Biomedical subjects

Ken Kleinman

Publications and source records attributed to Ken Kleinman.

At least 19 recordsLinked to original sources

PubMed2007

Multivariate scan statistics for disease surveillance.

In disease surveillance, there are often many different data sets or data groupings for which we wish to do surveillance. If each data set is analysed separately rather than combined, the statistical power to detect an outbreak that is present in all data sets may suffer due to low numbers in each. On the other hand, if the data sets are added by taking the sum of the counts, then a signal that is primarily present in one data set may be hidden due to random noise in the other data sets. In this paper, we present an extension of the spatial and space-time scan statistic that simultaneously incorporates multiple data sets into a single likelihood function, so that a signal is generated whether it occurs in only one or in multiple data sets. This is done by defining the combined log likelihood as the sum of the individual log likelihoods for those data sets for which the observed case count is more than the expected. We also present another extension, where the concept of combining likelihoods from different data sets is used to adjust for covariates. Using data from the National Bioterrorism Syndromic Surveillance Demonstration Project, we illustrate the new method using physician telephone calls, regular physician visits and urgent care visits by Harvard Pilgrim Health Care members cared for by Harvard Vanguard Medical Associates, a large multi-specialty group practice in Massachusetts. For upper and lower gastrointestinal (GI) illness, there were on average 20 telephone calls, nine urgent care visits and 22 regular physician visits per day. The strongest signal was generated by a single data set and due to a familial outbreak of pinworm disease. The second and third strongest signals were generated by the combined strength of two of the three data sets.

Boston↗

PubMed2007

Economic analysis of a randomized trial of academic detailing interventions to improve use of antihypertensive medications.

The authors estimated the costs and cost savings of implementing a program of mailed practice guidelines and single-visit individual and group academic detailing interventions in a randomized controlled trial to improve the use of antihypertensive medications. Analyses took the perspective of the payer. The total costs of the mailed guideline, group detailing, and individual detailing interventions were estimated at 1000 dollars, 5500 dollars, and 7200 dollars, respectively, corresponding to changes in the average daily per person drug costs of -0.0558 dollars (95% confidence interval, -0.1365 dollars to 0.0250 dollars) in the individual detailing intervention and -0.0001 dollars (95% confidence interval, -0.0803 dollars to 0.0801 dollars) in the group detailing intervention, compared with the mailed intervention. For all patients with incident hypertension in the individual detailing arm, the annual total drug cost savings were estimated at 21,711 dollars (95% confidence interval, 53,131 dollars savings to 9709 dollars cost increase). Information on costs of academic detailing could assist with health plan decision making in developing interventions to improve prescribing.

Antihypertensive Agents↗

PubMed2006

Variation in hepatitis B immunization coverage rates associated with provider practices after the temporary suspension of the birth dose.

