Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions.

OBJECTIVE: Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set. METHODS: We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups. RESULTS: Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category. CONCLUSIONS: Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Economic returns and the perceived obstacles to adopting active management in the forest-grassland transition ecoregion in south-central USA.

Forest-grassland ecotones are a mosaic of grassland, savanna, and upland forest. As such, landowners may have opportunities to choose to manage their lands for multiple objectives. We estimated the economic returns from managing forest and rangeland in southeastern Oklahoma, USA to produce different combinations of timber, cattle forage, and white-tailed deer (Odocoileus virginianus Zimmermann) browse for a 40-year period. We further conducted a survey to understand landowner perceptions of obstacles to adopting active management that involve timber harvest and prescribed fire. The highest net return was obtained from the treatment with harvested timber that was burned every four years (uneven-aged woodland/forest) because it had the greatest gross return from a combination of timber (46%), cattle forage (42%), and deer browse (11%). The return from this treatment was greater than that for managed for timber only (closed-canopy forest) or prioritizing cattle and deer (savanna). Survey results suggested that landowners were aware of the benefits of active management but that the majority (66%) considered cost a major obstacle in the management of their forest or rangeland. In particular, women forestland owners and older landowners considered cost an obstacle. Our findings advocate integrated timber, cattle, and deer management as the best economic strategy within the forest-grassland ecotone and for targeted outreach and landowner education related to the benefits of active management.

Geographic and social economic disparities in the risk of exposure to ambient air respiratory toxicants at Oklahoma licensed early care and education facilities.

BACKGROUND: Early life exposures to hazardous air pollutants has been associated with adverse asthma-related outcomes. Neighborhood-level social and economic factors play an essential role in the distribution of hazardous air pollutants and children spend a substantial amount of time at early care and education (ECE) facilities. While the indoor air quality of these facilities has been described, particularly for criteria air pollutants such as volatile organic compounds and particulate matter, little is known about the ambient air quality of ECE facilities. OBJECTIVES: We conducted a cross-sectional study to estimate the ambient air quality of Oklahoma licensed ECE facilities and to explore associations between ambient air quality and select geographic predictors. METHODS: We estimated ambient air quality using the total respiratory hazard quotient from the National Air Toxics Assessment according to the geographical location of licensed Oklahoma ECE facilities (N = 3184). We then determined whether urban and rural ECE facilities' air respiratory toxicant exposure risk differed by ECE facilities' neighborhood-level social and economic inequities including: 1) racial-ethnic minority community, 2) neighborhood socioeconomic status, and 3) residential segregation. RESULTS: Urban ECE facilities in Hispanic segregated counties were five times more likely to be at risk of high air respiratory exposure, adjusted for integrated urban counties (p < 0.0001, 95% CI [3.824, 7.699]). Rural ECE facilities in African American segregated counties were nine times more likely to be at risk of high air respiratory toxicant exposure, adjusted for integrated rural counties (p < 0.0001, 95% CI [5.641, 15.928]). CONCLUSION: We found geographically and socially disparate patterns of higher exposures to ambient air respiratory toxicants at Oklahoma ECE facilities. Safer siting policies and interventions are needed to mitigate air respiratory toxicant exposures, which may help to reduce asthma control disparities and improve respiratory health outcomes in Oklahoma ECE facilities.

A Snapshot of Oklahoma's CHR/CHW Workforce: Results from the Region 6 Training Needs Assessment Survey, 2019.

Background ­: The Region 6 South Central Public Health Training Center conducts needs assessments to inform the development of online trainings tailored to the HRSA Region 6 health and public health workforce. The purpose of this study was to assess Oklahoma's Community Health Representative (CHR) / Community Health Worker (CHW) workforce characteristics, current trainings, and training needs to guide the development of online trainings. Methods ­: This survey-based needs assessment for health and public health workforce training needs asked about alternative job titles, top three health issues addressed, roles played, skills used, current trainings, and training needs. Descriptive statistical analysis provided insights about CHRs/CHWs. The Fisher's exact test was used to compare frequency of responses between CHRs and CHWs, with p-values <0.05 considered significant. We analyzed qualitative data by using a modified content analysis. Results ­: Fifty-one self-identified CHRs/CHWs in Oklahoma participated in the 2019 regional health and public health training needs assessment. Most CHRs/CHWs were female and identified as "frontline public health workers." Respondents reported a range of educational attainment and diverse job titles. CHRs worked at tribal health or public health organizations primarily in rural areas. Most CHWs worked in urban areas and were employed by state and local health departments or community-based organizations. CHRs/CHWs had a broad spectrum of roles and skills, with required trainings reflecting various organizational needs. CHRs/CHWs expressed strong interest in receiving additional trainings via multiple delivery formats. Discussion and Conclusions ­: Oklahoma's CHRs/CHWs would benefit from and utilize workforce development, including trainings on a broad spectrum of roles and skills in multiple delivery formats. Potential employers and funders across the state would benefit from education on CHRs/CHWs as a workforce, team-integration, and sustainable funding.

