Vulnerable Populations

The Cost Implications of Prostate Cancer Screening in the Medicare Population

The Cost Implications of Prostate Cancer Screening in the Medicare Population
Cancer, Vol. 120, no. 1, pp. 96-102. DOI: 10.1002/cncr.28373

Ma, X., R. Wang, J.B. Long, J.S. Ross, P.R. Soulos, J.B. Yu, D.V. Makarov, H.T. Gold, and C.P. Gross
01/01/2014

Background: Recent debate about prostate-specific antigen (PSA)-based testing for prostate cancer screening among older men has rarely considered the cost of screening.

Methods: A population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer at the end of 2006 (n = 94,652), was assembled, and they were followed for 3 years to assess the cost of PSA screening and downstream procedures (biopsy, pathologic analysis, and hospitalization due to biopsy complications) at both the national and the hospital referral region (HRR) level.

Results: Approximately 51.2% of men received PSA screening tests during the 3-year period, with 2.9% undergoing biopsy. The annual expenditures on prostate cancer screening by the national fee-for-service Medicare program were $447 million in 2009 US dollars. The mean annual screening cost at the HRR level ranged from $17 to $62 per beneficiary. Downstream biopsy-related procedures accounted for 72% of the overall screening costs and varied significantly across regions. Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20, 95% confidence interval [CI] = 1.07-1.35) and localized cancer (IRR = 1.30, 95% CI = 1.15-1.47). The IRR for regional/metastasized cancer was also elevated, although not statistically significant (IRR = 1.31, 95% CI = 0.81-2.11).

Conclusions: Medicare prostate cancer screening–related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

Measuring the Degree of Integrated Tuberculosis and HIV Service Delivery in Cape Town, South Africa

Measuring the Degree of Integrated Tuberculosis and HIV Service Delivery in Cape Town, South Africa
Health Policy and Planning, Vol. 29, no. 1 (Jan 2014), pp. 42-55. doi: 10.1093/heapol/czs131

Uyei, J., D. Coetzee, J. Macinko, S.L. Weinberg, and S. Guttmacher
01/01/2014

To address the considerable tuberculosis (TB)/HIV co-infected population in Cape Town, a number of clinics have made an effort of varying degrees to integrate TB and HIV services. This article describes the development of a theory-based survey instrument designed to quantify the extent to which services were integrated in 33 clinics and presents the results of the survey. Using principal factor analysis, eight factors were extracted and used to make comparisons across three types of clinics: co-located TB and antiretroviral therapy (ART) services, clinics with TB services only and clinics with ART only. Clinics with co-located services scored highest on measures related to integrated TB/ART service delivery compared to clinics with single services, but within group variability was high indicating that co-location of TB and ART services is a necessary but insufficient condition for integrated service delivery. In addition, we found almost all clinics with only TB services in our sample had highly integrated pre-ART services, suggesting that integration of these services across a large number of clinics is feasible and acceptable to clinic staff. TB clinics with highly integrated pre-ART services appear to be efficient sites for introducing ART given that co-infected patients are already engaged in care, and may potentially facilitate earlier access to treatment and minimize loss to follow-up.

Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease

Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease
Health Affairs, 32, no.12 (2013):2099-2108

Billings, John and Maria C. Raven
12/01/2013

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients’ total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.

Banks and Microbanks

Banks and Microbanks
Journal of Financial Services Research (2014) 46:1–53. DOI 10.1007/s10693-013-0177-z

Robert Cull, Asli Demirgüç-Kunt, and Jonathan Morduch
09/16/2013

We combine two datasets to examine whether the presence of banks affects the profitability and outreach of microfinance institutions.We find evidence that competition matters. Greater bank penetration in the overall economy is associated with microbanks pushing toward poorer markets, as reflected in smaller average loans sizes and greater outreach to women. The evidence is particularly strong for microbanks relying on commercial-funding and using traditional bilateral lending contracts (rather than group lending methods favored by microfinance NGOs). We consider plausible alternative explanations for the correlations, including relationships that run through the nature of the regulatory environment and the structure of the banking environment, but we fail to find strong support for these alternative hypotheses.

