Surgical site infection risk following cesarean deliveries covered by Medicaid or private insurance.

OBJECTIVE: To compare risk of surgical site infection (SSI) following cesarean delivery between women covered by Medicaid and private health insurance. STUDY DESIGN: Retrospective cohort. STUDY POPULATION: Cesarean deliveries covered by Medicaid or private insurance and reported to the National Healthcare Safety Network (NHSN) and state inpatient discharge databases by hospitals in California (2011-2013). METHODS: Deliveries reported to NHSN and state inpatient discharge databases were linked to identify SSIs in the 30 days following cesarean delivery, primary payer, and patient and procedure characteristics. Additional hospital-level characteristics were obtained from public databases. Relative risk of SSI by primary payer primary payer was assessed using multivariable logistic regression adjusting for patient, procedure, and hospital characteristics, accounting for facility-level clustering. RESULTS: Of 291,757 cesarean deliveries included, 48% were covered by Medicaid. SSIs were detected following 1,055 deliveries covered by Medicaid (0.75%) and 955 deliveries covered by private insurance (0.63%) (unadjusted odds ratio, 1.2; 95% confidence interval [CI], 1.1-1.3; P < .0001). The adjusted odds of SSI following cesarean deliveries covered by Medicaid was 1.4 (95% CI, 1.2-1.6; P < .0001) times the odds of those covered by private insurance. CONCLUSIONS: In this, the largest and only multicenter study to investigate SSI risk following cesarean delivery by primary payer, Medicaid-insured women had a higher risk of infection than privately insured women. These findings suggest the need to evaluate and better characterize the quality of maternal healthcare for and needs of women covered by Medicaid to inform targeted infection prevention and policy.

Prenatal and Postnatal Fruit and Vegetable Intake Among US Women: Associations with WIC Participation.

Objective Evaluate variation in fruit and vegetable intake by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation and poverty status among pregnant, and postpartum women participating in the Infant Feeding Practice Study II (IFPSII). Methods IFPSII (2005-2007) followed US women from third trimester through 1 year postpartum through mailed questionnaires measuring income, WIC participation, breastfeeding; and dietary history questionnaires (DHQ) assessing prenatal/postnatal fruit and vegetable consumption. Poverty measurements used U.S. Census Bureau Federal Poverty thresholds to calculate percent of poverty index ratio (PIR) corresponding to WIC's financial eligibility (≤185 % PIR). Comparison groups: WIC recipients; WIC eligible (≤185 % PIR), but non-recipients; and women not financially WIC eligible (>185 % PIR). IFPSII participants who completed at least one DHQ were included. Intake variation among WIC/poverty groups was assessed by Kruskal-Wallis tests and between groups by Mann-Whitney Wilcoxon tests and logistic regression. Mann-Whitney Wilcoxon tests examined postnatal intake by breastfeeding. Results Prenatal vegetable intake significantly varied by WIC/poverty groups (p = 0.04) with WIC recipients reporting significantly higher intake than women not financially WIC eligible (p = 0.02); association remained significant adjusting for confounders [odds ratio 0.66 (95 % confidence interval: 0.49-0.90)]. Prenatal fruit and postnatal consumption did not significantly differ by WIC/poverty groups. Postnatal intake was significantly higher among breastfeeding than non-breastfeeding women (fruit: p < 0.0001; vegetable: p = 0.006). Conclusions for Practice Most intakes did not significantly differ by WIC/poverty groups and thus prompts research on WIC recipient's dietary behaviors, reasons for non-participation in WIC, and the influence of the recent changes to the WIC food package.

Agreement between the Perceived and Actual Fruit and Vegetable Nutrition Environments among Low-Income Urban Women.

The food environment is described by two measures: store-level (actual) and individual-level (perceived). Understanding the relationship between actual and perceived fruit and vegetable (F&V) nutrition environments is important as their association may influence F&V purchases and consumption. The study objective was to assess agreement between perceived and actual environment measures of availability, quality, and affordability/price for fresh and canned/frozen F&V. African American WIC recipients (n=84) self-reported perceptions corresponding to chain food stores (n=13) which were then assessed by surveyors. Nearly 80% of participants had positive perceptions of stores' F&V availability, quality, and affordability. Store assessments indicated high F&V availability and quality and lowest prices for canned varieties. Kappa statistics, sensitivity, and specificity calculated agreement between perceived and actual measures. Results indicated slight to fair agreements. Agreements were highest for quality measures (kappa=0.25 (95% CI:0.08-0.42), p=.008). Research implications include promoting nutrition education and resident interviewing to understand F&V expectations.

