Geocoding and linking data from population-based surveillance and the US Census to evaluate the impact of median household income on the epidemiology of invasive Streptococcus pneumoniae infections

Risk of Subsequent Breast Cancer in Women with Early Stage HER2-Positive Breast Cancer in a Large Community Health Plan

Purpose

Clinical outcomes have improved for women with early stage, HER2-positive breast cancer following the FDA approval of adjuvant trastuzumab use in 2006. However, only limited information exists on such patients' outcomes in real-world settings outside of clinical trials. We examined the risk of subsequent breast cancer in women with HER-2 positive disease, and the impact of trastuzumab use, in a large California community-based health plan.

Patients and Methods

A cohort of 3550 women with HER2-positive breast cancer (stages I-III) from 2009-2017 were followed through December 2018. We calculated subsequent breast cancer (SBC) rates overall and by trastuzumab use. Multivariable Cox proportional hazards modeling was used to compute hazard ratios (HR) and 95% confidence intervals (CI) for SBC by trastuzumab use.

Results

Within the cohort diagnosed with HER2-positive disease, 81% received adjuvant trastuzumab. After 4.1 mean years follow-up (maximum 10 years), the risk of SBC was 22% lower with adjuvant trastuzumab use (hazard ratio [HR] = 0.78, 95% confidence interval [CI]: 0.66-0.92) compared with non-use. The cumulative incidence of SBC precipitously rose two years after diagnosis and by the 10th year, the cumulative incidence was 31% among those who had trastuzumab therapy versus 34% without this therapy.

Conclusion

In community practice settings, the cumulative incidence of SBC in patients with early stage HER2-positive BC was 31% at 10 years in a cohort treated with adjuvant trastuzumab. Trastuzumab use was associated with a 22% reduced risk of developing SBC. This residual disease burden suggests breast cancer outcomes may be improved with further treatment given the advent of next-generation HER2-targeted therapies.

Describing and assessing a new method of approximating categorical individual-level income using community-level income from the census (weighting by income probabilities)

OBJECTIVE

To assess a new approach (weighting by "income probabilities [IP]") that uses US Census data from the patients' communities to approximate individual-level income, an important but often missing variable in health services research.

DATA SOURCES

Community (census tract level) income data came from the 2017 5-year American Community Survey (ACS). The patient data included those diagnosed with cancer in 2017 in Ohio (n = 65,759). The reference population was the 2017 5-year ACS Public Use Microdata Sample (n = 564,357 generalizing to 11,288,350 Ohioans).

STUDY DESIGN/METHODS

We applied the traditional approach of income approximation using median census tract income along with two IP based approaches to estimate the proportions in the patient data with incomes of 0%-149%, 150%-299%, 300%-499%, and 500%+ of the federal poverty level (FPL) ("class-relevant income grouping") or 0%-138%, 139%-249%, 250%-399%, and 400%+ FPL ("policy-relevant income grouping"). These estimated income distributions were then compared with the known income distributions of the reference population.

DATA COLLECTION/EXTRACTION METHODS

The patient data came from Ohio's cancer registry. The other data were publicly available.

PRINCIPAL FINDINGS

Both IP based approaches consistently outperformed the traditional approach overall and in subgroup analyses, as measured by the weighted average absolute percentage point differences between the proportions of each of the income categories of the reference population and the estimated proportions generated by the income approximation approaches ("average percent difference," or APD). The smallest APD for an IP based method, 0.5%, was seen in non-Hispanic White females in the class-relevant income grouping (compared with 16.5% for the conventional method), while the largest APD, 7.1%, was seen in non-Hispanic Black females in the policy-relevant income grouping (compared with 18.0% for the conventional method).

CONCLUSIONS

Weighting by IP substantially outperformed the conventional approach of estimating the distribution of incomes in patient data.

Dimensions of poverty as risk factors for antimicrobial resistant organisms in Canada: a structured narrative review

Background

Few studies have assessed the relationship between poverty and the risk of infection with antimicrobial resistant organisms (AROs). We sought to identify, appraise, and synthesize the available published Canadian literature that analyzes living in poverty and risk of AROs.

Methods

A structured narrative review methodology was used, including a systematic search of three databases: MedLINE, EMBASE and Web of Science for articles pertaining to poverty, and infection with AROs in Canada between 1990 and 2020. Poverty was broadly defined to include economic measures and associated social determinants of health. Based on inclusion and exclusion criteria, there were 889 initial articles, and 43 included in the final review. The final articles were extracted using a standard format and appraised using the Joanna Briggs Institute Levels of Evidence framework.

Results

Of 43 studies, 15 (35%) related to methicillin-resistant Staphylococcus aureus (MRSA). One study found a 73% risk reduction (RR 0.27, 95%CI 0.19–0.39, p =  < 0.0001) in community-acquired MRSA (CA-MRSA) infection for each $100,000 income increase. Results pertaining to homelessness and MRSA suggested transmission was related to patterns of frequent drug use, skin-to-skin contact and sexual contact more than shelter contact. Indigenous persons have high rates of CA-MRSA, with more rooms in the house being a significant protective factor (OR 0.86, p = 0.023). One study found household income over $60,000 (OR 0.83, p = 0.039) in univariate analysis and higher maternal education (OR 0.76, 95%CI 0.63–0.92, p = 0.005) in multivariate analysis were protective for otitis media due to an ARO among children. Twenty of 43 (46.5%) articles pertained to tuberculosis (TB). Foreign-born persons were four times more likely to have resistant TB compared to Canadian-born persons. None of the 20 studies used income in their analyses.

Conclusions

There is an association between higher income and protection from CA-MRSA. Mixed results exist regarding the impact of homelessness and MRSA, demonstrating a nuanced relationship with behavioural risk factors. Higher income and maternal education were associated with reduced ARO-associated acute otitis media in children in one study. We do not have a robust understanding of the social measures of marginalization related to being foreign-born that contribute to higher rates of resistant TB infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01059-1.

Relationship between neighborhood census-tract level socioeconomic status and respiratory syncytial virus-associated hospitalizations in U.S. adults, 2015-2017

Background

Respiratory syncytial virus (RSV) infection causes substantial morbidity and mortality in children and adults. Socioeconomic status (SES) is known to influence many health outcomes, but there have been few studies of the relationship between RSV-associated illness and SES, particularly in adults. Understanding this association is important in order to identify and address disparities and to prioritize resources for prevention.

Methods

Adults hospitalized with a laboratory-confirmed RSV infection were identified through population-based surveillance at multiple sites in the U.S. The incidence of RSV-associated hospitalizations was calculated by census-tract (CT) poverty and crowding, adjusted for age. Log binomial regression was used to evaluate the association between Intensive Care Unit (ICU) admission or death and CT poverty and crowding.

Results

Among the 1713 cases, RSV-associated hospitalization correlated with increased CT level poverty and crowding. The incidence rate of RSV-associated hospitalization was 2.58 (CI 2.23, 2.98) times higher in CTs with the highest as compared to the lowest percentages of individuals living below the poverty level (≥ 20 and < 5%, respectively). The incidence rate of RSV-associated hospitalization was 1.52 (CI 1.33, 1.73) times higher in CTs with the highest as compared to the lowest levels of crowding (≥5 and < 1% of households with > 1 occupant/room, respectively). Neither CT level poverty nor crowding had a correlation with ICU admission or death.

Conclusions

Poverty and crowding at CT level were associated with increased incidence of RSV-associated hospitalization, but not with more severe RSV disease. Efforts to reduce the incidence of RSV disease should consider SES.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05989-w.

Marked Reduction of Socioeconomic and Racial Disparities in Invasive Pneumococcal Disease Associated With Conjugate Pneumococcal Vaccines

BACKGROUND

It is not known whether reductions in socioeconomic and racial disparities in incidence of invasive pneumococcal disease (defined as the isolation of Streptococcus pneumoniae from a normally sterile body site) noted after pneumococcal conjugate vaccine (PCV) introduction have been sustained.

METHODS

Individual-level data collected from 20 Tennessee counties participating in Active Bacterial Core surveillance over 19 years were linked to neighborhood-level socioeconomic factors. Incidence rates were analyzed across 3 periods-pre-7-valent PCV (pre-PCV7; 1998-1999), pre-13-valent PCV (pre-PCV13; 2001-2009), and post-PCV13 (2011-2016)-by socioeconomic factors.

