Using multiple normalization procedures and contamination indices in the assessment of trace metal(loid) contents of the surface sediments of Lake Xingyun, southwestern China.

Trace metal(loid) (TM) contamination, especially of aquatic ecosystems, is a global ongoing environmental problem. Fully and accurately determining their anthropogenic sources is a key requirement for formulating remediation and management strategies. Herein, we developed a multiple normalization procedure, combined with principal component analysis (PCA) to assess the influence of data-treatment and environmental factors on the traceability of TMs in surface sediments of Lake Xingyun, China. Multiple contamination indices, i.e., Enrichment factor (EF), Pollution Load Index (PLI), Pollution Contribution Rate (PCR) and Exceeded multiple discharge standard limits (BSTEL) suggest that contamination is dominated by Pb with the average EF exceed 3, especially within the estuary aeras with the PCR >40 %. The analysis demonstrates that the mathematical normalization of data, which adjusts it for various geochemical influences, has a significant effect on analysis outputs and interpretation. Routine (Log) and extreme (outlier removing) transformations may mask and skew important information contained within the original (raw) data, which create biased or meaningless principal components. Granulometric and geochemical normalization procedures can obviously identify the influence of grain size and other environmental impact on TM contents in principal components, but incorrectly explains the potential sources and contamination on different sites. Reducing the influence of organic matter by normalization allowed the mineralogy, bio-degradation, salinity, and anthropogenic sources associated with local sewage and anthropogenic smelting to be identified and interpreted more clearly. Moreover, the co-occurrence network analysis also confirms that the influence of grain size, salinity, and organic matter content are the primary factors controlling the spatial variability in the type and concentrations of TMs.

Association of hemoglobin A1c time in range with risk for diabetes complications.

INTRODUCTION: We assessed the association between hemoglobin A1c time in range (A1c TIR), based on unique patient-level A1c target ranges, with risks of developing microvascular and macrovascular complications in older adults with diabetes. RESEARCH DESIGN AND METHODS: We used a retrospective observational study design and identified patients with diabetes from the Department of Veterans Affairs (n=397 634). Patients were 65 years and older and enrolled in Medicare during the period 2004-2016. Patients were assigned to individualized A1c target ranges based on estimated life expectancy and the presence or absence of diabetes complications. We computed A1c TIR for patients with at least four A1c tests during a 3-year baseline period. The association between A1c TIR and time to incident microvascular and macrovascular complications was studied in models that included A1c mean and A1c SD. RESULTS: We identified 74 016 patients to assess for incident microvascular complications and 89 625 patients to assess for macrovascular complications during an average follow-up of 5.5 years. Cox proportional hazards models showed lower A1c TIR was associated with higher risk of microvascular (A1c TIR 0% to <20%; HR=1.04; 95%) and macrovascular complications (A1c TIR 0% to <20%; HR=1.07; 95%). A1c mean was associated with increased risk of microvascular and macrovascular complications but A1c SD was not. The association of A1c TIR with incidence and progression of individual diabetes complications within the microvascular and macrovascular composites showed similar trends. CONCLUSIONS: Maintaining stability of A1c levels in unique target ranges was associated with lower likelihood of developing microvascular and macrovascular complications in older adults with diabetes.

Contamination and eco-risk assessment of toxic trace elements in lakebed surface sediments of Lake Yangzong, southwestern China.

Toxic trace elements represent an ongoing environmental problem in aquatic ecosystems. However, a lack of quantitative analysis and accurate evaluation has led to unguided control and water management strategies. Lake Yangzong is the main freshwater resource for nearly one million people in Yunnan Province in southwestern China. It has been heavily contaminated in recent years by significant anthropogenic activities including an industrial phosphor-gypsum spill, sewage effluent, and chemical remediation processes. Herein, we combine eco-environmental indices with multiple statistical analyses to determine the ecological risk and degree of contamination of 11 toxic trace elements in the upper sediments of the lakebed. Local geochemical background concentrations were determined using robust regression models developed from sediment core data. Pollution indices (EF/PLI) indicate that severe As contamination was centralized in the southwestern part of the lake. Other toxic trace elements (e.g., Cd, Cu, Pb) are slightly to moderately enriched, and progressively decrease from the northwestern to the southeastern areas of the lake. A more accurate and sensitive index (PCR) was proposed herein, suggesting that contamination was dominated by As and Pb in different lake sections. The northern section of the lake and the southwestern bay exhibited higher contaminant levels than other regions of the lake. Bio-toxic indices (ERF/PERI) indicate that As and Cd pose a high ecological risk, whereas Cu and Pb pose a low risk to biota. Statistical analyses (PCA/PMF) demonstrate that metal contaminants originated from three types of anthropogenic sources: the smelting of metal ores, the leakage of tailings effluent, and coal consumption.

