Michele E. Walsh

Hospital Admissions for Acute Myocardial Infarction, Angina, Stroke, and Asthma After Implementation of Arizona's Comprehensive Statewide Smoking Ban

OBJECTIVESnWe examined the impact of Arizonas May 2007 comprehensive statewide smoking ban on hospital admissions for diagnoses for which there is evidence of a causal relationship with secondhand smoke (SHS) exposure (acute myocardial infarction [AMI], angina, stroke, and asthma).nnnMETHODSnWe compared monthly hospital admissions from January 2004 through May 2008 for these primary diagnoses and 4 diagnoses not associated with SHS (appendicitis, kidney stones, acute cholecystitis, and ulcers) for Arizona counties with preexisting county or municipal smoking bans and counties with no previous bans. We attributed reductions in admissions to the statewide ban if they occurred only in diagnoses associated with SHS and if they were larger in counties with no previous bans. We analyzed the data with Poisson regressions, controlling for seasonality and admissions trends. We also estimated cost savings.nnnRESULTSnStatistically significant reductions in hospital admissions were seen for AMI, angina, stroke, and asthma in counties with no previous bans over what was seen in counties with previous bans. No ban variable coefficients were statistically significant for diagnoses not associated with SHS.nnnCONCLUSIONSnArizonas statewide smoking ban decreased hospital admissions for AMI, stroke, asthma, and angina.

Water-pipe tobacco smoking among middle and high school students in arizona

BACKGROUND. Using a water pipe to smoke tobacco is increasing in prevalence among US college students, and it may also be common among younger adolescents. The purpose of this study of Arizona middle and high school students was to examine the prevalence of water-pipe tobacco smoking, compare water-pipe tobacco smoking with other forms of tobacco use, and determine associations between sociodemographic variables and water-pipe tobacco smoking in this population. METHODS. We added items assessing water-pipe tobacco smoking to Arizonas 2005 Youth Tobacco Survey and used them to estimate statewide water-pipe tobacco smoking prevalence among various demographic groups by using survey weights. We also used multiple logistic regression to determine which demographic characteristics had independent relationships with each of 2 outcomes: ever use of water pipe to smoke tobacco and water-pipe tobacco smoking in the previous 30 days. RESULTS. Median age of the sample was 14. Accounting for survey weights, among middle school students, 2.1% had ever smoked water-pipe tobacco and 1.4% had done so within the previous 30 days. Among those in high school, 10.3% had ever smoked from a water pipe and 5.4% had done so in the previous 30 days, making water-pipe tobacco smoking more common than use of smokeless tobacco, pipes, bidis, and kreteks (clove cigarettes). In multivariate analyses that controlled for covariates, ever smoking of water-pipe tobacco was associated with older age, Asian race, white race, charter school attendance, and lack of plans to attend college. CONCLUSIONS. Among Arizona youth, water pipe is the third most common source of tobacco after cigarettes and cigars. Increased national surveillance and additional research will be important for addressing this threat to public health.

A Cluster-Randomized Trial of Benchmarking and Multimodal Quality Improvement to Improve Rates of Survival Free of Bronchopulmonary Dysplasia for Infants With Birth Weights of Less Than 1250 Grams

OBJECTIVE. We tested whether NICU teams trained in benchmarking and quality improvement would change practices and improve rates of survival without bronchopulmonary dysplasia in inborn neonates with birth weights of <1250 g. METHODS. A cluster-randomized trial enrolled 4093 inborn neonates with birth weights of <1250 g at 17 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Three centers were selected as best performers, and the remaining 14 centers were randomized to intervention or control. Changes in rates of survival free of bronchopulmonary dysplasia were compared between study year 1 and year 3. RESULTS. Intervention centers implemented potentially better practices successfully; changes included reduced oxygen saturation targets and reduced exposure to mechanical ventilation. Five of 7 intervention centers and 2 of 7 control centers implemented use of high-saturation alarms to reduce oxygen exposure. Lower oxygen saturation targets reduced oxygen levels in the first week of life. Despite these changes, rates of survival free of bronchopulmonary dysplasia were all similar between intervention and control groups and remained significantly less than the rate achieved in the best-performing centers (73.3%). CONCLUSIONS. In this cluster-randomized trial, benchmarking and multimodal quality improvement changed practices but did not reduce bronchopulmonary dysplasia rates.

