Education Outcomes of Children Born Late Preterm: A Retrospective Whole-Population Cohort Study.

BACKGROUND: Early life exposures can have an impact on a child's developmental trajectory and children born late preterm (34-36 weeks gestational age) are increasingly recognized to have health and developmental setbacks that extend into childhood. OBJECTIVES: The purpose of this study was to assess whether late preterm birth was associated with poorer developmental and educational outcomes in the early childhood period, after controlling for health and social factors. METHODS: We conducted a retrospective cohort study using administrative databases housed at the Manitoba Centre for Health Policy, including all children born late preterm (34-36 weeks gestational age (GA)) and at full-term (39-41 weeks GA) between 2000 and 2005 in urban Manitoba (N = 28,100). Logistic regression was used to examine the association between gestational age (GA) and outcomes, after adjusting for covariates. RESULTS: Adjusted analyses demonstrated that children born late preterm had a higher prevalence of attention deficit hyperactivity disorder (ADHD) (aOR = 1.25, 95% CI [1.03, 1.51]), were more likely to be vulnerable in the language and cognitive (aOR = 1.29, 95% CI [1.06, 1.57]), communication and general knowledge (aOR = 1.24, 95% CI [1.01, 1.53]), and physical health and well-being (aOR = 1.27, 95% CI [1.04, 1.53]) domains of development at kindergarten, and were more likely to repeat kindergarten or grade 1 (aOR = 1.52, 95% CI [1.03, 2.25]) compared to children born at term. They did not differ in receipt of special education funding, in social maturity or emotional development at kindergarten, and in reading and numeracy assessments in the third grade. CONCLUSIONS: Given that the late preterm population makes up 75% of the preterm population, their poorer outcomes have implications at the population level. This study underscores the importance of recognizing the developmental vulnerability of this population and adequately accounting for the social differences between children born late preterm and at term.

Long-term benefits of full-day kindergarten: a longitudinal population-based study.

In the first longitudinal, population-based study of full-day kindergarten (FDK) outcomes beyond primary school in Canada, we used linked administrative data to follow 15 kindergarten cohorts (n ranging from 112 to 736) up to grade 9. Provincial assessments conducted in grades 3, 7, and 8 and course marks and credits earned in grade 9 were compared between FDK and half-day kindergarten (HDK) students in both targeted and universal FDK programmes. Propensity score matched cohort and stepped-wedge designs allowed for stronger causal inferences than previous research on FDK. We found limited long-term benefits of FDK, specific to the type of programme, outcomes examined, and subpopulations. FDK programmes targeted at low-income areas showed long-term improvements in numeracy for lower income girls. Our results suggest that expectations for wide-ranging long-term academic benefits of FDK are unwarranted.

Attention-deficit hyperactivity disorder in Manitoba children: medical diagnosis and psychostimulant treatment rates.

OBJECTIVE: To describe physicians' diagnosis rates for attention-deficit hyperactivity disorder (ADHD) for children in the province of Manitoba and to describe the rate of psychostimulant medication use by these children. METHODS: This descriptive study reviewed the computerized administrative records of physician visits and prescriptions dispensed to examine a population-based, cross-sectional cohort of children diagnosed with ADHD or prescribed stimulant medication, or both. We found 4787 children with a diagnosis of ADHD over a 24-month period or a prescription for stimulant medication over a 12-month period, or both. Rates were calculated by age, sex, region of residence, neighbourhood income level, and physician specialty. RESULTS: Among Manitoba children, 1.52% received a medical diagnosis of ADHD and 0.89% received stimulant medication. Regionally, diagnosis rates for ADHD varied almost 4-fold, and over 8-fold for medications prescribed. Urban areas had higher rates than did rural areas, regardless of physician specialty. Diagnosis and prescription rates varied according to physician specialty, with the highest rates found among pediatricians. An income gradient was evident in rural areas, with rates of ADHD diagnosis and medication prescribed increasing with increased neighbourhood income level. CONCLUSIONS: The pattern of regional variation found in this study suggests that the diagnosis and treatment of ADHD in Manitoba are influenced strongly by the practice styles of local physicians.

