Topographical Differences of Infant Mortality in Nepal.

Background Infant mortality is a major problem in Nepal, particularly in the mountainous region of the country. Objective To identify factors that contributes to the high rate of infant mortality in the mountain zone in Nepal. Method Data were derived from the 2011 Nepal Demographic and Health Survey (NDHS). Infant mortality was analyzed across three ecological zones in a sample of 5,306 live births in the five years preceding the survey. The contribution of risk factors to the excess infant mortality was assessed using multiple logistic regression. Result Infant mortality rate (deaths per 1000 live births) in the ecological zones were 59 (95% CI: 36, 81), 44 (35, 53), and 40 (33, 47) for the mountain, hill and terai zones, respectively. Women living in the mountain zone were more likely to report that distance to care was a "big problem" and had a greater risk of infant mortality compared to the terai zone (OR=1.42, 95% CI: 1.01, 2.02, p=0.04). This increased risk was observed only among births to mothers who perceived distance to the nearest health facility as a "big problem" (aOR=1.57, 95% CI: 1.01, 2.40, p=0.04) controlling for other risk factors. Conclusion These findings suggest that the higher Infant mortality rate (IMR) in the mountain zone was among the women who perceived distance to health facilities as a big problem. Improved accessibility to health services, particularly in this zone, is an essential strategy for reducing infant mortality in Nepal.

Utilization of primary health care facilities: lessons from a rural community in southwest Nigeria.

BACKGROUND: This study assessed service/organisational factors and clients' perceptions that influenced utilisation of Primary Health Care (PHC) facilities in a rural community in Nigeria. METHOD: A cross-sectional household survey in the community as well as key-informant interviews of opinion leaders and health care providers and participant observations of health facilities and utilisation pattern was used to collect data. RESULTS: Forty-four percent of respondents to the survey who were ill in the preceding six months visited a PHC facility for treatment, while others relied on self-medication/self-treatment. Education was positively associated with utilisation of PHC services (P<0.05). Maternal and child health (45.4%), prompt attention (23.0%), and appropriate outpatient (20.5%) services attracted respondents to use PHC services. Poor education about when to seek care, poverty, perceived high cost of PHC services, lack of drugs and basic laboratory services, and a regular physician on site at the facility were identified as barriers to utilisation. CONCLUSION: We conclude that community perceptions of poor quality and inadequacy of available services was responsible for low use of PHC services.

Gestational diabetes. Incidence, maternal characteristics, and perinatal outcome.

Accurate estimates of the incidence of abnormal glucose tolerance during pregnancy are virtually nonexistent. Screening select populations of women with risk factors for the condition and the nonrandom, non-population-based nature of most studies have given rise to wide variances in reported incidence. We analyzed data from the states of Mississippi and Washington and from the National Natality and Fetal Mortality Surveys conducted in 1980 in an attempt to provide more accurate population-based estimates of the incidence of gestational diabetes mellitus (GDM). In the national surveys GDM was noted (screening and diagnostic criteria were unavailable) as a complication in 0.38% of all sampled pregnancies; overt (type I and type II) diabetes was noted in 0.78%. Mean maternal age for the GDM group was 28.4 yr; 85% were white (81% controls) and 15% non-white (19% controls). Prepregnancy weights were higher in the GDM group by an average of 20 lb. However, mean weight gain was less in this group than in controls (23 versus 29 lb). Perinatal mortality was noted in approximately 2.8% (1.3% in controls) of the offspring in GDM-complicated pregnancies and congenital malformations in 6.4% (7.9% in controls). Methodologic problems were encountered and included lack of screening and diagnostic criteria, underreporting, and underrecording.

Epidemiologic approaches to the identification of problems in diabetes care.

We conducted two epidemiologic studies in Washington state to identify remediable problems in health care for persons with diabetes. In one study, mortality among persons with diabetes under the age of 45 was found to be 8 times higher than that in nondiabetic individuals of the same age. One-third of the deaths may have been preventable; problems in access to care may have contributed to premature mortality for some of these cases. The second investigation found that in counties with high hospital admission rates for diabetes, medical care may have been suboptimal. In these counties there was greater likelihood of hospitalization for mild metabolic problems, and less vigorous diagnostic and therapeutic management of hospitalized patients with similar case urgency. Population-based epidemiologic studies can identify health care problems and help focus interventions to improve diabetes care.

Gestational diabetes is a herald of NIDDM in Navajo women. High rate of abnormal glucose tolerance after GDM.

