Development and Evaluation of Rehabilitation Service Areas for the United States.

BACKGROUND: Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries. METHODS: A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries. RESULTS: The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care. CONCLUSIONS: Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.

Rural-urban differences in estimated life expectancy associated with neighborhood-level cumulative social and environmental determinants.

Diverse neighborhood-level environmental and social impacts on health are well documented. While studies typically examine these impacts individually, examining potential health impacts from multiple sources as a whole can provide a broader context of overall neighborhood-level health impacts compared to examining each component independently. This study examined the association between cumulative neighborhood-level potential health impacts on health and expected life expectancy within neighborhoods (census tracts) across Texas using the Neighborhood Potential Health Impact Score tool. Among urban census tract neighborhoods, a difference of nearly 5 years was estimated between neighborhoods with the least health promoting cumulative health impacts compared to neighborhoods with the most health promoting cumulative health impacts. Differences were observed between rural and urban census tract neighborhoods, with rural areas having less variability in expected life expectancy associated with neighborhood-level cumulative potential health impacts compared to urban areas.

The utility of a system dynamics approach for understanding cumulative health risk from exposure to environmental hazards.

The potential of system dynamics modeling to advance our understanding of cumulative risk in the service of optimal health is discussed. The focus is on exploring system dynamics modeling as a systems science methodology that can provide a framework for examining the complexity of real-world social and environmental exposures among populations-particularly those exposed to multiple disparate sources of risk. The discussion also examines how system dynamics modeling can engage a diverse body of key stakeholders throughout the modeling process, promoting the collective assessment of assumptions and systematic gathering of critical data. Though not a panacea, system dynamics modeling provides a promising methodology to complement traditional research methods in understanding cumulative health effects from exposure to multiple environmental and social stressors.

Subjective neighborhood assessment and physical inactivity: An examination of neighborhood-level variance.

Research suggests a linkage between perceptions of neighborhood quality and the likelihood of engaging in leisure-time physical activity. Often in these studies, intra-neighborhood variance is viewed as something to be controlled for statistically. However, we hypothesized that intra-neighborhood variance in perceptions of neighborhood quality may be contextually relevant. We examined the relationship between intra-neighborhood variance of subjective neighborhood quality and neighborhood-level reported physical inactivity across 48 neighborhoods within a medium-sized city, Texas City, Texas using survey data from 2706 residents collected between 2004 and 2006. Neighborhoods where the aggregated perception of neighborhood quality was poor also had a larger proportion of residents reporting being physically inactive. However, higher degrees of disagreement among residents within neighborhoods about their neighborhood quality was significantly associated with a lower proportion of residents reporting being physically inactive (p=0.001). Our results suggest that intra-neighborhood variability may be contextually relevant in studies seeking to better understand the relationship between neighborhood quality and behaviors sensitive to neighborhood environments, like physical activity.

Firearm carrying and concurrent substance use behaviours in a community-based sample of emerging adults.

INTRODUCTION: This paper examines associations between high-risk gun carrying and substance use in emerging adults (ages 18-22). The coexistence of these high-risk behaviours in a general population of emerging adults can have disastrous consequences. METHODS: Dating it Safe is an ongoing longitudinal (2010-2016) survey of emerging adults recruited from seven high schools in five south-east Texas-area school districts (current sample n=684). Multiple logistic regression modelling was used to examine the association between past-year use of legal and illegal substances and past-year firearm carrying for a reason other than sport or hunting. RESULTS: 6% of emerging adults carried firearms in the past year, with most (68%) carrying for protection. Use of cocaine, hallucinogens, methamphetamine, ecstasy and prescription medications in the past year, as well as episodic heavy drinking in the past month, was associated with increased risk of carrying a firearm (p<0.05 for all). After controlling for covariates, hallucinogens (OR 2.81, 95% CI 1.00 to 7.81), ecstasy (OR 3.66, 95% CI 1.32 to 10.14) and prescription medications (OR 2.85, 95% CI 1.22 to 6.68) remained associated with firearm carrying. Episodic heavy drinking was associated with firearm carrying, but only for those who had five or more episodes/month (OR 3.61, 95% CI 1.51 to 8.66). CONCLUSIONS: In this community-based sample of emerging adults, firearm carrying, mostly for protection, was associated with a variety of past-year substance use behaviours. These findings extend previous research and suggest directions for further exploration of the clustering of high-risk behaviours in emerging adults.

