Lawrence C. Kleinman

Predicting Risk for Death from MRSA Bacteremia

Methicillin-resistant Staphylococcus aureus (MRSA) in the bloodstream is often fatal. Vancomycin is the most frequently prescribed drug for treatment of MRSA infections with demonstrated efficacy. Recently, however, some MRSA infections have not been responding to vancomycin, even those caused by strains considered susceptible. To provide optimal treatment and avoid vancomycin resistance, therapy should be tailored, especially for patients at highest risk for death. But who are these patients? A study that looked back at medical records and 699 frozen isolates found that risk for death from MRSA infection was highest among certain populations, including the elderly, nursing home residents, patients with severe sepsis, and patients with liver or kidney disease. Risk for death was not affected by the type of MRSA strain (vancomycin susceptible, heteroresistant, or intermediate resistant). Risk was lower among those who had consulted an infectious disease specialist. Thus, when choosing treatment for patients with MRSA infection, it is crucial to look at patient risk factors, not just MRSA strain type. For those at high risk, consultation with an infectious disease specialist is recommended.

Black/White Differences in Very Low Birth Weight Neonatal Mortality Rates Among New York City Hospitals

OBJECTIVE. We sought to determine whether differences in the hospitals at which black and white infants are born contribute to black/white disparities in very low birth weight neonatal mortality rates in New York City. METHODS. We performed a population-based cohort study using New York City vital statistics records on all live births and deaths of infants weighing 500 to 1499 g who were born in 45 hospitals between January 1, 1996, and December 31, 2001 (N = 11 781). We measured very low birth weight risk-adjusted neonatal mortality rates for each New York City hospital and assessed differences in the distributions of non-Hispanic black and non-Hispanic white very low birth weight births among these hospitals. RESULTS. Risk-adjusted neonatal mortality rates for very low birth weight infants in New York City hospitals ranged from 9.6 to 27.2 deaths per 1000 births. White very low birth weight infants were more likely to be born in the lowest mortality tertile of hospitals (49%), compared with black very low birth weight infants (29%). We estimated that, if black women delivered in the same hospitals as white women, then black very low birth weight mortality rates would be reduced by 6.7 deaths per 1000 very low birth weight births, removing 34.5% of the black/white disparity in very low birth weight neonatal mortality rates in New York City. Volume of very low birth weight deliveries was modestly associated with very low birth weight mortality rates but explained little of the racial disparity. CONCLUSION. Black very low birth weight infants more likely to be born in New York City hospitals with higher risk-adjusted neonatal mortality rates than were very low birth weight infants, contributing substantially to black-white disparities.

Lessons learned from the analysis of gender effect on risk factors and procedural outcomes of lower extremity arterial disease

INTRODUCTION Despite overall improvement, there is still a gender-related disparity in the outcomes of lower extremities peripheral arterial disease (PAD). We analyzed sex-related variability among factors that are known to influence outcomes. METHODS Data on PAD inpatient hospitalizations from New York, New Jersey, and Florida state hospital discharge databases (1998-2007) were analyzed using univariate and multivariate logistic regression analyses. RESULTS Of the 372,692 surgical hospitalizations identified, 162,730 (43.66%) involved women. Men and women undergoing vascular procedures differed in that more men smoked (18% vs 14%; P<.0001), and more men had coronary artery disease (40% vs 33%; P<.0001). Women were more likely to be obese (11.86% vs 4.89%; P<.0001), black (18.81% vs 12.66%; P<.0001), older, and have critical limb ischemia (CLI) (39.41% vs 37.67%; P<.0001). They had higher mortality (5.26% vs 4.21%; P<.0001) and complication rates, especially bleeding (10.62 % vs 8.19%; P<.0001) and infection (3.23% vs 2.88%; P<.0001). Mortality rates after endovascular procedures were lower and showed marginal difference between genders (2.87% vs 2.11%; P<.0001). The difference was more pronounced after open revascularizations (5.05% for women vs 4.00% for men; P<.0001) and amputations (9.82% for women vs 8.82% for men; P<.0001). Bleeding differences between men and women were greatest when both open and endovascular procedures were done during the same hospitalizations and lowest after major amputations. Similar to bleeding, transgender differences in postoperative infections were more pronounced after combination of open and endovascular procedures. Using a multivariable model, female gender remained a predictor of perioperative mortality, infection, and bleeding after vascular intervention (odds ratios 1.15, 1.21, and 1.32, respectively). Female gender negatively influenced the mortality of patients with cerebrovascular and coronary disease and those of black race even after adjusting for relevant clinical and demographic risk factors. Gender effect on mortality dissipated in octogenarians and patients with claudication. CONCLUSION Female gender continues to be an important risk factor that negatively influences the outcomes of vascular interventions; however, these effects vary between different high-risk groups and procedures. Gender effect on mortality dissipates in elderly patients. Prompt recognition of the associations between gender and various risk factors of cardiovascular disease and aggressive modification of these risk factors in female patients may improve gender-related disparity in the outcomes of vascular disease.

