Elissa H. Oh

Environmental tobacco smoke and asthma exacerbations and severity: the difference between measured and reported exposure

Objective To assess the impact of measured versus reported environmental tobacco smoke (ETS) exposure on asthma severity and exacerbations in an urban paediatric population. Design We analysed cross-sectional data from the Chicago Initiative to Raise Asthma Health Equity study that followed a cohort of 561 children aged 8–14 with physician-diagnosed asthma between 2003 and 2005. Participant sociodemographic data and asthma symptoms were gathered by parental survey; exposures to ETS were determined by salivary cotinine levels and parent report. Multivariable negative binomial and ordered logistic regressions were used to assess associations between ETS and asthma outcomes. Results Among 466 children included in our analysis, 58% had moderate or severe persistent asthma; 32% had >2 exacerbations requiring a hospitalisation or an emergency room visit or same day care in the previous year. Half of caregivers reported that at least one household member smoked. In multivariable analyses, salivary cotinine was significantly associated with frequently reported exacerbations in the previous year (adjusted incidence rate ratio=1.39, 95% CI 1.09 to 1.79), but not significantly associated with asthma severity. Reported household smoking was not significantly associated with either asthma severity or frequency of exacerbations. Conclusions Salivary cotinine was more predictive of asthma exacerbation frequency but caregiver- reported household smoking was not. Use of a nicotine biomarker may be important in both the clinical and research settings to accurately identify an important risk factor for asthma exacerbations.

Differences in empowerment and quality of life among parents of children with food allergy.

BACKGROUND Living with food allergy has been found to adversely affect quality of life. Previous studies of the psychosocial impact of food allergy on caregivers have focused on mothers. OBJECTIVE To describe differences in food allergy-related quality of life (FAQOL) and empowerment of mothers and fathers of a large cohort of children with food allergy. METHODS Eight hundred seventy-six families of children with food allergy were studied. Food allergy was defined by stringent criteria, including reaction history, skin prick testing, and specific IgE. Parental empowerment and FAQOL were assessed by the adapted Family Empowerment and FAQOL-Parental Burden scales. Parental scores were compared by Wilcoxon signed rank test. Multiple regression models examined the association of parental empowerment with FAQOL. RESULTS Mothers reported greater empowerment (P < .001) and lower FAQOL (P < .001) compared with fathers, regardless of allergen severity, type, or comorbidities. However, parental empowerment was not significantly associated with FAQOL for mothers or fathers. Although parents of children with peanut, cow milk, egg, and tree nut allergies were similarly empowered, milk and egg allergies were associated with lower FAQOL (P < .01). Parental concern in the QOL assessment was greatest for items involving fear of allergen exposure outside the home. CONCLUSION Parental empowerment and FAQOL vary significantly among mothers and fathers of children with food allergy. Greater effects on FAQOL were seen for milk and egg compared with other food allergies. Although parents of children with food allergy might be empowered to care for their child, they continue to experience impaired FAQOL owing to fears of allergen exposure beyond their control.

Significant J-shaped association between body mass index (BMI) and diabetic foot ulcers.

Disagreement exists regarding the relationship between body weight and foot ulceration risk among diabetic persons.

Adherence with postdischarge venous thromboembolism chemoprophylaxis recommendations after colorectal cancer surgery among elderly Medicare beneficiaries.

Objectives:To assess national adherence with extended venous thromboembolism (VTE) chemoprophylaxis guideline recommendations after colorectal cancer surgery. Background:Postoperative VTE remains a major cause of morbidity and mortality after abdominal cancer surgery. On the basis of the results from randomized controlled trials, since 2007, national guidelines have suggested that these patients be discharged on VTE chemoprophylaxis. Methods:Medicare beneficiaries undergoing open colorectal cancer resections in 2008–2009 were identified using the Medicare Provider Analysis and Review data and limited to those who were enrolled and used Part D for their postoperative prescriptions. Postdischarge use of low-molecular-weight-heparin and other anticoagulants was assessed. Results:A total of 5078 patients underwent open colorectal cancer surgery and met the inclusion criteria. Of these, 77% underwent colectomy and 23% underwent proctectomy. A prescription for an anticoagulant was filled immediately after discharge for 77 (1.5%) patients, and a low-molecular-weight-heparin for 60 (1.2%) patients. On multivariable analysis, patients were more likely to receive postdischarge VTE chemoprophylaxis if undergoing rectal cancer surgery [incidence rate ratio (IRR), 1.83; 95% confidence interval, 1.07–3.12; vs colon], if higher educational status (IRR, 2.20; 95% confidence interval, 1.23–3.95; vs low education), or if they had a higher Elixhauser comorbidity index (IRR, 1.13; 95% confidence interval, 1.01–1.25; vs lower index). Conclusions:Although VTE remains a major issue after abdominal cancer surgery, only 1.5% of Medicare beneficiaries undergoing colorectal cancer surgery received care consistent with established guidelines for postdischarge VTE chemoprophylaxis. Barriers to adherence must be elucidated to improve the quality of care for abdominal and pelvic cancer surgery patients.

