Variation in cervical cancer screening test utilization and results in a United States-based program

BACKGROUND

Little is known about cervical cancer screening strategy utilization (cytology alone, cytology plus high-risk human papillomavirus [HPV] testing [cotesting], primary HPV testing) and test results in the United States.

METHODS

Data from the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program were analyzed for 199,578 persons aged 21-65 years screened from 2019 to 2020. Screening test utilization and results were stratified by demographic characteristics and geographic region. Age-standardized pooled HPV test positivity and genotyping test positivity were estimated within cytology result categories.

RESULTS

Primary HPV testing was performed in 592 persons (0.3%). Among the remaining 176,290 persons aged 30-65 years, cotesting was utilized in 72.1% (95% confidence interval [CI] 71.9-72.3%), and cytology alone was utilized in 27.9% (95% CI 27.7-28.1%). Utilization of cytology alone varied by geographic region, ranging from 18.3% (95% CI 17.4-19.1%) to 49.0% (95% CI 48.4-49.6%). HPV genotyping test utilization among those with positive pooled HPV test results was 33.9%. In persons aged ≥30 years, variations in age-adjusted test results by region were observed for pooled HPV-positive test results and for HPV genotyping-positive test results.

CONCLUSIONS

Cervical cancer screening strategy utilization and test results vary substantially by geographic region within a national screening program. Variation in utilization may be due to regional differences in screening test availability or the preferences of healthcare systems, screened persons and/or clinicians. Test result variations may reflect differing risk factors for HPV infections by geographic region.

Differences in breast and cervical cancer screening between West and East Germany: a secondary analysis of a german nationwide health survey

BACKGROUND

Breast cancer and cervical cancer are among the most common cancers in women in Germany. Early detection examinations such as mammography and the cervical smear test (Pap-test) have been shown to contribute to the reduction in the mortality and/or incidence of these cancers and can be utilised free of charge by women in certain age groups as part of national screening programmes. Analyses show that the use of health services varies regionally, especially when comparing the federal states of the former German Democratic Republic (GDR, Eastern Germany) and the Federal Republic of Germany (FRG, Western Germany). This study investigated to what extent the utilisation of mammography examinations and Pap-tests by women differs in federal states of former GDR and FRG.

METHODS

For this purpose, we analysed data from the nationwide health survey GEDA14/15 conducted by the Robert Koch Institute (RKI) in 2014 and 2015. We calculated weighted proportions and compared attendance between eastern and western German states by a Chi-Square-test. Additionally, we conducted regression analysis to adjust for socio-economic status, living environment and place of birth.

RESULTS

2,772 female participants aged 20-34 years were analysed for Pap-test attendance in the last two years and 4,323 female participants aged 50-69 years old were analysed for mammography screening attendance in the last two years. 50-69-year-old women in eastern German states were with 78.3% (95%-CI 75.3%, 81.2%) more likely to attend mammography screening than in western Germany with 73.4% (95%-CI 71.8%, 74.9%). Pap-test uptake was statistically significantly higher in the East of Germany with 83.3% (95%-CI 79.6%, 87.1%) compared to 77.5% (95%-CI 75.8%, 79.3%) in the West of Germany. This relationship was robust to adjusting for socio-economic status, living environment and place of birth.

CONCLUSIONS

Cultural influences and socialization in the GDR might explain the higher utilisation of these cancer screening examinations at least to some extent. This could have many reasons, for example a higher health awareness through education or a possible greater trust in medical structures and the associated higher compliance of women. These hypotheses should be further explored to increase the uptake of screening examinations by women in Germany.

Geographic variations in opioid overdose patterns in Pennsylvania during the COVID-19 pandemic

The convergence of the opioid epidemic and the COVID-19 pandemic has created new health challenges throughout the United States. Since the onset of the pandemic, media attention and scholarly research have drawn attention to the intersections of addiction and COVID-19. However, there remain few empirical studies that examine the direct impacts of the COVID-19 pandemic for opioid overdose patterns. Even fewer have integrated quantitative and qualitative methods to detail the place-specific dynamics shaping opioid overdose and addiction treatment during the COVID-19 pandemic. This article measures and maps change in the age-adjusted rate of opioid-related overdose incidents at the county level from 2018 to 2020. These analyses are combined with interviews conducted since December 2020 with public health providers in the state of Pennsylvania to identify the key factors influencing opioid misuse and transformations in addiction treatment practices.

Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis

BACKGROUND

As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed.

RESULTS

A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost.

CONCLUSION

Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.

Structural and bioinformatic analyses of Azemiops venom serine proteases reveal close phylogeographic relationships to pitvipers from eastern China and the New World

The semi-fossil and pit-less Azemiops feae is possibly the most primitive crotalid species. Here, we have cloned and sequenced cDNAs encoding four serine proteases (vSPs) from the venom glands of Chinese A. feae. Full amino-acid sequences of the major vSP (designated as AzKNa) and three minor vSPs (designated as AzKNb, AzKNc and Az-PA) were deduced. Using Protein-BLAST search, the ten most-similar vSPs for each Azemiops vSP have been selected for multiple sequence alignment, and all the homologs are crotalid vSPs. The results suggest that the A. feae vSPs are structurally most like those of eastern-Chinese Gloydius, Viridovipera, Protobothrops and North American pitvipers, and quite different from more-specialized vSPs such as Agkistrodon venom Protein-C activators. The vSPs from Chinese A. feae and those from Vietnamese A. feae show significant sequence variations. AzKNa is acidic and contains six potential N-glycosylation sites and its surface-charge distribution differs greatly from that of AzKNb, as revealed by 3D-modeling. AzKNb and AzKNc do not contain N-glycosylation sites although most of their close homologs contain one or two. Az-PA belongs to the plasminogen-activator subtype with a conserved N²⁰-glycosylation site. The evolution of this subtype of vSPs in Azemiops and related pitvipers has been traced by phylogenetic analysis.

A Norwegian Epidemiologic Osteoporosis Studies (NOREPOS) study

A higher risk of hip fracture was found in areas of Norway at higher elevation and farther from the coast. However, the previously seen county variations could not be explained by these geographical factors.

INTRODUCTION

Norway is an elongated country extending north of the Arctic Circle with substantial coast-inland variation in topography and climate. Differences in hip fracture incidence between counties and a distinct seasonal variation have previously been shown. The aim of the current study was to explore these variations further by considering associations of height above sea level (elevation) and distance to the coast with hip fracture incidence.

METHODS

All patients with hip fractures admitted to Norwegian hospitals in the period 2009-2018 were included. Individual residential elevation and distance to the coast was calculated in Geographic Information Systems and combined with individual-level population data on all Norwegians 50 years of age or older during the observation period, including hospital information on fractures. Age-standardized incidences rate and incidence rate ratios with 95% confidence intervals (IRR, 95% CI) according to elevation and coastal proximity were estimated. The associations were tested using Poisson models adjusting for sex, urban/rural location of residency, country of birth, and season of hip fracture occurrence.

RESULTS

From 2009 to 2018, there were 85,776 first hip fractures. There was an increasing risk with higher residential elevation (above versus below mean) for women: IRR = 1.04, 95% CI: 1.02, 1.05), but not for men (IRR = 1.00, 95% CI: 0.97, 1.02). Incidence of hip fracture increased with distance from the coast. Women residing the farthest away from the coast (above versus below mean distance) had a higher age-adjusted incidence of hip fracture compared to those living closer to the coast (IRR = 1.04 (95% CI: 1.02, 1.06), whereas no association was found in men (IRR = 1.00 (95% CI: 1.00, 1.01). Combining elevation and distance to coast showed a higher incidence in women living at high elevation far from the coast compared with women living at low elevation near the coast (IRR = 1.07, 95% CI: 1.04, 1.10). A similar result was found in men but only for hip fractures occurring during March-May (IRR = 1.07, 95% CI: 1.00, 1.15). The previously shown patterns of county differences and seasonal variations were unchanged when considering geography.

CONCLUSION

We found a somewhat higher incidence of hip fracture in inland residents living in areas of high elevation, as compared to those living in more coastal proximity; however, the geographic variation did not explain county and seasonal differences in fracture incidence in Norway. More in-depth analyses on temperature and climate factors may give further clues.