Urinary phthalates and increased insulin resistance in adolescents

Urinary phthalates and increased insulin resistance in adolescents
Pediatrics. 2013 Sep;132(3):e646-55. doi: 10.1542/peds.2012-4022. Epub 2013 Aug 19.

Trasande L, Spanier AJ, Sathyanarayana S, Attina TM, Blustein J.
09/12/2013

BACKGROUND: Di-2-ethylhexylphthalate (DEHP) is an environmental chemical commonly found in processed foods. Phthalate exposures, in particular to DEHP, have been associated with insulin resistance in adults, but have not been studied in adolescents.

METHODS:

Using cross-sectional data from 766 fasting 12- to 19-year-olds in the 2003-2008 NHANES, we examined associations of phthalate metabolites with continuous and categorical measures of homeostatic model assessment of insulin resistance (HOMA-IR).

RESULTS:

Controlling for demographic and behavioral factors, diet, continuous age, BMI category, and urinary creatinine, for each log (roughly threefold) increase in DEHP metabolites, a 0.27 increase (95% confidence interval 0.14-0.40; P < .001) in HOMA-IR was identified. Compared with the first tertile of DEHP metabolite in the study population (14.5% insulin resistant), the third tertile had 21.6% prevalence (95% confidence interval 17.2%-26.0%; P = .02). Associations persisted despite controlling for bisphenol A, another endocrine-disrupting chemical commonly found in foods, and HOMA-IR and insulin resistance were not significantly associated with metabolites of lower molecular weight phthalates commonly found in cosmetics and other personal care products.

CONCLUSIONS:

Urinary DEHP concentrations were associated with increased insulin resistance in this cross-sectional study of adolescents. This study cannot rule out the possibility that insulin-resistant children ingest food with higher phthalate content, or that insulin-resistant children excrete more DEHP.

Scientific Publications on Firearms in Youth Before and After Congressional Action Prohibiting Federal Research Funding

Scientific Publications on Firearms in Youth Before and After Congressional Action Prohibiting Federal Research Funding
Journal of the American Medical Association [JAMA];310(5): 532-533.

Ladapo, Joseph, Benjamin Rodwin, Andrew M. Ryan, Leonardo Trasande, Jan Blustein
09/04/2013

In January 1996, Congress passed an appropriations bill amendment prohibiting the US Centers for Disease Control and Prevention (CDC) from using “funds made available for injury prevention … to advocate or promote gun control.” This provision was triggered by evidence linking gun ownership to health harms, created uncertainty among CDC officials and researchers about what could be studied, and led to significant declines in funding. We evaluated the change in the number of publications on firearms in youth compared with research on other leading causes of death before and after the Congressional action. We focused on children and adolescents because they disproportionately experience gun violence and injury.

Building Job Quality from the Inside-Out: Immigrants, Skill, and Jobs in the Construction Industry

Building Job Quality from the Inside-Out: Immigrants, Skill, and Jobs in the Construction Industry
Industrial Labor Relations Review. 66(4): 785-807.

Iskander, N. and N. Lowe
07/01/2013

Using an ethnographic case study of Mexican immigrant construction workers in two U.S. cities and in Mexico, the authors illustrate the contribution of immigrant skill as a resource for changing workplace practices. As a complement to explanations that situate the protection of job quality and the defense of skill to external institutions, the authors show that immigrants use collective learning practices to improve job quality from inside the work environment—that is to say from the inside-out. The authors also find that immigrants use collective skill-building practices to negotiate for improvements to their jobs; however, their ability to do so depends on the institutions that organize production locally. Particular attention is given to the quality of those industry institutions, noting that where they are more malleable, immigrant workers gain more latitude to alter their working conditions and their prospects for advancement.

Not Just for Poor Kids: The Impact of Universal Free School Breakfast on Meal Participation and Student Outcomes

Not Just for Poor Kids: The Impact of Universal Free School Breakfast on Meal Participation and Student Outcomes
Economics of Education Review, 36: 88-107

Leos-Urbel, J., Schwartz, A. E., Weinstein, M., & Corcoran, S.
06/18/2013

This paper examines the impact of the implementation of a universal free school breakfast policy on meals program participation, attendance, and academic achievement. In 2003, New York City made school breakfast free for all students regardless of income, while increasing the price of lunch for those ineligible for meal subsidies. Using a difference-indifference estimation strategy, we derive plausibly causal estimates of the policy’s impact by exploiting within and between group variation in school meal pricing before and after the policy change. Our estimates suggest that the policy resulted in small increases in breakfast participation both for students who experienced a decrease in the price of breakfast and for free-lunch eligible students who experienced no price change. The latter suggests that universal provision may alter behavior through mechanisms other than price, highlighting the potential merits of universal provision over targeted services. We find limited evidence of policy impacts on academic outcomes.

