Investigation of predictors of severity of diabetes complications among hospitalized patients with diabetes in Florida, 2016-2019.

BACKGROUND: Severe diabetes complications impact the quality of life of patients and may lead to premature deaths. However, these complications are preventable through proper glycemic control and management of risk factors. Understanding the risk factors of complications is important in guiding efforts to manage diabetes and reduce risks of its complications. Therefore, the objective of this study was to identify risk factors of severe diabetes complications among adult hospitalized patients with diabetes in Florida. METHODS: Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Adapted Diabetes Complications Severity Index (aDCSI) scores were computed for 1,061,140 unique adult patients with a diagnosis of diabetes. Severe complications were defined as those with an aDCSI ≥ 4. Population average models, estimated using generalized estimating equations, were used to identify individual- and area-level predictors of severe diabetes complications. RESULTS: Non-Hispanic Black patients had the highest odds of severe diabetes complications compared to non-Hispanic White patients among both males (Odds Ratio [OR] = 1.20, 95% Confidence Interval [CI]: 1.17, 1.23) and females (OR = 1.27, 95% CI: 1.23, 1.31). Comorbidities associated with higher odds of severe complications included hypertension (OR = 2.30, 95% CI: 2.23, 2.37), hyperlipidemia (OR = 1.29, 95% CI: 1.27, 1.31), obesity (OR = 1.24, 95% CI: 1.21, 1.26) and depression (OR = 1.09, 95% CI: 1.07, 1.11), while the odds were lower for patients with a diagnosis of arthritis (OR = 0.81, 95% CI: 0.79, 0.82). Type of health insurance coverage was associated with the severity of diabetes complications, with significantly higher odds of severe complications among Medicare (OR = 1.85, 95% CI: 1.80, 1.90) and Medicaid (OR = 1.83, 95% CI: 1.77, 1.90) patients compared to those with private insurance. Residing within the least socioeconomically deprived ZIP code tabulation areas (ZCTAs) in the state had a protective effect compared to residing outside of these areas. CONCLUSIONS: Racial, ethnic, and socioeconomic disparities in the severity of diabetes complications exist among hospitalized patients in Florida. The observed disparities likely reflect challenges to maintaining glycemic control and managing cardiovascular risk factors, particularly for patients with multiple chronic conditions. Interventions to improve diabetes management should focus on populations with disproportionately high burdens of severe complications to improve quality of life and decrease premature mortality among adult patients with diabetes in Florida.

Community Assessment for Public Health Emergency Response (CASPER) following Hurricane Michael: Gadsden, Calhoun, and Jackson Counties, Florida, 2020.

OBJECTIVES: To assess community preparedness and ongoing recovery efforts in the rural counties most severely impacted by Hurricane Michael, including structural and economic losses, injury and illness, healthcare access, and suicide risk and ideation. DESIGN: The Florida Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in January 2020, 15 months after Hurricane Michael made landfall in October 2018. SETTING: A total of 30 clusters were randomly selected from three rural counties in the Panhandle of Florida, including Jackson (15 clusters), Gadsden (11), and Calhoun (four) counties. PARTICIPANTS: A total of 185 face-to-face and two phone interviews were conducted with residents 18 years of age or older. MAIN OUTCOME MEASURE: Hurricane preparedness, structural and economic losses, access to care, and physical and mental health. RESULTS: Around 43 percent of respondents evacuated as a result of Hurricane Michael, and at least two-thirds of all respondents reported having an emergency supply kit and enough nonperishable food, water, and medication. Structural damage was extensive with 63 percent reporting home damage, averaging over $32,000. Few injuries or illnesses were reported post-landfall (9 percent), with the most common being minor injuries and bacterial infections. Most respondents reported continued access to healthcare if needed. The most common stress-related issues reported were difficulty sleeping (19 percent) and agitated behaviors (10 percent). Seven percent of respondents reported being at moderate to high risk for suicide. CONCLUSIONS: Rural areas may lack resources, such as healthcare facilities, skilled workers, and supplies, that hinder their ability to recover from storms when compared to more urban counties. Many residents reported that 15 months after the storm, their homes were still not fully repaired. A majority of residents were prepared with adequate supplies, had minimal disruption in employment or healthcare access, and had few illnesses or injuries during the storm or the recovery efforts.

