Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery.

BACKGROUND: Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors. OBJECTIVES: The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance. METHODS: Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model. RESULTS: Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers. CONCLUSIONS: Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.

Chronic Medication Burden After Cardiac Surgery for Pediatric Medicaid Beneficiaries.

BACKGROUND: Congenital heart defects are the most common and resource-intensive birth defects. As children with congenital heart defects increasingly survive beyond early childhood, it is imperative to understand longitudinal disease burden. OBJECTIVES: The purpose of this study was to examine chronic outpatient prescription medication use and expenditures for New York State pediatric Medicaid enrollees, comparing children who undergo cardiac surgery (cardiac enrollees) and the general pediatric population. METHODS: This was a retrospective cohort study of all Medicaid enrollees age <18 years using the New York State Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources database (2006-2019). Primary outcomes were total chronic medications per person-year, enrollees per 100 person-years using ≥1 and ≥3 medications, and medication expenditures per person-year. We described and compared outcomes between cardiac enrollees and the general pediatric population. Among cardiac enrollees, multivariable regression examined associations between outcomes and clinical characteristics. RESULTS: We included 5,459 unique children (32,131 person-years) who underwent cardiac surgery and 4.5 million children (22 million person-years) who did not. More than 4 in 10 children who underwent cardiac surgery used ≥1 chronic medication compared with approximately 1 in 10 children who did not have cardiac surgery. Medication expenditures were 10 times higher per person-year for cardiac compared with noncardiac enrollees. Among cardiac enrollees, disease severity was associated with chronic medication use; use was highest among infants; however, nearly one-half of adolescents used ≥1 chronic medication. CONCLUSIONS: Children who undergo cardiac surgery experience high medication burden that persists throughout childhood. Understanding chronic medication use can inform clinicians (both pediatricians and subspecialists) and policymakers, and ultimately the value of care for this medically complex population.

Long-Term Health Care Utilization After Cardiac Surgery in Children Covered Under Medicaid.

BACKGROUND: Understanding the longitudinal burden of health care expenditures and utilization after pediatric cardiac surgery is needed to counsel families, improve care, and reduce outcome inequities. OBJECTIVES: The purpose of this study was to describe and identify predictors of health care expenditures and utilization for Medicaid-insured pediatric cardiac surgical patients. METHODS: All Medicaid enrolled children age <18 years undergoing cardiac surgery in the New York State CHS-COLOUR database, from 2006 to 2019, were followed in Medicaid claims data through 2019. A matched cohort of children without cardiac surgical disease was identified as comparators. Expenditures and inpatient, primary care, subspecialist, and emergency department utilization were modeled using log-linear and Poisson regression models to assess associations between patient characteristics and outcomes. RESULTS: In 5,241 New York Medicaid-enrolled children, longitudinal health care expenditures and utilization for cardiac surgical patients exceeded noncardiac surgical comparators (cardiac surgical children: $15,500 ± $62,000 per month in year 1 and $1,600 ± $9,100 per month in year 5 vs noncardiac surgical children: $700 ± $6,600 per month in year 1 and $300 ± $2,200 per month in year 5). Children after cardiac surgery spent 52.9 days in hospitals and doctors' offices in the first postoperative year and 90.5 days over 5 years. Being Hispanic, compared with non-Hispanic White, was associated with having more emergency department visits, inpatient admissions, and subspecialist visits in years 2 to 5, but fewer primary care visits and greater 5-year mortality. CONCLUSIONS: Children after cardiac surgery have significant longitudinal health care needs, even among those with less severe cardiac disease. Health care utilization differed by race/ethnicity, although mechanisms driving disparities should be investigated further.

Race and Remdesivir: Examination of Clinical Outcomes in a Racially and Ethnically Diverse Cohort in New York City.