American Indian and Non-Hispanic White Midlife Mortality Is Associated With Medicaid Spending: An Oklahoma Ecological Study (1999-2016).

Objective: A one third reduction of premature deaths from non-communicable diseases by 2030 is a target of the United Nations Sustainable Development Goal for Health. Unlike in other developed nations, premature mortality in the United States (US) is increasing. The state of Oklahoma suffers some of the greatest rates in the US of both all-cause mortality and overdose deaths. Medicaid opioids are associated with overdose death at the patient level, but the impact of this exposure on population all-cause mortality is unknown. The objective of this study was to look for an association between Medicaid spending, as proxy measure for Medicaid opioid exposure, and all-cause mortality rates in the 45-54-year-old American Indian/Alaska Native (AI/AN45-54) and non-Hispanic white (NHW45-54) populations. Methods: All-cause mortality rates were collected from the US Centers for Disease Control & Prevention Wonder Detailed Mortality database. Annual per capita (APC) Medicaid spending, and APC Medicare opioid claims, smoking, obesity, and poverty data were also collected from existing databases. County-level multiple linear regression (MLR) analyses were performed. American Indian mortality misclassification at death is known to be common, and sparse populations are present in certain counties; therefore, the two populations were examined as a combined population (AI/NHW45-54), with results being compared to NHW45-54 alone. Results: State-level simple linear regressions of AI/NHW45-54 mortality and APC Medicaid spending show strong, linear correlations: females, coefficient 0.168, (R2 0.956; P < 0.0001; CI95 0.15, 0.19); and males, coefficient 0.139 (R2 0.746; P < 0.0001; CI95 0.10, 0.18). County-level regression models reveal that AI/NHW45-54 mortality is strongly associated with APC Medicaid spending, adjusting for Medicare opioid claims, smoking, obesity, and poverty. In females: [R2 0.545; (F)P < 0.0001; Medicaid spending coefficient 0.137; P < 0.004; 95% CI 0.05, 0.23]. In males: [R2 0.719; (F)P < 0.0001; Medicaid spending coefficient 0.330; P < 0.001; 95% CI 0.21, 0.45]. Conclusions: In Oklahoma, per capita Medicaid spending is a very strong risk factor for all-cause mortality in the combined AI/NHW45-54 population, after controlling for Medicare opioid claims, smoking, obesity, and poverty.

The ecological and economic determinants of eastern redcedar (Juniperus virginiana) encroachment in grassland and forested ecosystems: A case study from Oklahoma.

Frequent fires were used as a management tool to maintain prairies, savannas, and woodlands in the southern Great Plains of the United States. However, fire exclusion beginning in the mid-1900s allowed for the establishment and growth of fire-intolerant species such as eastern redcedar (Juniperus virginiana: ERC) beyond their naturally occurring habitats. Apart from the reduction in burning, wide soil and climate adaptability, and seed dispersal by birds have facilitated the expansion of ERC in the southern Great Plains. The encroachment of ERC has caused heavy ecological and economic losses to Oklahoma and thus has been a major management concern for the past few decades. This study utilized count data modeling to analyze USDA Forest Service's (USFS) Forest Inventory and Analysis (FIA) data to investigate the relationship between available ecological and economic factors and the abundance of ERC in grassland and forested ecosystems of Oklahoma. The results suggested that low site productivity, high basal area, dense canopy, and silt loam soil texture significantly increase the abundance of ERC on a given site. The results also indicated that the rate of ERC encroachment is 3.3% higher in the softwood and 2.0% higher in the miscellaneous forests, compared to the hardwood forests. However, the economic variables of the study such as ownership type, adoption of active management, and proximity to a metropolitan area did not show a significant relationship to the abundance of ERC.

Diabetes among Hispanics in Oklahoma: Assessing Disparities to Guide Basic and Applied Research.

