Coalitions for impacting the health of a community: the Summit County, Ohio, experience.

Community coalitions have the potential to catalyze important changes in the health and well-being of populations. The authors demonstrate how communities can benefit from a multisector coalition to conduct a community-wide surveillance, coordinate activities, and monitor health and wellness interventions. Data from Summit County, Ohio are presented that illustrate how this approach can be framed and used to impact community health positively across communities nationwide. By jointly sharing the responsibility and accountability for population health through coalitions, communities can use the Health Impact Pyramid framework to assess local assets and challenges and to identify and implement programmatic and structural needs. Such a coalition is well poised to limit duplication and to increase the efficiency of existing efforts and, ultimately, to positively impact the health of a population.

Pain and depression in a cohort of underserved, community-dwelling primary care patients.

PURPOSE: Almost 17% of the US population exhibits a major depressive disorder in their lifetimes. Prevalence data show that whites experience depression earlier than African Americans, and women have a higher prevalence than men. Less is known regarding depression among underserved minority populations. The goal of our study was to examine the relationship of depression and associated self-reported conditions in participants enrolled in a community-based research registry, a substantial number of whom were underrepresented minorities. METHODS: This study used a research registry of community members who had expressed interest in participating in health education projects conducted by the Center for Primary Care Community-Based Research. The patients received care at 10 family health centers. Participants were surveyed regarding family history of depression/anxiety and associated symptoms. Descriptive analyses, univariate analyses, and logistic regressions were used. RESULTS: The population (N = 2421) included women (72.2%), African Americans (54.9%), and reported good or very good general health (68.9%). Comorbid pain was found, with headache as the predominant complaint. Compared with nonwhites, whites had a significantly higher prevalence of current depression (26.3% vs. 23.8%; P = .01), current anxiety (25.5% vs. 16.6%), and current headache (14.2% vs. 11.2%). Whites also had a higher prevalence of a family history of depression (38.4% vs. 32.1%) and anxiety (8.9% vs. 7.7%) and of taking depression (22.4% vs. 14.8%) and anxiety (15.8% vs. 7.8%) medications. However, nonwhites had a higher prevalence of leg pain (18.8% vs. 14.9%) but a lower prevalence of headache (11.2% vs. 14.2%). CONCLUSIONS: Pain was common in patients with comorbid behavioral conditions. Headache was more common in whites, whereas leg pain was more common in nonwhites. Physicians should screen for depression and anxiety in patients with headache and other pain symptoms.

Impact of early sexual debut on gay men's tobacco use.

Young men's sexual experiences with men are different from their sexual experiences with women because of homophobia. Early sexual debut with another man could lead to tobacco use as a result. The study assessed 691 HIV-negative gay men recruited from southwestern Pennsylvania. Early sexual experiences with men and women were associated with participants' smoking behaviors. It is thought that the early sexual debut with men may place these individuals at risk for homophobia as well as for being socialized in environments that will influence their smoking behavior. To be effective, tobacco control programs need to be culturally competent regarding issues that affect gay men.

Content and context of a research registry for community-based research.

There is a dearth of evidence relative to the identification and the variability between the prevalence of chronic conditions in the greater geographic community and the prevalence of these chronic conditions reported through community-based primary care practices. Described is the content and context of a research registry and the variation in panels given the means of recruitment. Patients complete a medical form that includes their self-reported demographics, current and past medical conditions, current medications, family history of selected medical conditions, and a release for full access to their medical records. Two panels were examined, those patients served by community-based primary care practices and assessment of those citizens living in the greater underserved population. These results suggest that the recorded frequency of conditions is similar to those found in the most frequent diagnostic clusters reported in literature for primary care visits. Despite the equity of the demographic and geographical area for recruitment, the identified chronic conditions of those recruited from medical practices differed significantly than the participants from community venues. These findings are provocative in that they have an impact on the understanding of the content and context of a primary care community-based research registry, but also the possible variations in panels given the means of recruitment into a registry. These data are relevant not only as a measure of prevalence of conditions seen in primary care, but perhaps more importantly as a measure of the prevention of chronic diseases that disproportionately affect the underserved.

Vitamin D status and response to Vitamin D(3) in obese vs. non-obese African American children.