Objective: To compare clinical characteristics and examine in-hospital length of stay (LOS) differences for COVID-19 patients who received remdesivir, by race or ethnicity. Design: Retrospective descriptive analysis comparing cumulative LOS as a proxy of recovery time. Setting: A large academic medical center serving a minoritized community in Northern Manhattan, New York City. Participants: Inpatients (N=1024) who received remdesivir from March 30, 2020-April 20, 2021. Methods: We conducted descriptive analyses among patients who received remdesivir. Patients were described by proxies of social determinants of health (SDOH): race and ethnicity, residence, insurance coverage, and clinical characteristics. We calculated median hospital LOS as the cumulative incidence of hospitalized patients who were discharged alive, and tested differences between groups by using the Gray test. Patients who died or were discharged to hospice were censored at 29 days. Main Outcome Measures: The primary outcome was hospital LOS. The secondary outcome was in-hospital mortality. Results: Median LOS was 11.9 days (95% CI, 10.8-13.2) overall, with Black patients having the shortest (10.0 days, 95% CI, 8.0-13.2) and Asian patients having the longest (16.2 days, 95% CI, 8.3-27.2) LOS. A total of 214 patients (21%) died or were discharged to hospice, ranging from 16.5% to 23.7% of patients who identified as Black and Other (multiracial, biracial, declined), respectively. Conclusions: COVID-19 has disproportionately burdened communities of color. We observed no difference in median LOS between racial or ethnic groups, which supports the notion that the heterogeneous effect of remdesivir in the literature may be explained in part by underrecruitment or participation of Black, Hispanic, and Asian patients in clinical trials.

Temperature and work: Time allocated to work under varying climate and labor market conditions.

Workers in climate exposed industries such as agriculture, construction, and manufacturing face increased health risks of working on high temperature days and may make decisions to reduce work on high-heat days to mitigate this risk. Utilizing the American Time Use Survey (ATUS) for the period 2003 through 2018 and historical weather data, we model the relationship between daily temperature and time allocation, focusing on hours worked by high-risk laborers. The results indicate that labor allocation decisions are context specific and likely driven by supply-side factors. We do not find a significant relationship between temperature and hours worked during the Great Recession (2008-2014), perhaps due to high competition for employment, however during periods of economic growth (2003-2007, 2015-2018) we find a significant reduction in hours worked on high-heat days. During periods of economic growth, for every degree above 90 on a particular day, the average high-risk worker reduces their time devoted to work by about 2.6 minutes relative to a 90-degree day. This effect is expected to intensify in the future as temperatures rise. Applying the modeled relationships to climate projections through the end of century, we find that annual lost wages resulting from decreased time spent working on days over 90 degrees across the United States range from $36.7 to $80.0 billion in 2090 under intermediate and high emission futures, respectively.

The unintended effects from halting nuclear power production: Evidence from Fukushima Daiichi accident.

This paper provides novel evidence of the unintended health effects stemming from the halt in nuclear power production after the Fukushima Daiichi nuclear accident. After the accident, nuclear power stations ceased operation and nuclear power was replaced by fossil fuels, causing an increase in electricity prices. We find that this increase led to a reduction in energy consumption, which caused an increase in mortality during very cold temperatures, given the protective role that climate control plays against the elements. Our results contribute to the debate surrounding the use of nuclear as a source of energy by documenting a yet unexplored health benefit from using nuclear power, and more broadly to regulatory policy approaches implemented during periods of scientific uncertainty about potential adverse effects.

Using Crowd-Sourced Data to Assess the Temporal and Spatial Relationship between Indoor and Outdoor Particulate Matter.

Using hourly measures across a full year of crowd-sourced data from over 1000 indoor and outdoor pollution monitors in the state of California, we explore the temporal and spatial relationship between outdoor and indoor particulate matter (PM) concentrations for different particle sizes. The scale of this study offers new insight into both average penetration rates and drivers of heterogeneity in the outdoor-indoor relationship. We find that an increase in the daily outdoor PM concentration of 10% leads to an average increase of 4.2-6.1% in indoor concentrations. The penetration of outdoor particles to the indoor environment occurs rapidly and almost entirely within 5 h. We also provide evidence showing that penetration rates are associated with building age and climatic conditions in the vicinity of the monitor. Since people spend a substantial amount of each day indoors, our findings fill a critical knowledge gap and have significant implications for government policies to improve public health through reductions in exposure to ambient air pollution.

