Fluid management with a simplified conservative protocol for the acute respiratory distress syndrome*.

OBJECTIVES: In the Fluid and Catheter Treatment Trial (FACTT) of the National Institutes of Health Acute Respiratory Distress Syndrome Network, a conservative fluid protocol (FACTT Conservative) resulted in a lower cumulative fluid balance and better outcomes than a liberal fluid protocol (FACTT Liberal). Subsequent Acute Respiratory Distress Syndrome Network studies used a simplified conservative fluid protocol (FACTT Lite). The objective of this study was to compare the performance of FACTT Lite, FACTT Conservative, and FACTT Liberal protocols. DESIGN: Retrospective comparison of FACTT Lite, FACTT Conservative, and FACTT Liberal. Primary outcome was cumulative fluid balance over 7 days. Secondary outcomes were 60-day adjusted mortality and ventilator-free days through day 28. Safety outcomes were prevalence of acute kidney injury and new shock. SETTING: ICUs of Acute Respiratory Distress Syndrome Network participating hospitals. PATIENTS: Five hundred three subjects managed with FACTT Conservative, 497 subjects managed with FACTT Liberal, and 1,124 subjects managed with FACTT Lite. INTERVENTIONS: Fluid management by protocol. MEASUREMENTS AND MAIN RESULTS: Cumulative fluid balance was 1,918 ± 323 mL in FACTT Lite, -136 ± 491 mL in FACTT Conservative, and 6,992 ± 502 mL in FACTT Liberal (p < 0.001). Mortality was not different between groups (24% in FACTT Lite, 25% in FACTT Conservative and Liberal, p = 0.84). Ventilator-free days in FACTT Lite (14.9 ± 0.3) were equivalent to FACTT Conservative (14.6 ± 0.5) (p = 0.61) and greater than in FACTT Liberal (12.1 ± 0.5, p < 0.001 vs Lite). Acute kidney injury prevalence was 58% in FACTT Lite and 57% in FACTT Conservative (p = 0.72). Prevalence of new shock in FACTT Lite (9%) was lower than in FACTT Conservative (13%) (p = 0.007 vs Lite) and similar to FACTT Liberal (11%) (p = 0.18 vs Lite). CONCLUSIONS: FACTT Lite had a greater cumulative fluid balance than FACTT Conservative but had equivalent clinical and safety outcomes. FACTT Lite is an alternative to FACTT Conservative for fluid management in Acute Respiratory Distress Syndrome.

Can an Internet-based health risk assessment highlight problems of heart disease risk factor awareness? A cross-sectional analysis.

BACKGROUND: Health risk assessments are becoming more popular as a tool to conveniently and effectively reach community-dwelling adults who may be at risk for serious chronic conditions such as coronary heart disease (CHD). The use of such instruments to improve adults' risk factor awareness and concordance with clinically measured risk factor values could be an opportunity to advance public health knowledge and build effective interventions. OBJECTIVE: The objective of this study was to determine if an Internet-based health risk assessment can highlight important aspects of agreement between respondents' self-reported and clinically measured CHD risk factors for community-dwelling adults who may be at risk for CHD. METHODS: Data from an Internet-based cardiovascular health risk assessment (Heart Aware) administered to community-dwelling adults at 127 clinical sites were analyzed. Respondents were recruited through individual hospital marketing campaigns, such as media advertising and print media, found throughout inpatient and outpatient facilities. CHD risk factors from the Framingham Heart Study were examined. Weighted kappa statistics were calculated to measure interrater agreement between respondents' self-reported and clinically measured CHD risk factors. Weighted kappa statistics were then calculated for each sample by strata of overall 10-year CHD risk. Three samples were drawn based on strategies for treating missing data: a listwise deleted sample, a pairwise deleted sample, and a multiple imputation (MI) sample. RESULTS: The MI sample (n=16,879) was most appropriate for addressing missing data. No CHD risk factor had better than marginal interrater agreement (κ>.60). High-density lipoprotein cholesterol (HDL-C) exhibited suboptimal interrater agreement that deteriorated (eg, κ<.30) as overall CHD risk increased. Conversely, low-density lipoprotein cholesterol (LDL-C) interrater agreement improved (eg, up to κ=.25) as overall CHD risk increased. Overall CHD risk of the sample was lower than comparative population-based CHD risk (ie, no more than 15% risk of CHD for the sample vs up to a 30% chance of CHD for the population). CONCLUSIONS: Interventions are needed to improve knowledge of CHD risk factors. Specific interventions should address perceptions of HDL-C and LCL-C. Internet-based health risk assessments such as Heart Aware may contribute to public health surveillance, but they must address selection bias of Internet-based recruitment methods.

