Pneumococcal and Meningococcal Vaccination among Michigan Children with Sickle Cell Disease.

OBJECTIVES: To determine the proportion of Michigan children with sickle cell disease (SCD) who were vaccinated according to pneumococcal vaccination recommendations and, secondarily, to examine uptake of meningococcal vaccine, and to compare up-to-date (UTD) vaccination status between children with and without SCD. STUDY DESIGN: Children with SCD who were born in Michigan were matched to controls without SCD using age, sex, race, and zip code. Using data from the state immunization registry, we assessed the significance of SCD status on UTD vaccination in logistic regression models. RESULTS: By 36 months, substantially more children with SCD had completed the pneumococcal conjugate vaccine series (68.8%) than children without SCD (45.2%), and 59% of children with SCD had received a meningococcal vaccine. Compared with children without SCD, children with SCD had higher odds of UTD pneumococcal status at 5, 7, and 16 months. However, a large proportion of children with SCD were missing key vaccination targets: of those who received a full 7-valent pneumococcal conjugate vaccine series, 29.1% had not received a 13-valent pneumococcal conjugate vaccine dose, and 21.8% had not had pneumococcal polysaccharide vaccine administered. CONCLUSIONS: The pneumococcal and meningococcal vaccination schedules have become increasingly complex in recent years. Assessment algorithms programmed to forecast doses due based on high-risk conditions, such as SCD, could provide a useful reminder to healthcare providers in the context of increasingly complex and changing recommendations.

Incidence and prevalence of systemic lupus erythematosus among Arab and Chaldean Americans in southeastern Michigan: the Michigan Lupus Epidemiology and Surveillance Program.

OBJECTIVES: We assessed the burden of systemic lupus erythematosus (SLE) among Arab and Chaldean Americans residing in southeast Michigan. METHODS: For those meeting SLE criteria from the Michigan Lupus Epidemiology and Surveillance Registry, we determined Arab or Chaldean ethnicity by links with demographic data from birth certificates and with a database of Arab and Chaldean names. We compared prevalence and incidence of SLE for Arab and Chaldean Americans with estimates for non-Arab and non-Chaldean American Whites and Blacks. RESULTS: We classified 54 individuals with SLE as Arab and Chaldean Americans. The age-adjusted incidence and prevalence estimates for Arab and Chaldean Americans were 7.6 and 62.6 per 100 000, respectively. Arab and Chaldean Americans had a 2.1-fold excess SLE incidence compared with non-Arab and non-Chaldean American Whites. Arab and Chaldean American women had both significantly higher incidence rates (5.0-fold increase) and prevalence estimates (7.4-fold increase) than did Arab and Chaldean American men. CONCLUSIONS: Recognizing that Arab and Chaldean Americans experience different disease burdens from Whites is a first step toward earlier diagnosis and designing targeted interventions. Better methods of assigning ethnicity would improve research in this population.

Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in Medicaid--Michigan, 2011-2013.

In October 2011, the Advisory Committee on Immunization Practices (ACIP) first recommended the routine administration of a tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during pregnancy as a strategy to protect infants from pertussis (also known as whooping cough). This recommendation applied to women previously unvaccinated with Tdap and specified the optimal vaccination time as late second or third trimester (after 20 weeks' gestation). By vaccinating pregnant women, infants, who are at highest risk for mortality and morbidity from pertussis, gain passive immunity from maternal antibodies transferred to them in utero. Since this recommendation was made, little has been published on the percentage of women receiving Tdap during pregnancy. In Michigan, Medicaid pays for costs of pregnancy for approximately 40% of births. Infants enrolled in Medicaid are a particularly vulnerable population; in Michigan, their all-cause mortality is higher than that of privately insured infants. To assess vaccination coverage among pregnant women enrolled in a publicly funded insurance program in Michigan, Medicaid administrative claims data and statewide immunization information system data for mothers of infants born during November 2011-February 2013 were analyzed. This report describes the results of that analysis, which indicated that only 14.3% of these women received Tdap during pregnancy, with rates highest (17.6%) among non-Hispanic, non-Arab whites and lowest (6.8%) among Arab women. Vaccination was related to maternal age and gestational age at birth, but not to adequacy of prenatal care. In 2013, recognizing the importance of Tdap for every pregnancy, ACIP revised its guidelines to include a Tdap dose during every pregnancy. Ensuring that all infants receive the protection against pertussis afforded by maternal vaccination will require enhanced efforts to vaccinate pregnant women.

Compliance with the stroke education performance measure in the Michigan Paul Coverdell National Acute Stroke Registry.