Monitoring health reform: a report card approach.

UNLABELLED: During the past several years, budget cuts have forced hospitals in several countries to change the way they deliver care. Gilson (Gilson, L. (1998). DISCUSSION: In defence and pursuit of equity. Social Science & Medicine, 47(12), 1891-1896) has argued that, while health reforms are designed to improve efficiency, they have considerable potential to harm equity in the delivery of health care services. It is essential to monitor the impact of health reforms, not only to ensure the balance between equity and efficiency, but also to determine the effect of reforms on such things as access to care and the quality of care delivered. This paper proposes a framework for monitoring these and other indicators that may be affected by health care reform. Application of this framework is illustrated with data from Winnipeg, Manitoba, Canada. Despite the closure of almost 24% of the hospital beds in Winnipeg between 1992 and 1996, access to care and quality of care remained generally unchanged. Improvements in efficiency occurred without harming the equitable delivery of health care services. Given our increasing understanding of the weak links between health care and health, improving efficiency within the health care system may actually be a prerequisite for addressing equity issues in health.

The unintended and unexpected impact of downsizing: costly hospitals become more costly.

OBJECTIVES: In this project we assessed the impact of 1992 budget cuts ($50 million, or approximately 7% of urban hospitals' budgets) on the relative costliness of Manitoba's hospitals. The cuts targeted the teaching hospitals, those institutions we had found to be particularly costly in a previous Manitoba Centre for Health Policy and Evaluation study. RESULTS: Unexpectedly, we found that because budget cuts were smaller proportionately than the number of beds closed, the care at the teaching hospitals (as well as at several other hospitals) became relatively more, not less, costly. Also quite contrary to public perceptions, once other expenditures such as new hospital programs and expansions were accounted for, the actual change in urban hospital expenditures over the years compared was less than 1%. CONCLUSIONS: The study highlighted the importance of monitoring program outcomes.

Monitoring the impact of hospital downsizing on access to care and quality of care.

The most recent data used for monitoring the potential effects of bed closures in Winnipeg hospitals since 1992/93 found that despite downsizing, access to care was by no means compromised. Just as many patients were cared for in 1995/96 as in 1991/92. Changes in patterns of care included more outpatient and fewer inpatient surgeries, and a decrease in the number of hospital days. The number of high-profile surgical procedures, such as angioplasty, bypass, and cataract surgery, performed increased dramatically during downsizing. Quality of care delivered to patients, measured by mortality and readmission rates, was unaffected by bed closures. Of particular concern was the impact of downsizing on the two most vulnerable health groups--the elderly and Manitobans in the lowest income group. Access and quality of care for these groups also remained unchanged. However, those in the lowest income group spent almost 43% more days in hospital than those in the middle income group, and research demonstrates that these variations in hospital use across socioeconomic groups reflect real and important health differences and are not driven by social reasons for admissions. Finally, a large decrease in waiting time for nursing home placement underlines the relationship between downsizing and availability of alternatives to hospitalization.

Managing health services: how the Population Health Information System (POPULIS) works for policymakers.

OBJECTIVES: University-based researchers in Manitoba, Canada, have used administrative data routinely collected as part of the national health insurance plan to design an integrated database and population-based health information system. This information system is proving useful to policymakers for answering such questions as: Which populations need more physician services? Which need fewer? Are high-risk populations poorly served? or do they have poor health outcomes despite being well served? Does high utilization represent overuse? or is it related to high need? More specifically, this system provides decision makers with the capability to make critical comparisons across regions and subregions of residents' health status, socioeconomic risk characteristics and use of hospitals, nursing homes, and physicians. The system permits analyses of demographic changes, expenditure patterns, and hospital performance in relation to the population served. The integrated database has also facilitated outcomes research across hospitals and countries, utilization review within a single hospital, and longitudinal research on health reform. The discussion highlights the strengths of integrated population-based information in analyzing the health care system and raising important questions about the relationship between health care and health.

Private health care in Canada: savior or siren?

