Racial/Ethnic Disparities in the Association Between Preeclampsia Risk Factors and Preeclampsia Among Women Residing in Hawaii.

Objective To assess differences in the rates of preeclampsia among a multiethnic population in Hawaii. Methods We performed a retrospective study on statewide inpatient data for delivery hospitalizations in Hawaii between January 1995 and December 2013. Multivariable logistic regression was used to assess the impact of maternal race/ethnicity on the rates of preeclampsia after adjusting for age, multiple gestation, multiparity, chronic hypertension, pregestational diabetes, obesity and smoking. Results A total of 271,569 hospital discharges for delivery were studied. The rates of preeclampsia ranged from 2.0 % for Chinese to 4.6 % for Filipinos. Preeclampsia rates were higher among Native Hawaiians who are age <35 and non-obese (OR 1.54; 95 % CI 1.43-1.66), age ≥35 and non-obese (OR 2.31; 95 % CI 2.00-2.68), age ≥35 and obese (OR 1.80; 95 % CI 1.24-2.60); other Pacific Islanders who are age <35 and non-obese (OR 1.40; 95 % CI 1.27-1.54), age ≥35 and non-obese (OR 2.18; 95 % CI 1.79-2.64), age ≥35 and obese (OR 1.68; 95 % CI 1.14-2.49); and Filipinos who are age <35 and non-obese (OR 1.55; 95 % CI 1.43-1.67), age ≥35 and non-obese (OR 2.26; 95 % CI 1.97-2.60), age ≥35 and obese (OR 1.64; 95 % CI 1.04-2.59) compared to whites. Pregestational diabetes (OR 3.41; 95 % CI 3.02-3.85), chronic hypertension (OR 5.98; 95 % CI 4.98-7.18), and smoking (OR 1.19; 95 % CI 1.07-1.33) were also independently associated with preeclampsia. Conclusions for Practice In Hawaii, Native Hawaiians, other Pacific Islanders and Filipinos have a higher risk of preeclampsia compared to whites. For these high-risk ethnic groups, more frequent monitoring for preeclampsia may be needed.

Length of Stay and Deaths in Diabetes-Related Preventable Hospitalizations Among Asian American, Pacific Islander, and White Older Adults on Medicare, Hawai'i, December 2006-December 2010.

INTRODUCTION: The objective of this study was to compare in-hospital deaths and length of stays for diabetes-related preventable hospitalizations (D-RPHs) in Hawai'i for Asian American, Pacific Islander, and white Medicare recipients aged 65 years or older. METHODS: We considered all hospitalizations of older (>65 years) Japanese, Chinese, Native Hawaiians, Filipinos, and whites living in Hawai'i with Medicare as the primary insurer from December 2006 through December 2010 (n = 127,079). We used International Classification of Diseases - 9th Revision (ICD-9) codes to identify D-RPHs as defined by the Agency for Healthcare Research and Quality. Length of stays and deaths during hospitalization were compared for Asian American and Pacific Islander versus whites in multivariable regression models, adjusting for age, sex, location of residence (Oahu, y/n), and comorbidity. RESULTS: Among the group studied, 1,700 hospitalizations of 1,424 patients were D-RPHs. Native Hawaiians were significantly more likely to die during a D-RPH (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.42-10.87) than whites. Filipinos had a significantly shorter length of stay (relative risk [RR], 0.77; 95% CI, 0.62-0.95) for D-RPH than whites. Among Native Hawaiians with a D-RPH, 59% were in the youngest age group (65-75 y) whereas only 6.3% were in the oldest (≥85 y). By contrast, 23.2% of Japanese were in the youngest age group, and 32.2% were in the oldest. CONCLUSION: This statewide study found significant differences in the clinical characteristics and outcomes of D-RPHs for Asian American and Pacific Islanders in Hawai'i. Native Hawaiians were more likely to die during a D-RPH and were hospitalized at a younger age for a D-RPH than other studied racial/ethnic groups. Focused interventions targeting Native Hawaiians are needed to avoid these outcomes.