Obesity Paradox in Amputation Risk Among Nonelderly Diabetic Men

The association between BMI and amputation risk is not currently well known. We used data for a cohort of diabetic patients treated in the US Department of Veterans Affairs Healthcare System in 2003. Men aged <65 years at the end of follow‐up were examined for their amputation risk and amputation‐free survival during the next 5 years (2004–2008). Compared to overweight individuals (BMI 25–29.9 kg/m2), the risks of amputation and treatment failure (amputation or death) were higher for patients with BMI <25 kg/m2 and were lower for those with BMI ≥30 kg/m2. Individuals with BMI ≥40 kg/m2 were only half as likely to experience any (hazard ratios (HR) = 0.49; 95% confidence interval (CI), 0.30–0.80) and major amputations (HR = 0.53; 95% CI, 0.39–0.73) during follow‐up as overweight individuals. While the amputation risk continued to decrease for higher BMI, amputation‐free survival showed a slight upturn at BMI >40 kg/m2. The association between obesity and amputation risk in our data shows a pattern consistent with “obesity paradox” observed in many health conditions. More research is needed to better understand pathophysiological mechanisms that may explain the paradoxical association between obesity and lower‐extremity amputation (LEA) risk.

Effects of Welfare and Maternal Work on Recommended Preventive Care Utilization Among Low-Income Children

OBJECTIVES We examined how maternal work and welfare receipt are associated with children receiving recommended pediatric preventive care services. METHODS We identified American Academy of Pediatrics-recommended preventive care visits from medical records of children in the 1999-2004 Illinois Families Study: Child Well-Being. We used Illinois administrative data to identify whether mothers received welfare or worked during the period the visit was recommended, and we analyzed the child visit data using random-intercept logistic regressions that adjusted for child, maternal, and visit-specific characteristics. RESULTS The 485 children (95%) meeting inclusion criteria made 41% of their recommended visits. Children were 60% more likely (adjusted odds ratios [AOR` = 1.60; 95% confidence interval [CI] = 1.27, 2.01) to make recommended visits when mothers received welfare but did not work compared with when mothers did not receive welfare and did not work. Children were 25% less likely (AOR = 0.75; 95% CI = 0.60, 0.94) to make preventive care visits during periods when mothers received welfare and worked compared with welfare only periods. CONCLUSION The Temporary Assistance for Needy Families maternal work requirement may be a barrier to receiving recommended preventive pediatric health care.

Association Between State Medical Malpractice Environment and Surgical Quality and Cost in the United States.

Context:The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability. Objective:To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery. Design, Setting, and Patients:Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models. Main Outcome Measures:thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care. Results:Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22–1.41), pneumonia (OR: 1.36; 95%: CI, 1.16–1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22–1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70–2.61), acute renal failure (OR: 1.34; 95% CI; 1.22–1.47), and sepsis (OR: 1.38; 95% CI: 1.24–1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments. Conclusions:There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.

Development of a Composite Measure of State-Level Malpractice Environment

OBJECTIVE To develop a composite measure of state-level malpractice environment. DATA SOURCES Public use data from the National Practitioner Data Bank, Medical Liability Monitor, the National Conference of State Legislatures, and the American Bar Association. STUDY DESIGN Principal component analysis of state-level indicators (paid claims rate, malpractice premiums, lawyers per capita, average award size, and malpractice laws), with indirect validation of the composite using receiver-operating characteristic curves to determine how accurately the composite could identify states with high-tort activity and costs. PRINCIPAL FINDINGS A single composite accounted for over 73 percent of total variance in the seven indicators and demonstrated reasonable criterion validity. CONCLUSION An empirical composite measure of state-level malpractice risk may offer advantages over single indicators in measuring overall risk and may facilitate cross-state comparisons of malpractice environments.

Surveying a new multi-institution clinical data research network

Cultivated by the Patient-Centered Outcomes Research Network (PCORnet), thirteen regional clinical data research networks (CDRNs) are taking shape across the U.S. The PCORnet common data model was carefully planned, and the data marts assembled by the more than 80 data-contributing institutions (nodes) are undergoing, in 2016-2017, a series of data characterization cycles. PCORnet will adjudge each nodes-and thereby, in a significant way, each CDRNs-readiness or unreadiness for multi-institution research. Certifying each nodes quality and fidelity is of course essential. But in understanding network readiness there is an additional, vital dimension-one that has received too little attention. It is the development of knowledge about the nature of a CDRNs data, in its federated sense. With visualizations, how might one grasp the meta-data of a CDRN? We outline an approach that builds upon the HealthLNK Data Repository, a forerunner to the Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) CDRN.