Geographic variations in hip fracture incidence in a high-risk country stretching into the Arctic: a NOREPOS study

There are geographic variations in hip fracture incidence rates across Norway, with a lower incidence in the coastal areas of the southwest and in the Arctic north, contrary to what may be expected with regard to vitamin D exposure from sunlight. The regional differences have become smaller in recent years.

INTRODUCTION

To investigate geographic variation in hip fracture incidence within Norway and regional differences in time trends.

METHODS

All hip fractures treated in Norwegian hospitals 2002-2013 were included, and demographic information was obtained from Statistics Norway. Age-standardized incidence rates were calculated separately for 19 counties. Incidence rate ratios with 95% confidence intervals for county differences and time trends were estimated using Poisson regression.

RESULTS

Age-standardized number of hip fractures per 10,000 person-years varied between counties from 69 to 84 in women and from 34 to 41 in men. The highest rates were observed in the southeastern capital city of Oslo, while rates were low in the four northernmost counties. There was an east-west gradient, with lower incidence in the coastal southwest compared with the southeast. Women showed a statistically significant decline during 2002-2013 in almost all counties (up to 31%). In men, only a few counties showed a decline. In both genders, hip fracture rates at age 80 in the combined five counties with the highest rates were significantly higher than in the combined five counties with the lowest rates across the period, although the trends converged over time.

CONCLUSIONS

In Norway, the hip fracture incidence was lower in the north compared with the south. In addition, we observed an east-west gradient with the highest incidence in the southeast and lower incidence in the coastal southwest. While there has been an overall declining trend in hip fracture incidence over time, regional differences are still apparent.

Spatial risk adjustment between health insurances: using GWR in risk adjustment models to conserve incentives for service optimisation and reduce MAUP

This paper presents a new approach to deal with spatial inequalities in risk adjustment between health insurances. The shortcomings of non-spatial and spatial fixed effects in risk adjustment models are analysed and opposed against spatial kernel estimators. Theoretical and empirical evidence suggests that a reasonable choice of the spatial kernel could limit the spatial uncertainty of the modifiable area unit problem under heavy-tailed claims data, leading to more precise predictions and economically positive incentives on the healthcare market. A case study of the German risk adjustment shows a spatial risk spread of 86 Euro p.c., leading to incentives for spatial risk selection. The proposed estimator eliminates this issue and conserves incentives for services optimisation.

Generational differences in longitudinal blood pressure trajectories by geographic region during socioeconomic transitions in China

OBJECTIVES

To examine generational differences in longitudinal blood pressure trajectories by region following socioeconomic transitions, which is important for establishing the population risk of cardiovascular diseases (CVDs).

METHODS

With data from the China Health and Nutrition Survey (1991-2011), we used multilevel growth-curve models to estimate systolic/diastolic blood pressure (SBP/DBP) levels at the mean age and rates of change by cohort (born between 1931 and 1980), region, and sex.

RESULTS

Younger cohorts generally had higher SBP/DBP levels at 44.5 years but lower growth rates in SBP/DBP than older cohorts. They became prehypertensive (SBP ≥ 120 mm Hg or DBP ≥ 80 mm Hg) at an earlier age. The upward shift of SBP/DBP trajectories across cohorts was more pronounced in the Coastal and Southern Mountainous Regions than the Northeastern and Inland Regions, and for males versus females.

CONCLUSIONS

Younger cohorts have a longer lifetime duration of being susceptible to CVDs, posing warnings for an increased burden of CVDs. Generational differences in BP trajectories and geographic and sex variations in the cohort trends highlight the need for tailored interventions to tackle the generation, region, and sex-based risk of CVDs.

Temporal trends of geographic variation in mortality following cancer diagnosis: a population-based study

Background

Inequalities among the western population, combined with the introduction of new treatment options for cancer, have challenged endeavors to provide equal care to patients with cancer. Israel’s highly developed healthcare system and mandatory National Health Insurance afforded an opportunity to study geographic variation over time in mortality following cancer diagnosis.

