A prospective investigation of oral contraceptive use and breast cancer mortality: findings from the Swedish women's lifestyle and health cohort.

BACKGROUND: The association between oral contraceptive (OC) use and long-term mortality remains uncertain and previous studies have reported conflicting findings. We aim to assess the long-term impact of OC use on all-cause and cancer-specific mortality. METHODS: Out of 49,259 participants, we analysed data on 2120 (4.3%) women diagnosed with first primary breast cancer between 1993 and 2012, in the Swedish Women's Lifestyle and Health Study. Kaplan-Meier plots were used to graph the hazard of mortality in association with oral contraceptives use, stage of disease and hormone receptors status at diagnosis. Cox proportional hazard model were used to estimate hazard ratios (HR) between OC use and all-cause mortality. The same association was studied for breast cancer-specific mortality by modelling the log cumulative mortality risk, adjusting for clinical stage at diagnosis, hormone receptor status, body mass index and smoking. RESULTS: Among 2120 women with breast cancer, 1268 (84%) reported ever use of OC and 254 died within 10 years of diagnosis. The risk of death for OC ever-users relative to never-users was: HR = 1.13 (95% CI: 0.66-1.94) for all-cause mortality and HR = 1.29 (95% CI: 0.53-3.18) for breast cancer-specific mortality. A high percentage of women (42.9%) were diagnosed at early stage disease (stage I). CONCLUSIONS: Among women with primary breast cancer, OC ever-users compared to never- users did not have a higher all-cause or breast cancer specific-mortality, after the adjustment of risk factors.

Four-year evolution of a large, state-wide patient-centered medical home designation program in Michigan.

BACKGROUND: The patient-centered medical home (PCMH) has been recognized as a strategy to redesign and improve the delivery of primary health care. Collaboration between Blue Cross Blue Shield of Michigan (BCBSM) and 39 Physician Organizations in Michigan laid the foundation for a state-wide medical home program. OBJECTIVE: The objective of the study was to describe a unique methodology developed and implemented by BCBSM to designate primary care physician practices as medical homes. METHODS: Since 2009, practices were designated annually as medical homes on the basis of (1) implementation of PCMH-related capabilities, and (2) performance on quality-of-care and health resource utilization measures. An overall score for each practice was calculated. Practices were ranked relative to each other, with the top portion of the continuum representing an achievable level of performance. RESULTS: The number of practices designated as medical homes more than tripled since the program's inception: 302 (1283 physicians) in 2009, 513 (1876 physicians) in 2010, 772 (2547 physicians) in 2011, and 994 (3028 physicians) in 2012. Designated practices reported implementing more than double the PCMH capabilities of nondesignated practices, yet all practices increased their number of implemented capabilities during the 4 years. DISCUSSION: This program represents the largest state-based PCMH program in the United States. Over the 4-year period, 1130 unique practices have received designation, representing 3469 unique physicians. An estimated 1.4 million BCBSM members in Michigan received care from these practices. This program will continue to develop, drawing on changes in the health system landscape, collaboration with the physician community, and knowledge gained from PCMH evaluations.

Assessment and measurement of patient-centered medical home implementation: the BCBSM experience.

PURPOSE: Our goal was to describe an approach to patient-centered medical home (PCMH) measurement based on delineating the desired properties of the measurement relative to assumptions about the PCMH and the uses of the measure by Blue Cross Blue Shield of Michigan (BCBSM) and health services researchers. METHODS: We developed and validated an approach to assess 13 functional domains of PCMHs and 128 capabilities within those domains. A measure of PCMH implementation was constructed using data from the validated self-assessment and then tested on a large sample of primary care practices in Michigan. RESULTS: Our results suggest that the measure adequately addresses the specific requirements and assumptions underlying the BCBSM PCMH program-ability to assess change in level of implementation; ability to compare across practices regardless of size, affiliation, or payer mix; and ability to assess implementation of the PCMH through different sequencing of capabilities and domains. CONCLUSIONS: Our experience illustrates that approaches to measuring PCMH should be driven by the measures' intended use(s) and users, and that a one-size-fits-all approach may not be appropriate. Rather than promoting the BCBSM PCMH measure as the gold standard, our study highlights the challenges, strengths, and limitations of developing a standardized approach to PCMH measurement.

Risky Roads in Kuwait: An Uneven Toll on Migrant Workers.

