Retrospective observational study of asthma and chronic obstructive pulmonary disease prevalence and associated healthcare resource utilization in a large, integrated healthcare system.

Limited data exist on asthma and chronic obstructive pulmonary disease (COPD) management-major drivers of healthcare resource utilization (HCRU) in the USA. We describe prevalence and exacerbation rates, therapeutic interventions, and HCRU for asthma and/or COPD within a large, integrated healthcare system. Patients with asthma, COPD, and asthma + COPD were identified from retrospective electronic health record data (2016-2018) of >1.7 million patients. Descriptive analysis of disease prevalence and exacerbation frequencies, pharmacotherapies, and HCRU was performed. Time-to-event analysis of time to first exacerbation was performed in patients with asthma and/or COPD. Exacerbation rates, pharmacotherapies, and HCRU were examined by exploratory analysis in an outpatient subset. Overall, 149,086 unique patients (8.6%) had encounters for asthma, COPD, or asthma + COPD. Acute care utilization was high, including emergency department visits (asthma, 52.9%; COPD, 35.1%) and hospitalizations (asthma, 26.7%; COPD, 65.7%). Many patients were prescribed short-acting therapies (asthma, 45.3%; COPD, 40.0%; asthma + COPD, 54.7%). Prescription rates for maintenance therapies were low (17.1%, 20.8%, 31.7%) and annual exacerbation rates were 0.65, 0.80, and 1.33. This analysis showed a substantive prevalence of pulmonary disease, variability between documented prescriptions and pharmacotherapy guidelines, and high HCRU. Appropriate tailoring of pharmacotherapies and management of asthma and COPD over a continuum are opportunities to improve patient care.

Effectiveness of an algorithm-based care pathway for patients with non-valvular atrial fibrillation presenting to the emergency department.

OBJECTIVE: Atrial fibrillation (AF) carries substantial morbidity and mortality. Evidence-based guidelines have been synthesized into emergency department (ED) AF care pathways, but the effectiveness and scalability of such approaches are not well established. We thus evaluated the impacts of an algorithmic care pathway for ED management of non-valvular AF (EDAFMP) on hospital use and care process measures. METHODS: We deployed a voluntary-use EDAFMP in 4 EDs (1 tertiary hospital, 1 cardiac hospital, 2 community hospitals) of an integrated delivery organization using a multifaceted implementation approach. We compared outcomes between patients with AF treated using the EDAFMP and historical and contemporaneous "usual care" controls, using a propensity-score adjusted generalized estimating equation. Patients with an index ED encounter for a primary visit reason of non-valvular AF (and no excluding concurrent diagnoses) were eligible for inclusion. RESULTS: Preimplementation (January 1, 2016-December 31, 2016), 628 AF patients were eligible; postimplementation (September 1, 2017-June 30, 2019), 1296, including 271 (20.9%) treated with the EDAFMP, were eligible. EDAFMP patients were less likely to be admitted than both historical (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.45, 0.29-0.71) and contemporaneous controls (aOR, 95%CI: 0.63, 0.46-0.86). ED visits and hospital readmissions over 90 days subsequent to index ED encounters were similar between postimplementation EDAFMP and usual care groups. EDAFMP patients were more likely to be prescribed anticoagulation (38% v. 5%, P < 0.001) and be referred to a cardiologist (93% vs 29%, P < 0.001) versus the comparator group. CONCLUSION: EDAFMP use is associated with decreased hospital admission during an index ED encounter for non-valvular AF, and improved delivery of AF care processes.

Compliance with recommended care at trauma centers: association with patient outcomes.

BACKGROUND: State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. STUDY DESIGN: This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. RESULTS: Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. CONCLUSIONS: Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality.

Using the CER Hub to ensure data quality in a multi-institution smoking cessation study.

