Disparities in Prenatal Care Utilization Among U.S. Versus Foreign-Born Women with Chronic Conditions.

We examined disparities in prenatal care utilization (PNCU) among U.S. and foreign-born women with chronic conditions. We performed a cross-sectional analyses using data from 2011 to 2012 National Center for Health Statistics Natality Files (n = 6,644,577) to examine the association between maternal nativity (U.S. vs. foreign-born), presence of a chronic condition (diabetes or hypertensive disorder) and PNCU. After adjustment for selected maternal characteristics, overall and among those with chronic conditions, foreign-born women reported significantly lower odds of intensive and adequate PNCU and higher odds of intermediate and inadequate PNCU than U.S.-born women. Few differences in report of no care were found by maternal nativity. These findings suggest that foreign-born women may be receiving some form of prenatal care, but adequacy of care is likely to be lower compared to U.S.-born counterparts, even among those with chronic conditions.

Adequacy of Current State Setbacks for Directional High-Volume Hydraulic Fracturing in the Marcellus, Barnett, and Niobrara Shale Plays.

BACKGROUND: There is an increasing awareness of the multiple potential pathways leading to human health risks from hydraulic fracturing. Setback distances are a legislative method to mitigate potential risks. OBJECTIVES: We attempted to determine whether legal setback distances between well-pad sites and the public are adequate in three shale plays. METHODS: We reviewed geography, current statutes and regulations, evacuations, thermal modeling, air pollution studies, and vapor cloud modeling within the Marcellus, Barnett, and Niobrara Shale Plays. DISCUSSION: The evidence suggests that presently utilized setbacks may leave the public vulnerable to explosions, radiant heat, toxic gas clouds, and air pollution from hydraulic fracturing activities. CONCLUSIONS: Our results suggest that setbacks may not be sufficient to reduce potential threats to human health in areas where hydraulic fracturing occurs. It is more likely that a combination of reasonable setbacks with controls for other sources of pollution associated with the process will be required. CITATION: Haley M, McCawley M, Epstein AC, Arrington B, Bjerke EF. 2016. Adequacy of current state setbacks for directional high-volume hydraulic fracturing in the Marcellus, Barnett, and Niobrara Shale Plays. Environ Health Perspect 124:1323-1333; http://dx.doi.org/10.1289/ehp.1510547.

The impact of fragmentation of hospitalist care on length of stay.

BACKGROUND: Different hospitalist staffing models provide different levels of inpatient continuity of care, which may impact length of stay (LOS). OBJECTIVE: To determine if fragmentation of care (FOC) by hospitalist physicians is associated with LOS. DESIGN: Concurrent control study. SETTING: Hospitalist practices managed by IPC The Hospitalist Company. PATIENTS: A total of 10,977 patients admitted for diagnosis-related group (DRG) of 89 pneumonia with complications or comorbidities (PNA) or a DRG of 127 heart failure and shock (HF) between December 2006 and November 2007. MEASUREMENTS: FOC was defined as the percentage of care given by hospitalists other than the hospitalist who saw the patient the majority of the stay. Negative binomial regression was performed on DRG 89 and DRG 127 patients with LOS as the dependent variable. We adjusted for gender, age, severity of illness (SOI) scores, risk of mortality (ROM) scores, and number of secondary diagnoses, and admission day of the week. RESULTS: A 10% increase in fragmentation was associated with an increase of 0.39 days (P < 0.0001) in the LOS for pneumonia, and an increase of 0.30 days (P < 0.0001) in LOS for heart failure. CONCLUSIONS: As FOC increased for pneumonia and heart failure, the LOS increased significantly. Methods to reduce fragmentation should be explored, while more research is needed to identify the source of the relationship between FOC and LOS.

Utilization of elective hip and knee arthroplasty by age and payer.

Elective joint arthroplasty improves the quality of life for patients with severe arthritis. In the United States, utilization of services varies with insurance status. We asked the following questions: (1) Is there an increase in the utilization of elective hip and knee arthroplasty after age 65? (2) Does the difference in utilization between the insured and general populations decrease at age 65 (the age at which Medicare provides near universal coverage)? (3) Does Medicare become the primary payer of elective hip and knee arthroplasty after the age of 65? We used the National Inpatient Sample to identify patients and payers of elective hip and knee arthroplasties by age. We analyzed these data using regression models. At age 65, there was an upward shift in the incidence of arthroplasties in the general and the insured populations and the difference between these two populations decreased. Medicare was the primary payer for the majority of arthroplasties after age 65. We conclude at age 65 the following occurs: (1) utilization of elective joint arthroplasty increases; (2) the difference between the insured population and the general population decreases; and (3) Medicare becomes the primary payer of arthroplasties.

Extended use of urinary catheters in older surgical patients: a patient safety problem?

