Global hotspots for coastal ecosystem-based adaptation.

Helping the world's coastal communities adapt to climate change impacts requires evaluating the vulnerability of coastal communities and assessing adaptation options. This includes understanding the potential for 'natural' infrastructure (ecosystems and the biodiversity that underpins them) to reduce communities' vulnerability, alongside more traditional 'hard' infrastructure approaches. Here we present a spatially explicit global evaluation of the vulnerability of coastal-dwelling human populations to key climate change exposures and explore the potential for coastal ecosystems to help people adapt to climate change (ecosystem-based adaptation (EbA)). We find that mangroves and coral reefs are particularly well situated to help people cope with current weather extremes, a function that will only increase in importance as people adapt to climate change now and in coming decades. We find that around 30.9 million people living within 2km of the coast are highly vulnerable to tropical storms and sea-level rise (SLR). Mangroves and coral reefs overlap these threats to at least 5.3 and 3.4 million people, respectively, with substantial potential to dissipate storm surges and improve resilience against SLR effects. Significant co-benefits from mangroves also accrue, with 896 million metric tons of carbon stored in their soils and above- and below-ground biomass. Our framework offers a tool for prioritizing 'hotspots' of coastal EbA potential for further, national and local analyses to quantify risk reduction and, thereby, guide investment in coastal ecosystems to help people adapt to climate change. In doing so, it underscores the global role that conserving and restoring ecosystems can play in protecting human lives and livelihoods, as well as biodiversity, in the face of climate change.

Robust spatial analysis of sequestered metals in a Southern California Bioswale.

Bioswales are a type of permeable green infrastructure designed to slow stormwater and clean runoff by sequestering pollutants such as heavy metals. Measurements of dissolved pollutants before and after the bioswale often justify their ability to clean this runoff, but research addressing the physical and chemical sequestration of these pollutants is scarce. Soil samples were taken from an arid bioswale and analyzed for concentrations of aluminum, cobalt, chromium, copper, iron, magnesium, manganese, nickel, lead, vanadium and zinc. Heat maps of the concentration of these metals in soil were generated via Empirical Bayesian Kriging (EBK) and demonstrate that location-specific sequestration differs between metals within the same swale. Sequential extraction with a modified Tessier et al. (1979) protocol coupled with profiles of metal concentration versus distance along the main flow axis in the bioswale illustrate that the carbonate soil fraction contains elevated concentrations of zinc, lead, cobalt, and manganese, metals sequestered by the bioswale with statistical significance.

An analysis of chemicals and other constituents found in produced water from hydraulically fractured wells in California and the challenges for wastewater management.

As high-volume hydraulic fracturing (HF) has grown substantially in the United States over the past decade, so has the volume of produced water (PW), i.e., briny water brought to the surface as a byproduct of oil and gas production. According to a recent study (Groundwater Protection Council, 2015), more than 21 billion barrels of PW were generated in 2012. In addition to being high in TDS, PW may contain hydrocarbons, PAH, alkylphenols, naturally occurring radioactive material (NORM), metals, and other organic and inorganic substances. PW from hydraulically fractured wells includes flowback water, i.e., injection fluids containing chemicals and additives used in the fracturing process such as friction reducers, scale inhibitors, and biocides - many of which are known to cause serious health effects. It is hence important to gain a better understanding of the chemical composition of PW and how it is managed. This case study of PW from hydraulically fractured wells in California provides a first aggregate chemical analysis since data collection began in accordance with California's 2013 oil and gas well stimulation law (SB4, Pavley). The results of analyzing one-time wastewater analyses of 630 wells hydraulically stimulated between April 1, 2014 and June 30, 2015 show that 95% of wells contained measurable and in some cases elevated concentrations of BTEX and PAH compounds. PW from nearly 500 wells contained lead, uranium, and/or other metals. The majority of hazardous chemicals known to be used in HF operations, including formaldehyde and acetone, are not reported in the published reports. The prevalent methods for dealing with PW in California - underground injection and open evaporation ponds - are inadequate for this waste stream due to risks from induced seismicity, well integrity failure, well upsets, accidents and spills. Beneficial reuse of PW, such as for crop irrigation, is as of yet insufficiently safety tested for consumers and agricultural workers as well as plant health. Technological advances in onsite direct PW reuse and recycling look promising but need to control energy requirements, productivity and costs. The case study concludes that (i) reporting of PW chemical composition should be expanded in frequency and cover a wider range of chemicals used in hydraulic fracturing fluids, and (ii) PW management practices should be oriented towards safer and more sustainable options such as reuse and recycling, but with adequate controls in place to ensure their safety and reliability.