OBJECTIVE: To estimate the rate of deterioration of glucose tolerance and evaluate risk factors for development of NIDDM in Navajo women with a history of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: A retrospective analysis of 111 GDM deliveries over a 4-year period, 1983-1987, was conducted in 1994 to determine glucose tolerance status. Patients who had not developed NIDDM were recalled for a 2-h glucose tolerance test (GTT). Tested and non-tested patients were compared, as estimate of conversion to NIDDM was calculated, and risk factors for NIDDM were evaluated. A life-table analysis was developed to estimate the probability of NIDDM after GDM. RESULTS: At the time of chart review, 32 patients (29%) had already been diagnosed with NIDDM. Of the patients, 79 were offered GTT testing, and 56 (71%) returned for follow-up; 15 were diagnosed with NIDDM and 17 with impaired glucose tolerance (IGT); 47 (42%) and 64 (58%) patients in the cohort had developed NIDDM or NIDDM/IGT at the conclusion of the study period. Patients who developed NIDDM had greater BMIs, parity, and infant weights. Fasting blood glucose > 5.83 mmol/l, GTT > 41.63 mmol/l, and recurrence of GDM were associated with later NIDDM. A life-table analysis estimated a 53% likelihood of having NIDDM at an 11-year follow-up; a second model, based only on patients with known NIDDM status, predicted a 70% rate of NIDDM at an 11-year follow-up. CONCLUSIONS: A high proportion of Navajo women with GDM progressed to NIDDM. Postpartum counseling and periodic GTTs are recommended.

Why don't women with diabetes plan their pregnancies?

OBJECTIVE: To determine why women with diabetes generally do not plan their pregnancies, consequently entering their pregnancies with poor blood glucose control and greatly increasing the risk of birth defects in their infants. RESEARCH DESIGN AND METHODS: A population-based sample of 85 women with diabetes diagnosed before the index pregnancy were recruited within 6 months postpartum from 15 hospitals in the state of Washington. Women with planned and unplanned pregnancies were compared using qualitative and quantitative analysis of personal interviews, self-administered questionnaires, and medical record review. RESULTS: Although most women (79%) knew they should optimize their blood glucose levels before conception, fewer than half (41%) of their pregnancies were planned. Women with planned pregnancies had significantly higher income and more education; were more likely to have private health insurance, to see an endocrinologist before pregnancy, to be happily married, and to be Caucasian; and were less likely to use tobacco. Most unplanned pregnancies were not contraceptive failures, but may have been consciously or subconsciously intended. Women with planned pregnancies generally described an ongoing and positive relationship with their health care providers. Women who felt that their doctors discouraged pregnancy were more likely to have an unplanned pregnancy than were women who had been reassured they could have a healthy baby. CONCLUSIONS: Many women with diabetes still perceive negative messages about pregnancies and become pregnant without optimal planning. We believe there are many opportunities for increasing the proportion of women with diabetes who plan their pregnancies, particularly in the areas of prepregnancy information, support that women are given, and the quality of the relationships they experience within the health care system. It is crucial that couples be reassured that with pre-conception glucose control, almost all women with diabetes can have healthy babies.

Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997.

OBJECTIVES: Advances in medical technology and public health are changing the causes and patterns of pediatric mortality. To better inform health care planning for dying children, we sought to determine if an increasing proportion of pediatric deaths were attributable to an underlying complex chronic condition (CCC), what the typical age of CCC-associated deaths was, and whether this age was increasing. DESIGN: Population-based retrospective cohort from 1980 to 1997, compiled from Washington State annual censuses and death certificates of children 0 to 18 years old. MAIN OUTCOME MEASURES: For each of 9 categories of CCCs, the counts of death, mortality rates, and ages of death. RESULTS: Nearly one-quarter of the 21 617 child deaths during this period were attributable to a CCC. Death rates for the sudden infant death syndrome (SIDS), CCCs, and all other causes each declined, but less so for CCCs. Among infants who died because of causes other than injury or SIDS, 31% of the remaining deaths were attributable to a CCC in 1980 and 41% by 1997; for deaths in children 1 year of age and older, CCCs were cited in 53% in 1980, versus 58% in 1997. The median age of death for all CCCs was 4 months 9 days, with substantial differences among CCCs. No overall change in the age of death between 1980 to 1997 was found (nonparametric trend test). CONCLUSIONS: CCCs account for an increasing proportion of child deaths. The majority of these deaths occur during infancy, but the typical age varies by cause. These findings should help shape the design of support care services offered to children dying with chronic conditions and their families.