Distribution and health-ecological risk assessment of heavy metals: an endemic disease case study in southwestern China.

This research focuses on the health risks caused by heavy metal (HM) environmental pollution. Soil, water, corn, rice, and patients' hair samples from Daping Village, Yunnan Province, China, were analyzed for seven selected HMs. Geoaccumulation index (Igeo), pollution indexes (PI), and the Nemerow integrated pollution index (PN) were used to evaluate pollution levels. We employed principal component analysis (PCA), correlation analysis (CA), and spatial distribution to identify the source and distribution characteristics of HMs in soil. Health risks of HMs and exposure pathways were accessed by calculating the hazard quotient (HQ) and hazard index (HI). The Igeo, PI, and PN results show that cadmium (Cd) and arsenic (As) pollution is severe in soil, while other pollution is relatively little. PCA, CA, and spatial distribution show that HMs may be derived from black shale weathering and enrichment. Residents' drinking water is relatively safe. Arsenic is the element most threatening to local residents (HI = 3.8). Soil (HI = 3.55) ingestion and plant (HI = 1.67) ingestion are the primary exposure pathways to HMs. This unusual disease may be caused by children's relatively low immunity and long-term exposure to As. We must enhance the protection of children and encourage avoiding soil contact as much as possible. Our results highlight the importance of investigating HM pollution from geological sources and blocking potential exposure pathways.

Increased Hemoglobin A1c Time in Range Reduces Adverse Health Outcomes in Older Adults With Diabetes.

OBJECTIVE: Short- and long-term glycemic variability are risk factors for diabetes complications. However, there are no validated A1C target ranges or measures of A1C stability in older adults. We evaluated the association of a patient-specific A1C variability measure, A1C time in range (A1C TIR), on major adverse outcomes. RESEARCH DESIGN AND METHODS: We conducted a retrospective observational study using administrative data from the Department of Veterans Affairs and Medicare from 2004 to 2016. Patients were ≥65 years old, had diabetes, and had at least four A1C tests during a 3-year baseline period. A1C TIR was the percentage of days during the baseline in which A1C was in an individualized target range (6.0-7.0% up to 8.0-9.0%) on the basis of clinical characteristics and predicted life expectancy. Increasing A1C TIR was divided into categories of 20% increments and linked to mortality and cardiovascular disease (CVD) (i.e., myocardial infarction, stroke). RESULTS: The study included 402,043 veterans (mean [SD] age 76.9 [5.7] years, 98.8% male). During an average of 5.5 years of follow-up, A1C TIR had a graded relationship with mortality and CVD. Cox proportional hazards models showed that lower A1C TIR was associated with increased mortality (A1C TIR 0 to <20%: hazard ratio [HR] 1.22 [95% CI 1.20-1.25]) and CVD (A1C TIR 0 to <20%: HR 1.14 [95% CI 1.11-1.19]) compared with A1C TIR 80-100%. Competing risk models and shorter follow-up (e.g., 24 months) showed similar results. CONCLUSIONS: In older adults with diabetes, maintaining A1C levels within individualized target ranges is associated with lower risk of mortality and CVD.

Call center performance affects patient perceptions of access and satisfaction.

OBJECTIVES: There is little research on the relationship between call center performance and patient-centered outcomes. In this study, we quantified the relationships between 2 measures of telephone access, average speed of answer (ASA) and abandonment rate (AR), and patient satisfaction outcomes within the Veterans Health Administration (VHA). STUDY DESIGN: We analyzed 2015 and 2016 data from the Survey of Healthcare Experiences of Patients and linked them with administrative data to gather features of the patient visit and monthly measures of telephone access for each medical center. METHODS: We used mixed effects logistic regression models to estimate the effects of ASA and AR on a variety of access and satisfaction outcomes. Models were adjusted for patient-level demographics, time-varying facility-level characteristics, features of the patient visit, and facility-level random effects to control for care quality and case mix differences. RESULTS: The VHA made substantial strides in both access measures between 2015 and 2016. We found that a center's ASA was inversely associated with patients' perceptions of their ability both to access urgent care appointments and to do so in a timely manner. In contrast, telephone AR was not associated with any of the patient satisfaction outcomes. CONCLUSIONS: Our results associate decreased telephone waits with improved perceptions of urgent care access even without concomitant decreases in observed appointment waits. These findings may have important implications for regulators as well as for healthcare organizations that must decide resource levels for call centers, including hospitals, federal health insurance exchanges, and insurers.