This descriptive study reveals trends in citations and traffic-related mortality in Kuwait. Secondary data were utilized, where data on road traffic citations were obtained from the traffic police in the Ministry of Interior for the years from 2011 to 2015, and road traffic mortality data for the study period were obtained from the Ministry of Health. OBJECTIVE: To describe recent trends in data related to road traffic safety in Kuwait over time, which could serve as an important indicator for the level of enforcement of existing traffic regulations. Descriptive summary statistics are presented. RESULTS: There was a total of 24.2 million traffic violations during the study period. The number rose dramatically from 4 million citations in 2011 to nearly 6.5 million in 2015. The indirect method of citation (issued indirectly via surveillance methods) constituted a higher percentage of citations, 70.4%, compared to the direct method of citation (issued directly by the police officer), 29.6%. Furthermore, the top reason for citation was speeding, followed by parking in no parking/handicapped zones, driving with an expired license, and crossing a red light. Road traffic fatalities (RTFs) in Kuwait from 2011 to 2015 totaled 2282. About 450 people die each year in Kuwait from road traffic injuries and a slightly decreasing trend was found. Non-Kuwaitis have RTF counts that are four times higher than Kuwaitis, with 1663 and 263 deaths, respectively. CONCLUSIONS: Road traffic safety continues to be a major problem in Kuwait. Increases in citation issuance show a rise in traffic regulation enforcement, yet risky driving behaviors continue to account for most violations issued. Harsher penalties, road safety education, and implementing graduated driving licensing may be warranted to increase the safety of the roads.

Determinants of long-term weight change among middle-aged Swedish women.

OBJECTIVE: To describe the determinants of 12-year weight change among middle-aged women in Sweden. METHODS: In 1991/1992, 49,259 women across Sweden were recruited into a cohort. In 2003, 34,402 (73%) completed follow-up. Lifestyle and health characteristics including weight were collected, and 12-year weight change and substantial weight gain (≥+5.0 kg) were calculated; association between baseline characteristics and odds ratios (OR) with 95% confidence intervals (CI) of substantial weight gain were estimated. RESULTS: During the 12-year follow-up, 81% of women experienced weight gain. Being above average weight (64.5 kg) at baseline (OR =1.20, 95% CI: 1.14-1.26) and smoking 1 to 9 (OR = 1.10, 95% CI: 1.01-1.20), 10 to 19 (OR = 1.30, 95% CI: 1.21-1.39), or ≥20 cigarettes daily (OR = 1.17, 95% CI: 1.04-1.32) increased a woman's odds of experiencing substantial weight gain (influenced by smoking cessation). In contrast, risk of substantial weight gain was reduced among women 45 to 50 years of age (OR = 0.79, 95% CI: 0.73-0.85), women reporting high alcohol consumption (OR = 0.90, 95% CI: 0.83-0.98), and those with medium (OR = 0.93, 95% CI: 0.87-1.00) or high (OR 0.83, 95% CI: 0.77-0.90) physical activity levels. CONCLUSIONS: The majority of women experienced weight gain during middle age. Population-specific determinants of weight gain should guide obesity prevention efforts.

Implementation of Patient-Centered Medical Homes in Adult Primary Care Practices.

There has been relatively little empirical evidence about the effects of patient-centered medical home (PCMH) implementation on patient-related outcomes and costs. Using a longitudinal design and a large study group of 2,218 Michigan adult primary care practices, our study examined the following research questions: Is the level of, and change in, implementation of PCMH associated with medical surgical cost, preventive services utilization, and quality of care in the following year? Results indicated that both level and amount of change in practice implementation of PCMH are independently and positively associated with measures of quality of care and use of preventive services, after controlling for a variety of practice, patient cohort, and practice environmental characteristics. Results also indicate that lower overall medical and surgical costs are associated with higher levels of PCMH implementation, although change in PCMH implementation did not achieve statistical significance.

Association between maternal preventive care utilization and adolescent vaccination: it's not just about Pap testing.

STUDY OBJECTIVE: To examine the association between maternal preventive care utilization and human papillomavirus (HPV) vaccine uptake by their adolescent daughters. DESIGN: A cross-sectional study using immunization records from administrative claims and the state health department's immunization information system from June 2006 through May 2011. PARTICIPANTS: Commercially-insured Michigan females aged 13-17 in May 2011 and their mothers. Mothers were identified using relationship information on the insurance contract. MAIN OUTCOME MEASURES: Using logistic regression, we investigated whether initiating and/or completing the HPV vaccine series were associated with maternal preventive care utilization (Papaniculou testing, mammograms, primary care office visits) independently and using a combined maternal preventive care utilization index. RESULTS: Among 38,604 mother-daughter pairs, 36% of daughters initiated and 22% completed the HPV vaccine series. Maternal utilization of each recommended service was modestly associated with both daughter's initiation and completion of the HPV vaccine. Effect estimates for receipt of Papaniculou test on vaccine initiation (OR = 1.07, 95% CI = 1.06-1.08) were not any higher than for mammograms (OR = 1.10, 95% CI = 1.08-1.11) or primary care office visits (OR = 1.07, 95% CI = 1.06-1.09). Using a maternal preventive care utilization index, vaccine uptake increased with an increasing number of received services. CONCLUSIONS: Maternal receipt of recommended preventive care, which may reflect general attitudes toward prevention, is as or more predictive of daughter's vaccination status than cervical cancer screening alone. Engaging women in broad routine preventive care practices may have additional positive effects on adolescent HPV vaccination beyond those achieved through cervical cancer prevention efforts alone.

