Bayesian two-part spatial models for semicontinuous data with application to emergency department expenditures.

In health services research, it is common to encounter semicontinuous data characterized by a point mass at zero and a continuous distribution of positive values. Examples include medical expenditures, in which the zeros represent patients who do not use health services, while the continuous distribution describes the level of expenditures among users. Semicontinuous data are customarily analyzed using two-part mixture models. In the spatial analysis of semicontinuous data, two-part models are especially appealing because they provide a joint picture of how health services utilization and associated expenditures vary across geographic regions. However, when applying these models, careful attention must be paid to distributional choices, as model misspecification can lead to biased and imprecise inferences. This paper introduces a broad class of Bayesian two-part models for the spatial analysis of semicontinuous data. Specific models considered include two-part lognormal, log skew-elliptical, and Bayesian non-parametric models. Multivariate conditionally autoregressive priors are used to link model components and provide spatial smoothing across neighboring regions, resulting in a joint spatial modeling framework for health utilization and expenditures. We develop a fully conjugate Gibbs sampling scheme, leading to efficient posterior computation. We illustrate the approach using data from a recent study of emergency department expenditures.

Impact of regulatory interventions to reduce intake of artificial trans-fatty acids: a systematic review.

We examined the impact of regulatory action to reduce levels of artificial trans-fatty acids (TFAs) in food. We searched Medline, Embase, ISI Web of Knowledge, and EconLit (January 1980 to December 2012) for studies related to government regulation of food- or diet-related health behaviors from which we extracted the subsample of legislative initiatives to reduce artificial TFAs in food. We screened 38 162 articles and identified 14 studies that examined artificial TFA controls limiting permitted levels or mandating labeling. These measures achieved good compliance, with evidence of appropriate reformulation. Regulations grounded on maximum limits and mandated labeling can lead to reductions in actual and reported TFAs in food and appear to encourage food producers to reformulate their products.

A spatiotemporal quantile regression model for emergency department expenditures.

Motivated by a recent study of geographic and temporal trends in emergency department care, we develop a spatiotemporal quantile regression model for the analysis of emergency department-related medical expenditures. The model yields distinct spatial patterns across time for each quantile of the response distribution, which is important in the spatial analysis of expenditures, as there is often little spatiotemporal variation in mean expenditures but more pronounced variation in the extremes. The model has a hierarchical structure incorporating patient-level and region-level predictors as well as spatiotemporal random effects. We model the random effects via intrinsic conditionally autoregressive priors, improving small-area estimation through maximum spatiotemporal smoothing. We adopt a Bayesian modeling approach based on an asymmetric Laplace distribution and develop an efficient posterior sampling scheme that relies solely on conjugate full conditionals. We apply our model to data from the Duke support repository, a large georeferenced database containing health and financial data for Duke Health System patients residing in Durham County, North Carolina.

Nutrition practices of nurseries in England. Comparison with national guidelines.

Recent national guidelines call for improved nutrition within early years settings. The aim of this cross-sectional study was to describe foods and beverages served in nurseries, assess provider behaviors related to feeding, and compare these practices to national guidelines. We administered a mailed survey to a random sample of nurseries across England, stratifying by tertile of deprivation. A total of 851 nurseries returned the survey (54.3% response rate). We fitted separate multivariate logistic regression models to estimate the association of deprivation with each of the 13 food and beverage guidelines and the seven provider behavior guidelines. We also conducted a joint F-test for any deprivation effect, to evaluate the effect of the guidelines combined. After adjusting for confounders, we observed differences in the frequency of nurseries that reported serving healthier foods across the tertiles of deprivation (p = 0.02 for joint F test). These adjusted results were driven mainly by nurseries in more deprived areas serving more whole grains (OR 1.57 (95% CI 1.00, 2.46)) and legumes, pulses, and lentils (1.40 (1.01, 2.14)). We also observed differences in the frequency of nurseries reporting more provider behaviors consistent with national guidelines across the tertiles of deprivation (p = 0.01 for joint F test). Nurseries in more deprived areas were more likely to dilute juice with water (2.35 (1.48, 3.73)), allow children to select their own portions (1.09 (1.06, 1.58)), and sit with children during meals (1.84 (1.07, 3.15)). While nurseries in the most deprived areas reported serving more healthy foods, a large percentage were still not meeting national guidelines. Policy and intervention efforts may increase compliance with national guidelines in nurseries in more deprived areas, and across England.

A review of state regulations to promote infant physical activity in child care.

BACKGROUND: The purpose of this study was to review state regulations promoting increased physical activity and decreased sedentary behaviors in infants in child care and to assess consistency with recent Institute of Medicine (IOM) recommendations. METHODS: We compared existing state and territory licensing and administrative regulations to recent IOM recommendations to promote physical activity and decrease sedentary time in very young children attending out-of-home child care (both child care centers and family child care homes). Three independent reviewers searched two sources (a publicly available website and WestlawNext™) and compared regulations with five IOM recommendations: 1) providing daily opportunities for infants to move, 2) engaging with infants on the ground, 3) providing daily tummy time for infants less than six months of age, 4) using cribs, car seats and high chairs for their primary purpose, and 5) limiting the use of restrictive equipment for holding infants while they are awake. We used Pearson chi-square tests to assess associations between geographic region, year of last update, and number of state regulations consistent with the IOM recommendations. RESULTS: The mean (SD) number of regulations for states was 1.9 (1.3) for centers and 1.6 (1.2) for homes out of a possible 5.0. Two states had regulations for all five recommendations, Arizona for centers and Virginia for homes. Six states and territories had zero regulations for child care centers and seven states and territories had zero regulations for family child care homes. There were no significant associations between geographic region and number of regulations consistent with IOM recommendations. CONCLUSIONS: Out-of-home child care settings are important targets for optimal early child health interventions. While most states had some regulations related to the promotion of physical activity among infants, few states had regulations for more than three of the five IOM recommendations. Enhancing state regulations in child care facilities could aid in early childhood obesity prevention efforts.