Common and Critical Components Among Community Health Assessment and Community Health Improvement Planning Models.

Community health assessment and community health improvement planning are continuous, systematic processes for assessing and addressing health needs in a community. Since there are different models to guide assessment and planning, as well as a variety of organizations and agencies that carry out these activities, there may be confusion in choosing among approaches. By examining the various components of the different assessment and planning models, we are able to identify areas for coordination, ways to maximize collaboration, and strategies to further improve community health. We identified 11 common assessment and planning components across 18 models and requirements, with a particular focus on health department, health system, and hospital models and requirements. These common components included preplanning; developing partnerships; developing vision and scope; collecting, analyzing, and interpreting data; identifying community assets; identifying priorities; developing and implementing an intervention plan; developing and implementing an evaluation plan; communicating and receiving feedback on the assessment findings and/or the plan; planning for sustainability; and celebrating success. Within several of these components, we discuss characteristics that are critical to improving community health. Practice implications include better understanding of different models and requirements by health departments, hospitals, and others involved in assessment and planning to improve cross-sector collaboration, collective impact, and community health. In addition, federal and state policy and accreditation requirements may be revised or implemented to better facilitate assessment and planning collaboration between health departments, hospitals, and others for the purpose of improving community health.

Utilization of Professional Mental Health Services Related to Population-Level Screening for Anxiety, Depression, and Post-traumatic Stress Disorder Among Public High School Students.

This study examines results from three mental health screening measures in a cohort of adolescent public school students in seven public schools in Southeast Texas affiliated with the Dating it Safe study. We estimated the odds of receiving professional mental health treatment in the previous year given results from different mental health screening batteries: the CES-D 10 battery for depression screening, the Screen for Child Anxiety Related Disorders, and the Primary Care Posttraumatic Stress Disorder screen. Overall, students with higher scores on screening instruments for depression, posttraumatic stress disorder, and combinations of screening instruments were more likely to have sought past-year professional mental health treatment than non-symptomatic youth. However, the proportion of students screening positive and receiving professional treatment was low, ranging from 11 to 16 %. This study emphasizes the need for broader evaluation of population-based mental health screening among adolescents.

Interorganizational network changes among health organizations in the Brazos Valley, Texas.

Community health development is a process by which a community identifies factors influencing population health, assesses available resources to build the capacity to plan and take action, and implement interventions to address identified needs. At its core, community health development targets structural change and infrastructure development to facilitate more efficient and effective health service delivery systems and environmental changes to support improvements in community health. One indicator of structural change and common measure of community capacity is the relationships among the network of organizations that comprise that system. The Brazos Valley has employed a community health development approach to population health improvement in partnership with the Center for Community Health Development. Changes in interorganizational networks illustrate progress in the Brazos Valley. Contextual factors provide some insight into how the process has unfolded.

A NEIGHBORHOOD-LEVEL POTENTIAL HEALTH IMPACT SCORING TOOL TO SUPPORT LOCAL-LEVEL HEALTH IMPACT ASSESSMENTS.