BACKGROUND AND PURPOSE: Stroke education, 1 of 8 endorsed stroke performance measures, consists of 5 specific subcomponents: risk factors, stroke warning signs, emergency medical service activation, physician follow-up, and discharge medications. We identified predictors of stroke education performance measure compliance in the Michigan Paul Coverdell National Acute Stroke Registry. METHODS: Data were collected on 9609 acute stroke admissions to 20 registry hospitals during 2008 and 2009. Predictors of measure compliance (delivery of all 5 subcomponents) were determined using multivariable logistic regression. RESULTS: Overall compliance with the stroke education measure was 61.8% (hospital-level compliance ranged between 16% and 93%). Compliance with individual subcomponents were risk factors (65.5%), stroke warning signs (68.9%), emergency medical service activation (66.8%), physician follow-up (92.9%), and discharge medications (91.5%). Age, gender, stroke subtype, prestroke ambulation, discharge destination, and hospital size were all significant independent predictors of compliance. Stroke education was delivered less often to patients who were ≥ 70 years of age, nonambulatory prestroke, not discharged to home, had transient ischemic attack, or hemorrhagic stroke. CONCLUSIONS: Only 60% of patients received stroke education consistent with the endorsed performance measures. Strategies to increase stroke education, including the impact of incorporating stroke-specific education measures into hospital care protocols, should be explored.

Centralized COVID-19 Contact Tracing in a Home-Rule State.

Contact tracing is an evidence-based intervention to control many communicable diseases, including COVID-19. Before the COVID-19 pandemic, contact tracing in Michigan focused on HIV, sexually transmitted infections, and tuberculosis, and it was conducted by state and local health department staff. Within 2 weeks of the first reported COVID-19 cases in Michigan in March 2020, the existing public health workforce was overwhelmed by the need for contact tracing and daily symptom monitoring. This case study narrates the development of a staffing plan that included volunteers and contractual staff to conduct centralized contact tracing in a home-rule state (ie, a state in which local health departments have full authority and autonomy under public health code to conduct the functions necessary to prevent disease, including contact tracing). This case study details various training, workforce management, and technology tools that were used. During the study period (May 2020-June 2021), contact tracers called 432 218 contacts and 269 439 were successfully reached, 48 134 of whom reported developing symptoms. The most important lesson learned was the need for more automated processes to improve efficiency in processing volunteer applicants, training, and scheduling. Nonetheless, the centralized workforce was successful, was flexible, and met the changing demands in Michigan.

Fast-food consumption and obesity among Michigan adults.

INTRODUCTION: Consumption of meals eaten away from home, especially from fast-food restaurants, has increased in the United States since the 1970s. The main objective of this study was to examine the frequency and characteristics of fast-food consumption among adults in Michigan and obesity prevalence. METHODS: We analyzed data from 12 questions about fast-food consumption that were included on the 2005 Michigan Behavioral Risk Factor Survey, a population-based telephone survey of Michigan adults, using univariate and bivariate analyses and multivariate logistic regression, and compared these data with data on Michigan obesity prevalence. RESULTS: Approximately 80% of Michigan adults went to fast-food restaurants at least once per month and 28% went regularly (≥2 times/wk). Regular fast-food consumption was higher among younger adults (mostly men) but was not significantly associated with household income, education, race, or urbanicity (in a multivariate framework). The prevalence of obesity increased consistently with frequenting fast-food restaurants, from 24% of those going less than once a week to 33% of those going 3 or more times per week. The predominant reason for choosing fast food was convenience. Although hypothetically 68% of adults who go to fast-food restaurants would choose healthier fast-food items when available, only 16% said they ever use nutritional information when ordering. CONCLUSION: The prevalence of fast-food consumption is high in Michigan across education, income, and racial groups and is strongly associated with obesity. Making nutritional information at fast-food restaurants more readily available and easier to use may help consumers to order more healthful or lower-calorie items.

Lack of association between stroke symptom knowledge and intent to call 911: a population-based survey.

