Nursing Home–Hospice Collaboration and End-of-Life Hospitalizations Among Dying Nursing Home Residents

Objectives

Nursing homes (NHs) collaboration with hospices appears to improve end-of-life (EOL) care among dying NH residents. However, the potential benefits of NH-hospice collaboration may vary with the patterns of this collaboration. This study examines the relationship between the attributes of NH-hospice collaboration, especially the exclusivity of NH-hospice collaboration (ie, the number of hospice providers in a NH), and EOL hospitalizations among dying NH residents.

Racial Residential Segregation and Rates of Gonorrhea in the United States, 2003–2007

Objectives. In the United States, Black persons are disproportionately affected by sexually transmitted infections (STIs), including gonorrhea. Individual behaviors do not fully explain these racial disparities. We explored the association of racial residential segregation with gonorrhea rates among Black persons and hypothesized that specific dimensions of segregation would be associated with gonorrhea rates.Methods. We used 2003 to 2007 national STI surveillance data and 2000 US Census Bureau data to examine associations of 5 dimensions of racial residential segregation and a composite measure of hypersegregation with gonorrhea rates among Black persons in 257 metropolitan statistical areas, overall and by sex and age. We calculated adjusted rate ratios with generalized estimating equations.Results. Isolation and unevenness were significantly associated with gonorrhea rates. Centralization was marginally associated with gonorrhea. Isolation was more strongly associated with gonorrhea among the younger age groups. Concentration, clustering, and hypersegregation were not associated with gonorrhea.Conclusions. Certain dimensions of segregation are important in understanding STI risk among US Black persons. Interventions to reduce sexual risk may need to account for racial residential segregation to maximize effectiveness and reduce existent racial disparities.Sexually transmitted infections (STIs) remain an important public health problem in the United States, with approximately 19 million new infections per year.1 Black persons, especially adolescents, bear a disproportionate burden of most STIs, including gonorrhea.2–6 In 2008, rates of gonorrhea were highest among Black individuals, aged 15 to 19 and 20 to 24 years, compared with any other racial/ethnic and age groups.7,8 Among 15- to 19-year-old adolescents, rates of gonorrhea were nearly 21 times higher for Black (2201.9 per 100 000) than for White adolescents (107.0 per 100 000).7 Untreated gonorrhea can have serious and long-term sequelae, including the facilitation of HIV transmission, infertility, and adverse outcomes for infants born to infected mothers.8Exposure to and infection with STIs are conditioned by many factors, including individual behaviors, relationship patterns, and characteristics of the social environment. Substantial attention has been paid to differences in individual risk behaviors, such as condom use and number of sexual partners, but they do not fully explain racial disparities in STI risk.4 Therefore, focusing solely on these proximate factors to reduce risk and disparities may have only limited effect.4,9 A growing body of research has examined the contribution of contextual factors, such as neighborhood attributes, to sexual risk. Specifically, numerous studies have examined whether living in a neighborhood with lower socioeconomic status is associated with sexual risk behaviors, such as younger age at first sexual intercourse and unprotected sexual intercourse.10–20 The findings have been equivocal, with some showing an association and others not. Therefore, a better understanding of the possible effects of other contextual factors on sexual risk is necessary.Racial residential segregation—the extent to which 2 or more racial groups live separate from one another in a metropolitan area—is a characteristic of the social environment that many Black individuals continue to experience.21 Nearly two thirds of Black persons live in highly segregated areas.9 The available evidence suggests that Black individuals living in more segregated areas, compared with less segregated areas, are at higher risk for certain poor health outcomes, such as low birth weight, mental health conditions, and mortality.9,22–28 No published studies to date have examined the association of racial residential segregation with sexual risk, but recent commentary has identified racial residential segregation as a possible cause of disparities in sexual risk.5,9,22,29–31Racial residential segregation, which describes the racial composition of neighborhoods and the spatial distribution of these neighborhoods in larger metropolitan areas, may be more conceptually relevant to understanding racial disparities than are individual and neighborhood characteristics because it captures the unequal structure for Black and White people across the entire housing market. It has been conceptualized in 5 distinct dimensions—exposure, concentration, centralization, clustering, and unevenness. Metropolitan areas are defined by