Toward Consistent Methodology to Quantify Populations in Proximity to Oil and Gas Development: A National Spatial Analysis and Review.

BACKGROUND: Higher risk of exposure to environmental health hazards near oil and gas wells has spurred interest in quantifying populations that live in proximity to oil and gas development. The available studies on this topic lack consistent methodology and ignore aspects of oil and gas development of value to public health-relevant assessment and decision-making. OBJECTIVES: We aim to present a methodological framework for oil and gas development proximity studies grounded in an understanding of hydrocarbon geology and development techniques. METHODS: We geospatially overlay locations of active oil and gas wells in the conterminous United States and Census data to estimate the population living in proximity to hydrocarbon development at the national and state levels. We compare our methods and findings with existing proximity studies. RESULTS: Nationally, we estimate that 17.6 million people live within 1,600m (∼1 mi) of at least one active oil and/or gas well. Three of the eight studies overestimate populations at risk from actively producing oil and gas wells by including wells without evidence of production or drilling completion and/or using inappropriate population allocation methods. The remaining five studies, by omitting conventional wells in regions dominated by historical conventional development, significantly underestimate populations at risk. CONCLUSIONS: The well inventory guidelines we present provide an improved methodology for hydrocarbon proximity studies by acknowledging the importance of both conventional and unconventional well counts as well as the relative exposure risks associated with different primary production categories (e.g., oil, wet gas, dry gas) and developmental stages of wells. https://doi.org/10.1289/EHP1535.

California emergency department closures are associated with increased inpatient mortality at nearby hospitals.

Between 1996 and 2009 the annual number of emergency department (ED) visits in the United States increased by 51 percent while the number of EDs nationwide decreased by 6 percent, which placed unprecedented strain on the nation's EDs. To investigate the effects of an ED's closing on surrounding communities, we identified all ED closures in California during the period 1999-2010 and examined their association with inpatient mortality rates at nearby hospitals. We found that one-quarter of hospital admissions in this period occurred near an ED closure and that these admissions had 5 percent higher odds of inpatient mortality than admissions not occurring near a closure. This association persisted whether we considered ED closures as affecting all future nearby admissions or only those occurring in the subsequent two years. These results suggest that ED closures have ripple effects on patient outcomes that should be considered when health systems and policy makers decide how to regulate ED closures.

The association of trauma center closures with increased inpatient mortality for injured patients.

BACKGROUND: Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed. METHODS: We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure. RESULTS: The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51). CONCLUSION: Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure. LEVEL OF EVIDENCE: Prognostic and epidemiologic, level III.

Cigarette smoking prevalence in US counties: 1996-2012.

BACKGROUND: Cigarette smoking is a leading risk factor for morbidity and premature mortality in the United States, yet information about smoking prevalence and trends is not routinely available below the state level, impeding local-level action. METHODS: We used data on 4.7 million adults age 18 and older from the Behavioral Risk Factor Surveillance System (BRFSS) from 1996 to 2012. We derived cigarette smoking status from self-reported data in the BRFSS and applied validated small area estimation methods to generate estimates of current total cigarette smoking prevalence and current daily cigarette smoking prevalence for 3,127 counties and county equivalents annually from 1996 to 2012. We applied a novel method to correct for bias resulting from the exclusion of the wireless-only population in the BRFSS prior to 2011. RESULTS: Total cigarette smoking prevalence varies dramatically between counties, even within states, ranging from 9.9% to 41.5% for males and from 5.8% to 40.8% for females in 2012. Counties in the South, particularly in Kentucky, Tennessee, and West Virginia, as well as those with large Native American populations, have the highest rates of total cigarette smoking, while counties in Utah and other Western states have the lowest. Overall, total cigarette smoking prevalence declined between 1996 and 2012 with a median decline across counties of 0.9% per year for males and 0.6% per year for females, and rates of decline for males and females in some counties exceeded 3% per year. Statistically significant declines were concentrated in a relatively small number of counties, however, and more counties saw statistically significant declines in male cigarette smoking prevalence (39.8% of counties) than in female cigarette smoking prevalence (16.2%). Rates of decline varied by income level: counties in the top quintile in terms of income experienced noticeably faster declines than those in the bottom quintile. CONCLUSIONS: County-level estimates of cigarette smoking prevalence provide a unique opportunity to assess where prevalence remains high and where progress has been slow. These estimates provide the data needed to better develop and implement strategies at a local and at a state level to further reduce the burden imposed by cigarette smoking.