BACKGROUND: Serum 25-hydroxyvitamin D (25(OH)D) is low in obese adults. OBJECTIVE: To examine serum 25(OH)D in obese (BMI >95th percentile for age) vs. non-obese (BMI = 5th-75th percentile for age) 6-10-year-old African American children and compare their differences in therapeutic response to vitamin D supplementation. METHODS AND PROCEDURES: In an open label non-randomized pre-post comparison 21 obese (OB) and 20 non-obese (non-OB) subjects matched for age, sex, skin color, and pubertal maturation were treated with 400 IU of vitamin D(3) daily for 1 month. Serum 25(OH)D, 1,25-dihydroxyvitamin D (1,25(OH)(2)D), parathyroid hormone (PTH), leptin, and markers of bone turnover (serum bone-specific alkaline phosphatase (BSAP), osteocalcin (OC), and urine n -telopeptide cross-links of type 1 collagen (urine NTX)) were measured. Vitamin D deficiency was defined as serum 25(OH)D < or =20 ng/ml and insufficiency as 21-29 ng/ml respectively. RESULTS: Vitamin D deficiency occurred in 12/21 (57%) OB vs. 8/20 (40%) non-OB at baseline (P = 0.35) and persisted in 5/21 (24%) OB vs. 2/18 (11%) non-OB (P = 0.42) after treatment. When the cohort was stratified by the baseline levels of 25(OH)D, there were differences in the response to treatment in the obese and non-obese cohorts. DISCUSSION: Vitamin D deficiency was common among OB and non-OB preadolescent African American children, and 400 IU of vitamin D(3) (2x the recommended adequate intake) daily for 1 month was inadequate to raise their blood levels of 25(OH)D to > or =30 ng/ml.

Frequency and outcome of cervical cancer prevention failures in the United States.

We measured the frequency and outcome of cervical cancer prevention failures that occurred in the Papanicolaou (Pap) and colposcopy testing phases involving 1,646,580 Pap tests in 4 American hospital systems between January 1, 1998, and December 31, 2004. We defined a screening failure as a 2-step or greater discordant Pap test result and follow-up biopsy diagnosis. A total of 5,278 failures were detected (0.321% of all Pap tests); 48% and 52% of failures occurred in the Pap test and colposcopy phases, respectively. Missed squamous cancers (1 in 187,786 Pap tests), glandular cancers (1 in 19,426 Pap tests), and high-grade lesions (1 in 6,870 Pap tests) constituted 4.1% of all failures. Unnecessary repeated tests or diagnostic delays occurred in 70.8% and 63.9% of failures involving high- and low-grade lesions, respectively. We conclude that cervical cancer prevention practices are remarkably successful in preventing squamous cancers, although a high frequency of failures results in low-impact negative outcomes.

A performance curve for assessing change in Percentage of Consonants Correct Revised (PCC-R).

PURPOSE: Interpreting the rapidly changing speech skills of young children recovering from neurological injury is difficult because developmental expectations are generally available only at relatively lengthy intervals (e.g., 6 or 12 months). In this research note, the authors describe the process of generating a Percentage of Consonants Correct-Revised (PCC-R; L. D. Shriberg, D. Austin, B. A. Lewis, J. L. McSweeny, & D. L. Wilson, 1997a) performance curve and illustrate some of its applications for assessing change in performance over time. METHOD: The authors compiled mean PCC-R scores from 16 samples of typically developing children (18-172 months) and used curve fitting to test more than 11,000 statistical models of monthly growth in PCC-R. They selected a parsimonious and developmentally plausible model with R(2) = .9839 (p < .0005) and used it to generate the PCC-R, standard deviation, and standard error expected at each monthly age. RESULTS: The PCC-R performance curve distinguished among 65 children (37-57 months of age) diagnosed independently with normal or disordered speech with a high degree of success. More important, the PCC-R performance curve can be used to identify the points at which children (18-172 months) recovering from neurological injury achieve normal-range consonant production. CONCLUSION: The curve-fitting approach holds promise as a means of interpreting temporal variations in speech production at a finer grain than existing normative data currently allow.

Tympanostomy tubes and developmental outcomes at 9 to 11 years of age.

