Medicine and Health Sciences Commons^™

Dietary Carbohydrates And Breast Cancer Risk: A Prospective Study Of The Roles Of Overall Glycemic Index And Glycemic Load, Stephanie A. Navarro Silvera, Meera Jain, Geoffrey R. Howe, Anthony B. Miller, Thomas E. Rohan

Department of Public Health Scholarship and Creative Works

We examined breast cancer risk in association with overall glycemic index (GI), glycemic load (GL), and dietary carbohydrate and sugar intake in a prospective cohort of 49,613 Canadian women enrolled in the National Breast Screening Study who completed a self‐administered food frequency questionnaire between 1980 and 1985. Linkages to national mortality and cancer databases yielded data on deaths and cancer incidence, with follow‐up ending between 1998 and 2000. During a mean follow‐up of 16.6 years, we observed 1,461 incident breast cancer cases. GI, GL, total carbohydrate and total sugar intake were not associated with breast cancer risk in the total …

Dietary Carbohydrates And Breast Cancer Risk: A Prospective Study Of The Roles Of Overall Glycemic Index And Glycemic Load, Stephanie A. Navarro Silvera, Meera Jain, Geoffrey R. Howe, Anthony B. Miller, Thomas E. Rohan

Department of Public Health Scholarship and Creative Works

We examined breast cancer risk in association with an overall glycemic index (GI), glycemic load (GL), and dietary carbohydrate and sugar intake in a prospective cohort of 49,613 Canadian women enrolled in the National Breast Screening Study who completed a self-administered food frequency questionnaire between 1980 and 1985. Linkages to national mortality and cancer databases yielded data on deaths and cancer incidence, with follow-up ending between 1998 and 2000. During a mean follow-up of 16.6 years, we observed 1,461 incident breast cancer cases. GI, GL, total carbohydrate, and total sugar intake were not associated with breast cancer risk in the …

Ranking Usrds Provider-Specific Smrs From 1998-2001, Rongheng Lin, Thomas A. Louis, Susan M. Paddock, Greg Ridgeway

Johns Hopkins University, Dept. of Biostatistics Working Papers

Provider profiling (ranking, "league tables") is prevalent in health services research. Similarly, comparing educational institutions and identifying differentially expressed genes depend on ranking. Effective ranking procedures must be structured by a hierarchical (Bayesian) model and guided by a ranking-specific loss function, however even optimal methods can perform poorly and estimates must be accompanied by uncertainty assessments. We use the 1998-2001 Standardized Mortality Ratio (SMR) data from United States Renal Data System (USRDS) as a platform to identify issues and approaches. Our analyses extend Liu et al. (2004) by combining evidence over multiple years via an AR(1) model; by considering estimates …

Quality Improvement In Maryland: Partnerships And Progress, Judith D. Moore, Lisa Sprague

National Health Policy Forum

This one-and-a-half-day site visit to Easton, Maryland, explored the activities of the Delmarva Foundation, the Quality Improvement Organization (QIO) for Maryland and the District of Columbia. The program reviewed Delmarva’s responsibilities under their Medicare contract and the initiatives they have undertaken with hospitals and other providers to improve health care outcomes and to define, collect, and report quality data. Local hospital officials added their perspective on quality programs and working with Delmarva. Topics of particular interest were health information technology, patient safety, and quality reporting both to government agencies and to consumers.

Semi-Parametric Single-Index Two-Part Regression Models, Xiao-Hua Zhou, Hua Liang

UW Biostatistics Working Paper Series

In this paper, we proposed a semi-parametric single-index two-part regression model to weaken assumptions in parametric regression methods that were frequently used in the analysis of skewed data with additional zero values. The estimation procedure for the parameters of interest in the model was easily implemented. The proposed estimators were shown to be consistent and asymptotically normal. Through a simulation study, we showed that the proposed estimators have reasonable finite-sample performance. We illustrated the application of the proposed method in one real study on the analysis of health care costs.

