Research Activities, May 2012: Disparities/Minority Health: Sex-related health differences associated with income and marital status

Research Activities, May 2012: Disparities/Minority Health: Sex-related health differences associated with income and marital status

Sex-related health differences associated with income and marital status

Gender-related differences have been identified for multiple health-related outcomes, such as disease prevalence, mortality, health behaviors, health care use, and health-related quality of life (HRQoL). A new study finds that men in the United States have better estimated physical and psychosocial health and less pain than do women. These gender differences were mostly explained by income and marital status. Age, race, and education explained less of the differences, according to the study.
A greater proportion of women (29 vs. 23 percent) were in one of the two lower-income categories (<$20,000, $20,000 to $34,000) and more men than women (81 vs. 69 percent) were married or living with a partner. The magnitude of gender differences varied, with the smallest difference found on pain and the largest on the physical and psychosocial dimensions.
Gender differences in the three health dimensions (physical, psychosocial, and pain) underlying five different preference-based indexes of HRQoL were estimated using structural equation modeling. The findings are based on data from the National Health Measurement Study, a random-digit-dial telephone survey of a national community-dwelling sample of 3,844 adults aged 35 to 89 years. This research was supported in part by the Agency for Healthcare Research and Quality (T32 HS000046).
See "Gender differences in multiple underlying dimensions of health-related quality of life are associated with sociodemographic and socioeconomic status" by Dasha Cherepanov, Ph.D., Mari Palta, Ph.D., Dennis G. Fryback, Ph.D., and others in the November 2011 Medical Care 49(11), pp. 1021-1030.

Research Activities, May 2012: Disparities/Minority Health: Modeling inequalities helps to develop cervical cancer screening strategies that can improve outcomes and reduce disparities

Research Activities, May 2012: Disparities/Minority Health: Modeling inequalities helps to develop cervical cancer screening strategies that can improve outcomes and reduce disparities

Modeling inequalities helps to develop cervical cancer screening strategies that can improve outcomes and reduce disparities

The two fundamental goals of improving population health and distributing that health fairly are frequently in tension, because measures to improve one may not be optimal for and may conflict with the other. Researchers devised a typology of cancer disparities among black, white, and Hispanic populations in the United States that differentiated inequalities resulting from different factors, such as care access and quality of treatment and prevention. By explicitly modeling disparities between subgroups, they identified prevention strategies that could reduce the risk of cervical cancer overall, distribute health benefits equitably, and use health care resources efficiently. With a disease-simulation model of cervical cancer, they applied this typology to an evaluation of different screening and vaccination strategies in which the health and economic outcomes were calculated for the average population, and also for the three subgroups separately.
The researchers identified strategies that reduced the overall risk of cervical cancer by 60 percent to 74.5 percent, and that improved cancer outcomes in all racial subgroups. However, they also found that the benefits were unequally distributed. For example, one strategy using Pap smears and human papilloma virus (HPV) triage (cytology followed by HPV DNA testing) resulted in an average reduction of 69 percent in cancer incidence overall, but a 71.6 percent reduction for white women, 68.3 percent for black women, and 63.9 percent for Hispanic women.
The researchers found that screening strategies that directly targeted racial subgroups bearing the greatest inequalities provided a more equitable distribution of benefits. For example, reduction in cervical cancer incidence was 69.7 percent in white women versus 70.1 percent in Hispanic women. These strategies were also more effective and less costly than current screening patterns. Strategies that included adolescent HPV vaccination at coverage rates of 33 percent and targeted screening with new screening algorithms had a cost-effectiveness ratio of $28,200 per year of life saved when compared with the same strategy without vaccination. The disease-simulation model the researchers used was calibrated to epidemiological data for the United States. The researchers calculated the average reduction in cervical cancer incidence overall and for black, white, and Hispanic women under five different prevention strategies. This study was supported in part by the Agency for Healthcare Research and Quality (HS15570).
See "Model-based analyses to compare health and economic outcomes of cancer control: Inclusion of disparities" by Sue J. Goldie, M.D., and Norman Daniels, Ph.D., in the Journal of the National Cancer Institute 103, pp. 1373-1386, 2011

Research Activities, May 2012: Child/Adolescent Health: Children's hospitals are pressed to capacity by response to pandemic outbreaks

Research Activities, May 2012: Child/Adolescent Health: Children's hospitals are pressed to capacity by response to pandemic outbreaks