BACKGROUND: Developmental impairments in children have been attributed to persistent middle-ear effusion in their early years of life. Previously, we reported that among children younger than 3 years of age with persistent middle-ear effusion, prompt as compared with delayed insertion of tympanostomy tubes did not result in improved cognitive, language, speech, or psychosocial development at 3, 4, or 6 years of age. However, other important components of development could not be assessed until the children were older. METHODS: We enrolled 6350 infants soon after birth and evaluated them regularly for middle-ear effusion. Before 3 years of age, 429 children with persistent effusion were randomly assigned to undergo the insertion of tympanostomy tubes either promptly or up to 9 months later if effusion persisted. We assessed literacy, attention, social skills, and academic achievement in 391 of these children at 9 to 11 years of age. RESULTS: Mean (+/-SD) scores on 48 developmental measures in the group of children who were assigned to undergo early insertion of tympanostomy tubes did not differ significantly from the scores in the group that was assigned to undergo delayed insertion. These measures included the Passage Comprehension subtest of the Woodcock Reading Mastery Tests (mean score, 98+/-12 in the early-treatment group and 99+/-12 in the delayed-treatment group); the Spelling, Writing Samples, and Calculation subtests of the Woodcock-Johnson III Tests of Achievement (96+/-13 and 97+/-16; 104+/-14 and 105+/-15; and 99+/-13 and 99+/-13, respectively); and inattention ratings on visual and auditory continuous performance tests. CONCLUSIONS: In otherwise healthy young children who have persistent middle-ear effusion, as defined in our study, prompt insertion of tympanostomy tubes does not improve developmental outcomes up to 9 to 11 years of age. (ClinicalTrials.gov number, NCT00365092 [ClinicalTrials.gov].).

Use of a new method in reaching consensus on the cause of cytologic-histologic correlation discrepancy.

Pathologists exhibit very poor agreement in adjudicating the cause of cytologic-histologic correlation discrepancies, which contributes to problems in designing interventions to reduce discrepancy frequency. In this observational study, we developed a visual method of adjudicating discrepancy cause, termed the No-Blame Box method, which consisted of initially assessing specimen interpretability by separately evaluating specimen quality and the presence of tumor. Five pathologists blindly adjudicated the cause of discrepancy in pulmonary specimens from 40 patients. The kappa statistic of all pathologist pairs in adjudicating discrepancy cause using the No-Blame Box method ranged from 0.400 to 0.796, indicating acceptable to excellent agreement. Pathologists ranged in their assessment of specimen interpretability from 13% to 20%, and in no case did all 5 pathologists concur that a specimen was interpretable. Most discrepancies resulted from pathologists diagnosing noninterpretable samples. Pathologists who used the No-Blame Box showed significant agreement in the adjudication of discrepancy cause.

Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error.

Our objective was to determine whether the Toyota Production System process redesign resulted in diagnostic error reduction for patients who underwent cytologic evaluation of thyroid nodules. In this longitudinal, nonconcurrent cohort study, we compared the diagnostic error frequency of a thyroid aspiration service before and after implementation of error reduction initiatives consisting of adoption of a standardized diagnostic terminology scheme and an immediate interpretation service. A total of 2,424 patients underwent aspiration. Following terminology standardization, the false-negative rate decreased from 41.8% to 19.1% (P = .006), the specimen nondiagnostic rate increased from 5.8% to 19.8% (P < .001), and the sensitivity increased from 70.2% to 90.6% (P < .001). Cases with an immediate interpretation had a lower noninterpretable specimen rate than those without immediate interpretation (P < .001). Toyota process change led to significantly fewer diagnostic errors for patients who underwent thyroid fine-needle aspiration.

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

PURPOSE: The frequency of diagnostic error in patients who have a lung mass and a pathology specimen is as high as 15%. This study examined the role of inter-pathologist agreement in identifying the cause of error in these patients. METHODS: Pathologists from six institutions reviewed the slides of 40 patients who had a pulmonary specimen false-negative diagnosis. The initial assessment of error cause arose from cytologic-histologic correlation slide review of discrepant diagnostic samples in patients who had both a bronchial brushing cytologic and surgical specimen. The cause of error was attributed either to clinical sampling (diagnostic material obtained in one but not the other sample) or interpretation (pathologist failed to identify the salient diagnostic features). The pairwise kappa (kappa) statistic was used to calculate interobserver agreement between the review and original diagnoses and between the separate review diagnoses. RESULTS: The pairwise kappa statistic ranged widely from -0.154 to 1.0, and the pairwise kappa statistic of the slides from one institution was undetermined because that institutional pathologist never made the assessment that error was secondary to interpretation. Agreement for observers within the same institution was better than agreement between observers from different institutions. CONCLUSION: Pathologists exhibit poor agreement in determining the cause of error for pulmonary specimens sent for cancer diagnosis. We developed a psychosocial hypothesis (the "Big Dog" Effect) that partially explains biases in error assessment. This lack of agreement precludes confident targeting of these errors for quality improvement interventions with prospects of success across a variety of institutions.

