HepCCATT: a multilevel intervention for hepatitis C among vulnerable populations in Chicago.

BACKGROUND: Hepatitis C infection could be eliminated. Underdiagnosis and lack of treatment are the barriers to cure, especially for vulnerable populations (i.e. unable to pay for health care). METHODS: A multilevel intervention from September 2014 to September 2019 focused on the providers and organizations in 'the safety net' (providing health care to populations unable to pay), including: (i) public education, (ii) training for primary care providers (PCPs) and case managers, (iii) case management for high-risk populations, (iv) policy advice and (v) a registry (Registry) for 13 health centers contributing data. The project tracked the number of PCPs trained and, among Registry sites, the number of people screened, engaged in care (i.e. clinical follow-up after diagnosis), treated and/or cured. RESULTS: In Chicago, 215 prescribing PCPs and 56 other health professionals, 86% of whom work in the safety net, were trained to manage hepatitis C. Among Registry sites, there was a 137% increase in antibody screening and a 32% increase in current hepatitis C diagnoses. Engagement in care rose by 18%. CONCLUSIONS: Hepatitis C Community Alliance to Test and Treat (HepCCATT) successfully targeted safety net providers and organizations with a comprehensive care approach. While there were challenges, HepCCATT observed increased hepatitis C screening, diagnosis and engagement in care in the Chicago community.

Ectopic pregnancy morbidity and mortality in low-income women, 2004-2008.

STUDY QUESTION: Does the risk of adverse outcomes at the time of ectopic pregnancy vary by race/ethnicity among women receiving Medicaid, the public health insurance program for low-income people in the USA? SUMMARY ANSWER: Among Medicaid beneficiaries with ectopic pregnancy, 11% experienced at least one complication, and women from all racial/ethnic minority groups were significantly more likely than whites to experience complications. WHAT IS KNOWN ALREADY: In this population of Medicaid recipients, African American women are significantly more likely than whites to experience ectopic pregnancy, but the risk of adverse outcomes has not previously been assessed. STUDY DESIGN, SIZE, AND DURATION: We conducted a cross-sectional observational study of all women (n = 19 135 106) ages 15-44 enrolled in Medicaid for any amount of time during 2004-2008 who lived in one of the following 14 US states: Arizona; California; Colorado; Florida; Illinois; Indiana; Iowa; Louisiana; Massachusetts; Michigan; Minnesota; Mississippi; New York; and Texas. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: We analyzed Medicaid claims records for inpatient and outpatient encounters and identified ectopic pregnancies with a principal diagnosis code for ectopic pregnancy from 2004-2008. We calculated the ectopic pregnancy complication rate as the number of ectopic pregnancies with at least one complication (blood transfusion, hysterectomy, any sterilization, or length-of-stay (LOS) > 2 days) divided by the total number of ectopic pregnancies. We used Poisson regression to assess the risk of ectopic pregnancy complication by race/ethnicity. Secondary outcomes were each individual complication, and ectopic pregnancy-related death. We calculated the ectopic pregnancy mortality ratio as the number of deaths divided by live births. MAIN RESULTS AND THE ROLE OF CHANCE: Ectopic pregnancy-associated complications occurred in 11% of cases. Controlling for age and state, the risk of any complication was significantly higher among women who were black (incidence risk ratio [IRR] 1.47, 95% CI 1.43-1.53, P < 0.0001), Hispanic (IRR 1.16, 95% CI 1.12-1.21, P < 0.0001), Asian (IRR 1.34, 95% CI 1.24-1.45, P < 0.0001), American Indian/Alaskan Native (IRR 1.34 95% CI 1.16-1.55, P < 0.0001), and Native Hawaiian/Pacific Islander (IRR 1.61, 95% CI 1.39-1.87, P < 0.0001) compared with white women. The ectopic pregnancy mortality ratio was 0.48 per 100 000 live births, similar to that reported in previous US surveillance. LIMITATIONS, REASONS FOR CAUTION: This is a secondary analysis of insurance claims. WIDER IMPLICATIONS OF THE FINDINGS: Among women at higher baseline risk of pregnancy complications due to their economic status, women from racial/ethnic minority groups face an additional risk of ectopic pregnancy adverse outcomes compared with whites. Systematic changes to reduce racial disparities are an essential part of improving maternal health in the USA. STUDY FUNDING/COMPETING INTERESTS: The Eunice Kennedy Shriver National Institute of Child Health and Human Development (1 K08 HD060663 to D.B.S.). The authors report no conflict of interest. TRIAL REGISTRATION NUMBER: Not applicable.

