A novel risk-adjusted metric to compare hospitals on their antibiotic-prescribing at hospital discharge.

BACKGROUND: Antibiotic overuse at hospital discharge is common, but there is no metric to evaluate hospital performance at this transition of care. We built a risk-adjusted metric for comparing hospitals on their overall post-discharge antibiotic use. METHODS: This was a retrospective study across all acute-care admissions within the Veterans Health Administration during 2018-2021. For patients discharged to home, we collected data on antibiotics and relevant covariates. We built a zero-inflated negative binomial mixed-model with two random intercepts for each hospital to predict post-discharge antibiotic exposure and length of therapy (LOT). Data were split into training and testing sets to evaluate model performance using absolute error. Hospital performance was determined by the predicted random intercepts. RESULTS: 1,804,300 patient-admissions across 129 hospitals were included. Antibiotics were prescribed to 41.5% while hospitalized and 19.5% at discharge. Median LOT among those prescribed post-discharge antibiotics was 7 (IQR 4-10). The predictive model detected post-discharge antibiotic use with fidelity, including accurate identification of any exposure (area under the precision-recall curve=0.97) and reliable prediction of post-discharge LOT (mean absolute error = 1.48). Based on this model, 39 (30.2%) hospitals prescribed antibiotics less often than expected at discharge and used shorter LOT than expected. Twenty-eight (21.7%) hospitals prescribed antibiotics more often at discharge and used longer LOT. CONCLUSION: A model using electronically-available data was able to predict antibiotic use prescribed at hospital discharge and showed that some hospitals were more successful in reducing antibiotic overuse at this transition of care. This metric may help hospitals identify opportunities for improved antibiotic stewardship at discharge.

Relative exposure to swine animal feeding operations and childhood asthma prevalence in an agricultural cohort.

Large swine animal feeding operations (AFOs) have become the model of livestock production throughout the United States. Epidemiological studies have consistently shown an increase in adverse respiratory symptoms among workers at AFOs. However, the impact on communities surrounding these facilities is still being investigated. We evaluated the association between relative environmental exposure to AFOs and the prevalence of prescribed medication for wheeze and/or childhood asthma in rural Iowa. Demographic and health information on 565 children aged 0-17 was obtained from a previous population-based cohort study while data on the AFOs were collected from publically available tax records. We created a metric of each child's relative environmental exposure to swine CAFOs which incorporated the size of the AFO as well as distance and wind direction. We determined the association between self-reported prescription medication for wheeze and/or self-reported physician diagnosed asthma and relative exposure while controlling for recognized risk factors using correlated logistic regression. The prevalence of childhood asthma in the cohort was 11.0% while 22.7% of children had been previously prescribed medication for wheeze or had a lifetime asthma diagnosis. Children with a larger relative environmental exposure to AFOs had a significantly increased odds of both outcomes (OR=1.51, p=0.014 asthma; OR=1.38, p=0.023 asthma or medication for wheeze). When stratified into exposure quartiles a linear trend was observed with asthma or medication for wheeze as the dependent variable but not with asthma alone. This study is the first to investigate children's cumulative relative exposure to smaller AFOs and adds to the growing volume of literature supporting a link between proximity to swine AFOs and adverse respiratory health.

Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center.

Background: Veterans suffer substantial morbidity and mortality from lung cancer. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality. Guidelines recommend counseling and shared decision-making (SDM) to address the benefits and harms of screening and the importance of tobacco cessation before patients undergo screening. Observations: We implemented a centralized LCS program at the Iowa City Veterans Affairs Medical Center with a nurse program coordinator (NPC)-led telephone visit. Our multidisciplinary team ensured that veterans referred from primary care met eligibility criteria, that LDCT results were correctly coded by radiology, and that pulmonary promptly evaluated abnormal LDCT. The NPC mailed a decision aid to the veteran and scheduled a SDM telephone visit. We surveyed veterans after the visit using validated measures to assess knowledge, decisional conflict, and quality of decision making. We conducted 105 SDM visits, and 91 veterans agreed to LDCT. Overall, 84% of veterans reported no decisional conflict, and 59% reported high-quality decision making. While most veterans correctly answered questions about the harms of radiation, false-positive results, and overdiagnosis, few knew when to stop screening, and most overestimated the benefit of screening and the predictive value of an abnormal scan. Tobacco cessation interventions were offered to 72 currently smoking veterans. Conclusions: We successfully implemented an LCS program that provides SDM and tobacco cessation support using a centralized telehealth model. While veterans were confident about screening decisions, knowledge testing indicated important deficits, and many did not engage meaningfully in SDM. Clinicians should frame the decision as patient centered at the time of referral, highlight the importance of SDM, and be able to provide adequate decision support.