High-risk periods for childhood injury among siblings.

OBJECTIVE: To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling. DESIGN: Retrospective cohort. SETTING: King County, Washington. Participants. A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years). OUTCOME MEASURES: The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use. RESULTS: . There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56-1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk:.57; 95% confidence interval:.07-2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 21/2 months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children. CONCLUSIONS: Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.

A trade-off analysis of routine newborn circumcision.

BACKGROUND: The risks associated with newborn circumcision have not been as extensively evaluated as the benefits. OBJECTIVES: The goals of this study were threefold: 1) to derive a population-based complication rate for newborn circumcision; 2) to calculate the number needed to harm for newborn circumcision based on this rate; and 3) to establish trade-offs based on our complication rates and published estimates of the benefits of circumcision including the prevention of urinary tract infections and penile cancer. METHODS: Using the Comprehensive Hospital Abstract Reporting System for Washington State, we retrospectively examined routine newborn circumcisions performed over 9 years (1987-1996). We used International Classification of Diseases, Ninth Revision codes to identify both circumcisions and complications and limited our analyses to children without other surgical procedures performed during their initial birth hospitalization. RESULTS: Of 354, 297 male infants born during the study period, 130,475 (37%) were circumcised during their newborn stay. Overall 287 (.2%) of circumcised children and 33 (.01%) of uncircumcised children had complications potentially associated with circumcision coded as a discharge diagnosis. Based on our findings, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented. CONCLUSIONS: Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits. This information may help parents seeking guidance to make an informed decision.

Is greater continuity of care associated with less emergency department utilization?

BACKGROUND: The benefits of continuity of care (COC) have not been firmly established for pediatric patients. OBJECTIVE: To assess whether greater COC is associated with lower emergency department (ED) utilization. SETTING: Outpatient teaching clinic at Children's Hospital and Regional Medical Center, Seattle, WA. PATIENTS: All 785 Medicaid managed care children ages 0 to 19 years followed at Children's Hospital and Regional Medical Center between 1993 to 1997 who had at least four outpatient visits. METHODS: Retrospective claims-based analysis. COC was quantified based on the number of different care providers in relation to the number of clinic visits. RESULTS: Attending COC was significantly greater than resident COC. In a multiple event survival analysis, compared with those patients in the lowest tertile of attending COC, those in the middle tertile had 30% lower ED utilization (hazard ratio 0.70 [0.53-0.93]) and those in the highest tertile had 35% lower ED use (hazard ratio 0.65 [0.50-0.80]). Resident COC was not significantly associated with ED use. CONCLUSION: Greater COC with attending physicians in outpatient teaching clinics is associated with lower ED utilization.

Sentinel health events surveillance in diabetes. Deaths among persons under age 45 with diabetes.

The pilot study for a sentinel health events surveillance system for deaths among persons under age 45 with diabetes was conducted in six states in 1984 and 1985. Two hundred and thirty-three events were identified. Information from death certificates, physicians, and families revealed that 22% died from acute complications of diabetes and 53% from chronic complications. Blood pressure measurement and urinalysis testing had been performed in the last year for almost all of the decedents, but other preventive practices were reported less frequently. Hypertension was present in 57% and of those, was not controlled in 73%. Forty-four percent were cigarette smokers at the time of death. Agreement between physicians and families was generally higher for clinical conditions than for care practices. This surveillance system appears to yield information about the health care of persons with diabetes not readily available from other sources, although modifications may be necessary before implementation.

The impact of extended maternity services on prenatal care use among Medicaid women.

The goals of this study were to examine the use of maternity support services (MSS) and maternity case management (MCM) by Medicaid-eligible low-income pregnant women in Washington state, and to determine whether receipt of the services was associated with improved prenatal care use. We obtained data from linked birth certificates and Medicaid eligibility and claims files for women delivering between August 1989 and December 1991. Unconditional logistic regression was used to assess the programs' effects independent of other variables associated with prenatal care adequacy. The percentage of women receiving MSS and MCM was highest among women with demographic risks for adverse birth outcomes. Women receiving prenatal care from health departments or community clinics were more likely to receive MSS and MCM than those seen by private physicians or midwives. After adjustment for multiple confounding factors, we found that recipients of MSS, but not MCM, were significantly less likely than other women to receive an inadequate number of prenatal visits. Our findings suggest that public policies that pay for support services to low-income pregnant women can improve the use of prenatal care.