Race/Ethnicity-Specific Associations of Urinary Phthalates with Childhood Body Mass in a Nationally Representative Sample

Race/Ethnicity-Specific Associations of Urinary Phthalates with Childhood Body Mass in a Nationally Representative Sample
Environmental Health Perspectives. 121:501-506.

Trasande, Leonardo, Teresa M Attina, S Sathyanarayana, Adam J Spanier, Jan Blustein.
04/01/2013

Background: Phthalates have antiandrogenic effects and may disrupt lipid and carbohydrate metabolism. Racial/ethnic subpopulations have been documented to have varying urinary phthalate concentrations and prevalences of childhood obesity.

Objective: We examined associations between urinary phthalate metabolites and body mass outcomes in a nationally representative sample of U.S. children and adolescents.

Methods: We performed stratified and whole-sample cross-sectional analyses of 2,884 children 6–19 years of age who participated in the 2003–2008 National Health and Nutrition Examination Survey. Multivariable linear and logistic analyses of body mass index z-score, overweight, and obesity were performed against molar concentrations of low-molecular-weight (LMW), high-molecular-weight (HMW), and di-2-ethylhexylphthalate (DEHP) metabolites, controlling for sex, television watching, caregiver education, caloric intake, poverty–income ratio, race/ethnicity, serum cotinine, and age group. We used sensitivity analysis to examine robustness of results to removing sample weighting, normalizing phthalate concentrations for molecular weight, and examining different dietary intake covariates.

Results: In stratified, multivariable models, each log unit (roughly 3-fold) increase in LMW metabolites was associated with 21% and 22% increases in odds (95% CI: 1.05–1.39 and 1.07–1.39, respectively) of overweight and obesity, and a 0.090-SD unit increase in BMI z-score (95% CI: 0.003–0.18), among non-Hispanic blacks. Significant associations were not identified in any other racial/ethnic subgroup or in the study sample as a whole after controlling for potential confounders, associations were not significant for HMW or DEHP metabolites, and results did not change substantially with sensitivity analysis.

Conclusions: We identified a race/ethnicity–specific association of phthalates with childhood obesity in a nationally representative sample. Further study is needed to corroborate the association and evaluate genetic/epigenomic predisposition and/or increased phthalate exposure as possible explanations for differences among racial/ethnic subgroups.

Environmental and individual factors affecting menu labeling utilization: a qualitative research study

Environmental and individual factors affecting menu labeling utilization: a qualitative research study
Journal of the Academy of Nutrition and Dietetics. 2013 May;113(5):667-72. doi: 10.1016/j.jand.2012.11.011. Epub 2013 Feb 9.

Jennifer Schindler, Kamila Kiszko, Courtney Abrams, Nadia Islam, Brian Elbel
02/09/2013

Obesity is a prominent public health concern that disproportionally affects low-income and minority populations. Recent policies mandating the posting of calories on menus in fast-food chain restaurants have not proven to uniformly influence food choice. This qualitative research study used focus groups to study individual and environmental factors affecting the use of these menu labels among low-income minority populations. Ten focus groups targeting low-income residents (n=105) were held at various community organizations throughout New York City over a 9-month period in 2011. The focus groups were conducted in Spanish, English, or a combination of both languages. In late 2011 and early 2012, transcripts were coded through the process of thematic analysis using Atlas.ti for naturally emerging themes, influences, and determinants of food choice. Few participants used menu labels, despite awareness. The most frequently cited as barriers to menu label use included: price and time constraints, confusion and lack of understanding about caloric values, as well as the priority of preference, hunger, and habitual ordering habits. Based on the individual and external influences on food choice that often take priority over calorie consideration, a modified approach may be necessary to make menu labels more effective and user-friendly.

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