Creating a tipping point: Texas obesity policy actions in review, 2000-2010.

This paper discusses the historical context and current challenges of obesity prevention and control initiatives in Texas to understand how the obesity epidemic has been addressed by multiple interacting stakeholders over the past decade. By reviewing state reports and interviewing key decision makers, this paper chronicles recent efforts in Texas by highlighting health policy initiatives and champions who helped to create the foundation for obesity prevention and control. The findings outline the sentinel policy approaches that were implemented by public/private sector partnerships over the last decade, as well as the public figures that have been singular champions in creating the momentum for these changes. The efforts to address obesity with a collaborative approach in Texas have shown initial promise in creating a tipping point to control the obesity epidemic. These strategies can also serve as a model for obesity prevention and control at the national level.

The utility of rural and underserved designations in geospatial assessments of distance traveled to healthcare services: implications for public health research and practice.

Health disparities research in rural populations is based on several common taxonomies identified by geography and population density. However, little is known about the implications of different rurality definitions on public health outcomes. To help illuminate the meaning of different rural designations often used in research, service delivery, or policy reports, this study will (1) review the different definitions of rurality and their purposes; (2) identify the overlap of various rural designations in an eight-county Brazos Valley region in Central Texas; (3) describe participant characteristic profiles based on distances traveled to obtain healthcare services; and (4) examine common profile characteristics associated with each designation. Data were analyzed from a random sample from 1,958 Texas adults participating in a community assessment. K-means cluster analysis was used to identify natural groupings of individuals based on distance traveled to obtain three healthcare services: medical care, dental care, and prescription medication pick-up. Significant variation in cluster representation and resident characteristics was observed by rural designation. Given widely used taxonomies for designating areas as rural (or provider shortage) in health-related research, this study highlights differences that could influence research results and subsequent program and policy development based on rural designation.

Health and health care utilization among obese and diabetic baby boomers and older adults.

PURPOSE: Examine how sociodemographic, health, behavioral, and health care utilization factors are associated with being obese or having diabetes among baby boomers and older adults. DESIGN: Cross-sectional data were drawn from the 2007-2008 National Health and Nutrition Examination Survey. SETTING: United States. SUBJECTS: A sample of 3439 baby boomers and older adults included (mean age, 62 years). MEASURES: Covariates included sociodemographics, health outcomes, behaviors, and inpatient and outpatient health care utilization. ANALYSIS: Multinomial logistic regression was used to explore which similar or different covariates were associated with different health states between baby boomers and older adults. RESULTS: Approximately 8% of baby boomers and 10% of older adults had the twin diagnoses of obesity and diabetes. Having both obesity and diabetes was more common among baby boomers and older adults who were African-American (odds ratio [OR] = 1.79, p = .029 for baby boomers; OR = 3.45, p < .001 for older adults), perceived their general health as fair/poor (OR = 7.67, p < .001; OR = 4.13, p < .001), and utilized outpatient care more often (OR = 8.28, p < .001; OR = 5.35, p = .004). Being obese only was observed less among baby boomers who were current smokers (OR = .45, p < .001), whereas it was observed more among older adults who were former smokers (OR = 1.25, p = .046). Having diabetes only was observed more among baby boomers who had hypertension (OR = 2.44, p = .01), whereas it was observed more among older adults who had very high cholesterol (OR = 2.31, p = .029). CONCLUSION: Identifying chronic disease risk factors during middle age is important for ameliorating further complications in later life. Knowing more about the correlates of obesity and diabetes among different age groups can help health care planners better target preventive health care services.