Background ­: Diabetes, a leading cause of morbidity and mortality in the United States, disproportionally affects minority populations. In 2015, Hispanics, the largest minority in the country, had the third highest rate of diabetes prevalence and the third highest age-adjusted rate of diabetes-related mortality. Substantial progress in understanding diabetes disparities nationally and in many areas of the country has been made. However, little is known about diabetes and related mortality among Hispanics in Oklahoma, which is known as a Hispanic "new Settlement" state due to the relatively recent and substantial growth of this population. Methods ­: We used Oklahoma Behavioral and Risk Factor Surveillance Survey data (2011-2016) to calculate population estimates of diabetes prevalence and selected sociodemographic characteristics for Hispanic and Non-Hispanic adults in the state. We used Oklahoma Death Registry data to estimate diabetes-related mortality rates for Hispanic and Non-Hispanic adults for the same five-year period. We examined differences in diabetes prevalence and diabetes-related mortality across selected sociodemographic characteristics. Results ­: Hispanics are the largest minority group in Oklahoma. Spanish is the most common non-English language spoken in the state. Hispanics are younger, poorer, less educated and experience less access to health care compared to other populations in Oklahoma. While Hispanics had the fifth highest reported diabetes prevalence rate during the five-year period examined, they had the third highest diabetes-related mortality rate in the state. Discussion and Conclusions ­: There is a need for community engagement and basic and applied research to help identify and reduce diabetes disparities in the growing Hispanic population in Oklahoma.

Perceptions of Government and Research Expert Groups and Their Implications for Watershed Management in Oklahoma, USA.

The collaborative approach for sustainable management of watersheds is built on engagement of diverse stakeholders. Climate variability and anthropogenic activities increasingly impose challenges to successful management, as do contrasts in stakeholder perceptions about those processes. To assess differences in perceptions about watershed issues, we conducted a focus group meeting of expert stakeholder groups from research institutions, and state and federal agencies in the management of Cimarron River Watershed, Oklahoma. We employed the Strengths, Weaknesses, Opportunities, and Threats (SWOTs) approach to identify important issues, and the analytic hierarchy process to rank the perceptions of these groups. We found incongruity between these two groups over internal factors (SW) and external factors (OT) risking sustainable watershed management. External threats such as climate change dominated the research group perceptions, whereas internally prevalent weaknesses such as inability to track water use and lack of a common platform to share scientific data, dominated the government group perceptions. Despite these differences, both groups identified the negative aspect (W + T) as dominant over the positive aspect (S + O), which suggests a pessimistic watershed management future, with risks prevailing over the opportunities. We see this particular congruity of these two stakeholders as an opportunity to initiate a collaborative approach to watershed management in Oklahoma. We also note that the most important factor from each group corresponds to a relatively modest importance from the other group, and therefore suggests the possibility of cooperation rather than conflict in management goals should collaborative watershed management become established in the watershed.

Patterns of Care for Localized Breast Cancer in Oklahoma, 2003-2006.

Despite well-established clinical guidelines for breast cancer treatment, Standard of Care (SOC) is not universal in the U.S. The purpose of this study was to describe the extent to which patients receive guideline-based, stage-specific treatments for localized female breast cancer in Oklahoma. Data were obtained from the Oklahoma Central Cancer Registry for the period 2003-2006. We included localized, invasive female breast cancers and analyzed both treatment and demographic factors. We used the National Comprehensive Cancer Network (NCCN) treatment guidelines to determine SOC. Among women who received breast conserving surgery (BCS), we used logistic regression to evaluate factors related to SOC. In Oklahoma, 92 percent of the 4,177 localized breast cancer patients were treated with recognized SOC. In women aged ≥65 years with BCS, those ≥75 years had a lower adjusted odds of meeting SOC than did those without insurance, with comorbid conditions, or whose comorbid status was unknown. Among women aged <65 years, those with Medicare/Medicaid, Medicare only, or without insurance, along with comorbid conditions, had a lower adjusted odds of meeting SOC. Overall, 92 percent of women met SOC. Factors such as age, insurance type, and comorbid conditions were associated with meeting SOC.

Nonmarital births in Oklahoma 1975-1995.

This report uses data from the Oklahoma State Department of Health to describe past trends and current patterns of nonmarital births in Oklahoma. Between 1975 and 1995, the percentage of unmarried women delivering a live birth in Oklahoma increased from 12% to 31%. Adult nonmarital births increased faster than teen nonmarital births, but teens had a higher percentage of nonmarital births. White rates increased faster than African-American and Native American rates, but African-Americans had a higher percentage of nonmarital births. Unmarried women who give birth were more likely to be poor and lack education; additionally, they were less likely to receive early prenatal care, more likely to have had low weight births, and more likely to have had an unintended pregnancy. Birth outcomes are poorer among unmarried women, but this may be due to poverty and education rather than marital status alone.