BACKGROUND: In 1999, the American Academy of Pediatrics and U.S. Public Health Service recommended suspending the birth dose of hepatitis B vaccine due to concerns about potential mercury exposure. A previous report found that overall national hepatitis B vaccination coverage rates decreased in association with the suspension. It is unknown whether this underimmunization occurred uniformly or was associated with how providers changed their practices for the timing of hepatitis B vaccine doses. We evaluate the impact of the birth dose suspension on underimmunization for the hepatitis B vaccine series among 24-month-olds in five large provider groups and describe provider practices potentially associated with underimmunization following the suspension. METHODS: Retrospective cohort study of children enrolled in five large provider groups in the United States (A-E). Logistic regression was used to evaluate the association between the birth dose suspension and a child's probability of being underimmunized at 24 months for the hepatitis B vaccine series. RESULTS: Prior to July 1999, the percent of children who received a hepatitis B vaccination at birth varied widely (3% to 90%) across the five provider groups. After the national recommendation to suspend the hepatitis B birth dose, the percent of children who received a hepatitis B vaccination at birth decreased in all provider groups, and this trend persisted after the policy was reversed. The most substantial decreases were observed in the two provider groups that shifted the first hepatitis B dose from birth to 5-6 months of age. Accounting for temporal trend, children in these two provider groups were significantly more likely to be underimmunized for the hepatitis B series at 24 months of age if they were in the birth dose suspension cohort compared with baseline (Group D OR 2.7, 95% CI 1.7-4.4; Group E OR 3.1, 95% CI 2.3-4.2). This represented 6% more children in Group D and 9% more children in Group E who were underimmunized in the suspension cohort compared with baseline. Children in the reversal cohort in these groups remained significantly more likely to be underimmunized compared with baseline. In contrast, in a third provider group where the typical timing of the third dose was unchanged and in two other provider groups whose hepatitis B vaccination schedules were unaffected by the birth dose suspension, hepatitis B vaccination coverage either was maintained or improved. CONCLUSION: When the hepatitis B birth dose was suspended, provider groups that moved the first dose of vaccination to 5-6 months of age or later had decreases in hepatitis B vaccine coverage at 24 months. These findings suggest that as vaccine policy changes occur, providers could attempt to minimize underimmunization by adopting vaccination schedules that minimize delays in the recommended timing of vaccine doses.

Cohort Studies↗

PubMed2006

A trial of disclosing physicians' financial incentives to patients.

BACKGROUND: Concern regarding financial conflict of interest for physicians has led to calls for disclosure of financial incentives to patients. However, limited data on the outcomes of disclosure exist to guide policy. METHODS: This randomized trial was conducted among 8000 adult patients at 2 multispecialty group practices based in the Boston, Mass, and Los Angeles, Calif, areas. Intervention patients were mailed a compensation disclosure letter written by the chief medical officer of their physician group, and all patients were surveyed approximately 3 months later. RESULTS: Disclosure patients were significantly more able to identify correctly the compensation model of their primary care physician, in Boston (adjusted odds ratio, 2.30; 95% confidence interval, 1.92-2.75) and in Los Angeles (adjusted odds ratio, 1.37; 95% confidence interval, 1.03-1.82). Disclosure patients also had more confidence in their ability to judge the possible influence of incentives on their health care: in Boston, 32.5% vs 17.8% (P<.001); and in Los Angeles, 31.8% vs 26.4% (P = .20). The disclosure intervention did not change trust in primary care physicians overall. However, of patients who remembered receiving the disclosure, 21.4% in Boston and 24.4% in Los Angeles responded that the disclosure had increased trust either greatly or somewhat, while in both cities less than 5% of patients responded that the information decreased trust. Patients' loyalty to their physician group was higher among disclosure patients in Boston (73.4% vs 70.2%; P = .03) and Los Angeles (74.1% vs 66.9%; P = .08). CONCLUSIONS: Among diverse patient populations, a single mailed disclosure letter from physician groups was associated with improved knowledge of physicians' compensation models. Patients' trust in their physicians was unharmed, and their loyalty to their physician group was strengthened. For physician groups with similar compensation programs, disclosure to patients should be considered an effective method to enhance the patient-physician relationship.

Boston↗

PubMed2006

Evaluating spatial surveillance: detection of known outbreaks in real data.

Since the anthrax attacks of October 2001 and the SARS outbreaks of recent years, there has been an increasing interest in developing surveillance systems to aid in the early detection of such illness. Systems have been established which do this is by monitoring primary health-care visits, pharmacy sales, absenteeism records, and other non-traditional sources of data. While many resources have been invested in establishing such systems, relatively little effort has as yet been expended in evaluating their performance. One way to evaluate a given surveillance system is to compare the signals it generates with known outbreaks identified in other systems. In public health practice, for example, public health departments investigate reports of illness and sometimes track hospital admissions. Comparison of new systems with extant systems cannot generate estimates of test characteristics such as sensitivity and specificity, since the actual number of positives and negatives cannot be known. However, the comparison can reveal whether a new or proposed system's signals match outbreaks detected by the existing system. This could help support or reject the new system as an alternative or complement to the extant system. We propose three methods to test the null hypothesis that the new system does not signal true outbreaks more often than would be expected by chance. The methods differ in the restrictiveness of the assumptions required. Each test may detect weaknesses in the new system, depending on the distribution of outbreaks and can be used to construct confidence limits on the agreement between the new system's signals and the outbreaks, given the distribution of the signals. They can be used to assess whether the new system works in that it detects the outbreaks better than chance would suggest and can also determine if the new systems' signals are generated earlier than an extant system.