Dialing in: effect of telephonic wellness coaching on weight loss.

OBJECTIVE: To estimate the effect of telephonic wellness coaching on weight loss in a commercially insured population. STUDY DESIGN: Pre-post evaluation design. METHODS: Self-reported weight was obtained from 2 annual health assessment questionnaires administered during 2008 and 2010. Baseline (T1) information from these questionnaires was used to identify overweight/obese individuals and to determine targets for a 4-call wellness coaching program. Overweight/obese individuals identified at T1 were classified into following groups: (1) targeted for wellness coaching (N = 1448, including 1050 participants and 398 nonparticipants); (2) not targeted for wellness coaching, but targeted for other telephonic wellness care management (WCM) programs (N = 1270); (3) not targeted for any WCM programs (N = 7586). Weight reported on questionnaires a year later (T2) was used to calculate weight change between T1 and T2. Paired t-tests were used to detect significant weight changes over time. Multivariable linear regressions were used to compare weight changes between the groups. Stratified analysis was conducted to determine the effectiveness of telephonic wellness coaching for subgroups based on participants' selected health goals, intensity of the intervention received and initial stage of change. RESULTS: The group targeted for wellness coaching reported an average weight change of -0.44 kg (95% confidence interval [CI], -0.76 to -0.16) at T2, significantly more weight loss than reported by the group not targeted for any WCM programs. Participants who started in preparation stage and completed the program reported weight change of -1.43 kg (95% CI, -2.17 to -0.68), highest among program participants. CONCLUSIONS: Small weight loss was observed for obese/individuals targeted for telephonic wellness coaching.

Partial and incremental PCMH practice transformation: implications for quality and costs.

OBJECTIVE: To examine the associations between partial and incremental implementation of the Patient Centered Medical Home (PCMH) model and measures of cost and quality of care. DATA SOURCE: We combined validated, self-reported PCMH capabilities data with administrative claims data for a diverse statewide population of 2,432 primary care practices in Michigan. These data were supplemented with contextual data from the Area Resource File. STUDY DESIGN: We measured medical home capabilities in place as of June 2009 and change in medical home capabilities implemented between July 2009 and June 2010. Generalized estimating equations were used to estimate the mean effect of these PCMH measures on total medical costs and quality of care delivered in physician practices between July 2009 and June 2010, while controlling for potential practice, patient cohort, physician organization, and practice environment confounders. PRINCIPAL FINDINGS: Based on the observed relationships for partial implementation, full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population. CONCLUSIONS: Estimated effects of the PCMH model on quality and cost of care appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.

Lower rates of preterm birth in women of Arab ancestry: an epidemiologic paradox--Michigan, 1993-2002.

OBJECTIVE: Preterm birth (PTB), <37 weeks gestation, occurs in 12.1% of live births annually and is associated with significant morbidity and mortality in the United States. Racial/ethnic subgroups are disproportionately affected by PTB. Michigan is home to one of the largest Arab-American communities in the country; however, little is known about PTB in this population. This study examined the maternal demographic profile and risk factors of preterm birth (PTB) among foreign-born and US-born women of Arab ancestry relative to US-born Whites in Michigan. METHODS: Using Michigan Vital Statistics data, we examined correlates of PTB for primiparous U.S.-born white (n = 205,749), U.S.-born Arab (n=1,697), and foreign-born Arab (n=5,997) women who had had a live-born singleton infant during 1993-2002. We examined variables commonly reported to be associated with PTB, including mother's age and education; insurance type; marital status of parents; receipt of prenatal care; mother's chronic hypertension, diabetes, and tobacco use; and infant sex. RESULTS: Foreign-born Arabs are less educated and more likely to be on Medicaid, and they receive less prenatal care than US-born Whites. Prevalence of PTB was 8.5, 8.0, and 7.5% for US-born Whites, US-born Arabs, and foreign-born Arabs, respectively. Pregnancy-related hypertension was the only predictor of PTB that these three groups had in common: Adjusted Odds Ratio (AOR)=2.1 (95% Confidence Interval (CI)=1.99, 2.21), AOR=2.6 (95% CI=1.24, 5.51), and AOR=2.6 (95% CI=1.55, 4.31) for US-born whites, US-born Arabs, and foreign-born Arabs, respectively. CONCLUSIONS: Foreign-born Arab women in Michigan have a higher-risk maternal demographic profile than that of their US-born white counterparts; however, their prevalence of PTB is lower, which is consistent with the epidemiologic paradox reported among foreign-born Hispanic women.