Comparative effectiveness research (CER) studies involving multiple institutions with diverse electronic health records (EHRs) depend on high quality data. To ensure uniformity of data derived from different EHR systems and implementations, the CER Hub informatics platform developed a quality assurance (QA) process using tools and data formats available through the CER Hub. The QA process, implemented here in a study of smoking cessation services in primary care, used the 'emrAdapter' tool programmed with a set of quality checks to query large samples of primary care encounter records extracted in accord with the CER Hub common data framework. The tool, deployed to each study site, generated error reports indicating data problems to be fixed locally and aggregate data sharable with the central site for quality review. Across the CER Hub network of six health systems, data completeness and correctness issues were prevalent in the first iteration and were considerably improved after three iterations of the QA process. A common issue encountered was incomplete mapping of local EHR data values to those defined by the common data framework. A highly automated and distributed QA process helped to ensure the correctness and completeness of patient care data extracted from EHRs for a multi-institution CER study in smoking cessation.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed. STUDY DESIGN: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. DATA COLLECTION: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries.

OBJECT: Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS: This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS: The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS: Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

Developing electronic data methods infrastructure to participate in collaborative research networks.

CONTEXT: Collaborative networks support the goals of a learning health system by sharing, aggregating, and analyzing data to facilitate identification of best practices care across delivery organizations. This case study describes the infrastructure and process developed by an integrated health delivery system to successfully prepare and submit a complex data set to a large national collaborative network. CASE DESCRIPTION: We submitted four years of data for a diverse population of patients in specific clinical areas: diabetes, chronic heart failure, sepsis, and hip, knee, and spine. The most recent submission included 19 tables, more than 376,000 unique patients, and almost 5 million patient encounters. Data was extracted from multiple clinical and administrative systems. LESSONS LEARNED: We found that a structured process with documentation was key to maintaining communication, timelines, and quality in a large-scale data submission to a national collaborative network. The three key components of this process were the experienced project team, documentation, and communication. We used a formal QA and feedback process to track and review data. Overall, the data submission was resource intensive and required an incremental approach to data quality. CONCLUSION: Participation in collaborative networks can be time and resource intense, however it can serve as a catalyst to increase the technical data available to the learning health system.

Analysis of the direct cost of surgery for four diagnostic categories of adult spinal deformity.

BACKGROUND CONTEXT: Existing literature on adult spinal deformity (ASD) offers little guidance regarding an evidence-based approach to care. To optimize the value of medical treatment, a thorough understanding of the cost of surgical treatment for ASD is required. PURPOSE: To evaluate four clinically and radiographically distinct groups of ASD and identify and compare the cost of surgical treatment among the groups. STUDY DESIGN/SETTING: Multicenter retrospective study of consecutive surgeries for ASD. PATIENT SAMPLE: Three hundred twenty-five consecutive ASD patients treated between 2008 and 2010. OUTCOME MEASURES: Cost data were collected from hospital administrative records on the direct costs (DCs) incurred for the episode of surgical care, excluding overhead. METHODS: Based on preoperative radiographs and history, patients were categorized into one of four diagnostic categories of deformity: primary idiopathic scoliosis (PIS), primary degenerative scoliosis (PDS), primary sagittal plane deformity (PSPD), and revision (R). Analysis of variance and generalized linear model regressions were used to analyze the DCs of surgery and to assess differences in costs across the four diagnostic categories considered. RESULTS: Significant differences were observed in DC of surgery for different categories of ASD, with surgical treatment for PDS the most expensive followed in decreasing order by PSPD, PIS, and R (p<.01). Results further revealed a significant positive relationship between age and DC (p<.01) and a significant positive relationship between length of stay and DC (p<.01). Among PIS patients, for every incremental increase in levels fused, the expected DC increased by $3,997 (p=.00). Fusion to pelvis also significantly increased the DC of surgery for patients aged 18 to 29 years (p<.01) and 30 to 59 years (p<.01) but not for 60 years or more (p=.86). CONCLUSIONS: There is an increasing DC of surgery with increasing age, length of hospital stay, length of fusion, and fusions to the pelvis. Revision surgery is the least expensive surgery on average and should therefore not preclude its consideration from a pure cost perspective.

Frequency of adoption of practice management guidelines at trauma centers.