Data Interpretation, Statistical↗

PubMed2006

Four different study designs to evaluate vaccine safety were equally validated with contrasting limitations.

OBJECTIVE: We conducted a simulation study to empirically compare four study designs [cohort, case-control, risk-interval, self-controlled case series (SCCS)] used to assess vaccine safety. STUDY DESIGN AND METHODS: Using Vaccine Safety Datalink data (a Centers for Disease Control and Prevention-funded project), we simulated 250 case sets of an acute illness within a cohort of vaccinated and unvaccinated children. We constructed the other three study designs from the cohort at three different incident rate ratios (IRRs, 2.00, 3.00, and 4.00), 15 levels of decreasing disease incidence, and two confounding levels (20%, 40%) for both fixed and seasonal confounding. Each of the design-specific study samples was analyzed with a regression model. The design-specific beta; estimates were compared. RESULTS: The beta; estimates of the case-control, risk-interval, and SCCS designs were within 5% of the true risk parameters or cohort estimates. However, the case-control's estimates were less precise, less powerful, and biased by fixed confounding. The estimates of SCCS and risk-interval designs were biased by unadjusted seasonal confounding. CONCLUSIONS: All the methods were valid designs, with contrasting strengths and weaknesses. In particular, the SCCS method proved to be an efficient and valid alternative to the cohort method.

Acute Disease↗

PubMed2006

Clinical and nonclinical correlates of adherence to prescribing guidelines for hypertension in a large managed care organization.

To examine correlates of guideline adherence in a population with access to health care and prescription drug benefits, the authors conducted a cross-sectional analysis among 5789 patients undergoing hypertension treatment with a single medication in a large New England managed care organization. Logistic regression was used to determine correlates of adherence, defined as use of diuretics or beta blocker as antihypertensive monotherapy during the 1-year study period. Women were more likely than men to receive guideline-adherent therapy (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.45-1.85). Compared with patients covered by health maintenance organization plans, Medicare coverage was positively associated with guideline adherence (OR, 1.38; 95% CI, 1.13-1.69), but fee-for-service coverage was negatively associated (OR, 0.66; 95% CI, 0.48-0.91). Patient age was not a significant correlate of adherence to guidelines (OR, 1.01; 95% CI, 0.94-1.09). Understanding these observations may lead to strategies to improve guideline adherence and reduce health care disparities.

Adrenergic alpha-Antagonists↗

PubMed2006

Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice.

OBJECTIVE: Data are scarce regarding the sociodemographic predictors of antenatal and postpartum depression. This study investigated whether race/ethnicity, age, finances, and partnership status were associated with antenatal and postpartum depressive symptoms. SETTING: 1662 participants in Project Viva, a US cohort study. DESIGN: Mothers indicated mid-pregnancy and six month postpartum depressive symptoms on the Edinburgh postpartum depression scale (EPDS). Associations of sociodemographic factors with odds of scoring >12 on the EPDS were estimated. MAIN RESULTS: The prevalence of depressive symptoms was 9% at mid-pregnancy and 8% postpartum. Black and Hispanic mothers had a higher prevalence of depressive symptoms compared with non-Hispanic white mothers. These associations were explained by lower income, financial hardship, and higher incidence of poor pregnancy outcome among minority women. Young maternal age was associated with greater risk of antenatal and postpartum depressive symptoms, largely attributable to the prevalence of financial hardship, unwanted pregnancy, and lack of a partner. The strongest risk factor for antenatal depressive symptoms was a history of depression (OR = 4.07; 95% CI 3.76, 4.40), and the strongest risk for postpartum depressive symptoms was depressive symptoms during pregnancy (6.78; 4.07, 11.31) or a history of depression before pregnancy (3.82; 2.31, 6.31). CONCLUSIONS: Financial hardship and unwanted pregnancy are associated with antenatal and postpartum depressive symptoms. Women with a history of depression and those with poor pregnancy outcomes are especially vulnerable to depressive symptoms during the childbearing year. Once these factors are taken in account, minority mothers have the same risk of antenatal and postpartum depressive symptoms as white mothers.