What about tocilizumab? A retrospective study from a NYC Hospital during the COVID-19 outbreak.

BACKGROUND: Tocilizumab, an interleukin-6 receptor blocker, has been used in the inflammatory phase of COVID-19, but its impact independent of corticosteroids remains unclear in patients with severe disease. METHODS: In this retrospective analysis of patients with COVID-19 admitted between March 2 and April 14, 2020 to a large academic medical center in New York City, we describe outcomes associated with tocilizumab 400 mg (without methylprednisolone) compared to a propensity-matched control. The primary endpoints were change in a 7-point ordinal scale of oxygenation and ventilator free survival, both at days 14 and 28. Secondary endpoints include incidence of bacterial superinfections and gastrointestinal perforation. Primary outcomes were evaluated using t-test. RESULTS: We identified 33 patients who received tocilizumab and matched 74 controls based on demographics and health measures upon admission. After adjusting for illness severity and baseline ordinal scale, we failed to find evidence of an improvement in hypoxemia based on an ordinal scale at hospital day 14 in the tocilizumab group (OR 2.2; 95% CI, 0.7-6.5; p = 0.157) or day 28 (OR 1.1; 95% CI, 0.4-3.6; p = 0.82). There also was no evidence of an improvement in ventilator-free survival at day 14 (OR 0.8; 95% CI, 0.18-3.5; p = 0.75) or day 28 (OR 1.1; 95% CI, 0.1-1.8; p = 0.23). There was no increase in secondary bacterial infection rates in the tocilizumab group compared to controls (OR 0.37; 95% CI, 0.09-1.53; p = 0.168). CONCLUSIONS: There was no evidence to support an improvement in hypoxemia or ventilator-free survival with use of tocilizumab 400 mg in the absence of corticosteroids. No increase in secondary bacterial infections was observed in the group receiving tocilizumab.

Estimating Causal Effects of Particulate Matter Regulation on Mortality.

BACKGROUND: Estimating the causal effect of pollution on human health is integral for evaluating returns to pollution regulation, yet separating out confounding factors remains a perennial challenge. METHODS: We use a quasi-experimental design to investigate the causal relationship between regulation of particulate matter smaller than 2.5 micrograms per cubic meter (PM2.5) and mortality among those 65 years of age and older. We exploit regulatory changes in the Clean Air Act Amendments (CAAA). Regulation in 2005 impacted areas of the United States differentially based on pre-regulation air quality levels for PM2.5. We use county-level mortality data, extracted from claims data managed by the Centers for Medicare & Medicaid Services, merged to county-level average PM2.5 readings and attainment status as classified by the Environmental Protection Agency. RESULTS: Based on estimates from log-linear difference-in-differences models, our results indicate after the CAAA designation for PM2.5 in 2005, PM2.5 levels decreased 1.59 micrograms per cubic meter (95% CI = 1.39, 1.80) and mortality rates among those 65 and older decreased by 0.93% (95% CI = 0.10%, 1.77%) in nonattainment counties, relative to attainment ones. Results are robust to a series of alternate models, including nearest-neighbor matching based on propensity score estimates. CONCLUSION: This analysis suggests large health returns to the 2005 PM2.5 designations, and provides evidence of a causal association between pollution and mortality among the Medicare population.

Cost-effectiveness of diabetes screening initiated through a dental visit.