Children's hospitals are pressed to capacity by response to pandemic outbreaks

During 2009, a novel influenza A (H1N1) virus began to spread in North America, with children having the highest rates of illness and hospitalization. Yet, a new study shows that children's hospitals routinely operate so close to capacity that little available reserve exists for even a modest surge of inpatients.
A team of researchers led by Marion R. Sills, M.D., M.P.H., of the University of Colorado School of Medicine, examined how close 34 children's hospitals came to exhausting capacity during the 2009 outbreak. They found that for the 11-week pandemic period during the fall of 2009, the median overall inpatient occupancy was 95 percent, but this situation did not differ from typical levels of high occupancy commonly experienced. For example, in the prior 2008-09 flu season, the median occupancy was 101 percent, and occupancy was 91 percent for the entire 2008 calendar year.
Hospital experiences varied considerably, with hospital-level median occupancy rates ranging from 57.4 percent to 128.0 percent.To reach 100 percent occupancy across all study hospitals during the pandemic period, hospitals would have needed to admit a median of 0.2 additional patients per day for non-intensive care unit beds and 0.7 per day for intensive care unit beds.
Another part of the study measured the effect on children's hospital capacity if the H1N1 outbreak during fall 2009 had been more severe. Using historical precedents, the researchers constructed five models projecting inpatient occupancy. They varied the number of emergency department (ED) visits and admission rates for influenza-related ED visits. For the worst case scenario, the median occupancy would have been 132 percent.
Although the 2009 pandemic did not exhaust hospital capacity, surge capacity is scarce, as demonstrated by the many hospitals operating at or near capacity in the EDs and inpatient areas. For hospitals and government agencies, the results of this study should prompt review of preparedness planning and reconsideration of surge capacity, suggest the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (HS16418).
See "Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States" by Dr. Sills, Matthew Hall, Ph.D., Evan S. Fieldston, M.D., M.B.A., M.S.H.P., and others in the September 2011 Emerging Infectious Diseases 17(9), pp. 1685-1691.

Research Activities, May 2012: Child/Adolescent Health: Kidney-sparing surgery for children with renal tumors has equivalent in-hospital results to kidney removal surgery

Research Activities, May 2012: Child/Adolescent Health: Kidney-sparing surgery for children with renal tumors has equivalent in-hospital results to kidney removal surgery

Kidney-sparing surgery for children with renal tumors has equivalent in-hospital results to kidney removal surgery

It is widely accepted that, when feasible, partial removal of the kidney (nephron sparing surgery [NSS]), is preferable to complete removal of the kidney (radical nephrectomy [RN] for the treatment of kidney tumors in adults. In children, RN is more frequently used because of the relatively large size of the tumor and technical difficulty of NSS for most pediatric kidney tumors. However, recent research suggesting that adults undergoing RN may have decreased long-term survival compared with NSS patients has prompted a reconsideration of the role of NSS in children.
Among 1,235 children with kidney tumors who received either RN or NSS, patients in either group had similar median comorbidity scores, in-hospital charges, and surgical complication rates, according to a team of researchers from Children's Hospital in Boston. The researchers suggest that NSS may be performed in well-selected children with malignant renal tumors without significantly increasing their hospital charges, length of stay, or surgical complication rates. However, they further advise that implementation of management changes in children with malignant kidney tumors would be premature, since long-term data on oncological outcomes are lacking.
Data for the study came from 41 children's hospitals that treated the 1,235 children between 2003 and 2009. In this group, 91 percent received RN and 9 percent received NSS. This study was supported in part by the Agency for Healthcare Research and Quality (T32 HS000063).
See "Contemporary use of nephron-sparing surgery for children with malignant renal tumors at freestanding children's hospitals" by Jonathan C. Routh, M.D., M.P.H., Dionne A. Graham, Ph.D., Carlos R. Estrada, M.D., and Caleb P. Nelson, M.D., M.P.H., in Urology 78, pp. 422-426, 2011.

Research Activities, May 2012: Child/Adolescent Health: Annual screening for malignancy among children with spina bifida with cystoplasty unlikely to be cost effective

Research Activities, May 2012: Child/Adolescent Health: Annual screening for malignancy among children with spina bifida with cystoplasty unlikely to be cost effective

Annual screening for malignancy among children with spina bifida with cystoplasty unlikely to be cost effective

Screening programs for disease are frequently subject to cost-effectiveness analysis. Screening for malignancy following bladder augmentation among children with spina bifida (also known as "augmentation cystoplasty") is a case in point.
In order to determine the potential for screening cystoscopy and cytology to be cost effective, a research team from Children's Hospital in Boston used formal decision analysis techniques. Their analysis suggested that screening for malignancy in patients with spina bifida after cystoplasty with annual cystoscopy and cytology is highly unlikely to be cost effective at accepted willingness to pay thresholds. In a hypothetical group, the individual increase in life expectancy for the entire group was 2.3 months with an average lifetime cost of $55,200 per capita. The discounted incremental cost-effectiveness ratio was $273,718, which exceeds the $100,000 per life year gained threshold considered to be cost effective for medical interventions.
Neurogenic bladder dysfunction is common in children with spina bifida and is most often treated by bladder augmentation. This procedure appears to pose an increased risk of malignancy, but performing a controlled trial to learn more about this outcome is impractical due to the low incidence of malignancy and long interval from cystoplasty to tumor development. This study was supported in part by the Agency for Healthcare Research and Quality (T32 HS000063).
See "Screening for malignancy after augmentation cystoplasty in children with spina bifida: A decision analysis" by Paul J. Kokorowski, M.D., Jonathan C. Routh, M.D., Joseph G. Borer, M.D., and others in the October 2011 Journal of Urology 186, pp. 1437-1443.