Methods

This historical prospective cohort study included a nationally representative cohort that was assessed by the Israeli Central Bureau of Statistics 1995 census and followed until 2011. The cancer incidence (1995–2009) was ascertained by the Israel National Cancer Registry. We analyzed the effect on patient outcome of living in a given district, according to the Israeli Central Bureau of Statistics classification. Patients were stratified by the year of diagnosis (1995–1997, 1998–2000, etc.), and associations were adjusted for age, ethnicity, and districts. We excluded patients with malignancies associated with screening program (breast, prostate, colon, and cervical cancers).

Results

This study included 26,173 patients living in 13 residential districts. During the last years (2007–2009) of the study, the hazard ratio (HR) for risk of death was high in 8/13 districts (61.5%), compared to 4/13 (30.7%) during 2004–2006, and 0/13 (0%) during 2001–2003. Districts that were less likely to be associated with increased risk of death were located in the center of Israel and in metropolitan areas, compared to the peripheral regions. Furthermore, HRs were substantially higher in the last years of the study (2007–2009, HRs rose to 1.69, 95%CI: 1.38–2.08) compared to the earlier years (2004–2006, HRs rose to 1.35, 95%CI: 1.13–1.62).

Conclusion

Our findings suggested that geographic variation for mortality following cancer diagnosis have increased over time. Our results provide policy makers with vital information regarding the need for targeted interventions, mainly in peripheral regions.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6353-1) contains supplementary material, which is available to authorized users.

Understanding geographic variations in psychiatric inpatient admission rates: width of the variations and associations with the supply of health and social care in France

BACKGROUND

Inpatient care accounts for the majority of mental health care costs and is not always beneficial. It can indeed have detrimental consequences if not used appropriately, and is unpopular among patients. As a consequence, its reduction is supported by international recommendations. Varying rates of psychiatric inpatient admissions therefore deserve to draw attention of researchers, clinicians and policy makers alike as such variations can challenge quality, equity and efficiency of care. In this context, our objectives were first to describe variations in psychiatric inpatient admission rates across the whole territory of mainland France, and second to identify their association with characteristics of the supply of care, which can be targeted by dedicated health policies.

METHODS

Our study was carried out in French psychiatric sectors' catchment areas for the year 2012. Inpatient admission rates per 100,000 adult inhabitants were calculated using data from the national psychiatric discharge database. Their variations were described numerically and graphically. We then carried out a negative binomial regression to identify characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) which were associated with these variations while adjusting our analysis for other relevant factors, in particular epidemiological differences.

RESULTS

Considerable variations in inpatient admission rates were observed between psychiatric sectors' catchment areas and were widespread on the French territory. Institutional characteristics of the hospital to which each sector was linked (private non-profit status, specialisation in psychiatry and participation to teaching activities and to emergency care) were associated with inpatient admission rates. Similarly, an increase in the availability of community-based private psychiatrists was associated with a decrease in the inpatient admission rate while an increase in the capacity of housing institutions for disabled individuals was associated with an increase in this rate.

CONCLUSIONS

Our results advocate for a homogenous repartition of health and social care for mental disorders in lines with the health needs of the population served. This should apply particularly to community-based private psychiatrists, whose heterogeneity of repartition has often been underscored.

Geographic variations in involuntary care and associations with the supply of health and social care: results from a nationwide study

Background

Involuntary psychiatric care remains controversial. Geographic disparities in its use can challenge the appropriateness of the care provided when they do not result from different health needs of the population. These disparities should be reduced through dedicated health policies. However, their association with the supply of health and social care, which could be targeted by such policies, has been insufficiently studied. Our objectives were therefore to describe geographic variations in involuntary admission rates across France and to identify the characteristics of the supply of care which were associated with these variations.

Methods

Involuntary admission rate per 100,000 adult inhabitants was calculated in French psychiatric sectors’ catchment areas using 2012 data from the national psychiatric discharge database. Its variations were first described numerically and graphically. Several factors potentially associated with these variations were then considered in a negative binomial regression with an offset term accounting for the size of catchment areas. They included characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) as well as adjustment factors related to epidemiological characteristics of the population of each sector’s catchment area and its level of urbanization. Such variables were extracted from complementary administrative databases. Supply characteristics associated with geographic variations were identified using a significance level of 0.05.

