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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.

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.

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.

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?

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.

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.

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.

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.

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.

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.

Mexican American men living in the United States who are more acculturated exhibit higher rates of cancer compared to those less acculturated. This study explored the association between acculturation and serum levels of nutrients thought to be involved with cancer prevention among Mexican American men.Our sample included 2,479 Mexican American men from the Third National Health and Nutrition Examination Survey (1988-1994). Outcomes were serum levels of micronutrients. Acculturation in Mexican American men was assessed by a combined measure including country of origin, language of interview, and years of residence in the United States and was categorized as follows: (1) foreign-born, 0-5 years in the United States (lowest acculturation), (2) foreign-born, 6-15 years in the United States, (3) foreign-born,15 years in the United States, (4) US-born Spanish-speaking, and (5) US-born English-speaking (highest acculturation).Adjusted analyses showed that acculturation decreased the serum levels for vitamin E, vitamin C, and folate and also for some carotenoids (alpha and beta carotenes, beta cryptoxanthin, and lutein-zeaxanthin). By contrast, acculturation increased the serum levels for selenium and lycopene.With the exception of selenium and lycopene, acculturation among Mexican American men decreased the serum levels for most carotenoids and for vitamin E, vitamin C, and folate. These changes in nutrient profiles, reflecting altered patterns in food consumption or other behaviors, may explain in part why Mexican American men who are more acculturated have an increased risk for diet-related cancer

Nguyen-Oghalai TU, Ottenbacher KJ, Kuo Y-F, Wu H, Grecula M, Eschbach K, Goodwin JS. Disparities in utilization of outpatient rehabilitative care following hip fracture hospitalization with respect to race and ethnicity. Objective To compare the prevalence of discharge home to self-care after hip fracture hospitalization among the elderly in 3 racial groups: whites, Hispanics, and blacks. Design Secondary data analysis. Setting US hospitals. Participants Patients (N=34,203) aged 65 and older with Medicare insurance discharged after hip fracture hospitalization between 2001 and 2005. Interventions Not applicable. Main Outcome Measure Discharge home to self-care. Results Bivariate analyses showed higher rates of discharge home to self-care among minorities, 16.4% for Hispanics, 8.7% for blacks, and 5.9% for whites. Hispanics had 3-fold higher odds of being discharged home to self-care, and blacks had about 50% higher odds of being discharged home to self-care after adjusting for age, sex, Klabunde's comorbidity index, income, year of admission, type of hip fracture, surgical stabilization procedure, and length of hospital stay. Conclusions The higher rate of discharge home to self-care among minorities underscores the risk of suboptimal outpatient rehabilitative care among minorities with hip fracture.

Substantial ethnic differences have been reported in the probability that death will occur in a hospital setting rather than at home, in a hospice, or in a nursing home. To date, no study has investigated the role of both individual characteristics and contextual characteristics, including local health care environments, to explain ethnic differentials in end-of-life care.: The study purpose is to examine ethnic differences in the association between death as a hospital in-patient and individual and contextual characteristics, as well as medical resource supply.: This study employed a secondary data analysis.: We used data from the California Death Statistical Master file for the years 1999-2001, which included 472,382 complete cases. These data were geocoded and linked to data from the US Census Bureau and the American Hospital Association.: Death as an in-patient was most common for Asian (54%) and Hispanic immigrants (49%) and least common for non-Hispanic whites (36%) and US-born Asians (41%). Medical resource supply variables are of considerable importance in accounting for ethnic differentials in the probability of dying in a hospital. Residual differences in in-hospital site of death were largest for immigrant populations.: There are sizeable ethnic differentials in the probability that a death will occur in a hospital in California. These differences are substantially mediated by sociodemographic characteristics of the decedent and local medical care supply. One implication of these findings is that variation exists in the efficiency and quality of end of life care delivered to ethnic minorities.

Background: We have previously reported that cancer incidence for lung, female breast, and colon and rectum for Hispanics decreases with increasing percentage of Hispanics at the census tract. In contrast, cervical cancer incidence increases with increasing percentage of Hispanics at the census tract. Methods: In this study, we investigate the hypothesis that Hispanics living in census tracts with high percentages of Hispanics are diagnosed with more advanced cancer, with respect to tumor size and stage of diagnosis. Data from the Surveillance, Epidemiology, and End Results registry and the U.S. Census Bureau were used to estimate the odds of diagnosis at a “late” stage (II, III, IV) versus “early” stage (I) and breast cancer tumor size among Hispanics as a function of census tract percent Hispanic. Hispanic ethnicity in the Surveillance, Epidemiology, and End Results registry was identified by medical record review and Hispanic surname lists. The study also used income of Hispanics living in the census tract and controlled for age at diagnosis and gender. Results: We found that Hispanics living in neighborhoods with higher density of Hispanic populations were more likely to be diagnosed with late-stage breast, cervical, or colorectal cancer, and to have a larger tumor size of breast cancer. Conclusions: Our findings suggest that the benefits of lower cancer incidence in high tract percent Hispanics are partially offset by poorer access and reduced use of screening in conjunction with lower income, poorer health insurance coverage, and language barriers typical of these communities. (Cancer Epidemiol Biomarkers Prev 2008;17(11):2931–6)