Novel loci associated with usual sleep duration: the CHARGE Consortium Genome-Wide Association Study.

Usual sleep duration is a heritable trait correlated with psychiatric morbidity, cardiometabolic disease and mortality, although little is known about the genetic variants influencing this trait. A genome-wide association study (GWAS) of usual sleep duration was conducted using 18 population-based cohorts totaling 47 180 individuals of European ancestry. Genome-wide significant association was identified at two loci. The strongest is located on chromosome 2, in an intergenic region 35- to 80-kb upstream from the thyroid-specific transcription factor PAX8 (lowest P=1.1 × 10(-9)). This finding was replicated in an African-American sample of 4771 individuals (lowest P=9.3 × 10(-4)). The strongest combined association was at rs1823125 (P=1.5 × 10(-10), minor allele frequency 0.26 in the discovery sample, 0.12 in the replication sample), with each copy of the minor allele associated with a sleep duration 3.1 min longer per night. The alleles associated with longer sleep duration were associated in previous GWAS with a more favorable metabolic profile and a lower risk of attention deficit hyperactivity disorder. Understanding the mechanisms underlying these associations may help elucidate biological mechanisms influencing sleep duration and its association with psychiatric, metabolic and cardiovascular disease.

The complex relationship between CD4 count, HIV viral load, trimethoprim-sulfamethoxazole prophylaxis, and skin-and-soft-tissue infection risk in patients with HIV: insights from a causal diagram and simulation study.

Skin and soft tissue infection (SSTIs) due to Staphylococcus aureus, particularly community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), are common in human immunodeficiency virus (HIV)-infected populations in the United States. Studies have differed as to the importance of epidemiological and immunological factors in this relationship, and have employed conflicting strategies for variable selection in multivariate analyses. Developments in causal inference methods in epidemiology have emerged in the last decade to clarify relationships between variables and identify appropriate variables to include in and exclude from multivariate analysis. In this paper, we develop a causal diagram to clarify the pathways linking CA-MRSA and HIV. We focus on the role played by trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis, prescribed to many severely immunocompromised HIV patients and potentially protective against SSTIs, which both mediates and moderates the relationship between immunological parameters and SSTI risk. We demonstrate, using simulated data, that statistical models may yield biased results if they do not account for how HIV viral load may also be a marker of adherence to TMP-SMX prophylaxis. We conclude with a proposed causal model that includes both the epidemiological as well as immunological factors that may explain the increased risk of initial and recurrent SSTI risk in HIV-infected populations.

Asian Americans have greater prevalence of metabolic syndrome despite lower body mass index.

OBJECTIVE: To examine the relationship between body mass index (BMI) and metabolic syndrome for Asian Americans and non-Hispanic Whites (NHWs), given that existing evidence shows racial/ethnic heterogeneity exists in how BMI predicts metabolic syndrome. RESEARCH DESIGN AND METHODS: Electronic health records of 43,507 primary care patients aged 35 years and older with self-identified race/ethnicity of interest (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese or NHW) were analyzed in a mixed-payer, outpatient-focused health-care organization in the San Francisco Bay Area. RESULTS: Metabolic syndrome prevalence is significantly higher in Asians compared with NHWs for every BMI category. For women at the mean age of 55 and BMI of 25 kg m(-2), the predicted prevalence of metabolic syndrome is 12% for NHW women compared with 30% for Asians; similarly for men, the predicted prevalence of metabolic syndrome is 22% for NHWs compared with 43% of Asians. Compared with NHW women and men with a BMI of 25 kg m(-2), comparable prevalence of metabolic syndrome was observed at BMI of 19.6 kg m(-2) for Asian women and 19.9 kg m(-2) for Asian men. A similar pattern was observed in disaggregated Asian subgroups. CONCLUSIONS: In spite of the lower BMI values and lower prevalence of overweight/obesity than NHWs, Asian Americans have higher rates of metabolic syndrome over the range of BMI. Our results indicate that BMI ranges for defining overweight/obesity in Asian populations should be lower than for NHWs.

