Alva O. Ferdinand

The Relationship Between Built Environments and Physical Activity: A Systematic Review

OBJECTIVES We conducted a systematic review of the literature examining the relationship between built environments (e.g., parks, trails, sidewalks) and physical activity (PA) or obesity rates. METHODS We performed a 2-step inclusion protocol to identify empirical articles examining any form of built environment and any form of PA (or obesity rate) as the outcome. We extracted data from included abstracts for analysis by using a standard code sheet developed for this study. RESULTS Of 169 included articles, 89.2% reported beneficial relationships-but virtually all articles utilized simple observational study designs not suited for determining causality. Studies utilizing objective PA measures (e.g., pedometer) were 18% less likely to identify a beneficial relationship. Articles focusing on children in community settings (-14.2%), those examining direct measures of obesity (-6.2%), or those with an academic first author (-3.4%) were less likely to find a beneficial relationship. CONCLUSIONS Policymakers at federal and local levels should encourage more rigorous scientific research to determine whether altered built environments will result in increased PA and decreased obesity rates.

Associations Between Driving Performance and Engaging in Secondary Tasks: A Systematic Review

We conducted a systematic review and meta-analysis of the literature examining the relationship between driving performance and engaging in secondary tasks. We extracted data from abstracts of 206 empirical articles published between 1968 and 2012 and developed a logistic regression model to identify correlates of a detrimental relationship between secondary tasks and driving performance. Of 350 analyses, 80% reported finding a detrimental relationship. Studies using experimental designs were 37% less likely to report a detrimental relationship (P = .014). Studies examining mobile phone use while driving were 16% more likely to find such a relationship (P = .009). Quasi-experiments can better determine the effects of secondary tasks on driving performance and consequently serve to inform policymakers interested in reducing distracted driving and increasing roadway safety.

The impact of texting bans on motor vehicle crash-related hospitalizations

We used a panel design and the Nationwide Inpatient Sample from 19 states between 2003 and 2010 to examine the impact of texting bans on crash-related hospitalizations. We conducted conditional negative binomial regressions with state, year, and month fixed effects to examine changes in crash-related hospitalizations in states after the enactment of a texting ban relative to those in states without such bans. Results indicate that texting bans were associated with a 7% reduction in crash-related hospitalizations among all age groups. Texting bans were significantly associated with reductions in hospitalizations among those aged 22 to 64 years and those aged 65 years or older. Marginal reductions were seen among adolescents. States that have not passed strict texting bans should consider doing so.

Overstatement of results in the nutrition and obesity peer-reviewed literature.

BACKGROUND Scientific authors who overreach in presenting results can potentially, without intending to, distort the state of knowledge and inappropriately influence clinicians, decision makers, the media, and the public. PURPOSE The goal of the study was to determine the extent to which authors present overreaching statements in the obesity and nutrition literature, and whether journal, author, or study characteristics are associated with this practice. METHODS A total of 937 papers on nutrition or obesity published in 2001 and 2011 in leading specialty, medical, and public health journals were systematically studied to estimate the extent to which authors overstate the results of their study in the published abstract. Focus was placed on overreaching statements that may include (1) reporting an associative relationship as causal; (2) making policy recommendations based on observational data that show associations only (e.g., not cause and effect); and (3) generalizing to a population not represented by their sample. Data were compiled in 2012 and analyzed in 2013. RESULTS Results indicate that 8.9% of studies have overreaching conclusions with a higher percentage in 2011 compared to 2001 (OR=2.14, risk difference=+3.9%, p=0.020). Unfunded studies (OR=2.41, p=0.039) were more likely to have an overstatement of results of the type described here. In contrast, those with a greater number of coauthors were significantly less likely than those with four or fewer authors (the reference group) to have overstated results (seven or eight authors: OR=0.30, risk difference=-6.1%, p=0.008; ≥9 authors: OR=0.41, risk difference= -4.0%, p=0.037). CONCLUSIONS Overreaching in presenting results in studies focused on nutrition and obesity topics is common in articles published in leading journals. Testable strategies are proposed to reduce the prevalence of such instances in the literature.