A Theater-Based Approach To Primary Prevention Of Sexual Behavior For Early Adolescents, Jessica B. Janega, David M. Murray, Sherri P. Varnell, Jonathan L. Blitstein, Amanda Birnbaum, Leslie A. Lytle

Department of Public Health Scholarship and Creative Works

This article compares four mixed-model analyses valid for group-randomized trials (GRTs) involving a nested cohort design with a single pretest and posttest. This study makes estimates of intraclass correlations (ICCs) available to investigators planning GRTs addressing dietary outcomes. It also provides formulae demonstrating the potential benefits to the standard error of the intervention effect (σΔ) from adjustments for both fixed and time-varying covariates and correlations over time. These estimates will allow other researchers using these variables to plan their studies by estimating a priori detectable differences and sample size requirements for any of the four analytic options. These methods are …

Assessing Intervention Effects In A School-Based Nutrition Intervention Trial: Which Analytic Model Is Most Powerful?, Jessica B. Janega, David M. Murray, Sherri P. Varnell, Jonathan L. Blitstein, Amanda Birnbaum, Leslie A. Lytle

Department of Public Health Scholarship and Creative Works

This article compares four mixed-model analyses valid for group-randomized trials (GRTs) involving a nested cohort design with a single pretest and posttest. This study makes estimates of intraclass correlations (ICCs) available to investigators planning GRTs addressing dietary outcomes. It also provides formulae demonstrating the potential benefits to the standard error of the intervention effect (σΔ) from adjustments for both fixed and time-varying covariates and correlations over time. These estimates will allow other researchers to use these variables to plan their studies by estimating a priori detectable differences and sample size requirements for any of the four analytic options. These methods …

Diagnosing Crohn's Disease: An Economic Analysis Comparing Wireless Capsule Endoscopy With Traditional Diagnostic Procedures, Neil I. Goldfarb, Laura T. Pizzi, Joseph P. Fuhr Jr., Christopher Salvador, Vanja Sikirica, Asher Kornbluth, Blair Lewis

College of Population Health Faculty Papers

The purpose of this study was to review economic considerations related to establishing a diagnosis of Crohn's disease, and to compare the costs of a diagnostic algorithm incorporating wireless capsule endoscopy (WCE) with the current algorithm for diagnosing Crohn's disease suspected in the small bowel. Published literature, clinical trial data on WCE in comparison to other diagnostic tools, and input from clinical experts were used as data sources for (1) identifying contributors to the costs of diagnosing Crohn's disease; (2) exploring where WCE should be placed within the diagnostic algorithm for Crohn's; and (3) constructing decision tree models with sensitivity …

Mainecare Behavioral Health Care Expenditures State Fiscal Years 1996 – 2002, Susan Payne Phd, Stuart Bratesman Mpp, David Lambert Phd

Disability & Aging

No abstract provided.

Ethics, Physician Incentives And Managed Care, Alberto Coustasse, Douglas Mains, Kristine Lykens

Management Faculty Research

The authors review the principle features of the managed care system in an effort to understand the ethical assumptions inherent in managed care. The interrelationships among physician incentives, responsibilities of patients and the physician-patient relationship are examined in light of the ethical concerns identified in the managed care system. The managed care system creates ethical tensions for those who influence the allocation of scare resources.

Managed care’s administrative controls have increasingly changed the doctor-patient relationship to the business person-consumer relationship. Managed care goals of quality and access demand that physicians be both patient advocate and organizational advocate, even though these …

Aging In Place At Harbor Point: Outreach Follow-Up Of Older Adults Living In Independent Mixed-Income Apartments, Judith M. Conahan, Nina M. Silverstein, Kelly Fitzgerald

Gerontology Institute Publications

Most older people, despite functional impairments, plan to stay in their homes and/or communities as long as possible. According to an AARP survey, 82% of adults 65+ reported that they believe that they are “very likely” or “somewhat likely” to stay in their current homes or apartments for the rest of their lives. With increasing age, housing and community characteristics and services gain importance in meeting the challenges of “aging in place.” Staying in their homes maximizes elder’s independence, sustains their social connections, and reaffirms their identity and value.