1. low exposure (or isolated) if minority members do not often share neighborhoods with other groups,
2. concentrated if minorities occupy relatively little physical space per capita,
3. centralized if minorities are more likely to live in neighborhoods around an urban core relative to other groups,
4. clustered if minorities live in neighborhoods that are crowded together to form a large enclave, and
5. uneven if minorities are overrepresented in some neighborhoods and underrepresented in other neighborhoods.32

Racial residential segregation is hypothesized to lead to differential exposure to STIs through a variety of mechanisms. First, segregation might lead to increased rates of STIs among Black persons by affecting the sexual network (e.g., partner availability and density of individuals).5,31 Second, segregation may create or foster environments (e.g., restricted economic and employment opportunities, disordered neighborhoods) that are conducive to sexual risk behaviors and increased STI risk.9,24,29,31 Each dimension of segregation may have varying degrees of salience in describing distinct mechanisms that affect sexual risk and STI transmission.22,24,31 According to a conceptual model proposed by Acevedo-Garcia,22 exposure, concentration, and, to a lesser extent, centralization are relevant to understanding infectious disease risk because of their effect on transmission patterns and social networks.We used 5 years of national sexually transmitted disease (STD) surveillance data to study the associations of racial residential segregation with gonorrhea rates among Black people in the United States at the metropolitan statistical area (MSA) level. According to Acevedo-Garcia’s model, we hypothesized that certain dimensions of segregation, such as exposure and concentration, would be more positively associated with gonorrhea rates compared with other dimensions of segregation. Additionally, we hypothesized that the associations would be modified by sex and age because of differences across sex and age groups in patterns of social influence.     

Tuberculosis Among Persons Born in the Philippines and Living in the United States, 2000–2007

Objectives. We examined demographic, clinical, and treatment outcome characteristics of Filipinos with tuberculosis (TB) in the United States.Methods. We calculated TB case rates from US Census Bureau population estimates and National Tuberculosis Surveillance System data for US-born non-Hispanic Whites and for US residents born in the Philippines, India, China, Cambodia, Vietnam, Pakistan, and Korea––countries that are major contributors to the TB burden in the United States. We compared Filipinos with the other groups through univariate and multivariate analyses.Results. Of 45 504 TB patients, 15.5% were Filipinos; 43.0% were other Asian/Pacific Islander groups; and 41.6% were Whites. Per 100 000 persons in 2007, the TB rate was 73.5 among Cambodians, 54.0 among Vietnamese, 52.1 among Filipinos, and 0.9 among Whites. Filipinos were more likely than other groups to be employed as health care workers and to have used private health care providers but less likely to be HIV positive and to be offered HIV testing.Conclusions. The relatively high TB rate among Filipinos indicates that TB control strategies should target this population. Providers should be encouraged to offer HIV testing to all TB patients.Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is transmitted through the air by droplet nuclei, most often infecting the lungs and resulting in pulmonary disease.¹ The people of the Philippines have many risk factors for latent TB infection and TB disease, including poverty and lack of access to quality health care.^2–5 In 2005, the Philippines ranked ninth among countries with high TB burdens, with an incidence rate of 291 per 100 000 persons and a prevalence of 450 per 100 000 persons.⁶ In recent years, implementation of effective public health practices in the Philippines has achieved high rates of treatment success and a decrease in unfavorable treatment outcomes. Nonetheless, in 2002 TB was the fourth leading cause of death in the Philippines,⁷and it continues to be a major cause of mortality.⁸In 2007, the United States reported 13 299 new TB cases and a case rate of 4.4 per 100 000 persons.⁹ The TB case rate was more than 10 times as high among foreign-born as among US-born residents. Foreign-born persons accounted for 58.6% (n = 7799) of the total 13 299 TB cases in the United States in 2007. Countries of origin accounting for the majority of cases were Mexico (24%), the Philippines (12%), India (8%), Vietnam (7%), and China (5%). In 2007, 861 foreign-born TB patients reported the Philippines as their country of origin, second in number only to persons born in Mexico.¹⁰We found no published national studies about TB among Filipinos in the United States. We performed an epidemiological analysis of US-residing Filipinos with TB disease reported to the National Tuberculosis Surveillance System (NTSS) of the Centers for Disease Control and Prevention (CDC) from 2000 to 2007. We compared TB case rates among US residents born in Asian/Pacific Islander (API) countries (the Philippines, India, China, Cambodia, Vietnam, Pakistan, and Korea) as well as rates for non-Hispanic Whites born in the United States. People born in these 7 API countries accounted for the majority of API TB cases in the United States.To determine the extent to which country of birth is a risk factor for TB, we compared characteristics and treatment outcomes among Filipinos born in the Philippines but now residing in the US with those of TB patients born in 43 other API countries and non-Hispanic Whites born in the United States. We chose the 43 API countries of origin because data on characteristics and outcomes were available. We chose US-born non-Hispanic Whites as a comparison group because they have the lowest TB case rate in the United States. We hypothesized that we would find significant differences in factors underlying TB case rates among persons born in the Philippines and other API countries and non-Hispanic Whites born in the United States.     