Causes of death and relative survival of older women after a breast cancer diagnosis.

PURPOSE: To understand the impact of breast cancer on older women's survival, we compared survival of older women diagnosed with breast cancer with matched controls. METHODS Using the linked 1992 to 2003 Surveillance, Epidemiology, and End Results (SEER) -Medicare data set, we identified women age 67 years or older who were newly diagnosed with ductal carcinoma in situ (DCIS) or breast cancer. We identified women not diagnosed with breast cancer from the 5% random sample of Medicare beneficiaries residing in SEER areas.We matched patient cases to controls by birth year and registry (99% or 66,039 [corrected] patient cases matched successfully). We assigned the start of follow-up for controls as the patient cases' date of diagnosis. Mortality data were available through 2006. We compared survival of women with breast cancer by stage with survival of controls using multivariable proportional hazards models adjusting for age at diagnosis, comorbidity, prior mammography use, and sociodemographics. We repeated these analyses stratifying by age. RESULTS: Median follow-up time was 7.7 years. Differences between patient cases and controls in sociodemographics and comorbidities were small (< 4%). Women diagnosed with DCIS (adjusted hazard ratio [aHR], 0.7; 95% CI, 0.7 to 0.7) or stage I disease (aHR, 0.8; 95% CI, 0.8 to 0.8) had slightly lower mortality than controls.Women diagnosed with stage II disease or higher had greater mortality than controls (stage II disease:aHR, 1.2; 95% CI, 1.2 to 1.2). The association of a breast cancer diagnosis with mortality declined with age among women with advanced disease [corrected]. CONCLUSION: Compared with matched controls, a diagnosis of DCIS or stage I breast cancer in older women is associated with better [corrected] survival, whereas a diagnosis of stage II or higher breast cancer is associated with worse survival.

Early stage breast cancer treatments for younger Medicare beneficiaries with different disabilities.

OBJECTIVE: To explore how underlying disability affects treatments and outcomes of disabled women with breast cancer. DATA SOURCES: Surveillance, Epidemiology, and End Results program data, linked with Medicare files and Social Security Administration disability group. STUDY DESIGN: Ninety thousand two hundred and forty-three incident cases of early-stage breast cancer under age 65; adjusted relative risks and hazards ratios examined treatments and survival, respectively, for women in four disability groups compared with nondisabled women. PRINCIPAL FINDINGS: Demographic characteristics, treatments, and survival varied among four disability groups. Compared with nondisabled women, those with mental disorders and neurological conditions had significantly lower adjusted rates of breast conserving surgery and radiation therapy. Survival outcomes also varied by disability type. CONCLUSIONS: Compared with nondisabled women, certain subgroups of women with disabilities are especially likely to experience disparities in care for breast cancer.

Managed care and cancer outcomes for Medicare beneficiaries with disabilities.

OBJECTIVE: To determine if the type of insurance arrangement, specifically health maintenance organization (HMO) vs fee-for-service (FFS), affects cancer outcomes for Medicare beneficiaries with disabilities. STUDY DESIGN: Retrospective cohort. METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare linked dataset to identify beneficiaries older and younger than 65 years entitled to Medicare benefits because of disability (Social Security Disability Insurance) who subsequently were diagnosed as having breast cancer (n = 6839) or non-small cell lung cancer (n = 10,229) from 1988 through 1999. We categorized persons according to Medicare insurance arrangement (continuous FFS, continuous HMO, or mixed FFS/HMO) during the periods 12 months before diagnosis and 6 months after diagnosis. Using a retrospective cohort design, we examined stage at diagnosis, cancer-directed treatments, and survival. RESULTS: Women with continuous HMO insurance had earlier-stage breast cancer diagnosis (adjusted relative risk, 0.77; 95% confidence interval, 0.65-0.91) and were more likely to receive radiation therapy following breast-conserving surgery (adjusted relative risk, 1.11; 95% confidence interval, 1.03-1.19). Women having continuous HMO insurance had better breast cancer survival, primarily resulting from earlier-stage diagnosis. Among persons with non-small cell lung cancer, those having mixed FFS/HMO insurance were more likely to receive definitive surgery for early-stage disease (adjusted odds ratio, 1.23; 95% confidence interval, 1.02-1.49) and to have better overall survival but not significantly better lung cancer survival. CONCLUSION: When diagnosed as having breast cancer or non-small cell lung cancer, some Medicare beneficiaries with disabilities fare better with managed care compared with FFS insurance plans.

