A robust health equity metric.

OBJECTIVES: Progress on health equity will require a robust metric. The aim of this article is to propose a new health equity metric that is distinct from existing measures and that allows meaningful comparisons across time and place, is calculable using health data typically available, and measures health equity across all major forms of social exclusion. STUDY DESIGN: A cross-sectional study. METHODS: The new health equity measure was calculated using data included from all 50 states and the District of Columbia in the 2017 Behavioral Risk Factor Surveillance Survey, collected by the US Centers for Disease Control and Prevention. The total sample size was 287,602. State-specific sample sizes ranged from 2269 (Alaska) to 14,685 (Kansas) with a median of 4452. A Healthy Days measure was calculated as the mean number of days that the respondents reported being physically healthy and mentally healthy out of the previous 30 days. The proposed measure defines individual health disutility as the distastefulness associated with one's health falling short of optimal achievable health, instrumentalized as the median health of the most socially privileged category, that of upper-income white men. The value of the health equity metric in a population is the mean value of this distastefulness over the entire population and has a theoretical range of -∞ to 1. RESULTS: There is substantial variation across states (mean: 0.13; standard deviation: 0.15), with the District of Columbia (0.48), Minnesota (0.37), and Connecticut (0.30) showing the greatest health equity, and West Virginia (-0.26), Arkansas (-0.18), and Kentucky (-0.13) exhibiting the least. Across states, the value of the health equity metric is not correlated with the size of black-white health disparities. CONCLUSIONS: It is feasible to use a single health equity metric for consistent and objective measurement of health equity. Doing so may facilitate more rapid progress toward health equity.

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children.

CONTEXT: The benefits of continuity of pediatric care remain controversial. OBJECTIVE: To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. DESIGN: Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. MAIN OUTCOME MEASURES: ED utilization and hospitalization. RESULTS: Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma. CONCLUSIONS: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.

A randomized controlled trial of point-of-care evidence to improve the antibiotic prescribing practices for otitis media in children.

CONTEXT: Prescribing practices for otitis media are not consistent with current evidence-based recommendations. OBJECTIVE: To determine whether point-of-care evidence delivery regarding the use and duration of antibiotics for otitis media decreases the duration of therapy from 10 days and decreases the frequency of prescriptions written. DESIGN: Randomized, controlled trial. SETTING: Primary care pediatric clinic affiliated with university training program. Intervention. A point-of-care evidence-based message system presenting real time evidence to providers based on their prescribing practice for otitis media. MAIN OUTCOME MEASURES: Proportion of prescriptions for otitis media that were for <10 days and frequency with which antibiotics were prescribed. RESULTS: Intervention providers had a 34% greater reduction in the proportion of time they prescribed antibiotics for <10 days. Intervention providers were less likely to prescribe antibiotics than were control providers. CONCLUSIONS: A point-of-care information system integrated into outpatient pediatric care can significantly influence provider behavior for a common condition.

The effect of cardiac cycle length on ventricular end-diastolic pressure and maximum time derivative of pressure in the stage 24 chick embryo.

We hypothesized that developmental increases in both ventricular end-diastolic pressure (EDP) and the maximum time derivative of pressure (dP/dt) observed in stage 12 to 29 chick embryos are the result of observed cardiac cycle length (CL) decrease (heart rate increase). To test this hypothesis, we evaluated EDP and dP/dt changes that occur during acute CL alterations in the Hamburger-Hamilton stage 24 chick embryo (n = 18). Ventricular pressure measurements were obtained with a servo-null pressure system and digitally recorded at 500 samples/s. A 1-mm steel probe, heated (decrease CL) or cooled (increase CL), was applied to the sinus venosus. The average baseline CL was 454 ms. The heart rate perturbation resulted in CL that varied over a range of 200-2966 ms, assimilating the range of CL change observed during development. Changes in EDP ranged from 0.014 to 0.130 kPa (baseline = 0.061 kPa) and maximum dP/dt ranged from 0.33 to 13.33 kPa/s (baseline = 5.99) kPa/s). In each study, EDP varied directly with CL (R2 = 0.70). Conversely, maximum dP/dt changes were inversely related to CL alterations (R2 = 0.54). Thus, we found that there is a direct relationship between changes in CL and EDP in the stage 24 chick embryo, whereas CL and dP/dt vary inversely. During cardiac development, observed increases in maximum dP/dt may be attributed to CL decreases. In contrast, developmental increases in EDP cannot be explained by CL decrease and must be accounted for by maturational changes in cardiac function in the chick embryo.

Natural and surgically imposed anastomoses of the circle of Willis.

The efficacy of the circle of Willis as a flow equalizer is well known. Most cerebral macrovasculatures also contain other natural anastomoses which are activated in times of stenotic stress. For the past several decades, neurosurgeons have surgically augmented the cerebral network with additional vessels which further increase the flow of blood to a defrauded region of the brain. It is desirable to know quantitatively what role these anastomoses play in the delivery of blood. Apart from computer simulation, such knowledge remains out of reach to the medical community but with modern simulation techniques, a wealth of information can be made available. This paper presents both time-dependent and period-averaged results of a detailed study of cerebral anastomoses. Four different models of the macrovasculature in the circle of Willis vicinity have been developed, two of which contain an extracranial-intracranial (EC-IC) anastomosis. Five cases were developed to show how the amount of blood flow is related to the sizes of the anastomoses. Since the EC-IC bypass is only marginally beneficial in those patients whose cerebral circulations are well-equipped with naturally occurring anastomotic vessels, procedures should be developed to screen for their presence or absence. The fluid mechanics associated with the EC-IC bypass operation dictate a beneficial result. Since the surgical procedures fail to consistently show reduction in risk even when good grafts have been made, there is an enigma in the study group results.