Profile of Methicillin-resistant Staphylococcus aureus Among Nursing Home Residents in Hawai‘i

Residing in long-term care facilities has long been identified as a risk factor for methicillin-resistant Staphylococcus aureus (MRSA) carriage and infection. The objective of this study was to describe MRSA epidemiology among residents in skilled nursing and intermediate care facilities (SNF/ICF) in Hawai‘i, using a statewide, population-based antimicrobial resistance surveillance system. From 2000 to 2005, proportions of MRSA increased significantly during the 6-year study period, from 35.0% in 2000 to 58.6% in 2005 (p<0.001). High levels of MRSA resistance to several commonly used antibiotics were observed, e.g., the level of MRSA resistance to clindamycin, ciprofloxacin, and erythromycin was at 77%, 90%, and 89% respectively. Nevertheless, there is a significant difference in the MRSA resistance pattern against certain antimicrobials in different geographic areas. For example, the level of MRSA resistance to trimethoprim-sulfamethoxazole was close to zero in Hawai‘i County, but 13% in Kaua‘i County. In contrast, the MRSA resistance to tetracycline was 46% in Hawai‘i County, but 5% in Kaua‘i County. Multi-drug resistant MRSA was well-established among nursing homes in Hawai‘i. Regional antibiograms are important in the assistance of empirical therapy.     

Tuberculosis Among Africans Living in the United States, 2000–2009

The incidence of tuberculosis (TB) has declined steadily in the United States; however, foreign-born persons are disproportionately affected. The aim of our study was to describe characteristics of TB patients diagnosed in the United States who originated from the African continent. Using data from the U.S. National Tuberculosis Surveillance System, we calculated TB case rates and analyzed differences between foreign-born patients from Africa compared with other foreign-born and U.S.-born patients. The 2009 TB case rate among Africans (48.1/100,000) was 3 times as high as among other foreign-born and 27 times as high as among U.S.-born patients. Africans living in the United States have high rates of TB disease; they are more likely to be HIV-positive and to have extrapulmonary TB. Identification and treatment of latent TB infection, HIV testing and treatment, and a high index of suspicion for extrapulmonary TB are needed to better address TB in this population.     

Changing Trends in Low Birth Weight Rates Among Non-Hispanic Black Infants in the United States, 1991–2004

We examined trends in low birth weight (LBW, <2,500 g) rates among US singleton non-Hispanic black infants between 1991 and 2004. We conducted Joinpoint regression analyses, using birth certificate data, to describe trends in LBW, moderately LBW (MLBW, 1,500–2,499 g), and very LBW (VLBW, <1,500 g) rates. We then conducted cross-sectional and binomial regression analyses to relate these trends to changes in maternal or obstetric factors. Non-Hispanic black LBW rates declined −7.35% between 1991 and 2001 and then increased +4.23% through 2004. The LBW trends were not uniform across birth weight subcategories. Among MLBW births, the 1991–2001 decease was −10.20%; the 2001–2004 increase was +5.61%. VLBW did not follow this pattern, increasing +3.84% between 1991 and 1999 and then remaining relatively stable through 2004. In adjusted models, the 1991–2001 MLBW rate decrease was associated with changes in first-trimester prenatal care, cigarette smoking, education levels, maternal foreign-born status, and pregnancy weight gain. The 2001–2004 MLBW rate increase was independent of changes in observed maternal demographic characteristics, prenatal care, and obstetric variables. Between 1991 and 2001, progress occurred in reducing MLBW rates among non-Hispanic black infants. This progress was not maintained between 2001 and 2004 nor did it occur for VLBW infants between 1991 and 2004. Observed population changes in maternal socio-demographic and health-related factors were associated with the 1991–2001 decrease, suggesting multiple risk factors need to be simultaneously addressed to reduce non-Hispanic black LBW rates.     