Health Impact Assessments (HIAs) have quickly become a widely utilized tool for integrating health and health-related evidence and data into decision making processes across a range of projects and polices. Integrating and utilizing the wide range of available data can be daunting. To support communities seeking to engage in health impact assessments, we developed the Neighborhood Potential Health Impact Score (NPHIS) methodology. We present the NPHIS method's four step process, and how this process was applied to an HIA focusing on the rebuilding of public housing following a natural disaster. We discuss developing the boundary definition, selection and definition of indicators, calculation of the NPHIS, and interpretation and utilization of the scores. Findings were validated using feedback from a community stakeholder advisory board as well as through feedback collected from focus groups of community residents. NPHIS methodology has proven to be a useful resource in better understanding the complex sources of potential health impacts facing communities, and in being an evidence-based, data-driven resource for HIA decision-makers and their stakeholders in our specific application. Other groups seeking to integrate similar data into their decision-making processes could benefit from replicating the NPHIS in their efforts.

An examination between census tract unhealthy food availability and colorectal cancer incidence.

BACKGROUND: Unhealthy food environments may be associated with higher risks of developing diet-related cancers, such as, colorectal cancer. We conducted an ecological analysis to evaluate the relationship between the local food environment and colorectal cancer incidence overall and separately for males and females. METHODS: Data from the Texas Cancer Registry was utilized to geocode individuals aged 40 years and older diagnosed with colorectal cancer from 2005 to 2015 to their residential 2010 census tract. Total number of establishments classified as Limited Service Restaurants for each census tract was retrieved from the 2005 Business Patterns Survey by using a crosswalk to map zip codes to census tract. Census tract unhealthy food availability was calculated by dividing the estimated number of Limited Service Restaurant establishments in each census tract by the census tract population and divided into quartiles. Generalized estimating equations were used to assess the association between unhealthy food availability quartiles and colorectal cancer incidence. RESULTS: Adjusting for the census tract level sociodemographic characteristics, the incidence of colorectal cancer was slightly higher in unhealthy food availability quartile 2 (Incidence Rate Ratio (IRR) = 1.03, 95 % CI: 1.00-1.05), but not quartile 3 (IRR = 1.02, 95 % CI: 1.00-1.05), and quartile 4 (highest availability, IRR = 1.02, 95 % CI: 0.99-1.05) compared to census tracts with lowest unhealthy food availability. CONCLUSION: Colorectal cancer incidence was not strongly associated with census tracts with higher unhealthy food availability. Future observational studies should be conducted to examine the influence of the built environment on colorectal cancer risk.

Proximity to Oil Refineries and Risk of Cancer: A Population-Based Analysis.

BACKGROUND: The association between proximity to oil refineries and cancer rate is largely unknown. We sought to compare the rate of cancer (bladder, breast, colon, lung, lymphoma, and prostate) according to proximity to an oil refinery in Texas. METHODS: A total of 6 302 265 persons aged 20 years or older resided within 30 miles of an oil refinery from 2010 to 2014. We used multilevel zero-inflated Poisson regression models to examine the association between proximity to an oil refinery and cancer rate. RESULTS: We observed that proximity to an oil refinery was associated with a statistically significantly increased risk of incident cancer diagnosis across all cancer types. For example, persons residing within 0-10 (risk ratio [RR] = 1.13, 95% confidence interval [CI] = 1.07 to 1.19) and 11-20 (RR = 1.05, 95% CI = 1.00 to 1.11) miles were statistically significantly more likely to be diagnosed with lymphoma than individuals who lived within 21-30 miles of an oil refinery. We also observed differences in stage of cancer at diagnosis according to proximity to an oil refinery. Moreover, persons residing within 0-10 miles were more likely to be diagnosed with distant metastasis and/or systemic disease than people residing 21-30 miles from an oil refinery. The greatest risk of distant disease was observed in patients diagnosed with bladder cancer living within 0-10 vs 21-30 miles (RR = 1.30, 95% CI = 1.02 to 1.65), respectively. CONCLUSIONS: Proximity to an oil refinery was associated with an increased risk of multiple cancer types. We also observed statistically significantly increased risk of regional and distant/metastatic disease according to proximity to an oil refinery.

Assessing diabetes practices in clinical settings: precursor to building community partnerships around disease management.

