H. Shelton Brown

Cost-effectiveness analysis of a community health worker intervention for low-income hispanic adults with diabetes

Introduction The objective of our study was to estimate the long-term cost-effectiveness of a lifestyle modification program led by community health workers (CHWs) for low-income Hispanic adults with type 2 diabetes. Methods We forecasted disease outcomes, quality-adjusted life years (QALYs) gained, and lifetime costs associated with attaining different hemoglobin A1c (A1c) levels. Outcomes were projected 20 years into the future and discounted at a 3.0% rate. Sensitivity analyses were conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness, projected years, discount rates, and costs. Results The incremental cost-effectiveness ratio of the intervention ranged from

Persistent Disparities in the Use of Health Care Along the US–Mexico Border: An Ecological Perspective

10,995 to

Missed opportunities for diagnosis and treatment of diabetes, hypertension, and hypercholesterolemia in a Mexican American population, Cameron County Hispanic Cohort, 2003-2008.

33,319 per QALY gained when compared with usual care. The intervention was particularly cost-effective for adults with high glycemic levels (A1c > 9%). The results are robust to changes in multiple parameters. Conclusion The CHW program was cost-effective. This study adds to the evidence that culturally sensitive lifestyle modification programs to control diabetes can be a cost-effective way to improve health among Hispanics with diabetes, particularly among those with high A1c levels.

Crime rates and sedentary behavior among 4th grade Texas school children

OBJECTIVES We examined disparities in health care use among US-Mexico border residents, with a focus on the unique binational environment of the region, to determine factors that may influence health care use in Mexico. METHODS Data were from 2 waves of a population-based study of 1048 Latino residents of selected Texas border counties. Logistic regression models examined predictors of health insurance coverage. Results from these models were used to examine regional patterns of health care use. RESULTS Of the respondents younger than 65 years, 60% reported no health insurance coverage. The uninsured were 7 and 3 times more likely in waves 3 and 4, respectively, to use medical care in Mexico than were the insured. Preference for medical care in Mexico was an important predictor. CONCLUSIONS For those who were chronically ill, old, poor, or burdened by the lengthy processing of their documents by immigration authorities, the United States provided the only source of health care. For some, Mexico may lessen the burden at the individual level, but it does not lessen the aggregate burden of providing highly priced care to the regions neediest. Health disparities will continue unless policies are enacted to expand health care accessibility in the region.

Educational outcomes associated with childhood obesity in the United States: cross-sectional results from the 2011–2012 National Survey of Children’s Health

Introduction Diabetes, hypertension, and hypercholesterolemia are common chronic diseases among Hispanics, a group projected to comprise 30% of the US population by 2050. Mexican Americans are the largest ethnically distinct subgroup among Hispanics. We assessed the prevalence of and risk factors for undiagnosed and untreated diabetes, hypertension, and hypercholesterolemia among Mexican Americans in Cameron County, Texas. Methods We analyzed cross-sectional baseline data collected from 2003 to 2008 in the Cameron County Hispanic Cohort, a randomly selected, community-recruited cohort of 2,000 Mexican American adults aged 18 or older, to assess prevalence of diabetes, hypertension, and hypercholesterolemia; to assess the extent to which these diseases had been previously diagnosed based on self-report; and to determine whether participants who self-reported having these diseases were receiving treatment. We also assessed social and economic factors associated with prevalence, diagnosis, and treatment. Results Approximately 70% of participants had 1 or more of the 3 chronic diseases studied. Of these, at least half had had 1 of these 3 diagnosed, and at least half of those who had had a disease diagnosed were not being treated. Having insurance coverage was positively associated with having the 3 diseases diagnosed and treated, as were higher income and education level. Conclusions Although having insurance coverage is associated with receiving treatment, important social and cultural barriers remain. Failure to provide widespread preventive medicine at the primary care level will have costly consequences.

Lawsuit activity, defensive medicine, and small area variation: the case of cesarean sections revisited