Adjustments to diabetes medications in response to increases in hemoglobin a1c: an epidemiologic study.

OBJECTIVE: The primary objective was to assess associations between increases in glycated hemoglobin (HbA1c) levels and medication adjustments among patients with diabetes. A secondary objective was to measure the effect of adjustments on subsequent HbA1c levels. METHODS: A retrospective analysis of administrative data from a large health insurer in Hawaii of 7654 patients with diabetes mellitus type II, HbA1c levels greater than 7%, and who were taking oral diabetic medications. Patients were eligible if they had an HbA1c measurement in 2009, a prior measure 30 or more days previously, and at least 30 days of follow-up to identify medication adjustments. Patients were classified into 3 groups based on their extent of change in HbA1c levels. Patients were followed to determine the frequency of medication adjustments and to observe the possible benefit of making adjustments on subsequent HbA1c levels. RESULTS: Medication adjustments were the exception, occurring among less than a fourth of patients. Compared with patients without HbA1c increases, patients with <1% HbA1c increases made adjustments 20% more frequently, and patients with increased HbA1c levels of 1% or more made adjustments 60% more frequently. Patients with similar HbA1c increases were more likely to adjust their medications if they had higher baseline HbA1c levels. Medication adjustments were mostly for oral diabetes medications; insulin use was seldom initiated, and then primarily by patients with HbA1c levels of 9% or higher. Patients with medication adjustments averaged about 0.40% lower HbA1c levels when reassessed after 120 days or more. CONCLUSION: The results show limited responsiveness to increases in HbA1c levels and a low initiation rate of insulin use. Patients adjusting their medications, however, had clinically significant improvements in their HbA1c levels. Clinical inertia and patient concerns are discussed as factors possibly limiting the frequency of medication adjustments.

Comparison of potentially preventable hospitalizations related to diabetes among Native Hawaiian, Chinese, Filipino, and Japanese elderly compared with whites, Hawai'i, December 2006-December 2010.

INTRODUCTION: Approximately 25% of individuals aged 65 years or older in the United States have diabetes mellitus. Diabetes rates in this age group are higher for Asian American and Pacific Islanders (AA/PI) than for whites. We examined racial/ethnic differences in diabetes-related potentially preventable hospitalizations (DRPH) among people aged 65 years or older for Japanese, Chinese, Filipinos, Native Hawaiians, and whites. METHODS: Discharge data for hospitalizations in Hawai'i for people aged 65 years or older from December 2006 through December 2010 were compared. Annual rates of DRPH by patient were calculated for each racial/ethnic group by sex. Rate ratios (RRs) were calculated relative to whites. Multivariable models controlling for insurer, comorbidity, diabetes prevalence, age, and residence location provided final adjusted rates and RRs. RESULTS: A total of 1,815 DRPH were seen from 1,515 unique individuals. Unadjusted RRs for DRPH by patient were greater than 1 in all AA/PI study groups compared with whites, but were highest among Native Hawaiians and Filipinos [corrected]. In fully adjusted models accounting for higher diabetes prevalence in AA/PI groups, Native Hawaiian (adjusted rate ratio [aRR] = 1.59), Filipino (aRR = 2.26), and Japanese (aRR = 1.86) men retained significantly higher rates of diabetes-related potentially preventable hospitalizations than whites, as did Filipino women (aRR = 1.61). CONCLUSION: Native Hawaiian, Filipino, and Japanese men and Filipino women aged 65 years or older have a higher risk than whites for DRPH. Health care providers and public health programs for elderly patients should consider effective programs to reduce potentially preventable hospitalizations among Native Hawaiian, Filipino, and Japanese men and Filipino women aged 65 years or older.

Prevalence of comorbid conditions with aging among patients with diabetes and cardiovascular disease.