Current Tobacco Use Trends and Harm Perceptions Among High School Students by Asthma Status and Sex, 2012-2018.

BACKGROUND: Tobacco use is known to worsen asthma management. No studies have investigated how trends in youth tobacco use and related harm perceptions vary by asthma status and sex. This study examined these trends among Florida high school students during 2012-2018. METHODS: Data from the 2012, 2014, 2016, and 2018 Florida Youth Tobacco Survey were analyzed. Public high school students (grades 9-12) with known asthma status were included along with their current tobacco product use, tobacco product harm perceptions, and demographics. Weighted multivariable logistic regression was used to assess trends in tobacco product use and harm perceptions and test differences by asthma status and sex. RESULTS: From 2012 to 2018, high school students with asthma had the slowest decline in cigarette and cigar use prevalence (asthma status-time interaction p = .01) compared to those with no asthma. Cigarette and cigar smoking were perceived as less harmful over time, except among females with asthma who smoked cigarettes (p < .05). CONCLUSIONS: Those with asthma showed a slower decline and were more likely to smoke cigarettes. Results indicate that further public health efforts are needed to address tobacco use among high school students with asthma.

Prevalence and predictors of stroke among individuals with prediabetes and diabetes in Florida.

BACKGROUND: The prevalence of both prediabetes and diabetes have been increasing in Florida. These increasing trends will likely result in increases of stroke burden since both conditions are major risk factors of stroke. However, not much is known about the prevalence and predictors of stroke among adults with prediabetes and diabetes and yet this information is critical for guiding health programs aimed at reducing stroke burden. Therefore, the objectives of this study were to estimate the prevalence and identify predictors of stroke among persons with either prediabetes or diabetes in Florida. METHODS: The 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey data were obtained from the Florida Department of Health and used for the study. Weighted prevalence estimates of stroke and potential predictor variables as well as their 95% confidence intervals were computed for adults with prediabetes and diabetes. A conceptual model of predictors of stroke among adults with prediabetes and diabetes was constructed to guide statistical model building. Two multivariable logistic models were built to investigate predictors of stroke among adults with prediabetes and diabetes. RESULTS: The prevalence of stroke among respondents with prediabetes and diabetes were 7.8% and 11.2%, respectively. The odds of stroke were significantly (p ≤ 0.05) higher among respondents with prediabetes that were ≥ 45 years old (Odds ratio [OR] = 2.82; 95% Confidence Interval [CI] = 0.74, 10.69), had hypertension (OR = 5.86; CI = 2.90, 11.84) and hypercholesterolemia (OR = 3.93; CI = 1.84, 8.40). On the other hand, the odds of stroke among respondents with diabetes were significantly (p ≤ 0.05) higher if respondents were non-Hispanic Black (OR = 1.79; CI = 1.01, 3.19), hypertensive (OR = 3.56; CI = 1.87, 6.78) and had depression (OR = 2.02; CI = 1.14, 3.59). CONCLUSIONS: Stroke prevalence in Florida is higher among adults with prediabetes and diabetes than the general population of the state. There is evidence of differences in the importance of predictors of stroke among populations with prediabetes and those with diabetes. These findings are useful for guiding health programs geared towards reducing stroke burden among populations with prediabetes and diabetes.

Community Assessment for Public Health Emergency Response (CASPER) Following Hurricane Michael, Bay and Gulf Counties, Florida, 2019.