BACKGROUND AND PURPOSE: Excessive prehospital delay between acute stroke onset and hospital arrival is an ongoing problem. Translating knowledge of stroke warning signs into appropriate action is critical to decrease prehospital delay. Our objectives were to estimate the proportion of Michigan adults who would react appropriately by calling 911 when presented with hypothetical stroke-related scenarios and to examine the association between knowledge of warning signs and calling 911. METHODS: In 2004, questions regarding initial response to health-related scenarios were added to the Michigan Behavioral Risk Factor Survey, a population-based telephone survey of adults. We calculated the proportion of respondents who would call 911 in response to 3 stroke-related scenarios and examined the association between stroke warning sign knowledge and 911 activation. RESULTS: Among 4841 adults, 27.6% (95% CI, 26.2 to 29.0) had adequate knowledge of stroke warning signs (defined as reporting 3 correct warning signs), and 14.0% (95% CI, 12.9 to 15.1) reported they would call 911 for all 3 stroke-related scenarios. Knowledge of specific stroke warning signs was only modestly associated with calling 911 in response to medical scenarios that involved the same stroke symptom (OR, 1.17 to 1.39). Even among those with adequate knowledge of stroke warning signs, only 17.6% (95% CI, 15.5 to 20.0) would call 911 for all 3 stroke scenarios. CONCLUSIONS: In this population-based survey, stroke symptom knowledge was not associated with the intent to call 911 for stroke. This study emphasizes the critical role of motivation in addition to symptom knowledge to reducing delay time to hospital arrival for stroke.

An examination of EPPM predictions when threat is perceived externally: an asthma intervention with school workers.

Little research informs the use of the Extended Parallel Process Model (EPPM) of persuasion when threat and efficacy judgments are rendered for someone other than the message recipient. Nevertheless, a wide range of health promotion consists of influencing such judgments. Two studies examine the utility of using the EPPM in a context involving threats to others. Results show that the expected measurement models hold in this new context, and that an additive model is a stronger fit than a multiplicative one when considering how threat and efficacy combine to affect behavioral intentions but not when considering behavior. The study also examines the effects of a print intervention implemented with school employees in Michigan derived from the EPPM. The results are discussed in terms of their theoretical import and their application in this new context.

Knowledge of tissue plasminogen activator for acute stroke among Michigan adults.

BACKGROUND AND PURPOSE: Although tissue plasminogen activator (tPA) is an effective therapy for acute ischemic stroke, treatment rates remain low. Efforts to address the underuse of tPA include public education to increase the recognition of stroke symptoms and the awareness of tPA treatment. Our objective was to determine the level of knowledge about tPA treatment for acute stroke among a representative sample of Michigan adults. METHODS: The Michigan Behavioral Risk Factor Survey (BRFS) is a random-digit-dial telephone survey of adults conducted annually as part of the national BRFS. Questions regarding tPA treatment for acute stroke were included in the 2004 Michigan BRFS. We examined the prevalence of awareness using chi(2) tests and generated multivariable logistic regression models. RESULTS: Among 4724 respondents, only 32.2% (95% CI=30.8 to 33.8%) were aware of the existence of tPA treatment for acute stroke, of whom 52.7% (50.0 to 55.4%) knew that it needed to be administered within 3 hours of symptom onset. Awareness of tPA was higher among middle aged adults, females, whites, and those with higher education and income. Awareness of the time window for tPA was higher among middle aged adults and whites. CONCLUSIONS: In this population-based survey only a third of the public were aware of tPA as a treatment for stroke, and only 1 in 6 were aware that the treatment exists and needs to be given within 3 hours of symptom onset. Continuing efforts are necessary to increase public knowledge about tPA treatment for acute stroke.

Racial disparities in knowledge of stroke and heart attack risk factors and warning signs among Michigan adults.

OBJECTIVE: To describe the level of knowledge regarding risk factors and warning signs for stroke and heart attack among White and African American adults in Michigan and to quantify racial disparities. METHODS: Knowledge of stroke and heart attack risk factors and warning signs was assessed by using data from the 2004 Michigan Behavioral Risk Factor Survey. Prevalence estimates of knowledge were generated, and statistical differences in knowledge between Whites and African Americans were assessed. Adequate knowledge was defined as knowing 3 correct warning signs or risk factors. Logistic regression models were used to quantify the racial disparity in knowledge while controlling for potential confounding. RESULTS: Whites had substantially higher levels of adequate knowledge of risk factors (stroke: 31.6% vs 13.8%; heart attack: 52.6% vs 24.3%) and warning signs (stroke: 30.0% vs 17.2%; heart attack: 29.3% vs 13.8%) compared with African Americans (all observed differences were significant at P < .05). The odds of adequate knowledge of risk factors (stroke: adjusted odds ratio [AOR] 2.9; heart attack: AOR 3.4) and warning signs (stroke: AOR 2.0; heart attack: AOR 2.4) were significantly higher for Whites than for African Americans. CONCLUSION: A strong racial disparity in the knowledge of stroke and heart attack risk factors and warning signs exists among Michigan adults. Communitywide public education programs in conjunction with targeted interventions for at-risk populations are necessary to produce meaningful improvements in the awareness of stroke and heart attack risk factors and warning signs among Michigan adults.

