Patient preferences and willingness-to-pay for community pharmacy-led Medicare Part D consultation services: A discrete choice experiment.

INTRODUCTION: Community pharmacies currently offer Medicare Part D consultation services, often at no-cost. Despite facilitating plan-switching behavior, identifying potential cost-savings, and increasing medication adherence, patient uptake of these services remains low. OBJECTIVES: To investigate patient preferences for specific service-offering attributes and marginal willingness-to-pay (mWTP) for an enhanced community pharmacy Medicare Part D consultation service. METHODS: A discrete choice experiment (DCE) guided by the SERVQUAL framework was developed and administered using a national online survey panel. Study participants were English-speaking adults (≥65 years) residing in the United States enrolled in a Medicare Part D or Medicare Advantage plan and had filled a prescription at a community pharmacy within the last 12 months. An orthogonal design resulted in 120 paired-choice tasks distributed equally across 10 survey blocks. Data were analyzed using mixed logit and latent class models. RESULTS: In total, 540 responses were collected, with the average age of respondents being 71 years. The majority of respondents were females (60%) and reported taking four or more prescription medication (51%). Service attribute levels with the highest utility were: 15-min intervention duration (0.392), discussion of services + a follow-up phone call (0.069), in-person at the pharmacy (0.328), provided by a pharmacist the patient knew (0.578), and no-cost (3.382). The attribute with the largest mWTP value was a service provided by a pharmacist the participant knew ($8.42). Latent class analysis revealed that patient preferences for service attributes significantly differed by gender and difficulty affording prescription medications. CONCLUSIONS: Quantifying patient preference using discrete choice methodology provides pharmacies with information needed to design service offerings that balance patient preference and sustainability. Pharmacies may consider providing interventions at no-cost to subsets of patients placing high importance on a service cost attribute. Further, patient preference for 15-min interventions may inform Medicare Part D service delivery and facilitate service sustainability.

Assessing the ability of an instrumental variable causal forest algorithm to personalize treatment evidence using observational data: the case of early surgery for shoulder fracture.

BACKGROUND: Comparative effectiveness research (CER) using observational databases has been suggested to obtain personalized evidence of treatment effectiveness. Inferential difficulties remain using traditional CER approaches especially related to designating patients to reference classes a priori. A novel Instrumental Variable Causal Forest Algorithm (IV-CFA) has the potential to provide personalized evidence using observational data without designating reference classes a priori, but the consistency of the evidence when varying key algorithm parameters remains unclear. We investigated the consistency of IV-CFA estimates through application to a database of Medicare beneficiaries with proximal humerus fractures (PHFs) that previously revealed heterogeneity in the effects of early surgery using instrumental variable estimators. METHODS: IV-CFA was used to estimate patient-specific early surgery effects on both beneficial and detrimental outcomes using different combinations of algorithm parameters and estimate variation was assessed for a population of 72,751 fee-for-service Medicare beneficiaries with PHFs in 2011. Classification and regression trees (CART) were applied to these estimates to create ex-post reference classes and the consistency of these classes were assessed. Two-stage least squares (2SLS) estimators were applied to representative ex-post reference classes to scrutinize the estimates relative to known 2SLS properties. RESULTS: IV-CFA uncovered substantial early surgery effect heterogeneity across PHF patients, but estimates for individual patients varied with algorithm parameters. CART applied to these estimates revealed ex-post reference classes consistent across algorithm parameters. 2SLS estimates showed that ex-post reference classes containing older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to benefit and more likely to have detriments from higher rates of early surgery. CONCLUSIONS: IV-CFA provides an illuminating method to uncover ex-post reference classes of patients based on treatment effects using observational data with a strong instrumental variable. Interpretation of treatment effect estimates within each ex-post reference class using traditional CER methods remains conditional on the extent of measured information in the data.

Increased opioid use following rotator cuff repair associated with prior opioid use and surgeon prescription patterns.