OBJECTIVE: To analyse the cost-effectiveness of a screening programme and follow-up interventions for persons with dysglycemia who are identified during a dental visit. METHODS: This study is a secondary analysis utilizing data from two relevant publications. Those studies identified persons with dysglycemia who were seen in a dental school clinic for routine dental care and determined compliance with a recommendation to seek medical care. The response site was 59.4%. The Archimedes disease simulation model was utilized to simulate the effect of a weight loss programme for identified subjects on several outcomes. RESULTS: Two scenarios for weight loss programmes were considered: a 10% permanent loss in body weight and a 10% loss that decays over time. Both diabetes and prediabetes were analysed. The decay path costs $21 243 per quality adjusted life year (QALY) with 3 years required to achieve the weight reduction. This cost decreases to $6655 if only 1 year is needed to achieve the weight goal. Without decay, the cost per QALY is $15 873 with 20 years of intervention, vs $647 per QALY with 10 years of intervention. For individuals with type 2 diabetes mellitus, the cost per QALY is $48 604 to $56 207 depending on adherence. With the addition of oral medication (a sulfonylurea), the cost is three times higher. CONCLUSIONS: Under the conditions described here, identification of persons with dysglycemia in the dental office for initiating prediabetic care is a cost-effective means of identifying and treating affected individuals.

Association of groundwater constituents with topography and distance to unconventional gas wells in NE Pennsylvania.

Recently we reported an association of certain diseases with unconventional gas development (UGD). The purpose of this study is to examine UGD's possible impacts on groundwater quality in northeastern Pennsylvania. In this study, we compared our groundwater data (Columbia 58 samples) with those published data from Cabot (1701 samples) and Duke University (150 samples). For each dataset, proportions of samples with elevated levels of dissolved constituents were compared among four groups, identified as upland far (i.e. ≥1km to the nearest UGD gas well), upland near (<1km), valley far (≥1km), and valley near (<1km) groups. The Columbia data do not show statistically significant differences among the 4 groups, probably due to the limited number of samples. In Duke samples, Ca and CI levels are significantly higher in the valley near group than in the valley far group. In the Cabot dataset, methane, Na, and Mn levels are significantly higher in valley far samples than in upland far samples. In valley samples, Ca, Cl, SO4, and Fe are significantly higher in the near group (i.e. <1km) than in the far group. The association of these constituents in valley groundwater with distance is observed for the first time using a large industry dataset. The increase may be caused by enhanced mixing of shallow and deep groundwater in valley, possibly triggered by UGD process. If persistent, these changes indicate potential for further impact on groundwater quality. Therefore, there is an urgent need to conduct more studies to investigate effects of UGD on water quality and possible health outcomes.

Early-Life Exposure to the Great Smog of 1952 and the Development of Asthma.

RATIONALE: Little is known about the long-term effects of air pollution exposure and the root causes of asthma. We use exposure to intense air pollution from the 1952 Great Smog of London as a natural experiment to examine both issues. OBJECTIVES: To determine whether exposure to extreme air pollution in utero or soon after birth affects asthma development later in life. METHODS: This was a natural experiment using the unanticipated pollution event by comparing the prevalence of asthma between those exposed to the Great Smog in utero or the first year of life with those conceived well before or after the incident and those residing outside the affected area at the time of the smog. MEASUREMENTS AND MAIN RESULTS: Prevalence of asthma during childhood (ages 0-15) and adulthood (ages >15) is analyzed for 2,916 respondents to the Life History portion of the English Longitudinal Study on Aging born from 1945 to 1955. Exposure to the Great Smog in the first year of life increases the likelihood of childhood asthma by 19.87 percentage points (95% confidence interval [CI], 3.37-36.38). We also find suggestive evidence that early-life exposure led to a 9.53 percentage point increase (95% CI, -4.85 to 23.91) in the likelihood of adult asthma and exposure in utero led to a 7.91 percentage point increase (95% CI, -2.39 to 18.20) in the likelihood of childhood asthma. CONCLUSIONS: These results are the first to link early-life pollution exposure to later development of asthma using a natural experiment, suggesting the legacy of the Great Smog is ongoing.

Trends in mortality, length of stay, and hospital charges associated with health care-associated infections, 2006-2012.