RESULTS

A total of 8491 cases of invasive pneumococcal disease were identified. Incidence for invasive pneumococcal disease decreased from 22.9 (1998-1999) to 17.9 (2001-2009) to 12.7 (2011-2016) cases per 100 000 person-years. Post-PCV13 incidence (95% confidence interval [CI]) of PCV13-serotype disease in high- and low-poverty neighborhoods was 3.1 (2.7-3.5) and 1.4 (1.0-1.8), respectively, compared with pre-PCV7 incidence of 17.8 (15.7-19.9) and 6.4 (4.9-7.9). Before PCV introduction, incidence (95% CI) of PCV13-serotype disease was higher in blacks than whites (17.3 [15.1-19.5] vs 11.8 [10.6-13.0], respectively); after introduction, PCV13-type disease incidence was greatly reduced in both groups (white: 2.7 [2.4-3.0]; black: 2.2 [1.8-2.6]).

CONCLUSIONS

Introduction of PCV13 was associated with substantial reductions in overall incidence and socioeconomic and racial disparities in PCV13-serotype incidence.

Investigating the impact of poverty on colonization and infection with drug-resistant organisms in humans: a systematic review

BACKGROUND

Poverty increases the risk of contracting infectious diseases and therefore exposure to antibiotics. Yet there is lacking evidence on the relationship between income and non-income dimensions of poverty and antimicrobial resistance. Investigating such relationship would strengthen antimicrobial stewardship interventions.

METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Ovid, MEDLINE, EMBASE, Scopus, CINAHL, PsychINFO, EBSCO, HMIC, and Web of Science databases were searched in October 2016. Prospective and retrospective studies reporting on income or non-income dimensions of poverty and their influence on colonisation or infection with antimicrobial-resistant organisms were retrieved. Study quality was assessed with the Integrated quality criteria for review of multiple study designs (ICROMS) tool.

RESULTS

Nineteen articles were reviewed. Crowding and homelessness were associated with antimicrobial resistance in community and hospital patients. In high-income countries, low income was associated with Streptococcus pneumoniae and Acinetobacter baumannii resistance and a seven-fold higher infection rate. In low-income countries the findings on this relation were contradictory. Lack of education was linked to resistant S. pneumoniae and Escherichia coli. Two papers explored the relation between water and sanitation and antimicrobial resistance in low-income settings.

CONCLUSIONS

Despite methodological limitations, the results suggest that addressing social determinants of poverty worldwide remains a crucial yet neglected step towards preventing antimicrobial resistance.

Socioeconomic Background and Commercial Health Plan Spending

BACKGROUND

Risk-adjustment algorithms typically incorporate demographic and clinical variables to equalize compensation to insurers for enrollees who vary in expected cost, but including information about enrollees' socioeconomic background is controversial.

METHODS

We studied 1 182 847 continuously insured 0 to 19-year-olds using 2008-2012 Blue Cross Blue Shield of Massachusetts and American Community Survey data. We characterized enrollees' socioeconomic background using the validated area-based socioeconomic measure and calculated annual plan payments using paid claims. We evaluated the relationship between annual plan payments and geocoded socioeconomic background using generalized estimating equations (γ distribution and log link). We expressed outcomes as the percentage difference in spending and utilization between enrollees with high and low socioeconomic backgrounds.

RESULTS

Geocoded socioeconomic background had a significant, positive association with annual plan payments after applying standard adjusters. Every 1 SD increase in socioeconomic background was associated with a 7.8% (95% confidence interval, 7.2% to 8.3%; P < .001) increase in spending. High socioeconomic background enrollees used higher-priced outpatient and pharmacy services more frequently than their counterparts from low socioeconomic backgrounds (eg, 25% more outpatient encounters annually; 8% higher price per encounter; P < .001), which outweighed greater emergency department spending among low socioeconomic background enrollees.

CONCLUSIONS

Higher socioeconomic background is associated with greater levels of pediatric health care spending in commercially insured children. Including socioeconomic information in risk-adjustment algorithms may address concerns about adverse selection from an economic perspective, but it would direct funds away from those caring for children and adolescents from lower socioeconomic backgrounds who are at greater risk of poor health.

Antibiotic Resistance of Helicobacter pylori Among Male United States Veterans

BACKGROUND & AIMS

The most recent information published on resistance of Helicobacter pylori to antibiotics in a large population in the United States is more than 10 years old. We assessed the susceptibility of H pylori to antibiotics among patients in a large metropolitan hospital, as well as demographic, clinical, and lifestyle factors associated with antimicrobial resistance.

METHODS

We performed a cross-sectional study of a random sample of 656 patients (90.2% men) from a cohort of 1559 undergoing esophagogastroduodenoscopy with collection of gastric biopsies from 2009 through 2013 at the Houston Veterans Affairs Medical Center. We performed culture analyses of gastric tissues to detect H pylori. The minimum inhibitory concentrations of amoxicillin, clarithromycin, metronidazole, levofloxacin, and tetracycline were determined by the Epsilometer test. Logistic regression analysis was performed to estimate the association between risk factors and antimicrobial resistance.

RESULTS

Biopsies from 135 subjects (20.6%) tested positive for H pylori; 128 of these were from men (94.8%). Only 65 strains were susceptible to all 5 antibiotics. The prevalence of resistance to levofloxacin was 31.3% (95% confidence interval [CI], 23.1%-39.4%), to metronidazole it was 20.3% (95% CI, 13.2%-27.4%), to clarithromycin it was 16.4% (95% CI, 9.9%-22.9%), and to tetracycline it was 0.8% (95% CI, 0.0%-2.3%). No isolate was resistant to amoxicillin. Clarithromycin resistance increased from 9.1% in 2009-2010 to 24.2% in 2011-2013. In multivariate analysis, prior treatment of H pylori infection and use of fluoroquinolones were significantly associated with clarithromycin and levofloxacin resistance, respectively.

CONCLUSIONS

H pylori resistance to clarithromycin increased between 2009 and 2013; resistance to metronidazole remains high in infected men in the United States. The high frequency of resistance to levofloxacin is a new and concerning finding.

Association between intentional injury and long-term survival after trauma

OBJECTIVE

To determine the risk-adjusted mortality of intentionally injured patients within 7 to 9 years postinjury, compared with unintentionally injured patients.

BACKGROUND

Violent injury contributes significantly to trauma mortality in the United States. Homicide is the second leading killer of American youth, aged 15 to 24 years. Long-term survival among intentionally injured patients has not been well studied. It is also unknown whether intentionally injured patients have worse long-term survival compared with unintentionally or accidentally injured patients with equivalent injuries.

METHODS

Adult trauma patients admitted for 24 hours or more and discharged alive from the Johns Hopkins Hospital from January 1, 1998, to December 31, 2000, were included. The primary outcome was mortality within 7 to 9 years postinjury. Long-term patient survival was determined using the National Death Index. The association between injury intentionality and mortality was investigated using a Cox proportional hazard regression model, adjusted for confounders such as injury severity and patient race, socioeconomic status, and comorbid conditions. Overall differences in survival between those with intentional versus unintentional injury were also determined by comparing adjusted Kaplan-Meier survival curves.

RESULTS

A total of 2062 patients met inclusion criteria. Of these, 56.4% were intentionally injured and 43.6% were unintentionally injured. Compared with unintentionally injured patients, intentionally injured patients were younger and more often male and from a zip code with low median household income. Approximately 15% of all patients had died within 7 to 9 years of follow-up. Older age and presence of comorbidities were associated with this outcome; however, intentional injury was not found to be significantly associated with long-term mortality rates. There was also no significant difference in survival curves between groups; intentionally injured patients were much more likely to die of a subsequent injury, whereas those with unintentional injury commonly died of noninjury causes.

CONCLUSIONS

There was no significant difference in mortality between intentionally injured and unintentionally injured patients within 7 to 9 years postinjury. These results confirm the long-term effectiveness of lifesaving trauma care for those with intentional injury. However, given that patients with intentional injuries were more likely to suffer a subsequent violent death, interventions focused on breaking the cycle of violence are needed.