BACKGROUND: Prescription opioids are standard of care for postoperative pain management after musculoskeletal surgery, but there is no guideline or consensus on best practices. Variability in the intensity of opioids prescribed for postoperative recovery has been documented, but it is unclear whether this variability is clinically motivated or associated with provider practice patterns, or how this variation is associated with patient outcomes. This study described variation in the intensity of opioids prescribed for patients undergoing rotator cuff repair (RCR) and examined associations with provider prescribing patterns and patients' long-term opioid use outcomes. METHODS: Medicare data from 2010 to 2012 were used to identify 16,043 RCRs for patients with new shoulder complaints in 2011. Two measures of perioperative opioid use were created: (1) any opioid fill occurring 3 days before to 7 days after RCR and (2) total morphine milligram equivalents (MMEs) of all opioid fills during that period. Patient outcomes for persistent opioid use after RCR included (1) any opioid fill from 90 to 180 days after RCR and (2) the lack of any 30-day gap in opioid availability during that period. Generalized linear regression models were used to estimate associations between provider characteristics and opioid use for RCR, and between opioid use and outcomes. All models adjusted for patient clinical and demographic characteristics. Separate analyses were done for patients with and without opioid use in the 180 days before RCR. RESULTS: In this sample, 54% of patients undergoing RCR were opioid naive at the time of RCR. Relative to prior users, a greater proportion of opioid naive users had any opioid fill (85.7% vs. 75.4%), but prior users received more MMEs than naive users (565 vs. 451 MMEs). Providers' opioid prescribing for other patients was associated with the intensity of perioperative opioids received for RCR. Total MMEs received for RCR were associated with higher odds of persistent opioid use 90-180 days after RCR. CONCLUSIONS: The intensity of opioids received by patients for postoperative pain appears to be partially determined by the prescribing habits of their providers. Greater intensity of opioids received is, in turn, associated with greater odds of patterns of chronic opioid use after surgery. More comprehensive, patient-centered guidance on opioid prescribing is needed to help surgeons provide optimal postoperative pain management plans, balancing needs for short-term symptom relief and risks for long-term outcomes.

Maternity waiting homes as a cost-effective intervention in rural Liberia.

OBJECTIVE: To analyze the cost-effectiveness of maternity waiting homes (MWHs) in rural Liberia by examining the cost per life saved and economic effect of MWHs on maternal mortality. METHODS: A cost-effectiveness analysis was used to evaluate costs and economic effect of MWHs on maternal mortality in rural Liberia to guide future resource allocation. A secondary data analysis was performed based on a prior quasi-experimental cohort study of 10 rural primary healthcare facilities, five with a MWH and five without a MWH, that took place from October 30, 2010 to February 28, 2015. RESULTS: Calculations signified a low cost per year of life saved at MWHs in a rural district in Liberia. Total population-adjusted number of women's lives saved over 3 years was 6.25. CONCLUSION: While initial costs were considerable, over a period of 10 or more years MWHs could be a cost-effective and affordable strategy to reduce maternal mortality rates in Liberia. Discussion of the scaling up of MWH interventions for improving maternal outcomes in Liberia and other low- and middle-income countries is justified. Findings can be used to advocate for policy changes to increase the apportionment of resources for building more MWHs in low resource settings.

Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus.

BACKGROUND: Using a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached. METHODS: This was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level. RESULTS: Among patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles. CONCLUSIONS: Persistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

Athletic Trainers' Effect on Population Health: Improving Access to and Quality of Care.

CONTEXT: The scope of athletic training practice combined with the magnitude of scholastic athletic injuries means that the scholastic athletic trainer (AT) is uniquely positioned to positively affect the overall health care of this population. The AT is equipped to serve in the prevention and primary management of injuries and return to activity of scholastic athletes. However, to optimize the musculoskeletal health of all athletes within a given setting, the gaps in clinical care must be continuously evaluated. Quality improvement (QI) approaches are often used to establish a framework for delivering care that promotes the best health status of the targeted population. OBJECTIVE: To describe the creation, implementation, and early results of a QI initiative aimed at advancing the health of the scholastic athletes served in the Greenville County, South Carolina, school district. DESIGN: Cohort study. PATIENTS OR OTHER PARTICIPANTS: A total of 49 793 athletes. MAIN OUTCOME MEASURE(S): The QI framework consisted of a process that documented the magnitude of athletic injuries, established risk factors for injury, defined intervention steps for at-risk athletes, and evaluated the QI process before and after implementation. The results were regularly reported to participating stakeholders, including ATs, athletic directors, coaches, parents, and athletes. RESULTS: After the QI process, injury rates decreased (absolute risk difference between the 2011-2012 and 2016-2017 academic years = 22%) and resources were more strategically allocated, which resulted in a decrease in health care costs of more than 50%. CONCLUSIONS: Collectively, the QI framework as described provides a systematic process for empowering the AT as the foundation of the scholastic sports medicine team.

