent for first jailing as a teenager and as an adult, as well as for those with short (less than a week) or longer (a week or more) spells of incarceration. Prepubertal sexual touching has a significant and enduring effect on later adolescent and adult incarcerations.

A partir d'une enquete realisee en 1987 (Survey of American Indians and Alaska Natives), les AA. tentent de mettre en evidence les caracteristiques individuelles, ainsi que les contextes sociaux de residence, des Amerindiens qui participent aux powwows. S'interrogeant sur l'importance et le role des powwows pour l'affirmation de l'identite amerindienne contemporaine, ils evaluent les motivations et les facteurs de mobilisation des differents groupes socioculturels amerindiens a partir de deux modeles explicatifs : 1. le modele conventionnel de l'assimilation ; 2. le modele de la consommation ethnique, ou de l'expression de l'identite ethnique par l'acquisition d'objets et par la participation a des experiences qui symbolisent le sentiment d'appartenance de l'individu a un groupe ethnique.

Debates about United States border control policies have generally ignored the human costs of undocumented migration. We focus attention on these costs by estimating the number, causes and location of migrant deaths at the southwest border of the United States between 1993 and 1997. We document more than 1,600 possible migrant fatalities along the border in this period. More than 1,000 of these deaths were reported by United States data sources, and the remainder were Rio Grande drowning deaths reported by Mexican sources. Additional deaths may go unrecorded because the bodies of the decedents do not come to the attention of government officials. Deaths from hyperthermia, hypothermia and dehydration increased sharply from 1993 to 1997 as intensified border enforcement redirected undocumented migration flows from urban crossing points to more remote crossing areas where the migrants are exposed to a greater risk of death.

ObjectiveStudies have shown that there is sufficient availability of mammography; however, little is known about geographic variation in capacity. The purpose of this study was to determine the locations and extent of over/undersupply of mammography in 14 southern states from 2002 to 2008. Data SourcesMammography facility data were collected from the U.S. Food and Drug Administration (FDA). Population estimates, used to estimate the potential demand for mammography, were obtained from GeoLytics Inc. Study DesignUsing the two-step floating catchment area method, we calculated spatial accessibility at the block group level and categorized the resulting index to represent the extent of under/oversupply relative to the potential demand. Principal FindingsResults show decreasing availability of mammography over time. The extent of over/undersupply varied significantly across the South. Reductions in capacity occurred primarily in areas with an oversupply of machines, resulting in a 68 percent decrease in the percent of women living in excess capacity areas from 2002 to 2008. The percent of women living in poor capacity areas rose by 10 percent from 2002 to 2008. ConclusionsOur study found decreasing mammography availability and capacity over time, with substantial variation across states. This information can assist providers and policy makers in their business planning and resource allocation decisions.

BACKGROUND/STUDY CONTEXT: Physical performance measures have been found to be strong predictors of adverse outcomes in aging populations. Few studies have examined the predictive ability of physical performance measures exclusively within populations of the very old. This study explores the predictive ability of the Short Physical Performance Battery (SPPB) and its three subcomponents-a timed walk, balance test, and repeated timed chair stands-on mortality in a sample of Mexican Americans aged 75 and older.Logistic regression analyses were used with data from the Hispanic Established Population for the Epidemiological Study of the Elderly (Hispanic EPESE), to investigate the relationship between timed walk, balance test, repeated timed chair stands, and the SPPB and mortality over a 2½-year period.The authors find that being unable to complete the timed walk, the balance test, and repeated timed chair stands, or unable to complete any of the SPPB was significantly associated with mortality over 2½ years.These findings indicate that physical performance measures may be less predictive of short-term mortality in very old Mexican Americans than previously thought. More research is needed to understand this relationship.

This review examines research about current levels and recent changes in ethnic and racial stratification in the United States. Research about ethnic inequality emphasizes that economic stagnation and restructuring are troubling impediments to progress toward equality, and it shows evidence that employers may still use racial and ethnic queues in hiring. A number of issues arise with respect to the incorporation of the new waves of immigrants who have arrived since immigration law reform in 1965. We discuss patterns of adaptation of new immigrants, including available evidence on the ethnic enclave economy and substitution in the labor market of immigrants for native minorities. We summarize new theories and hypotheses about the fate of the children of recent immigrants, and we point to topics in this area needing further research.