Asthma surveillance using Medicaid administrative data: a call for a national framework.

Connecticut, Michigan, and New York have successfully used Medicaid administrative data to conduct surveillance of asthma prevalence, related health service utilization and costs, and quality of asthma care. Since these assessments utilize beneficiary-level data, a wide range of population-based summaries is feasible. Opportunities exist to build upon the collective experiences of these three states to establish a national framework for asthma surveillance using Medicaid administrative data. This framework could be designed to respond to each state's unique data considerations and asthma management priorities, while establishing standardized criteria to enhance the comparability of asthma surveillance data among states. Importantly, a common asthma case definition using comparable methods is necessary to enable comparisons of prevalence estimates between states. Case definitions that could serve as the foundation for such a framework are presented. Mechanisms to foster sharing of methodologies and experiences will be instrumental for broad implementation across states. This collaboration will be of increasing importance as states experience mounting financial pressures due to increasing Medicaid enrollment and dwindling resources.

Quantifying the excess risk of infant mortality based on race/ethnicity at the county level to inform Michigan's home visiting outreach plans.

OBJECTIVE: Michigan's infant mortality rate is consistently higher than the national rate, with persistent and significant racial/ethnic disparities. In Michigan, nine counties account for more than 80% of all infant deaths. A home visiting program serving low-income, first-time mothers in high-risk communities is one strategy to reduce infant mortality. The objective of this study was to quantify the risk of infant mortality based on race/ethnicity within Michigan's highest-risk counties to guide outreach for home visiting services in these counties. METHODS: To maximize the efficiency of limited resources and to identify women at highest risk, we used decomposition to develop risk-based, county-specific estimates of excess infant deaths in nine Michigan counties using data from the 2007 to 2009 Michigan resident infant death file linked to the live birth/file. RESULTS: The sample size for these counties was 200,610 live births and 1,836 infant deaths and for the reference population it was 195,180 live births and 1,133 infant deaths The study found that excess mortality varies among populations at the county level when compared to the reference population of infants born to Michigan mothers who attained more than a high school education and were at least 20 years of age at the infant's birth. The excess risk of mortality was highest for African American infants in seven of the nine counties (56.5% to 132.8%) and for Hispanic infants (86.6%) and white infants (48.2%) in one county each. CONCLUSION: Even with a longstanding commitment and legal mandate to reduce disparities and with efforts to improve outreach into high-risk areas, disparities persist. An improved understanding of the racial/ethnic disparities within communities was useful to focus outreach efforts on reaching women at highest risk as part of subsequent program enrollment.

A review of potential state and local policies to reduce asthma disparities.

Although policies promoting asthma-friendly communities should reduce asthma disparities, not much is known about the status of policy implementation or effectiveness. We review the efforts of state and local agencies to identify and target asthma disparities for reduction, as evidenced by written laws and policy documents and use of funding. Policies targeting health care, homes, schools, and workplaces hold promise for creating asthma-friendly communities; however, the scope and reach of these activities must be increased to have statewide or national impact. In addition, there is a general lack of systematic review of evidence about the institutionalization of successful demonstration programs into policy.

Investigating asthma deaths among children and young adults: Michigan Asthma Mortality Review.

OBJECTIVE: We developed a surveillance system to investigate asthma deaths in children and young adults. METHODS: A rapid asthma death notification and investigation system for Michigan was developed to identify interventions to prevent future deaths among people aged 2-34 years. Multidisciplinary panels to determine causal factors and recommend preventative actions reviewed information from death certificates, autopsies, next-of-kin interviews, and medical records. An annual report was disseminated to public health workers, health-care providers, insurers, and others. RESULTS: Eighty-six asthma deaths in Michigan residents, aged 2-34, occurred from 2002-2004. Sixty-one next of kin were interviewed and medical records were obtained for 84 of the deceased. Summaries were prepared on each of the deceased and were reviewed by expert panels, which reached consensus on causal factors and potential preventive action for each death. Each year an annual report, which summarized the causal factors and potential preventive activity, was prepared. CONCLUSION: This review has informed and catalyzed interventions to improve asthma care and management in Michigan. Factors leading to the review's success and future activities are discussed.

Characteristics and Outcomes of Stroke Patients Transferred to Hospitals Participating in the Michigan Coverdell Acute Stroke Registry.