Analysis, assessment, and presentation of risk-adjusted statewide obstetrical care data: the StORQS II study in Washington State. Statewide Obstetrics Review and Quality System.

OBJECTIVE: To develop an effective, concise presentation of hospital-specific birth event and delivery-related complication rates, including significant deviations from expected rates calculated using risk-adjusted peer hospital data, for distribution to all Washington State hospitals with delivery services. DATA SOURCES: Complete data for calendar year 1993, including inpatient discharge records for mothers and newborns, birth certificates, and infant death records, for 74 hospitals from Washington state source files. STUDY DESIGN: Institutions were classified into four peer groups based on presence of neonatal intensive care units, number of births, and rural/urban location. Twenty-three clinical indicators of procedure (e.g., cesarean section) and complication rates were analyzed and presented. METHODS: For each indicator, observed and expected rates (adjusted within peer group for categorized baseline risk factors) were calculated and presented by institution. Effective graphic and numeric techniques for presenting significant deviations from expected rates were developed. Results were calculated in terms of numbers of events as well as rates. Approaches applicable to institutions with small numbers of deliveries were selected. PRINCIPAL FINDINGS: Exact confidence intervals (C.I.s) for event rates were superior to binomial or Poisson approximations for small hospitals. For calculating expected rates, indirect adjustment was used due to small numbers within risk factor categories. For all indicators, observed and expected rates along with 95 percent C.I.s for the true rate were presented graphically by institution for each peer group. Transforming C.I.s into "statistically acceptable ranges" allowed hospital personnel to assess their performance in terms of actual numbers of events as well as rates. CONCLUSIONS: Readily available statistical methods and straightforward descriptive approaches allow accurate presentation of outcomes for both large and small institutions.

Short, thin, or obese? Comparing growth indexes of children from high- and low-poverty areas.

This study compared the growth indexes of first-grade, white children living in geographic areas of high poverty (n = 281) and low poverty (n = 442) in the state of Washington. Obesity was the most common growth deviance observed in these children. In the low-poverty area, 18% of children had a weight for height greater than the 90th percentile on the National Center for Health Statistics (NCHS) growth standards, whereas only 12% of children from the high-poverty area were in this category. Neither area had high numbers of children with reduced weight for height (less than the 10th percentile on the NCHS growth standards), but children from the high-poverty area were almost twice as likely to be short for their age; 9% of children from the high-poverty area and 5% of children from the low-poverty area had height-for-age values less than the 10th percentile on the NCHS growth standards. Criteria used to determine students' eligibility for financial support for school lunch did not accurately identify children who were thin or short. The prevalence of obesity in these first-grade children suggests that school-based growth screening as well as weight management and physical fitness programs are needed to identify and avert childhood obesity.

Quality of life and health-risk behaviors among adolescents.

PURPOSE: To assess the association between health-risk behaviors and self-perceived quality of life among adolescents METHODS: A sample of 2801 students (957 seventh and eighth graders and 1844 ninth through twelfth graders) completed the Teen Assessment Survey (TAP) and the surveillance module of the Youth Quality of Life Instrument (YQOL-S). TAP responses were used to determine health-risks related to tobacco use, alcohol use, illicit drug use, and high risk sexual behavior. Separate multivariate analyses of variance showed mean differences in contextual and perceptual items of the YQOL-S for each health-risk behavior. Differences among engagers (adolescents who often engage), experimenters (occasionally engage), and abstainers (never engage) in the health-risk behavior were evaluated by gender and junior/senior high school groups. RESULTS: In general, adolescent abstainers reported higher quality of life (QoL) than engagers and experimenters on YQOL-S items. Adolescents who engaged in multiple risk behaviors scored even lower than those who engaged in only one health-risk behavior. Experimenters tended to rate their QoL more similar to that of abstainers than to that of engagers. CONCLUSIONS: The framework of QoL proved useful in the evaluation of adolescents' engagement in health-risk behaviors. Additionally, assessing the areas of QoL that differ between the groups may provide information for planning interventions aimed at risk reduction among engagers and experimenters.

Small area analysis of surgery for low-back pain.