Adult↗

PubMed2005

Impact of the introduction of pneumococcal conjugate vaccine on immunization coverage among infants.

BACKGROUND: The introduction of pneumococcal conjugate vaccine (PCV) to the U.S. recommended childhood immunization schedule in the year 2000 added three injections to the number of vaccinations a child is expected to receive during the first year of life. Surveys have suggested that the addition of PCV has led some immunization providers to move other routine childhood vaccinations to later ages, which could increase the possibility of missing these vaccines. The purpose of this study was to evaluate whether introduction of PCV affected immunization coverage for recommended childhood vaccinations among 13-month olds in four large provider groups. METHODS: In this retrospective cohort study, we analyzed computerized data on vaccinations for 33,319 children in four large provider groups before and after the introduction of PCV. The primary outcome was whether the child was up to date for all non-PCV recommended vaccinations at 13 months of age. Logistic regression was used to evaluate the association between PCV introduction and the primary outcome. The secondary outcome was the number of days spent underimmunized by 13 months. The association between PCV introduction and the secondary outcome was evaluated using a two-part modelling approach using logistic and negative binomial regression. RESULTS: Overall, 93% of children were up-to-date at 13 months, and 70% received all non-PCV vaccinations without any delay. Among the entire study population, immunization coverage was maintained or slightly increased from the pre-PCV to post-PCV periods. After multivariate adjustment, children born after PCV entered routine use were less likely to be up-to-date at 13 months in one provider group (Group C: OR = 0.5; 95% CI: 0.3-0.8) and were less likely to have received all vaccine doses without any delay in two Groups (Group B: OR = 0.4, 95% CI: 0.3 - 0.6; Group C: OR = 0.5, 95% CI: 0.4-0.7). This represented 3% fewer children in Group C who were up-to-date and 14% (Group C) to 16% (Group B) fewer children who spent no time underimmunized at 13 months after PCV entered routine use compared to the pre-PCV baseline. Some disruptions in immunization delivery were also observed concurrent with temporary recommendations to suspend the birth dose of hepatitis B vaccine, preceding the introduction of PCV. CONCLUSION: These findings suggest that the introduction of PCV did not harm overall immunization coverage rates in populations with good access to primary care. However, we did observe some disruptions in the timely delivery of other vaccines coincident with the introduction of PCV and the suspension of the birth dose of hepatitis B vaccine. This study highlights the need for continued vigilance in coming years as the U.S. introduces new childhood vaccines and policies that may change the timing of existing vaccines.

Cohort Studies↗

PubMed2005

Longitudinal study of birth weight and adult body mass index in predicting risk of coronary heart disease and stroke in women.

