Stephanie Bernell

The Association Between Urban Sprawl And Obesity: Is It A Two-Way Street?

We empirically examine the relationship between obesity and urban development patterns where individuals reside. Previous analyses treat urban form as exogenous to weight, and find higher body mass indices (BMI) among residents of areas with sprawl patterns of development. Using samples of recent movers, we find that the causality runs in both directions. Individuals who move to denser locations lose weight. As well, BMI is a determinant of the choice of a dense or sprawling location. In sum, while moving to a dense area results in weight loss, such locations are unlikely to be selected by individuals with high BMI.

Oregon's Experiment in Health Care Delivery and Payment Reform: Coordinated Care Organizations Replacing Managed Care

To control Medicaid costs, improve quality, and drive community engagement, the Oregon Health Authority introduced a new system of coordinated care organizations (CCOs). While CCOs resemble traditional Medicaid managed care, they have differences that have been deliberately designed to improve care coordination, increase accountability, and incorporate greater community governance. Reforms include global budgets integrating medical, behavioral, and oral health care and public health functions; risk-adjusted payments rewarding outcomes and evidence-based practice; increased transparency; and greater community engagement. The CCO model faces several implementation challenges. If successful, it will provide improved health care delivery, better health outcomes, and overall savings.

Does the Racial Composition of the School Environment Influence Children's Body Mass Index?

PURPOSE This study investigates the degree to which the racial composition of the school environment may influence the body mass index (BMI) of children aged 10 to 18 years. This research may be viewed as extending prior work that has found that the prevalence of risk behaviors among nonwhite adolescents is influenced by exposure to white adolescents. METHODS This research used data from the Survey of Adults and Youth, which was conducted as part of the evaluation of the Robert Wood Johnson Foundations Urban Health Initiative. The study population for this analysis is comprised of parent and child respondents in the 2004 to 2005 survey wave who lived in one of the five program cities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. We constructed two-level school random effects models and added school and census tract-level variables that describe the racial composition of the residential community and the school attended. RESULTS Black and Hispanic adolescent girls who attend schools with a mostly nonwhite student body have higher BMIs than do their white counterparts. However, black girls in predominately white schools do not have higher BMIs than white girls. Further, black and Hispanic girls whose schoolmates are predominately white have significantly lower BMIs than black and Hispanic girls in schools where fewer than half the students are white. These associations are not found among boys, and are net of a broad variety of individual, household, and group level characteristics. CONCLUSIONS Our findings suggest that the BMI of minority adolescent girls is influenced by the norms of the social environment.

Use Your Words Carefully: What Is a Chronic Disease?

One important element of effective communication is having a shared language or at least a shared understanding of the meaning of the central words used in a conversation. One term that is often used in discussions between patients and medical providers, in the academic literature, and in policy discussions, is “chronic disease.” There is not only tremendous variation in the diseases that are included under the umbrella term “chronic disease” but also variation in the time a disease must be present for something to be referred to as chronic. Furthermore, there is a move to include chronic conditions that are not indicators of disease, but long-standing functional disabilities, including developmental disorders and visual impairment (1–4). Within professional communities (i.e., medical, public health, academic, and policy), there is a large degree of variation in the use of the term chronic disease. For example, the Centers for Disease Control (CDC) classify the following as chronic diseases: heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis (5). The Centers for Medicare and Medicaid Services have a more extensive list of 19 chronic conditions that includes Alzheimer’s disease, depression, and HIV, to name a few. This difference, within the Department of Health and Human Services alone, although not surprising to those in the field, has the potential to create confusion and misunderstanding when speaking in generalities about the impact of chronic disease, the cost of chronic disease, and overall measures to reduce chronic disease. The academic literature is not immune to the same kind of terminology variation. Differences in how “chronic disease” is used are largely dependent on the data used for the research and the discipline of the lead authors (i.e., public health and sociology). For example, one study, authored by individuals from Harvard Medical School, explored the prevalence of chronic disease using NHANES data (1999–2004). The study classifies the following as chronic diseases: cardiovascular disease, hypertension, diabetes mellitus, hypercholesterolemia, asthma, COPD, and previous cancer (6). Another academic study on chronic disease, authored by a geriatrician, classifies chronic illness as “conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living” (7). The implication of a non-uniform use of the term is that a detailed read of each study is necessary to avoid erroneous conclusions regarding interventions necessary to reduce chronic disease burden for the individual and society. Popular Internet sources used by the general public to gather medical information use the terms “chronic disease” or “chronic condition” to mean slightly different things. For example, MedicineNet describes a chronic disease as,

Oregon's Coordinated Care Organizations: A Promising and Practical Reform Model

Continuing its path of Medicaid program innovation, Oregon recently embarked on a major reform that gives regional coordinated care organizations (CCOs) global budgets and accountability for the physical, behavioral, and dental care of the states Medicaid beneficiaries (Howard et al. 2014). There are some who maintain that the states bold reform initiative is overly aggressive in scope and unrealistically optimistic in schedule and may prove to be a costly debacle to the state of Oregon. We argue that the Oregon CCO model is not only bold in its aims and timetable but also realistically achievable.