Use of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Geriatric Ischemic Stroke Patients: Are the Rates Right?

BACKGROUND: Our objective is to estimate the effects associated with higher rates of renin-angiotensin system antagonists, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs), in secondary prevention for geriatric (aged >65 years) patients with new ischemic strokes by chronic kidney disease (CKD) status. METHODS AND RESULTS: The effects of ACEI/ARBs on survival and renal risk were estimated by CKD status using an instrumental variable (IV) estimator. Instruments were based on local area variation in ACEI/ARB use. Data abstracted from charts were used to assess the assumptions underlying the instrumental estimator. ACEI/ARBs were used after stroke by 45.9% and 45.2% of CKD and non-CKD patients, respectively. ACEI/ARB rate differences across local areas grouped by practice styles were nearly identical for CKD and non-CKD patients. Higher ACEI/ARB use rates for non-CKD patients were associated with higher 2-year survival rates, whereas higher ACEI/ARB use rates for patients with CKD were associated with lower 2-year survival rates. While the negative survival estimates for patients with CKD were not statistically different from zero, they were statistically lower than the estimates for non-CKD patients. Confounders abstracted from charts were not associated with the instrumental variable used. CONCLUSIONS: Higher ACEI/ARB use rates had different survival implications for older ischemic stroke patients with and without CKD. ACEI/ARBs appear underused in ischemic stroke patients without CKD as higher use rates were associated with higher 2-year survival rates. This conclusion is not generalizable to the ischemic stroke patients with CKD, as higher ACEI/ARBS use rates were associated with lower 2-year survival rates that were statistically lower than the estimates for non-CKD patients.

Understanding Treatment Effect Estimates When Treatment Effects Are Heterogeneous for More Than One Outcome.

BACKGROUND: Patient-centred care requires evidence of treatment effects across many outcomes. Outcomes can be beneficial (e.g. increased survival or cure rates) or detrimental (e.g. adverse events, pain associated with treatment, treatment costs, time required for treatment). Treatment effects may also be heterogeneous across outcomes and across patients. Randomized controlled trials are usually insufficient to supply evidence across outcomes. Observational data analysis is an alternative, with the caveat that the treatments observed are choices. Real-world treatment choice often involves complex assessment of expected effects across the array of outcomes. Failure to account for this complexity when interpreting treatment effect estimates could lead to clinical and policy mistakes. OBJECTIVE: Our objective was to assess the properties of treatment effect estimates based on choice when treatments have heterogeneous effects on both beneficial and detrimental outcomes across patients. METHODS: Simulation methods were used to highlight the sensitivity of treatment effect estimates to the distributions of treatment effects across patients across outcomes. Scenarios with alternative correlations between benefit and detriment treatment effects across patients were used. Regression and instrumental variable estimators were applied to the simulated data for both outcomes. RESULTS: True treatment effect parameters are sensitive to the relationships of treatment effectiveness across outcomes in each study population. In each simulation scenario, treatment effect estimate interpretations for each outcome are aligned with results shown previously in single outcome models, but these estimates vary across simulated populations with the correlations of treatment effects across patients across outcomes. CONCLUSIONS: If estimator assumptions are valid, estimates across outcomes can be used to assess the optimality of treatment rates in a study population. However, because true treatment effect parameters are sensitive to correlations of treatment effects across outcomes, decision makers should be cautious about generalizing estimates to other populations.

2SLS versus 2SRI: Appropriate methods for rare outcomes and/or rare exposures.