Effects of common agricultural tasks on measures of hearing loss.

BACKGROUND: Among agricultural populations, hearing loss caused by excessive noise exposure is common. However, examinations of associations between exposure to agricultural tasks and hearing loss are limited. METHODS: Audiometry and lifetime exposure to 11 agricultural tasks were analyzed among 1,568 participants. Gender stratified multivariable linear regression was used to estimate associations between exposure duration and three hearing loss metrics. RESULTS: Among men, significant associations were observed between hearing loss and hunting or target shooting, all-terrain vehicle (ATV) or motorcycle riding, chain saw use, electric or pneumatic tool use, living on a farm, and all agricultural tasks combined. When all significant exposure metrics were included in a single model, associations remained for hunting or target shooting, electric or pneumatic tool use and living on a farm. Significant associations were sparse among women, and in all cases paradoxical. CONCLUSIONS: Despite imprecise estimation of noise exposure, specific agricultural tasks were associated with hearing loss.

Statement on national worklife priorities.

The National Institute for Occupational Safety and Health (NIOSH) WorkLife Initiative (WLI) [http://www.cdc.gov/niosh/worklife] seeks to promote workplace programs, policies, and practices that result in healthier, more productive employees through a focus simultaneously on disease prevention, health promotion, and accommodations to age, family, and life stage. The Initiative incorporates the Institute's foundational commitment to workplaces free of recognized hazards into broader consideration of the factors that affect worker health and wellbeing. Workplace hazards, such as physical demands, chemical exposures, and work organization, often interact with non-work factors such as family demands and health behaviors to increase health and safety risks. New workplace interventions being tested by the first three NIOSH WLI Centers of WorkLife Excellence are exploring innovative models for employee health programs to reduce the human, social, and economic costs of compromised health and quality of life. Many parties in industry, labor, and government share the goals of improving employee health while controlling health care costs. NIOSH convened a workshop in 2008 with representatives of the three Centers of Excellence to develop a comprehensive, long-range strategy for advancing the WorkLife Initiative. The recommendations below fall into three areas: practice, research, and policy. Responding to these recommendations would permit the WorkLife Center system to establish a new infrastructure for workplace prevention programs by compiling and disseminating the innovative practices being developed and tested at the Centers, and elsewhere. The WLI would also extend the customary scope of NIOSH by engaging with multiple NIH Institutes that are already generating research-to-practice programs involving the working-age population, in areas such as chronic disease prevention and management. Research to Practice (r2p) is a concept focused on the translation of research findings, technologies, and information into evidence-based prevention practices and products that are adopted in the workplace or other "real-world" settings. NIOSH's goal is to overcome the translational issues that now prevent state-of-the-art occupational health, health promotion, and chronic disease research findings from benefiting working age populations immediately, regardless of workplace size, work sector, or region of the country.

Leptospirosis infections among hospital patients, Sarawak, Malaysia.