Oregon’s Coordinated Care Organizations Increased Timely Prenatal Care Initiation And Decreased Disparities

Policies at the state and federal levels affect access to health services, including prenatal care. In 2012 the State of Oregon implemented a major reform of its Medicaid program. The new model, called a coordinated care organization (CCO), is designed to improve the coordination of care for Medicaid beneficiaries. This reform effort provides an ideal opportunity to evaluate the impact of broad financing and delivery reforms on prenatal care use. Using birth certificate data from Oregon and Washington State, we evaluated the effect of CCO implementation on the probability of early prenatal care initiation, prenatal care adequacy, and disparities in prenatal care use by type of insurance. Following CCO implementation, we found significant increases in early prenatal care initiation and a reduction in disparities across insurance types but no difference in overall prenatal care adequacy. Oregons reforms could serve as a model for other Medicaid and commercial health plans seeking to improve prenatal care quality and reduce disparities.

Link Between Perceived Body Weight and Smoking Behavior Among Adolescents

INTRODUCTION This study investigates a relationship between overweight perception and smoking among adolescents. METHODS Data were retrieved from the Youth Risk Behavior Survey (YRBS), a biennial survey of a nationally representative sample of students in grades 9 through 12 in the United States. We analyze five waves of repeated cross-sections (N = 73 376) for the years 2005-2013. We estimate a recursive simultaneous-equations system in which body weight perception, which is a function of actual weight, influences smoking status. Outcome measures are binary indicators for current smoking and frequent current smoking. Perceived weight is categorized into very overweight perception, slightly overweight perception, and about the right weight/underweight perception. RESULTS In comparison to adolescents who perceive themselves to be the right weight or underweight, adolescents who perceive themselves to be very overweight are 6.1 percentage points (pp) (standard error [SE] = 1.6pp) more likely to currently smoking and 3.3pp (SE = 1.2pp) more likely to frequently smoke. Adolescents with slightly overweight perception are 7.9pp (SE = 1.0pp) and 2.5pp (SE = 0.6pp) more likely to currently smoke and frequently smoke, respectively, as compared to those with the right weight/underweight perception. The relationships are larger for females, and appear to be mediated by weight-loss activity. DISCUSSION In an era of tight budgets, it is crucial to address both obesity and smoking in manners that do not work at cross purposes. Strategies to combat youth smoking may be more effective if the perception of being overweight is considered an important risk factor, especially among female adolescents. IMPLICATIONS We find that perception of being overweight is an important causal risk factor for adolescent smoking. Main findings of this study imply that even a slight change in the perception of body weight may lead to a significant change in smoking behavior among adolescents, especially among females and that the perception of being overweight induces adolescents to smoke regularly. Unlike most prior studies, we discovered a positive effect of slight overweight perception on smoking for adolescent males. Our findings emphasize the importance of addressing both obesity and smoking in manners that do not work at cross purposes.

The new co-payment policy under Taiwan’s National Health Insurance: welfare gain or welfare loss?

This paper provides a welfare assessment of the new Taiwan National Health Insurance (NHI) co-payment policy, enacted July 15, 2005. This policy creates a pricing mechanism designed to entice patients to first seek outpatient care at local clinics rather than hospitals. Our empirical findings suggest that while the new policy results in a net welfare gain, it is far less than the expected annual growth in NHI medical expenditure. Thus, additional policy changes will be required to deal with Taiwan’s NHI future financial shortfalls.

Factors influencing maternal nutrition in rural Nepal: an exploratory research project.

In this pilot project we examined factors contributing to maternal nutrition among women of child-bearing age in the Western Region of Nepal. We found that rural women are interested in learning about nutrition regardless of educational attainment and that level of education is strongly associated with interest in learning about nutrition (p <.001). Although the majority of women with no education expressed interest in learning about nutrition (71%), a substantial percentage (22%) were not interested. Education and the teaching of basic health messages may hold important benefits for improving maternal and child health.

The cost of a pediatric neurocritical care program for traumatic brain injury: a retrospective cohort study

BackgroundInpatient care for children with severe traumatic brain injury (sTBI) is expensive, with inpatient charges averaging over