Recurrence of group B streptococcus colonization in successive pregnancies.

OBJECTIVE: To identify risk factors for group B streptococcus (GBS) colonization in a subsequent pregnancy using microbiological and clinical data from a prior pregnancy. STUDY DESIGN: A retrospective cohort study of women over a 10-year period, using laboratory records to identify women with GBS culture results available in two successive pregnancies. RESULT: One thousand eight hundred and ninety-four women met eligibility criteria. Of these, 1293 were not GBS-colonized in either pregnancy, 198 were colonized in both pregnancies and 403 had discordant colonization status. GBS colonization in the index pregnancy was positively associated with multiparity, premature delivery and lower maternal age and negatively associated with chorioamnionitis. The strongest predictor of colonization in a subsequent pregnancy was colonization in the index pregnancy (50% likelihood if colonized compared with 14% if not in the index pregnancy, relative risk 3.6, confidence interval (CI)=3.1 to 4.3). GBS colonization in the subsequent pregnancy was independently associated with: GBS colonization in the index pregnancy (odds ratio (OR)=6.28; CI=4.91 to 8.05), preterm delivery in the index pregnancy (OR=1.80; CI=1.05 to 3.09) and prior early pregnancy loss (OR=1.15; CI=1.04 to 1.27). CONCLUSION: GBS colonization in a prior pregnancy is informative of colonization in a subsequent pregnancy. These data support providing antimicrobial prophylaxis in unscreened parous women with known prior GBS colonization.

Bone mineral density and fracture among prevalent kidney stone cases in the Third National Health and Nutrition Examination Survey.

Concern that people who form kidney stones may have reduced bone mineral density (BMD) and increased fracture risk has motivated clinical and population-based studies, but findings are inconsistent. In this cross-sectional study, we use the Third National Health and Nutrition Examination Survey (NHANES III) to determine whether a history of kidney stones (n = 793) is associated with lower femoral neck BMD and whether the association is similar for men and women. We further ask whether dietary calcium modifies the association between kidney stone history and BMD and whether there is an association between kidney stone history and prevalent spine or wrist fracture. We find that men with kidney stone history have lower femoral neck BMD than men without kidney stone history after adjusting for age, body mass index (BMI), race/ethnicity, and other potential confounders. The effect of kidney stone history on BMD is weaker for women. Men with kidney stone history also are more likely to report prevalent wrist and spine fractures. Dietary calcium, represented by usual milk consumption, is associated positively with BMD for both men and women and modifies the effect of kidney stone history on BMD for men. For men who form kidney stones, milk consumption is associated more strongly with femoral neck BMD than for men without such a history. The effect modification is such that the difference in BMD between men with and without kidney stone history is observed only at lower levels of milk consumption.

Familial determinants of moderate and intense physical activity: a twin study.

This twin study estimates familial clustering of moderate and intense leisure-time physical activity and investigates quantitatively its genetic and environmental components. Study subjects are 3,344 male twin pairs aged 33-51 yr. Moderate activity levels were assessed with six questions about discretionary walking or stair climbing for exercise. Five questions assessed regular participation in specific, intense athletic activities (running, bicycling, swimming, racquet, and other sports). Familial aggregation is estimated by odds ratio of one twin engaging in an activity when his co-twin does. Monozygotic and dizygotic twin correlations were compared to estimate genetic and nongenetic sources of phenotypic variation. For each activity, the familial aggregation odds ratio was statistically significant with values between 2.9 to 4.6 for intense activities and between 1.4 to 1.9 for all moderate activities but one. Monozygotic twin correlations were higher than dizygotic, suggesting genes play a role in the observed phenotypic variation. For four questions, and a compromise scale of moderate activity, the difference between correlations was statistically significant (P < 0.05). In this cohort, much of the phenotypic variability for both moderate and intense activities is a result of familial effects. Genes may influence regular participation in specific intense exercises more than moderate activity, such as walking for exercise.