CONTEXT: On October 10, 2018, Hurricane Michael made landfall near Mexico Beach, Florida, as one of the strongest storms on record to hit the US mainland. Hurricane Michael brought strong winds, heavy rain, and life-threatening storm surge, causing extensive damage across the Florida Panhandle. OBJECTIVES: To assess community preparedness and effects experienced by Panhandle residents, including structural and economic losses, injury and illness, health care access, and suicide risk and ideation in the counties most severely impacted by Hurricane Michael. DESIGN: The Florida Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in October and November 2019, a year after Hurricane Michael made landfall. CASPER is a 2-stage cluster sampling method designed to provide household-level information about a community's needs in a timely, inexpensive, and representative manner. SETTING: A total of 30 clusters were randomly selected from Bay and Gulf Counties, Florida. PARTICIPANTS: In total, 178 face-to-face interviews were completed with adult residents 18 years or older. MAIN OUTCOME MEASURES: Hurricane-related impacts, including structural and economic losses, injury and illness, health care access; and mental health. RESULTS: Almost half of respondents did not evacuate despite mandatory evacuation orders. Most houses (78.1%) received some damage, with more than half still not repaired 1 year later. Access to emergency supply kits, water, nonperishable foods, medications, and health care was common, though many reported needing supplies not included in their kit. Less than half reported having working household carbon monoxide detectors. Injuries and illnesses associated with the hurricane were uncommon; however, anxiety, depression, and insomnia were reported as occurring or worsening by more than one-third of respondents posthurricane. CONCLUSIONS: Increased education and communication regarding hurricane preparedness and recovery, which include clearer messaging on evacuation, improving emergency supply kits, importance of carbon monoxide detectors, and proper generator use, could enhance the safety of the community.

Heat illness data strengthens vulnerability maps.

BACKGROUND: Previous extreme heat and human health studies have investigated associations either over time (e.g. case-crossover or time series analysis) or across geographic areas (e.g. spatial models), which may limit the study scope and regional variation. Our study combines a case-crossover design and spatial analysis to identify: 1) the most vulnerable counties to extreme heat; and 2) demographic and socioeconomic variables that are most strongly and consistently related to heat-sensitive health outcomes (cardiovascular disease, dehydration, heat-related illness, acute renal disease, and respiratory disease) across 67 counties in the state of Florida, U. S over 2008-2012. METHODS: We first used a case-crossover design to examine the effects of air temperature on daily counts of health outcomes. We employed a time-stratified design with a 28-day comparison window. Referent periods were extracted from ±7, ±14, or ± 21 days to address seasonality. The results are expressed as odds ratios, or the change in the likelihood of each health outcome for a unit change in heat exposure. We then spatially examined the case-crossover extreme heat and health odds ratios and county level demographic and socioeconomic variables with multiple linear regression or spatial lag models. RESULTS: Results indicated that southwest Florida has the highest risks of cardiovascular disease, dehydration, acute renal disease, and respiratory disease. Results also suggested demographic and socioeconomic variables were significantly associated with the magnitude of heat-related health risk. The counties with larger populations working in farming, fishing, mining, forestry, construction, and extraction tended to have higher risks of dehydration and acute renal disease, whereas counties with larger populations working in installation, maintenance, and repair workers tended to have lower risks of cardiovascular, dehydration, acute renal disease, and respiratory disease. Finally, our results showed that high income counties consistently have lower health risks of dehydration, heat-related illness, acute renal disease, and respiratory disease. CONCLUSIONS: Our study identified different relationships with demographic/socioeconomic variables for each heat-sensitive health outcome. Results should be incorporated into vulnerability or risk indices for each health outcome.

Geographic disparities and temporal changes of diabetes prevalence and diabetes self-management education program participation in Florida.