Epidemiology of Tuberculosis Among US- and Foreign-Born Children and Adolescents in the United States, 1994–2007

Objectives. We examined trends in tuberculosis (TB) cases and case rates among US- and foreign-born children and adolescents and analyzed the potential effect of changes to overseas screening of applicants for immigration to the United States.Methods. We analyzed TB case data from the National Tuberculosis Surveillance System for 1994 to 2007.Results. Foreign-born children and adolescents accounted for 31% of 18 659 reported TB cases in persons younger than age 18 years from 1994 to 2007. TB rates declined 44% among foreign-born children and adolescents (20.3 per 100 00 to 11.4 per 100 000 population) and 48% (2.1 per 100 000 to 1.1 per 100 000) among those who were born in the United States. Rates were nearly 20 times as high among foreign-born as among US-born adolescents. Among foreign-born children and adolescents with known month of US entry (88%), more than 20% were diagnosed with TB within 3 months of entry.Conclusions. Marked disparities in TB morbidity persist between foreign- and US-born children and adolescents. These disparities and the high proportion of TB cases diagnosed shortly after US entry suggest a need for enhanced pre- and postimmigration screening.Tuberculosis (TB) case rates continue to decline in the United States and were recently recorded at their lowest level since national recording began in 1953.¹ Although annual TB incidence among US-born persons is declining, the number of new cases reported each year among foreign-born persons has been relatively stable over the past decade; foreign-born persons accounted for almost 60% of TB cases reported in the United States in 2008.¹ TB in foreign-born persons in the United States is largely attributable to acquisition of latent TB infection (LTBI) in TB-endemic countries of origin and subsequent activation of disease after US arrival.² The large burden of TB among foreign-born persons in the United States likely reflects the persistently large burden of TB in many other countries.³An estimated 11% of all TB cases worldwide occur in children younger than age 15 years.⁴ In TB-endemic settings, acquisition of TB infection often occurs in childhood because children are more likely to have frequent and close contact with adults with infectious TB.^5,6 Compared with adult rates of progression from infection to disease (historically 5%–10% progress to disease), rates are higher for children of all ages and highest for infants younger than 1 year (43%) and children aged 1 to 5 years (24%).^4,7,8 Furthermore, children who become infected with TB but do not progress to disease in childhood represent a potential pool for disease in adulthood.^4,7 Elucidating the epidemiology of TB in foreign-born children could therefore facilitate efforts to improve children''s health and control TB by preventing future disease.TB cases are generally reported in the broad age categories of children (defined as < 15 years) and adults (≥ 15 years).^2,9,10 However, adolescents are an important group to study because TB rates rise in adolescence following the decline seen in the elementary school years.¹¹ In addition, adolescents are more likely to present with adult-type pulmonary TB (characterized by disease in the lung apices and a tendency to form cavitary lesions).¹¹ As a result, adolescents are more likely than are younger children to transmit TB to others.^8,11As part of an effort to limit importation of TB disease, the Centers for Disease Control and Prevention in 2007 published revised requirements for overseas medical screening of applicants for US immigration.¹² All persons aged 15 years or older continue to be screened with chest radiographs. Revised technical instructions now require a tuberculin skin test (TST) for all applicants aged 2 to 14 years who live in countries with a large TB burden. Chest radiographs are performed for those whose TST is positive.¹² The potential effect of these changes is not known.We sought to describe the epidemiology of TB among foreign- and US-born children and adolescents in terms of demographic and clinical characteristics and to analyze the potential effect of the 2007 changes to the instructions for overseas screening of applicants for immigration to the United States.     

Hospital Readmissions Among Post-acute Nursing Home Residents: Does Obesity Matter?

