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Joshua G. Behr, the Old Dominion University political scientist who directs the annual Quality of Life Survey in the Hampton Roads region, was not pulling anyone's leg when he worded one of his recent survey questions: "Does a doctor or nurse ever examine your bare feet?"

Understanding the relevance of the question requires some background that has little to do with podiatry. The bare-feet question relates to diabetes, amputation of limbs, demographics and equal access to quality health care. An investment made by the ODU Office of Research also figured in the origin of the question.

Behr, who began his Quality of Life surveys in 2004, decided last year that disparities in health care deserved a closer look. The 1,000-1,200 participants in each of his QOL telephone surveys are asked questions on dozens of topics, ranging from roads and traffic conditions to entertainment and shopping opportunities. "But large variations in chronic diseases and conditions really stand out in the data, and as scientists we are geared toward finding explanations for these variations," he said.

That led him to apply to the ODU Office of Research for funding for an investigative, health-only survey. As it happened, the office was taking applications for seed grants of about $100,000 each to encourage interdisciplinary research projects. Behr put together a research team that included representatives from ODU's College of Health Sciences, Eastern Virginia Medical School (EVMS) and the U.S. Navy, and the team won a grant.
The grants are designed to nurture research projects to the point that they can attract outside funding. The Office of Research, in effect, invested $100,000 in Behr's project with the hope that external grants and client funding could sustain it down the road.

At the outset of the project, the young assistant professor asked around for advice about questions that should be on the survey. One of the parties most interested in what he was doing was Sentara Health System, whose Norfolk General Hospital shares a campus with EVMS and the Strelitz Diabetes Institutes. Researchers at the Strelitz facility suggested the bare-feet question.

"At the diabetes center, they had noticed a disparity, one that turns up all over the country. Leg amputations for complications from diabetes are four times as high for African Americans as for others," Behr explained. "The conventional wisdom for 20 years has blamed the disparity on quality of medical care. But at the Strelitz Institutes, they suspected something else was at work."

The prevailing theory, according to Behr, has been that the examination of diabetic patients, such as checking for signs of poor blood circulation in the feet and swelling or soreness of the legs and ankles, has been less thorough in the African American population relative to the non-African American population.

"Nevertheless, researchers at the Strelitz Institutes for sometime have suspected that the relatively high rates of amputations within the African American community may be explained, in part, by physiological differences. That is, there may be something other than quality of care that led to dramatically higher rates of amputations. That led to the nature of the survey question, and we find that among respondents in Hampton Roads there is no statistically significant racial disparity in the rate of foot examinations. This challenges prevailing wisdom, and researchers at the Strelitz Institutes are now working on a grant to further pursue a physiological explanation for the high rates of amputations," Behr said.

"The beauty of our research is that we can show precisely for this area where the needs are, where the disparities are," he added. "We're not just guessing based on state or national figures that have been interpolated for the Hampton Roads region. We have the demographic information, and this is invaluable when you're going to agencies for grants to improve medical services or to fund interventions."

The special survey funded by the ODU Office of Research, and which is titled "Health Matters," sampled 1,675 people in the greater Hampton Roads area. The telephone survey was conducted by the ODU Social Sciences Research Center (SSRC) during May and June 2006. Other project researchers were Cmdr. John B. Baccus (Navy); Aaron I. Vinik (Strelitz Institutes, EVMS); Margaret Camarena, director, SSRC; and Stacey Plichta, associate professor of community and environmental health, James Alan Neff, professor of community and environmental health, and Harry J. Tillman, assistant professor of nursing, ODU College of Health Sciences.

"Health Matters" results were augmented by health-related questions on Behr's regular Quality of Life survey, which was conducted by the SSRC during July 2006. (The full results of that survey are due to be publicized in early 2007.)

On Oct. 31, Behr presented highlights of his findings at the annual Regional Community Leaders' Breakfast. His appearance was on behalf of Access Partnership, which is a Hampton Roads initiative launched by health care providers, universities, churches, civic groups, social services departments and volunteers to improve medical services for underinsured and uninsured residents. Behr's collaboration with Access Partnership led recently to ODU partnering with the organization.

One of the headline "Health Matters" findings has to do with the percentage of local residents (ages 18-64) who do not have private medical insurance. "The total is a whopping 21.7 percent," Behr said. "More than one-fifth!"

African American survey respondents were about 30 percent more likely to be without coverage than whites, although at higher income levels the disparity disappeared. Female respondents, both African American and white, were much more likely than same-race males to report no coverage.
Also according to the surveys, diabetes-especially among African Americans-is by far the most commonly diagnosed serious illness/condition. The disease affects about 10 percent of the Hampton Roads population. Other conditions reported: heart disease (5.78 percent), cancer (4.83), stroke (2.21) and kidney disease (1.73). Whites are more likely than African Americans to report heart disease and cancer.

High blood pressure (34.28 percent overall and 44.97 percent for African Americans) was the most serious chronic ailment reported. High cholesterol ranked second (28.94 percent overall and 30.83 percent for whites).

The portion of the survey that has generated the most interest applies to hospital emergency rooms, Behr said.

"An Institute of Medicine report not long ago said that there is a crisis in America caused by inappropriate use of hospital emergency departments (EDs). At Sentara, they have known for some time that a lot of people are using their hospitals' EDs as primary care facilities," Behr explained. "Sentara knows the high cost associated with this and they want to know the 'drivers' that leads people to their EDs."

The local surveys have identified African Americans-especially low-income females-as heavy users of emergency rooms. But only a small percentage of frequent ED users say they do it because they do not have a regular doctor. A much more likely response is that they have trouble getting prompt appointments to see their doctors.

Because of the preliminary survey findings, Sentara has invested about $100,000 in a pilot study by Behr at Norfolk General's emergency department. About 15 students from the ODU College of Health Sciences are being trained to conduct extensive interviews with patients in the department.

"What we know so far is only the tip of the iceberg," Behr said. "There are so many underlying factors driving ED utilization we need to explore. For example, when a person arrives in the ED due to an episodic diabetic shock, we don't know whether it has come about because of mismanagement of medicine due to poor literacy or, perhaps, failure to receive the appropriate continuity in medicine due to a lack of a stable medical home. Until this point, there has been no systematic attempts to track these drivers. Understanding such things will allow us to design interventions."

Behr said the Institute of Medicine report points out the potentially disastrous financial effect that inappropriate emergency room use can have for hospitals, and that the report should influence funding agencies such as the National Institutes of Health. "If money is freed up to study ED usage, we believe we're at the cutting edge of this research," he said. "The investment by the Office of Research could reap great returns."

This article was posted on: November 21, 2006

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