Emergency department charges for asthma-related outpatient visits by insurance status.

Though Americans make 1.8 million asthma-related outpatient visits to the emergency department (ED) annually, little is known about the episodic charges for asthma care in the ED. We therefore sought to assess the bills patients could face for acute asthma incidents by examining hospital charges for asthma-related outpatient ED visits. We performed a nationwide, cross-sectional study of 2.9 million weighted asthma-related outpatient ED visits from 2006-2008 using data from the Medical Expenditure Panel Survey. We found that the average charge for an outpatient ED visit was $1,502 (95% CI $1,493-$1,511). The charges did not vary significantly by insurance group but did increase significantly with age. Our results indicate that the financial burden of ED care for asthma may take a severe toll on low-income populations who have limited ability to pay, especially patients who must pay undiscounted charges, including the uninsured and those on high-deductible health plans.

"How much will I get charged for this?" Patient charges for top ten diagnoses in the emergency department.

OBJECTIVES: We examined the charges, their variability, and respective payer group for diagnosis and treatment of the ten most common outpatient conditions presenting to the Emergency department (ED). METHODS: We conducted a cross-sectional study of the 2006-2008 Medical Expenditure Panel Survey. Analysis was limited to outpatient visits with non-elderly, adult (years 18-64) patients with a single discharge diagnosis. RESULTS: We studied 8,303 ED encounters, representing 76.6 million visits. Median charges ranged from $740 (95% CI $651-$817) for an upper respiratory infection to $3437 (95% CI $2917-$3877) for a kidney stone. The median charge for all ten outpatient conditions in the ED was $1233 (95% CI $1199- $1268), with a high degree of charge variability. All diagnoses had an interquartile range (IQR) greater than $800 with 60% of IQRs greater than $1550. CONCLUSION: Emergency department charges for common conditions are expensive with high charge variability. Greater acute care charge transparency will at least allow patients and providers to be aware of the emergency department charges patients may face in the current health care system.

Is emergency department closure resulting in increased distance to the nearest emergency department associated with increased inpatient mortality?

STUDY OBJECTIVE: We seek to determine whether patients living in areas affected by emergency department (ED) closure, with subsequent increased distance to the nearest ED, have a higher risk of inpatient death from time-sensitive conditions. METHODS: Using the California Office of Statewide Health and Planning Development database, we performed a nonconcurrent cohort study of hospital admissions in California between 1999 and 2009 for patients admitted for acute myocardial infarction, stroke, sepsis and asthma or chronic obstructive pulmonary disease. We used generalized linear mixed-effects models comparing adjusted inpatient mortality for patients experiencing increased distance to the nearest ED versus no change in distance. RESULTS: Of 785,385 patient admissions, 67,577 (8.6%) experienced an increase in distance to ED care because of an ED closure. The median change for patients experiencing an increase in distance to the nearest ED was only 0.8 miles, with a range of 0.1 to 33.4 miles. Patients with an increase did not have a significantly higher mortality (adjusted odds ratio 1.04; 95% confidence interval 0.99 to 1.09). In subgroups, we also observed no statistically significant differences in adjusted mortality among patients with acute myocardial infarction, stroke, asthma or chronic obstructive pulmonary disease, and sepsis. We did not observe any significant variations in mortality for time-sensitive conditions in sensitivity analyses that incorporated a lag effect of time after change in distance, allowance for a larger affected population, or removal of ST-segment elevation myocardial infarction from the acute myocardial infarction subgroup. CONCLUSION: In this large population-based sample, less than 10% of the patients experienced an increase in distance to the nearest ED, and of that group, the majority had less than a 1-mile increase. These small increased distances to the nearest ED were not associated with higher inpatient mortality among time-sensitive conditions.