BACKGROUND: Many factors associated with hospital-acquired infections (HAIs), including reimbursement policies, drug prices, practice patterns, and the distribution of organisms causing infections, change over time. We examined whether outcomes, including mortality, length of stay (LOS), daily charges, and total charges associated with HAIs, changed during 2006-2012. METHODS: Electronic data on adults discharged from 2 tertiary-quaternary hospitals and 1 community hospital during 2006-2012 were collected retrospectively. Computerized algorithms identified infections using laboratory and administrative codes. Propensity scores were used to match cases with uninfected controls. Differences in mortality, LOS, daily charges, and total charges were modeled against infection status and time period (2006-2008 vs 2009-2012), including interaction for infection status by time period. RESULTS: Among 352,077 discharges, 24,466 HAIs were detected. There was no significant change in mortality. LOS declined only for bloodstream infections (3-day reduction; P < 0.01). Daily charges rose 4% for urinary tract infections but did not change significantly for other HAIs. Total charges declined by 11% for bloodstream infections and 13% for pneumonia. CONCLUSIONS: We found no appreciable or consistent improvement in HAI mortality or LOS during 2006-2012. Costs of bloodstream infections and pneumonia have declined, with most of the change occurring before 2008.

Cost-Effectiveness Analysis of Dental Sealants versus Fluoride Varnish in a School-Based Setting.

While sealants are more effective than fluoride varnish in reducing the development of new carious lesions on occlusal surfaces, and a course of treatment requires fewer clinical visits, they are more expensive per application. This analysis assessed which treatment is more cost-effective. We estimate the costs of sealants and fluoride varnish over a 4-year period in a school-based setting, and compare this to existing estimates of the relative benefits in terms of caries reduction to calculate the relative cost-effectiveness of these two preventive treatments. In our base case scenario, varnish is more cost-effective in preventing caries. Allowing for caries benefits to nonocclusal surfaces further improves the cost-effectiveness of varnish. Although we found that varnish is more cost-effective, the results are context specific. Sealants become equally cost-effective if a dental hygienist applies the sealants instead of a dentist, while varnish becomes increasingly cost-effective when making comparisons outside of a traditional dental clinic setting.

The Norwood operation: Relative effects of surgeon and institutional volumes on outcomes and resource utilization.

BACKGROUND: Hypoplastic left heart syndrome is the most expensive birth defect managed in the United States, with a 5-year survival rate below 70%. Increasing evidence suggests that hospital volumes are inversely associated with mortality for infants with single ventricles undergoing stage 1 surgical palliation. Our aim was to examine the relative effects of surgeon and institutional volumes on outcomes and resource utilisation for these children. METHODS: A retrospective study was conducted using the Pediatric Health Information System database to examine the effects of the number of procedures performed per surgeon and per centre on mortality, costs, and post-operative length of stay for infants undergoing Risk Adjustment for Congenital Heart Surgery risk category six operations at tertiary-care paediatric hospitals, from 1 January, 2004 to 31 December, 2013. Multivariable modelling was used, adjusting for patient and institutional characteristics. Gaussian kernel densities were constructed to show the relative distributions of the effects of individual institutions and surgeons, before and after adjusting for the number of cases performed. RESULTS: A total of 2880 infants from 35 institutions met the inclusion criteria. Mortality was 15.0%. Median post-operative length of stay was 24 days (IQR 14-41). Median standardized inpatient hospital costs were $156,000 (IQR $108,000-$248,000) in 2013 dollars. In the multivariable analyses, higher institutional volume was inversely associated with mortality (p=0.001), post-operative length of stay (p=0.004), and costs (p=0.001). Surgeon volume was associated with none of the measured outcomes. Neither institutional nor surgeon volumes explained much of the wide variation in outcomes and resource utilization observed between institutions and between surgeons. CONCLUSIONS: Increased institutional - but not surgeon - volumes are associated with reduced mortality, post-operative length of stay, and costs for infants undergoing stage 1 palliation.

Unconventional Gas and Oil Drilling Is Associated with Increased Hospital Utilization Rates.