Treatment disparities for disabled medicare beneficiaries with stage I non-small cell lung cancer.

UNLABELLED: Treatment disparities for disabled Medicare beneficiaries with stage I non-small cell lung cancer. OBJECTIVE: To compare initial treatment and survival of nonelderly adults with and without disabilities newly diagnosed with non-small cell lung cancer. DESIGN: Retrospective analyses; population-based cohorts. SETTING: Eleven Surveillance, Epidemiology, and End Results cancer registries. PARTICIPANTS: Persons with disability Medicare entitlement (n=1016) and nondisabled persons (n=8425) ages 21 to 64 years when diagnosed with stage I, pathologically confirmed, first primary non-small cell lung cancer between January 1, 1988, and December 31, 1999. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Initial cancer treatments (surgery, radiotherapy), survival (through December 31, 2001). Multivariable logistic regression and Cox proportional hazards regression estimated adjusted associations of disability status with treatments and survival. RESULTS: Persons with disabilities were much more likely to be male, non-Hispanic black, and not currently married. Although 82.2% of nondisabled persons had surgery, 68.5% of disabled persons received operations. Adjusted relative risks (RRs) of receiving surgery were especially low for persons with respiratory disabilities (adjusted RR=.76; 95% confidence interval [CI], .67-.85), nervous system conditions (adjusted RR=.86; 95% CI, .76-.98), and mental health and/or mental retardation disorders (adjusted RR=.92; 95% CI, .86-.99). Persons with disabilities had significantly higher cancer-specific mortality rates (hazard ratio [HR]=1.37; 95% CI, 1.24-1.51) than persons without disabilities. Observed differences in cancer mortality persisted after adjusting for demographic and tumor characteristics (adjusted relative HR=1.23; 95% CI, 1.10-1.39). Further adjustment for surgery use eliminated statistically significant differences in cancer mortality between persons with and without disabilities across disabling conditions. CONCLUSIONS: Persons with disabilities were much less likely than nondisabled Medicare beneficiaries to receive surgery; statistically significant cancer-specific mortality differences disappeared after accounting for these treatment differences. Future research must explore reasons for these findings and whether survival of disabled Medicare beneficiaries with early-stage, non-small cell lung cancer could improve if surgical treatment disparities were eliminated.

Cancer stage at diagnosis and survival among persons with Social Security Disability Insurance on Medicare.

OBJECTIVE: To examine stage at diagnosis and survival for disabled Medicare beneficiaries diagnosed with cancer under age 65 and compare their experiences with those of other persons diagnosed under age 65. DATA SOURCES: Surveillance, Epidemiology, and End Results (SEER) Program data and SEER-Medicare linked data for 1988-1999. SEER-11 Program includes 11 population-based tumor registries collecting information on all incident cancers in catchment areas. Tumor registry and Medicare data are linked for persons enrolled in Medicare. STUDY DESIGN: 307,595 incident cases of non-small cell lung (51,963), colorectal (52,092), breast (142,281), and prostate (61,259) cancer diagnosed in persons under age 65 from 1988 to 1999. Persons who qualified for Social Security Disability Insurance and had Medicare (SSDI/Medicare) were identified from Medicare enrollment files. Ordinal polychotomous logistic regression and Cox proportional hazards regression were used to estimate adjusted associations between disability status and later-stage diagnoses and mortality (all-cause and cancer-specific). PRINCIPAL FINDINGS: Persons with SSDI/Medicare had lower rates of Stages III/IV diagnoses than others for lung (63.3 versus 69.5 percent) and prostate (25.5 versus 30.8 percent) cancers, but not for breast or colorectal cancers. After adjustment, they remained less likely to be diagnosed at later stages for lung and prostate cancers. Nevertheless, persons with SSDI/Medicare experienced higher all-cause mortality for each cancer. Cancer-specific mortality was higher among persons with SSDI/Medicare for breast and colorectal cancer patients. CONCLUSIONS: Disabled Medicare beneficiaries are diagnosed with cancer at similar or earlier stages than others. However, they experience higher rates of cancer-related mortality when diagnosed at the same stage of breast and colorectal cancer.

Disparities in breast cancer treatment and survival for women with disabilities.

