Space-Time Analyses of Alcohol Outlets and Related Motor Vehicle Crashes: Associations at City and Census Block-Group Levels.

BACKGROUND: Past research has linked alcohol outlet densities to drinking, drunken driving, and alcohol-related motor vehicle crashes (MVCs). Because impaired drivers travel some distances from drinking places to crash locations, spatial relationships between outlets and crashes are complex. We investigate these relationships at 3 geographic levels: census block groups (CBGs), adjacent (nearby) areas, and whole cities. METHODS: We examined risks of all injury MVCs as well as "had been drinking" (HBD) and single-vehicle-nighttime (SVN) subgroups using data from the Statewide Integrated Traffic Records System across CBGs among 50 California cities from 2001 to 2008. Relationships between outlet densities at the city level, within CBGs, and in adjacent CBGs and crashes were examined using Bayesian Poisson space-time analyses controlling for population size income and other demographics (all as covariates). RESULTS: All injury MVCs were positively related to adjacent CBG population size (relative rate [RR] = 1.008, 95% credible interval (CI) = 1.004, 1.012), and outlet densities at CBG (RR = 1.027, CI = 1.020, 1.035), nearby area (RR = 1.084, CI = 1.060, 1.106) and city levels (RR = 1.227, CI = 1.147, 1.315), and proportion of bars or pubs at the city level (RR = 2.257, CI = 1.187, 4.125). HBD and SVN crashes were comparatively less frequent in high outlet density CBG (RR = 0.993, CI = 0.987, 0.999; RR = 0.963, CI = 0.951, 0.975) and adjacent areas (RR = 0.979, CI = 0.962, 0.996; RR = 0.909, CI = 0.883, 0.936), but positively associated with city-level proportions of bars (RR = 3.373, CI = 0.736, 15.644; RR = 10.322, CI = 1.704, 81.215). Overall, a 10% increase in all outlets was related to 2.8% more injury crashes (CI = 2.3, 3.3) and 2.5% more HBDs (CI = 1.7, 3.3). A 10% increase in bars was related to 1.4% more crashes, 4.3% more HBDs, and 10.3% more SVNs. CONCLUSIONS: Population size and densities of bars or pubs were found to be associated with crash rates, with population effects appearing across cities and outlet effects appearing within dense downtown areas. Summary estimates of outlet and population impacts on MVCs must consider varying contributions at multiple spatial scales.

Patient- and Community-Level Sociodemographic Characteristics Associated with Emergency Department Visits for Childhood Injury.

OBJECTIVE: To examine pediatric emergency department (ED) visits over 5 years, trends in injury severity, and associations between injury-related ED visit outcome and patient and community-level sociodemographic characteristics. STUDY DESIGN: Retrospective analysis of administrative data provided to the Pediatric Emergency Care Applied Research Network Core Data Project, 2004-2008. Home addresses were geocoded to determine census block group and associated sociodemographic characteristics. Maximum Abbreviated Injury Scale severity and Severity Classification System scores were calculated. Generalized estimating equations were used to test for associations between sociodemographic characteristics and admission or transfer among injury-related ED visits. RESULTS: Overall ED visits and injury-related visits increased from 2004 to 2008 at study sites. Of 2,833676 successfully geocoded visits, 700,821 (24.7%) were injury-related. The proportion of higher severity injury-related visits remained consistent. Nearly 10% of injury-related visits resulted in admission or transfer each year. After adjusting for age, sex, payer, and injury severity, odds of admission or transfer were lower among minority children and children from areas with moderate and high prevalence of poverty. CONCLUSIONS: Pediatric injury-related ED visits to included sites increased over the study period while injury severity, anticipated resource utilization, and visit outcomes remained stable, with low rates of admission or transfer. Sociodemographic differences in injury-related visits and ED disposition were apparent. ED-based injury surveillance is essential to understand disparities, inform targets for prevention programs, and reduce the overall burden of childhood injuries.

The Effect of Neighborhood Context on the Relationship Between Substance Misuse and Weapons Aggression in Urban Adolescents Seeking ED Care.