Background The association between obesity and mortality is reduced or eliminated in older subjects. In addition to mortality, disability is an important health outcome. The objectives of this study were to examine the association between body mass index (BMI), calculated as weight in kilograms divided by height in meters squared, and subsequent disability and mortality among older Americans, as well as to estimate the effect of BMI on life expectancy and disability-free life expectancy among older Americans. Methods We studied 8359 non-Hispanic white Americans, 1931 African Americans, and 2435 Mexican Americans 65 years or older who were not disabled at baseline from 5 sites of the Established Populations for Epidemiologic Studies of the Elderly. Measures included BMI, medical conditions, activities of daily living, and demographic information. Cox proportional hazards regression analysis was used to estimate the hazard ratios (HRs) for subsequent disability and mortality during 7 years of follow-up. Total life expectancy and disability-free life expectancy were estimated using the interpolation of Markov chain approach. Results The lowest HR (1.02; 95% confidence interval [CI], 0.94-1.10) for disability was at a BMI of 25 to less than 30. Subjects with BMIs of lower than 18.5 or 30 or higher at baseline were significantly more likely to experience disability during the follow-up period. In contrast, the lowest HRs for mortality were seen among subjects with BMIs of 25 to less than 30 (HR, 0.78; 95% CI, 0.72-0.85) and 30 to less than 35 (HR, 0.80; 95% CI, 0.72-0.90), with subjects with BMIs of lower than 25 or 35 or higher experiencing higher hazards for mortality. Disability-free life expectancy is greatest among subjects with a BMI of 25 to less than 30. Conclusion Assessments of the effect of obesity on the health of older Americans should account for mortality and incidence of disability.

Objectives. We determined the size and correlates of underascertainment of Hispanic ethnicity on California death certificates. Methods. We used 1999 to 2000 vital registration data. We compared Hispanic ethnicity reported on the death certificate to Hispanic ethnicity derived from birthplace for the foreign-born and an algorithm that used first and last name and percentage of Hispanics in the county of residence for the US-born. We validated death certificate nativity by comparing data with that in linked Social Security Administration records. Results. Ethnicity and birthplace information was concordant for foreign-born Hispanics, who have mortality rates that are 25% to 30% lower than those of non-Hispanic Whites. Death certificates likely underascertain deaths of US-born Hispanics, particularly at older ages, for persons with more education, and in census tracts with lower percentages of Hispanics. Conservative correction for under-ascertainment eliminates the Hispanic mortality advantage for US-born men. Conclusions. Hispanic ethnicity is accurately ascertained on the California death certificate for immigrants. Immigrant Hispanics have lower age-adjusted mortality rates than do non-Hispanic Whites. For US-born Hispanics, the mortality advantage compared with non-Hispanic Whites is smaller and may be explained by underreporting of Hispanic ethnicity on the death certificate.

Objectives. We examined whether Mexican Americans living in high-density Mexican American neighborhoods experience increased morbidity and mortality compared with the rates observed among Mexican Americans living in low-density areas. Methods. We conducted a prospective analysis of a cohort of 3050 Mexican Americans aged 65 years or older. We examined prevalence of 6 medical conditions and survival over 7 years of follow-up in relation to percentage of Mexican Americans in the census tract. Results. With adjustment for covariates, odds for disease prevalence among older Mexican Americans as a function of percentage of Mexican Americans in the census tract were 0.33 (95% confidence interval [CI]=0.16, 0.71) for stroke, 0.28 (95% CI= 0.11, 0.70) for cancer, and 0.31 (95% CI=0.10, 0.98) for hip fracture. The hazard ratio for all-cause mortality over 7 years’ follow-up was 0.64 (95% CI=0.42, 0.96). Conclusions. Sociocultural advantages conferred on Mexican Americans by living in high-density Mexican American neighborhoods outweigh the disadvantages conferred by the high poverty of those neighborhoods.