Socioeconomic and racial disparities of pediatric invasive pneumococcal disease after the introduction of the 7-valent pneumococcal conjugate vaccine

BACKGROUND

Racial differences have been well described for invasive pneumococcal disease (IPD), but little information exists on how race interacts with community socioeconomic factors.

METHODS

The Active Bacterial Core surveillance/Emerging Infections Program performed active surveillance for IPD in the 20-county Metropolitan Atlanta area. All IPD cases among children younger than 5 years from 2001 to 2009 were geocoded and linked to census tract-level socioeconomic measures from the 2000 US Census. Race- and socioeconomic-specific average annual incidence rates per 100,000 population were calculated. Trends in IPD incidence were determined by χ² tests for trend. Rate ratios (RRs) and 95% confidence intervals (CIs) were estimated using Poisson regression.

RESULTS

IPD incidence among the total population of children increased as percentage of household poverty increased (P = 0.002), as median household income decreased (P < 0.001), as wealth decreased (P = 0.018) and as percentage of individuals with less than a high school education increased (P = 0.023). After stratifying by race, there was no significant linear trend between socioeconomic characteristics and IPD incidence among white children; among black children, however, IPD incidence decreased as socioeconomic conditions worsened. Despite adjusting for sex and socioeconomic factors, the IPD rate remained higher among black children compared with white children (RR = 1.60; 95% CI: 1.39-1.84). Differences in RR of IPD associated with highest poverty and lowest wealth noted in 2001 [RR = 2.71 (95% CI: 2.17-3.39) and 1.80 (95% CI: 1.09-2.96), respectively] declined in 2009 [RR = 1.33 (95% CI: 0.90-1.96) and 0.76 (95% CI: 0.48-1.19), respectively].

CONCLUSIONS

Although socioeconomic disparities in IPD incidence exist among children, the association between socioeconomic characteristics and IPD rates may differ by race and may change over time. Community-level socioeconomic factors did not account for racial differences in IPD incidence.

Correlations between Income inequality and antimicrobial resistance

Objectives

The aim of this study is to investigate if correlations exist between income inequality and antimicrobial resistance. This study’s hypothesis is that income inequality at the national level is positively correlated with antimicrobial resistance within developed countries.

Data collection and analysis

Income inequality data were obtained from the Standardized World Income Inequality Database. Antimicrobial resistance data were obtained from the European antimicrobial Resistance Surveillance Network and outpatient antimicrobial consumption data, measured by Defined daily Doses per 1000 inhabitants per day, from the European Surveillance of antimicrobial Consumption group. Spearman’s correlation coefficient (r) defined strengths of correlations of: > 0.8 as strong, > 0.5 as moderate and > 0.2 as weak. Confidence intervals and p values were defined for all r values. Correlations were calculated for the time period 2003-10, for 15 European countries.

Results

Income inequality and antimicrobial resistance correlations which were moderate or strong, with 95% confidence intervals > 0, included the following. Enterococcus faecalis resistance to aminopenicillins, vancomycin and high level gentamicin was moderately associated with income inequality (r= ≥0.54 for all three antimicrobials). Escherichia coli resistance to aminoglycosides, aminopenicillins, third generation cephalosporins and fluoroquinolones was moderately-strongly associated with income inequality (r= ≥0.7 for all four antimicrobials). Klebsiella pneumoniae resistance to third generation cephalosporins, aminoglycosides and fluoroquinolones was moderately associated with income inequality (r= ≥0.5 for all three antimicrobials). Staphylococcus aureus methicillin resistance and income inequality were strongly associated (r=0.87).

Conclusion

As income inequality increases in European countries so do the rates of antimicrobial resistance for bacteria including E. faecalis, E. coli, K. pneumoniae and S. aureus. Further studies are needed to confirm these findings outside Europe and investigate the processes that could causally link income inequality and antimicrobial resistance.

Cost-effectiveness of a program to eliminate disparities in pneumococcal vaccination rates in elderly minority populations: an exploratory analysis

OBJECTIVE

Invasive pneumococcal disease is a major cause of preventable morbidity and mortality in the United States, particularly among the elderly (>65 years). There are large racial disparities in pneumococcal vaccination rates in this population. Here, we estimate the cost-effectiveness of a hypothetical national vaccination intervention program designed to eliminate racial disparities in pneumococcal vaccination in the elderly.

METHODS

In an exploratory analysis, a Markov decision-analysis model was developed, taking a societal perspective and assuming a 1-year cycle length, 10-year vaccination program duration, and lifetime time horizon. In the base-case analysis, it was conservatively assumed that vaccination program promotion costs were $10 per targeted minority elder per year, regardless of prior vaccination status and resulted in the elderly African American and Hispanic pneumococcal vaccination rate matching the elderly Caucasian vaccination rate (65%) in year 10 of the program.

RESULTS

The incremental cost-effectiveness of the vaccination program relative to no program was $45,161 per quality-adjusted life-year gained in the base-case analysis. In probabilistic sensitivity analyses, the likelihood of the vaccination program being cost-effective at willingness-to-pay thresholds of $50,000 and $100,000 per quality-adjusted life-year gained was 64% and 100%, respectively.

CONCLUSIONS

In a conservative analysis biased against the vaccination program, a national vaccination intervention program to ameliorate racial disparities in pneumococcal vaccination would be cost-effective.

Risk of invasive pneumococcal disease varies by neighbourhood characteristics: implications for prevention policies

This study investigates neighbourhood variation in rates of pneumococcal bacteraemia and community-level factors associated with neighbourhood heterogeneity in disease risk. We analysed data from 1416 adult and paediatric cases of pneumococcal bacteraemia collected during 2005-2008 from a population-based hospital surveillance network in metropolitan Philadelphia. Cases were geocoded using residential address to measure disease incidence by neighbourhood and identify potential neighbourhood-level risk factors. Overall incidence of pneumococcal bacteraemia was 36∙8 cases/100,000 population and varied significantly (0-67∙8 cases/100,000 population) in 281 neighbourhoods. Increased disease incidence was associated with higher population density [incidence rate ratio (IRR) 1∙10/10,000 people per mile², 95% confidence interval (CI) 1∙0-1∙19], higher percent black population (per 10% increase) (IRR 1∙07, 95% CI 1∙04-1∙09), population aged ≤5 years (IRR 3∙49, CI 1∙8-5∙18) and population aged ≥65 years (IRR 1∙19, CI 1∙00-1∙38). After adjusting for these characteristics, there was no significant difference in neighbourhood disease rates. This study demonstrates substantial small-area variation in pneumococcal bacteraemia risk that appears to be explained by neighbourhood sociodemographic characteristics. Identifying neighbourhoods with increased disease risk may provide valuable information to optimize implementation of prevention strategies.

Housing data-based socioeconomic index and risk of invasive pneumococcal disease: an exploratory study

We previously developed and validated an index of socioeconomic status (SES) termed HOUSES (housing-based index of socioeconomic status) based on real property data. In this study, we assessed whether HOUSES overcomes the absence of SES measures in medical records and is associated with risk of invasive pneumococcal disease (IPD) in children. We conducted a population-based case-control study of children in Olmsted County, MN, diagnosed with IPD (1995-2005). Each case was age- and gender-matched to two controls. HOUSES was derived using a previously reported algorithm from publicly available housing attributes (the higher HOUSES, the higher the SES). HOUSES was available for 92·3% (n = 97) and maternal education level for 43% (n = 45). HOUSES was inversely associated with risk of IPD in unmatched analysis [odds ratio (OR) 0·22, 95% confidence interval (CI) 0·05-0·89, P = 0·034], whereas maternal education was not (OR 0·77, 95% CI 0·50-1·19, P = 0·24). HOUSES may be useful for overcoming a paucity of conventional SES measures in commonly used datasets in epidemiological research.

Factors affecting the likelihood of presentation to the emergency department of trauma patients after discharge

STUDY OBJECTIVE

We determine the rate at which trauma patients re-present to the emergency department (ED) after discharge from the hospital and determine whether re-presentation is related to race, insurance, and socioeconomic factors such as neighborhood income level.