BACKGROUND: Although Diabetes Self-Management Education (DSME) programs are recommended to help reduce the burden of diabetes and diabetes-related complications, Florida is one of the states with the lowest DSME participation rates. Moreover, there is evidence of geographic disparities of not only DSME participation rates but the burden of diabetes as well. Understanding these disparities is critical for guiding control programs geared at improving participation rates and diabetes outcomes. Therefore, the objectives of this study were to: (a) investigate geographic disparities of diabetes prevalence and DSME participation rates; and (b) identify predictors of the observed disparities in DSME participation rates. METHODS: Behavioral Risk Factor Surveillance System (BRFSS) data for 2007 and 2010 were obtained from the Florida Department of Health. Age-adjusted diabetes prevalence and DSME participation rates were computed at the county level and their geographic distributions visualized using choropleth maps. Significant changes in diabetes prevalence and DSME participation rates between 2007 and 2010 were assessed and counties showing significant changes were mapped. Clusters of high diabetes prevalence before and after adjusting for common risk factors and DSME participation rates were identified, using Tango's flexible spatial scan statistics, and their geographic distribution displayed in maps. Determinants of the geographic distribution of DSME participation rates and predictors of the identified high rate clusters were identified using ordinary least squares and logistic regression models, respectively. RESULTS: County level age-adjusted diabetes prevalence varied from 4.7% to 17.8% while DSME participation rates varied from 26.6% to 81.2%. There were significant (p≤0.05) increases in both overall age-adjusted diabetes prevalence and DSME participation rates from 2007 to 2010 with diabetes prevalence increasing from 7.7% in 2007 to 8.6% in 2010 while DSME participation rates increased from 51.4% in 2007 to 55.1% in 2010. Generally, DSME participation rates decreased in rural areas while they increased in urban areas. High prevalence clusters of diabetes (both adjusted and unadjusted) were identified in northern and central Florida, while clusters of high DSME participation rates were identified in central Florida. Rural counties and those with high proportion of Hispanics tended to have low DSME participation rates. CONCLUSIONS: The findings confirm that geographic disparities in both diabetes prevalence and DSME participation rates exist. Specific attention is required to address these disparities especially in areas that have high diabetes prevalence but low DSME participation rates. Study findings are useful for guiding resource allocation geared at reducing disparities and improving diabetes outcomes.

Using social security number to identify sub-populations vulnerable to the health impacts from extreme heat in Florida, U.S.

BACKGROUND: Some socioeconomically vulnerable groups may experience disproportionately higher risk of extreme heat illness than other groups, but no study has utilized the presence/absence of a social security number (SSN) as a proxy for vulnerable sub-populations. METHODS: This study focused on the warm season from 2008 to 2012 in Florida, U.S. With a total number of 8,256,171 individual level health outcomes, we devised separate case-crossover models for five heat-sensitive health outcomes (cardiovascular disease, dehydration, heat-related illness, renal disease, and respiratory disease), type of health care visit (emergency department (ED) and hospitalization), and patients reporting/not reporting an SSN. Each stratified model also considered potential effect modification by sex, age, or race/ethnicity. RESULTS: Mean temperature raised the odds of five heat-sensitive health outcomes with the highest odds ratios (ORs) for heat-related illness. Sex significantly modified heat exposure effects for dehydration ED visits (Males: 1.145, 95 % CI: 1.137-1.153; Females: 1.110, 95 % CI: 1.103-1.117) and hospitalization (Males: 1.116, 95 % CI: 1.110-1.121; Females: 1.100, 95 % CI: 1.095-1.105). Patients not reporting an SSN between 25 and 44 years (1.264, 95 % CI: 1.192-1.340) exhibited significantly higher dehydration ED ORs than those reporting an SSN (1.146, 95 % CI: 1.136-1.157). We also observed significantly higher ORs for cardiovascular disease hospitalization from the no SSN group (SSN: 1.089, 95 % CI: 1.088-1.090; no SSN: 1.100, 95 % CI: 1.091-1.110). CONCLUSIONS: This paper partially supports the idea that individuals without an SSN could experience higher risks of dehydration (for those 25-45 years), renal disease, and cardiovascular disease than those with an SSN.

