Norman J. Waitzman

Phantom of the area: poverty-area residence and mortality in the United States.

OBJECTIVES The purpose of the study was to conduct a national multivariate analysis on poverty-area residence and mortality in the United States. METHODS Proportional hazards analyses were performed of the effect of poverty-area residence on the risk of mortality among adult examinees in the 1971 through 1974 National Health and Nutrition Examination Survey who were followed through 1987. RESULTS Poverty-area residence was associated with significantly elevated risk of all-cause mortality (rate ratio = 1.78, 95% confidence interval = 1.33, 2.38) and some cause-specific mortality among those aged 25 through 54 years, but not among those aged 55 through 74 years, at baseline after adjustment for several individual and household characteristics. CONCLUSIONS Residence in poverty areas contributes to socioeconomic gradients in mortality among nonelderly adults in the United States.

Separate but lethal: the effects of economic segregation on mortality in metropolitan America.

The increase in income inequality in the United States over the past 20 years has been accompanied by a pronounced increase in economic segregation in urban areas. No research to date has analyzed the potential effects of such spatial segregation on mortality. To investigate these effects, the mortality experience of respondents aged 30 years and older on the 1986-94 National Health Interview Surveys residing in any one of 30 large metropolitan areas in the United States was analyzed. Concentrated poverty was associated with significantly elevated risk of mortality, even after controlling for individual household income. Concentrated affluence showed a consistent, protective effect only among the elderly. The effects were most pronounced among the poor, but were not confined to them. Urban planning should take into account the effects associated with economic residential segregation.

Reevaluating the Benefits of Folic Acid Fortification in the United States: Economic Analysis, Regulation, and Public Health

Before a 1996 US regulation requiring fortification of enriched cereal-grain products with folic acid, 3 economic evaluations projected net economic benefits or cost savings of folic acid fortification resulting from the prevention of pregnancies affected by a neural tube defect. Because the observed decline in neural tube defect rates is greater than was forecast before fortification, the economic gains are correspondingly larger. Applying both cost-benefit and cost-effectiveness analytic techniques, we estimated that folic acid fortification is associated with annual economic benefit of 312 million dollars to 425 million dollars. The cost savings (net reduction in direct costs) were estimated to be in the range of 88 million dollars to 145 million dollars per year.

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Double jeopardy: Interaction effects of marital and poverty status on the risk of mortality

The purpose of this paper is to examine the hypothesis that marital and poverty status interact in their effects on mortality risks beyond their main effects. This study examines the epidemiological bases for applying an additive rather than a multiplicative specification when testing for interaction between two discrete risk factors. We specifically predict that risks associated with being nonmarried and with being poor .interact to produce mortality risks that are greater than each risk acting independently. The analysis is based on men and women who were ages 25–74 during the 1971–1975 National Health and Nutrition Examination Survey I (NHANES I) and who were traced successfully in the NHANES I Epidemiologic Follow-Up Study in 1982–1984. Overall, being both poor and nonmarried places nonelderly (ages 25–64) men, but not women, at risk of mortality greater than that expected from the main effects. This study shows that for all-cause mortality, marital and poverty status interact for men but less so for women; these findings exist when interaction is assessed with either a multiplicative or an additive standard. This difference is most pronounced for poor, widowed men and (to a lesser degree) poor, divorced men. For violent/accidental deaths among men, the interaction effects are large on the basis of an additive model. Weak main and interaction effects were detected for the elderly (age 65 +).

Living with Phenylketonuria: Perspectives of Patients and Their Families

SummaryThis study surveyed PKU patients and their primary caretakers to assess their current management practices, the barriers to effective management, and the potential utility of a home monitor in managing PKU. A survey instrument was mailed to caretakers of all 50 patients with PKU in Utah between the ages of 2 and 18 years in 1997 (response rate 64%). It included separate components for caretakers and patients aged 10 to 18 years. Although there was uneven compliance with recommended practices, caretakers universally recognized the negative consequences of not adhering to the low-protein diet. There was, however, disagreement regarding such consequences among the older children surveyed. The primary obstacles cited to better adherence were time constraints and stress associated with food preparation and record-keeping, and the restrictions imposed on social life. Phenylalanine test results were regarded as the principal signal for the need for dietary adjustment. Despite the facts that obstacles to dietary adherence are multifaceted and that no single intervention would therefore serve as a panacea, a large majority of respondents believed a home monitor would facilitate better management of PKU through more regular and timely feedback.