This study used Monte Carlo simulations to examine the ability of the two-stage least squares (2SLS) estimator and two-stage residual inclusion (2SRI) estimators with varying forms of residuals to estimate the local average and population average treatment effect parameters in models with binary outcome, endogenous binary treatment, and single binary instrument. The rarity of the outcome and the treatment was varied across simulation scenarios. Results showed that 2SLS generated consistent estimates of the local average treatment effects (LATE) and biased estimates of the average treatment effects (ATE) across all scenarios. 2SRI approaches, in general, produced biased estimates of both LATE and ATE under all scenarios. 2SRI using generalized residuals minimized the bias in ATE estimates. Use of 2SLS and 2SRI is illustrated in an empirical application estimating the effects of long-term care insurance on a variety of binary health care utilization outcomes among the near-elderly using the Health and Retirement Study.

The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry.

Study Design Retrospective study. Background Alternative models of care that allow patients to choose direct access to physical therapy have shown promise in terms of cost reduction for neck and back pain. However, real-world exploration within the US health care system is notably limited. Objectives To compare total claims paid and patient outcomes for patients with neck and back pain who received physical therapy intervention via direct access versus medical referral. Methods Data were accessed for patients seeking care for neck or back pain (n = 603) between 2012 and 2014, who chose to begin care either through traditional medical referral or direct access to a physical therapy- led spine management program. All patients received a standardized, pragmatic physical therapy approach, with patient-reported measures of pain and disability assessed before and after treatment. Patient demographics and outcomes data were obtained from the medical center patient registry and combined with total claims paid calculated for the year after the index claim. Linear mixed-effects modeling was used to analyze group differences in pain and disability, visits/time, and annualized costs. Results Patients who chose to enter care via the direct-access physical therapy-led spine management program displayed significantly lower total costs (mean difference, $1543; 95% confidence interval: $51, $3028; P = .04) than those who chose traditional medical referral. Patients in both groups showed clinically important improvements in pain and disability, which were similar between groups (P>.05). Conclusion The initial patient choice to begin care with a physical therapist for back or neck pain resulted in lower cost of care over the next year, while resulting in similar improvements in patient outcomes at discharge from physical therapy. These findings add to the emerging literature suggesting that patients' choice to access physical therapy through direct access may be associated with lower health care expenditures for patients with neck and back pain. Level of Evidence Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(2):63-71. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7423.

Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo.

BACKGROUND: Conflict-affected communities face poverty and mental health problems, with sexual violence survivors at high risk for both given their trauma history and potential for exclusion from economic opportunity. To address these problems, we conducted a randomized controlled trial of a group-based economic intervention, Village Savings and Loans Associations (VSLA), for female sexual violence survivors in the Democratic Republic of Congo. METHODS: In March 2011, 66 VSLA groups, with 301 study participants, were randomized to the VSLA program or a wait-control condition. Data were collected prior to randomization, at 2-months post-program in June 2012, and 8-months later for VSLA participants only. Outcome data included measures of economic and social functioning and mental health severity. VSLA program effect was derived by comparing intervention and control participants' mean changes from baseline to 2-month follow-up. RESULTS: At follow-up, VSLA study women reported significantly greater per capita food consumption and significantly greater reductions in stigma experiences compared with controls. No other study outcomes were statistically different. At 8-month follow-up, VSLA participants reported a continued increase in per capita food consumption, an increase in economic hours worked in the prior 7 days, and an increase in access to social resources. CONCLUSIONS: While female sexual violence survivors with elevated mental symptoms were successfully integrated into a community-based economic program, the immediate program impact was only seen for food consumption and experience of stigma. Impacts on mental health severity were not realized, suggesting that targeted mental health interventions may be needed to improve psychological well-being.

Use of statins by medicare beneficiaries post myocardial infarction: poor physician quality or patient-centered care?