Evidence-based management guidelines have been shown to improve patient outcomes, yet their utilization by trauma centers remains unknown. This study measured adoption of practice management guidelines or protocols by trauma centers. A survey of 228 trauma centers was conducted over 1 year; 55 completed the survey. Centers were classified into three groups: noncompliant, partially compliant, and compliant with adoption of management protocols. Characteristics of compliant centers were compared with those of the other two groups. Most centers were Level I (58%) not-for-profit (67%) teaching hospitals (84%) with a surgical residency (74%). One-third of centers had an accredited fellowship in surgical critical care (37%). Only one center was compliant with all 32 management protocols. Half of the centers were compliant with 14 of 32 protocols studied (range, 4 to 32). Of the 21 trauma center characteristics studied, only two were independently associated with compliant centers: use of physician extenders and daily attending rounds (both P < .0001). Adoption of management guidelines by trauma centers is inconsistent, with wide variations in practices across centers.

Comparative effectiveness research using electronic health records: impacts of oral antidiabetic drugs on the development of chronic kidney disease.

PURPOSE: Little is known about the comparative effects of common oral antidiabetic drugs ([OADs] metformin, sulfonylureas, or thiazolidinediones [THZs]) on chronic kidney disease (CKD) outcomes in patients newly diagnosed with type 2 diabetes (T2DM) and followed in community primary care practices. Electronic health records (EHRs) were used to evaluate the relationships between OAD class use and incident proteinuria and prevention of glomerular filtration rate decline. METHODS: A retrospective cohort study on newly diagnosed T2D cases requiring OADs documented in the EHRs of two primary care networks between 1998 and 2009 was conducted. CKD outcomes were new-onset proteinuria and estimated GFR (eGFR) falling below 60 ml/min/1.73 m(2). OAD exposures defined cohorts. Hazard ratios represent differential CKD outcome risk per year of OAD class use. RESULTS: A total of 798 and 977 patients qualified for proteinuria and eGFR outcome analyses, respectively. With metformin as the reference group, sulfonylurea exposure trended toward association with an increased risk of developing proteinuria ([adjusted hazard ratio; 95% CI] 1.27; 0.93, 1.74); proteinuria risk associated with THZ exposure (1.00; 0.70, 1.42) was similar to metformin. Compared with metformin, sulfonylurea exposure was associated with an increased risk of eGFR reduction to <60 ml/min/1.73 m(2) (1.41; 1.05, 1.91). THZ exposure (1.04; 0.71, 1.50) was not associated with change in the risk of eGFR decline. CONCLUSIONS: In a primary care population, metformin appeared to decrease the risk of CKD development compared with sulfonlyureas; risks of CKD development between metformin and THZs were similar. EHR use in pharmacotherapy comparative effectiveness research creates specific challenges and study limitations.

Description and evaluation of adaptations to the global trigger tool to enhance value to adverse event reduction efforts.

OBJECTIVE: To adapt the Global Trigger Tool (GTT) as a sustainable monitoring tool able to characterize adverse events (AEs) for organizational learning, within the context of limited resources. METHODS: Baylor Health Care System (BHCS) expanded the AE data collected to include judgments of preventability, presence on admission, relation to care provided or not provided, and narrative descriptions. To reduce costs, we focused on patients with length of stay (LOS) of 3 days or more, suspecting greater likelihood they had experienced an AE; adapted the sample size and frequency of review; and used a single nurse reviewer followed by quality assurance review within the Office of Patient Safety. We compared AE rates in patients with LOS of less than 3 days versus 3 days or greater, assessed trigger yields and interrater reliability, and submitted identified AEs to each hospital for validation as event types targeted for reduction. RESULTS: In 2008, 91% of identified AEs were in patients with LOS of 3 days or greater; there were 6.4 AEs per 100 discharges with LOS of less than 3 days versus 27.1 AEs per 100 discharges with LOS of 3 days or greater. Over 4 years, we reviewed 16,172 medical records; 14,184 had positive triggers, 17.1% of which were associated with an AE. Most AEs were identified via the "surgical" (36.3%) and "patient care" (36.0%) trigger modules. Reviewers showed fair to good agreement (κ = 0.62), and hospital clinical leaders strongly agreed that the identified events were AEs. CONCLUSIONS: The GTT can be adapted to health-care organizations' goals and resource limitations. This flexibility was essential in crossing our organization's "value threshold."