The effects of occupational class transitions on hypertension: racial disparities among working-age men.

OBJECTIVES This study was undertaken to examine how the interaction between occupational class transitions and race affects the incidence of hypertension. METHODS A cohort of 1982 men (183 Black), ages 25 to 55, received a baseline medical exam between 1971 and 1975 and a follow-up between 1982 and 1984. Logistic regressions were estimated for hypertension at follow-up controlling for hypertension at baseline, other risk factors associated with blood pressure, and interaction terms identifying specific occupational class transitions among Blacks and Whites. The occupational class matrix was based largely on scores of US Census Bureau occupations from the Dictionary of Occupational Titles. RESULTS Relative to Whites who remained in professional and technical jobs between baseline and follow-up, Blacks and Whites who remained in lower occupational classes or made specific transitions--notably into the lowest class--had significantly higher incidence rates of hypertension. These differences were greater among Blacks, who are also more concentrated in and less likely to move upward from the lower end of the occupational class matrix. CONCLUSIONS Widening racial disparities in high blood pressure over the period of study may be partly attributable to characteristics associated with occupational class position and dynamics.

A Multivariate Analysis of Federally Mandated School Wellness Policies on Adolescent Obesity

PURPOSE To evaluate the effects of school wellness policies mandated by the 2004 Child Nutrition and WIC Reauthorization Act on the prevalence of overweight and obesity among adolescents. METHODS Multivariate logistic regressions, adjusted for clustering within school districts, were used to estimate the effects of district-level wellness policies on the odds of overweight and obesity among adolescents. The analyses were performed on a population-based sample obtained from the Utah Population Database, a compilation of vital characteristic, administrative, and genealogical records on all residents in Utah. Models controlled for individual, maternal, and familial characteristics, as well as characteristics of school district of residence. Self-reported body mass index was taken from drivers license data. RESULTS Each additional component included in a districts wellness policy was associated with as much as: 3.2% lower odds in the prevalence of adolescent overweight (OR = .968; 95% CI = .941-.997), 2.5% lower odds of obesity (OR = .975; CI = .952-.997), and 3.4% lower odds of severe obesity (OR = .966; CI = .938-.995). Wellness policy components related to diet were significantly associated with lower body mass indexes across all three thresholds, whereas those related to physical activity had significant associations for lower odds of severe obesity only. CONCLUSION Results suggest that school wellness policies can significantly reduce the risk of adolescent obesity. Further research should address specific policy components that are most effective in various populations, as well as the level of commitment that is required at both the school- and district-levels for sustained effect.

Retrospective Assessment of Cost Savings From Prevention

INTRODUCTION Although fortification of food with folic acid has been calculated to be cost saving in the U.S., updated estimates are needed. This analysis calculates new estimates from the societal perspective of net cost savings per year associated with mandatory folic acid fortification of enriched cereal grain products in the U.S. that was implemented during 1997-1998. METHODS Estimates of annual numbers of live-born spina bifida cases in 1995-1996 relative to 1999-2011 based on birth defects surveillance data were combined during 2015 with published estimates of the present value of lifetime direct costs updated in 2014 U.S. dollars for a live-born infant with spina bifida to estimate avoided direct costs and net cost savings. RESULTS The fortification mandate is estimated to have reduced the annual number of U.S. live-born spina bifida cases by 767, with a lower-bound estimate of 614. The present value of mean direct lifetime cost per infant with spina bifida is estimated to be

Quality, Satisfaction, and Financial Efficiency Associated With Elements of Primary Care Practice Transformation: Preliminary Findings

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