Ryan Butterfield

Receipt of Health Care Transition Counseling in the National Survey of Adult Transition and Health

OBJECTIVE: The goal of this study was to examine factors associated with receiving health care transition counseling services as reported by young adults. METHODS: We analyzed data from the 2007 Survey of Adult Transition and Health, a nationwide survey of young adults aged 19 to 23 years conducted by the National Center for Health Statistics, to explore self-reported receipt of services to support transition from pediatric to adult health care. Multivariate logistic regression was used to identify whether sociodemographic characteristics, health status, or markers of provider-youth health communication were associated with the receipt of 3 key transition counseling services. RESULTS: Among the 1865 Survey of Adult Transition and Health respondents, 55% reported that their physicians or other health care providers had discussed how their needs would change with age, 53% reported that their physicians or other health care providers had discussed how to obtain health insurance as an adult, and 62% reported having participated in a transition plan in school. Only 24% reported receiving all 3 transition counseling services. In multivariate logistic regression analyses, although gender, age, and race were not associated with increased receipt of the transition-related outcomes, markers of strong communication with the health system were associated with increased rates of receiving transition guidance. CONCLUSIONS: Many young adults reported not having received health care transition counseling. Provider-youth communication was associated with increased health care transition guidance, and suggests that a medical home model that promotes anticipatory guidance for health care transition could promote improvements in the transition process.

Association of cardiac events with coronary artery disease detected by 64-slice or greater coronary CT angiography: A systematic review and meta-analysis ☆

BACKGROUND The value of ≥64-slice coronary CT angiography (CCTA) to determine odds of cardiac death or non-fatal myocardial infarction (MI) needs further clarification. METHODS We performed a systematic review and meta-analysis using publications reporting events/severity of coronary artery disease (CAD) in patients with suspected CAD undergoing CCTA. Patients were divided into: no CAD, non-obstructive CAD (maximal stenosis <50%), and obstructive CAD (≥50% stenosis). Odds ratios with 95% confidence intervals were calculated using a fixed or random effects model. Heterogeneity was assessed using the I(2) index. RESULTS We included thirty-two studies comprising 41,960 patients with 363 all-cause deaths (15.0%), 114 cardiac deaths (4.7%), 342 MI (14.2%), 69 unstable angina (2.8%), and 1527 late revascularizations (63.2%) over 1.96 (SD 0.77) years of follow-up. Cardiac death or MI occurred in 0.04% without, 1.29% with non-obstructive, and 6.53% with obstructive CAD. OR for cardiac death or MI was: 14.92 (95% CI, 6.78 to 32.85) for obstructive CAD, 6.41 (95% CI, 2.44 to 16.84) for non-obstructive CAD versus no CAD, and 3.19 (95% CI, 2.29 to 4.45) for non-obstructive versus obstructive CAD and 6.56 (95% CI, 3.07 to 14.02) for no versus any CAD. Similar trends were noted for all-cause mortality and composite major adverse cardiovascular events. CONCLUSIONS Increasing CAD severity detected by CCTA is associated with cardiac death or MI, all-cause mortality, and composite major adverse cardiovascular events. Absence of CAD is associated with very low odds of major adverse events, but non-obstructive disease significantly increases odds of cardiac adverse events in this follow-up period.

A Quality Improvement Evaluation Case Study: Impact on Public Health Outcomes and Agency Culture