OBJECTIVES: To determine whether birth weight and adult body size interact to predict coronary heart disease in women, as has been observed for men. To determine whether birth weight and adult body size interact to predict risk of stroke. DESIGN: Longitudinal cohort study. SETTING AND PARTICIPANTS: 66,111 female nurses followed since 1976 who were born of singleton, term pregnancies and reported their birth weight in 1992. MAIN OUTCOME MEASURES: 1504 events of coronary heart disease (myocardial infarction or sudden cardiac death) and 1164 strokes. RESULTS: For each kilogram of higher birth weight, age adjusted hazard ratios from prospective analysis were 0.77 (95% confidence interval 0.69 to 0.87) for coronary heart disease and 0.89 (0.78 to 1.01) for total stroke. In combined prospective and retrospective analysis, hazard ratios were 0.84 (0.76 to 0.93) for total stroke, 0.83 (0.71 to 0.96) for ischaemic stroke, and 0.86 (0.66 to 1.11) for haemorrhagic stroke. Exclusion of macrosomic infants (> 4536 g) yielded stronger estimates. Risk of coronary heart disease was especially high for women who crossed from a low centile of weight at birth to a high centile of body mass index in adulthood. The association of lower birth weight with increased risk of stroke was apparent across categories of body mass index in adults and was not especially strong among heavier women. CONCLUSIONS: Higher body mass index in adulthood is an especially strong risk factor for coronary heart disease among women who were small at birth. In this large cohort of women, size at birth and adiposity in adulthood interacted to predict events of coronary heart disease but not stroke events.

Adolescent↗

PubMed2005

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial.

PURPOSE: To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension. METHODS: We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians. RESULTS: In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care. CONCLUSION: Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

Adrenergic beta-Antagonists↗

PubMed2005

Effects of race, insurance status, and hospital volume on perforated appendicitis in children.

OBJECTIVE: Previous research suggests that perforated appendicitis is more common in Medicaid patients, but the roles of minority race and hospital volume remain largely unstudied. We sought to investigate the association of perforated appendicitis in children with minority race, insurance status, and hospital volume. METHODS: We conducted a retrospective, population-based cohort study of 33184 children who had an International Classification of Diseases, Ninth Revision diagnosis code for acute appendicitis in The Kids' Inpatient Database, a pediatric database from 22 states in 1997. A multivariate logistic regression model was developed to determine patient and hospital characteristics predictive of perforated appendicitis. RESULTS: Of 33184 children with acute appendicitis, 10777 (32.5%) were perforated. In multivariate analysis, black (odds ratio [OR]: 1.24; 95% confidence interval [CI]: 1.10-1.39) and Hispanic (OR: 1.19; 95% CI: 1.10-1.29) children were more likely to have perforated appendicitis than white children. Perforation was also more likely in Medicaid patients (OR: 1.30; 95% CI 1.22-1.39) compared with privately insured children. Annual hospital volume of cases of appendicitis was not significantly associated with perforation in multivariate analysis. CONCLUSIONS: Perforated appendicitis disproportionately affected both children of minority race and children insured by Medicaid. No effect of hospital volume was observed. To reduce this racial disparity, efforts should focus on the causes of delayed diagnosis and the treatment of appendicitis in children of minority race.

Acute Disease↗

PubMed2005

Race differences in long-term diabetes management in an HMO.

OBJECTIVE: We examined race differences in diabetes outcomes over 4-8 years in a single HMO. RESEARCH DESIGN AND METHODS: We identified black and white adult diabetic patients who were continuously enrolled (1992-2001) and in whom diabetes was 1) diagnosed before 1994 (n = 1,686) or 2) newly diagnosed in 1994-1997 (n = 1,280). We used hierarchical models to estimate the effect of race on average annual HbA(1c) (A1C) controlling for baseline A1C, BMI, and age, as well as annual measures of type of diabetes medications, diabetes-related hospitalization, time and the number of A1C tests, physician visits, and nondiabetes medications. Stratifying by sex accounted for significant interactions between sex and race. RESULTS: At baseline, black and white patients had similar rates of A1C testing and physician visits, but blacks had higher unadjusted A1C values. In multivariate models, among patients with previously diagnosed diabetes, average A1C was nonsignificantly 0.11 higher (95% CI -0.12 to 0.34) in black than in white men but was 0.30 higher (0.14-0.46; P = 0.0007) in black than in white women. Among patients with newly diagnosed diabetes, the adjusted black-white gap was 0.49 among men (0.17-0.80; P = 0.007) and was 0.05 among women (-0.20 to -0.31), which was positive but not significant. CONCLUSIONS: Factors other than the quality of care may explain persistent race differences in A1C in this setting. Future interventions should target normalization of A1C by identifying potential psychosocial barriers to therapy intensification among patients and clinicians and development of culturally appropriate interventions to aid patients in successful self-management.