Self-reports of stress in Asian immigrants: effects of ethnicity and acculturation.

INTRODUCTION: Although the concept of stress is hard to define or measure, it is a phenomenon associated with a number of health conditions, including hypertension, heart disease, and decreased immunocompetency. Events such as migration are known to create stress; researchers refer to this as acculturative stress. Given that cultural background might influence a patient's recognition, interpretation, and coping mechanisms for stress, we wondered how self-reports of stress by Asian immigrants compare with those of non-Hispanic Whites, and how these self-reports vary with years since immigration, a proxy for acculturation. METHODS: Data from the National Health Information Survey for 1993 and 1995 were analyzed for six groups of Asian national origin, and were compared with non-Hispanic Whites. Using ordered logistic regression, we examined self-reports of stress over two weeks and twelve months, as well as the changes in these self-reports with years since immigration. RESULTS: Adjusted for age, income, educational level, marital status, and gender, Asian immigrants were uniformly less likely to report stress over a two-week period than were non-Hispanic Whites (OR ranges: 0.34[Asian Indian]-0.59[Korean], P values<.05). There were no significant differences in reported stress among Asian ethnic groups. Compared with immigrants who have lived in the United States for at least 15 years, recent immigrants (<1 year) were likely to report less stress over two weeks and twelve months, OR = 0.13 and 0.23, respectively, P values<.005. CONCLUSIONS: Despite their status as immigrants, Asians report less stress than non-Hispanic Whites. These reports of stress increase as years since immigration increase. One potential explanation for these discrepancies is under-reporting, which might reflect underlying cultural differences in the perception or definition of stress, differences that may diminish with "acculturation."

The economic burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).

The economic impact of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) remains unclear. We developed an economic simulation model to quantify the costs associated with CA-MRSA infection from the societal and third-party payer perspectives. A single CA-MRSA case costs third-party payers $2277-$3200 and society $7070-$20 489, depending on patient age. In the United States (US), CA-MRSA imposes an annual burden of $478 million to 2.2 billion on third-party payers and $1.4-13.8 billion on society, depending on the CA-MRSA definitions and incidences. The US jail system and Army may be experiencing annual total costs of $7-11 million ($6-10 million direct medical costs) and $15-36 million ($14-32 million direct costs), respectively. Hospitalization rates and mortality are important cost drivers. CA-MRSA confers a substantial economic burden on third-party payers and society, with CA-MRSA-attributable productivity losses being major contributors to the total societal economic burden. Although decreasing transmission and infection incidence would decrease costs, even if transmission were to continue at present levels, early identification and appropriate treatment of CA-MRSA infections before they progress could save considerable costs.

Education and survival: birth cohort, period, and age effects.

Previous studies have found that educational differences in mortality are weaker among the elderly. In this study I examine whether either cohort or period effects may have influenced the interpretation of age effects. Six 10-year birth cohorts are followed over 30 years through decennial censuses. Differential survival is inferred from changes in the relative proportions of a cohort in each education category as the cohort ages. In cross-section, younger persons generally show stronger education effects on survival, although this pattern is clearer for women than for men. There is evidence of period effects. Within cohorts, relative survival tends to increase with age.

The expanded racial and ethnic codes in the Medicare data files: their completeness of coverage and accuracy.

OBJECTIVES: This paper evaluates the new race/ethnicity codes for Asian Americans, Hispanics, and Native Americans that have recently been added to the Medicare enrollment database. METHODS: The race/ethnicity code revisions made by the Health Care Financing Administration are described and evaluated by (1) comparing the numbers of persons identified as Asian Americans, Hispanics, and Native Americans with corresponding population census projections and (2) determining whether Medicare enrollees born in Asian and Hispanic countries are assigned Asian and Hispanic codes. RESULTS: Among persons 65 years of age and older, approximately 24% of Hispanics, 17% of Native Americans, and 56% of Asian Americans are identifiable by the new codes. From 18% to 29% of enrollees 65 years old or older born in Mexico, Puerto Rico, and Cuba are coded as Hispanic, and from 14% to 73% of enrollees born in nine Asian countries are classified as Asian American. Classification is not random but is related to timing of migration and to country of origin. CONCLUSIONS: Researchers should resist the temptation to base analyses on the revised Health Care Financing Administration race/ethnicity codes, since coverage is incomplete and biased.