PIP: This study examined trends in nonmarital births during 1975-95 in Oklahoma. Data were obtained from the Oklahoma State Department of Health vital records and the Oklahoma Pregnancy Risk Assessment Monitoring System's annual surveys during 1988-95. Findings indicate that the percentage of unmarried women delivering a live birth in Oklahoma increased from 12% to 31% during 1975-99, a 158% increase. Nonmarital births rose from 5075 to 13,856. By 1995, almost one-third of births in Oklahoma were to unmarried women. Adult nonmarital births increased more rapidly than adolescent nonmarital births, especially among unmarried women aged 30-34 years. Most of the increase in older women with nonmarital births was from women who had nonmarital births as teens. Adolescents had a higher percentage of nonmarital births: 76% for women aged 15-17 years compared to 14.1% for women aged 30-34 years. White rates increased faster than African-American and Native-American rates (a 2.7-fold increase compared to 1.6- and 2.8-fold increases, respectively). African-Americans had a higher percentage of nonmarital births (69.2%) compared to White women (24.5%). Unmarried women were more likely to be poor and lack education and less likely to receive early prenatal care. 53.1% lived below the Federal Poverty Level. Unmarried mothers were more likely to have had a low-birth-weight baby and an unintended pregnancy. The percentage of nonmarital births in 1945 was only 3.4%, which means an 800% increase during 1945-95, a 50-year period of time. The state pattern followed a national pattern of increase.

Predicting the health-related values and preferences of geriatric patients.

BACKGROUND: Those who must make health care decisions on behalf of persons who lack decision-making capacity often have too little information. The purpose of this study was to determine whether and to what degree sociodemographic factors, social support, religious involvement, and functional status served as predictors of the health-related values and preferences of geriatric patients. METHODS: A retrospective chart review involving 178 cognitively intact patients enrolled at a geriatric clinic at a university medical center was conducted. Patient variables included age, race, sex, marital status, years of education, participation in formal religious activities, self-reported functional status, and adequacy of social and family support. These were compared with responses to a modified version of the Values History questionnaire, an established method of evaluating patient values that includes advance directives. RESULTS: Patients were likely to value quality (82%) over quantity of life (18%) and the ability to think clearly (64%) over 13 other specific health-related values. They were likely (93%) to want to be taken to a hospital emergency department on losing consciousness or becoming confused. Seventy-eight percent expressed a desire to be resuscitated using cardiopulmonary resuscitation (CPR), and 76% expressed a preference for use of a respirator, if necessary. Most (85%) considered a permanent vegetative state to be worse than death. High functional status predicted a preference for quality of life over length of life and the perception of a persistent vegetative state as worse than death (positive predictive value = 89%). Persons with better social and family support were more likely to accept treatment with CPR or a respirator and less likely to consider a permanent vegetative state to be worse than death. No single patient factor was strong enough to increase the probability of a particular value or preference by more than 17% above baseline. CONCLUSIONS: Sociodemographic and functional status variables are relatively weak predictors of personal values and directives. This reinforces the importance of routinely eliciting patient values and preferences and of updating the information, particularly following changes in functional status or family support. Baseline information regarding the health-related values and preferences of this primary care geriatric clinic population may provide valuable information about the values and preferences of decisionally impaired older patients.

Johnson v. Thompson.

KIE: The U.S. Court of Appeals, Tenth Circuit, held that the Federal Rehabilitation Act does not create a substantive right to medical treatment. A complaint was brought on behalf of infants born with myelomeningocele (spina bifida). The infants were participants in a study in which doctors recommended vigorous treatment, consisting of surgery and antibiotics, for roughly half of the infants studied. The appellate court held that, because the study considered both medical and nonmedical factors, infants who were not recommended for vigorous treatment were not discriminated against solely because of their handicap. The plaintiffs failed to show that, despite the handicap, the infants were otherwise qualified to receive vigorous treatment. Due to insufficient evidence that the infants' families' socioeconomic status was a determinative factor in the recommendation, the infants were not denied equal protection under the law. While the Constitution protects an interest in life, it does not impose an affirmative obligation on a state to preserve life.^ieng

Act relating to husband and wife ..., 16 March 1988.

This Act repeals Oklahoma statutory language providing that the husband is the "head of the family" and requiring the wife to conform to "any reasonable mode of living" that the husband may choose.