BACKGROUND Quality improvement (QI) is increasingly recognized as an important strategy to improve healthcare services and health outcomes, including reducing health disparities. However, there is a paucity of evidence documenting the value of QI to public health agencies and services. PURPOSE The purpose of this project was to support and assess the impact on the outcomes and organizational culture of a QI project to increase immunization rates among children aged 2 years (4:3:1:3:3:1 series) within a large public health agency with a major pediatric health mission. METHODS The intervention consisted of the use of a model-for-improvement approach to QI for the delivery of immunization services in public health clinics, utilizing plan-do-study-act cycles and multiple QI techniques. A mixed-method (qualitative and quantitative) model of evaluation was used to collect and analyze data from June 2009 to July 2011 to support both summative and developmental evaluation. The Florida Immunization Registry (Florida SHOTS [State Health Online Tracking System]) was used to monitor and analyze changes in immunization rates from January 2009 to July 2012. An interrupted time-series application of covariance was used to assess significance of the change in immunization rates, and paired comparison using parametric and nonparametric statistics were used to assess significance of pre- and post-QI culture items. RESULTS Up-to-date immunization rates increased from 75% to more than 90% for individual primary care clinics and the overall county health department. In addition, QI stakeholder scores on ten key items related to organizational culture increased from pre- to post-QI intervention. Statistical analysis confirmed significance of the changes. CONCLUSIONS The application of QI combined with a summative and developmental evaluation supported refinement of the QI approach and documented the potential for QI to improve population health outcomes and improve public health agency culture.

Validation of a pre-existing formula to calculate the contribution of ethanol to the osmolar gap.

Purpose. The aim of this study was to validate the formula derived by Purssell et al. that relates blood ethanol concentration to the osmolar gap and determine the best coefficient for use in the formula. The osmolar gap is often used to help diagnose toxic alcohol poisoning when direct measurements are not available. Methodology. Part I of the study consisted of a retrospective review of 603 emergency department patients who had a concurrent ethanol, basic metabolic panel and a serum osmolality results available. Estimated osmolarity (excluding ethanol) was calculated using a standard formula. The osmolar gap was determined by subtracting estimated osmolarity from the actual osmolality measured by freezing point depression. The relationship between the osmolar gap and the measured ethanol concentration was assessed by linear regression analysis. In Part II of this study, predetermined amounts of ethanol were added to aliquots of plasma and the estimated and calculated osmolarities were subjected to linear regression analysis. Results. In the cases of 603 patients included in Part I of the study, the median ethanol concentration in these patients was 166 mg/dL (Q1: 90, Q3: 254) and the range ethanol concentrations was 10–644 mg/dL. The mean serum osmolality was 338 mOsm/kg (SD: 30) and a range of 244–450 mOsm/kg. The mean osmolar gap was 47 (SD: 29) and a range of − 15 to 55. There was a significant proportional relationship between ethanol concentration and osmolar gap (r2 = 0.9882). The slope of the linear regression line was 0.2498 (95% CI: 0.2472–0.2524). The slope of the linear regression line derived from the data in Part II of the study was 0.2445 (95% CI: 0.2410–0.2480). Conclusions. The results of our study are in fairly close agreement with previous studies that used smaller samples and suggest that an accurate conversion factor for estimating the contribution of ethanol to the osmolar gap is [Ethanol (mg/dL)]/4.0.

The impact of third-hand smoke education in a pediatric emergency department on caregiver smoking policies and quit status: a pilot study

Abstract Environmental tobacco smoke (ETS) exposure is an international problem. Parental smoking is the primary exposure for children. While the adverse health effects of secondhand smoke to children are well recognized and used to educate caregivers, the concept of “third-hand smoke” (THS) and its use as an educational tool has been less studied. The purpose of this project was to determine the impact of brief THS intervention on smoking behaviors of caregivers of children seen in an urban pediatric ED. A convenience sample of children <36 months with caregivers who smoke brought to a pediatric ED was recruited. Consented caregivers were randomized to a control group who received routine education or intervention group who received brief THS education. Follow-up phone assessments were completed to evaluate smoking behavior changes. Of 40 caregivers analyzed, 85% were female, 72% were non-white, and mean age was 29 years. Results revealed the treatment group was more likely to change smoking policies (OR 2.0, 95% CI 0.166–24.069), reduce the number of cigarettes (OR 4.88, 95% CI 0.785–30.286), or quit smoking (OR 1.12, 95% CI 0.346–3.590). This study demonstrated that a brief THS intervention in our sample influenced smokers to change smoking behaviors. These changes would ultimately decrease ETS exposure to children and its adverse health effects. With the limitations of small sample size and high loss to follow-up, the study does not show statistical significance for generalizability.