METHODS

Trauma patients admitted to a Level I trauma center between January 1, 1997, and December 31, 2007, were identified with the hospital's trauma registry. These patients were linked to administrative data to obtain information about re-presentation to the hospital. Neighborhood income was obtained with census block data; multiple imputation was implemented to account for missing income data. Logistic regression analysis was used to determine the predictors of re-presentation.

RESULTS

There were 6,675 patients who were included in the study. A total of 886 patients (13.3%) returned to the ED within 30 days of discharge from the hospital. Uninsured patients (odds ratio [OR]=1.64; 95% confidence interval [CI] 1.30 to 2.06) and publicly insured patients (OR=1.60; 95% CI 1.20 to 2.14) were more likely to re-present to the ED than those with commercial insurance. Residing in a neighborhood with a median household income less than $20,000 was associated with a higher odds of re-presentation (OR=1.77; 95% CI 1.37 to 2.29). Only 13.2% of patients who came to the ED were readmitted to the hospital.

CONCLUSION

A substantial number of trauma patients return to the ED within 30 days of being discharged, but only a small proportion of these patients required readmission. Re-presentation is associated with being uninsured or underinsured and with lower neighborhood income level.

Neighborhood socioeconomic status and influenza hospitalizations among children: New Haven County, Connecticut, 2003-2010

OBJECTIVES

We examined surveillance data for disparities in pediatric influenza-associated hospitalizations according to neighborhood socioeconomic status (SES) measures in New Haven County, Connecticut.

METHODS

We geocoded influenza-associated hospitalization case data from the past 7 years for children from birth to age 17 years and linked these to US Census 2000 tract-level SES data. Following the methods of Harvard's Public Health Disparities Geocoding Project, we examined neighborhood SES variables, including measures of poverty and crowding. We calculated influenza-associated hospitalization incidence by influenza season and individual case characteristics, stratified by SES measures.

RESULTS

Overall, the mean annual incidence of pediatric influenza-associated hospitalization in high-poverty and high-crowding census tracts was at least 3 times greater than that in low-poverty and low-crowding tracts. This disparity could not be fully explained by prevalence of underlying conditions or receipt of influenza vaccination.

CONCLUSIONS

Linkage of geocoded surveillance data and census information allows for ongoing monitoring of SES correlates of health and may help target interventions. Our analysis indicates a correlation between residence in impoverished or crowded neighborhoods and incidence of influenza-associated hospitalization among children in Connecticut.

New approaches to estimating national rates of invasive pneumococcal disease

National infectious disease incidence rates are often estimated by standardizing locally derived rates using national-level age and race distributions. Data on other factors potentially associated with incidence are often not available in the form of patient-level covariates. Including characteristics of patients' area of residence may improve the accuracy of national estimates. The authors used data from the Centers for Disease Control and Prevention's Active Bacterial Core Surveillance program (2004-2005), adjusted for census-based variables, to estimate the national incidence of invasive pneumococcal disease (IPD). The authors tested Poisson and negative binomial models in a cross-validation procedure to select variables best predicting the incidence of IPD in each county. Including census-level information on race and educational attainment improved the fit of both Poisson and negative binomial models beyond that achieved by adjusting for other census variables or by adjusting for an individual's race and age alone. The Poisson model with census-based predictors led to a national estimate of IPD of 16.0 cases per 100,000 persons as compared with 13.5 per 100,000 persons using an individual's age and race alone. Accuracy of, and confidence intervals for, these estimates can only be determined by obtaining data from other randomly selected US counties. However, incorporating census-derived characteristics should be considered when estimating national incidence of IPD and other diseases.

Socioeconomic and racial/ethnic disparities in the incidence of bacteremic pneumonia among US adults

OBJECTIVES

We examined associations between the socioeconomic characteristics of census tracts and racial/ethnic disparities in the incidence of bacteremic community-acquired pneumonia among US adults.

METHODS

We analyzed data on 4870 adults aged 18 years or older with community-acquired bacteremic pneumonia identified through active, population-based surveillance in 9 states and geocoded to census tract of residence. We used data from the 2000 US Census to calculate incidence by age, race/ethnicity, and census tract characteristics and Poisson regression to estimate rate ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

During 2003 to 2004, the average annual incidence of bacteremic pneumonia was 24.2 episodes per 100 000 Black adults versus 10.1 per 100 000 White adults (RR = 2.40; 95% CI = 2.24, 2.57). Incidence among Black residents of census tracts with 20% or more of persons in poverty (most impoverished) was 4.4 times the incidence among White residents of census tracts with less than 5% of persons in poverty (least impoverished). Racial disparities in incidence were reduced but remained significant in models that controlled for age, census tract poverty level, and state.

CONCLUSIONS

Adults living in impoverished census tracts are at increased risk of bacteremic pneumonia and should be targeted for prevention efforts.

Moving beyond traditional measurement of mortality after injury: evaluation of risks for late death

BACKGROUND

The purpose of this study was to evaluate long-term mortality after trauma, and to determine risk factors and possible disparities related to mortality after hospital discharge.

STUDY DESIGN

Level I trauma center registry data from a 6-year period (2000 through 2005) were linked to patient electronic medical records, the National Death Index with cause of death codes, and census data using geographic information science (GIS) methodologies. Census data provided supplemental demographic and socioeconomic information from patient neighborhoods.

RESULTS

The hospital mortality rate for 15,285 patients was 3.3%, and mortality after discharge was 4.8%. Overall mortality for the study period was 8.1% (average follow-up, 2.8 years, 1-year mortality, 5.4%). Mortality after discharge was related to the initial injury in 33%, possibly related in 23%, and unrelated in 44% of patients. Logistic regression analysis demonstrated that independent predictors of hospital mortality were age, Injury Severity Score, gunshot injury, significant head injury, fall, and spinal cord injury. In contrast, independent risk factors for mortality after discharge were age, hospital length of stay, discharge from the hospital to a locale other than home, and the presence of spinal cord injury. Intoxication at hospital admission and injury due to a gunshot wound or motor vehicle collision were protective for late mortality. Bivariate analysis of census data demonstrated that lower socioeconomic status was associated with improved hospital survival, and non-native status was associated with mortality after discharge.

CONCLUSIONS

There is significant mortality attributable to trauma for up to 1 year after hospital discharge. These findings suggest that mortality after trauma needs to be measured beyond hospital discharge in order to assess the complete impact of injury.

Intravitreal bevacizumab and ranibizumab for age-related macular degeneration a multicenter, retrospective study

OBJECTIVE

To compare visual acuity (VA) outcomes after bevacizumab or ranibizumab treatment for AMD.

DESIGN

Comparative, retrospective case series.

PARTICIPANTS

We followed 452 patients in a retrospective study of exudative AMD treated with anti-vascular endothelial growth factor drugs; 324 patients were treated with bevacizumab and 128 patients with ranibizumab.

METHODS

All treatment-naïve patients who received either bevacizumab or ranibizumab were followed for 1 year. Baseline characteristics and VA were recorded using standard descriptive statistics.

MAIN OUTCOME MEASURES

Visual acuity.

RESULTS

At 12 months, the distribution of VA improved in both groups with 22.9% of bevacizumab and 25.0% of ranibizumab attaining >or=20/40. Improvement in vision was observed in 27.3% of the bevacizumab group and 20.2% of the ranibizumab group. The mean number of injections at 12 months was 4.4 for bevacizumab and 6.2 for ranibizumab. There were 8 (2%) deaths in the bevacizumab group and 4 (3%) in the ranibizumab group. Two patients developed endophthalmitis in the bevacizumab group and the ranibizumab group. The bevacizumab group had slightly worse acuity at baseline, but both groups showed improvement and stability of vision over time.

CONCLUSIONS

Both treatments seem to be effective in stabilizing VA loss. There was no difference in VA outcome between the 2 treatment groups. Because the study is a nonrandomized comparison, selection bias could mask a true treatment difference. Results from the Comparison of the Age-related Macular Degeneration Treatment Trials will provide more definitive information about the comparative effectiveness of these drugs.

A case-control study of sociodemographic and geographic characteristics of 335 children with eosinophilic esophagitis

BACKGROUND & AIMS

The epidemiology of pediatric eosinophilic esophagitis (EE) is poorly characterized. In this study, we aimed to determine demographic, socioeconomic, and geographic characteristics of our cohort of EE children.