The Provider System For Children's Mental Health: Workforce Capacity And Effective Treatment, Jane Koppelman

National Health Policy Forum

This issue brief examines two issues that are key to meeting children’s unmet needs for mental health care: ensuring that the provider supply is adequate and that the care delivered is effective. It describes the shortage of qualified providers to address children’s mental disorders, as well its possible causes; it describes how managed care, to a certain extent, drives practice patterns; and it discusses the gray areas in deciding which providers are most qualified to deliver what care. In addition, this paper introduces what is known about evidence-based care in children’s mental health, the extent to which it is being …

Mainecare Managed Care Performance Report 2003, Catherine Ormond, Stuart Bratesman

Disability & Aging

No abstract provided.

Estimating The Retransformed Mean In A Heteroscedastic Two-Part Model, Alan H. Welsh, Xiao-Hua Zhou

UW Biostatistics Working Paper Series

Two distribution free estimators are proposed to estimate the mean of a dependent variable after fitting a semiparametric two-part heteroscedastic regression model to a transformation of the dependent variable. We show that the proposed estimators are consistent and have asymptotic normal distributions. We also compare their finite-sample performance in a simulation study. Finally, we illustrate the proposed methods in a real-world example of predicting in-patient health care costs.

Electronic Health Records: How Close? How Far To Go?, Lisa Sprague

National Health Policy Forum

This paper looks at the central role of the electronic health record (EHR) in health information technology. It considers the extent to which EHRs are in use and initiatives designed to increase their prevalence, as well as barriers to the widespread adoption of EHRs and efforts to surmount them. Particular attention is given to such obstacles as cost, the professional culture of physicians, standardization, and legal questions.

Medicaid's Disproportionate Share Hospital Program: Complex Structure, Critical Payments, Robert E. Mechanic

National Health Policy Forum

This background paper describes the history and political evolution of Medicaid’s disproportionate share hospital (DSH) program and examines DSH as it exists today. It highlights the importance of DSH payments for the viability of safety net hospitals and considers the consequences of states’ creative financing strategies for maximizing federal Medicaid matching funds. Finally, this paper reviews several options for improving the structure and effectiveness of the DSH program.

Nonparametric Confidence Intervals For The One- And Two-Sample Problems, Xiao-Hua Zhou, Phillip Dinh

UW Biostatistics Working Paper Series

Confidence intervals for the mean of one sample and the difference in means of two independent samples based on the ordinary-t statistic suffer deficiencies when samples come from skewed distributions. In this article, we evaluate several existing techniques and propose new methods to improve coverage accuracy. The methods examined include the ordinary-t, the bootstrap-t, the biased-corrected acceleration (BCa) bootstrap, and three new intervals based on transformation of the t-statistic. Our study shows that our new transformation intervals and the bootstrap-t intervals give best coverage accuracy for a variety of skewed distributions; and that our new transformation intervals have shorter interval …

Re-Engineering Systems For The Treatment Of Depression In Primary Care: Cluster Randomised Controlled Trial, A. J. Dietrich, Thomas E. Oxman, John W. Williams Jr., Herbert C. Schulberg, Martha L. Bruce, Pamela W. Lee, Sheila Barry

Dartmouth Scholarship

Objective: To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources.