In canada, health care is publicly insured and available to all at no charge. Recently, financial pressures have threatened the system and led to considerable debate about how to save it. One proposal is to permit privately funded health care alongside the public system, resulting in what is popularly called a two-tiered system. This paper presents some of the arguments for and against two-tiered health care. Using as an example cataract surgery-a procedure that is available both publicly and privately-the authors look at some common beliefs about private health care in Canada. They conclude that the growth in private sector cataract surgery does not appear to be related to cutbacks or rationing, that private access does not necessarily shorten waiting times, and that, contrary to popular belief, it is not only the well-to-do who pay for private surgery in Canada.

Discharging patients earlier from Winnipeg hospitals: does it adversely affect quality of care?

OBJECTIVE: To determine whether decreasing lengths of stay over time for selected diagnostic categories were associated with increased hospital readmission rates and mean number of physician visits after discharge. DESIGN: Retrospective descriptive study. SETTING: The seven large (125 beds or more) acute care hospitals in Winnipeg. PATIENTS: Manitoba residents admitted to any one of the seven hospitals because acute myocardial infarction (AMI), bronchitis or asthma, transurethral prostatectomy (TURP) and uterine or adnexal procedures for nonmalignant disease during the fiscal years 1989-90 to 1992-93. Patients from out of province, those who died in hospital, those with excessively long stays (more than 60 days) and those who were transferred to or from another institution were excluded. OUTCOME MEASURES: Length of hospital stay, and rate of readmission within 30 days after discharge for all four categories and mean number of physician visits within 30 days after discharge for two categories (AMI and bronchitis or asthma. RESULTS: The length of stay decreased significantly over the 4 years for all of the four categories, the smallest change being observed for patients with AMI (11.1%) and the largest for those with bronchitis or asthma (22.0%). The readmission rates for AMI, bronchitis or asthma, and TURP showed no consistent change over the 4 years. The readmission rate for uterine or adnexal procedures increased significantly between the first and second year (chi 2 = 4.28, p = 0.04) but then remained constant over the next 3 years. The mean number of physician visits increased slightly for AMI in the first year (1.92 to 2.01) and then remained virtually the same. It decreased slightly for bronchitis or asthma over the 4 years. There was no significant correlation between length of stay and readmission rates for individual hospitals in 1992-93 in any of the four categories. Also, no correlation was observed between length of stay and mean number of physician visits for individual hospitals in 1992-93 in the categories AMI and bronchitis or asthma. CONCLUSIONS: Improving hospital efficiency by shortening length of stay does not appear to result in increased rates of readmission or numbers of physician visits within 30 days after discharge from hospital. Research is needed to identify optimal lengths of stay and expected readmission rates.

Variation in length of stay as a measure of efficiency in Manitoba hospitals.

OBJECTIVE: To examine the efficiency of Manitoba hospitals by analysing variations in length of stay for patients with similar characteristics. DESIGN: Retrospective study. Multiple regression analyses were used to adjust for patient (case-mix) characteristics and to identify differences in length of stay attributable to the hospital of admission for 14 specific, frequently encountered diagnostic categories and for all acute admissions. SETTING: The eight major acute care hospitals in Manitoba. PARTICIPANTS: Manitoba residents admitted to any one of the eight hospitals during the fiscal year 1989-90, 1990-91 or 1991-92. Patients transferred to or from another institution, those with atypically long stays and those who died in hospital were excluded. OUTCOME MEASURE: Length of hospital stay. RESULTS: The length of stay was strongly influenced by hospital of admission, even after adjustment for key patient characteristics. Excluding the most seriously ill patients and those with the longest stays, approximately 186 beds could potentially have been saved if each hospital had discharged its patients as efficiently as the hospital with the shortest overall length of stay. CONCLUSIONS: A substantial proportion of days currently invested in treating acute care patients could be eliminated. At least some bed closures in Manitoba hospitals could be accommodated simply through more efficient treatment of patients in the remaining beds, without decreasing access to hospital care.

Development and training of referential communication in children with mental retardation.

In referential communication, the speaker must communicate to the listener about how a referent is different from other stimuli (i.e., employ the "difference rule"--Whitehurst & Sonnenschein, 1985). In Experiment 1 we compared use of the difference rule by children with and without mental retardation matched for Quick Test MA. Participants with mental retardation were less likely to employ the difference rule. Experiment 2 demonstrated that perceptual feedback training, which teaches use of the difference rule, enhances referential communication of children with mental retardation.