ObjectivesTo explore profiles of obese residents who receive post-acute care in nursing homes (NHs) and to assess the relationship between obesity and hospital readmissions and how it is modified by individual comorbidities, age, and type of index hospitalizations.DesignRetrospective cohort study.Setting and participantsMedicare fee-for-service beneficiaries who were newly admitted to free-standing US NHs after an acute inpatient episode between 2011 and 2014 (N = 2,323,019).MeasuresThe Minimum Data Set 3.0 were linked with Medicare data. The outcome variable was 30-day hospital readmission from an NH. Residents were categorized into 3 groups based on their body mass index (BMI): nonobese, mildly obese, moderate-to-severely obese. We tested the relationship between obesity and 30-day readmissions by fixed-effects logit models and stratified analyses by the type of index hospitalization and residents' age.ResultsForty percent of the identified residents were admitted after a surgical episode, and the rest were admitted after a medical episode. The overall relationship between obesity and readmissions suggested that obesity was associated with higher risks of readmission among the oldest old (≥85 years) residents but with lower risks of readmission among the youngest group (65-74 years). After accounting for individual co-covariates, the association between obesity and readmissions among the oldest old residents became weaker; the adjusted odds ratio was 1.061 (P = .049) and 1.004 (P = .829) for moderate-to-severely obese patients with surgical and medical index hospitalizations, respectively. The protective effect of obesity among younger residents reduced after adjusting for covariates.Conclusions/RelevanceThe relationship between obesity and hospital readmission among post-acute residents could be affected by comorbidities, age, and the type of index hospitalization. Further studies are also warranted to understand how to effectively measure NH quality outcomes, including hospital readmissions, so that policies targeting at quality improvement can successfully achieve their goals without unintended consequences.     

Prevalence of Anogenital Warts Among Participants in Private Health Plans in the United States, 2003–2010: Potential Impact of Human Papillomavirus Vaccination

Objectives. We estimated anogenital wart prevalence from 2003 to 2010 by gender and age group in a large US cohort with private insurance to detect potential decreases among people most likely to be affected by human papillomavirus (HPV) vaccination.Methods. We restricted health care claims to those from individuals aged 10 to 39 years with continuous insurance within a given year. We derived anogenital wart diagnoses from a diagnosis of condyloma acuminata, or either a less specific viral wart diagnosis or genital wart medication combined with either a benign anogenital neoplasm or destruction or excision of a noncervical anogenital lesion.Results. Prevalence increased slightly in 2003 to 2006, then significantly declined in 2007 to 2010 among girls aged 15 to 19 years; increased in 2003 to 2007, remained level through 2009, and declined in 2010 among women aged 20 to 24 years; and increased through 2009 but not in 2010 for women aged 25 to 39 years. For males aged 15 to 39 years, prevalence for each 5-year age group increased in 2003 to 2009, but no increases were observed for 2010.Conclusions. These data indicate reductions in anogenital warts among US females aged 15 to 24 years, the age group most likely to be affected by introduction of the HPV vaccine.In mid-2006, a quadrivalent human papillomavirus (HPV) vaccine was licensed in the United States for females (Merck & Co., Inc., Whitehouse Station, NJ). This vaccine is specific against HPV types 16 and 18, which cause approximately 70% of cervical cancers worldwide,1,2 as well as types 6 and 11, which are nononcogenic but can cause benign cervical lesions and anogenital warts.1,3,4 A bivalent vaccine (GlaxoSmithKline, Research Triangle Park, NC), specific for only HPV types 16 and 18, was licensed in late 2009. These vaccines are routinely recommended for girls aged 11 to 12 years, with catch-up vaccination through age 26 years.5,6 In late 2011, the quadrivalent vaccine was recommended for boys aged 11 to 12, with catch-up vaccination through age 21 years.7,8 However, HPV vaccine uptake in the United States is relatively low. In 2011, a national survey found that 53% of girls aged 13 to 17 years had received at least 1 dose of the HPV vaccine series, but only 35% had received all 3 doses.9 Vaccine uptake was extremely low among boys.9Postlicensure monitoring of new vaccines is important to assess the progress of immunization programs, demonstrate population impact, and evaluate policy needs.10–14 Clinical trials have demonstrated the prophylactic efficacy of the quadrivalent HPV vaccine,15,16 and questions of interest about currently available HPV vaccines now center on population effectiveness and cost-effectiveness.17 However, several factors complicate efforts to monitor the population impact of HPV vaccine, including multiple clinical outcomes and variable, often extended, time to outcome development.10,12,14 Cervical cancer is the most important anogenital outcome of HPV infection and may take several decades to develop.18 Cervical intraepithelial neoplasia and adenocarcinoma in situ are the most common cervical cancer precursor lesions, often occurring 1 to 3 years after HPV infection.19–22 In contrast to these outcomes, anogenital warts can develop within months of HPV infection, and therefore monitoring changes in anogenital wart diagnoses can be used to assess the most immediate impact of HPV vaccination.19The objective of this analysis was to estimate annual prevalence of anogenital wart diagnoses during 2003 to 2010 in a large group of privately insured patients, by gender and age group, to detect potential decreases among people most likely to be affected by quadrivalent HPV vaccination.     