Cohort effects in a genetically determined trait: eye colour among US whites.

BACKGROUND: While the inheritance of eye colour is likely polygenic, blue eye colour is thought to follow an inheritance pattern similar to that of a recessive trait. Consequently, age-related differences in the prevalence of blue eye colour would be unanticipated. AIM: This study explores the finding and explanation for birth cohort differences in the prevalence of blue eye colour in the US white population. SUBJECTS AND METHODS: Data from the first (1971-1975) and third (1988-1994) US National Health and Nutrition Examination Surveys (NHANES-I and NHANES-III), nationally representative surveys of the US population, were analysed. Trends in eye colour prevalence by birth cohort were analysed together with mortality rates according to eye colour. US census data (1980) were examined to explore cohort differences in ancestry and assortative mating by ancestry. RESULTS: The prevalence of blue eye colour among non-Hispanic whites in NHANES-III was 57.4% (95% CI: 50.1-64.7) for individuals born between 1899 and 1905 compared to 33.8% (95% CI: 31.3-36.5) for those born between 1936 and 1951. No association was found between survival and eye colour, nor was a cohort effect evident for primary ancestry. However, proportions reporting only one ancestry in census data declined with successive birth cohorts. CONCLUSIONS: A cohort effect in blue eye colour prevalence was found for the US white population. A secular trend of decreasing assortative mating by ancestry is the likely explanation.

Body mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic status.

OBJECTIVE: To examine body mass index (BMI) and the proportion overweight and obese among adults age 18-59 in the six largest Asian American ethnic groups (Chinese, Filipino, Asian Indian, Japanese, Korean, Vietnamese), and investigate whether BMI varies by nativity (foreign-vs native-born), years in US, or socioeconomic status. DESIGN: Cross-sectional interview data were pooled from the 1992-1995 National Health Interview Survey (NHIS). SUBJECTS: 254,153 persons aged 18-59 included in the 1992-1995 NHIS. Sample sizes range from 816 to 1940 for each of six Asian American ethnic groups. MEASUREMENTS: Self-reported height and weight used to calculate BMI and classify individuals as overweight (BMI > or = 25 kg/m2) or obese (BMI > or = 30 kg/m2), age, sex, years in the US, household income and household size. RESULTS: For men, the percentage overweight ranges from 17% of Vietnamese to 42% of Japanese, while the total male population is 57% overweight. For women, the percentage overweight ranges from 9% of Vietnamese and Chinese to 25% of Asian Indians, while the total female population is 38% overweight. The percentage of Asian Americans classified as obese is very low. Adjusted for age and ethnicity, the odds ratio for obese is 3.5 for women and 4.0 for men for US-vs foreign-born. Among the foreign-born, more years in the US is associated with higher risk of being overweight or obese. The association between household income for women is similar for US-born Asian Americans and Whites and Blacks, but is much weaker for foreign-born Asian Americans. CONCLUSIONS: While these data find low proportions of Asian Americans overweight at present, they also imply the proportion will increase with more US-born Asian Americans and longer duration in the US.

Evidence of environmental suppression of familial resemblance: height among US Civil War brothers.

This study examines, with historical data, whether within family correlations in height varied across environments and whether variability in height was greater in worse environments. To investigate these hypotheses, brothers were identified who were mustered into the Union Army of the US Civil War, using linked records from the 1850 and 1860 censuses and military and medical records. Heights were available for 3898 men aged 18 and older, of whom 595 were further identified as belonging to 288 family sets of two, three or four brothers. Generalized estimating equations were used to concurrently model the mean height, the variance and the correlation between brothers as a function of county population. Heights decreased as county population size increased (p<0.001). The correlation between brothers' heights decreased significantly (p = 0.032) with increasing county population, and the variance increased (p = 0.026). The correlation ranged approximately from 0.63 in the least populous to 0.24 in the most populous counties. The degree of familial resemblance was lower in environments where mean height was lower, and the variability in height was greater, suggesting that the environmental contribution to the variability in height is of greater relative importance in populations reared, on average, in worse environments.