Rates of spine surgery (discectomy, laminectomy, fusion) vary several-fold among "small areas" such as counties or hospital market areas. To ascertain why this is so, an analysis was conducted of variability in rates among counties in the State of Washington (N = 39). Since, unlike previous published reports, this study excluded patients with cancer, major trauma, and infection, as well as those with cervical and thoracic procedures, rates in this study pertain specifically to the problem of low-back pain. Six classes of variables to explain variability among county rates were defined: I) percentage of the labor force in heavy labor and transportation occupations; II) socioeconomic conditions; III) neurologic and orthopedic surgeon density; IV) occupancy rate of back surgery hospitals; V) primary payer and VI) health care availability. In all, the effect of 28 explanatory variables was tested. In doing so, the authors took into account the possibility of spurious correlation. The rate of surgery for low-back pain varied nearly 15-fold among counties. The explanatory variables that were tested, however, accounted for only a minor part of the variability. The hypothesis that "physician practice style factor" accounts for the major part is explored; potential properties of practice style factor are specified for further testing.

Outcomes of a diabetes education program.

This study is the first part of an evaluation of a model program of education on diabetes mellitus for diabetic outpatients, currently in progress in Washington State. The program consists of 16 hours of education, covering all aspects of self-care, with an emphasis on the prevention of unnecessary morbidity from poor control of the disorder or from infections. Eighty-eight percent of participants included in this study had not had formal diabetes education since receiving their diagnosis. The average duration of participants' diabetes was more than 7 years, and their average age was 55 years. Participants were evaluated just before and 3 months after the education program. During this interval, they made significant improvements in their knowledge of diabetes and their attitudes toward and skills in managing the disorder, as well as in their degree of satisfaction with control. Moreover, their random blood glucose and glycosylated hemoglobin (Hb Alc) levels were significantly lower at the 3-month followup. The authors suggest that outpatient education offers a significant improvement in diabetic control.

Situational and financial barriers to prenatal care in a sample of low-income, inner-city women.

The relationship between the use of prenatal care and factors that may impede access to care was examined in a sample of low-income, inner-city women. Situational and financial barriers to care were not important correlates of utilization. In unadjusted analyses, only insurance status and employment status were associated with utilization. Of the sociodemographic characteristics studied, only parity was strongly associated with the use of prenatal care. When the apparent associations between utilization and insurance status and utilization and employment were analyzed controlling for parity, the estimated strength and statistical significance of these relationships diminished considerably. Multiparous women who were more likely than primiparous women to be underutilizers were also more likely to be on medical assistance and to be unemployed. These findings suggest that situational and financial barriers are not important correlates of utilization for low-income, adult women living in urban areas where there are accessible clinic facilities and public transportation. Efforts to identify and surmount other kinds of barriers may prove to be a more effective approach to prenatal outreach for women in these circumstances.

Methodologic issues in pediatric outcomes research.

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

Continuity and quality of care for children with diabetes who are covered by medicaid.

BACKGROUND: Poor and minority children with Type 1 diabetes mellitus are at increased risk of severe adverse outcomes as a result of their disease. However, little is known about the quality of care that these children receive and which factors are associated with better quality of care. OBJECTIVES: Our objectives were as follows: 1) to describe the utilization of services associated with quality of care for children with Type 1 diabetes mellitus who are covered by Medicaid and 2) to test the hypothesis that increased continuity of primary care is associated with better care for these children. DESIGN: Retrospective cohort study. METHODS: Washington State Medicaid claims data for 1997 were used to determine what proportion of children with diabetes had 1) an inpatient or outpatient diagnosis of diabetic ketoacidosis (DKA), 2) a glycosylated hemoglobin (HgA1c) level that had been checked, 3) a retinal examination, and 4) thyroid function studies. Continuity of care was quantified using a pre-established index. RESULTS: Two hundred fifty-two eligible patients were identified. During the observation year, 20% had an outpatient diagnosis of DKA, 6% were admitted with DKA, 43% visited an ophthalmologist, 54% had their HgA1c checked, and 21% had their thyroid function assessed. Children with high continuity of care were less likely to have DKA as an outpatient (0.30 [0.13-0.71]). Children with medium continuity of care and high continuity of care were less likely to be hospitalized for DKA (0.22 [0.05-0.87] and 0.14 [0.03-0.67], respectively). For preventive services utilization, high continuity of care was associated only with an increased likelihood of visiting an ophthalmologist (2.80 [1.08-3.88]). CONCLUSIONS: The quality of care for Medicaid children with diabetes can be substantially improved. Low continuity of primary care is an identifiable risk factor for DKA.