Colorectal cancer is an Ambulatory Care Sensitive Condition.

Ambulatory Care Sensitive Conditions (ACSC) are conditions where the provision of ambulatory care may affect the probability of hospitalization or the severity of the disease at the time of hospitalization. Population-based measurement of ACSCs can focus attention on aspects of ambulatory care that merit strengthening to improve access, quality, or patient compliance to achieve better outcomes and reduce costs. If colorectal cancer was added to the list of ACSCs, it would highlight the continuum of care that starts in the ambulatory setting and includes risk assessment as well as access to colonoscopy, which is the only means of adenoma removal after a positive screen. Each link in the continuum of care can increase or reduce the rates of colorectal cancer incidence and mortality at the local and national levels. Employing colorectal cancer as an ACSC at the hospital level or state level can provoke policy makers and managers to examine these links for gaps and weaknesses that merit attention and may be addressed.

Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study.

BACKGROUND: In the US, a growing body of epidemiological studies has documented widespread potentially inappropriate medication prescribing among the elderly in outpatient settings. However, only limited information exists in Europe. OBJECTIVE: To evaluate the prevalence of potentially inappropriate medication prescribing among elderly outpatients in Emilia Romagna, Italy and to investigate factors associated with potentially inappropriate medication prescribing in that setting. METHODS: Retrospective cohort study using the Emilia Romagna outpatient prescription claims database from 1 January 2001 to 31 December 2001 linked with information (age, sex and other variables) available from a demographic file of approximately 1 million Emilia Romagna residents aged >or=65 years. The cohort comprised 849 425 elderly patients who had at least one drug prescription during the study period. The prevalence of potentially inappropriate medication prescribing, as defined by the 2002 Beers' criteria, was measured together with predictors associated with potentially inappropriate medication prescribing. RESULTS: A total of 152 641 (18%) elderly Emilia Romagna outpatients had one or more occurrences of potentially inappropriate medication prescribing. Of these, 11.5% received prescriptions for two medications of concern and 1.7% for three or more. Doxazosin (prescribed to 23% of subjects) was the most frequently occurring potentially inappropriate prescribed medication, followed by ketorolac (20.5%), ticlopidine (18.3%) and amiodarone (12.6%). Factors associated with greater likelihood of potentially inappropriate medication prescribing were older age, overall number of drugs prescribed and greater number of chronic conditions. The odds of receiving potentially inappropriate prescribed medications were lower for females, subjects living in more urban areas and subjects with a higher income level. CONCLUSIONS: This study provides strong evidence that potentially inappropriate medication prescribing for elderly outpatients is a substantial problem in Emilia Romagna. Focusing on the prevalence of potentially inappropriate medication prescribing and associated predictors can help in the development of educational programmes targeting outpatient practitioners to influence prescribing behaviour and, therefore, reduce potentially inappropriate medication prescribing.

Utilization of the office, hospital and emergency department for adult sickle cell patients: a five-year study.

Sickle cell disease (SCD) is a hematological disorder that is manifested primarily by severe pain and chronic organ damage. Little normative data exists on what the usual healthcare utilization is of a population of SCD patients, especially adults. Our study analyzed the office, emergency department (ED) and hospital use data for 142 patients who received care for three consecutive years. Relationships between health service use, patient age, gender and sickle cell phenotype were described. Multivariate analyses studied relationships between demographic and clinical characteristics and levels of office, independent ED and inpatient encounters over a five-year period (1997-2001). We found female patients were older and had less ED and hospital admissions. The 20% highest inpatient utilizers accounted for 54% of the ED total visits, 52% of the ED independent visits, 54% of hospital bed days and 24% of office visits. The ED was a common place for utilization, with a mean of 7.4 visits per patient year, a third of which resulted in a hospital admission. The healthcare utilization of our adult sickle cell population is very complex, with a subset of our patients accounting for a majority of the resources used and female patients living longer but with less ED and hospital admissions.

Using pharmacy data to identify those with chronic conditions in Emilia Romagna, Italy.