BACKGROUND: Leptospirosis diagnoses have increased in Sarawak, Malaysia in recent years. METHODS: To better understand the burden of disease and associated risk factors, we evaluated 147 patients presenting with clinical leptospirosis to local hospitals in Sarawak, Malaysia for the presence of Leptospira and associated antibodies. Sera and urine specimens collected during the acute illness phase were assessed via a commercially available rapid diagnostic test (Leptorapide, Linnodee Ltd., Antrim, Northern Ireland), an ELISA IgM assay (Leptospira IgM ELISA, PanBio, Queensland, Australia) and a pan-Leptospira real-time PCR (qPCR) assay to estimate disease prevalence and diagnostic accuracy of each method. Microagglutination testing was performed on a subset of samples. RESULTS: Overall, 45 out of 147 patients (30.6%) showed evidence of leptospires through qPCR in either one or both sera (20 patients) or urine (33 patients), and an additional ten (6.8%) were considered positive through serological testing, for an overall prevalence of 37.4% within the study population. However, each diagnostic method individually yielded disparate prevalence estimates: rapid test 42.2% for sera and 30.5% for urine, ELISA 15.0% for sera, qPCR 13.8% for sera and 23.4% for urine. Molecular characterization of a subset of positive samples by conventional PCR identified the bacterial species as Leptospira interrogans in 4 specimens. A multivariate risk factor analysis for the outcome of leptospirosis identified having completed primary school (OR = 2.5; 95 CI% 1.0-6.4) and weekly clothes-washing in local rivers (OR = 10.6; 95 CI% 1.4-214.8) with increased likelihood of leptospirosis when compared with those who had not. CONCLUSION: Overall, the data suggest a relatively high prevalence of leptospirosis in the study population. The low sensitivities of the rapid diagnostic test and ELISA assay against qPCR highlight a need for better screening tools.

Health effects of airborne exposures from concentrated animal feeding operations.

Toxic gases, vapors, and particles are emitted from concentrated animal feeding operations (CAFOs) into the general environment. These include ammonia, hydrogen sulfide, carbon dioxide, malodorous vapors, and particles contaminated with a wide range of microorganisms. Little is known about the health risks of exposure to these agents for people living in the surrounding areas. Malodor is one of the predominant concerns, and there is evidence that psychophysiologic changes may occur as a result of exposure to malodorous compounds. There is a paucity of data regarding community adverse health effects related to low-level gas and particulate emissions. Most information comes from studies among workers in CAFO installations. Research over the last decades has shown that microbial exposures, especially endotoxin exposure, are related to deleterious respiratory health effects, of which cross-shift lung function decline and accelerated decline over time are the most pronounced effects. Studies in naïve subjects and workers have shown respiratory inflammatory responses related to the microbial load. This working group, which was part of the Conference on Environmental Health Impacts of Concentrated Animal Feeding Operations: Anticipating Hazards-Searching for Solutions, concluded that there is a great need to evaluate health effects from exposures to the toxic gases, vapors, and particles emitted into the general environment by CAFOs. Research should focus not only on nuisance and odors but also on potential health effects from microbial exposures, concentrating on susceptible subgroups, especially asthmatic children and the elderly, since these exposures have been shown to be related to respiratory health effects among workers in CAFOs.

Sleep duration and body mass index in a rural population.

BACKGROUND: A growing body of epidemiological evidence suggests an association between short sleep duration and obesity. Recently, potential hormonal links have been observed that may account for the relationship. The possible connection between sleep duration and body mass index (BMI) has not been explored in rural populations. Rural populations are of interest because obesity rates are high and lifestyle patterns of nutrition, physical activity, work hours, and sleep may differ from those in urban and suburban populations. We conducted this study to determine whether short sleep duration is related to BMI and obesity in a rural population in southeast Iowa. METHODS: We conducted a cross-sectional analysis of data collected in the Keokuk County Rural Health Cohort Study, 1999-2004. Study participants were from a population-based sample consisting of 990 employed adults in a rural community in southeastern Iowa. The main outcome measure was BMI. Multiple linear regression modeling was used to adjust for potential confounding variables. RESULTS: Self-reported sleep duration on weeknights was negatively correlated (beta = -0.42; 95% confidence interval, -0.77 to -0.07) with higher BMI after adjusting for sex, age, educational achievement, physical job demand, household income, depressive symptoms, marital status, alcohol consumption, and snoring. CONCLUSION: These data support an association between short sleep duration and higher BMI in this rural population, which is consistent with the relationship found in other settings.

Workforce Characteristics and Attitudes Regarding Participation in Worksite Wellness Programs.