Adult↗

PubMed2005

Simulated anthrax attacks and syndromic surveillance.

We measured sensitivity and timeliness of a syndromic surveillance system to detect bioterrorism events. A hypothetical anthrax release was modeled by using zip code population data, mall customer surveys, and membership information from HealthPartners Medical Group, which covers 9% of a metropolitan area population in Minnesota. For each infection level, 1,000 releases were simulated. Timing of increases in use of medical care was based on data from the Sverdlovsk, Russia, anthrax release. Cases from the simulated outbreak were added to actual respiratory visits recorded for those dates in HealthPartners Medical Group data. Analysis was done by using the space-time scan statistic. We evaluated the proportion of attacks detected at different attack rates and timeliness to detection. Timeliness and completeness of detection of events varied by rate of infection. First detection of events ranged from days 3 to 6. Similar modeling may be possible with other surveillance systems and should be a part of their evaluation.

Anthrax↗

PubMed2004

Community-level predictors of pneumococcal carriage and resistance in young children.

Pneumococcal carriage and resistance vary markedly among communities and are not fully explained by individual predictors. Community risk factors may explain this variation. The authors geocoded addresses from a multicommunity sample of 710 Massachusetts children previously swabbed for pneumococcal carriage in 2001. Using regression models, the authors evaluated associations between census tract measures and pneumococcal carriage or resistance. Living in census tracts with an average household size of more than 2.9 predicted carriage (odds ratio = 3.0, 95% confidence interval: 1.7, 5.5), and living in socioeconomically disadvantaged census tracts conferred an additional two- to threefold odds of carriage equal to attending child care. Living in a census tract with a median household income of less than $35,000 predicted carriage among nonattendees (odds ratio = 2.7, 95% confidence interval: 1.7, 4.3). The predictive value of a low-income census tract was interchangeable with any of several socioeconomic measures, including poverty, unemployment, low educational attainment, and low owner occupancy, in addition to high density of children and limited household plumbing facilities. Furthermore, living in census tracts with low educational attainment significantly predicted resistance (odds ratio = 4.0, 95% confidence interval: 1.3, 12.7) and was interchangeable with a high density of children (odds ratio = 3.5, 95% confidence interval: 1.0, 11.7). The two- to threefold odds of pneumococcal carriage conferred by certain community characteristics suggest that these measures may target communities for interventions to decrease transmission.

Carrier State↗

PubMed2004

A generalized linear mixed models approach for detecting incident clusters of disease in small areas, with an application to biological terrorism.

Since the intentional dissemination of anthrax through the US postal system in the fall of 2001, there has been increased interest in surveillance for detection of biological terrorism. More generally, this could be described as the detection of incident disease clusters. In addition, the advent of affordable and quick geocoding allows for surveillance on a finer spatial scale than has been possible in the past. Surveillance for incident clusters of disease in both time and space is a relatively undeveloped arena of statistical methodology. Surveillance for bioterrorism detection, in particular, raises unique issues with methodological relevance. For example, the bioterrorism agents of greatest concern cause initial symptoms that may be difficult to distinguish from those of naturally occurring disease. In this paper, the authors propose a general approach to evaluating whether observed counts in relatively small areas are larger than would be expected on the basis of a history of naturally occurring disease. They implement the approach using generalized linear mixed models. The approach is illustrated using data on health-care visits (1996-1999) from a large Massachusetts managed care organization/multispecialty practice group in the context of syndromic surveillance for anthrax. The authors argue that there is great value in using the geographic data.