BACKGROUND AND OBJECTIVES: Automated pharmacy data have been used to develop a measure of chronic disease status in the general population. The objectives of this project were to refine and apply a model of chronic disease identification using Italian automated pharmacy data; to describe how this model may identify patterns of morbidity in Emilia Romagna, a large Italian region; and to compare estimated prevalence rates using pharmacy data with those available from a 2000 Emilia Romagna disease surveillance study. METHODS: Using the Chronic Disease Score, a list of chronic conditions related to the consumption of drugs under the Italian pharmaceutical dispensing system was created. Clinical review identified medication classes within the Italian National Therapeutic Formulary that were linked to the management of each chronic condition. Algorithms were then tested on pharmaceutical claims data from Emilia Romagna for 2001 to verify the applicability of the classification scheme. RESULTS: Thirty-one chronic condition drug groups (CCDGs) were identified. Applying the model to the pharmacy data, approximately 1.5 million individuals (37.1%) of the population were identified as having one or more of the 31 CCDGs. The 31 CCDGs accounted for 77% (E556 million) of 2001 pharmaceutical expenditures. Cardiovascular diseases, rheumatological conditions, chronic respiratory illness, gastrointestinal diseases and psychiatric diseases were the most frequent chronic conditions. External validation comparing rates of the diseases found through using pharmacy data with those of a 2000 Emilia Romagna disease surveillance study showed similar prevalence of illness. CONCLUSIONS: Using Italian automated pharmacy data, a measure of population-based chronic disease status was developed. Applying the model to pharmaceutical claims from Emilia Romagna 2001, a large proportion of the population was identified as having chronic conditions. Pharmacy data may be a valuable alternative to survey data to assess the extent to which large populations are affected by chronic conditions.

Spatio-temporal variability in the distribution of ground-dwelling riparian spiders and their potential role in water-to-land energy transfer along Hong Kong forest streams.

Terrestrial predators have been shown to aggregate along stream margins during periods when the emergence of adult aquatic insects is high. Such aggregation may be especially evident when terrestrial surroundings are relatively unproductive, and there are steep productivity gradients across riparia. In tropical forests, however, the productivity of inland terrestrial habitats may decrease the resource gradient across riparia, thus lessening any tendency of terrestrial predators to aggregate along stream margins. We elucidated the spatio-temporal variability in the distribution of ground-dwelling spiders and terrestrial arthropod prey within the riparia of two forest streams in tropical Hong Kong by sampling arthropods along transects at different distances from the streams during the wet and dry seasons. Environmental variables that may have influenced spider distributions were also measured. The vast majority of ground-dwelling predators along all transects at both sites were spiders. Of the three most abundant spiders captured along stream margins, Heteropoda venatoria (Sparassidae) and Draconarius spp. (Agelenidae) were terrestrially inclined and abundant during both seasons. Only Pardosa sumatrana (Lycosidae) showed some degree of aggregation at the stream banks, indicating a potential reliance on aquatic insect prey. Circumstantial evidence supports this notion, as P. sumatrana was virtually absent during the dry season when aquatic insect emergence was low. In general, forest-stream riparia in Hong Kong did not appear to be feeding hotspots for ground-dwelling predators. The lack of aggregation in ground-dwelling spiders in general may be attributed to the low rates of emergence of aquatic insects from the study streams compared to counterpart systems, as well as the potentially high availability of terrestrial insect prey in the surrounding forest. Heteropoda venatoria, the largest of the three spiders maintained a high biomass (up to 28 mg dry weight/m(2)) in stream riparia, exceeding the total standing stock of all other spiders by 2-80 times. The biomass and inland distribution of H. venatoria could make it a likely conduit for the stream-to-land transfer of energy.

Differential Role of Social Connectedness in Geriatric Depression Among Southeast Asian Ethnic Groups.