PURPOSE: To estimate workforce participation characteristics and employees' attitudes regarding participation in workplace wellness programs. DESIGN: Data from a statewide stratified random sample were used to compare small (<50 employees) and larger (50+ employees) workplaces to estimate participation in screening programs and likelihood of participation in workplace wellness programs. SETTING: A telephone survey of employed Iowans registered to vote. SUBJECTS: Surveyed were 1171 employed Iowans registered to vote, ages 18 to 65. MEASURE: Among questionnaire survey modules were items from the Wellness Council of America Employee Needs and Interest Survey, the U.S. Census Bureau for employment documentation, and the World Health Organization Health and Work Performance Questionnaire for assessment of sickness absenteeism and presenteeism. ANALYSIS: Prevalence of participation in screening and wellness programs was analyzed by employment size and levels of likeliness to participate, and multivariable analyses of employee baseline characteristics regarding participation in screening programs and likelihood of participation in wellness programs was presented as top and bottom quartiles. RESULTS: Those employed in smaller workplaces participated less often in screening programs. Multivariable models identified male gender and those with an abnormal body mass index were associated with nonparticipation, while having a primary care physician was associated with participation. Very few items showed significant statistical difference in willingness to participate. CONCLUSION: Workforce characteristics and access to health care may influence participation in screening and wellness programs. Employment size is not a determining factor for willingness to participate in wellness programs.

Are swine workers in the United States at increased risk of infection with zoonotic influenza virus?

BACKGROUND: Pandemic influenza strains originate in nonhuman species. Pigs have an important role in interspecies transmission of the virus. We examined multiple swine-exposed human populations in the nation's number 1 swine-producing state for evidence of previous swine influenza virus infection. METHODS: We performed controlled, cross-sectional seroprevalence studies among 111 farmers, 97 meat processing workers, 65 veterinarians, and 79 control subjects using serum samples collected during the period of 2002-2004. Serum samples were tested using a hemagglutination inhibition assay against the following 6 influenza A virus isolates collected recently from pigs and humans: A/Swine/WI/238/97 (H1N1), A/Swine/WI/R33F/01 (H1N2), A/Swine/Minnesota/593/99 (H3N2), A/New Caledonia/20/99 (H1N1), A/Panama/2007/99 (H3N2), and A/Nanchang/933/95 (H3N2). RESULTS: Using multivariable proportional odds modeling, all 3 exposed study groups demonstrated markedly elevated titers against the H1N1 and H1N2 swine influenza virus isolates, compared with control subjects. Farmers had the strongest indication of exposure to swine H1N1 virus infection (odds ratio [OR], 35.3; 95% confidence interval [CI], 7.7-161.8), followed by veterinarians (OR, 17.8; 95% CI, 3.8-82.7), and meat processing workers (OR, 6.5; 95% CI, 1.4-29.5). Similarly, farmers had the highest odds for exposure to swine H1N2 virus (OR, 13.8; 95% CI, 5.4-35.4), followed by veterinarians (OR, 9.5; 95% CI, 3.6-24.6) and meat processing workers (OR, 2.7; 95% CI, 1.1-6.7). CONCLUSIONS: Occupational exposure to pigs greatly increases workers' risk of swine influenza virus infection. Swine workers should be included in pandemic surveillance and in antiviral and immunization strategies.

Asthma and farm exposures in a cohort of rural Iowa children.

Epidemiologic studies of farm children are of international interest because farm children are less often atopic, have less allergic disease, and often have less asthma than do nonfarm children--findings consistent with the hygiene hypothesis. We studied a cohort of rural Iowa children to determine the association between farm and other environmental risk factors with four asthma outcomes: doctor-diagnosed asthma, doctor-diagnosed asthma/medication for wheeze, current wheeze, and cough with exercise. Doctor-diagnosed asthma prevalence was 12%, but at least one of these four health outcomes was found in more than a third of the cohort. Multivariable models of the four health outcomes found independent associations between male sex (three asthma outcomes), age (three asthma outcomes), a personal history of allergies (four asthma outcomes), family history of allergic disease (two asthma outcomes), premature birth (one asthma outcome), early respiratory infection (three asthma outcomes), high-risk birth (two asthma outcomes), and farm exposure to raising swine and adding antibiotics to feed (two asthma outcomes). The high prevalence of rural childhood asthma and asthma symptoms underscores the need for asthma screening programs and improved asthma diagnosis and treatment. The high prevalence of asthma health outcomes among farm children living on farms that raise swine (44.1%, p = 0.01) and raise swine and add antibiotics to feed (55.8%, p = 0.013), despite lower rates of atopy and personal histories of allergy, suggests the need for awareness and prevention measures and more population-based studies to further assess environmental and genetic determinants of asthma among farm children.