Community benefits provided by religious, other nonprofit, and for-profit hospitals: a longitudinal analysis 2000-2009.

Background: Nonprofit hospitals (NFPs) are expected to provide community benefits to justify the tax benefits they receive, but recent budgetary constraints have called into question the degree to which the tax benefits are justified. The empirical literature comparing community benefits provided by NFPs and their for-profit counterparts is mixed. However, NFPs are not a homogenous group and can include religious hospitals, community-owned hospitals, or academic medical centers. Purpose: This longitudinal study examines how religious hospitals compare with other NFPs and for-profit hospitals with respect to providing community benefits and how the provision of community benefits by hospitals has changed over time. Methodology: Using a pooled cross-sectional design, we examine two summated scores based on questions from the American Hospital Association annual survey that focus on community orientation among hospitals. We analyze two regressions with year, facility, and market controls to determine how religious hospitals compare with the other groups over time. Findings: Overall, 11% of U.S. hospitals are religious. Religious hospitals were more likely to engage in each individual community benefit activity examined. In addition, the mean values of community benefits provided by religious hospitals, as measured on two summated scores, were significantly higher than those provided by other hospital types in bivariate and regression analyses. Overall, community benefits provided by all hospitals increased over time and then leveled off during the start of the recent economic downturn. Practice Implications: As the debate continues regarding federal tax exemption status, policymakers should consider religious hospitals separately from NFPs. Managers at religious hospitals should consider how their increased levels of community benefits are related to their missions and set benchmarks that recognize and communicate those achievements.

Local public health department characteristics associated with likelihood to participate in national accreditation

OBJECTIVES We examined factors associated with completing, initiating, or intending to pursue voluntary national accreditation among local health departments (LHDs). METHODS We examined National Association of County and City Health Officials 2010 and 2013 profile data in a pooled cross-sectional design with bivariate and multivariable regression analyses. We conducted individual multivariable models with interest in accreditation and likely to accredit as outcome variables, comparing changes between 2010 and 2013. RESULTS LHDs with formal quality improvement programs are significantly more likely to have initiated or completed the accreditation process (odds ratio [OR] = 7.99; confidence interval [CI] = 1.79, 35.60), to be likely to accredit (OR = 2.41; CI = 1.65, 3.50), or to report an interest in accreditation (OR = 2.32; CI = 1.67, 3.20). Interest was lower among LHDs in 2013 than in 2010 (OR = 0.56; CI = 0.41, 0.77); however, there was no difference regarding being likely to accredit. LHDs with a high number of full-time equivalent employees were more likely to indicate being likely to accredit or interest in accreditation. CONCLUSIONS Quality improvement may facilitate the accreditation process or be a proxy measure for an unmeasurable LHD attribute that predicts accreditation.

Assessing Diabetes and Factors Associated with Foregoing Medical Care among Persons with Diabetes: Disparities Facing American Indian/Alaska Native, Black, Hispanic, Low Income, and Southern Adults in the U.S. (2011–2015)

Objective: Identify individual- and place-based factors associated with diagnosed diabetes and forgone medical care among those diagnosed with diabetes. Background: Diabetes affects millions of individuals globally. In the U.S. alone the prevalence rate of diagnosed diabetes has more than doubled over the past 20 years (4.2% in 1994 to 10% in 2014). Methods: The Behavioral Risk Factor Surveillance System (2011–2015) was used to identify factors associated with self-reported diabetes diagnoses (ever diagnosed) among U.S. adults. Logistic regression modeled: (1) the likelihood of having diabetes; (2) the likelihood of forgone medical care among those with diabetes, given appropriate medical care has been linked to preventing complications associated with diabetes. Results: Rates of diabetes remained relatively stable from 2011 to 2015. The likelihood of diabetes was higher (p < 0.01) among racial and ethnic minority groups, men, those with lower incomes and those with lower education. Place-based disparities indicating a higher likelihood of having a diagnosis of diabetes were found for those living in rural areas (urban versus rural, unadjusted OR = 0.844–0.908; p < 0.01) and those living in the South (North, Midwest, and Western/Pacific regions versus the South, unadjusted OR = 0.794–0.889; p < 0.01). Similar results were found with forgone medical care among those diagnosed with diabetes being more likely in the South (North, Midwest, and Western/Pacific regions versus the South, unadjusted OR = 0.542–0.819). In fully-adjusted analyses, the prevalence of diabetes and forgone medical care among those diagnosed with diabetes was higher for those with lower incomes, from several racial/ethnic minority groups, and in the South versus most other regions. Conclusions: Identifying at-risk groups informs targets for prevention and assists efforts to address chronic disease self-management among those already diagnosed with diabetes.