Even though guidelines strongly recommend that patients receive a statin for secondary prevention after an acute myocardial infarction (MI), many elderly patients do not fill a statin prescription within 30 days of discharge. This paper assesses whether patterns of statin use by Medicare beneficiaries post-discharge may be due to a mix of high-quality and low-quality physicians. Our data come from the Centers for Medicare & Medicaid Services (CMS) Chronic Condition Data Warehouse (CCW) and include 100% of Medicare beneficiaries hospitalized for an acute myocardial infarction in 2008 or 2009. Our study sample included physicians treating at least 10 Medicare fee-for-service beneficiaries during their MI institutional stay. Physician-specific statin fill rates (the proportion of each physician's patients with a statin within 30 days post-discharge) were calculated to assess physician quality. We hypothesized that if the observed statin rates reflected a mix of high-quality and low-quality physicians, then physician-specific statin fill rates should follow a u-shaped or bimodal distribution. In our sample, 62% of patients filled a statin prescription within 30 days of discharge. We found that the distribution of statin fill rates across physicians was normal, with no clear distinctions in physician quality. Physicians, especially cardiologists, with relatively younger and healthier patient populations had higher rates of statin use. Our results suggest that physicians were engaging in patient-centered care, tailoring treatments to patient characteristics.

Statin use after acute myocardial infarction by patient complexity: are the rates right?

BACKGROUND: Guidelines suggest statin use after acute myocardial infarction (AMI) should be close to universal in patients without safety concerns yet rates are much lower than recommended, decline with patient complexity, and display substantial geographic variation. Trial exclusions have resulted in little evidence to guide statin prescribing for complex patients. OBJECTIVE: To assess the benefits and risks associated with higher rates of statin use after AMI by baseline patient complexity. RESEARCH DESIGN: Sample includes Medicare fee-for-service patients with AMIs in 2008-2009. Instrumental variable estimators using variation in local area prescribing patterns by statin intensity as instruments were used to assess the association of higher statin prescribing rates by statin intensity on 1-year survival, adverse events, and cost by patient complexity. RESULTS: Providers seem to have individualized statin use across patients based on potential risks. Higher statin rates for noncomplex AMI patients were associated with increased survival rates with little added adverse event risk. Higher statin rates for complex AMI patients were associated with tradeoffs between higher survival rates and higher rates of adverse events. CONCLUSIONS: Higher rates of statin use for noncomplex AMI patients are associated with outcome rate changes similar to existing evidence. For the complex patients in our study, who were least represented in existing trials, higher statin-use rates were associated with survival gains and higher adverse event risks not previously documented. Policy interventions promoting higher statin-use rates for complex patients may need to be reevaluated taking careful consideration of these tradeoffs.

What is the effect of area size when using local area practice style as an instrument?

OBJECTIVES: Discuss the tradeoffs inherent in choosing a local area size when using a measure of local area practice style as an instrument in instrumental variable estimation when assessing treatment effectiveness. STUDY DESIGN: Assess the effectiveness of angiotensin converting-enzyme inhibitors and angiotensin receptor blockers on survival after acute myocardial infarction for Medicare beneficiaries using practice style instruments based on different-sized local areas around patients. We contrasted treatment effect estimates using different local area sizes in terms of the strength of the relationship between local area practice styles and individual patient treatment choices; and indirect assessments of the assumption violations. RESULTS: Using smaller local areas to measure practice styles exploits more treatment variation and results in smaller standard errors. However, if treatment effects are heterogeneous, the use of smaller local areas may increase the risk that local practice style measures are dominated by differences in average treatment effectiveness across areas and bias results toward greater effectiveness. CONCLUSION: Local area practice style measures can be useful instruments in instrumental variable analysis, but the use of smaller local area sizes to generate greater treatment variation may result in treatment effect estimates that are biased toward higher effectiveness. Assessment of whether ecological bias can be mitigated by changing local area size requires the use of outside data sources.

Quantitative assessment of a new preparatory tool for board certification in urology.