Advanced practice nurses and program evaluation: can solicitation of an e-mail address lead to longitudinal selection bias?

OBJECTIVES: To identify if survey respondents providing an e-mail address for program evaluation represent a risk of longitudinal selection bias. METHODS: A survey was administered to advanced practice nurses after a chronic disease self-management presentation. Chi-square statistics and logistic regression were used to identify variables associated with successful solicitation of an e-mail address. RESULTS: Relative to those 'not at all likely' to suggest someone in their practice train to become a certified chronic disease self-management facilitator, those stating they were 'very likely' or 'quite likely' to take this action were 10.20 and 13.60 times more likely, respectively, to provide an e-mail address. These differences were statistically significant (OR = 10.20, CI = 2.91-35.77, p < 0.001 and OR = 13.60, CI = 2.14-86.40, p = 0.006, respectively). CONCLUSION: Soliciting an e-mail address could pose a risk of selection bias when developing a longitudinal sample for further analysis.

Disparity of risk-adjusted inpatient outcomes among African American and white patients hospitalized with community-acquired pneumonia.

The objectives of this study were to examine the associations between inpatient pneumonia outcomes, health care factors, and sociodemographics with an emphasis on race. African American and white patients from the 2008 National Hospital Discharge Survey who were admitted to nonprofit and for-profit hospitals with a principal diagnosis of pneumonia were sampled (n=1924). Three outcomes were measured: length of hospital stay, discharge to home, and deceased at discharge. Length of hospital stay was measured with negative binomial regression including incidence rate ratios (IRRs), while the remaining 2 outcomes were measured with logistic regression including odds ratios (ORs). Patients with longer hospital stays relative to peers were likely older (IRR=1.01, 95% confidence interval [CI]=1.01-1.01, P<0.001) and African American (IRR=1.19, 95% CI=1.10-1.30, P<0.001), but had fewer comorbidities (IRR=0.97, 95% CI=0.94-0.99, P=0.016). Patients were less likely to be discharged to home if they were older (OR=0.96, 95% CI=0.95-0.96, P<0.001), African American (OR=0.68, 95% CI=0.52-0.90, P=0.006), and had government insurance (OR=0.59, 95% CI=0.44-0.79, P<0.001). Patients deceased at discharge were more likely to be older (OR=1.03, 95% CI=1.01-1.05, P=0.001), African American (OR=1.97, 95% CI=1.10-3.53, P=0.023), and to have fewer comorbidities (OR=0.71, 95% CI=0.57-0.88, P=0.002). African Americans with pneumonia experience inequitable inpatient pneumonia-related outcomes relative to whites. Hospital interventions addressing equity are needed.

College students' perceived disease risk versus actual prevalence rates.

OBJECTIVE: To compare college students' perceived disease risk with disease prevalence rates. METHODS: Data were analyzed from 625 college students collected with an Internet-based survey. Paired t-tests were used to separately compare participants' perceived 10-year and lifetime disease risk for 4 diseases: heart disease, cancer, diabetes, and overweight/obesity. RESULTS: Respondents estimated their risk of developing heart disease as lower than cancer, yet rated their risk of developing heart disease as higher than diabetes and being overweight/obese. CONCLUSION: Incongruence between college students' perceived disease risk and disease prevalence rates calls for improved public health education.

Correlates of chronic disease and patient-provider discussions among middle-aged and older adult males: Implications for successful aging and sexuality.