Intercenter Differences in Bronchopulmonary Dysplasia or Death Among Very Low Birth Weight Infants

OBJECTIVES: To determine (1) the magnitude of clustering of bronchopulmonary dysplasia (36 weeks) or death (the outcome) across centers of the Eunice Kennedy Shriver National Institute of Child and Human Development National Research Network, (2) the infant-level variables associated with the outcome and estimate their clustering, and (3) the center-specific practices associated with the differences and build predictive models. METHODS: Data on neonates with a birth weight of <1250 g from the cluster-randomized benchmarking trial were used to determine the magnitude of clustering of the outcome according to alternating logistic regression by using pairwise odds ratio and predictive modeling. Clinical variables associated with the outcome were identified by using multivariate analysis. The magnitude of clustering was then evaluated after correction for infant-level variables. Predictive models were developed by using center-specific and infant-level variables for data from 2001 2004 and projected to 2006. RESULTS: In 2001–2004, clustering of bronchopulmonary dysplasia/death was significant (pairwise odds ratio: 1.3; P < .001) and increased in 2006 (pairwise odds ratio: 1.6; overall incidence: 52%; range across centers: 32%–74%); center rates were relatively stable over time. Variables that varied according to center and were associated with increased risk of outcome included lower body temperature at NICU admission, use of prophylactic indomethacin, specific drug therapy on day 1, and lack of endotracheal intubation. Center differences remained significant even after correction for clustered variables. CONCLUSION: Bronchopulmonary dysplasia/death rates demonstrated moderate clustering according to center. Clinical variables associated with the outcome were also clustered. Center differences after correction of clustered variables indicate presence of as-yet unmeasured center variables.

Unpacking cultural factors in adaptation to type 2 diabetes mellitus.

Background. Race and ethnicity are used as predictors of outcome in health services research. Often, however, race and ethnicity serve merely as proxies for the resources, values, beliefs, and behaviors (ie, ecology and culture) that are assumed to correlate with them. “Unpacking” proxy variables–directly measuring the variables believed to underlie them–would provide a more reliable and more interpretable way of looking at group differences. Objective. To assess the use of a measure of ecocultural domains that is correlated with ethnicity in accounting for variance in adherence, quality of life, clinical outcomes, and service utilization. Design. A cross-sectional observational study. Participants. Twenty-six Hispanic and 29 non-Hispanic white VA primary care patients with type 2 diabetes mellitus. Measures. The independent variables were patient ethnicity and a summed score of ecocultural domains representing patient adaptation to illness. The outcomes were adherence to treatment, health-related quality of life, clinical indicators of disease management, and utilization of urgent health care services. Results. Patient adaptation was correlated with ethnicity and accounted for more variance in all outcomes than did ethnicity. The unique variance accounted for by adaptation was small to moderate, whereas that accounted for by ethnicity was negligible. Conclusions. It is possible to identify and measure ecocultural domains that better account for variation in important health services outcomes for patients with type 2 diabetes than does ethnicity. Going beyond the study of ethnic differences alone and measuring the correlated factors that play a role in disease management can advance understanding of the phenomena involved in this variation and provide better direction for service design and delivery.

Health Insurance Status, Medical Debt, and Their Impact on Access to Care in Arizona

OBJECTIVESnWe examined the impact of health insurance status on medical debt among Arizona residents and the impact of both of these factors on access to care.nnnMETHODSnWe estimated logistic regression models for medical debt (problems paying and currently paying medical bills) and access to care (medical care and medications delayed or missed because of cost or lack of insurance).nnnRESULTSnInsured status did not predict medical debt after control for health status, income, age, and household characteristics. Insured status (adjusted odds ratio [AOR]u200a=u200a0.32), problems paying medical bills (AORu200a=u200a4.96), and currently paying off medical bills (AORu200a=u200a3.04) were all independent predictors of delayed medical care, but only problems paying (AORu200a=u200a6.16) and currently paying (AORu200a=u200a3.68) medical bills predicted delayed medications. Inconsistent coverage, however, was a strong predictor of problems paying bills, and both of these factors led to delays in medical care and medications.nnnCONCLUSIONSnAt least in Arizona, health insurance does not protect individuals from medical debt, and medical debt and lack of insurance coverage both predict reduced access to care. These results may represent a troubling message for US health care in general.

