Phyllis Brawarsky

Body Mass Index, Provider Advice, and Target Gestational Weight Gain

OBJECTIVE: To study the relationships among prepregnancy body mass index (BMI), womens target gestational weight gain, and provider weight gain advice. METHODS: Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women in the San Francisco Bay area. We excluded subjects with preterm birth, multiple gestation, or maternal diabetes. RESULTS: Among overweight women (prepregnancy BMI 26.1–29.0), 24.1% reported a target weight gain above the Institute of Medicine (IOM) guidelines, compared with 4.3% of normal weight women (P < .001). Among women with a low prepregnancy BMI (< 19.8), 51.2% reported a target weight gain below the guidelines, compared with 10.4% of normal weight women (P < .001). These patterns persisted in a multivariate analysis. Latina ethnicity, lower maternal education, low prepregnancy BMI (< 19.8), lack of provider advice about weight gain, and provider advice to gain below guidelines were all independently associated with a target weight gain below IOM guidelines. Prepregnancy BMI more than 26, multiparity, lower age, and provider advice to gain above guidelines were all associated with a target gain above IOM guidelines. CONCLUSION: Womens beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain. LEVEL OF EVIDENCE: II-2

Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain

Objective: Gestational weight gain consistent with the Institute of Medicines recommendations is associated with better maternal and infant outcomes. The objective was to quantify the effect of pre‐pregnancy factors, pregnancy‐related health conditions, and modifiable pregnancy factors on the risks of inadequate and excessive gestational weight gain. Method: A longitudinal cohort of pregnant women (N = 1100) who completed questions about diet and weight gain during pregnancy and delivered a singleton, full‐term infant. Results: Gestational weight gain was inadequate for 14% and excessive for 53%. Pre‐pregnancy factors contributed 74% to excessive gain, substantially more than pregnancy‐related health conditions (15%) and modifiable pregnancy factors (11%). Pre‐pregnancy factors, pregnancy‐related health conditions, and modifiable pregnancy factors contributed fairly equally to the risk of inadequate gain. Conclusion: Interventions to prevent excessive gestational gain may need to start before pregnancy. Women at risk for inadequate gain would also benefit from interventions directed toward modifiable factors during pregnancy.

Changes in the Health Status of Women During and After Pregnancy

OBJECTIVE: To characterize the changes in health status experienced by a multi-ethnic cohort of women during and after pregnancy.DESIGN: Observational cohort.SETTING/PARTICIPANTS: Pregnant women from 1 of 6 sites in the San Francisco area (N=1,809).MEASUREMENTS AND MAIN RESULTS: Women who agreed to participate were asked to complete a series of telephone surveys that ascertained health status as well as demographic and medical factors. Substantial changes in health status occurred over the course of pregnancy. For example, physical function declined, from a mean score of 95.2 prior to pregnancy to 58.1 during the third trimester (0–100 scale, where 100 represents better health), and improved during the postpartum period (mean score, 90.7). The prevalence of depressive symptoms rose from 11.7% prior to pregnancy to 25.2% during the third trimester, and then declined to 14.2% during the postpartum period. Insufficient money for food or housing and lack of exercise were associated with poor health status before, during, and after pregnancy.CONCLUSIONS: Women experience substantial changes in health status during and after pregnancy. These data should guide the expectations of women, their health care providers, and public policy.

Massachusetts Health Reform and Disparities in Coverage, Access and Health Status

ABSTRACTBackgroundMassachusetts health reform has achieved near-universal insurance coverage, yet little is known about the effects of this legislation on disparities.ObjectiveSince racial/ethnic minorities and low-income individuals are over-represented among the uninsured, we assessed the effects of health reform on disparities.DesignCross-sectional survey data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 2006–2008.ParticipantsAdults from Massachusetts (n = 36,505) and other New England states (n = 63,263).Main MeasuresSelf-reported health coverage, inability to obtain care due to cost, access to a personal doctor, and health status. To control for trends unrelated to reform, we compared adults in Massachusetts to those in all other New England states using multivariate logistic regression models to calculate adjusted predicted probabilities.Key ResultsOverall, the adjusted predicted probability of health coverage in Massachusetts rose from 94.7% in 2006 to 97.7% in 2008, whereas coverage in New England remained around 92% (p < 0.001 for difference-in-difference). While cost-related barriers were reduced in Massachusetts, there were no improvements in access to a personal doctor or health status. Although there were improvements in coverage and cost-related barriers for some disadvantaged groups relative to trends in New England, there was no narrowing of disparities in large part because of comparable or larger improvements among whites and the non-poor.ConclusionsAchieving equity in health and health care may require additional focused intervention beyond health reform.

Racial segregation and disparities in breast cancer care and mortality.

Questions have existed as to whether residential segregation is a mediator of racial/ethnic disparities in breast cancer care and breast cancer mortality, or has a differential effect by race/ethnicity.