OBJECTIVES: The objectives were to develop a methodology to understand the prevalence of medically complex patients, and to apply the methodology to examine patients with one or more of hypertension, hyperlipidemia, diabetes, and heart disease. METHODS: Prevalence was measured using insurance data by calculating the proportion of days patients in a health state of interest contributed to the total days of enrollment. Graphs summarized the prevalence patterns within age and morbidity categories. Results by age and gender were supplemented with cubic spline curves that closely fit the prevalence data. RESULTS: The study provides basic epidemiologic information on changes with aging in the prevalence of patients with one or more comorbid conditions. Patients such as those with hyperlipidemia alone rose in prevalence at younger ages and fell at older ages, whereas the prevalence of other patients, such as patients having hypertension, diabetes, and heart disease, progressively increased with age. With straightforward extensions of the methodology other issues such as the incidence of emergency department visits and hospitalizations might be investigated.

Identifying characteristics of patients with low urgency emergency department visits in a managed care setting.

PURPOSE: Studies worldwide in emergency departments (ED) find that a substantial proportion of patients seek care for non-urgent conditions. Managed care programs may help address this overuse of ED facilities, but non-urgent ED care is not easily identified outside of ED settings. This article employed an algorithm using insurance data to identify and characterize patients having low urgency ED visits. Non-urgentis the term used in the ED literature for ED visits that might have been managed outside an ED setting such as in a physician office. Low urgency ED visits could include visits that require an ED setting but for less severe conditions than high urgency ED visits. DESIGN: Analysis of ED visits by members of the largest health insurer in Hawaii. METHODOLOGY: Visits were defined as low urgency if classified by the ED as low severity and if, in addition, the patients required no procedures beyond physician and nursing care. A simple example would be a physician order for a laboratory test. Even if the test was routine, the fact the doctor ordered the test during the ED visit suggests the result might be needed right away to make a management decision. Another example of a procedure would be a radiograph. PRINCIPAL FINDING: Medicaid participants, children age 1 to 5, and people living on less populated Hawaiian Islands most frequently had low urgency visits. The visits were also more common on weekends than weekdays, and more common among males compared to females. Of all low urgency visits by Medicaid participants, 32% were by repeat users of the ED. The percentage for members of non-Medicaid plans was 16%. People with one low urgency visit in the past year were more than twice as likely as others to have a similar visit in the next year. People with two or more low urgency visits in the past year were five times as likely to have a low urgency ED visit in the next year. CONCLUSION: The results identify several areas such as youth, island of residence, and past history of low urgency ED visits that might become the focus of managed care programs.

Factors affecting the influenza vaccination of high risk adults in Hawai'i.

Influenza infections cause a substantial toll in respiratory infections, hospitalizations, and death; and immunization has proven effective in reducing these outcomes. This article describes a study to understand variations in influenza vaccination rates for a population ages 50 and older using data from a large insurer in Hawai'i. Vaccination rates were lower in adults without than with a chronic disease, and especially low in those without chronic disease of ages 50-64. People who had been vaccinated in the past year were likely to become vaccinated again, and people with a history of regular physician visits were more likely than others to become vaccinated. Having vaccine available at the worksite led to improved vaccination rates. By ethnicity Japanese, Koreans, and Chinese were most likely to obtain influenza vaccinations; the greatest ethnic differences occurred among adults ages 50 to 64 without a chronic disease. People seeing a physician during the influenza season were especially likely to become vaccinated during the week of the visit. Patients were more likely to become vaccinated by an existing physician than if seeing a new one. The percentage of office visits in weeks in which patients became vaccinated varied four-fold by physician specialty Internal medicine and family medicine physicians had the highest percentages whereas gynecologists and cardiologists had the lowest. The results suggest multiple reasons that high risk adults may fail to become vaccinated. Better understanding barriers may lead to improved strategies to improve influenza vaccination rates.

Big data in pharmacy practice: current use, challenges, and the future.