Vital Signs: Repeat Births Among Teens — United States, 2007–2010

Background

Teen childbearing has potential negative health, economic, and social consequences for mother and child. Repeat teen childbearing further constrains the mother’s education and employment possibilities. Rates of preterm and low birth weight are higher in teens with a repeat birth, compared with first births.

Methods

To assess patterns of repeat childbearing and postpartum contraceptive use among teens, CDC analyzed natality data from the National Vital Statistics System (NVSS) and the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2007–2010.

Results

Based on 2010 NVSS data from all 50 states and the District of Columbia, of more than 367,000 births to teens aged 15–19 years, 18.3% were repeat births. The percentage of teen births that represented repeat births decreased by 6.2% between 2007 and 2010. Disparities in repeat teen births exist by race/ethnicity, with the highest percentages found among American Indian/Alaska Natives (21.6%), Hispanics (20.9%), and non-Hispanic blacks (20.4%) and lowest among non-Hispanic whites (14.8%). Wide geographic disparities in the percentage of teen births that were repeat births also exist, ranging from 22% in Texas to 10% in New Hampshire. PRAMS data from 16 reporting areas (15 states and New York City) indicate that 91.2% of teen mothers used a contraceptive method 2–6 months after giving birth, but only 22.4% of teen mothers used the most effective methods. Teens with a previous live birth were significantly more likely to use the most effective methods postpartum compared with those with no prior live birth (29.6% versus 20.9%, respectively). Non-Hispanic white and Hispanic teens were significantly more likely to use the most effective methods than non-Hispanic black teens (24.6% and 27.9% versus 14.3%, respectively). The percentage of teens reporting postpartum use of the most effective methods varied greatly geographically across the PRAMS reporting areas, ranging from 50.3% in Colorado to 7.2% in New York State.

Conclusions

Although the prevalence of repeat teen birth has declined in recent years, nearly one in five teen births is a repeat birth. Large disparities exist in repeat teen births and use of the most effective contraceptive methods postpartum, which was reported by fewer than one out of four teen mothers.

Implications for Public Health Practice

Evidence-based approaches are needed to reduce repeat teen childbearing. These include linking pregnant and parenting teens to home visiting and similar programs that address a broad range of needs, and offering postpartum contraception to teens, including long-acting methods of reversible contraception.     

HIV Diagnoses and Prevalence in the Southern Region of the United States, 2007–2010

On a number of leading health indicators, including HIV disease, individuals in the southern states of the United States fare worse than those in other regions. We analyzed data on adults and adolescents diagnosed with HIV infection through December 2010, and reported to the Centers for Disease Control and Prevention (CDC) through June 2011 from 46 states with confidential name-based HIV reporting since January 2007 to describe the impact of HIV in the South. In 2010 46.0 % of all new diagnoses of HIV infection occurred in the South. Compared to other regions, a higher percentage of diagnoses in the South were among women (23.8 %), blacks/African Americans (57.2 %), and among those in the heterosexual contact category (15.0 % for males; 88.5 % for females). From 2007 to 2010 the estimated number and rate of diagnoses of HIV infection decreased significantly in the South overall (estimated annual percentage change [EAPC] = ?1.5 % [95 %CI ?2.3 %, ?0.7 %] and ?2.1 % [95 % CI ?4.0 %, ?0.2 %], respectively) and among most groups of women, but there was no change in the number or rate of diagnoses of HIV infection among men overall. Significant decreases in men 30–39 and 40–49 years of age were offset by increases in young men 13–19 and 20–29 years of age. A continued focus on this area of high HIV burden is needed to yield success in the fight against HIV disease.     

Examining the “Potentially Preventable Emergency Department Transfer” Indicator Among Nursing Home Residents

ObjectiveTo determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non–potentially preventable emergency department transfers (non-PPEDs).DesignWe conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument–Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers.Setting and ParticipantsWe assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs.MethodsWe assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision.ResultsApproximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25–1.70] and oxygen therapy (HR 1.88; CI 1.69–2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01–1.18) and delirium (HR 1.08; CI 1.04–1.13).Conclusions and ImplicationsPPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.     