The American Indian and Alaskan Native population has grown rapidly since 1950 because of changes in the racial classification of persons with mixed Indian and non‐Indian descent. These changes have challenged once common expectations that the Indian population was likely to shrink over time through assimilation. However, in regions of the United States where the recent growth of the Indian population has been particularly sharp most married Indians are married to non‐Indians. Fertility rates of women who are part of intermarried couples are lower than fertility rates for Indian women in racially endogamous marriages. The majority of the children of intermarried Indians in high intermarriage regions are labelled with the race of the non‐Indian parent. Intermarriage is likely to substantially reduce the long‐run impact of changes in identification on the future growth of the Indian population. At the same time, in a few states the American Indian population remains ethnically homogenous and shows ...

This study projects the number of nonelderly people who could gain coverage under the Patient Protection and Affordable Care Act (PPACA) for the period from 2014 through 2020 in the 13-county Houston-Galveston area region. The major PPACA provisions aimed at expanding coverage as well as the populations targeted by those provisions are described. Projections of the impact of PPACA on coverage in the area are based on estimates of growth in the size of targeted populations in each county and the anticipated responses of those populations to the major provisions of PPACA. The projections indicate that, if fully implemented, PPACA could cut the uninsurance rate in the region by half, from 26% in 2010 to 13% in 2020. This change translates into health insurance coverage for approximately 2 million additional people, from the current 4.2 million to a projected 5.9 million. The number of Medicaid enrollees could increase by an estimated 600,000 (a 79% increase), although private insurance coverage, which could increase by as much as 1 million enrollees (a 30% increase), will remain the primary source of coverage for most people. Coverage gains from PPACA will vary considerably by county, depending on the age-income-citizenship characteristics of the population, current uninsurance rates, and the rate of population growth.

This chapter provides an update to our earlier review on the Hispanic paradox in adult mortality (Markides and Eschbach 2005). We focus primarily on manuscripts published beginning in 2005. As in our earlier review, we concentrate on mortality at adult and older ages. When relevant, however, we will draw on recent literature examining other outcomes, such as disability, health behaviors, medical conditions, and mental health.

OBJECTIVES: Stroke mortality rates are reported to be lower for Hispanics than non-Hispanic Whites. We investigate the degree to which this lower reported mortality is explained by inaccuracies introduced through omission of nativity, imprecise measurement of cause of death, and under-ascertainment of Hispanic ethnicity on death certificates. We used national vital registration data for the years 1989-1991 and 1999-2002, including foreign- and US-born Hispanics and non-Hispanic Whites. Hispanic deaths were adjusted for misclassification of ethnicity on the death certificate. Denominators for the rates were derived from census estimates. RESULTS: Adjustment for nativity and death certificate misclassification removes the stroke mortality advantage for US-born Hispanic men, but not women. After adjustment, US-born Hispanic men and women have higher rates of mortality from subarachnoid hemorrhage than non-Hispanic Whites (RR: 1.23 and 1.23, respectively), but lower rates of mortality from Ischemic (RR: 0.76 and 0.73, respectively) and chronic effects of stroke (RR: 0.87 and 0.73, respectively). CONCLUSIONS: When adjusted for misclassification the lower stroke mortality remains for Hispanic men and women at older ages. Part of the previously reported advantage is a combination of imprecise measurement and data quality.

Objectives. We investigated ethnic differences in allostatic load in a population-based sample of adults living in Texas City, TX, and assessed the effects of nativity and acculturation status on allostatic load among people of Mexican origin. Methods. We used logistic regression models to examine ethnic variations in allostatic load scores among non-Hispanic Whites, non-Hispanic Blacks, and people of Mexican origin. We also examined associations between measures of acculturation and allostatic load scores among people of Mexican origin only. Results. Foreign-born Mexicans were the least likely group to score in the higher allostatic load categories. Among individuals of Mexican origin, US-born Mexican Americans had higher allostatic load scores than foreign-born Mexicans, and acculturation measures did not account for the difference. Conclusions. Our findings expand on recent research from the National Health and Nutrition Examination Survey with respect to ethnicity and allostatic load. Our results are consistent with the healthy immigrant hypothesis (i.e., newer immigrants are healthier) and the acculturation hypothesis, according to which the longer Mexican immigrants reside in the United States, the greater their likelihood of potentially losing culture-related health-protective effects.