OBJECTIVE: Effective erectile dysfunction (ED) treatments and cardiovascular disease (CVD) and diabetes risk assessments are available, but require patient-provider communication. The present study explored this issue using 2010 National Social Life, Health and Aging Project data for males age 57 years and older (n = 1011). METHODS: Multinomial logistic regression was performed to compare factors associated with being without CVD/diabetes (39.9%), being diagnosed with CVD only (43.1%), and having comorbid CVD/diabetes (CVD 17.0%). Logistic regression compared factors associated with having ever discussed sexual issues with physicians. RESULTS: CVD-only participants were more likely to be ≥ 75 years (p = 0.004) and smoke (p = 0.019); CVD&D participants were more likely to report activity limitations (p < 0.001) and less likely to have sex within the previous year (p = 0.014). Compared to CVD-only, men with CVD&D were more likely to be minorities, obese, have daily activity limitations, and report erectile difficulties (all p < 0.05). Males discussing sexual issues with physicians were more likely to report higher education [OR = 1.68, p = 0.001], have sex in previous year [OR = 1.73, p = 0.006], and have erectile difficulties [OR = 2.26, p < 0.001]. DISCUSSION: Increased patient and provider awareness and communication are needed to lifestyle behaviors, promote self-care practices, and improve health care utilization among male patients affected by chronic disease and ED.

Perceived risk of developing diabetes in early adulthood: beliefs about inherited and behavioral risk factors across the life course.

This study aimed to determine how college students perceive their risk of developing diabetes over their life course, with specific emphasis on their beliefs about the influence of inherited versus behavioral risk factors. A bivariate ordered probit regression model was used to simultaneously predict perceived risk for 10-year absolute risk of diabetes and lifetime absolute risk of diabetes. Ten-year and lifetime absolute risk were both increased when the respondent self-identified with a race/ethnicity other than non-Hispanic white (ß = 0.42, p < .001 and ß = 0.33, p = .004, respectively), and when the respondent had an increasing number of family members with diabetes (ß = 0.33, p < .001 and ß = 0.45, p < .001, respectively). Beliefs linking behavioral risk factors to perceived risk of developing diabetes across the life course were not statistically significant. The absence of significant association between perceptions of behavioral risk as factors for developing diabetes and perceived risk for diabetes over the life course supports the need for educational interventions about behavioral and genetic causes of diabetes among the college-aged population.

The association of physical activity, sedentary behaviors, and body mass index classification in a cross-sectional analysis: are the effects homogenous?

BACKGROUND: While much is known about the benefits of physical activity (PA) and the consequence of sedentary behaviors relative to body mass index (BMI), little is known about the homogeneity of these effects across individuals. The goal of this study was to determine if PA and sedentary behaviors have the same effect on individuals of all BMI classifications. METHODS: Data from a community health assessment were analyzed and a sample was selected to include respondents who self-reported a chronic disease associated with obesity (n = 2,840). Descriptive statistics were used to describe the association between selected independent variables and BMI. Simultaneous quantile regression was used to identify the degree of homogeneity in the effect of demographic independent variables, minutes per week of moderate PA, and hours per day spent watching television on BMI classification. In studies using simultaneous quantile regression, the word "effect" is used to describe association, not causation. RESULTS: Minutes per week of moderate PA had a significant effect on lower BMI, but only when respondents were at least classified as obese-class I (ß = -0.001, p = 0.006). The change in effect of moderate PA in lower BMI increased significantly when respondents were classified as obese-class II versus obese-class I (F = 4.54, p = 0.033). Hours per day spent watching television had a significant effect on higher BMI, but only when the respondent was at least classified as overweight (ß = 0.87, p < 0.001). The change in effect of watching television on higher BMI increased significantly when respondents were classified as obese-class I versus overweight (F = 5.57, p = 0.018). CONCLUSION: PA and watching television were more related to BMI for obese individuals than those who were just overweight. Customized interventions for specific BMI classifications should be developed to maximize public health benefits.

Advanced practice nurses' perspectives on the use of health optimization strategies for managing chronic disease among older adults in different care settings: pushing the boundaries of self-management programs.