METHODS

A case-control design was used to compare 335 EE subjects with control subjects from gastroenterology (GI) and allergy clinics as well as 2000 U.S. census data.

RESULTS

EE subjects were significantly different than the greater Philadelphia population as well as control subjects from our gastroenterology and allergy clinics. EE subjects were 83.6% Caucasian, compared with 70.9% of GI control subjects (odds ratio [OR], 2.17; P < .001; confidence interval [CI], 1.52-3.11), 64.9% of allergy control subjects (OR, 2.83; P < .001; CI, 1.99-4.04), and 73.0% of the greater Philadelphia population. EE subjects were 75.8% male, compared with 48.0% of GI control subjects (OR, 3.39; P < .001; CI, 2.47-4.65), 60.4% of allergy control subjects (OR, 1.62; P < .001; CI, 1.19-2.19), and 48.0% of the greater Philadelphia population. We initially demonstrated that EE subjects are more affluent, more educated, and reside more often in suburban areas. However, Caucasian race was a significant confounding variable and accounted for socioeconomic or geographic differences among EE subjects and our control populations with one exception. A significant difference remained between suburban and urban residence in EE and allergy control populations.

CONCLUSIONS

EE subjects are significantly different than control groups in their demographic characteristics of Caucasian race and male sex. EE subject socioeconomic and geographic characteristics are not different than our typical referral patterns to GI clinic when adjusted for race as a confounding factor.

Identification and characteristics of vaccine refusers

Background

This study evaluated the utility of immunization registries in identifying vaccine refusals among children. Among refusers, we studied their socioeconomic characteristics and health care utilization patterns.

Methods

Medical records were reviewed to validate refusal status in the immunization registries of two health plans. Racial, education, and income characteristics of children claiming refusal were collected based on the census tract of each child. Health care utilization was identified using both electronic medical record and insurance claims. Within the immunization registries of two HMOs in the study, some providers use refusal and medical contraindication interchangeably, and some providers tend to always use "ever refusal." Therefore, we combined medical contraindication and refusal together and treated them all as "refusal" in this study.

Results

The immunization registry, compared to chart review, had negative predictive values of 85–92% and 90–97% for 2- and 6-year olds, and positive predictive values of only 52–74% and 59–62% to identify vaccine refusals. Refusers were more likely to reside in well-educated, higher income areas than non-refusers. Refusers had not opted out of health care system and continued, although less frequently for the age 2 and under group, to use services.

Conclusion

Without enhancements to immunization registries, identifying children with immunization refusal would be time consuming. Since communities where refusers live are well educated, interventions should target these communities to communicate vaccine adverse events and consequences of vaccine preventable diseases.

Socioeconomic risk factors for bacteraemic pneumococcal pneumonia in adults

Demographic and clinical risk factors are important in guiding vaccination policy for pneumococcal pneumonia. We present data on these variables from a population-based surveillance network covering adult bacteraemic pneumococcal pneumonia (BPP) in the Delaware Valley region from 2002 to 2004. Surveillance data were used with U.S. Census data and a community health survey to calculate stratified incidence rates. Missing data were handled using multiple imputation. Overall rates of adult BPP were 10.6 cases/100 000 person-years. Elevated rates were seen in the elderly (>65 years), Native Americans, African Americans, the less-educated (less than high-school education), the poor, smokers, and individuals with histories of asthma, cancer, or diabetes. Multivariable modelling suggested that income was more robustly associated with risk than African American race. Of methodological interest, this association was not apparent if census block-group median income was used as a proxy for self-reported income. Further research on socioeconomic risk factors for BPP is needed.

Tobacco use among Native Hawaiian middle school students: its prevalence, correlates and implications

OBJECTIVES

This study sought to explore whether Native Hawaiian primary ethnic identity is associated with cigarette use among Native Hawaiian middle school students. This study also explored whether social influence, psychosocial and cultural factors are associated with cigarette use in this sample.

DESIGN

The data are from a cross-sectional survey of 1,695 Native Hawaiian middle school students at 22 public and private schools on five islands in Hawaii. A subset of these students from Native Hawaiian serving schools (N=136) completed additional measures of Hawaiian cultural variables.

RESULTS

Based on univariate analyses, students whose primary ethnic identification was Hawaiian were more likely to have tried smoking (p<0.001) and to be current smokers (p<0.05) as compared to those classified as part Hawaiian. However, these findings were no longer significant in multivariate analyses. Social influence variables (i.e. peer and parental smoking) were most influential in explaining both prior and current smoking. Attendance at public school was also an important factor in explaining previous (OR=2.43; 95% CI=1.74, 3.38) and current (OR=7.20; 95% CI=4.58, 11.32) smoking behavior. Finally, cultural variables such as valuing Hawaiian folklore, customs, activities and lifestyle were largely unassociated with smoking behavior among Native Hawaiian middle school youth.

CONCLUSIONS

Additional research is needed to understand what aspects of ethnic identity are associated with smoking behavior among Native Hawaiian youth. The strong influence of peer and parental smoking suggests the need for interventions that support the creation of social environments that discourage tobacco use.

Perinatal risk factors for hospitalization for pneumococcal disease in childhood: a population-based cohort study

OBJECTIVE

The objective of this study was to examine the relation of factors that are present at birth to subsequent hospitalization for childhood pneumococcal disease.

METHODS

We conducted a cohort study of all singletons born in 3 counties in western Denmark from 1980 through 2001, using population-based registries to obtain data on pregnancy- and birth-related variables and hospitalizations through age 12. We calculated incidence rates of pneumococcal disease hospitalization overall and within strata of study variables and used Poisson regression to estimate rate ratios for pneumococcal disease hospitalization while accounting for other birth characteristics.

RESULTS

Among 338,504 eligible births, 1052 children were later hospitalized for pneumococcal disease. Pneumonia accounted for most hospitalizations (81.9%). The pneumococcal disease hospitalization rate was highest among 7- to 24-month-olds, followed by 0- to 6-month-olds and 25- to 60-month-olds. The highest rates, typically over 200 hospitalizations per 100,000 person-years, were in 0- to 6- and 7- to 24-month-old children who were born preterm or with low birth weight, a low 5-minute Apgar score, or birth defects. The hospitalization rate was lower for first-born children at 0 to 6 months but not at older ages. At older ages, hospitalization rates were not substantially different for children whose mothers smoked during pregnancy, but at 0 to 6 months, the rate was higher for children of multiparous nonsmokers than for others. Adjusted rate ratios were elevated across all age categories for several variables, including low birth weight, presence of birth defects, and low 5-minute Apgar. For several others, including preterm birth, maternal multiparity, age < or = 20 years, and non-Danish/European Union citizenship, adjusted rate ratios were elevated only for 0- to 6-month-olds.

CONCLUSIONS

This large cohort study of hospitalization for childhood pneumococcal disease clarifies the roles of some gestation and birth factors while raising new questions about how these factors work.

Activating multi-ethnic youth for smoking prevention: design, baseline findings, and implementation of project SPLASH

BACKGROUND

Achieving significant reductions in tobacco use by youth is an important challenge. There is a pressing need to develop and evaluate innovative strategies that stimulate youth involvement and are effective in multi-ethnic populations. This article describes an innovative tobacco prevention trial, and reports baseline characteristics of participants and findings about implementation of the curriculum.

METHODS

The aim of Project SPLASH is to evaluate the impact of a school-based smoking prevention intervention that emphasizes active involvement of middle school students, on rates of smoking initiation and regular smoking in a multi-ethnic cohort of youth in Hawaii. Project SPLASH is a group randomized trial that compares a 2-year innovative intervention with a social influence prevention program, in 20 public schools in Hawaii. The main outcome is mean 30-day smoking prevalence rates.

RESULTS

The response rate was 78.4%. Approximately 1 in 4 students had tried smoking and 30-day smoking prevalence at baseline was 8%. Intervention and control groups were comparable in terms of tobacco use, gender, ethnicity, behavioral, environmental, and psychosocial characteristics. Differences in ethnic identification, socio-economic status, acculturation, and involvement in prevention activities may be due to chance. The intervention was well implemented by teachers across both the intervention and control school classes.