Pharmacy informatics is defined as the use and integration of data, information, knowledge, technology, and automation in the medication-use process for the purpose of improving health outcomes. The term "big data" has been coined and is often defined in three V's: volume, velocity, and variety. This paper describes three major areas in which pharmacy utilizes big data, including: 1) informed decision making (clinical pathways and clinical practice guidelines); 2) improved care delivery in health care settings such as hospitals and community pharmacy practice settings; and 3) quality performance measurement for the Centers for Medicare and Medicaid and medication management activities such as tracking medication adherence and medication reconciliation.

Cost Burden of Potentially Preventable Hospitalizations for Cardiovascular Disease and Diabetes for Asian Americans, Pacific Islanders, and Whites in Hawai'i.

We compared the cost burdens of potentially preventable hospitalizations for cardiovascular disease and diabetes for Asian Americans, Pacific Islanders, and Whites using Hawai'i statewide 2007-2012 inpatient data. The cost burden of the 27,894 preventable hospitalizations over six years (total cost: over $353 million) fell heavily on Native Hawaiians who had the largest proportion (23%) of all preventable hospitalizations and the highest unadjusted average costs (median: $9,117) for these hospitalizations. Diabetes-related amputations (median cost: $20,167) were the most expensive of the seven preventable hospitalization types. After adjusting for other factors (including age, insurance, and hospital), costs for preventable diabetes-related amputations were significantly higher for Native Hawaiians (ratio estimate:1.23; 95%CI:1.05-1.44), Japanese (ratio estimate:1.44; 95%CI:1.20-1.72), and other Pacific Islanders (ratio estimate:1.26; 95%CI:1.04-1.52) compared with Whites. Reducing potentially preventable hospitalizations would not only improve health equity, but could also relieve a large and disproportionate cost burden on some Pacific Islander and Asian American communities.

Risk-Adjusted In-Hospital Mortality Models for Congestive Heart Failure and Acute Myocardial Infarction: Value of Clinical Laboratory Data and Race/Ethnicity.

OBJECTIVE: To examine the impact of key laboratory and race/ethnicity data on the prediction of in-hospital mortality for congestive heart failure (CHF) and acute myocardial infarction (AMI). DATA SOURCES: Hawaii adult hospitalizations database between 2009 and 2011, linked to laboratory database. STUDY DESIGN: Cross-sectional design was employed to develop risk-adjusted in-hospital mortality models among patients with CHF (n = 5,718) and AMI (n = 5,703). DATA COLLECTION/EXTRACTION METHODS: Results of 25 selected laboratory tests were requested from hospitals and laboratories across the state and mapped according to Logical Observation Identifiers Names and Codes standards. The laboratory data were linked to administrative data for each discharge of interest from an all-payer database, and a Master Patient Identifier was used to link patient-level encounter data across hospitals statewide. PRINCIPAL FINDINGS: Adding a simple three-level summary measure based on the number of abnormal laboratory data observed to hospital administrative claims data significantly improved the model prediction for inpatient mortality compared with a baseline risk model using administrative data that adjusted only for age, gender, and risk of mortality (determined using 3M's All Patient Refined Diagnosis Related Groups classification). The addition of race/ethnicity also improved the model. CONCLUSIONS: The results of this study support the incorporation of a simple summary measure of laboratory data and race/ethnicity information to improve predictions of in-hospital mortality from CHF and AMI. Laboratory data provide objective evidence of a patient's condition and therefore are accurate determinants of a patient's risk of mortality. Adding race/ethnicity information helps further explain the differences in in-hospital mortality.

Using quantile regression to assess disparities in medication adherence.