Receipt of cancer screening procedures among Hispanic and non-Hispanic health maintenance organization members.

BACKGROUND: Hispanic Americans have been shown to receive fewer cancer screening procedures than nonminority populations. Although lack of insurance or a regular source of care appear to be important determinants, cultural factors also have been suggested. This study examines whether Hispanic patients receive cancer screening at the same rate as the non-Hispanic population when both groups have equivalent insurance and a regular source of care. METHODS: Receipt of five cancer screening procedures (mammography, Pap test, fecal occult blood testing, breast examination, and rectal examination) was determined for adult health maintenance organization (HMO) members who met appropriate age and gender criteria. Rates of receipt were compared for 2 cohorts over a 2-year period: Hispanic members identified by surname and a comparison group, a 10% random sample of the non-Spanish surnamed members. Only members with at least one HMO contact over the study period were included. Logistic regression was used to test whether being in the Hispanic group was associated with decreased likelihood of receiving the procedure at least once over the 2 years, adjusting for potential confounders. RESULTS: Among the comparison group, a high proportion received each recommended procedure at least once (0.70-0.86). The proportions were very similar for the Hispanic group (0.67-0.84). None of the rates differed statistically for the two groups. CONCLUSIONS: Hispanic HMO members received cancer screening at the same high rate as non-Hispanics, suggesting that insurance coverage and continuity of care are more important than cultural factors in determining rates of cancer screening receipt.

Is geographic variation in hip fracture rates related to current or former region of residence?

This study examines geographic variation in male and female age-adjusted hip fracture rates in white elderly Medicare enrollees. We assembled a cohort of more than 2 million 1992 enrollees and followed them passively through record linkage for 2 years for a hospitalization containing a diagnostic code indicating hip fracture. We simultaneously estimated rate ratios by region of residence early (inferred from the Social Security number) and late in life. Residence region early in life is associated with substantial variation in hip fracture rates. Conversely, current region has little relation with hip fracture risk.

Knowledge of Centers for Disease Control and Prevention guidelines for the use of vancomycin at a large tertiary care children's hospital.

OBJECTIVE: In 1994, the Centers for Disease Control and Prevention (CDC) published guidelines to encourage prudent use of vancomycin. We sought to determine whether physicians could demonstrate knowledge consistent with the guidelines. DESIGN: Survey consisting of 18 clinical vignettes based on the CDC guidelines. PARTICIPANTS: All residents, fellows, and attending physicians involved in pediatric inpatient services. SETTING: Tertiary care children's hospital providing service to an inner-city population and community referral base. MAIN OUTCOME MEASURES: Comparison of survey scores and individual responses among respondents. RESULTS: Survey scores did not vary with level of training or whether the respondent was a pediatrician or non-pediatrician. Average scores of attending physicians, fellows, and residents were 74.1% (SD = 13.1), 77.2% (SD = 11.5), and 73.4% (SD = 10.5), respectively, and did not differ significantly. Questions incorrectly answered by more than 30% of respondents concerned the use of vancomycin as: (1) first-line treatment of Clostridium difficile colitis, (2) a topical solution for wound infection, (3) initial, empiric treatment of patients with fever and neutropenia, (4) peri-operative prophylaxis, (5) a preferred agent over beta-lactam antimicrobial agents. CONCLUSION: Deficits in knowledge regarding appropriate vancomycin use can be localized to certain clinical settings. This observation lends optimism to the notion that targeted educational intervention may improve the appropriate use of vancomycin.

A methodology for identifying married couples in Medicare data: mortality, morbidity, and health care use among the married elderly.

We describe a method for the development of cohorts of up to three quarters of the 14 million married couples aged 65 and over in the United States. The health care experiences, illness histories, and mortality of these identified couples can be assessed longitudinally using Medicare data. We summarize strengths and limitations of using data from Medicare administrative records for the study of marriage, health, and aging. We illustrate the method by demonstrating substantial differences in survival in a cohort of hospice patients as a function of not only the patient's own diagnosis and illness burden but also the patient's spouse's illness burden.