Cost-Effectiveness of Surgical Treatment for Adult Spinal Deformity: A Comparison of Dollars per Quality of Life Improvement Across Health Domains.

DESIGN: Retrospective, single-center analysis of consecutive patients undergoing surgical treatment for adult spinal deformity (ASD). OBJECTIVE: Assess the value of surgical treatment for ASD across different health domains. SUMMARY OF BACKGROUND DATA: The cost of improvement in health-related quality of life (HRQOL) is an important consideration for resource allocation. There is also growing concern among policy makers regarding the incorporation of patient-specific preferences in the appropriate definition and assessment health care value. METHODS: Single-center, retrospective study of consecutive ASD patients undergoing primary surgery with principal diagnosis code 737.0-737.9 from 2005 through May 2010. Patients less than 18 years of age were excluded. The HRQOL measures were based on the Short Form-36, the Oswestry Disability Index (ODI), and the Scoliosis Research Society (SRS)-22 questionnaire after at least 2 years after surgery. The SRS scores were translated to a 100-point scale. Costs were collected from hospital data on the total costs incurred for the episode of surgical care. Confidence intervals were calculated using nonparametric bootstrap methods. RESULTS: Baseline and minimum 2-year HR follow-up data were available for 164 patients, with an average follow-up of 3.2 years and a range of 2 to 7.4 years. Patients were predominantly female (14; 88%) and ranged from 18 to 82 years of age at index surgery (average of 51 years of age). The cost-effectiveness (CE) ratios varied across different HRQOL outcomes, ranging from an average cost of $5,658 per 1-point improvement in SRS Self-image to an average cost of $25,918 per 1-point improvement in SF-36 Physical Component Score (PCS). Results revealed statistically significant differences (p < .05) in CE ratios across different HRQOL outcomes. CONCLUSIONS: Statistically significant differences were found in CE ratios across HRQOL sub-domains. This has important implications in the assessment of patient-specific value of health care services, and illustrates that surgical treatment for ASD may be more cost-effective for some purposes (eg, pain reduction) and less cost-effective for others (eg, improved functional activity).

Insuring the uninsured: potential impact of Health Care Reform Act of 2010 on trauma centers.

BACKGROUND: Viability of trauma centers is threatened by cost of care provided to patients without health insurance. The health care reform of 2010 is likely to benefit trauma centers by mandating universal health insurance by 2014. However, the financial benefit of this mandate will depend on the reimbursement provided. The study hypothesis was that compensation for the care of uninsured trauma patients at Medicare or Medicaid rates will lead to continuing losses for trauma centers. METHODS: Financial data for first hospitalization were obtained from an urban Level I trauma center for 3 years (n = 6,630; 2006-2008) and linked with clinical information. Patients were grouped into five payments categories: commercial (29%), Medicaid (8%), Medicare (20%), workers' compensation (6%), and uninsured (37%). Prediction models for costs and payments were developed for each category using multiple regression models, adjusting for patient demographics, injury characteristics, complications, and survival. These models were used to predict payments that could be expected if uninsured patients were covered by different insurance types. Results are reported as net margin per patient (payments minus total costs) for each insurance type, with 95% confidence intervals, discounted to 2008 dollar values. RESULTS: Patients were typical for an urban trauma center (median age of 43 years, 66% men, 82% blunt, 5% mortality, and median length of stay 4 days). Overall, the trauma center lost $5,655 per patient, totaling $37.5 million over 3 years. These losses were encountered for patients without insurance ($14,343), Medicare ($4,838), and Medicaid ($15,740). Patients with commercial insurance were profitable ($5,295) as were those with workers' compensation ($6,860). Payments for the care of the uninsured at Medicare/Medicaid levels would lead to continued losses at $2,267 to $4,143 per patient. CONCLUSION: The health care reforms of 2010 would lead to continued losses for trauma centers if uninsured are covered with Medicare/Medicaid-type programs. LEVEL OF EVIDENCE: Economic analysis, level II.