CONCLUSION

For this study, 20 schools in Hawaii with close to 4000 participating students were recruited. Student smoking behavior and curriculum implementation were comparable by group status. The intervention study has the potential to elucidate how youth respond to an intervention with student involvement that incorporates cognitive and social action components.

Invasive pneumococcal disease in a cohort of HIV-infected adults: incidence and risk factors, 1990-2003

OBJECTIVE

To investigate the association between the introduction of HAART and invasive pneumococcal disease (IPD) in HIV-infected patients.

METHODS

Incidence of IPD was determined from 1990 to 2003 in a cohort of HIV-infected individuals and a nested case-control study assessed risk factors of IPD.

RESULTS

There were 72 cases over 19,020 person-years of follow-up (overall IPD rate, 379/100,000 person-years). In the calendar periods 1990-1995, 1995-1998, and 1998-2003, the IPD incidence per 100,000 person-years was 279 [95% confidence interval (CI), 150-519], 377 (95% CI, 227-625) and 410 (95% CI, 308-545), respectively (P = 0.516). CD4 cell count < 200 cells/microl [odds ratio (OR), 3.0; 95% CI, 1.2-7.6), HIV RNA > 50,000 copies/ml (OR, 2.8; 95% CI, 1.2-6.5), hepatitis C (OR, 4.9; 95% CI, 1.7-14.9), serum albumin (OR, 0.1; 95% CI, 0.04-0.5), injection drug use in women (OR, 3.8; 95% CI, 1.6-8.8), and education beyond high school (OR, 0.2; 95% CI, 0.05-0.8) were significantly associated with IPD in multivariate analysis. No treatment factor, including HAART (OR, 0.7; 95% CI, 0.3-1.5) and pneumococcal vaccination (OR, 0.9; 95% CI, 0.5-1.6), was associated with IPD.

CONCLUSIONS

IPD incidence did not change significantly during the widespread dissemination of HAART in this cohort. IPD risk was associated with several sociodemographic and clinical factors.

Asthma and air pollution in the Bronx: methodological and data considerations in using GIS for environmental justice and health research

This paper examines methods of environmental justice assessment with Geographic Information Systems, using research on the spatial correspondence between asthma and air pollution in the Bronx, New York City as a case study. Issues of spatial extent and resolution, the selection of environmental burdens to analyze, data and methodological limitations, and different approaches to delineating exposure are discussed in the context of the asthma study, which, through proximity analysis, found that people living near (within specified distance buffers) noxious land uses were up to 66 percent more likely to be hospitalized for asthma, and were 30 percent more likely to be poor and 13 percent more likely to be a minority than those outside the buffers.

Ethnicity, sense of coherence, and tobacco use among adolescents

BACKGROUND

Prevention of youth smoking has great potential to improve the health of Americans. There is limited information about correlates of tobacco use among adolescents from ethnic minority groups, especially Asians, Pacific Islanders, and Native Hawaiians.

PURPOSE

This article examines the relationships among ethnicity, sense of coherence (SOC), and tobacco use.

METHODS

We conducted a baseline survey of a cluster randomized tobacco prevention trial in public middle schools in Hawaii with a multiethnic sample of 3,438 seventh-grade students.

RESULTS

Ethnic differences in smoking prevalence were very large, with high smoking rates among Native Hawaiian/Pacific Islander, White, and Filipino students and with low rates among Japanese and Chinese students. Higher SOC scores predicted significantly lower risk of having ever smoked and of smoking in the past 30 days. SOC was most strongly related to ever smoking among Filipino, Hawaiian/Pacific Islander, and White students; Japanese students experienced the strongest protective effect from SOC for past-month smoking.

CONCLUSIONS

The results suggest that SOC is strongly associated with tobacco use among this age group. It will be important to examine whether SOC can be improved by an intervention program and whether increases in SOC are associated with reduced smoking.

Impact of socioeconomic factors and antibiotic prescribing on penicillin- non-susceptible Streptococcus pneumoniae in the city of Malmö

Carriage or infection with penicillin-non-susceptible Streptococcus pneumoniae (PNSP) has been associated with antibiotic prescribing, socioeconomic factors, and attendance at day-care centres (DCCs). In the present study, linear regression was used to estimate the relation between these risk factors and the incidence of PNSP cases (non-susceptible defined as MIC =0.5 microg/ml for penicillin) in 19 residential areas in Malmö. The number of PNSP cases was associated with the number of preschool children in the area (r=0.950, p<0.0001). The incidence of PNSP cases per 1000 children was positively correlated with antibiotic prescribing (r=0.614, p<0.01) but not with DCC attendance or any of the socioeconomic factors studied. Antibiotic prescribing was, however, positively correlated with per capita income (r = 0.597, p<0.05). Thus, even if higher socioeconomic status alone had no apparent influence on the incidence of PNSP in Malmö, there was still an indirect relation between these 2 factors, since inhabitants in these areas consumed more antibiotics. Based on these results, the spread of antibiotic-resistant pneumococci seems to be most reliably restricted by pursuing a restrictive policy regarding antibiotic prescription.

Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization

BACKGROUND

Dementia is a growing public health problem and a well-described risk factor for delirium. Yet little is known about delirium superimposed on dementia in community-dwelling populations. The purpose of this study was to examine the 3-year occurrence, healthcare utilization, and costs associated with delirium superimposed on dementia in community-dwelling persons.

METHODS

We used a 3-year cross-sectional, retrospective design with an administrative database from a large managed care organization. Four individually matched samples of 699 individuals each were selected for comparison purposes: delirium superimposed on dementia (DSD), dementia alone, delirium alone, and a control group with neither delirium nor dementia. The occurrence rate of DSD was calculated by measuring those individuals with a dementia diagnosis that were also coded with an International Classification of Diseases, Ninth Edition Clinical Modification (ICD-9 CM) code for delirium or delirium with dementia.

RESULTS

Of the total sample of 76,688 persons aged 65 years or older in the managed care organization, 7347 (10%) were coded as having dementia, and an additional 763 (1%) as having delirium alone. Among the 7347 with dementia, 976 (13%) had DSD, representing 1.3% of the total sample. After log transformation of total costs and adjustment for multiple covariates, the adjusted mean total health care costs remained significantly higher for the DSD group than for all other groups.

CONCLUSIONS

This study is the first to report the occurrence rate of DSD in a community-dwelling population, and to demonstrate the substantial health care costs and utilization associated with DSD.

Modeling Community- and Individual-Level Effects of Child-Care Center Attendance on Pneumococcal Carriage

BACKGROUND

The prevalence of pneumococcal carriage varies widely across communities. This variation is not fully explained by risk factors at the individual level but may be explained by factors producing effects at both the individual and community levels, such as child-care center (CCC) attendance.

METHODS

We developed a transmission model to evaluate whether the combined risks of attending CCCs and associating with playmates who attend CCCs account for a large proportion of the variability in the prevalence of pneumococcal carriage across communities. We based parameters for the model on data from a multicommunity study.

RESULTS

According to our model, differences in the proportion of children who attend CCCs can account for a range of 4%-56% in the prevalence of pneumococcal carriage across communities. Our model, which was based on data collected from 16 Massachusetts communities, predicts that the odds of carriage associated with CCC attendance are 2-3 times the odds associated with no CCC attendance (individual-level effect). The model also predicts that the odds of carriage for nonattendees in a community with CCCs are up to 6 times the odds for children in a community without CCCs (community-level effect). In addition, the mean number of hours spent at CCCs by a single attendee appears to exert effects on pneumococcal carriage that are independent of either the proportion of CCC attendance in the community or the mean number of hours these attendees spend in child care.

CONCLUSIONS

We used data from multiple communities to develop a transmission model that explains marked differences in pneumococcal carriage across communities by variations in CCC attendance. This model only accounts for CCC attendance among young children and does not include other known risk factors for pneumococcal carriage.

Socioeconomic disparities in health: the impact of pharmacotherapy

Along with age and gender, socioeconomic status is a fundamental driver of health. This review discusses the meaning of socioeconomic status and how it influences health across a person's life. Particular attention is paid to the role of psychosocial stress and self-determination. Through various pathways, socioeconomic status may affect biologic aging. This review also discusses the implications of the socioeconomic status-health relationship for understanding international differences in population health such as differences in life expectancy. The review concludes with a discussion of the implications of these findings for national policies and the potential impact of pharmacotherapy.