Methodologic issues in a population-based health survey of Gulf War veterans.

This report describes the principal methods used in the development, conduct, and analysis of the research study "Health Assessment of Persian Gulf War Veterans from Iowa" (Iowa Gulf War Study). The methods presented include an outline of the organizational structure, study timeline, hypotheses, outcome definitions, and study design. Adhering to a strict timeline, the study protocol and instruments were developed, and a stratified sample of 3,695 military personnel (76% participation) was located and surveyed by structured telephone interview. The study tracked personnel from all service branches residing nationally and internationally, including those discharged from service. This study required development and implementation of methods appropriate to analysis of data collected in a complex sampling framework and methodological procedures to ensure scientific rigor in a highly public and politicized environment. Statistical analyses were conducted on a priori health outcomes and required development of methods to compute Cochran-Mantel-Haenszel adjusted rate differences. This environment facilitated rapid implementation, critique by scientific and public advisors, a high participation rate, and rapid publication.

Chronic disease and injury in an agricultural county: The Keokuk County Rural Health Cohort Study.

The Keokuk County Rural Health Study (KCRHS) was designed as a 20-year, prospective cohort study focusing on chronic disease and injury in an agricultural southeastern Iowa county. The goals of the KCRHS are to prospectively describe, measure, and analyze prevalent rural and agriculturally related adverse health outcomes and their respective risk factors and to provide the basis for future community-based intervention programs to reduce disease and injury incidence. Methods of data collection included in-person interviews, medical screenings, and environmental assessments of homes and farms. All households studied were rural; comparisons were made among farm, rural nonfarm, and town households, between men and women, and between smokers and nonsmokers. The present paper reports selected adult baseline data from Round 1 of this study. Residents of farm households were somewhat younger and better educated than residents of rural nonfarm and town households; smoked less; were more likely to have ridden an all-terrain vehicle; and were more likely to report firearms in the home. Eighty-nine percent of the men and 66% of the women engaged in farming or did so in the past. Men more often reported hearing loss, were more often overweight and obese, more often reported an injury, less often reported asthma, and less often saw a medical practitioner. Women reported poorer emotional health and higher rates of depression symptoms. The KCRHS has identified several modifiable health outcomes and risk factors as candidates for further analysis and targets for community-based prevention and intervention programs.

Oral health: perceptions of need in a rural Iowa county.

Several studies have shown that oral health problems impact the quality of life of older adults. However, few data are available to describe the oral health status, barriers to care, and patterns of care for adults and older populations living in rural areas. The purpose of this study was to evaluate the perceived need for treatment of oral health problems by adult residents in a rural county in Iowa. The oral health component was part of a larger longitudinal health study of the residents. The sample was stratified into three groups by residence, that is, farm households, rural non-farm households and town households. The sample was subsequently post-stratified by gender and age group into young elderly, 65-74 years old, and old elderly, 75 years and older. Dentition status varied according to age and was related to the perception of treatment needs. Edentulous persons had fewer perceived treatment needs and utilized a dentist less frequently. Place of residence, education, and marital status were not associated with the subjects' perceived problems with eating and chewing. However, persons with difficulty chewing were more likely to have some missing upper teeth, have a perceived need to have denture work, and have smoked for a number of years. The results suggest that this rural population is retaining more teeth and consequently may need and may seek dental services more often than previous more edentulous cohorts.

Employment status matters: a statewide survey of quality-of-life, prevention behaviors, and absenteeism and presenteeism.