OBJECTIVES: To explore the relationship between the extended postoperative use of indwelling urinary catheters and outcomes for older patients who have undergone cardiac, vascular, gastrointestinal, or orthopedic surgery in skilled nursing facilities and to describe patient and hospital characteristics associated with the extended use of indwelling urinary catheters. DESIGN: Retrospective cohort study. SETTING: US acute care hospitals and skilled nursing facilities. PATIENTS: A total of 170,791 Medicare patients aged 65 years or more who were admitted to skilled nursing facilities after discharge from a hospital with a primary diagnosis code indicating major cardiac, vascular, orthopedic, or gastrointestinal surgery in 2001. MAIN OUTCOME MEASURES: Patient-specific 30-day rate of rehospitalization for urinary tract infection (UTI) and 30-day mortality rate, as well as the risk of having an indwelling urinary catheter at the time of admission to a skilled nursing facility. RESULTS: A total of 39,282 (23.0%) of the postoperative patients discharged to skilled nursing facilities had indwelling urinary catheters. After adjusting for patient characteristics, the patients with catheters had greater odds of rehospitalization for UTI and death within 30 days than patients who did not have catheters. The adjusted odds ratios (aORs) for UTI ranged from 1.34 for patients who underwent gastrointestinal surgery (P<.001) to 1.85 for patients who underwent cardiac surgery (P<.001); the aORs for death ranged from 1.25 for cardiac surgery (P=.01) to 1.48 for orthopedic surgery (P=.002) and for gastrointestinal surgery (P<.001). After controlling for patient characteristics, hospitalization in the northeastern or southern regions of the United States was associated with a lower likelihood of having an indwelling urinary catheter, compared with hospitalization in the western region (P=.002 vs P=.03). CONCLUSIONS: Extended postoperative use of indwelling urinary catheters is associated with poor outcomes for older patients. The likelihood of having an indwelling urinary catheter at the time of discharge after major surgery is strongly associated with a hospital's geographic region, which reflects a variation in practice that deserves further study.

Extended use of indwelling urinary catheters in postoperative hip fracture patients.

BACKGROUND: Indwelling urinary catheters are used postoperatively in hip fracture care. Their use beyond the immediate postoperative period may result in excess nosocomial infections. OBJECTIVES: The objectives of this study were to explore the relationship between extended indwelling urinary catheterization and outcomes for patients sustaining hip fracture discharged to skilled nursing facilities (SNFs), and to describe patient and hospital predictors of extended indwelling urinary catheterization. RESEARCH DESIGN: The authors conducted a retrospective cohort study. SUBJECTS: This study consisted of Medicare admissions to SNFs of patients discharged from a hospital with a primary diagnosis of hip fracture in 2001 (n=111,330). MEASURES: Dependent variables were the presence of urinary catheter at SNF admission and the patient-specific 30-day outcomes of rehospitalization for urinary tract infection, rehospitalization for sepsis, discharge to the community, and mortality. Independent variables were demographic, clinical, and hospital characteristics. RESULTS: Thirty-two percent of hip fracture discharges to SNFs had urinary catheters. These patients had greater odds of rehospitalization for urinary tract infection (adjusted odds ratio [AOR] 1.6, P<0.001) and death (AOR 1.3, P<0.001) at 30 days than patients without catheters after adjusting for patient characteristics such as age and comorbid conditions. Western region and urban location were associated with a higher likelihood of having an indwelling urinary catheter, whereas northern region and teaching hospital status were associated with a lower likelihood of having an indwelling urinary catheter. CONCLUSIONS: Extended use of indwelling urinary catheters postoperatively is associated with poor outcomes. The likelihood of having an indwelling urinary catheter at hospital discharge after hip fracture is associated with hospital characteristics in addition to patient characteristics. This practice variation deserves further study.

Effects of vitamin therapy on plasma total homocysteine, endothelial injury markers, and fibrinolysis in stroke patients.

Hyperhomocystinemia linked to B-vitamin deficiency is prevalent and associated with increased risk for stroke. While in vitro studies suggest homocysteine directly injures vascular endothelial thrombomodulin (TM), inhibits vonWillebrand factor (vWF) synthesis, and blocks tissue plasminogen activator (t-PA) receptor binding, these mechanisms and their reversibility by vitamin therapy are not established in humans. We investigated the effects of high-dose B-vitamin therapy on endogenous fibrinolysis and endothelial injury markers by randomizing 50 nonvitamin users with prior ischemic stroke to 3 months of treatment with multivitamins either containing folate (5 mg), B6 (100 mg), and B12 (1 mg), or lacking these components. Fasting before noon and post-methionine load plasma total homocysteine (tHcy), t-PA antigen levels, t-PA and plasminogen activator inhibitor (PAI) activities, total vWF antigen, and TM levels were measured before and after vitamin therapy. The primary analysis between treatment groups across time revealed no significant changes (P > .1) for any hematologic variables. However, within-groups analysis showed reductions of 23% in plasma TM (P < .005) and 27% in fasting tHcy levels (P < .0001) and a paradoxical 30% rise in vWF antigen levels (P < .05) after high-dose B-vitamin, treatment with no changes in controls. Pooled data revealed a significant and reproducible 20% to 28% decline in plasma t-PA activity after methionine load (n = 49, P < .02). Our findings demonstrate methionine load lowers plasma t-PA activity by a plasminogen activator inhibitor (PAI-1) independent mechanism that is not attenuated by 3 months of high-dose B-vitamin treatment. While not improving endogenous fibrinolysis profiles, these results provide initial evidence that B-vitamin treatment may selectively alter markers of vascular endothelial injury after stroke.