The Likelihood of Hospital Readmission Among Patients With Hospital-Onset Central Line-Associated Bloodstream Infections.

OBJECTIVE: To determine whether central line-associated bloodstream infections (CLABSIs) increase the likelihood of readmission. DESIGN: Retrospective matched cohort study for the years 2008-2009. SETTING: Acute care hospitals. PARTICIPANTS: Medicare recipients. CLABSI and readmission status were determined by linking National Healthcare Safety Network surveillance data to the Centers for Medicare and Medicaid Services' Medical Provider and Analysis Review in 8 states. Frequency matching was used on International Classification of Diseases, Ninth Revision, Clinical Modification procedure code category and intensive care unit status. METHODS: We compared the rate of readmission among patients with and without CLABSI during an index hospitalization. Cox proportional hazard analysis was used to assess rate of readmission (the first hospitalization within 30 days after index discharge). Multivariate models included the following covariates: race, sex, length of index hospitalization stay, central line procedure code, Gagne comorbidity score, and individual chronic conditions. RESULTS: Of the 8,097 patients, 2,260 were readmitted within 30 days (27.9%). The rate of first readmission was 7.1 events/person-year for CLABSI patients and 4.3 events/person-year for non-CLABSI patients (P<.001). The final model revealed a small but significant increase in the rate of 30-day readmissions for patients with a CLABSI compared with similar non-CLABSI patients. In the first readmission for CLABSI patients, we also observed an increase in diagnostic categories consistent with CLABSI, including septicemia and complications of a device. CONCLUSIONS: Our analysis found a statistically significant association between CLABSI status and readmission, suggesting that CLABSI may have adverse health impact that extends beyond hospital discharge.

Assessment of a new web-based sexual concurrency measurement tool for men who have sex with men.

BACKGROUND: Men who have sex with men (MSM) are the most affected risk group in the United States' human immunodeficiency virus (HIV) epidemic. Sexual concurrency, the overlapping of partnerships in time, accelerates HIV transmission in populations and has been documented at high levels among MSM. However, concurrency is challenging to measure empirically and variations in assessment techniques used (primarily the date overlap and direct question approaches) and the outcomes derived from them have led to heterogeneity and questionable validity of estimates among MSM and other populations. OBJECTIVE: The aim was to evaluate a novel Web-based and interactive partnership-timing module designed for measuring concurrency among MSM, and to compare outcomes measured by the partnership-timing module to those of typical approaches in an online study of MSM. METHODS: In an online study of MSM aged ≥18 years, we assessed concurrency by using the direct question method and by gathering the dates of first and last sex, with enhanced programming logic, for each reported partner in the previous 6 months. From these methods, we computed multiple concurrency cumulative prevalence outcomes: direct question, day resolution / date overlap, and month resolution / date overlap including both 1-month ties and excluding ties. We additionally computed variants of the UNAIDS point prevalence outcome. The partnership-timing module was also administered. It uses an interactive month resolution calendar to improve recall and follow-up questions to resolve temporal ambiguities, combines elements of the direct question and date overlap approaches. The agreement between the partnership-timing module and other concurrency outcomes was assessed with percent agreement, kappa statistic (κ), and matched odds ratios at the individual, dyad, and triad levels of analysis. RESULTS: Among 2737 MSM who completed the partnership section of the partnership-timing module, 41.07% (1124/2737) of individuals had concurrent partners in the previous 6 months. The partnership-timing module had the highest degree of agreement with the direct question. Agreement was lower with date overlap outcomes (agreement range 79%-81%, κ range .55-.59) and lowest with the UNAIDS outcome at 5 months before interview (65% agreement, κ=.14, 95% CI .12-.16). All agreements declined after excluding individuals with 1 sex partner (always classified as not engaging in concurrency), although the highest agreement was still observed with the direct question technique (81% agreement, κ=.59, 95% CI .55-.63). Similar patterns in agreement were observed with dyad- and triad-level outcomes. CONCLUSIONS: The partnership-timing module showed strong concurrency detection ability and agreement with previous measures. These levels of agreement were greater than others have reported among previous measures. The partnership-timing module may be well suited to quantifying concurrency among MSM at multiple levels of analysis.

Relationship between resource utilization and length of stay following tetralogy of Fallot repair.