Racial segregation and disparities in cancer stage for seniors

SummaryBackgroundDisparities in cancer survival may be related to differences in stage. Segregation may be associated with disparities in stage, particularly for cancers for which screening promotes survival.ObjectivesThe objective of the study was to examine whether segregation modifies racial/ethnic disparities in stage.DesignThe design of the study was analysis of Surveillance, Epidemiology, and End Results Medicare data for seniors with breast, colorectal, lung, and prostate cancer (n = 410,870).Measurements and main resultsThe outcome was early- versus late-stage diagnosis. Area of residence was categorized into 4 groups: low segregation/high income (potentially the most advantaged), high segregation/high income, low segregation/low income, and high segregation/low income (possibly the most disadvantaged). Blacks were less likely than whites to be diagnosed with early-stage breast, colorectal, or prostate cancer, regardless of area. For colorectal cancer, the black/white disparity was largest in low-segregation/low-income areas (black/white odds ratio [OR] of early stage 0.51) and smallest in the most segregated areas (ORs 0.71 and 0.74, P < .005). Differences in disparities in stage by area category were not apparent for breast, prostate, or lung cancer. Whereas there were few Hispanic–white differences in early-stage diagnosis, the Hispanic/white disparity in early-stage diagnosis of breast cancer was largest in low-segregation/low-income areas (Hispanic/white OR of early stage 0.54) and smallest in high-segregation/low-income areas (OR 0.96, P < .05 compared to low-segregation/low-income areas).ConclusionsDisparities in stages for cancers with an established screening test were smaller in more segregated areas.

An electronic health record-based intervention to improve tobacco treatment in primary care: a cluster-randomized controlled trial.

BACKGROUND To improve the documentation and treatment of tobacco use in primary care, we developed and implemented a 3-part electronic health record enhancement: (1)smoking status icons, (2) tobacco treatment reminders, and (3) a Tobacco Smart Form that facilitated the ordering of medication and fax and e-mail counseling referrals. METHODS We performed a cluster-randomized controlled trial of the enhancement in 26 primary care practices between December 19, 2006, and September 30, 2007. The primary outcome was the proportion of documented smokers who made contact with a smoking cessation counselor. Secondary outcomes included coded smoking status documentation and medication prescribing. RESULTS During the 9-month study period, 132 630 patients made 315 962 visits to study practices. Coded documentation of smoking status increased from 37% of patients to 54% (+17%) in intervention practices and from 35% of patients to 46% (+11%) in control practices (P < .001 for the difference in differences). Among the 9589 patients who were documented smokers at the start of the study, more patients in the intervention practices were recorded as nonsmokers by the end of the study (5.3% vs 1.9% in control practices; P < .001). Among 12 207 documented smokers, more patients in the intervention practices made contact with a cessation counselor (3.9% vs 0.3% in control practices; P < .001). Smokers in the intervention practices were no more likely to be prescribed smoking cessation medication (2% vs 2% in control practices; P = .40). CONCLUSION This electronic health record-based intervention improved smoking status documentation and increased counseling assistance to smokers but not the prescription of cessation medication.

Race/Ethnicity, Socioeconomic Status and the Health of Pregnant Women

We examined how traditional (income, education) and nontraditional (public assistance, material deprivation, subjective social standing) socioeconomic status (SES) indicators were associated with self-rated health, physical functioning, and depression in ethnically diverse pregnant women. Using multiple regression, we estimated the association of race/ethnicity (African American, Latino, Asian/Pacific Islander (PI) and white) and sets of SES measures on each health measure. Education, material deprivation, and subjective social standing were independently associated with all health measures. After adding all SES variables, race/ethnic disparities in depression remained for all minority groups; disparities in self-rated health remained for Asian/Pacific Islanders. Few race/ethnic differences were found in physical functioning. Our results contribute to a small literature on how SES might interact with race/ethnicity in explaining health.

Association of area sociodemographic characteristics and capacity for treatment with disparities in colorectal cancer care and mortality

Disparities in treatment and mortality for colorectal cancer (CRC) may reflect differences in access to specialized care or other characteristics of the area where an individual lives.

What if the federal government negotiated pharmaceutical prices for seniors? An estimate of national savings.

The government is prohibited from directly negotiating drug prices for Medicare Part D, resulting in substantial policy debate. However, the government has an established mechanism for setting prices with pharmaceutical manufacturers for certain other federal programs - the Federal Supply Schedule (FSS). To estimate how much could be saved nationwide if prices equivalent to the 2006 FSS were achieved for the top 200 drug formulations dispensed to seniors. Cross-sectional analysis of drug utilization patterns and costs from the nationally representative Medical Expenditure Panel Surveys (MEPS), 2003–2004, and the 2006 FSS. Seniors who filled a prescription for any of these common drugs (n = 6,135 individuals). Prescription expenditures were obtained from MEPS, and a price/unit was calculated in 2006 dollars. This price/unit was compared to the 2006 FSS, and a savings/unit was calculated and summed across the observed units dispensed in MEPS. The potential annual savings with FSS prices would be