Results

Significant variations in involuntary admission rates were observed between psychiatric sectors’ catchment areas with a coefficient of variation close to 80%. These variations were associated with some characteristics of the supply of health and social care in the sectors’ catchment areas. Notably, an increase in the availability of community-based private psychiatrists and the capacity of housing institutions for disabled individuals was associated with a decrease in involuntary admission rates while an increase in the availability of general practitioners was associated with an increase in those rates.

Conclusions

There is evidence of considerable variations in involuntary admission rates between psychiatric sectors’ catchment areas. Our results provide lines of thoughts to reduce such variations, in particular by supporting an increase in the availability of upstream and downstream care in the community.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3064-3) contains supplementary material, which is available to authorized users.

Geographic variations in female breast cancer incidence in relation to ambient air emissions of polycyclic aromatic hydrocarbons

A significant geographic variation of breast cancer incidence exists, with incidence rates being much higher in industrialized regions. The objective of the current study was to assess the role of environmental factors such as exposure to ambient air pollution, specifically carcinogenic polycyclic aromatic hydrocarbons (PAHs) that may be playing in the geographic variations in breast cancer incidence. Female breast cancer incidence and ambient air emissions of PAHs were examined in the northeastern and southeastern regions of the USA by analyzing data from the Surveillance, Epidemiology, and End Results (SEER) Program and the State Cancer Profiles of the National Cancer Institute and from the Environmental Protection Agency. Linear regression analysis was conducted to evaluate the association between PAH emissions and breast cancer incidence in unadjusted and adjusted models. Significantly higher age-adjusted incidence rates of female breast cancer were seen in northeastern SEER regions, when compared to southeastern regions, during the years of 2000-2012. After adjusting for potential confounders, emission densities of total PAHs and four carcinogenic individual PAHs (benzo[a]pyrene, dibenz[a,h]anthracene, naphthalene, and benzo[b]fluoranthene) showed a significantly positive association with annual incidence rates of breast cancer, with a β of 0.85 (p = 0.004), 58.37 (p = 0.010), 628.56 (p = 0.002), 0.44 (p = 0.041), and 77.68 (p = 0.002), respectively, among the northeastern and southeastern states. This study suggests a potential relationship between ambient air emissions of carcinogenic PAHs and geographic variations of female breast cancer incidence in the northeastern and southeastern US. Further investigations are needed to explore these interactions and elucidate the role of PAHs in regional variations of breast cancer incidence.

Geographic variation within the military health system

Background

This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS).

Methods

Data for fiscal years 2007 – 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF.

Results

Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas.

Conclusions

In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare.

Geographic variation in selected hospital procedures and services in the Israeli health care system

Background

Medical practice variation refers to differences in health service utilization among regions in the same country. It is used as a tool for studying health inequities.

In 2011, the OECD launched a Medical Practice Variation Project which examines regional differences within countries and explores the sources of the inter-regional differences. The aim of this study is to examine the patterns and trends in geographic variation for selected health services in Israel.

Methods

The analysis is based on data from the National Hospital Discharges Database (NHDD) of the Israeli Ministry of Health. The eight procedures and services studied were: medical admissions (i.e. admissions without surgical procedures); hip fractures; caesarian sections; diagnostic cardiac catheterization; cardiac angioplasty (PTCA); cardiac bypass surgery (CABG); hysterectomy; and knee replacement surgery. The data are presented for the 7 districts in Israel, determined by address of residence.

Results

The procedures and services with the lowest variation across the seven districts were medical admissions (RR between regions-maximum/minimum 1.3) and hip fractures (RR 1.44), while the one with the highest variation was CABG (RR 1.98). The Israeli periphery, and the northern district in particular, had higher rates of medical admissions, knee replacement and cardiac procedures. When studying the trend over time, we found a decrease in use rates for most procedures, such as coronary bypass (R. 04) and CABG (R 0.8). Medical admissions decreased by 8%, with the highest decline (16%) observed in the central districts.

Conclusions

This study provides Israeli policy makers with information which is vital for the strategic planning of service development, such as strengthening preventive medical services in the community, reducing cardiovascular risk factors in the periphery and expanding the national publication of clinical quality scores.

Electronic supplementary material

The online version of this article (doi:10.1186/s13584-016-0127-y) contains supplementary material, which is available to authorized users.