Nutrition and physical activity randomized control trial in child care centers improves knowledge, policies, and children's body mass index.

BACKGROUND: To address the public health crisis of overweight and obese preschool-age children, the Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) intervention was delivered by nurse child care health consultants with the objective of improving child care provider and parent nutrition and physical activity knowledge, center-level nutrition and physical activity policies and practices, and children's body mass index (BMI). METHODS: A seven-month randomized control trial was conducted in 17 licensed child care centers serving predominantly low income families in California, Connecticut, and North Carolina, including 137 child care providers and 552 families with racially and ethnically diverse children three to five years old. The NAP SACC intervention included educational workshops for child care providers and parents on nutrition and physical activity and consultation visits provided by trained nurse child care health consultants. Demographic characteristics and pre - and post-workshop knowledge surveys were completed by providers and parents. Blinded research assistants reviewed each center's written health and safety policies, observed nutrition and physical activity practices, and measured randomly selected children's nutritional intake, physical activity, and height and weight pre- and post-intervention. RESULTS: Hierarchical linear models and multiple regression models assessed individual- and center-level changes in knowledge, policies, practices and age- and sex-specific standardized body mass index (zBMI), controlling for state, parent education, and poverty level. Results showed significant increases in providers' and parents' knowledge of nutrition and physical activity, center-level improvements in policies, and child-level changes in children's zBMI based on 209 children in the intervention and control centers at both pre- and post-intervention time points. CONCLUSIONS: The NAP SACC intervention, as delivered by trained child health professionals such as child care health consultants, increases provider knowledge, improves center policies, and lowers BMI for children in child care centers. More health professionals specifically trained in a nutrition and physical activity intervention in child care are needed to help reverse the obesity epidemic. TRIAL REGISTRATION: National Clinical Trials Number NCT01921842.

Association of obesity with hypertension and type 2 diabetes mellitus in India: A meta-analysis of observational studies.

AIM: To perform a meta-analysis of the association of obesity with hypertension and type 2 diabetes mellitus (T2DM) in India among adults. METHODS: To conduct meta-analysis, we performed comprehensive, electronic literature search in the PubMed, CINAHL Plus, and Google Scholar. We restricted the analysis to studies with documentation of some measure of obesity namely; body mass index, waist-hip ratio, waist circumference and diagnosis of hypertension or diagnosis of T2DM. By obtaining summary estimates of all included studies, the meta-analysis was performed using both RevMan version 5 and "metan" command STATA version 11. Heterogeneity was measured by I2 statistic. Funnel plot analysis has been done to assess the study publication bias. RESULTS: Of the 956 studies screened, 18 met the eligibility criteria. The pooled odds ratio between obesity and hypertension was 3.82 (95%CI: 3.39 to 4.25). The heterogeneity around this estimate (I2 statistic) was 0%, indicating low variability. The pooled odds ratio from the included studies showed a statistically significant association between obesity and T2DM (OR = 1.14, 95%CI: 1.04 to 1.24) with a high degree of variability. CONCLUSION: Despite methodological differences, obesity showed significant, potentially plausible association with hypertension and T2DM in studies conducted in India. Being a modifiable risk factor, our study informs setting policy priority and intervention efforts to prevent debilitating complications.

Assessment of screening practices for gestational hyperglycaemia in public health facilities: a descriptive study in bangalore, India.

BACKGROUND: Screening and timely treatment of gestational hyperglycaemia (GH) is proved to be beneficial and improves maternal and foetal health outcomes. To understand screening practices, we explored the knowledge and perceptions of doctors working in public health facilities in Bangalore, India. We also studied participation factors by examining whether undergoing glucose estimation tests affects morning sickness in pregnant women. DESIGN AND METHODS: We aimed to understand the screening practices and knowledge of doctors. A semi-structured questionnaire was self-administered by the 50 participant doctors, selected from the sampling frame comprising of all the doctors working in public health facilities. We included 105 pregnant women for baseline assessment, in whom a well-structured questionnaire was used. RESULTS: We reported that gestational diabetes mellitus (GDM) screening was done in nearly all the health centres (96%). However, only 12% of the doctors could provide all components of GDM diagnosis and management correctly and 46% would diagnose by using a random blood glucose test. A majority (92%) of the doctors had poor knowledge (68%) about the cut-off values of glucose tests. More than 80% of pregnant women experienced some discomfort mostly due to rapid ingestion glucose in short span of time. CONCLUSIONS: Our study established that screening for GH is done in most public health facilities. Nonetheless, knowledge of doctors on the glucose tests and their interpretation needs improvement. Re-orientation trainings of the doctors can improve their knowledge and thereby can efficiently screen for GH. Further, adequate planning prior to the tests can aid successful completion of them. Significance for public healthRising burden of hyperglycaemia in pregnancy is a cause for concern and is associated with short and long term deleterious consequences for mother and offspring. Hence, there is an urgent need to explore the screening practices for gestational hyperglycaemia (GH). The current study considers patient and doctors' perspectives regarding GH screening. The results from our study indicate several issues during screening of gestational hyperglycaemia in public health facilities in Bangalore, India. These included low awareness levels among doctors, lack of standard operating procedures and lack of adequate care and attention provided to pregnant women. Re-orientation trainings of the doctors within public health facilities can improve their knowledge and thereby can efficiently screen for GH. Further, adequate planning and preparation of the patient prior to the tests can help ensure successful completion of the tests. The findings of the study are comparable with the practices of public health hospitals in India.