System-level health disparities in California emergency departments: minorities and Medicaid patients are at higher risk of losing their emergency departments.

STUDY OBJECTIVE: Emergency department (ED) closures threaten community access to emergency services, but few data exist to describe factors associated with closure. We evaluate factors associated with ED closure in California and seek to determine whether hospitals serving more vulnerable populations have a higher rate of ED closure. METHODS: This was a retrospective cohort study of California hospital EDs between 1998 and 2008, using hospital- and patient-level data from the California Office of Statewide Health Planning and Development (OSHPD), as well as OSHPD patient discharge data. We examined the effects of hospital and patient factors on the hospital's likelihood of ED closure by using Cox proportional hazards models. RESULTS: In 4,411 hospital-years of observation, 29 of 401 (7.2%) EDs closed. In a model adjusted for total ED visits, hospital discharges, trauma center and teaching status, ownership, operating margin, and urbanicity, hospitals with more black patients (hazard ratio [HR] 1.41 per increase in proportion of blacks by 0.1; 95% confidence interval [CI] 1.16 to 1.72) and Medi-Cal recipients (HR 1.17 per increase in proportion insured by Medi-Cal by 0.1; 95% CI 1.02 to 1.34) had higher risk of ED closure, as did for-profit institutions (HR 1.65; 95% CI 1.13 to 2.41). CONCLUSION: The population served by EDs and hospitals' profit model are associated with ED closure. Whether our findings are a manifestation of poorer reimbursement in at-risk EDs is unclear.

A novel framework for validating and applying standardized small area measurement strategies.

BACKGROUND: Local measurements of health behaviors, diseases, and use of health services are critical inputs into local, state, and national decision-making. Small area measurement methods can deliver more precise and accurate local-level information than direct estimates from surveys or administrative records, where sample sizes are often too small to yield acceptable standard errors. However, small area measurement requires careful validation using approaches other than conventional statistical methods such as in-sample or cross-validation methods because they do not solve the problem of validating estimates in data-sparse domains. METHODS: A new general framework for small area estimation and validation is developed and applied to estimate Type 2 diabetes prevalence in US counties using data from the Behavioral Risk Factor Surveillance System (BRFSS). The framework combines the three conventional approaches to small area measurement: (1) pooling data across time by combining multiple survey years; (2) exploiting spatial correlation by including a spatial component; and (3) utilizing structured relationships between the outcome variable and domain-specific covariates to define four increasingly complex model types - coined the Naive, Geospatial, Covariate, and Full models. The validation framework uses direct estimates of prevalence in large domains as the gold standard and compares model estimates against it using (i) all available observations for the large domains and (ii) systematically reduced sample sizes obtained through random sampling with replacement. At each sampling level, the model is rerun repeatedly, and the validity of the model estimates from the four model types is then determined by calculating the (average) concordance correlation coefficient (CCC) and (average) root mean squared error (RMSE) against the gold standard. The CCC is closely related to the intraclass correlation coefficient and can be used when the units are organized in groups and when it is of interest to measure the agreement between units in the same group (e.g., counties). The RMSE is often used to measure the differences between values predicted by a model or an estimator and the actually observed values. It is a useful measure to capture the precision of the model or estimator. RESULTS: All model types have substantially higher CCC and lower RMSE than the direct, single-year BRFSS estimates. In addition, the inclusion of relevant domain-specific covariates generally improves predictive validity, especially at small sample sizes, and their leverage can be equivalent to a five- to tenfold increase in sample size. CONCLUSIONS: Small area estimation of important health outcomes and risk factors can be improved using a systematic modeling and validation framework, which consistently outperformed single-year direct survey estimates and demonstrated the potential leverage of including relevant domain-specific covariates compared to pure measurement models. The proposed validation strategy can be applied to other disease outcomes and risk factors in the US as well as to resource-scarce situations, including low-income countries. These estimates are needed by public health officials to identify at-risk groups, to design targeted prevention and intervention programs, and to monitor and evaluate results over time.