BACKGROUND: Frameworks for studying the ecology of human behavior suggest that multiple levels of the environment influence behavior and that these levels interact. Applied to studies of weapons aggression, this suggests proximal risk factor (e.g., substance use) effects may differ across neighborhoods. OBJECTIVES: To estimate how the association between weapons aggression and substance use varies as a function of several community-level variables. METHODS: Individual-level measures (demographics, behavioral measures) were obtained from a survey of youth aged 14-24 years old seeking care at a Level-1 ED in Flint, Michigan. Community-level variables were obtained from public sources. Logistic generalized additive models were used to test whether community-level variables (crime rates, alcohol outlets, demographics) modify the link between individual-level substance use variables and the primary outcome measure: self-reported past 6-month weapon (firearm/knife) related aggression. RESULTS: The effect of marijuana misuse on weapons aggression varied significantly as a function of five community-level variables: racial composition, vacant housing rates, female headed household rates, density of package alcohol outlets, and nearby drug crime rates. The effect of high-risk alcohol use did not depend on any of the eight community variables tested. CONCLUSIONS: The relationship between marijuana misuse and weapons aggression differed across neighborhoods with generally less association in more disadvantaged neighborhoods, while high-risk alcohol use showed a consistently high association with weapons aggression that did not vary across neighborhoods. The results aid in understanding the contributions of alcohol and marijuana use to the etiology of weapon-related aggression among urban youth, but further study in the general population is required.

A Spatial Analysis of Heterogeneity in the Link Between Alcohol Outlets and Assault Victimization: Differences Across Victim Subpopulations.

The positive association between alcohol outlet density and assault rates is well established, but little is known about how this association differs across victim subpopulations. We use spatial point process models on police data from Flint, Michigan, to test how the link between alcohol outlet density and assault rates changes as a function of three victim characteristics: age, gender, and race. We found that, although both on-premises and package outlet densities consistently emerge as risk factors for victimization, their relative effects are markedly larger in Whites than in African Americans. No analogous age- or gender-based differences were found. These results suggest the racial effects arise more from relative differences in the atmosphere in and around alcohol outlets than differences in drinking behavior alone.

Health care system hazard vulnerability analysis: an assessment of all public hospitals in Abu Dhabi.

Hazard vulnerability analysis (HVA) is used to risk-stratify potential threats, measure the probability of those threats, and guide disaster preparedness. The primary objective of this project was to analyse the level of disaster preparedness in public hospitals in the Emirate of Abu Dhabi, utilising the HVA tool in collaboration with the Disaster Medicine Section at Harvard Medical School. The secondary objective was to review each facility's disaster plan and make recommendations based on the HVA findings. Based on the review, this article makes eight observations, including on the need for more accurate data; better hazard assessment capabilities; enhanced decontamination capacities; and the development of hospital-specific emergency management programmes, a hospital incident command system, and a centralised, dedicated regional disaster coordination centre. With this project, HVAs were conducted successfully for the first time in health care facilities in Abu Dhabi. This study thus serves as another successful example of multidisciplinary emergency preparedness processes.

The geography of violence, alcohol outlets, and drug arrests in Boston.

OBJECTIVES: We examined the relationship between alcohol outlets, drug markets (approximated by arrests for possession and trafficking), and violence in Boston, Massachusetts, in 2006. We analyzed geographic and environmental versus individual factors related to violence and identified areas high in violent crime. METHODS: We used data from the Boston Police Department, US Census, and Massachusetts State Alcohol Beverage Control Commission. Spatial modeling was employed at the block group level, and violent crime, alcohol outlets, and drug markets were mapped. RESULTS: Relative to other block groups, block groups in the highest decile of violent crime (n = 55) were found to be poorer (e.g., lower incomes, higher percentages of vacant homes), and they had greater numbers of alcohol outlets and higher drug arrest rates. Alcohol outlets and drug possession and trafficking arrests were predictive of violent crime. Also, spatial effects resulting from neighboring block groups were related to violent crime. Both alcohol outlet density and type were associated with violent crime in a differentiated and complex way. CONCLUSIONS: With drug possession and trafficking arrests as a proxy for drug markets, spatial relationships between alcohol outlets and violence were found in addition to typical sociodemographic predictors.

Quality of publications in emergency medicine.

OBJECTIVE: The objective of this study is to describe emergency medicine (EM) publications in terms of methodology, approval by institutional review board, method of consent, external validity, and setting (eg, prehospital or emergency department). METHODS: The 12 top-ranked emergency journals were selected. We manually reviewed the last 30 original articles in each EM journal, to represent more than 2 months of publications for all EM journals (range, 2-6 months). Only clinical original articles on human subjects were included. To ensure accurate data transcription, each article was read at least twice by 2 different reviewers and graded by written criteria using an extraction standard chart. RESULTS: Over the articles reviewed, 330 were analyzed. One hundred eighty-nine (57.3%) were prospective studies; 29 (8.8%) were randomized studies. Two hundred twenty-six studies (68.5%) mentioned an institutional review board approval or a waiver of authorization, and an informed consent was not mentioned in 227 (68.8%) of studies. Fifty-nine (17.9%) were conducted in a prehospital setting. Two hundred thirty-eight (72.1%) of these studies were at single-center institutions; the Unite States contributed 158 (47.9%) of the total publications. CONCLUSION: This study describes publications in the field of EM. Randomized studies represent 9% of publications, most studies are cross-sectional, and more than half have a retrospective design. We found that, in one-third of the studies, an institutional review board review was not mentioned and informed consent was not specified in two-thirds of the studies. Emergency medicine research volume, quality, and grants activity must increase in order for EM to progress within academic medicine.