Predictors of Hospital Patient Satisfaction as Measured by Hcahps: A Systematic Review

EXECUTIVE SUMMARY Because Medicare reimbursements are now, in part, based on patient satisfaction scores, hospitals are increasingly concerned about improving patient satisfaction. However, little is known about the different characteristics that are associated with higher patient satisfaction. This study was conducted to systematically review the patient satisfaction literature and to identify predictors of patient satisfaction based on measures from the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey. We searched the PubMed and Scopus databases from January 2007 to February 2015 for relevant peer-reviewed studies. A total of 41 studies met our inclusion criteria and were categorized into three groups (levels) based on the types of predictors used in the study: patient (12 articles, 29.9%), hospital (29 articles, 70.1%), or market (4 articles, 9.7%) predictors. We present a narrative review of the included studies in which certain patient- and hospital-level predictors were consistently associated with higher patient satisfaction (e.g., patient perception of well-managed pain and not-for-profit status) or lower patient satisfaction (e.g., racial/ethnic minority, hospital’s safety net status, metropolitan area). Moreover, several predictors had mixed relationships with patient satisfaction across studies (e.g., teaching status, number of beds). Finally, we found that only a small number of studies have examined the association between market-level predictors and patient satisfaction.

Urban Park Development and Pediatric Obesity Rates: A Quasi-Experiment Using Electronic Health Record Data

Introduction: Childhood obesity affects ~20% of children in the United States. Environmental influences, such as parks, are linked with increased physical activity (PA). Objective: To examine whether changes in Body Mass Index (BMI) z-score were associated with construction of a new park. Methods: A quasi-experimental design was used to determine whether living in proximity of a park was associated with a reduction in BMI z-score. Children were selected from health clinics within an 11 mile radius of the park. A repeated-measure ANOVA was employed for analysis of the relationship between exposure (new park) and BMI z-score. Results: Participants were 1443 (median age 10.3 range (2–17.9 years), BMI: z-score 0.84 ± 1.09) African American (77.4%) adolescents. Change in BMI z-score was not statistically different for children living at different distances from the park after controlling for age, gender, race, ethnicity, or payer type (p = 0.4482). We did observe a small 0.03 increase in BMI z-score from pre- to post-park (p = 0.0007). There was a significant positive association between child’s baseline age and BMI z-score (p < 0.001). Conclusions: This study found proximity to a park was not associated with reductions in BMI z-score. Additional efforts to understand the complex relationship between park proximity, access, and PA are warranted.

The Impact of IRS Tax Policy on Hospital Community Benefit Activities

The Internal Revenue Service (IRS) recently introduced tax code revisions requiring stricter oversight of community benefit activities (CBAs) conducted by tax-exempt, not-for-profit hospitals. We examine the impact of this tax requirement on CBAs among these hospitals relative to for-profit and government hospitals that were not subject to the new policy. We employed a quasi-experimental, difference-in-difference study design using a longitudinal observational approach and used secondary data collected by the American Hospital Association (years 2006-2010 including 20,538 hospital year observations). Findings show a significant increase in the reporting of 7 of the 13 CBAs among tax-exempt, not-for-profit hospitals compared with other hospitals after the policy change. Examples include partnering to conduct community health assessments (b = 0.035, p = .002) and using capacity assessments to identify unmet community health needs (b = 0.041, p = .001). Recent tax revisions are associated with increases in reported CBAs among tax-exempt, not-for-profit hospitals. As the debate continues regarding tax exemption status for not-for-profit hospitals, policy makers should expand efforts for enhanced accountability.