BACKGROUND: There is little empirical evidence on the effects of social connectedness on geriatric depression for Southeast Asians. Studies have rarely examined interethnic differences in the resilience factors for depression in this diverse population. Greater understanding is needed as the number of older Southeast Asians in the United States increases. OBJECTIVES: We sought to examine the association between social connectedness and depressive symptoms in Vietnamese, Laotian, and Cambodian elders. METHODS: Using a community-based participatory research (CBPR) approach, bilingual/bicultural staff collected demographics, the Lubben Social Network Scale, and the Geriatric Depression Scale (GDS). Univariate and multivariate regression models were constructed for the full aggregated sample and for each ethnic subgroup. RESULTS: In the full aggregated sample analysis, Southeast Asian elders were at increased risk for depression and had low social connectedness. Marriage and English proficiency were resilience factors, whereas social connectedness did not play a significant role. In disaggregated analyses, high social connectedness, marriage, and younger age were resilience factors for Vietnamese elders. English proficiency was the only significant resilience factor for Laotians, and age at the time of immigration was the only significant resilience factor for Cambodian elders. CONCLUSIONS: This study underscores the need for researchers to disaggregate data for ethnic subgroups in the Asian American population. Southeast Asian elders are at increased risk for depression and have low social connectedness. There exist important interethnic differences in resilience factors for geriatric depression, suggesting the need for more studies and interventions that are sensitive to subtle cultural differences among Southeast Asian subgroups.

Severity of illness and ambulatory care-sensitive conditions.

This study describes how severity of illness may refine the definition of ambulatory care-sensitive conditions, or ACSCs. Hospital discharge abstract data from Philadelphia were combined with census data to develop population-based adjusted rates of hospitalization for diabetes and asthma, two ACSCs. By stratifying ACSC hospitalization by severity of illness, variations were observed by age, race, and gender. Minority groups may be at higher risk for less access to outpatient primary care and were observed to have higher rates of more severely ill, Stage 3 hospitalization. Geographic map displays indicated wide ranges of age-sex-adjusted rates for high-severity hospitalization in the five-county Philadelphia region. This refined ACSC measure may help to identify specific groups and clinical conditions within a population to assist health care planners estimate health care resources such as facilities, manpower, and programs, as well as to evaluate their outcomes.

Modeling risk-adjusted capitation rates for Umbria, Italy.

We studied the potential effect of refining per capita financing in Italy by risk adjustment using severity of illness as well as age and gender. Data were drawn from hospital, pharmaceutical, and demographic files for the entire population of the Umbrian region of Italy in 1997 and 1998. Hospitalization data from 1997 were used to classify patients into severity of illness categories which were hypothesized to be at risk for higher health services costs in 1998. Data on costs in 1998 were developed from hospital and pharmaceutical administrative data. Coefficients from 1997 models were used to develop predicted 1998 costs. Predicted costs in 1998 were compared to observed costs. Disease Staging models identified 155 unique clinical risk adjustment categories. These categories included 5.3% of the Umbrian population in 1997, who accounted for 21.6% of costs in the next year. In prediction models of future year costs using Umbrian data, R(2) values for Disease Staging models were 0.16, compared to values of 0.07 for a risk adjustment model used by Medicare. By identifying groups within the overall population who were more severely ill and who used more resources, these models can be used to assist health care planners estimate health care resources such as facilities, manpower, and programs.

Variation among local health units in follow-up care of breast cancer patients in Emilia-Romagna, Italy.

AIMS AND BACKGROUND: This study examines the patterns of follow-up care for breast cancer survivors in one region in Italy. METHODS AND STUDY DESIGN: This retrospective analysis included 10,024 surgically treated women, with incident cases of breast cancer in the years 2002-2005 who were alive 18 months after their incidence date. Rates of use of follow-up mammograms, abdominal echogram, bone scans and chest x-rays were estimated from administrative data and compared by Local Health Unit (LHU) of residence. Logistic regression analyses were performed to assess possible "overuse", accounting for patient age, cancer stage, type of surgery and LHU of residence. RESULTS: A total of 7168 (72.1%) women received a mammogram within 18 months of their incidence date, while 6432 (64.2%) had an abdominal echogram, 3852 (38.4%) had a bone scan and 5231 (52.2%) had a chest x-ray. The rates of use of abdominal echograms, bone scans and chest x-rays were substantially higher in the population of breast cancer survivors than in the general female population. Taking account of patient age, cancer stage at diagnosis and type of surgery, multivariate analyses demonstrated significant variation in the use of these tests by LHU of residence. CONCLUSIONS: The observed variation in the use of abdominal echograms, bone scans and chest x-rays supports the conclusion that there is substantial misuse of these tests in the population of postsurgical breast cancer patients in the Emilia-Romagna region in Italy. In the absence of a documented survival benefit, overtesting has both a human and financial cost. We recommend additional review of the methods of follow-up care in breast cancer patients in the LHUs of Emilia-Romagna, with the aim of developing, disseminating and evaluating the implementation of specific guidelines targeting primary care physicians and oncologists providing care to breast cancer survivors. Patient education materials may also help to reduce unnecessary testing.