COVID-19 Information-Seeking and Prevention Behaviors in Florida, April 2020.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) surveillance can be enhanced by collecting population-level data on individual prevention measures. We described the use of a state-based, population-level surveillance system on COVID-19 prevention and information-seeking behaviors in Florida during the first month of survey administration. METHODS: Beginning in April 2020, respondents of the Florida Behavioral Risk Factor Surveillance System were asked a series of 8 questions about sources of COVID-19 information and prevention behaviors. We analyzed the prevalence of information-seeking and prevention behaviors among respondents who answered at least 1 of the 8 questions (N = 1,004) overall, by demographic characteristics, and by the presence of chronic conditions. RESULTS: Most respondents reported engaging in prevention behaviors, including handwashing (98.2%), reducing or avoiding travel (96.6%), avoiding crowds and public events (96.5%), and keeping household members at home (87.5%); however, the prevalence of prevention behaviors varied significantly by age, sex, and education. The most frequently reported source of COVID-19 information was the Centers for Disease Control and Prevention's website (40.8%) followed by the Florida Department of Health's website (32.9%). We found significant differences in information sources across all demographic and chronic condition subgroups. A larger proportion of respondents with chronic conditions (vs without chronic conditions) reported consulting their personal doctor for COVID-19 information. CONCLUSION: Understanding the uptake and characteristics associated with individual prevention and information-seeking behaviors at the population level facilitates COVID-19 response efforts. The rapid implementation of COVID-19-related questions in the Florida BRFSS provides a useful model for other population-based surveillance systems.

Florida neighborhood analysis of social determinants and their relationship to life expectancy.

BACKGROUND: Social determinants of health (SDOH) contribute to unequal life expectancy (LE). Only a handful of papers have analyzed these relationships at the neighborhood level as opposed to the county level. This study draws on both the SDOH and social vulnerability literature to identify relevant factors affecting LE. METHODS: LE was calculated from mortality records for Florida from 2009 to 2013 for 3640 census tracts with reliable estimates. A spatial Durbin error model (SDEM) quantified the direction and magnitude of the factors to LE. The SDEM contains a spatial error term and jointly estimates both local and neighborhood associations. This methodology controls for non-independence between census tracts to provide unbiased statistical estimates. RESULTS: Factors significantly related to an increase in LE, include percentage (%) of the population who identify as Hispanic (beta coefficient [ß]: 0.06, p-value [P] < 0.001) and % of age dependent populations (% population < 5 years old and % population > 65) (ß: 0.13, P < 0.001). Conversely, the following factors exhibited significant negative LE associations, % of households with no automobile (ß: -0.05, P < 0.001), % of mobile homes (ß: -0.02, P < 0.001), and % of female headed households (ß: -0.11, P < 0.001). CONCLUSIONS: Results from the SDEM demonstrate social vulnerability indicators account for additional geographic LE variability beyond commonly studied SDOH. Empirical findings from this analysis can help local health departments identify drivers of spatial health disparities at the local level.

Cumulative Inequality at the End of Life?: Racial Disparities in Impairment in the Time Before Death.

OBJECTIVES: Drawing from cumulative inequality (CI) theory, the current study examined racial disparities in impairment as individuals approached death to determine whether proposed mechanisms hypothesized to fuel or diminish racial disparities at late ages were at work at the end of individualized life spans. METHOD: Black-white disparities were analyzed among decedents using latent growth curves based on the data from the North Carolina Established Populations for Epidemiologic Studies of the Elderly (EPESE) (N = 1,926). RESULTS: Consistent with previous literature, racial inequalities in functional disparities diminish at late ages. However, significant black-white disparities emerge as older adults approach death, exponentially increasing within the 2 years immediately preceding death. Further, these disparities are not fully mediated by socioeconomic status. DISCUSSION: The results confirm that CI in health outcomes is observable in late life among individual life spans, suggesting the years surrounding death may be a particularly vulnerable period for health inequality. Future research should examine how advantaged statuses translate to increased access to health-related resources that aid in maintaining greater functional independence until the last stage of life.