BACKGROUND: Interhospital transfer of acute stroke patients is becoming increasingly important as regional stroke systems of care continue to evolve. We describe the characteristics and outcomes of stroke cases transferred to hospitals participating in the Michigan Coverdell Stroke Registry. METHODS AND RESULTS: Thirty-six hospitals participated in the Michigan registry during 2009 to 2011. Transfer patients were transferred from another hospital either acutely or after admission. Multivariable logistic regression was used to determine predictors of transfer and the independent association between transfer and in-hospital mortality and complications. Of 16 202 acute stroke admissions, 19.1% were transferred. Independent predictors of being transferred included younger age, hemorrhagic stroke, and higher stroke severity, but having a past history of stroke decreased the likelihood of being transferred. Transferred cases had higher in-hospital mortality (12.0% versus 6.4%; P<0.001) compared with regular admissions and were more likely to suffer complications (18.4% versus 12.8%; P<0.001). These differences remained after adjustment for confounding variables (adjusted odds ratio for mortality =1.32, 95% confidence interval 1.12, 1.56; adjusted odds ratio for complications =1.39, 95% confidence interval 1.22, 1.58). Among ischemic stroke, elevated odds of poor outcomes among transferred patients remained after adjustment for stroke severity. CONCLUSIONS: Transferred patients represent a complex admixture of patient characteristics that result in higher risks of poor outcomes. Our results suggest that it is prudent to account for patient transfer status when comparing hospital outcomes and that stroke registries need to expand their data collection capacity to provide a better understanding of the relative benefits and risks of transferring patients.

Pediatric asthma surveillance using Medicaid claims.

OBJECTIVE: The purpose of this study was to describe the prevalence of asthma among children using alternative case definitions applied to administrative claims data, and to assess year-to-year classification concordance. METHODS: This study was a retrospective cohort analysis of 357,729 children 0-18 years using 2001-2002 Michigan Medicaid claims. Asthma cases were classified using six alternative definitions based on outpatient, emergency department, inpatient, and pharmacy claims for asthma, including the Health Plan Employer Data Information Set (HEDIS) persistent asthma criteria commonly used for assessments of asthma health care quality: at least one asthma inpatient admission or emergency department visit, four or more asthma medications events, or four asthma outpatient visits and two asthma medication events. RESULTS: Overall, asthma prevalence varied widely between alternative case definitions, ranging from 14.9% based on claims evidence of any type of asthma utilization to 3.7% when restricted to those with four or more asthma medication dispensing events. Among cases meeting HEDIS persistent asthma criteria in 2001, 55.5% met these criteria in 2002. Those with four or more asthma medication dispensing events had the best overall classification concordance between 2001 and 2002. Utilization of asthma services and prevalence estimates were highest among children younger than 5 years old, but year-to-year classification concordance was poorest among these cases (p < 0.0001), irrespective of case definition. CONCLUSIONS: While overall asthma prevalence may remain relatively stable from year to year, individuals may not be classified consistently as cases over time, regardless of case definition. Studies that identify asthma cases in one year and assess asthma outcomes in a subsequent year may introduce substantial bias as a result of case misclassification. Among the case definitions considered in this study, our findings suggest that this bias is minimized among cases classified using the four or more asthma medication dispensing events criterion.

Identifying sickle cell disease cases using administrative claims.

OBJECTIVE: To develop and test the accuracy of administrative claims method for identifying children with sickle cell disease (SCD) to enable quality of care assessments among children enrolled in Medicaid. METHODS: All administrative claims with an SCD diagnosis were obtained from Michigan Medicaid from 2008 to 2011 for children ≤18 years, representing 1828 individuals. All Medicaid claims were obtained for these children and classified into categories on the basis of SCD care; these classifications were used to develop 37 alternative case definitions for identifying children with SCD. Children with ≥1 SCD claim in 2010 or 2011 were identified as confirmed SCD or not SCD using the gold standard of Michigan newborn screening administrative records. Measures of performance were calculated for each case definition for eligible children in 2010. Further validation of the case definitions was performed among eligible children in 2011. RESULTS: In 2010, a total of 938 children met eligibility criteria and were linked to newborn screening records; 605 (59%) were confirmed SCD, and 333 (32%) were not SCD. Measures of performance varied among the 37 case definitions, and the 4 best case definitions on the basis of the sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve were validated among 924 children meeting eligibility criteria in 2011. The case definition of at least 3 SCD claims in any position identified children with SCD with the most accuracy, with an area under the ROC curve of 0.91 (95% confidence interval 0.89, 0.93). CONCLUSIONS: This definition can be used to facilitate a more accurate identification of children with SCD in future studies. Further investigation is necessary to determine whether this method translates to other populations besides Michigan Medicaid-insured children.