Surveying linguistically challenged Southeast Asian American populations: use of a community-partnered methodology.

Southeast (SE) Asians suffer from health disparities often caused by lack of preventive care, exacerbated by linguistic barriers which exclude many from surveys that fail to include minorities. This survey of linguistically-challenged SE Asians captured health status indicators, behaviors and access. Items were based upon Public Health Management Corporation's Household Health Survey. Participants were recruited by a community-based organization serving SE Asians; interviews were conducted in nine languages. Data were weighted to match age-sex distributions of Asians in Philadelphia. Of 527 interviews completed, 57% were U.S. citizens, 48% uninsured, 23% had gone without care due to cost. English was the main language at home for 3%, yet 53% reported their primary health care site did not have an interpreter. Nearly half reported health as fair/poor, and 22% had a chronic health condition. This community survey illuminates the need to profile the health care needs of these immigrant populations.

Using administrative data to identify and stage breast cancer cases: implications for assessing quality of care.

AIMS AND BACKGROUND: The study evaluated the use of Italian hospital discharge data (SDO, scheda di dimissione ospedaliera) for identifying women with incident breast cancer, determining stage at diagnosis and assessing quality of care. STUDY DESIGN: Women aged 20+ years residing in the Regione Emilia-Romagna, Italy, between 2002 and 2005 were studied. Case identification using algorithms based on ICD-9-CM codes on hospital discharge data were compared with AIRTUM-accredited cancer registry data. Sensitivity, specificity and positive predictive value were computed overall, by age and cancer stage. Compliance with guidelines for radiation therapy using registry and hospital data were compared. RESULTS: A total of 11,615 women was identified by AIRTUM-accredited cancer registries as incident cases, whereas 10,876 women were identified by the SDO algorithm. Sensitivity was 84.8%, specificity was 99.9%, and the positive predictive value was 90.6%. Of the 1,022 who were false positives, 363 (35.5%) were women identified in registry data as having an incident case prior to 2002 and therefore were not included in the analysis. There were 1,761 false negatives; nearly 50% were over 70 years of age or did not undergo a surgical procedure and therefore were not included in our SDO-based case finding. Sensitivity declined as the patient population became older. However, we observed relatively good positive predictive value for all age groups. Algorithms using the SDO data did not clearly identify specific cancer stages. However, the algorithm may have utility where stages are grouped together for use in quality measures. CONCLUSIONS: Cases were identified with good sensitivity, specificity and positive predictive value with SDO data, with better rates than similar previously published algorithms based on Italian data. These hospital claims-based algorithms facilitate quality of care analyses for large populations when registry data are not available by identifying individual women and their subsequent use of health care services.

Partnering to collect health services and public health data in hard-to-reach communities: a community-based participatory research approach for collecting community health data.

BACKGROUND: Community-based participatory research (CBPR) approaches are increasingly used in behavioral studies but also may allow public health and health services researchers to study determinants of health in hard-to-reach communities for whom existing data are missing. OBJECTIVES: We describe our experience with a CBPR project in diverse communities of limited English proficient minorities. METHODS: The process included relationship building, recognition of community needs, resource investment by community and academic partners, and shared decision-making. Community-driven implementation, academic-driven analysis, and joint reporting took advantage of diverse layers of expertise. RESULTS/LESSONS LEARNED: We mobilized eighteen community interviewers, involved researchers from three institutions, and collected public health/health services data from 525 adults in seven weeks using a 117-item survey in nine languages. CONCLUSION: A CBPR approach can make the process of collecting public health and health services data in hard-to-reach communities not only viable, but also highly successful.