OBJECTIVE: To analyse the performance of candidates in a Canadian national mock-examination for final-year urology residents with respect to North American speciality examinations in urology. METHODS: In 1997 the Queen's Urology Examination Skills Training Program (QUEST) was established as an annual national mock examination for final-year Canadian urology residents. It consists of a short answer question component and an objective structured clinical examination. During the 5-year period (1997-2001), 91 final-year residents from all 11 Canadian urology residency-training programmes participated in QUEST and the Royal College of Physicians and Surgeons of Canada certifying examinations (RCPSCE); 43 (47%) of candidates also attempted the American Board of Urology part 1 qualifying examinations (ABU 1). Performance on QUEST was correlated with the RCPSCE and ABU 1 in a blinded fashion after submitting QUEST scores to governing bodies. Thresholds were determined to help to predict a candidate's performance on the RCPSCE and ABU 1, based on QUEST scores. RESULTS: There was a moderately close correlation between overall QUEST and RCPSCE performance (r = 0.68, P < 0.001) and a moderate correlation between overall QUEST and ABU 1 performance (r = 0.42, P = 0.005). For the following QUEST scores, the probability of success on the RCPSCE was: < 65%, 67% pass; 66-75%, 80% pass; > 75%, 100% pass (P = 0.002). For ABU 1, QUEST overall score of 80% gave a 69% probability of scoring > or = 70% on ABU 1 (P = 0.003). CONCLUSIONS: QUEST is a moderate predictor of performance on speciality examinations in urology. We consider that the time, effort and expense to maintain QUEST are justified.

Social Security fixes--beware of conjurers!

Among the many proposals for reform, there is one that offers the best chance of truly solving Social Security's financial problems, these authors believe. That proposal would increase savings by requiring workers to invest an additional 2% of their covered wages in individual accounts. At retirement, 75% of the money would go toward buying the current level of Social Security benefits, and 25% would be given to the individual as an "extra" pension. Individuals, not the government, would control investment of these accounts.

The application of "integrated marketing communications" to social marketing and health communication: organizational challenges and implications.

PIP: Influencing consumer behavior is a difficult and often resource-intensive undertaking, with success usually requiring identifying, describing, and understanding target audiences; solid product and/or service positioning relative to competitors; and significant media and communication resources. Integrated marketing communication (IMC) is a new way of organizing and managing persuasive communication tools and functions which involves realigning communications to consider the flow of information from an organization from the viewpoint of end consumers. Although the application of IMC to social marketing remains relatively unexplored, the IMC literature and recent efforts by the US Centers for Disease Prevention and Control suggest that integrated communication approaches have much to offer social marketing and health communication efforts. IMC, IMC and social marketing, and implications of IMC for public and private sector social marketing programs are discussed.^ieng

Is the objective assessment of cerebral palsy gait reproducible?

It is important to determine the reproducibility of objective measures of gait in children with motor disorders in order that the effect of interventions to improve gait can be monitored. Data for walking velocity and vertical ground reaction force expressed as a percentage of body weight were collected from 15 normal children and 11 with spastic cerebral palsy. Five recordings were obtained for each foot of each child on 3 consecutive days, and calculations of variability made for each set of five recordings. Children with cerebral palsy had slower walking velocities and greater ground reaction force values, and both these parameters had low intraindividual variation for both normal children and those with cerebral palsy (coefficients of variation < 12.5%). This good reproducibility applied to intrasubject and intraday variability; no learning effect was seen over 3 days' recordings. There was no significant difference in variability whether the first three recordings or all five were used. These techniques of gait measurement in children have good reproducibility and a potential role in the objective assessment of medical and surgical interventions.

Mexican-Americans' use of prenatal care and its relationship to maternal risk factors and pregnancy outcome.

We evaluate the adequacy of prenatal care use and the association of use to a series of maternal risk factors and pregnancy outcomes, such as low birthweight, preterm delivery, and macrosomia in both Mexican-Americans and non-Hispanic whites in Arizona. The data came from all live-birth certificates from 1986 and 1987 for a total of 101,202 (26,826 Mexican-Americans). We evaluated the adequacy of prenatal care using a redesigned index that accounts for three factors: the month when prenatal care began, the number of prenatal care visits, and the duration of pregnancy. From this index we identified six prenatal care groups: intensive, adequate, intermediate, inadequate, no-care, and missing/unknown. Overall, we observed ethnic differences in patterns of prenatal care use, social profiles, and medical risk factors. Non-Hispanic whites, compared to Mexican-Americans, showed a greater risk for low birthweight and preterm delivery in those groups receiving poor prenatal care versus those who received adequate care. Within Mexican-Americans the risk of low birthweight was not the same for all subgroups. A higher overall prevalence of preterm delivery and macrosomia in comparison to low birthweight occurred in Mexican-Americans. We discuss the implications of the results for the identification, interpretation, evaluation, and public health significance of perinatal health problems of Mexican-Americans.