This study examines the intention of advanced practice nurses (APNs) to utilize health optimization programs (HOPs) for addressing clients' chronic disease in various work settings (i.e., nursing homes or other care settings). A paper-based survey was administered to 270 APNs at a continuing education conference to determine their intentions to refer patients to HOPs for chronic disease management. APNs working in nursing homes were 0.23 times as likely to utilize HOPs for management of their patients' chronic disease compared with their counterparts working in other care settings (odds ratio = 0.23, confidence interval = 0.06-0.80, P = .021). APNs who had previously used a HOP for management of their patients' chronic disease were 5.2 times as likely to do so again relative to those who had not previously used a HOP for management of their patients' chronic disease (odds ratio = 5.17, confidence interval = 1.78-14.99, P = .002). Educational and organizational interventions are recommended to disseminate further HOPs for chronic disease in nursing home settings as part of an overall health optimization strategy.

Quality of primary care processes for individuals with chronic diseases associated with the metabolic syndrome: a comparative study.

AIM: The aim of this study is to investigate whether individuals diagnosed with chronic diseases associated with the metabolic syndrome (MetS) receive favorable quality of care processes in the primary care setting relative to other individuals with and without chronic diseases. BACKGROUND: Data from the 2010 Brazos Valley Health Status Assessment (BVHSA) (n = 3964) were analyzed. Individuals diagnosed with chronic diseases that are collectively associated with a diagnosis of MetS, namely obesity, diabetes, high cholesterol, and hypertension, were characterized as a group (ie, analytic sample, n = 168). Clinical guidelines were utilized to identify indicators representing the quality of care processes received by these individuals during visits with their health-care provider. METHOD: Measures of quality of care processes were analyzed relative to a comparator group comprising individuals with no chronic diseases and an alternative test group comprising those diagnosed with other chronic diseases (eg, arthritis, depression, and cancer among others) using multinomial and binary logistic regression. FINDINGS: Physician communication of critical issues such as diet, stress, and weight status was statistically more pronounced in the analytic sample relative to the comparator group. However, differences in physician communication about physical activity were not statistically significant relative to the comparator group (OR = 1.26, P = 0.533). Differences in testing of cholesterol (OR = 0.94, P = 0.743) and blood pressure (OR = 1.16, P = 0.619) were also not statistically significant relative to the comparator group. Individuals who may have MetS generally receive favorable quality of care processes from their health-care provider, but opportunities exist to enhance provider communication about physical activity, and to possibly improve frequency of cholesterol and blood pressure testing.

Provenge: revolutionary technology or ethical bust?

Sipuleucel-T (known by the trade name, "Provenge") is the first prostate cancer vaccine approved by the Food and Drug Administration (FDA), and represents a new type of cancer therapy termed, Autologous Cellular Immunotherapy (ACT). This therapy has been described as a revolution in technology by clinicians and researchers alike. However, policy-makers and health economists question the efficacy of such treatment given its costs, while mainstream media often bemoan Provenge as yet another example of a healthcare system gone awry. This paper examines the debate for and against Provenge, and discusses why Medicare adoption of payment protocols for the vaccine may violate the egalitarian and feminist principles of distributive justice theory. The paper also acknowledges the larger context of the Provenge debate within the bioethical community; that is, how much should society be willing to invest to prevent death? The paper concludes by arguing for a more thorough ethical review of such new technologies by policy-makers prior to the adoption of funding protocols.

Increasing uptake of Gardasil among American adolescents: comparisons with the history of Hepatitis B vaccination.

OBJECTIVES: This paper identifies differences in the uptake rate of Gardasil and contrasts Gardasil uptake rate with the history of Hepatitis B vaccination. METHODS: A targeted review of peer-reviewed journals and industry commentary was conducted. New trends were calculated and figures created based on secondary data. RESULTS: The distribution of HPV vaccine does not conform to the geographic incidence rate of cervical cancer. Contrary to contemporary belief, school immunization mandates for Hepatitis B vaccines were not the impetus for their acceptance. Familial beliefs about HPV vaccines appear to be the most significant challenge to Gardasil uptake rate. CONCLUSIONS: Gardasil is at a critical juncture for increased uptake. Evidence-based educational interventions are needed.

Assessing costs and potential returns of evidence-based programs for seniors.