Research Activities, May 2012: Health Care Costs and Financing: Affordable Care Act likely to create uncertainties in Medicaid enrollment, costs, and physician workforce needs

Research Activities, May 2012: Health Care Costs and Financing: Affordable Care Act likely to create uncertainties in Medicaid enrollment, costs, and physician workforce needs

Affordable Care Act likely to create uncertainties in Medicaid enrollment, costs, and physician workforce needs

The expansion in 2014 of Medicaid to millions of additional United States citizens and residents by the Affordable Care Act of 2010 (ACA) will bring major uncertainties in enrollment, costs, and the need for additional physicians, concludes a new study. The ACA will expand Medicaid eligibility to all U.S. citizens and qualified residents with incomes below 138 percent of the Federal poverty level in order to increase access to care. Estimates of new Medicaid enrollment in 2019 are 16 million and 18 million individuals, by the Congressional Budget Office and the Centers for Medicare & Medicaid Services, respectively.
The researchers developed a simulation model to identify for policymakers the factors that most strongly influence enrollment, costs, and provider workforce needs under the new law and to provide a range of estimates of these values as of 2019 under a variety of plausible conditions. Their model found that the number of new enrollees in Medicaid could vary by more than 10 million individuals, from a base case estimate of 13.4 million individuals and a range of 8.5 million to 22.4 million new participants. This would result in additional Federal spending for new Medicaid enrollees from $34 billion to $98 billion annually, and a need for 4,500–12,100 new physicians to care for the new Medicaid participants. The largest group of new enrollees would be newly eligible uninsured adults, estimated to range from 4.6 million to 11.3 million new enrollees.
For their simulation, the researchers used data from two different surveys conducted by the U.S. Census Bureau, the 2009 Current Population Survey and the 2008 Survey of Income and Program Participation. The study was funded in part by the Agency for Healthcare Research and Quality (HS19754).
More details are in "Policy makers should prepare for major uncertainties in Medicaid enrollment, costs, and needs for physicians under health reform," by Benjamin D. Sommers, M.D., Ph.D., Katherine Swartz, Ph.D., and Arnold Epstein, M.D., M.S., in the November 2011 Health Affairs 30(11), pp. 2186-2193.

Research Activities, May 2012: Child/Adolescent Health: Increased child hospitalizations are associated with the mother's mental state and confidence in parenting

Research Activities, May 2012: Child/Adolescent Health: Increased child hospitalizations are associated with the mother's mental state and confidence in parenting

Increased child hospitalizations are associated with the mother's mental state and confidence in parenting

Studies show that depressed mothers generally have low confidence in their ability to parent (parenting self-efficacy). Children of mothers who suffer from depression are more likely to have higher rates of hospitalization, including from potentially preventable causes such as dehydration and asthma flareups. A new study looked at maternal parenting self-efficacy as a possible mediator between maternal depression and child hospitalizations.
The researchers analyzed data from 432 mother-child pairs. These were mostly minority women living in low-income urban areas. Each mother was interviewed at 6 months, 1 year, and then 2 years after their first child's birth. More than one-third of the mothers had given birth to a second child by the time their first child was 2 years old. During these interviews, the mothers were asked questions to determine their level of depressive symptoms and self-efficacy.
After 1 year, 28.8 percent of mothers had increased depressive symptoms. At 2 years, 46.5 percent of depressed women still had symptoms. Both elevated symptoms of depression and lower maternal self-efficacy were individually associated with increased child hospitalizations. When these two factors were combined, the researchers identified self-efficacy as a mediator between maternal depression and child hospitalizations. Clinicians may wish to assess maternal self-efficacy during medical encounters, particularly in those mothers with depressive symptoms. Depressed mothers with low self-efficacy can be given parenting skills and also improve the lives of both the mother and her children, suggest the researchers. Their study was supported in part by the Agency for Healthcare Research and Quality (T32 HS00044).
See "Self-efficacy as a mediator between maternal depression and child hospitalizations in low-income urban families," by Margaret L. Holland, Ph.D., Byung-Kwang Yoo, M.D., Ph.D., Helena Temkin-Greener, Ph.D., and others in Maternal and Child Health 15, pp. 1011-1019, 2011.