Impact of vaccine economic programs on physician referral of children to public vaccine clinics: a pre-post comparison.

BACKGROUND: The Vaccines for Children (VFC) Program is a major vaccine entitlement program with limited long-term evaluation. The objectives of this study are to evaluate the effect of VFC on physician reported referral of children to public health clinics and on doses administered in the public sector. METHODS: Minnesota and Pennsylvania primary care physicians (n = 164), completed surveys before (e.g., 1993) and after (2003) VFC, rating their likelihood on a scale of 0 (very unlikely) to 10 (very likely) of referring a child to the health department for immunization. RESULTS: The percentage of respondents likely to refer was 60% for an uninsured child, 14% for a child with Medicaid, and 3% for a child with insurance that pays for immunization. Half (55%) of the physicians who did not participate in VFC were likely to refer a Medicaid-insured child, as compared with 6% of those who participated (P < 0.001). Physician likelihood to refer an uninsured child for vaccination, measured on a scale of 0 to 10 where 10 is very likely, decreased by a mean difference of 1.9 (P < 0.001) from pre- to post-VFC. The likelihood to refer a Medicaid-insured child decreased by a mean of 1.2 (P = 0.001). CONCLUSION: Reported out-referral to public clinics decreased over time. In light of increasing immunizations rates, this suggests that more vaccines were being administered in private provider offices.

Vitamin D insufficiency in preadolescent African-American children.

To determine the proportion of vitamin D insufficiency in 6- to 10-year-old preadolescent African-American children residing in Pittsburgh, Pennsylvania and to estimate their therapeutic response to vitamin D 400 IU/day for 1-month, an open-label pre- and post-comparison of vitamin D status following vitamin D 400 IU daily for 1 month during winter and early spring was conducted. Outcomes included serum calcium, phosphorus, albumin, 25 hydroxyvitamin D [25 (OH) D], 1, 25 dihydroxyvitamin D [1, 25 (OH) (2) D], parathyroid hormone (PTH), and markers of bone turnover (serum bone-specific alkaline phosphatase, osteocalcin, and urine n-telopeptide crosslinked collagen type 1 [NTX]). Dietary intake of vitamin D was assessed using a food frequency questionnaire. Forty-one of the 42 enrolled subjects (mean age: 8.9 +/- 1.2 yrs [SD]) were analyzed, and 20/41 (49%) were vitamin D insufficient. Vitamin D insufficient group had a suggestive trend of being older (9.2 +/- 1.0 years vs. 8.5 +/- 1.3 years, p = 0.06) and more pubertally advanced (Tanner II: 7/20 vs. Tanner II: 1/21, p = 0.02). Mean dietary intake of vitamin D was 277 ( 146 IU/day (n = 41). Adequate intake for vitamin D (200 IU/day) was not met in 16/41 (39%); however, the dietary intake of vitamin D was not significantly different between the vitamin D insufficient and vitamin D sufficient groups.

Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.

BACKGROUND: To the authors' knowledge, the frequency and clinical impact of errors in the anatomic pathology diagnosis of cancer have been poorly characterized to date. METHODS: The authors examined errors in patients who underwent anatomic pathology tests to determine the presence or absence of cancer or precancerous lesions in four hospitals. They analyzed 1 year of retrospective errors detected through a standardized cytologic-histologic correlation process (in which patient same-site cytologic and histologic specimens were compared). Medical record reviews were performed to determine patient outcomes. The authors also measured the institutional frequency, cause (i.e., pathologist interpretation or sampling), and clinical impact of diagnostic cancer errors. RESULTS: The frequency of errors in cancer diagnosis was found to be dependent on the institution (P < 0.001) and ranged from 1.79-9.42% and from 4.87-11.8% of all correlated gynecologic and nongynecologic cases, respectively. A statistically significant association was found between institution and error cause (P < 0.001); the cause of errors resulting from pathologic misinterpretation ranged from 5.0-50.7% (the remainder were due to clinical sampling). A statistically significant association was found between institution and assignment of the clinical impact of error (P < 0.001); the aggregated data demonstrated that for gynecologic and nongynecologic errors, 45% and 39%, respectively, were associated with harm. The pairwise kappa statistic for interobserver agreement on cause of error ranged from 0.118-0.737. CONCLUSIONS: Errors in cancer diagnosis are reported to occur in up to 11.8% of all reviewed cytologic-histologic specimen pairs. To the authors' knowledge, little agreement exists regarding whether pathology errors are secondary to misinterpretation or poor clinical sampling of tissues and whether pathology errors result in serious harm.