Many recommended best practices exist for clinical and community diabetes management and prevention. However, in many cases, these recommendations are not being fully utilized. It is useful to gain a sense of currently utilized and needed practices when beginning a partnership building effort to ameliorate such practice problems. The purpose of this study was to assess current practices in clinical settings within the Brazos Valley in preparation for beginning a community-based participatory research project on improving diabetes prevention and management in this region. Fifty-seven physicians with admission privileges to a regional health system were faxed a survey related to current diabetes patient loads, knowledge and implementation of diabetes-related best practices, and related topics. Both qualitative and quantitative examination of the data was conducted. Fifteen percent of responding providers indicated they implemented diabetes prevention best practices, with significant differences between primary-care physicians and specialists. Respondents indicated a need for educational and counseling resources, as well as an increased health-care workforce in the region. The utilization of a faxed-based survey proved an effective means for assessing baseline data as well as serving as a catalyst for further discussion around coalition development. Results indicated a strong need for both clinical and community-based services regarding diabetes prevention and management, and provided information and insight to begin focused community dialogue around diabetes prevention and management needs across the region. Other sites seeking to begin similar projects may benefit from a similar process.

Sociodemographic and healthcare characteristics of Colonia residents: the role of life stage in predicting health risks and diabetes status in a disadvantaged Hispanic population.

An assessment of the risk or diagnosis of diabetes in a random sample of 386 adult border residents found 46% obese, 12% at risk for diabetes, and 18% diagnosed with diabetes. While obesity was associated with greater diabetes risk, > 50% of obese adults reported not being told of their diabetes risk. Independent of other characteristics, boomers were at increased risk (OR 3.88) for diabetes. Comorbidities increased the risk for actual diabetes diagnosis (OR 4.79). Skipping medications increased risk of developing diabetes (OR 2.98). Disadvantaged obese boomers are at particular risk, warranting culturally appropriate interventions before onset of chronic illnesses.

The impact of a communitywide smoke-free ordinance on smoking among older adults.

INTRODUCTION: Clean-air and smoke-free ordinances have been shown to reduce the prevalence of smoking among the overall population, but their effects on the smoking prevalence among older adults deserves further attention. We examined changes in self-reported cigarette smoking and in attitudes toward smoking after the implementation of such ordinances in Fort Collins, Colorado, in 2003. METHODS: Communitywide health status surveys were mailed out to northern Larimer County residents recruited via random-digit dialing in 2001 and 2004. Secondary data analysis was conducted for respondents living in Fort Collins, comparing the entire sample with a subsample of adults aged 50 years or older. Univariate analyses were used to determine differences in self-reported cigarette smoking between the groups across the 2 surveys. Multivariate logistic regression models estimated differences in smoking status and in attitudes toward acceptability of public smoking between the 2 survey administrations, controlling for demographic correlates. RESULTS: Smoking rates among older respondents failed to change, despite significant decreases in smoking rates in the entire adult population. Furthermore, attitudes toward smoking in public did not change between the 2 surveys for either of the groups. CONCLUSION: Different factors may influence the decision to stop smoking for older adults and younger adults. We recommend the use of multiple approaches on different ecological levels to ensure that communitywide antismoking intervention efforts reach all population segments.

Stress and health behaviors as potential mediators of the relationship between neighborhood quality and allostatic load.

PURPOSE: Neighborhood quality is associated with health. Increasingly, researchers are focusing on the mechanisms underlying that association, including the role of stress, risky health behaviors, and subclinical measures such as allostatic load (AL). METHODS: This study uses mixed-effects regression modeling to examine the association between two objective measures and one subjective measure of neighborhood quality and AL in an ethnically diverse population-based sample (N = 2706) from a medium-sized Texas city. We also examine whether several measures of psychological stress and health behaviors mediate any relationship between neighborhood quality and AL. RESULTS: In this sample, all three separate measures of neighborhood quality were associated with individual AL (P < .01). However, only the subjective measure, perceived neighborhood quality, was associated with AL after adjusting for covariates. In mixed-effects multiple regression models there was no evidence of mediation by either stress or health behaviors. CONCLUSIONS: In this study, only one measure of neighborhood quality was related to a measure of health, which contrasts with considerable previous research in this area. In this sample, neighborhood quality may affect AL through other mechanisms, or there may be other health-affecting factors is this area that share that overshadow local neighborhood variation.