Small lymphocytic lymphoma: a clinicopathologic analysis of 268 cases.

We analyzed specimens from 268 patients with small lymphocytic lymphoma (SL) to identify prognostic factors significant for survival. These patients were staged and treated according to the protocols of the Cancer and Leukemia Group B, Eastern Cooperative Oncology Group, Southeastern Cancer Study Group, and the Southwest Oncology Group. Univariate analysis showed that a large-cell grade greater than I, WBC greater than 10,000/microL, hemoglobin (Hgb) less than 11 g/dL, age greater than or equal to 55 years, and failure to respond to treatment were all poor prognostic factors. Multivariate analysis showed that large-cell grade, age, degree of capsular invasion, and symptom type were independently associated with survival. Separate analyses of cases with and without leukocytosis indicated differences in survival. In patients without leukocytosis, age, presence or absence of anemia, and treatment response were significant prognostic variables; in patients with leukocytosis, large-cell grade, presence or absence of anemia, symptom type, and treatment response were significantly related to survival. Multivariate analysis showed that age was the only significant independent prognostic variable in patients without leukocytosis; in patients with leukocytosis, symptom type, large-cell grade, and bone marrow involvement were independently associated with survival. We conclude that several parameters, both clinical and pathologic, should be assessed at the initial diagnosis of SL to predict prognosis better.

Variability in interpretation of immunohistologic findings in lymphoproliferative disorders by hematopathologists. A comprehensive statistical analysis of interobserver performance.

Eight hematopathologists independently reviewed 56 consecutive cases of benign and malignant lymphoproliferative disorders (LPD) to determine: (1) the degree of interobserver agreement on the interpretation of immunologic findings on fresh-frozen sections alone and on that of the immunologic findings in conjunction with corresponding hematoxylin and eosin (H & E)-stained histologic sections; (2) whether prior knowledge of morphologic characteristics influences the interpretation of immunohistologic sections; (3) whether immunologic phenotype could be predicted reliably based solely on study of histologic sections; and (4) the significance of immunologic data as an aid in the interpretation of histologic sections. The study was carried out in three independent review sessions consisting of (1) review of immunohistologic sections only, (2) review of the same immunohistologic sections together with histologic sections, and (3) review of the histologic sections alone. A consensus diagnosis was defined as agreement of five or more pathologists on the final diagnosis and identification of the immunophenotype. When the authors compared the total number of major disagreements in the first review session with those in the second, the accuracy of the determination of immunophenotype in the second session was clearly superior (P less than 0.05). Similarly, the total number of major disagreements in the second review session was significantly lower than that in the third review session (P less than 0.001). When histologic diagnoses in the second session were compared with those in the third session, it became apparent that the immunologic data helped the pathologist to correct major misinterpretations in 14 cases (25%). This study is the first to demonstrate quantitatively that (1) knowledge of morphologic features influences and greatly enhances the accuracy of the interpretation of immunologic findings, (2) the immunophenotype of LPD cannot be predicted based on morphologic findings alone, and (3) immunologic findings improve the accuracy of interpretation of histologic findings in situations in which a diagnosis cannot be made from morphologic features only.

Distinction between undifferentiated (small noncleaved) and lymphoblastic lymphoma. An immunohistologic study on paraffin-embedded, fixed tissue sections.