IntroductionAlthough per capita crime has generally fallen over the period which coincides with the obesity epidemic, it has not fallen uniformly across communities. It also has not fallen enough to allay fears on the part of parents. Over the past 30 years, technological changes have made the indoor alternatives to playing outside, where children are more vulnerable to criminal activity, more enjoyable (cable TV, video games, and the internet) and comfortable (the spread of air conditioning to low income neighborhoods). We determined whether indoor sedentary behavior patterns are associated with community crime statistics. 4thgraders in the U.S. are typically 9 or 10 years old.MethodsWe used data from the 2004–2005 Texas School Physical Activity and Nutrition (SPAN) survey linked with U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics data for the years 2000 through 2005 and Texas State data on sexual offenders. The probability-based sample included a total of 7,907 children in grade four. Multistage probability sampling weights were used. The dependent variables included were hours of TV watching, video game playing, computer use and total indoor sedentary behavior after school. Incremental Relative Rates were computed for community crime rates including robberies, all violent crimes, murders, assaults, property crimes, rapes, burglaries, larcenies and motor vehicle thefts as well as for sexual offenders living in the neighborhood. The neighborhood refers to the areas where the students at each school live. In the case of sexual offenders, sexual offenders per capita are estimated using the per capita rate in the zip code of the school attended; all other crime statistics are estimated by the crimes per capita in the police department jurisdiction covering the school attended. After controlling for sex, age, and African-American and Hispanic, cross-sectional associations were determined using multivariate Poisson regression.Results4thgrade boys were more likely to play video games in communities with increased per 100 population rates of larceny and burglary as well as in communities with increased per capita sexual offenders; 4thgrade girls were more likely to watch television in communities with increased per capita sexual offenders. While 4thgrade girls were more likely to watch TV in communities with increased per capita sex offenders, they were less likely to use computers. Per capita sexual offenders were negatively related to computer use amongst 4thgrade girls.ConclusionBy combining community crime and cross-sectional individual level data on indoor sedentary behavior, we found that there is an association between community crimes/sex offender rates and certain types of indoor sedentary behavior. The development of technologies in recent decades which makes supervising children easier indoors, where children are much less vulnerable to crime, may be contributing to the epidemic of childhood obesity.

The cost-effectiveness of a school-based smoking prevention program in India

BackgroundPast research examining the effects of childhood obesity has largely focused on its projected effects into adulthood. However, there is emerging evidence that childhood obesity may have more immediate effects on school-related outcomes. We examine a range of educational attainment indicators to examine the possible pathway between obesity status and academic performance, while investigating the proximal effects of childhood obesity on health and utilization of health services, and whether these variables attenuate the relationship between obesity status and educational outcomes.MethodsData for the current study come from the 2011-2012 National Survey of Children’s Health, which details the impacts of childhood obesity on a range of outcomes among a nationally representative sample of children and adolescents aged 10-17 years (N=45,255). Educational outcomes (school absences, school problems, repeating a grade and school engagement) were modeled by logistic regression as a function of BMI, overall health status, health care utilization, and a range of sociodemographic variables.ResultsBMI status was significantly associated with all educational outcomes (p<0.001 for all), overall health status (p<0.001), and health care utilization (p=0.016). Prior to adjustment for covariates, obese children were significantly more likely to have school absences and school problems, to repeat a grade, and to have lower school engagement than non-overweight children. After adjustment for sociodemographic and health/healthcare variables, these outcomes remained significant for all but repeating a grade. The odds of having school problems, repeating a grade, and low school engagement that were associated with obesity were attenuated by the addition of sociodemographic variables into the model, while the addition of health and health care variables in the model decreased the odds of school absences.ConclusionsThis study provides evidence that increased weight status in children is associated with poorer educational outcomes. While recognizing that these are cross-sectional data, we suggest that 1) health-related and sociodemographic factors should be a focus point of intervention, and 2) a socio-structural approach including Coordinated School Health intervention is crucial to reducing childhood obesity and improving educational outcomes in this population.

Observable weight distributions and children's individual weight assessment.

This paper examines whether delivery practice patterns (Cesarean sections or vaginal) are influenced by lawsuits or whether the hypothesized relationship is confounded by small area variation. The analysis uses multilevel analysis to deal with hospital- and Dartmouth Hospital Referral Region-level variation. The model includes patient clinical variables, patient socio-economic status, and hospital characteristics as control variables. The secondary data sources include hospital discharges from the 2002 Texas Health Care Information Council as well as 1988-2001 Texas Department of Insurance Closed Claim File data. After extracting the variation in delivery practice between hospitals and between Dartmouth Hospital Referral Regions in a multilevel model, the effects of lawsuits on defensive medicine are reduced but are still significant.

Managed care and the scale efficiency of US hospitals

Intervention programs aimed at preventing tobacco use among youth have been shown to be effective in curbing tobacco use onset and progression. However, the effects of even very successful tobacco prevention programs may not always impress policy-makers and lay audiences. Economic analysis potentially strengthens the case. In this paper, we evaluate the cost-effectiveness of a youth tobacco use prevention program which has been translated and implemented in India, a developing country. Although programs like these are inexpensive to implement in the USA, they are even less expensive in India due to low labor costs. Our results show that the costs per quality-adjusted life-year added, due to averted smoking, was

Lifetime Cover in Private Insurance Markets

2057, even without including averted medical costs. If we ignore student time, cost-effectiveness improves by roughly 10%. To put the cost-effectiveness of this smoking prevention program into context, it is over 24 times more cost-effective than dialysis in the USA, which costs