OBJECTIVE: To estimate quality-of-life (QoL), primary care, health insurance, prevention behaviors, absenteeism, and presenteeism in a statewide sample of the unemployed, self-employed, and organizationally employed. METHODS: A statewide survey of 1602 Iowans included items from the Centers for Disease Control and Prevention QoL and Behavioral Risk Factor Surveillance System Survey prevention behavior questionnaires used to assess employee well-being; their indicator results are related to World Health Organization's Health and Work Performance Questionnaire-derived absenteeism and presenteeism scores. RESULTS: The unemployed exhibited poorer QoL and prevention behaviors; the self-employed exhibited many better QoL scores due largely to better prevention behaviors than those employed by organizations. Higher QoL measures and more prevention behaviors are associated with lower absenteeism and lower presenteeism. CONCLUSIONS: Employment status is related to measures of well-being, which are also associated with absenteeism and presenteeism.

An employee total health management-based survey of Iowa employers.

OBJECTIVE: To implement an Employee Total Health Management (ETHM) model-based questionnaire and provide estimates of model program elements among a statewide sample of Iowa employers. METHODS: Survey a stratified random sample of Iowa employers, and characterize and estimate employer participation in ETHM program elements. RESULTS: Iowa employers are implementing less than 30% of all 12 components of ETHM, with the exception of occupational safety and health (46.6%) and workers' compensation insurance coverage (89.2%), but intend modest expansion of all components in the coming year. CONCLUSIONS: The ETHM questionnaire-based survey provides estimates of progress Iowa employers are making toward implementing components of Total Worker Health programs.

Indoor and outdoor particulate matter and endotoxin concentrations in an intensely agricultural county.

The objectives of this study were to characterize rural populations' indoor and outdoor exposure to particulate matter (PM)(10), PM(2.5), and endotoxin and identify factors that influence these concentrations. Samples were collected at 197 rural households over five continuous days between 2007 and 2011. Geometric mean (GM) indoor PM(10) (21.2 µg/m(3)) and PM(2.5) (12.2 µg/m(3)) concentrations tended to be larger than outdoor PM(10) (19.6 µg/m(3)) and PM(2.5) (8.2 µg/m(3)) concentrations (PM(10) P=0.086; PM(2.5) P<0.001). Conversely, GM outdoor endotoxin concentrations (1.93 EU/m(-3)) were significantly larger than indoor (0.32 EU/m(3); P<0.001). Compared with measurements from previous urban studies, indoor and outdoor concentrations of PM(10) and PM(2.5) in the study area tended to be smaller, whereas ambient endotoxin concentrations measured outside rural households were 3-10 times larger. Contrary to our initial hypothesis, seasonality did not have a significant effect on mean ambient PM(10) concentrations; however, endotoxin concentrations in the autumn were almost seven times larger than winter. Excluding home cleanliness, the majority of agricultural and housing characteristics evaluated were found to be poorly associated with indoor and outdoor particulate and endotoxin concentrations.

At what age should children engage in agricultural tasks?

PURPOSE: We compared parents' perceived-as-appropriate ages with actual-performance ages for their children engaging in selected agricultural tasks or practices, and we examined the factors associated with age discrepancy. METHODS: We analyzed data from the Keokuk County Rural Health Study collected among parents of children age 17 or younger. Parents were interviewed separately regarding the age of their children's involvement in 14 selected agricultural tasks and their opinions about appropriate age of involvement. FINDINGS: Of the 264 families included, 86.5% with a son and 69.8% with a daughter reported having children involved in at least 1 of 14 selected agricultural tasks. The average actual-performance ages for children to be involved in any of the tasks were younger than those that parents perceived appropriate. Furthermore, in 6 of the 9 North American Guidelines for Children's Agricultural Tasks (NAGCAT) that we assessed, parents' perceived-as-appropriate ages were younger than minimum ages recommended by the NAGCAT. Driving an all-terrain vehicle (ATV) was the most common task with actual-performance age younger than the NAGCAT-recommended age; 53.0% of boys (n = 106) and 36.1% of girls (n = 61) did so under the recommended age. Boys and children who live on a farm, or whose parents have been or are farmers, were significantly more likely to perform agricultural tasks at earlier ages. CONCLUSIONS: Our results suggest farm parents and other rural stakeholders need to be better educated and encouraged to follow the NAGCAT guidelines, and that multilevel interventions need to be developed to ensure protection of children from agricultural injury and death.