The morphologic differentiation between malignant lymphoma of the small noncleaved cell (SNC) type and lymphoblastic lymphoma (LBL) is at times difficult, particularly when fresh tissue is not available for immunologic studies. We have examined the reactivities of a panel of monoclonal and polyclonal antibodies, including LN-1, LN-2, and antibodies to immunoglobulin light chains, leukocyte common antigen (LCA), Leu-M1, vimentin, S-100 protein, lysozyme, and alpha-1-antitrypsin, in paraffin-embedded, B5- and formalin-fixed tissue involved by SNC or LBL. The immunophenotypes in all of the cases included in this study had been characterized previously in fresh-frozen sections or cell suspensions. Among 21 samples of B5-fixed SNC, LN-1 was reactive in 17 and LN-2 in 18 cases. Among 13 B5-fixed LBL, LN-1 was reactive in two cases and LN-2 was reactive in two cases. Each of 20 B5-fixed samples of SNC was reactive with at least one of the antibodies, whereas 10 of the 13 B5-fixed samples of LBL were negative for both antibodies. Lesser reactivity was evident in formalin-fixed tissues, with only nine of 27 SNC specimens positive for LN-1 and 16 of 27 positive for LN-2. Most or all of the SNC and LBL samples were negative for immunoglobulin light chains, Leu-M1, vimentin, S-100 protein, lysozyme, and alpha-1-antitrypsin. The majority of both SNC and LBL were positive for LCA. We conclude that LN-1, preferably in combination with LN-2, can be used for distinguishing between SNC and LBL in paraffin-embedded, B5-fixed tissue when fresh tissue is not available.

Synthesis, processing, and secretion of the core-specific lectin by rat hepatocytes and hepatoma cells.

A lectin, previously designated the Man/GlcNAc-specific lectin or mannan-binding protein, is found in rat liver and plasma. Analysis of the structural requirements for oligosaccharide binding indicated that the specificity of this lectin is directed primarily at the "core" and peptide region of glycopeptides (Maynard, Y., and Baenziger, J. U. (1982) J. Biol. Chem. 257, 3788-3794). We have examined synthesis and secretion of the core-specific lectin by primary rat hepatocytes and a rat hepatoma, H-4-II-E, utilizing pulse labeling with [35S]methionine, immunoprecipitation with a monospecific rabbit antibody raised against the purified lectin, and analysis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and fluorography. A post-translational modification occurs between 10 and 40 min of chase which results in an increase in the Mr from 24,000 to 26,000. This modification is not due to asparagine-linked glycosylation or oligosaccharide processing. The kinetics of secretion are unusual. Secretion begins at 1 h of chase and proceeds linearly for approximately 8 h until a maximum of 70% of the lectin has been secreted. Secretion, but not the post-translational modification is inhibited by monensin. The pattern of synthesis and secretion in conjunction with the presence of the lectin in plasma indicate that it is a plasma protein of hepatocyte origin. The slow kinetics of secretion compared to other secretory proteins indicate an unusual mechanism for the segregation of the lectin from other secretory proteins and/or a different intracellular pathway for secretion.

Evidence for transmembrane modulation of the ligand-binding site of the hepatocyte galactose/N-acetylgalactosamine-specific receptor.

The ligand-binding activity of the galactose/N-acetylgalactosamine-specific receptor (Gal/GalNAc receptor) present on the surface of hepatocytes can be modulated under a number of conditions in the intact cell. The carboxylic acid ionophores monensin and nigericin inhibit endocytosis by the Gal/GalNAc receptor in a concentration-dependent manner. Monensin at a concentration of 100 microM reduces the number of binding sites for asialo-orosomucoid and a tri-branched glycopeptide (F2) 5-10-fold; however, the number of Gal/GalNAc receptor subunits detected at the cell surface by a competitive radioimmunoassay and by immunoprecipitation of surface labeled receptor is not significantly altered. Replacement of NaCl in the medium with either N-methylglucamine or sorbitol to isotonicity also inhibits binding and endocytosis. The monensin, nigericin, N-methylglucamine, and sorbitol treatments have in common the ability to alkalinize the cytosol of the hepatocyte. None of these agents has any effect on binding by the isolated Gal/GalNAc receptor nor is the intracellular pH shift of such a magnitude that it would alter binding by the isolated Gal/GalNAc receptor. This has led us to conclude that the ligand-binding properties of the Gal/GalNAc receptor at the cell surface can be modulated in a transmembrane fashion by events other than those involving pH or Ca2+ regulation at the ligand-binding site itself. Such transmembrane modulation of ligand binding by the Gal/GalNAc receptor may provide a rapid and efficient mechanism for mediating ligand release and immediate return of the receptor to the cell surface.