Tobacco Use, Quitting, and Service Access for Northern California Arab Americans: A Participatory Study.

BACKGROUND: Cigarette smoking rates have decreased in the United States, particularly in California. Despite representing a large population in the United States and particularly in California, Arab Americans are not typically assessed in tobacco-related health studies. Disparately high smoking rates have been found in community samples of Arab Americans. In a formative participatory research study, we aimed to assess experiences with tobacco products and access to cessation and prevention services for Arab Americans who use commercial tobacco products. METHODS: In partnership with a community advisory board, we conducted a brief survey of adult Northern California Arab Americans who use tobacco products, both men and women (n = 101), followed by assets mapping to identify services, and focus groups with a subset of survey participants (n = 30), to assess tobacco product use, readiness to quit, and access to culturally appropriate cessation services. RESULTS: The majority of people who smoked did so daily. Waterpipe use was as common as cigarette smoking, and more so for women. Intent to quit was offset by highly normative tobacco use in the social environment, and limited access to culturally appropriate cessation services. CONCLUSIONS: Improvement in outreach and services specific to Arab Americans may support prevention and cessation of commercial tobacco products.

Emergency department utilization after the implementation of Massachusetts health reform.

STUDY OBJECTIVE: Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions. METHODS: We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation. RESULTS: Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%). CONCLUSION: Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

Impacts of confounding roadway characteristics on estimates of associations between alcohol outlet densities and alcohol-related motor vehicle crashes.

INTRODUCTION AND AIMS: Previous research on alcohol-related motor vehicle crashes (AMVC) share a substantial limitation: sources of geographic variations in background crash risks may confound estimated spatial relationships between alcohol outlets and AMVCs. The aim of this study was to address this concern by examining, spatial-temporally, relationships between alcohol outlets and AMVCs adjusting for a set of six roadway characteristics that may be, independently, related to crash risks. While most similar studies focus on one metropolitan area, we use a unique sample of 50 cities. DESIGN AND METHODS: The spatial sample for this study consisted of 8726 Census 2000 block groups representing 50 mid-sized California cities. Dependent measures were counts of crashes located within Census block groups. Independent measures included socio-demographics, social disadvantage, alcohol outlets and roadway characteristics. We assessed relationships of crashes to independent measures using hierarchical generalised linear models. RESULTS: Greater roadway length, greater percentage of highways, greater average speeds, fewer T-intersections, greater curviness and less fragmentation were related to greater numbers of crashes as was alcohol outlet density. DISCUSSION: Above and beyond alcohol outlet type and density, we found that roadway characteristics were related to AMVC risks across a sample of 50 mid-sized cities. Measures of roadway characteristics are an essential component of any model of motor vehicle crashes that attempts to assess impacts of alcohol outlets on motor vehicle crashes risks.

Changes in alcohol consumption and drinking patterns during 11 years of follow-up among ageing men: the FinDrink study.

BACKGROUND: Alcohol consumption is often reported to decrease with ageing. We investigated alcohol consumption and drinking patterns in an ageing population-based male sample during an 11-year follow-up period. METHODS: This study with baseline and two follow-up examinations (at 4 and 11 years) included 1516 randomly selected participants, aged 42, 48, 54 and 60 years from Eastern Finland. Alcohol consumption and drinking patterns during the year preceding the examination were assessed. Data were analysed using Generalized Estimating Equations and Mixed Models. RESULTS: Over the 11-year study period, the amount of alcohol consumed weekly increased among the 42-year-olds (P < 0.001) and remained constant among the older cohorts. The risk of frequent drinking (alcohol consumption at least twice weekly) increased among all cohorts (OR = 2.04, 95% CI = 1.50-2.79 for 42-year-olds; OR = 1.71, 95% CI = 1.13-2.58 for 48-year-olds; OR = 1.67, 95% CI = 1.16-2.39 for 54-year-olds and OR = 1.67, 95% CI = 1.21-2.29 for 60-year-olds). There was also an increasing probability of heavy consumption (more than 14 weekly drinks) among the 42-year-olds (OR = 1.47, 95% CI = 1.09-2.00). The risk of binging (six-plus drinks at one occasion) decreased among the older participants (OR = 0.65, 95% CI = 0.47-0.89 for 54-year-olds, and OR = 0.56, 95% CI = 0.39-0.81 for 60-year-olds). CONCLUSION: Finnish men born in 1926-1946 do not seem to decrease drinking while ageing. In contrast those born in 1944-1946 increase drinking until their 60's. This should be taken into consideration in planning health services for aged men in the near future.