Tobacco Product Use Among Youths With and Without Lifetime Asthma - Florida, 2016.

The increasing availability of diverse tobacco products has led to complex tobacco product use patterns among youths (1). Use by youths of products containing nicotine in any form is unsafe (2); among young persons with asthma, use of combustible tobacco products, particularly cigarettes, is associated with worsening symptoms, poor asthma control, and an increased need for medical management (3,4). Studies suggest that youths with asthma adopt health risk behaviors, including tobacco product use, at rates similar to or higher than those of youths without asthma (3-7); however, these studies are often limited to a partial list of tobacco product types among high school students. To assess current use (≥1 days during the past 30 days) of one or more of five tobacco product types (cigarettes, electronic cigarettes [defined as e-cigarettes, e-cigars, vape pipes, vaping pens, e-hookah, and hookah pens], hookah, smokeless tobacco, or cigars) among Florida middle school (grades 6-8) and high school (grades 9-12) students with or without a previous medical diagnosis of asthma, the Florida Department of Health analyzed data from the 2016 Florida Youth Tobacco Survey (FYTS). In 2016, 11.1% of middle school and 27.9% of high school students with asthma, and 7.9% of middle school and 24.2% of high school students without asthma, reported any current tobacco product use. Current use of each tobacco product type was considerably higher among students with asthma than among those without asthma. E-cigarettes were the most commonly used tobacco product type reported by middle and high school students with asthma (7.9% and 19.6%, respectively) and without asthma (5.8% and 17.2%, respectively). Statewide tobacco prevention strategies could help reduce all forms of tobacco product use among youths, particularly among those with asthma.

Social support, stress, and maternal postpartum depression: A comparison of supportive relationships.

A large body of literature documents the link between social support, stress, and women's mental health during pregnancy and the postpartum period; however, uncertainty remains as to whether a direct effect or stress mediating pathway best describes the relationship between these factors. Moreover, specific dimensions of social support that may be influential (family type, sources of support) have largely been neglected. Using data from the Fragile Families and Child Well-being Study (N=4150), we examine the pathway between social support, stress exposure, and postpartum depression in greater detail. Findings reveal that social support is a significant, protective factor for postpartum depression, and the variety of support providers in a woman's social network is important, especially in the context of family type. Findings also reveal the importance of considering social support and stress exposure as part of a larger causal pathway to postpartum mental health.

The relationship between parents' poor emotional health status and childhood mood and anxiety disorder in Florida children, national survey of children's health, 2011-2012.

The purpose of this study was to examine how parents' emotional health relates to childhood mood and anxiety disorder among Florida children in the 2011-2012 National Survey of Children's Health. Analyses were restricted to 1,241 Florida children 6-17 years of age. Childhood mood and anxiety disorder was defined as a parent-reported diagnosis of current depression or anxiety. Parents' emotional health status was a composite measure of the lowest reported emotional health of any parent in the household. To assess the association between parents' emotional health and childhood mood and anxiety disorder, bivariate and multivariate logistic regression analyses were performed. Nearly 5 % of Florida children had a mood or anxiety disorder in 2011-2012. Children living with a parent in poor emotional health were significantly more likely to have a mood or anxiety disorder compared to children living with a parent in good emotional health (OR 5.01; 95 % CI 1.89, 13.29). After adjusting for covariates, this association remained substantial and significant (aOR 4.33; 95 % CI 1.49, 12.57). Findings presented here are consistent with national findings and emphasize the strong link between parents' emotional health status and childhood mood and anxiety disorders. To address the mental health of children in the state of Florida, Florida public health initiatives should consider family processes and child level characteristics.