Over the past ten years, unconventional gas and oil drilling (UGOD) has markedly expanded in the United States. Despite substantial increases in well drilling, the health consequences of UGOD toxicant exposure remain unclear. This study examines an association between wells and healthcare use by zip code from 2007 to 2011 in Pennsylvania. Inpatient discharge databases from the Pennsylvania Healthcare Cost Containment Council were correlated with active wells by zip code in three counties in Pennsylvania. For overall inpatient prevalence rates and 25 specific medical categories, the association of inpatient prevalence rates with number of wells per zip code and, separately, with wells per km2 (separated into quantiles and defined as well density) were estimated using fixed-effects Poisson models. To account for multiple comparisons, a Bonferroni correction with associations of p<0.00096 was considered statistically significant. Cardiology inpatient prevalence rates were significantly associated with number of wells per zip code (p<0.00096) and wells per km2 (p<0.00096) while neurology inpatient prevalence rates were significantly associated with wells per km2 (p<0.00096). Furthermore, evidence also supported an association between well density and inpatient prevalence rates for the medical categories of dermatology, neurology, oncology, and urology. These data suggest that UGOD wells, which dramatically increased in the past decade, were associated with increased inpatient prevalence rates within specific medical categories in Pennsylvania. Further studies are necessary to address healthcare costs of UGOD and determine whether specific toxicants or combinations are associated with organ-specific responses.

Prenatal exposure to airborne polycyclic aromatic hydrocarbons and IQ: estimated benefit of pollution reduction.

Outdoor air pollution, largely from fossil fuel burning, is a major cause of morbidity and mortality in the United States, costing billions of dollars every year in health care and loss of productivity. The developing fetus and young child are especially vulnerable to neurotoxicants, such as polycyclic aromatic hydrocarbons (PAH) released to ambient air by combustion of fossil fuel and other organic material. Low-income populations are disproportionately exposed to air pollution. On the basis of the results of a prospective cohort study in a low-income population in New York City (NYC) that found a significant inverse association between child IQ and prenatal exposure to airborne PAH, we estimated the increase in IQ and related lifetime earnings in a low-income urban population as a result of a hypothesized modest reduction of ambient PAH concentrations in NYC of 0.25 ng/m(3). For reference, the current estimated annual mean PAH concentration is ~1 ng/m(3). Restricting to NYC Medicaid births and using a 5 per cent discount rate, we estimated the gain in lifetime earnings due to IQ increase for a single year cohort to be US$215 million (best estimate). Using much more conservative assumptions, the estimate was $43 million. This analysis suggests that a modest reduction in ambient concentrations of PAH is associated with substantial economic benefits to children.

Disconcordance in statistical models of bisphenol A and chronic disease outcomes in NHANES 2003-08.

BACKGROUND: Bisphenol A (BPA), a high production chemical commonly found in plastics, has drawn great attention from researchers due to the substance's potential toxicity. Using data from three National Health and Nutrition Examination Survey (NHANES) cycles, we explored the consistency and robustness of BPA's reported effects on coronary heart disease and diabetes. METHODS AND FINDINGS: We report the use of three different statistical models in the analysis of BPA: (1) logistic regression, (2) log-linear regression, and (3) dose-response logistic regression. In each variation, confounders were added in six blocks to account for demographics, urinary creatinine, source of BPA exposure, healthy behaviours, and phthalate exposure. Results were sensitive to the variations in functional form of our statistical models, but no single model yielded consistent results across NHANES cycles. Reported ORs were also found to be sensitive to inclusion/exclusion criteria. Further, observed effects, which were most pronounced in NHANES 2003-04, could not be explained away by confounding. CONCLUSIONS: Limitations in the NHANES data and a poor understanding of the mode of action of BPA have made it difficult to develop informative statistical models. Given the sensitivity of effect estimates to functional form, researchers should report results using multiple specifications with different assumptions about BPA measurement, thus allowing for the identification of potential discrepancies in the data.