An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services

OBJECTIVE ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone. METHODS All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone. RESULTS ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%). CONCLUSIONS In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.

Abstract A76: Poverty as a carcinogen

Background: The breast cancer mortality rate for black women in Duval County, FL (greater Jacksonville, FL) is the highest in the state of Florida, and is 38% higher for black women (36.7 per 100,000), than for white women (24.0 per 100,000). We sought to evaluate county specific breast cancer data, in an effort to better understand the disparities, and to begin designing effective targeted interventions to reduce these disparities. Methods: Data on female breast cancer cases from 2004-2010 were extracted using the Florida Cancer Data System (FCDS). This data was analyzed using traditional descriptive statistics. Additional classification included residence, race, insurance, and age. The primary outcomes were Stage at diagnosis, and time from diagnosis to treatment. Results: Using the FCDS, 6,579 new breast cancers were identified in Duval County from 2004 – 2010. Of these women, 73% were white, 24% black, 5% Hispanic, 2% Asian, and 2% unknown/other. Initially, univariate analyses identified black race, living in the urban core, being uninsured or having Medicaid insurance as having the worst outcomes in percentage of Stage IV disease at diagnosis and longer times from diagnosis to treatment (p Conclusion: Although initially black race was included as a significant predictor of poorer outcomes, advanced multivariate analyses revealed that living in the urban core, and lack of insurance or Medicaid funding was significantly associated with advanced stage at diagnosis and longer time from diagnosis to treatment in Duval County, Florida. Therefore, it seems that markers of poverty in Duval County, FL are better predictors of breast cancer disparities. These findings can inform targeted interventions to reduce the disparities in Duval County, FL. Citation Format: Sarah Rausch Osian, Laila Samiian, Dale Kraemer, Ryan Butterfield. Poverty as a carcinogen. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A76. doi:10.1158/1538-7755.DISP13-A76

Breast cancer disparities in Duval County, Florida.

117 Background: The age-adjusted death rate from breast cancer in Duval County is higher than the national average, with 26 deaths per 100,000 for all women. Breast cancer mortality is 38% higher for black women (37 per 100,000) in Duval County, than for white women (24 per 100,000). We sought to evaluate county specific breast cancer disparity data, in an effort to begin designing effective targeted interventions to reduce the disparities. METHODS Data on female breast cancer cases from 2004-2010 was extracted using the Florida Cancer Data System (FCDS). This data was analyzed using traditional descriptive statistics. Additional classification included health zones within Duval County, race, insurance, and age. Government (Tricare) and private or commercial insurance were combined in one group. The primary outcome was Stage at diagnosis, and time from diagnosis to treatment. RESULTS Using the FCDS, 6,502 new breast cancers were identified in Duval County from 2004-2010. Of these women, 73% were white, 24% black, 5% Hispanic, 2% Asian, and 2% unknown/other. Health Zone 1 which represents the urban core, has the largest population of Black women with breast cancer (76%), followed by health zone 5 and 4 (35% and 19%). Health Zone 1 has the highest volume of uninsured (10% vs 4% average for zones 2-6), and Medicaid breast cancer patients (8% vs 4% average for zones 2-6), and the lowest number of breast cancer patients with Government/Private insurance (33% vs 56%). Black women had higher percentage of advanced stage IV disease than any other race (8 % vs 4 %, p< .001). Women in Health Zone 1 are more likely to present with stage IV breast cancer than any other health zone in Duval County (10% vs 5%, p<0.01). Medicaid patients followed by the uninsured had the highest rate of stage IV at diagnosis (20% and 12% vs 4%, p<.001). Time from diagnosis to treatment was found to be longest in Black women (29 days vs 26 days, p< .001), Health Zone 1 (30 days vs county average 27 days, p<. 001), and those who were uninsured or had Medicaid (34 days vs 25 days for private insurance, p<0.001). CONCLUSIONS Living in the urban core, black race, lack of insurance, and Medicaid funding was significantly associated with advanced stage at diagnosis and longer time from diagnosis to treatment in Duval County, Florida.