Barriers to compliance with evidence-based care in trauma.

BACKGROUND: We have preciously demonstrated that trauma patients receive less than two-thirds of the care recommended by evidence-based medicine. The purpose of this study was to identify patients least likely to receive optimal care. METHODS: Records of a random sample of 774 patients admitted to a Level I trauma center (2006-2008) with moderate to severe injuries (Abbreviated Injury Scale score ≥3) were reviewed for compliance with 25 trauma-specific processes of care (T-POC) endorsed by Advanced Trauma Life Support, Eastern Association for the Surgery of Trauma, the Brain Trauma Foundation, Surgical Care Improvement Project, and the Glue Grant Consortium based on evidence or consensus. These encompassed all aspects of trauma care, including initial evaluation, resuscitation, operative care, critical care, rehabilitation, and injury prevention. Multivariate logistic regression was used to identify patients likely to receive recommended care. RESULTS: Study patients were eligible for a total of 2,603 T-POC, of which only 1,515 (58%) were provided to the patient. Compliance was highest for T-POC involving resuscitation (83%) and was lowest for neurosurgical interventions (17%). Increasing severity of head injuries was associated with lower compliance, while intensive care unit stay was associated with higher compliance. There was no relationship between compliance and patient demographics, socioeconomic status, overall injury severity, or daily volume of trauma admissions. CONCLUSION: Little over half of recommended care was delivered to trauma patients with moderate to severe injuries. Patients with increasing severity of traumatic brain injuries were least likely to receive optimal care. However, differences among patient subgroups are small in relation to the overall gap between observed and recommended care. LEVEL OF EVIDENCE: II.

Initial and subsequent therapy for newly diagnosed type 2 diabetes patients treated in primary care using data from a vendor-based electronic health record.

BACKGROUND: Diabetes is a leading cause of death and disability, and its prevalence is increasing. When diet fails, patients with type 2 diabetes mellitus (T2DM) are prescribed oral hypoglycemics for glycemic control. Few studies have explored initial use or change from initial oral hypoglycemic therapy in the primary care setting. We aimed to describe the utilization of initial oral hypoglycemics among newly diagnosed patients with diabetes from 1998-2009 and changes from initial to subsequent therapy among patients prescribed older oral hypoglycemic agents using electronic health records. METHODS: This observational cohort study used electronic health records from newly diagnosed patients with T2DM between 1 January 1998 and 31 March 2009 at two large health systems in the USA. Oral hypoglycemics included older (biguanide, sulfonylurea, and thiazolidinedione) and newer agents (incretin mimetic agents, alpha-glucosidase inhibitors, and D-phenylalanine derivatives). Multinomial regression models were fit to evaluate initial older oral hypoglycemic medication. We used incidence density sampling and conditional logistic regression models to evaluate predictors of regimen change. RESULTS: Most patients were treated from the biguanide class of oral hypoglycemics (67%), but there were differences in initial prescribing by age and race. HbA1c (Odds Ratio for HbA1c 7.0-8.9 vs < 7.0, 5.87 [95% Confidence Interval: 3.62-9.52]; Odds Ratio for HbA1c ≥ 9 vs < 7.0, 20.25 [95% Confidence Interval: 8.32-49.29] and Black people (Odds Ratio, 0.29 [95% Confidence Interval: 0.14, 0.60]) versus White people were associated with regimen change in the adjusted analysis. CONCLUSIONS: Clinical and demographic characteristics influence choice and duration of initial oral hypoglycemic treatment as well as regimen changes.

Electronic health record use to classify patients with newly diagnosed versus preexisting type 2 diabetes: infrastructure for comparative effectiveness research and population health management.