BACKGROUND: The relationship between resource utilization and postoperative length of stay (PLOS) following congenital heart disease surgery is unknown. METHODS: We performed a retrospective cohort study using data from the Pediatric Health Information Systems database. We included subjects 1 month to 1 year of age with a PLOS of ≤ 1 month following elective, complete repair of tetralogy of Fallot (TOF) during 2004-2008 at children's hospitals that performed ≥ 10 such surgeries during the study period. We constructed three generalized linear models to assess the relationships of total costs, laboratory costs, and imaging costs during the first three postoperative days with overall PLOS. Race/ethnicity, insurance type, sex, and presence of a genetic syndrome (by ICD-9 codes) were included in the models as fixed effects; hospital of surgery was included as a random effect. RESULTS: For 1161 eligible surgical encounters at 36 children's hospitals, mean PLOS was 7.1 days (median = 6 days). Mean total, laboratory, and imaging costs for the first three postoperative days were $26,455, $2941, and $813, respectively. Most subjects were male (58.9%), did not have a genetic syndrome (88.3%), were non-Hispanic white (58.3%), and had either public or private insurance (41.0% and 39.1%, respectively). An estimated increase in total costs of $4600 or laboratory costs of $700 in the first three postoperative days was associated with a 1-day increase in PLOS. Imaging costs were not associated with PLOS. CONCLUSIONS: Increased resource utilization is not associated with a shorter PLOS following elective TOF repair, and it may be associated with longer PLOS.

Effect of the Expanded Program on Immunization Contact Method of data collection on health behaviors in Mali.

BACKGROUND: The Expanded Program on Immunization Contact Method (EPI-CM) is a proposed monitoring and program management tool for developing countries. The method involves health workers tallying responses to questions about health behaviors during routine immunizations and providing targeted counseling. We evaluated whether asking caretakers about health behaviors during EPI visits led to changes in those behaviors. METHODS: We worked in 2 districts in Mali: an intervention district where during immunization visits workers asked about 4 health behaviors related to bed net use, fever, respiratory disease, and diarrhea, and a control district where workers conducted routine immunization activities without health behavior questions. To evaluate the effect of EPI-CM, we conducted a cross-sectional household survey at baseline and 1 year postintervention. We used multivariate logistic regression to compare between districts the change over 1 year in 4 health behaviors: use of insecticide-treated nets, appropriate fever treatment, care-seeking for respiratory complaints, and appropriate diarrhea treatment. RESULTS: There were no significant differences between the 2 districts in the change in the 4 health behaviors when controlling for age, sex, maternal education and occupation, immunization history, and wealth. CONCLUSIONS: We found no evidence that EPI-CM increases healthy behaviors. Further evaluation of other potential benefits and costs of EPI-CM is warranted.

Neighborhood poverty and racial disparities in kidney transplant waitlisting.

Racial disparities persist in the United States renal transplantation process. Previous studies suggest that the distance between a patient's residence and the transplant facility may associate with disparities in transplant waitlisting. We examined this possibility in a cohort study using data for incident, adult ESRD patients (1998 to 2002) from the ESRD Network 6, which includes Georgia, North Carolina, and South Carolina. We linked data with the United Network for Organ Sharing (UNOS) transplant registry through 2005 and with the 2000 U.S. Census geographic data. Of the 35,346 subjects included in the analysis, 12% were waitlisted, 57% were black, 50% were men, 20% were impoverished, 45% had diabetes as the primary etiology of ESRD, and 73% had two or more comorbidities. The median distance from patient residence to the nearest transplant center was 48 mi. After controlling for multiple covariates, distance from patient residence to transplant center did not predict placement on the transplant waitlist. In contrast, race, neighborhood poverty, gender, age, diabetes, hypertension, body mass index, albumin, and the use of erythropoietin at dialysis initiation was associated with waitlisting. As neighborhood poverty increased, the likelihood of waitlisting decreased for blacks compared with whites in each poverty category; in the poorest neighborhoods, blacks were 57% less likely to be waitlisted than whites. This study suggests that improving the allocation of kidneys may require a focus on poor communities.

Neighborhood poverty and racial differences in ESRD incidence.

Poverty is associated with increased risk of ESRD, but its contribution to observed racial differences in disease incidence is not well-defined. To explore the contribution of neighborhood poverty to racial disparity in ESRD incidence, we analyzed a combination of US Census and ESRD Network 6 data comprising 34,767 patients that initiated dialysis in Georgia, North Carolina, or South Carolina between January 1998 and December 2002. Census tracts were used as the geographic units of analysis, and the proportion of the census tract population living below the poverty level was our measure of neighborhood poverty. Incident ESRD rates were modeled using two-level Poisson regression, where race, age and gender were individual covariates (level 1), and census tract poverty was a neighborhood covariate (level 2). Neighborhood poverty was strongly associated with higher ESRD incidence for both blacks and whites. Increasing poverty was associated with a greater disparity in ESRD rates between blacks and whites, with the former at greater risk. This raises the possibility that blacks may suffer more from lower socioeconomic conditions than whites. The disparity persisted across all poverty levels. The reasons for increasingly higher ESRD incidence among US blacks as neighborhood poverty increases remain to be explained.