Pre-surgery evaluations by telephone decrease travel and cost for families of children with cerebral palsy.

INTRODUCTION: Children with cerebral palsy need highly specialized care. This can be very burdensome for families, particularly in large rural states, due to the need for long-distance travel to appointments. In this study, children undergoing the selective percutaneous myofascial lengthening surgery utilized a telephone-based telemedicine evaluation to assess for surgical eligibility. The goal was to avoid a separate preoperative clinic visit weeks before the surgery. If possible, eligibility was determined by telephone, and then, the patient could be scheduled for a clinic visit and possible surgery the next day, saving the family a trip. The purposes of the study were to calculate estimated reductions in miles traveled, in travel expenses, and in carbon emissions and to determine whether the telephone assessment was accurate and effective in determining eligibility for surgery. METHODS: From 2010 to 2012, 279 patients were retrospectively reviewed, and of those, 161 mailed four-page questionnaire and anteroposterior pelvis X-ray followed by a telephone conference. Geographic information system methods were used to geocode patients by location. Savings in mileage and travel costs were calculated. From 2014 to 2015, 195 patients were additionally studied to determine accuracy and effectiveness. RESULTS: The telephone prescreening method saved 106,070 miles in transportation over 3 years, a 38% reduction with US$55,326 in savings. Each family saved an average of 658 (standard deviation = 340) miles of travel and US$343.64 (standard deviation = US$178) in travel expenses. For each increase of 10 miles in distance from the health center, the odds of a patient utilizing telephone screening increased by 10% (odds ratio: 1.101, 95% confidence interval: 1.073-1.129, p < 0.001). After the telephone prescreening, 86% were determined to be likely candidates for the procedure. For 14%, a clinic visit only was scheduled, and they were not scheduled for surgery. CONCLUSION: Families seeking specialized surgical care for their disabled children particularly benefited from this approach.

Social Determinants of Health in Environmental Justice Communities: Examining Cumulative Risk in Terms of Environmental Exposures and Social Determinants of Health.

Residents of environmental justice (EJ) communities may bear a disproportionate burden of environmental health risk, and often face additional burdens from social determinants of health. Accounting for cumulative risk should include measures of risk from both environmental sources and social determinants. This study sought to better understand cumulative health risk from both social and environmental sources in a disadvantaged community in Texas. Key outcomes were determining what data are currently available for this assessment, clarifying data needs, identifying data gaps, and considering how those gaps could be filled. Analyses suggested that the traditionally defined EJ community in Port Arthur may have a lower environmental risk from air toxics than the rest of the City of Port Arthur (although the entire city has a higher risk than the average for the state), but may have a larger burden from social determinants of health. However, the results should be interpreted in light of the availability of data, the definitions of community boundaries, and the areal unit utilized. Continued focus on environmental justice communities and the cumulative risks faced by their residents is critical to protecting these residents and, ultimately, moving towards a more equitable distribution and acceptable level of risk throughout society.

Assessing healthful eating among community dwelling rural older adults using self-reported fruit and vegetable consumption via a community-wide mail-out health status assessment.

This project assessed fruit and vegetable intakes among rural older adults on a regional mail-out community health assessment. Over 95% of respondents answered questions regarding fruit and vegetable consumption. Rural older adults in this sample were willing to respond to questions regarding their fruit and vegetable intake; yet they were not likely to be meeting minimum recommended intakes of these foods. Including questions about dietary healthfulness on such an assessment may provide key stakeholders and policymakers a clearer understanding of their community's overall health status.