Geographic variations in orthopedic trauma billing and reimbursements for hip and pelvis fractures in the Medicare population

We investigated geographic variations in Medicare spending for DRG 536 (hip and pelvis fracture). We identified 22,728 patients. The median number of charges, discharges, and payments were recorded. Hospitals were aggregated into core based statistical (CBS) areas and the coefficient of variation (CV) was calculated for each area. On average, hospitals charged 3.75 times more than they were reimbursed. Medicare charges and reimbursements demonstrated variability within each area. Geographic variation in Medicare spending for hip fractures is currently unexplained. It is imperative for orthopedists to understand drivers behind such high variability in hospital charges for management of hip and pelvis fractures.

Medicare and Private Insurance Variations in New Medical Technology: The Case of Drug Eluting Stents

IMPORTANCE

Little is known about the geographic and hospital variations of the new medical technologies in Medicare. Even less is known about these variations for the privately insured.

OBJECTIVE

To examine geographic and hospital variations in the diffusion of drug eluting stents, comparing Medicare and privately insured populations.

DESIGN

Retrospective analyses of discharges from the State Inpatient Databases for 11 states (2004-2005) supplemented with data on hospital characteristics from the American Hospital Association Annual Survey.

SETTING/PARTICIPANTS

Study sample included discharges with percutaneous coronary intervention (PCI) procedures that involved a cardiac stent.

EXPOSURE

Insurance type: Medicare versus private insurance.

MAIN OUTCOME

Use of a drug eluting stent during the PCI was our outcome variable. We estimated linear probability models at the discharge level that related our outcome variable to patient and hospital characteristics separately for Medicare and private insurance. To examine variations across hospital referral regions (HRRs) and across hospitals, our models included HRR and hospital indicators respectively.

RESULTS

Our analysis included 390,649 records (237,991 Medicare, 152,658 private insurance). We found large HRR variations in the use of drug eluting stents in 2004 for both payer types, the year after drug eluting stents were approved (adjusted CoV: 0.35 (Medicare); 0.24 (Private Insurance)). We also found large hospital variations in 2004 (adjusted CoV: 0.32 (Medicare); 0.29 (Private Insurance)). Between 2004 and 2005, adjusted HRR and hospital variations decreased across both payer types, suggesting that practice styles converged as the drug eluting stents diffused and became more common. Finally, adjusted drug eluting stent rates were highly correlated both at the HRR and hospital level across payer types.

CONCLUSION

Our findings are consistent with the hypothesis that private insurance closely follows the lead of Medicare in terms of medical technology coverage and reimbursement.

Regional geographic variations in kidney cancer incidence rates in European countries

CONTEXT

Marked unexplained national variations in incidence rates of kidney cancer have been observed for decades in Europe.

OBJECTIVE

To investigate geographic variations at the regional level and identify European regions with high incidence rates of kidney cancer.

EVIDENCE ACQUISITION

Regional- and national-level incidence data were extracted from the Cancer Incidence in Five Continents databases, local cancer registry databases, and local published reports. World population age-standardised rates (ASRs) were calculated for the periods 2003-2007 and 1988-1992. Rates by period and sex were compared using map visualisation.

EVIDENCE SYNTHESIS

During 2003-2007, the highest ASR was found in the Plzen region, Czech Republic (31.4/100,000 person-years in men). Other regions of the Czech Republic had ASRs of 18.6-27.5/100,000 in men, with a tendency for higher rates in regions south of Prague. Surrounding regions, including eastern Germany and regions of Slovakia and Austria, had medium-to-high incidence rates (13.0-16.8/100,000 in men). Three other areas in Europe showed higher incidence rates in men compared with the rest of the continent: Lithuania, Estonia, Latvia, and Belarus (15.0-17.6/100,000); Iceland (13.5/100,000), and northern Italy (up to 16.0/100,000). Similar regional differences were observed among women, with rates approximately half of those observed in men in the same region. In general, these regional geographic variations remained stable over the periods 1988-1992 and 2003-2007, although higher incidence rates were detected in the Baltic countries in 2003-2007.

CONCLUSIONS

Several European regions show particularly high rates of kidney cancer incidence. Large variations were observed within countries covered by national health-care systems, implying that overdetection is not the major factor.