Socioeconomic Disparities in Colorectal Cancer Mortality in the United States, 1990–2007

United States colorectal cancer mortality rates have declined; however, disparities by socioeconomic status and race/ethnicity persist. The objective of this study was to describe the temporal association between colorectal cancer mortality and socioeconomic status by sex and race/ethnicity. Cancer mortality rates in the United States from 1990 to 2007, which were generated by the National Center for Health Statistics, and county-level socioeconomic status, which was estimated as the proportion of county residents living below the national poverty line based on 1990 US Census Bureau data, were obtained from the Surveillance, Epidemiology, and End Results program. The Kunst–Mackenbach relative index of inequality, which considers data across all poverty levels when comparing risks in the poorest (≥20 %) and richest counties (<10 %), was calculated as the measure of association. The study found that colorectal cancer mortality rates were significantly lower in the poorest counties than the richest counties during 1990–1992 among non-Hispanic whites, non-Hispanic black women and non-Hispanic API men. Over time though the tendency was for the poorest counties to have higher mortality rates. By 2003–2007 colorectal cancer mortality rates were significantly higher in the poorest than the richest counties among all sex-race/ethnicity groups. This disparity was most noticeable and appeared to be increasing most among Hispanic men. This suggests that socioeconomic disparities in colorectal cancer mortality were apparent after stratifying by sex and race/ethnicity and reversed over time. Further studies into the causes of these disparities would provide a basis for targeted cancer control interventions and allocation of public health resources.     

Temporal Patterns in Work-Related Fatalities Among Foreign-Born Workers in the US, 1992–2007

In the United States, approximately 20% of all workers who died on the job in 2007 were foreign-born. The objective of this study was to describe trends in occupational fatalities among foreign-born workers. An analysis of fatal injuries among foreign-born workers in the US occurring from 1992 through 2007 was conducted using the Bureau of Labor Statistics’ Census of Fatal Occupational Injuries. Individual characteristics, employment characteristics, injury events and industry employment were summarized and evaluated for trends. Both the number and proportion of foreign-born workers who died from a traumatic work-related injury increased substantially over the time period studied. The proportion who were men, aged 25–44 years, Hispanic, non self-employed, employed by business establishments with 10 or fewer employees, working at private residences and working in Construction and Services consistently increased throughout the time period. While some trends among foreign-born decedents are improving, others are worsening. More comprehensive research efforts are needed to address the occupational injury and safety issues among foreign-born workers, with a focus on Hispanics.     

Escherichia coli O157 Outbreaks in the United States, 2003–2012

Infections with the Shiga toxin–producing bacterium Escherichia coli O157 can cause severe illness and death. We summarized reported outbreaks of E. coli O157 infections in the United States during 2003–2012, including demographic characteristics of patients and epidemiologic findings by transmission mode and food category. We identified 390 outbreaks, which included 4,928 illnesses, 1,272 hospitalizations, and 33 deaths. Transmission was through food (255 outbreaks, 65%), person-to-person contact (39, 10%), indirect or direct contact with animals (39, 10%), and water (15, 4%); 42 (11%) had a different or unknown mode of transmission. Beef and leafy vegetables, combined, were the source of >25% of all reported E. coli outbreaks and of >40% of related illnesses. Outbreaks attributed to foods generally consumed raw caused higher hospitalization rates than those attributed to foods generally consumed cooked (35% vs. 28%). Most (87%) waterborne E. coli outbreaks occurred in states bordering the Mississippi River.Signs and symptoms of infection with Shiga toxin–producing Escherichia coli O157 can include diarrhea that is often bloody, severe stomach cramps, and vomiting; infection can progress to hemolytic uremic syndrome (HUS) and death (1). In the United States, these infections and related illnesses are estimated to cost >$405 million annually (2).E. coli O157 can be transmitted to humans through contaminated food and water, directly between persons, and through contact with animals or their environment. The most common reservoir is cattle, and ground beef is the most frequently identified vehicle of transmission to humans. E. coli O157 was first recognized as a foodborne pathogen after outbreaks during 1982 were linked to ground beef consumption (1). Since then, many other sources have been identified (3), mostly through outbreak investigations. We describe the epidemiology of E. coli O157 outbreaks during 2003–2012.