Spouses of persons with dementia: their healthcare problems, utilization, and costs

Spouses of persons with dementia (PWD) often experience poor health outcomes related to the experience of living with the afflicted spouse. Using the Anderson and Aday Healthcare Utilization Model, we conducted a retrospective review of an administrative database from a private healthcare insurer to compare health problems that precipitate utilization, patterns of utilization, and costs of care of spouses of PWD (n = 979) to those of spouses of persons without dementia (n = 979). Spouses of PWD were treated for more anxiety disorders (OR = 2.97; 95% CI = 1.63-5.44), falls (OR = 7.72; 95% CI = 2.73-21.84), rheumatologic diseases (OR = 2.5; 95% CI = 1.24-5.06), and diabetes with no complications (OR = 1.53; 95% CI = 1.06-2.22), but less pneumonia (OR =.55; 95%; CI =.35-.88) than comparison spouses. Spouses of PWD had a higher number of emergency room (ER) visits (p =.01). There were no differences in costs between the groups. The findings can be used to develop interventions for spouses of PWD.

Prognostic importance of presenting symptoms in patients undergoing exercise testing for evaluation of known or suspected coronary disease

PURPOSE

Chest symptoms, along with standard cardiovascular risk factors, are commonly factored into pretest risk stratification of patients who are referred for stress testing. We sought to determine the independent prognostic value of chest symptoms.

METHODS

We studied the outcomes of 10,870 patients referred for symptom-limited exercise testing who had no history of myocardial revascularization, heart failure, or arrhythmias. Chest symptoms were prospectively characterized according to prespecified definitions. Propensity analysis was used to account for differences in baseline and exercise characteristics.

RESULTS

Typical angina was present in 635 patients (6%), atypical angina in 3408 (33%), nonanginal chest pain in 1805 (17%), and dyspnea in 841 (8%). The remaining 4181 patients (38%) were asymptomatic. During a mean follow-up of 4.3 years, there were 381 deaths. After propensity matching patients who had typical angina with asymptomatic patients, symptoms were not predictive of mortality (adjusted hazard ratio [HR] = 0.8; 95% confidence interval [CI]: 0.6 to 1.3; P = 0.4). Among patients who had chest pain, typical angina was associated with a highly significant risk of mortality as compared with nonanginal chest pain (HR = 2.7; 95% CI: 1.4 to 5.1; P = 0.002), but not compared with atypical angina (HR = 1.3; 95% CI: 0.9 to 2.1; P = 0.21).

CONCLUSION

After accounting for baseline and exercise characteristics, the presence of symptoms was not independently associated with increased mortality among patients undergoing testing for known or suspected coronary disease. Among patients who actually had chest pain, typical angina carried a higher mortality risk.

Invasive pneumococcal disease in the Australian Capital Territory and Queanbeyan region: do high infant rates reflect more disease or better detection?

OBJECTIVE

To describe the epidemiology of invasive pneumococcal disease in the Australian Capital Territory (ACT) and Queanbeyan region prior to the introduction of conjugate pneumococcal vaccines.

METHODOLOGY

Residents with sterile site isolates of Streptococcus pneumoniae from 1998 to 2000 were identified from a prospective bacteraemia surveillance project involving all ACT public hospitals, supplemented by retrospective laboratory-based detection of other sterile site isolates.

RESULTS

Incidence of invasive pneumococcal disease was 15.2 cases per 105 per year, and 193.4 per 105 per year in infants under 2 years. Primary bacteraemia was significantly more common in infants and young children than in older subjects. Reduced penicillin susceptibility was observed in 9.6% of isolates, and no high-level penicillin resistance was observed.

CONCLUSIONS

Infants in the ACT and Queanbeyan have a higher invasive pneumococcal disease incidence than similar populations worldwide. Better detection is the most likely explanation. This population would be ideal for studies of the 'real life' effectiveness of infant conjugate vaccination.

Assessment of a national health interview survey-based method of measuring community socioeconomic status

PURPOSE

Increasingly researchers are interested in assessing the role of community socioeconomic status (SES) in poor health outcomes, above and beyond the influence of low individual SES. However, the feasibility of conducting these multi-level studies is often limited by restrictions on release of confidential identifiers for linkage to census data, resources for the linkage, and the availability of data sources with individual SES measures. This study assessed a new method of measuring community socioeconomic status (SES) that can be used with the publicly available National Health Interview Survey (NHIS) and preserves confidentiality and can be used with individual SES measures from the NHIS.

METHODS

The associations between community SES and mortality from all causes and breast cancer in women were assessed in two samples: 1) deaths in 1987-1993 NHIS respondents linked to community SES measures developed with the new method; and 2) deaths in 1991 from the National Multiple Cause of Death Files linked to 1990 county-level census SES measures. The magnitude of crude mortality rates, direction of trend, and age-adjusted relative risk of mortality for low vs. high SES were compared in the two samples.

RESULTS

Crude all-cause mortality and breast cancer mortality rates were similar in both samples in terms of magnitude and direction of trend. In both samples, as SES decreased, rates of all-cause mortality increased, whereas breast cancer mortality rates tended to decrease. Age-adjusted relative risks of mortality from all causes and breast cancer for low vs. high SES were similar in the two samples.

CONCLUSIONS

Similarity of associations between community SES and mortality from all causes and breast cancer in the two samples provides support for the validity of a new NHIS-based method of measuring community SES. Since the NHIS is a large, nationally representative survey with high response rates and low loss to mortality follow-up, this method represents an important resource for multi-level studies.

Invasive Pneumococcal Disease in Older Adults Residing in Long-Term Care Facilities and in the Community

OBJECTIVES

To examine the epidemiology of invasive pneumococcal disease in older adults hospitalized for invasive pneumococcal disease who are living in the community and in long-term care facilities (LTCFs) in the United States.

DESIGN

Analysis of 2402 cases of invasive pneumococcal disease requiring hospitalization in 2000 and 2001 that the Centers for Disease Control and Prevention's Active Bacterial Core Surveillance collected in nine states.

SETTING

Hospital.

PARTICIPANTS

Hospitalized LTCF residents and community-living older adults in the United States.

MEASUREMENTS

Age- and residence-specific pneumococcal disease incidence rates per 100000 persons, case-fatality rates, and trends in antimicrobial resistance.

RESULTS

Nationally, the rate of invasive pneumococcal disease in LTCF residents was 194.2 cases per 100000 persons aged 65 and older and 44.6 for community-living older adults (relative risk=4.4, 95% confidence interval (CI)=4.2-4.5). Compared with community-living older adults, case-fatality rates were 1.9 times higher (30.8% vs 16.0%, 95% CI=1.5-2.5). Pneumococcal strains from LTCF residents were significantly more likely to be nonsusceptible to levofloxacin than strains from community- living older adults (5.7% vs 0.4%, P<.001).

CONCLUSION

Older adults living in LTCFs are at a higher risk for invasive pneumococcal disease and death than are community-living older adults. Additionally, fluoroquinolone resistance is significantly higher in older adults living in LTCFs and may provide clues to emerging antimicrobial resistance in the general population.

Invasive pneumococcal disease in Scotland, 1999-2001: use of record linkage to explore associations between patients and disease in relation to future vaccination policy

A record linkage study was done to provide comprehensive data on the epidemiologic characteristics of invasive pneumococcal disease (IPD) in Scotland. The overall incidence of IPD was 11 cases/10(5) persons and 21 cases/10(5) persons <1 year of age, 51 cases/10(5) persons 1 year of age, 45 cases/10(5) elderly persons (age > or =65 years), 176-483 cases/10(5) persons with chronic medical conditions, and 562-2031 cases/10(5) persons with severe immunosuppression. The case-fatality rate was 11% among elderly persons and ranged from 3% to 13% among persons with underlying medical conditions. The most common pneumococcal serogroups associated with IPD were 14, 9, 6, 19, 23, 8, and 4. Serogroups included in the 23-valent polysaccharide vaccine caused the majority of cases of IPD. The proportion of IPD due to the 7-, 9-, and 11-valent conjugate vaccine serogroups was lower among older people and persons with underlying medical conditions.