A Schematic For Focusing On Youth In Investigations Of Community Design And Physical Activity, Kevin J. Krizek, Amanda Birnbaum, David M. Levinson

Department of Public Health Scholarship and Creative Works

This paper provides a first step in addressing special considerations for youth in a relatively new area of physical activity research. After reviewing the urgent need for novel approaches to increasing physical activity, the growing interest in the effects of community design are discussed. Although most discussion on this topic has focused on adults, there are important differences between youth and adults that warrant a special focus on youth and need to be accounted for. This article presents a schematic that accounts for how and where youth spend their time, decomposing the day into time spent in travel and time …

Fundamentals Of Community Health Centers, Jessamyn Taylor

National Health Policy Forum

This background paper examines the dominant model of federal grant funding for primary care in the health care safety net: the community health center. It describes the history of the health center program and highlights key policy issues influencing health centers, such as Medicaid payment policies and medically underserved area designations. The paper also examines the recent presidential initiative to expand health centers, including a review of the process used to identify new grantees, an assessment of remaining gaps in capacity, an exploration of continuing challenges, and a discussion of unresolved policy questions.

A Report From The Forum Session "Implementing The New Medicare Drug Benefit: Challenges And Opportunities For States", Judith D. Moore

National Health Policy Forum

The National Health Policy Forum convened a meeting on July 22, 2004 to discuss state-based challenges associated with implementing the Medicare Prescription Drug, Improvement, and Modernization Act (MMA). The meeting brought together an extremely insightful and experienced group of current and former state officials and other experts to discuss key issues. In keeping with its tradition of promoting a frank, off-the-record exchange on health policy issues, NHPF does not normally prepare written summaries or reports of meetings. However, because this meeting provided vivid illustrations of the importance of state-federal collaboration for the successful implementation of the new Medicare drug benefit, …

Studying Effects Of Primary Care Physicians And Patients On The Trade-Off Between Charges For Primary Care And Specialty Care Using A Hierarchical Multivariate Two-Part Model, John W. Robinson, Scott L. Zeger, Christopher B. Forrest

Johns Hopkins University, Dept. of Biostatistics Working Papers

Objective. To examine effects of primary care physicians (PCPs) and patients on the association between charges for primary care and specialty care in a point-of-service (POS) health plan.

Data Source. Claims from 1996 for 3,308 adult male POS plan members, each of whom was assigned to one of the 50 family practitioner-PCPs with the largest POS plan member-loads.

Study Design. A hierarchical multivariate two-part model was fitted using a Gibbs sampler to estimate PCPs' effects on patients' annual charges for two types of services, primary care and specialty care, the associations among PCPs' effects, and within-patient associations between charges for …

A Hierarchical Multivariate Two-Part Model For Profiling Providers' Effects On Healthcare Charges, John W. Robinson, Scott L. Zeger, Christopher B. Forrest

Johns Hopkins University, Dept. of Biostatistics Working Papers

Procedures for analyzing and comparing healthcare providers' effects on health services delivery and outcomes have been referred to as provider profiling. In a typical profiling procedure, patient-level responses are measured for clusters of patients treated by providers that in turn, can be regarded as statistically exchangeable. Thus, a hierarchical model naturally represents the structure of the data. When provider effects on multiple responses are profiled, a multivariate model rather than a series of univariate models, can capture associations among responses at both the provider and patient levels. When responses are in the form of charges for healthcare services and sampled …

Tick-Tock: Preparing For The Next Influenza Pandemic, Eileen Salinsky

National Health Policy Forum

This paper describes the nature of pandemic influenza and highlights key challenges for responding to this disease threat. It explains how an influenza pandemic would differ from annual influenza outbreaks and examines how a pandemic virus could emerge. It also explores important issues involved in pandemic preparedness capabilities, including disease surveillance, vaccine production and distribution, antiviral stockpiling, health care system readiness, and public health containment measures. The national pandemic preparedness plan is briefly reviewed, and unresolved policy issues related to the plan’s implementation are identified.