Bioterrorism↗

PubMed2004

Differential association of modifiable health behaviors with hot flashes in perimenopausal and postmenopausal women.

OBJECTIVE: To determine the association of modifiable factors, such as smoking, body mass index, and alcohol use, with hot flashes, and to ascertain whether the association with hot flashes varies by menopausal stage. DESIGN: A written survey completed by perimenopausal and postmenopausal women enrolling in a randomized, controlled trial of a menopause risk management program in 1999. Survey items included questions on demographics, health status, and health behaviors. SETTING: A Massachusetts-based health maintenance organization. PATIENTS/PARTICIPANTS: Female members, age 40 to 65, excluding women with chronic conditions precluding study participation, were randomly selected from an automated medical record system. MEASUREMENTS AND MAIN RESULTS: The majority of the 287 postmenopausal and 468 perimenopausal women participating in the study were white, college educated, and nonsmoking. Approximately 30% of both groups reported experiencing hot flashes. Separate multivariable logistic regression models were developed for perimenopausal and postmenopausal women to identify correlates of reporting any versus no hot flashes. After controlling for age, race, oral contraceptive use, hormone replacement therapy use, and depression, correlates of hot flashes in perimenopausal women were body mass index >/=25 kg/m(2) (odds ration [OR], 2.00; 95% confidence interval [CI], 1.28 to 3.12) and alcohol use of 1 to 5 drinks per week (OR, 0.52; 95% CI, 0.31 to 0.86). The only significant correlate of hot flashes in the postmenopausal population was high dietary fat intake (OR, 0.35; 95% CI, 0.15 to 0.81). CONCLUSION: Although study respondents were from similiar sociodemographic groups and received their health care in the same health maintenance organization, modifiable factors associated with hot flashes were different for perimenopausal and postmenopausal women.

Adult↗

PubMed2004

The effect of hospital volume of pediatric appendectomies on the misdiagnosis of appendicitis in children.

BACKGROUND: Although appendicitis is a common pediatric surgical condition, it is often misdiagnosed. Because higher hospital volume has been associated with improved outcome for many surgical procedures, the current study investigates whether hospital volume of pediatric appendectomies is associated with misdiagnosis of appendicitis in children. METHODS: The Kids' Inpatient Database is a national sample of pediatric discharges from 2521 hospitals in 22 states in 1997. In this study, misdiagnosis was defined as a patient with a principal International Classification of Diseases, Ninth Revision procedure code for nonincidental appendectomy without a corresponding diagnosis code for appendicitis. Hospitals were stratified into 5 groups based on the number of nonincidental appendectomies performed on children in 1997: lowest (<1 per month), low (>or=1 per month but <1 per week), medium (1-2 per week), high (2-3 per week), and highest (>or=3 per week). Using generalized estimating equations to control for clustering within hospitals, we developed a logistic regression model of the effect of hospital volume on misdiagnosis while adjusting for patient age, gender, race, and insurance status. RESULTS: In the database, 37,109 nonincidental appendectomies were performed on children 1 to 18 years old in 1997. Of those, 3103 (8.4%) were misdiagnosed. Of all appendectomies, 24,655 (66.4%) were performed at lowest- or low-volume hospitals. After adjusting for patient characteristics, lowest- (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.0-2.2) and low- (OR: 1.6; 95% CI: 1.1-2.3) volume hospitals had a significantly increased likelihood of misdiagnosis compared with highest-volume hospitals. Misdiagnosis at medium- (OR: 1.5; 95% CI: 1.0-2.2) and high- (OR: 1.4; 95% CI: 0.9-2.2) volume hospitals was similar to misdiagnosis at lower-volume hospitals, although not statistically different from highest-volume hospitals. CONCLUSIONS: Almost two thirds of pediatric appendectomies are performed at hospitals performing <1 pediatric appendectomy per week. Lower hospital volume of pediatric appendectomies is associated with a significantly increased likelihood of misdiagnosis of appendicitis in children.

Adolescent↗