The authors evaluated underascertainment bias in Hispanic mortality rates from population surveys linked to the US National Death Index (NDI). They compared vital status through 7 years ascertained from an NDI search and from active follow-up for 2,886 Mexican-American subjects, aged >/=65 years at baseline in 1993-1994, from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE). Estimates of NDI underascertainment were applied to mortality rate ratios for 66,667 older Mexican Americans and non-Hispanic Whites from the 1986-1994 National Health Interview Surveys linked to the NDI. The NDI and active follow-up agreed on vital status for 91.2% of Hispanic EPESE subjects. The NDI did not identify 177 deaths (20.7%) reported by proxies. Underascertainment was greater for women and when stratified by age and nativity. The ratios of proxy-reported to NDI mortality rates were 1.31 (95% confidence interval (CI): 1.06, 1.62) for immigrant men and 1.65 (95% CI: 1.32, 2.08) for immigrant women. Before adjustment, National Health Interview Surveys-NDI age-standardized mortality rate ratios comparing Mexican Americans with non-Hispanic Whites were 0.77 (95% CI: 0.65, 0.92) for men and 0.92 (95% CI: 0.77, 1.09) for women but were 0.84 and 1.18, respectively, with adjustment for underascertainment. Findings suggest that NDI-based Hispanic mortality rates may be understated.

Research suggests that economically disadvantaged neighbourhoods confer an increased risk of depression to their residents. Little research has been reported about the association between ethnic group concentration and depression. This study investigated the association between neighbourhood poverty and neighbourhood percentage Mexican American and depressive symptoms for older Mexican Americans in the south western United States.A population based study of older non-institutionalised Mexican Americans from the baseline assessment (1993/94) of the Hispanic established population for the epidemiologic study of the elderly (H-EPESE) merged with 1990 census data.Five south western states in the United States.3050 Mexican Americans aged 65 years or older.There was a strong correlation between the percentage of neighbourhood residents living in poverty and the percentage who were Mexican American (r = 0.62; p0.001). Percentage neighbourhood poverty and percentage Mexican American had significant and opposite effects on level of depressive symptoms among older Mexican Americans. After adjusting for demographic and other individual level factors, each 10% increase in neighbourhood population in poverty was associated with a 0.763 (95% CI 0.06 to 1.47) increase in CES-D score, while each 10% increase in Mexican American neighbourhood population was associated with a -0.548 (95% CI -0.96 to -0.13) unit decrease in CES-D score among older Mexican Americans residing in their neighbourhoods.The findings suggest a sociocultural advantage conferred by high density Mexican American neighbourhoods, and suggest the need to include community level factors along with individual level factors in community based epidemiological health studies.

The census-enumerated American Indian population dispersed rapidly between 1930 and 1990. Changes in ethnic classification account for most of the change. In the 1980 count, 10 states with historically large Indian populations account for 53% of births of Indians between the ages of 10 and 80, compared with 72% of the first enumerations of the same cohorts. Migration further reduced the share of these states to 46% of Indian residents in these cohorts. Study of the dispersal of the Indian population should focus primarily on the new emergence of the expression of Indian identity, rather than on migration from former population centers.

Background To our knowledge, no detailed analysis exists of the incidence and mortality of hepatocellular carcinoma (HCC) among Hispanics in the United States. In previous studies, the rates for Hispanics have not been reported separately from other racial or ethnic groups. Methods We used information on patients diagnosed as having HCC from 13 registries in the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to calculate race-specific, age-adjusted incidence rates (AIR) between 1992 and 2002. We also used California and Texas state death records from between 1979 and 2001 to calculate race-specific, age-adjusted mortality rates for liver cancer excluding intrahepatic cholangiocarcinoma. For Hispanics and Asians/Pacific Islanders, the rates were calculated for native-born subjects and immigrants separately. Results In SEER, the yearly AIRs were higher by 1.2-fold in Hispanics than in blacks (6.3 vs 5.0 per 100 000 person-years of the underlying US population) and by 2.7-fold than in non-Hispanic whites (2.4 per 100 000 person-years) but lower than in Asians/Pacific Islanders (10.8 per 100 000 person-years). The median age at HCC diagnosis in Hispanics (64 years) was intermediate between whites (the oldest) and blacks (the youngest). Between the periods 1992-1995 and 2000-2002, there was a 31% increase in the incidence of HCC in Hispanic men and a 63% increase in Hispanic women. The race-specific, age-adjusted mortality rates were remarkably similar in California and Texas and were highest in immigrant Asian/Pacific Islanders followed by native Hispanics. The rates for native Hispanic men were more than twice as high as those for immigrant Hispanic men. For Texas, the rates for native Hispanic men were 65% higher than those for immigrant Hispanic men. Conclusion Hispanics in the United States have high rates of HCC that are second only to Asians/Pacific Islanders.