The authors describe the customary tools used by health services researchers to conduct economic evaluations of health interventions. Recognizing the inherent challenges of these tools for utilization in contemporary public health practice, we recommend a practical cost-benefit analysis (PCBA) to allow public health practitioners to assess the economic merits of their existing public health programs. The PCBA estimates what health effects and corresponding medical cost avoidance would be required to support the costs associated with implementing a community-based prevention program. We apply the PCBA to evaluate a statewide evidence-based falls prevention program for seniors in Texas. We estimate a positive return on realized costs due to avoided direct and indirect medical expenses if the program averts 7 falls among 140 participants within the first year. While acknowledging the demonstrated health-related benefits of public health interventions, we provide a practical ex-post economic evaluation methodology to assess return on investment as a more simplistic yet effective alternative for public health practitioners versus contemporary analyses of health services researchers.

Associations between health care factors and self-reported health status among individuals with diabetes: results from a community assessment.

To identify the influence of select health care variables on self-reported physical and mental health status of individuals with diabetes. Data from the 2006 Brazos Valley Health Status Assessment (BVHSA) were analyzed. Aspects of health care were defined through exploratory factor analysis. Structural equation modeling was used to create relationships between health care aspects, personal characteristics of the participants, and self-reported physical and mental health status of individuals with diabetes. The significant predictors of self-reported physical health status were the number of co-morbid chronic diseases (ß = 0.27, P = .002), and medical system access (ß = -0.20, P = .035). The significant predictor of self-reported mental health status was the number of co-morbid chronic diseases (ß = 0.35, P < .001). Self-reported physical (ß = 0.27, P = .028) and mental (ß = 0.29, P = .020) health status were both predictive of physician communication of mental health issues. Communication about mental health issues strongly relates to both self-reported physical and mental health status and should be an important part of physicians' care for individuals with diabetes. Further, the nuances of medical system access for diabetes care should be further examined.

The influence of episodic mood disorders on length of stay among patients admitted to private and non-profit hospitals with alcohol dependence syndrome.

Episodic mood disorders are often associated with alcohol dependence. Few studies have explored the contribution of episodic mood disorders to length of stay among those hospitalized with alcohol dependence syndrome. Filling this research gap could improve care for patients while minimizing hospital utilization costs. This study was a cross-sectional analysis of the National Hospital Discharge Survey. ICD-9-CM diagnosis codes were used to identify those admitted to a private or non-profit hospital with alcohol dependence syndrome, and a co-morbid diagnosis of an episodic mood disorder (n=358). Descriptive statistics were used to highlight differences in key demographic and hospital variables between those with and without episodic mood disorders. Negative binomial regression was used to associate episodic mood disorders with hospital length of stay. Incidence rate ratios were calculated. Co-morbid episodic mood disorders (ß=0.31, P=0.001), referral to a hospital by a physician (ß=0.35, P=0.014), and increasing age (ß= 0.01, P=0.001) were associated with longer hospital stays. Hospital patients with an admitting diagnosis of alcohol dependence syndrome were 36% more likely to have a longer hospital stay if they also had a co-morbid diagnosis of an episodic mood disorder (IRR=1.36, CI=1.14-1.62). Patients admitted to a hospital with alcohol dependence syndrome should be routinely screened for episodic mood disorders. Opportunities exist for enhanced transitional care between acute, ambulatory, and community-based care settings to lower hospital utilization.

Hypercholesterolemia in youth: opportunities and obstacles to prevent premature atherosclerotic cardiovascular disease.

Treatment of hypercholesterolemia in youth is predicated on the knowledge that we can identify those youth with this atherosclerotic risk factor most likely to develop premature cardiovascular disease. Unfortunately, this is not the case. Before we can adequately address appropriate lipid-lowering therapies in this special population, we must address and resolve current barriers related to screening and diagnosis. In this article, we describe some of the opportunities and obstacles that clinicians and policy makers confront when applying the current pediatric guidelines focused on screening and treating hypercholesterolemia in the pediatric population.