The spatial distribution of underage tobacco sales in Los Angeles.

OBJECTIVE: Underage tobacco sales is considered a serious public health problem in Los Angeles. Anecdotally, rates have been thought to be quite high. In this paper, using spatial statistical techniques, we describe underage tobacco sales, identifying areas with high levels of sales and hot spots controlling for sociodemographic measures. METHODS: Six hundred eighty-nine tobacco outlets were investigated throughout the city of Los Angeles in 2001. We consider the factors that explain vendor location of illegal sales of tobacco to underage youth and focus on those areas with especially high rates of illegal sales when controlling for other independent measures. Using data from the census, the LA City Attorney's Office, and public records on school locations in Los Angeles, we employ general least-squares (GLS) estimators in order to avoid biased estimates. MAIN OUTCOME MEASURE: vendor location of underage tobacco compliance checks, violators, and nonviolators. RESULTS: Underage tobacco sales in Los Angeles were very high (33.5%) for the entire city in 2001. In many zip codes this rate is considerably higher (60%-100%). When conducting spatial modeling, lower income and ethnicity were strongly associated with increases in underage tobacco sales. Hotspot areas of underage tobacco sales also had much lower mean family income and a much higher percentage of foreign born and greater population density. CONCLUSIONS: Spatial techniques were used to better identify areas where vendors sell tobacco to underage youth. Lower income areas were much more likely to both have higher rates of underage tobacco sales and to be a hot spot for such sales. Population density is also significantly associated with underage tobacco sales. The study's limitations are noted.

Latitude-of-birth and season-of-birth effects on human color vision in the Arctic.

Extreme natural ambient light reduction, in both energy and range of wavelength spectrum, occurs during the winter season at very high latitudes (above the Arctic Circle or 66 degrees 32' North) that in turn results in increased exposure to artificial lighting. In contrast, during the summer months, the sun remains above the horizon and there is no darkness or night. Little is known about these extreme changes in light exposure on human visual perception. Measuring color discriminations with the FM100 Test revealed that Norwegians born above the Arctic Circle were less sensitive to yellow-green, green, and green-blue spectrum differences whereas they were more sensitive to hue variations in the purple range than individuals born below the Arctic Circle. Additionally, it was found that the Norwegian individuals born above the Arctic Circle and during autumn showed an overall decrease in color sensitivity, whereas those born in the summer showed a relative increase. All participants were adults and their color vision was tested in the same location (i.e., in Tromsø at 69.7 degrees North). These findings are consistent with the idea that there is a measurable impact on colour vision as adults of the photic environment that individuals born above the Arctic Circle and in the autumn experienced during infancy, namely a reduction in exposure to direct sunlight and an increase in exposure to twilight and artificial lighting.

The geography of chronic obstructive pulmonary disease across time: California in 1993 and 1999.

We investigated changes in the geography of Chronic Obstructuve Pulmonary Disease (COPD) hospitalization charges in California over the period of 1993 and 1999. There is little information available at less than the county level for this increasingly costly disease in California. We found, using a uniform grid unit method, (4X4 and 16X16 mile urban and rural grids respectively, using zip codes as the base source for information) positive relationships between COPD charges and age, percentage Hispanics, and number of tobacco outlets. Further, inverse relationships were found between the incidence of COPD charges and income level and the percentage of the population with undergraduate degrees. When examining "hotspot" grid units, we found that COPD was clearly associated with minority/immigrant status and depressed socio-economic measures, suggesting the need for better smoking interventions among persons of color and the poor. In summary, the Los Angeles area had a marked increase in hotspots both in 1993 and 1999, and also experienced a significant increase in COPD hospitalization charges between 1993 and 1999. Transforming zip code level data into a uniform grid allows for relatively simple comparisons across time, without such a transformation, such temporal comparisons are extremely difficult to implement. This more, "fine grained" geographical analysis allows public health planners a better platform than is typically available to assess changes in COPD.

Wine preference and related health determinants in a U.S. national sample of young adults.