OBJECTIVE: To examine racial/ethnic disparities in medication adherence between Asian and Pacific Islander Americans and Whites. METHODS: This retrospective data analysis included diabetes patients enrolled in a health plan in Hawaii (N = 43,445). For anti-diabetic, lipid-lowering, and anti-hypertensive medications, quantile regression was estimated at 25(th), 50(th), and 75(th) quantiles to examine the association with race and ethnicity, controlling for other patient characteristics. RESULTS: Consistently, Filipinos, Native Hawaiians, and other Pacific Islanders were significantly less adherent than Whites. The greatest disparities were found for other Pacific Islanders using lipid-lowering medications, with adjusted differences in medication adherence, with reductions relative to Whites of as much as 19% for lipid-lowering medications for the 25(th) quantile of adherence. CONCLUSION: Whereas the large sample size undoubtedly contributed to the statistical significance, the large magnitude of the disparities, particularly for Filipinos, Native Hawaiians, and other Pacific Islanders, which suggests that these are meaningful differences that need to be addressed. The largest disparities were found at the lowest quantile suggests that they may be occurring among the most vulnerable populations with potentially poor access to care.

Disparities in diabetes-related preventable hospitalizations among working-age Native Hawaiians and Asians in Hawai'i.

Elderly (65+) Native Hawaiian, Filipino, and Japanese men and Filipino women have a higher risk of diabetes-related potentially preventable hospitalizations than Whites even when demographic factors and the higher diabetes prevalence in these populations is considered. The study objective was to determine if similar disparities are seen among the non-elderly (< 65). We used discharge data for all non-maternity hospitalizations by working-age adults (18-64 years) in Hawai'i from December 2006 to December 2010. Annual diabetes-related preventable hospitalization rates (by population diabetes prevalence) were compared by race/ethnicity (Japanese, Chinese, Native Hawaiian, Filipino, and White) and gender. Adjusted rate ratios (aRR) were calculated relative to Whites using multivariable models controlling for insurer, comorbidity, residence location, and age. After adjusting for ethnic-specific prevalence of diabetes and demographic factors, preventable hospitalizations rates were significantly higher for Native Hawaiians males (aRR:1.48; 95%CI:1.08-2.05) compared to Whites, but significantly lower for Chinese men (aRR:0.43;95%CI:0.30-0.61) and women (aRR:0.18;95%CI: 0.08-0.37), Japanese men (aRR:0.33;95%CI: 0.25-0.44) and women (aRR:0.34; 95%CI:0.23-0.51), and Filipino men (aRR:0.35;95%CI:0.28-0.43) and women (aRR:0.47;95%CI: 0.36-0.62). Rates for Native Hawaiian females did not differ significantly from Whites. Disparities in diabetes-related preventable hospitalizations were seen for working-age (18-64) Native Hawaiian men even when their higher population-level diabetes prevalence was considered. Further research is needed to determine factors affecting these disparities and to develop targeted interventions to reduce them. Significantly lower preventable hospitalization rates were seen among Asian groups compared to Whites. A better understanding of these findings may provide guidance for improving rates among Asian elderly as well as other non-elderly groups with disparities.

Prevalence of heart disease and its risk factors related to age in Asians, Pacific Islanders, and Whites in Hawai'i.

OBJECTIVE: To examine disparities in disease prevalence related to age and race/ethnicity. Study design. Retrospective observational study. METHODS: Eligible population included enrollees with largest insurer in Hawai'i. Chronic diseases were identified from claims data (1999-2009) based on algorithms including diagnostic codes and pharmaceutical utilization. Relative risk of heart disease and its risk factors were calculated for Native Hawaiians and Asian sub-groups by age. RESULTS: Prevalence of heart disease and its risk factors differed substantially by age and race/ethnicity. Native Hawaiians and Filipinos had higher rates of hypertension and diabetes; Asians had highest rates of hyperlipidemia. Whites had the lowest prevalence of risk factors yet their risk of heart disease equaled other groups. CONCLUSION: Prevalence curves began diverging at age 30 for risk factors and age 40 for heart disease. This suggests approaches to reduce the burden of disease for vulnerable groups need to begin in early adulthood if not sooner.