Overuse of tympanostomy tubes in New York metropolitan area: evidence from five hospital cohort

Objectives To compare tympanostomy tube insertion for children with otitis media in 2002 with the recommendations of two sets of expert guidelines. Design Retrospective cohort study. Setting New York metropolitan area practices associated with five diverse hospitals. Participants 682 of 1046 children who received tympanostomy tubes in the five hospitals for whom charts from the hospital, primary care physician, and otolaryngologist could be accessed. Results The mean age was 3.8 years. On average, children with acute otitis media had fewer than four infections in the year before surgery. Children with otitis media with effusion had less than 30 consecutive days of effusion at the time of surgery. Concordance with recommendations was very low: 30.3% (n=207) of all tympanostomies were concordant with the explicit criteria developed for this study and 7.5% (n=13) with the 1994 guideline from the American Academy of Pediatrics, American Academy of Family Medicine, and American Academy of Otolaryngology—Head and Neck Surgery. Children who had previously had tympanostomy tube surgery, who were having a concomitant procedure, or who had “at risk conditions” were more likely to be discordant. Conclusions A significant majority of tympanostomy tube insertions in the largest and most populous metropolitan area in the United States were inappropriate according to the explicit criteria and not recommended according to both guidelines. Regardless of whether current practice represents a substantial overuse of surgery or the guidelines are overly restrictive, the persistent discrepancy between guidelines and practice cannot be good for children or for people interested in improving their health care.

Subverting criteria: the role of precedent in decisions to finance surgery

This paper investigates prospective utilisation review for tympanostomy. In the studied procedure, a medical corporation reviews cases for third-party payers (insurance companies), and used explicit criteria to determine whether a case is appropriate for surgery. Earlier findings that inappropriate decisions to approve surgery are strongly related to previous surgeries for the same condition are investigated to trace the emergence of this theme within the review process and its consolidation into a ‘precedent’ for further surgery, notwithstanding the explicit criteria which the reviewers are mandated to enforce. The significance of previous surgeries as a factor favouring further surgery emerges at all levels of the review process, indicating a medical culture that validates precedent in medical decision making despite the absence of evidence-based findings that would support it.

Clinical Characteristics of New York City Children Who Received Tympanostomy Tubes in 2002

OBJECTIVE. Tympanostomy tube insertion is the most common procedure that requires general anesthesia for children in the United States. We report on the clinical characteristics of a cohort of New York City children who received tympanostomy tubes in 2002. METHODS. This retrospective cohort study included all 1046 children who received tubes in 2002 in any of 5 New York City area hospitals. We analyzed clinical data for all 682 (65%) children for whom we were able to abstract data for the preceding year from all of 3 sources: hospital, pediatrician, and otolaryngologist medical charts. RESULTS. Mean age was 3.8 years, 57% were male, and 74% had private insurance. More than 25% of children had received tubes previously. The stated reason for surgery was otitis media with effusion for 60.4% of children, recurrent acute otitis media for 20.7%, and eustachian tube dysfunction for 10.6%. Children with recurrent acute otitis media averaged 3.1 ± 0.2 episodes (median: 3.0) in the previous year; those with otitis media with effusion averaged effusions that were 29 ± 1.7 days long (median: 16 days) at surgery. Twenty-five percent of children had bilateral effusions of >42 days’ duration at surgery. Despite a clinical practice guideline for otitis media with effusion that recommends withholding tympanostomy tubes for otherwise healthy children until a bilateral effusion is at least 3 to 4 months old, 50% of children had surgery without having had 3 months of effusion cumulatively during the year before surgery. CONCLUSIONS. The clinical characteristics of children who received tympanostomy tubes varied widely. Many children with otitis media with effusion had shorter durations of effusions than are generally recommended before surgery. The extent of variation in treating this familiar condition with limited treatment options suggests both the importance and the difficulty of managing common practice in accordance with clinical practice guidelines.

Assessing quality improvement in health care: theory for practice.

OBJECTIVES: To review the role of theory as a means to enhance the practice of quality improvement (QI) research and to propose a novel conceptual model focused on the operations of health care. METHODS: Conceptual model, informed by literature review. RESULTS: To optimize learning across QI studies requires the integration of small-scale theories (middle-range theories, theories of change) within the context of larger unifying theories. We propose that health care QI research would benefit from a theory that describes the operations of health care delivery, including the multiplicity of roles that interpersonal interactions play. The broadest constructs of the model are entry into the system, and assessment and management of the patient, with the subordinate operations of access; recognition, assessment, and diagnosis; and medical decision-making (developing a plan), coordination of care, execution of care, referral and reassessment, respectively. Interpersonal aspects of care recognize the patient/caregiver as a source of information, an individual in a cultural context, a complex human being, and a partner in their care. Impacts to any and all of these roles may impact the quality of care. CONCLUSIONS: Such a theory can promote opportunities for moving the field forward and organizing the planning and interpretation of comparable studies. The articulation of such a theory may simultaneously provide guidance for the QI researcher and an opportunity for refinement and improvement.