BACKGROUND: Breast-conserving surgery combined with axillary lymph node dissection and radiotherapy or mastectomy are definitive treatments for women with early-stage breast cancer. Little is known about breast cancer treatment for women with disabilities. OBJECTIVE: To compare initial treatment for early-stage breast cancer between women with and without disabilities and to examine the association of treatment differences and survival. DESIGN: Retrospective cohort study. SETTING: 11 Surveillance, Epidemiology, and End Results (SEER) Program tumor registries. PARTICIPANTS: 100,311 women who received a diagnosis of stage I to IIIA breast cancer at 21 to 64 years of age from 1988 to 1999. Women who qualified for Social Security Disability Insurance (SSDI) and Medicare at breast cancer diagnosis were considered disabled. MEASUREMENTS: Receipt of breast-conserving surgery versus mastectomy. For women who had breast-conserving surgery (n = 49 166), the authors examined receipt of radiotherapy and axillary lymph node dissection. Survival was measured from diagnosis until death or until 31 December 2001. RESULTS: Women with SSDI and Medicare coverage had lower rates of breast-conserving surgery than other women (43.2% vs. 49.2%; adjusted relative risk, 0.80 [95% CI, 0.76 to 0.84]). Among women who had breast-conserving surgery, women with SSDI and Medicare coverage were less likely than other women to receive radiotherapy (adjusted relative risk, 0.83 [CI, 0.77 to 0.90]) and axillary lymph node dissection (adjusted relative risk, 0.81 [CI, 0.74 to 0.90]). Women with SSDI and Medicare coverage had lower survival rates than those of other women in all-cause mortality (adjusted hazard ratio, 2.02 [CI, 1.88 to 2.16]) and breast cancer-specific mortality (adjusted hazard ratio, 1.31 [CI, 1.18 to 1.45]). Results were similar after adjustment for treatment differences. LIMITATIONS: Findings are limited to women who qualified for SSDI and Medicare. No data on adjuvant chemotherapy and hormonal therapy were available, and details about the underlying disability were lacking. CONCLUSIONS: Women with disabilities had higher breast cancer mortality rates and were less likely to undergo standard therapy after breast-conserving surgery than other women. Differences in treatment did not explain the differences in breast cancer mortality rates.

Racial and ethnic differences in utilization of health services in patients with diabetes enrolled in medicaid.

We evaluated racial and ethnic differences in use of medical care between patients with diabetes enrolled in Medicaid and explored whether differences varied by state Medicaid program. Using data from 137,006 patients we created a multivariable Poisson regression model to examine the effect of race on ambulatory care visits, emergency ward visits, and hospitalization rates for patients with diabetes mellitus enrolled in three state Medicaid programs. We found significant differences in service use between groups, which varied depending on state. For example, black patients compared with whites had significantly fewer outpatient visits but more hospitalizations in New Jersey; by contrast, blacks had higher outpatient visit rates and lower hospitalization rates in Georgia. Racial and ethnic differences in health service use among Medicaid enrollees were not consistent across states, suggesting that local factors, including varied Medicaid policies, may affect racial and ethnic differences in use of health care services.

Modelling the ability of risk adjusters to reduce adverse selection in managed care.

Population-based risk adjustment, as applied to reimbursement in managed care settings, may reduce pressures for adverse selection by managed care organisations. Using insurance claims data from 184 340 plan members, we compared the performance of three risk-adjustment methods. We present a model for measuring the impact of risk adjustment on the likelihood that individual members will be at risk for adverse selection. These results are compared with resource allocation based on age/sex. The predictive ability of alternative allocation schemes increased from an R(2) of 1.2% for age-sex allocation to 11.4% based on risk adjustment using diagnostic cost groups. However, the impact of risk adjustment on the proportion of members at risk for adverse selection was small. At an absolute threshold loss of $US2400 per year, 8.3% to 8.6% of members were at risk for adverse selection compared with 9.3% based on age-sex allocation. The limited impact of risk adjustment on the likelihood of adverse selection suggests that other strategies for reducing adverse selection may be required.

Maintenance of effects of the CATCH physical education program: results from the CATCH-ON study.

Long-term maintenance effects of physical education (PE) curriculum and staff development programs have not been studied. The authors assessed the sustainability of the Child and Adolescent Trial for Cardiovascular Health (CATCH) PE intervention using direct observations of 1,904 PE lessons in former intervention and control schools in four U.S. states 5-years postintervention. Student physical activity levels, lesson contexts, and level of CATCH PE training of teachers were analyzed. Student energy expenditure levels and proportion of PE time in moderate-to-vigorous physical activity in intervention schools were maintained 5 years later, but vigorous activity declined sharply. Meanwhile, postintervention gains in former control schools, influenced by delayed program implementation and secular trends, resulted in a convergence of activity levels in intervention and control schools. Use of CATCH PE curricula was associated with increased levels of teacher training and school support for PE in both former intervention and control schools.