This study examined relationships between wine preference and selected health determinants in a U.S. national sample of young adults to improve understanding of the association between light-moderate wine consumption and long-term morbidity and mortality risk. Interview data collected from 12,958 young adults who participated in the National Longitudinal Study of Adolescent Health were analyzed to determine whether wine preference was related to educational, health and lifestyle characteristics that are predictive of long-term morbidity and mortality. Wine drinkers generally had more formal education, better dietary and exercise habits, and more favorable health status indicators (e.g., normal body mass) than other drinkers and non-drinkers. A larger proportion of wine drinkers were light-moderate drinkers compared to beer or liquor drinkers, and wine drinkers were less likely to report smoking or problem drinking than beer or liquor drinkers. These findings indicate that wine preference in young adulthood is related to educational, health and lifestyle characteristics that may help to explain the association between light-moderate wine consumption and morbidity, and mortality risk in later adulthood.

Causal thinking and causal language in epidemiology: it's in the details.

Although epidemiology is necessarily involved with elucidating causal processes, we argue that there is little practical need, having described an epidemiological result, to then explicitly label it as causal (or not). Doing so is a convention which obscures the valuable core work of epidemiology as an important constituent of public health practice. We discuss another approach which emphasizes the public health "use value" of research findings in regard to prediction and intervention independent from explicit metaphysical causal claims. Examples are drawn from smoking and lung cancer, with particular focus on the original 1964 Surgeon General's report on smoking and the new version released in 2004. The intent is to help the epidemiologist focus on the pertinent implications of research, which, from a public health point of view, in large part entails the ability to predict and to intervene. Further discussion will center on the importance of differentiating between technical/practical uses of causal language, as might be used in structural equations or marginal structural modeling, and more foundational notions of cause. We show that statistical/epidemiological results, such as "smoking two packs a day increases risk of lung cancer by 10 times" are in themselves a kind of causal argument that are not in need of additional support from relatively ambiguous language such as "smoking causes lung cancer." We will show that the confusion stemming from the use of this latter statement is more than mere semantics. Our goal is to allow researchers to feel more confident in the power of their research to tell a convincing story without resorting to metaphysical/unsupportable notions of cause.

Changes in body mass index associated with head start participation.

OBJECTIVES: The goal of this study was to determine if Head Start participation is associated with healthy changes in BMI. METHODS: The sample included children participating in Head Start between 2005 and 2013 and children from 2 comparison groups drawn from a Michigan primary care health system: 5405 receiving Medicaid and 19,320 not receiving Medicaid. Change in BMI z score from the beginning to the end of each of 2 academic years and the intervening summer was compared between groups by using piecewise linear mixed models adjusted for age, gender, and race/ethnicity. RESULTS: The total sample included 43,748 children providing 83,239 anthropometric measures. The Head Start sample was 64.9% white, 10.8% black, and 14.4% Hispanic; 16.8% of the children were obese and 16.6% were overweight at the initial observation. Children who entered Head Start as obese exhibited a greater decline in the BMI z score during the first academic year versus the comparison groups (ß = -0.70 [SE: 0.05] vs -0.07 [0.08] in the Medicaid group [P < .001] and -0.15 [SE: 0.05] in the Not Medicaid group [P < .001]); patterns were similar for overweight children. Head Start participants were less obese, less overweight, and less underweight at follow-up than children in the comparison groups. CONCLUSIONS: Preschool-aged children with an unhealthy weight status who participated in Head Start had a significantly healthier BMI by kindergarten entry age than comparison children in a primary care health system (both those receiving and those not receiving Medicaid).

The spatial dynamics of violence and alcohol outlets.

OBJECTIVE: This study examines whether the association between violence and population density is moderated by the presence of alcohol outlets, both within a target geographical area and in adjacent geographical areas. The effect of sociodemographic variables on violence is also examined controlling for spatial confounding. METHOD: Zip code areas (N = 766) in California from four distinct areas (three urban and one rural) were examined for rates of violence, taking into consideration population characteristics of persons living in those areas and the potential interaction effects of alcohol outlets on violence rates. Population characteristics were assessed using Census data: outlet densities were obtained from the California Department of Alcohol Beverage Control; and violence rates were abstracted from hospital discharge data. A spatial population model of the production of violence was used to examine the relationships of population characteristics of target and surrounding areas to violence rates. RESULTS: The density of bars was found to be strongly associated with greater rates of assault, while density of restaurants was associated with less violence. Both appeared to have greatest effect in densely populated areas. Local and nearby population characteristics were also found to be related to greater rates of violence. CONCLUSIONS: While limited to cross-sectional data, the current study suggests that alcohol outlets, in the presence of socioeconomic measures, moderate the occurrence of violence in urban areas.