PATIENT SUMMARY

We present regional geographic variations in kidney cancer incidence rates in Europe. We highlight several regions with high incidence rates where further studies should be conducted for cancer control and prevention.

Geographic region and racial variations in polypharmacy in the United States

PURPOSE

Medications can have unintended effects. High medication use populations may benefit from increased regimen oversight. Limited knowledge exists concerning racial and regional polypharmacy variation. We estimated total medication distributions (excluding supplements) of American black and white adults and assessed racial and regional polypharmacy variation.

METHODS

REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort data (n = 30,239 U.S. blacks and whites aged ≥45 years) were analyzed. Home pill bottle inspections assessed the last two weeks' medications. Polypharmacy (≥8 medications) was determined by summing prescription and/or over-the-counter ingredients. Population-weighted logistic regression assessed polypharmacy's association with census region, race, and sex.

RESULTS

The mean ingredient number was 4.12 (standard error = 0.039), with 15.7% of REGARDS using 8 ingredients or more. In crude comparisons, women used more medications than men, and blacks and whites reported similar mean ingredients. A cross-sectional, logistic model adjusting for demographics, socioeconomics, and comorbidities showed increased polypharmacy prevalence in whites versus blacks (OR [95% CI]: 0.63, [0.55-0.72]), women (1.94 [1.68-2.23]), and Southerners (broadly Southeasterners and Texans; 1.48 [1.17-1.87]) versus Northeasterners (broadly New England and upper Mid-Atlantic). Possible limitations include polypharmacy misclassification and model misspecification.

CONCLUSION

Polypharmacy is common. Race and geography are associated with polypharmacy variation. Further study of underlying factors explaining these differences is warranted.

Seasonal and geographical variations in the biochemical composition of the blue mussel (Mytilus edulis L.) from Ireland

Blue mussel (Mytilus edulis L.) farming constitutes the largest volume of the shellfish sector in Ireland. Recently, interest in mussel dietary supplements and functional foods has increased significantly. To identify the optimal harvesting time and location in Ireland, blue mussels were investigated for their biochemical composition over a period of one year. The study included samples from aquaculture facilities, wild grown mussels and waste material. Each sample was analysed at four time points to determine the total content of (i) glycogen, (ii) lipids, (iii) proteins, (iv) inorganic substances, and (v) energy. Moreover, fatty acid profiles were investigated by GC-FID revealing high contents of PUFAs and a high ω-3/ω-6 ratio. Compared to less pronounced geographical variations, distinct seasonal trends could be observed for all samples. The content of the investigated metabolite classes, inorganic substances, and energy was at a maximum level in spring or late summer.

Multilevel evaluation of 'China Healthy Lifestyles for All', a nationwide initiative to promote lower intakes of salt and edible oil

OBJECTIVE

To evaluate the impact of 'China Healthy Lifestyle for All' on levels of knowledge, taste and intentions to modify future consumption of salt and edible oil.

METHODS

Between May and August 2012, a face-to-face survey carried out in all 31 provinces, autonomous regions, and municipalities in mainland China, achieved a 98.1% response. Intention-To-Treat analysis via multilevel logistic regression was used to examine differences in outcomes between 31,396 non-institutionalised individuals aged > 18 years from 31 'intervention' (i.e. participating) and 26 'control' (i.e. non-participating) counties respectively.

RESULTS

Adjusting for socioeconomic confounders, participants in 'intervention' counties were more likely to know the limit of salt (Odds Ratio 3.14, 95% Confidence Interval (95% CI) 1.98, 4.96) and oil consumption (3.67, 95% CI 2.31, 5.82), and were more intent to modify their consumption (salt 1.98, 95% CI 1.41, 2.76; oil OR 1.99, 95% CI 1.41, 2.81) and to report a change in taste (salt 1.90, 95% CI 1.31, 2.75; oil 2.07, 95% CI 1.38, 3.10). 'Intervention' effects were consistent regardless of income or education, but women and older participants benefited disproportionately. Outcomes were 2.8 and 4.7 times more likely among those with better recall.

CONCLUSION

Place-based health promotion interventions have an important role to play in addressing non-communicable disease in China.