Impact of State Laws That Extend Eligibility for Parents’ Health Insurance Coverage to Young Adults

BACKGROUND AND OBJECTIVES: The 2010 Affordable Care Act mandates that health insurance companies make those up to age 26 eligible for their parents’ policies. Thirty-four states previously enacted similar laws. The authors sought to examine the impact on access to care of state laws extending eligibility of parents’ insurance to young adults. METHODS: By using a difference-in-differences analysis, we examined the 2002–2004 and 2008–2009 Behavior Risk Factor Surveillance System to compare 3 states enacting laws in 2005 or 2006 with 17 states that have not enacted laws on 4 outcomes: self-reported health insurance coverage, identification of a personal physician/clinician, physical exam from a physician within the past 2 years, and forgoing care in the past year due to cost. RESULTS: For each outcome there was differential improvement among states enacting laws compared with states without laws. Health insurance differentially increased 0.2% (95% confidence interval [CI], −3.8% to 4.2%), from 67.6% to 68.1% pre-post in states enacting laws and from 68.5% to 68.7% in states without. Personal physician/clinician identification differentially increased 0.9% (95% CI −3.1% to 5.0%), from 62.4% to 65.5% in states enacting laws and from 58.0% to 60.2% in states without. Recent physical exams differentially increased significantly 4.6% (95% CI, 0%–9.2%), from 77.3% to 81.2% in states enacting laws and from 76.2% to 75.5% in states without. Forgone care due to cost differentially decreased significantly 3.9% (95% CI, −0.3% to −7.5%), from 20.4% to 18.2% in states enacting laws and from 17.8% to 19.4% in states without. CONCLUSIONS: States that expanded eligibility to parents’ insurance in 2005 or 2006 experienced improvements in access to care among young adults.

Barriers to Physical Activity in East Harlem, New York

Background. East Harlem is an epicenter of the intertwining epidemics of obesity and diabetes in New York. Physical activity is thought to prevent and control a number of chronic illnesses, including diabetes, both independently and through weight control. Using data from a survey collected on adult (age 18+) residents of East Harlem, this study evaluated whether perceptions of safety and community-identified barriers were associated with lower levels of physical activity in a diverse sample. Methods. We surveyed 300 adults in a 2-census tract area of East Harlem and took measurements of height and weight. Physical activity was measured in two ways: respondents were classified as having met the weekly recommended target of 2.5 hours of moderate physical activity (walking) per week (or not) and reporting having engaged in at least one recreational physical activity (or not). Perceived barriers were assessed through five items developed by a community advisory board and perceptions of neighborhood safety were measured through an adapted 7-item scale. Two multivariate logistic regression models with perceived barriers and concerns about neighborhood safety were modeled separately as predictors of engaging in recommended levels of exercise and recreational physical activity, controlling for respondent weight and sociodemographic characteristics. Results. The most commonly reported perceived barriers to physical activity identified by nearly half of the sample were being too tired or having little energy followed by pain with exertion and lack of time. Multivariate regression found that individuals who endorsed a greater number of perceived barriers were less likely to report having met their weekly recommended levels of physical activity and less likely to engage in recreational physical activity controlling for covariates. Concerns about neighborhood safety, though prevalent, were not associated with physical activity levels. Conclusions. Although safety concerns were prevalent in this low-income, minority community, it was individual barriers that correlated with lower physical activity levels.

Surfactant use for premature infants with respiratory distress syndrome in three New York city hospitals: discordance of practice from a community clinician consensus standard

Objective:To assess concordance with a locally developed standard of care for premature infants with respiratory distress syndrome (RDS) for whom the standard recommends surfactant treatment within 2 h of birth, and to examine the association between clinical, demographic, and hospital characteristics with discordance from the standard.Study Design:Retrospective cohort study of 773 infants weighing ⩽1750 g born in any of the three New York City hospitals between 1999 and 2002.Result:227 of the 773 infants (29%) met criteria for treatment according to the standard. Of these, 37% received surfactant by 2 h. By 4 h, 70% of infants who met the standard received surfactant. White infants were more likely to receive surfactant by 4 h (85%) than African American (61%) or Latino infants (67%). Multivariable logistic regression revealed significant odds ratios predicting discordance from the relaxed criteria (4 h) for African American race (4.10, 95% confidence interval: 1.30 to 13.00), 100 g of birth weight (odds ratio: 1.22, 95% confidence interval: 1.10 to 1.34), and hospital of birth.Conclusion:Many infants with RDS failed to receive surfactant replacement therapy at 2 and 4 h after birth. African Americans and those born larger were less likely to receive surfactant. If these data can be generalized, there is a large opportunity to reduce infant morbidity from RDS and to reduce racial/ethnic disparities in birth outcomes by increasing the rate and speed with which surfactant is delivered to these infants.