Mediator Assessment, Documentation, and Disposition of Child Custody Cases Involving Intimate Partner Abuse: A Naturalistic Evaluation of One County's Practices

The contentious and costly nature of the adversarial process for resolving child custody disputes has prompted scholars, practitioners, and policy makers to advocate for the development and implementation of less divisive forms of dispute resolution, notably, mediation. Mediation has been championed for its potential to resolve disputes with less acrimony among disputants, reduced economic costs, increased satisfaction with outcomes, and fewer adverse consequences for family members. Despite the increasing popularity, arguments have cautioned against the use of mandated mediation when intimate partner abuse (IPA) is alleged. This research documents a mediation screening process and models mediators’ decision-making process as instantiated, naturally, in one jurisdiction.

Perceptual, thematic and taxonomic relations in children’s mental representations: Responses to triads

Recent research into children’s conceptual representation-much of it based on the so-called ‘triads’ task-has created a number of issues such as the age at which children become capable of representation at the superordinate level; the relative prominence of taxonomic, perceptual or thematic relations as the basis of representation; and the range of categories to which these different representations apply at different ages. In the study reported in this paper we presented children of three different ages with three types of triads designed to assess children’s sensitivity to these different relations separately across ten common superordinate categories. The approach which allowed us to track preferences for perceptual, thematic and taxonomic relations simultaneously across the three age groups showed an increase in sensitivity to both thematic and taxonomic relations with age. We conclude by suggesting that these relations are part of a common representation based on patterns of covariation within (static taxonomic relations) and across (event relations) time.

Evaluating Intense Rehabilitative Therapies With and Without Acupuncture for Children With Cerebral Palsy: A Randomized Controlled Trial

OBJECTIVEnTo compare the outcomes of conventional therapies (physical, occupational, and hydrotherapies) plus acupuncture with those without acupuncture when administered intensely in the management of children with spastic cerebral palsy (CP).nnnDESIGNnEvaluation-blind, prospective randomized controlled trial.nnnSETTINGnTherapies and video-recorded assessments at a childrens hospital in Beijing, China, and blind scoring and data analyses at a university in the United States.nnnPARTICIPANTSnChildren (N=75), 12 to 72 months of age, with spastic CP.nnnINTERVENTIONSnIntensely administered (5 times per week for 12wk) physical therapy, occupational therapy, and hydrotherapy either with acupuncture (group 1) or without acupuncture (group 2). To satisfy standard of care, group 2 subsequently received acupuncture (weeks 16-28).nnnMAIN OUTCOME MEASURESnThe Gross Motor Function Measure (GMFM)-66 and the Pediatric Evaluation of Disability Inventory (PEDI) assessments at 0, 4, 8, 12, 16, and 28 weeks.nnnRESULTSnAt the end of 12 weeks, there was no statistically significant difference between the 2 groups, but when group 2 received acupuncture (16-28wk) there was a shift toward improvement in the GMFM-66 and the PEDI-Functional Skills Self-Care and Mobility domain. When groups were combined, statistically significant improvements after intense therapies occurred from baseline to 12 weeks for each outcome measure at each Gross Motor Function Classification System (GMFCS) level. After adjusting for expected normative maturational gains based on age, the GMFM gains for children with GMFCS II level was statistically significant (P<.05) with a mean gain of 6.5 versus a predicted gain of 3.4.nnnCONCLUSIONSnIntense early administered rehabilitation improves function in children with spastic CP. The contribution from acupuncture was unclear. Childrens response varied widely, suggesting the importance of defining clinical profiles that identify which children might benefit most. Further research should explore how this approach might apply in the U.S.

Are cost-inclusive evaluations worth the effort?

Relative costs are as important as relative effectiveness when choosing between program alternatives or among a set of programs competing for scarce funds. Nevertheless, the number of cost-inclusive evaluations remains comparatively small. This article presents the results of three first-time cost-inclusive evaluations each performed by an experienced evaluator. Each evaluator performed a different type of cost-inclusive evaluation using different tobacco control programs as examples: standard cost-effectiveness analysis, threshold or break-even analysis, and a simulation model. Results are presented in terms of the challenges faced, and informational and insight benefits gained, as well as in terms of program cost-effectiveness. All three evaluators agreed that the benefits from performing cost-inclusive evaluations are well worth time and effort involved. They also found that this type of evaluation provides abundant information that can be used to improve program effectiveness and cost-effectiveness.