Use of electronic health record (EHR) content for comparative effectiveness research (CER) and population health management requires significant data configuration. A retrospective cohort study was conducted using patients with diabetes followed longitudinally (N=36,353) in the EHR deployed at outpatient practice networks of 2 health care systems. A data extraction and classification algorithm targeting identification of patients with a new diagnosis of type 2 diabetes mellitus (T2DM) was applied, with the main criterion being a minimum 30-day window between the first visit documented in the EHR and the entry of T2DM on the EHR problem list. Chart reviews (N=144) validated the performance of refining this EHR classification algorithm with external administrative data. Extraction using EHR data alone designated 3205 patients as newly diagnosed with T2DM with classification accuracy of 70.1%. Use of external administrative data on that preselected population improved classification accuracy of cases identified as new T2DM diagnosis (positive predictive value was 91.9% with that step). Laboratory and medication data did not help case classification. The final cohort using this 2-stage classification process comprised 1972 patients with a new diagnosis of T2DM. Data use from current EHR systems for CER and disease management mandates substantial tailoring. Quality between EHR clinical data generated in daily care and that required for population health research varies. As evidenced by this process for classification of newly diagnosed T2DM cases, validation of EHR data with external sources can be a valuable step.

Children's environmental health in Central Asia and the Middle east.

Children in Central Asia and the Middle East bear disproportionate environmental threats to health, of which the most widespread and serious result from poverty, malnutrition, lack of access to safe drinking water and food, and exposures to toxic chemicals. Their psychological health is threatened in several parts of this region by internal wars and strife. Many, or even most, children are regularly exposed to environmental tobacco smoke. In many of these countries, children constitute very high percentages of the population. Because children constitute the future, it is critical that these threats to their health be addressed and reduced to the greatest extent possible through both provision of safe and adequate drinking water and nutrition and reduction of exposures to environmental contaminants.

Respiratory disease in relation to patient residence near to hazardous waste sites.

We have examined rates of hospitalization for respiratory diseases in relation to residences in zip codes with hazardous waste sites, as well as socio-economic status. Chronic bronchitis and chronic airway obstruction were elevated in persons who live in zip codes containing persistent organic pollutants (POPs) (PCBs and persistent pesticides) as compared to "clean" zip codes without hazardous waste sites or zip codes with hazardous waste sites containing other kinds of wastes, but the differences could be due to socio-economic status and behavioral risk factors since these are also important risk factors for respiratory diseases. Therefore, we investigated rates of hospitalization for individuals living in zip codes along the Hudson River, because here the average per capita income is higher than in the rest of the state, and there is less smoking, better diet and more exercise. We found a similar elevation of chronic bronchitis and chronic airway obstruction along the Hudson. These observations are consistent with the possibility that living near a POPs-contaminated site poses a risk of exposure and increased risk of chronic respiratory disease, probably secondary to suppression of the immune system.

Low birth weight and residential proximity to PCB-contaminated waste sites.

Previous investigations have shown that women exposed to polychlorinated biphenyls (PCBs) are at increased risk of giving birth to an infant with low birth weight (< 2,500 g), and that this relationship is stronger for male than for female infants. We have tested the hypothesis that residents in a zip code that contains a PCB hazardous waste site or abuts a body of water contaminated with PCBs are at increased risk of giving birth to a low-birth-weight baby. We used the birth registry of the New York State Vital Statistics to identify all births between 1994 and 2000 in New York State except for New York City. This registry provides information on the infant, mother, and father together with the zip code of the mother's residence. The 865 state Superfund sites, the 86 National Priority List sites, and the six Areas of Concern in New York were characterized regarding whether or not they contain PCBs as a major contaminant. We identified 187 zip codes containing or abutting PCB-contaminated sites, and these zip codes were the residences of 24.5% of the 945,077 births. The birth weight in the PCB zip codes was on average 21.6 g less than in other zip codes (p < 0.001). Because there are many other risk factors for low birth weight, we have adjusted for these using a logistic regression model for these confounders. After adjusting for sex of the infant, mother's age, race, weight, height, education, income, marital status, and smoking, there was still a statistically significant 6% increased risk of giving birth to a male infant of low birth weight. These observations support the hypothesis that living in a zip code near a PCB-contaminated site poses a risk of exposure and giving birth to an infant of low birth weight.