Geocoding addresses from a large population-based study: lessons learned

BACKGROUND

Geographic information systems (GIS) and spatial statistics are useful for exploring the relation between geographic location and health. The ultimate usefulness of GIS depends on both completeness and accuracy of geocoding (the process of assigning study participants' residences latitude/longitude coordinates that closely approximate their true locations, also known as address matching). The goal of this project was to develop an iterative geocoding process that would achieve a high match rate in a large population-based health study.

METHODS

Data were from a study conducted in Wisconsin using mailing addresses of participants who were interviewed by telephone from 1988 to 1995. We standardized the addresses according to US Postal Service guidelines, used desktop GIS geocoding software and two versions of the Topologically Integrated Geographic Encoding and Referencing street maps, accessed Internet mapping engines for problematic addresses, and recontacted a small number of study participants' households. We also tabulated the project's cost, time commitment, software requirements, and brief notes for each step and their alternatives.

RESULTS

Of the 14,804 participants, 97% were ultimately assigned latitude/longitude coordinates corresponding to their respective residences. The remaining 3% were geocoded to their zip code centroid.

CONCLUSION

The multiple methods described in this work provide practical information for investigators who are considering the use of GIS in their population health research.

Environmental measures of physical activity supports: perception versus reality

BACKGROUND

Perceptions of the environment and physical activity have been associated using survey methods, yet little is known about the validity of environmental surveys. In this study, perceptions of the environment at neighborhood and community levels were assessed (1) to determine validity by comparing respondent perceptions to objective measures and (2) to determine test-retest reliability of the survey.

METHODS

A telephone survey was administered to a stratified sample of Sumter County, South Carolina adults. Respondents' home addresses were mapped using a geographic information system (GIS) (n =1112). As an indicator of validity, kappa statistics were used to measure agreement between perceptions and objective measures identified at neighborhood and community levels using GIS. A second survey in an independent sample (n=408) assessed test-retest reliability.

RESULTS

When assessing perceptions of environmental and physical activity in a defined geographic area, validity and reliability for neighborhood survey items were kappa= -0.02 to 0.37 and rho=0.42 to 0.74, and for community survey items were kappa= -0.07 to 0.25 and rho=0.28 to 0.56.

CONCLUSIONS

Although causality between perception of access and safety and actual physical activity level cannot be assumed, those meeting national physical activity guidelines or reporting some physical activity demonstrated greatest agreement with access to recreation facilities, while those not meeting the guidelines demonstrated greater agreement with safety of recreation facilities. Factors such as distance and behavior may explain differences in perceptions at neighborhood and community levels. Using local environments with short distances in survey methods improves validity and reliability of results.

Sentinel surveillance: a reliable way to track antibiotic resistance in communities?

We used population-based data to evaluate how often groups of randomly selected clinical laboratories accurately estimated the prevalence of resistant pneumococci and captured trends in resistance over time. Surveillance for invasive pneumococcal disease was conducted in eight states from 1996 to 1998. Within each surveillance area, we evaluated the proportion of all groups of three, four, and five laboratories that estimated the prevalence of penicillin-nonsusceptible pneumococci (%PNSP) and the change in %PNSP over time. We assessed whether sentinel groups detected emerging fluoroquinolone resistance. Groups of five performed best. Sentinel groups accurately predicted %PNSP in five states; states where they performed poorly had high between-laboratory variation in %PNSP. Sentinel groups detected large changes in prevalence of nonsusceptibility over time but rarely detected emerging fluoroquinolone resistance. Characteristics of hospital-affiliated laboratories were not useful predictors of a laboratory's %PNSP. Sentinel surveillance for resistant pneumococci can detect important trends over time but rarely detects newly emerging resistance profiles.

Rethinking recommendations for use of pneumococcal vaccines in adults

Streptococcus pneumoniae remains a major cause of disease worldwide; the emergence of antibiotic-resistant strains emphasizes the importance of disease prevention by use of vaccines. Recent studies have provided information that is useful for the evaluation of current vaccine recommendations. Recommendations target most people who are at high risk for invasive pneumococcal disease. However, higher risk has also been identified for African Americans and smokers, but these groups are not specifically targeted by current recommendations. The vaccine is effective against invasive disease in immunocompetent people, although studies in immunocompromised subjects have found few subgroups in which the vaccine appears to be effective. Questions with regard to optimal timing and indications for revaccination remain a challenge, because the duration of protection and effectiveness of revaccination remain unknown. New pneumococcal vaccines appear promising but will need to be tested against the performance of the polysaccharide vaccine. Improving delivery of the currently available pneumococcal polysaccharide vaccine to adults who will benefit should be a high priority.

On the wrong side of the tracts? Evaluating the accuracy of geocoding in public health research

OBJECTIVES

This study sought to determine the accuracy of geocoding for public health databases.

METHODS

A test file of 70 addresses, 50 of which involved errors, was generated, and the file was geocoded to the census tract and block group levels by 4 commercial geocoding firms. Also, the "real world" accuracy of the best-performing firm was evaluated.

RESULTS

Accuracy rates in regard to geocoding of the test file ranged from 44% (95% confidence interval [CI] = 32%, 56%) to 84% (95% CI = 73%, 92%). The geocoding firm identified as having the best accuracy rate correctly geocoded 96% of the addresses obtained from the public health databases.

CONCLUSIONS

Public health studies involving geocoded databases should evaluate and report on methods used to verify accuracy.

A new conjugate vaccine against pneumococcal disease

Streptococcus pneumoniae (pneumococcus) is a major cause of morbidity and mortality, particularly among infants and children. Pneumococcal 7-valent conjugate vaccine (PNCRM7) is the first conjugate vaccine known to prevent most invasive pneumococcal disease in infants and children. PNCRM7, which has a favorable safety profile, provides protection against invasive disease caused by antibiotic-resistant strains of S. pneumoniae, and the vaccine has demonstrated a significant impact on otitis media recurrence. Routine immunization with this vaccine should substantially reduce morbidity and mortality and improve the quality of life for infants, children, and their families.

Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States

BACKGROUND

The emergence of drug-resistant strains of bacteria has complicated treatment decisions and may lead to treatment failures.

METHODS

We examined data on invasive pneumococcal disease in patients identified from 1995 to 1998 in the Active Bacterial Core Surveillance program of the Centers for Disease Control and Prevention. Pneumococci that had a high level of resistance or had intermediate resistance according to the definitions of the National Committee for Clinical Laboratory Standards were defined as "resistant" for this analysis.

RESULTS

During 1998, 4013 cases of invasive Streptococcus pneumoniae disease were reported (23 cases per 100,000 population); isolates were available for 3475 (87 percent). Overall, 24 percent of isolates from 1998 were resistant to penicillin. The proportion of isolates that were resistant to penicillin was highest in Georgia (33 percent) and Tennessee (35 percent), in children under five years of age (32 percent, vs. 21 percent for persons five or more years of age), and in whites (26 percent, vs. 22 percent for blacks). Penicillin-resistant isolates were more likely than susceptible isolates to have a high level of resistance to other antimicrobial agents. Serotypes included in the 7-valent conjugate and 23-valent pneumococcal polysaccharide vaccines accounted for 78 percent and 88 percent of penicillin-resistant strains, respectively. Between 1995 and 1998 (during which period 12,045 isolates were collected), the proportion of isolates that were resistant to three or more classes of drugs increased from 9 percent to 14 percent; there also were increases in the proportions of isolates that were resistant to penicillin (from 21 percent to 25 percent), cefotaxime (from 10 percent to 15 percent), meropenem (from 10 percent to 16 percent), erythromycin (from 11 percent to 16 percent), and trimethoprim-sulfamethoxazole (from 25 percent to 29 percent). The increases in the frequency of resistance to other antimicrobial agents occurred exclusively among penicillin-resistant isolates.

CONCLUSIONS

Multidrug-resistant pneumococci are common and are increasing. Because a limited number of serotypes account for most infections with drug-resistant strains, the new conjugate vaccines offer protection against most drug-resistant strains of S. pneumoniae.