Influenza immunization of medical residents: knowledge, attitudes, and behaviors.

BACKGROUND: There have been few studies of barriers to acceptance of influenza immunization among medical residents. EXPERIMENTAL DESIGN: We conducted a cross-sectional survey of residents at the Western Pennsylvania Hospital during the 2003-2004 influenza season. An anonymous questionnaire designed specifically for this study was used to collect demographic, health beliefs and attitudes, and medical knowledge data related to the influenza vaccine. RESULTS: 43 residents were surveyed from January to February 2004. 58% of the respondents reported receiving the vaccine. Immunization rates were significantly associated with postgraduate level, prior vaccination, media influence, whether they knew co-residents who were vaccinated, medical knowledge scores, and plan to be vaccinated next year. Immunization rates by age, sex, type of medical school, department, whether they had children younger than 16, whether they would recommend the vaccine to patients, and the respondents' health status did not differ significantly. Residents who had higher medical knowledge scores were significantly more likely to be immunized and recommend the vaccine to patients. CONCLUSIONS: Resident influenza immunization rate in this sample was higher than the national average for healthcare workers. The rate of immunization was associated with demographic, knowledge, and behavioral factors.

Predicting dire outcomes of patients with community acquired pneumonia.

Community-acquired pneumonia (CAP) is an important clinical condition with regard to patient mortality, patient morbidity, and healthcare resource utilization. The assessment of the likely clinical course of a CAP patient can significantly influence decision making about whether to treat the patient as an inpatient or as an outpatient. That decision can in turn influence resource utilization, as well as patient well being. Predicting dire outcomes, such as mortality or severe clinical complications, is a particularly important component in assessing the clinical course of patients. We used a training set of 1601 CAP patient cases to construct 11 statistical and machine-learning models that predict dire outcomes. We evaluated the resulting models on 686 additional CAP-patient cases. The primary goal was not to compare these learning algorithms as a study end point; rather, it was to develop the best model possible to predict dire outcomes. A special version of an artificial neural network (NN) model predicted dire outcomes the best. Using the 686 test cases, we estimated the expected healthcare quality and cost impact of applying the NN model in practice. The particular, quantitative results of this analysis are based on a number of assumptions that we make explicit; they will require further study and validation. Nonetheless, the general implication of the analysis seems robust, namely, that even small improvements in predictive performance for prevalent and costly diseases, such as CAP, are likely to result in significant improvements in the quality and efficiency of healthcare delivery. Therefore, seeking models with the highest possible level of predictive performance is important. Consequently, seeking ever better machine-learning and statistical modeling methods is of great practical significance.

What predicts influenza vaccination status in older Americans over several years?

OBJECTIVES: To examine the correlates of repeat influenza vaccination and determine whether there are age-group (50-64, > or =65) differences in decision-making behavior. DESIGN: Longitudinal survey study. SETTING: Two community health centers in Pittsburgh, Pennsylvania. PARTICIPANTS: Two hundred fifty-three patients aged 50 and older in 2001 who visited one of the health centers and completed telephone surveys in 2002 and 2003 after the respective influenza seasons. MEASUREMENTS: Influenza vaccination status, demographic characteristics, and decision-making behavior were self-reported. Vaccination status was identified for three seasons: 2000-2001, 2001-2002, and 2002-2003. A three-level outcome was defined as unvaccinated all 3 years, vaccinated one to two times over 3 years, and vaccinated all 3 years. Factor analysis identified three decision-making behaviors. RESULTS: Predictors of being vaccinated across 3 years included being older, the belief that social forces influence vaccination behavior, and disagreement with the view that vaccine is detrimental. CONCLUSION: National educational efforts should be intensified to dispel the myths about alleged adverse events, including contracting influenza from inactivated influenza vaccine. Physicians should continue to share their personal experiences of treating patients with influenza, including the incidence of hospitalization and death.