Readmissions and the quality of care in patients hospitalized with heart failure.

OBJECTIVES: Clinical practice guidelines based on the results of randomized clinical trials recommend that patients with heart failure due to left ventricular systolic dysfunction (LVSD) be treated with angiotensin-converting enzyme inhibitors (ACEI) at doses shown to reduce mortality and readmission. This study examined the relationship between ACEI use at discharge and readmission among patients with heart failure due to LVSD. METHODS AND RESULTS: Data were abstracted from the medical records of 2943 randomly selected patients hospitalized for heart failure in 50 hospitals. The outcome of interest was the number of readmissions occurring up to 21 months after discharge. Six-hundred and eleven patients were eligible for analysis. Compared with patients discharged at a recommended ACEI dose, patients not prescribed an ACEI at discharge had an adjusted rate ratio of readmission (RR) of 1.74 [95% confidence interval (CI) 1.22-2.48], while patients prescribed an ACEI at less than a recommended dose had an RR of 1.24 (95% CI 0.91-1.69) (P = 0.005 for the trend). CONCLUSION: Our results show that ACEI use at discharge in patients with LVSD is associated with decreased rate of readmission. These findings suggest that compliance with the ACEI prescribing recommendations listed in clinical practice guidelines for patients with heart failure due to LVSD confers benefit.

Effectiveness and cost-effectiveness analysis of neuroreflexotherapy for subacute and chronic low back pain in routine general practice: a cluster randomized, controlled trial.

STUDY DESIGN: A cluster randomized, controlled trial was performed. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of adding patients' referral to neuroreflexotherapy intervention to the usual management of subacute and chronic low back pain in routine general practice. SUMMARY OF BACKGROUND DATA: Neuroreflexotherapy consists of the temporary implantation of epidermal devices in trigger points in the back and referred tender points in the ear. The efficacy of this procedure for treating subacute and chronic low back pain has been demonstrated in previous randomized, double-blind, controlled clinical trials. METHODS: Twenty-one primary care physicians working in seven primary care centers of the Spanish National Health Service in Palma de Mallorca, Spain, were randomly assigned to the intervention group (n = 11) or the control group (n = 10). The physicians recruited patients who had low back pain that had lasted for 14 or more days despite drug treatment and who did not meet criteria for surgery. The 45 patients recruited by physicians from the control group were treated according to the standard protocol, whereas the 59 patients recruited by physicians from the intervention group were, in addition, referred to neuroreflexotherapy intervention. The analysis of variables was performed taking into account that physicians, not patients, were randomly assigned. RESULTS: Patients underwent clinical evaluations at baseline and 15, 60, and 365 days later. At baseline, median intensity of pain was higher in patients undergoing neuroreflexotherapy than in control patients (visual analogue scale, 6.07; range, 4.67-8.80 vs. 5.15, range 4.11-8.00) and median duration of pain was also higher (48.1, range 28.4-211.1 vs. 17.5, range 15.0-91.5 days). At the last follow-up visit, patients treated with neuroreflexotherapy showed greater improvement than did control patients in low back pain (visual analogue scale, 5.5; range, 3.7-8.8 vs. 1.9; range, -1.2-3.0; P < 0.001); referred pain (visual analogue scale, 3.6; range, 2.7-7.3 vs. 0.6; range, -1.5-2.0; P = 0.001); and disability (Roland-Morris scale, 8.7; range, 2.0-13.3 vs. 2.0; range, -1.5-6.7; P = 0.007). Moreover, neuroreflexotherapy intervention was associated with a significantly (P < 0.035) lower number of consultations to private or public specialists, fewer indications of radiographs by primary care physicians, lower cost of drug treatment, and less duration of sick leave throughout the follow-up period. There were also differences in favor of neuroreflexotherapy intervention in the cost-effectiveness ratio for pain, disability, and quality of life that persisted in the most optimistic, the most conservative, and the average (break-even case) assumptions. CONCLUSIONS: Referral to neuroreflexotherapy intervention improves the effectiveness and cost-effectiveness of the management of nonspecific low back pain.