Fundamentals Of The Prescription Drug Market, Christie Provost Peters

National Health Policy Forum

This background paper is a primer on the prescription drug market. It provides information on the fundamentals of the pharmaceutical industry and various marketplace stakeholders, including manufacturers, retailers, consumers, regulators, researchers, and purchasers. This paper also examines the various ways the federal government interacts with the pharmaceutical market. Due to the breadth of material addressed, some complex issues and relationships are presented in broad conceptual terms without extensive technical detail.

The Promise And The Reality Of Long-Term Care Insurance, Randy Desonia

National Health Policy Forum

The aging of the nation’s population will create a surge in the need for long-term care services, putting pressure on existing funding sources and fueling demand for more. This paper examines one financing option—private long-term care insurance—and summarizes its brief history and the several critical precedents that have influenced the products as currently sold. Other topics discussed include the challenges to encouraging sales growth as well as increasing the role of this type of insurance in paying for long-term care.

Ozone And Mortality: A Meta-Analysis Of Time-Series Studies And Comparison To A Multi-City Study (The National Morbidity, Mortality, And Air Pollution Study), Michelle L. Bell, Jonathan M. Samet, Francesca Dominici

Johns Hopkins University, Dept. of Biostatistics Working Papers

While many time-series studies of ozone and daily mortality identified positive associations,others yielded null or inconclusive results. We performed a meta-analysis of 144 effect estimates from 39 time-series studies, and estimated pooled effects by lags, age groups,cause-specific mortality, and concentration metrics. We compared results to estimates from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS), a time-series study of 95 large U.S. cities from 1987 to 2000. Both meta-analysis and NMMAPS results provided strong evidence of a short-term association between ozone and mortality, with larger effects for cardiovascular and respiratory mortality, the elderly, and current day ozone exposure as …

Research In Home-Care Telemedicine: Challenges In Patient Recruitment, Usha Subramanian, Faith Hopp, Julie Lowery, Peter Woodbridge, David Smith

Social Work Faculty Publications

This study reports challenges in recruiting patients for a randomized controHed trial of home-care telemedicinae. Descriptive statistics on patient eligibility for home-care telemedidne services and patient refusals for participation are provided. Frequency counts of reasons for study exclusion and participant refusal and Chi-square tests to compare race and age-related differences are given. Of 302 home-care patients reviewed, 197 (65.2%) did not meet inclusion criteria. The most common reasons for study exclusion were patients either needing <2 visits per month (n = 59, 30%) or >3 skilled nurse visits per week (n = 46, 23.4%). Of the eligible patients (n = 105), 79 …

Comparison Of Medical Subject Headings And Text-Word Searches In Medline To Retrieve Studies On Sleep In Healthy Individuals, Elizabeth Sergeevna Jenuwine, Judith A. Floyd

Nursing Faculty Research Publications

Objective: The objective was to investigate the performance of two search strategies in the retrieval of primary research papers containing descriptive information on the sleep of healthy people from MEDLINE.

Methodology: Two search strategies - one based on the use of only Medical Subject Headings (MeSH), the second based on text-word searching - were evaluated as to their specificity and sensitivity in retrieving a set of relevant research papers published in the journal Sleep from 1996 to 2001 that were preselected by a hand search.

Results: The subject search provided higher specificity than the text- word search …

Racial Discrepancies In The Association Between Paternal Vs. Maternal Educational Level And Risk Of Low Birthweight In Washington State, Christina Nicolaidis, Cynthia W. Ko, Somnath Saha, Thomas D. Koepsell

School of Social Work Faculty Publications and Presentations

Background: The role of paternal factors in determining the risk of adverse pregnancy outcomes has received less attention than maternal factors. Similarly, the interaction between the effects of race and socioeconomic status (SES) on pregnancy outcomes is not well known. Our objective was to assess the relative importance of paternal vs. maternal education in relation to risk of low birth weight (LBW) across different racial groups.

Methods: We conducted a retrospective population-based cohort study using Washington state birth certificate data from 1992 to 1996 (n = 264,789). We assessed the associations between maternal or paternal education and LBW, adjusting for …