Evaluation of Hospitalizations Preventable with Idealized Outpatient Care and Continuity of Care.

BACKGROUND: Unnecessary hospitalizations may pose the risk of iatrogenic complications, suboptimal patient experience, and increased cost. Administrative data lack granularity to understand the proportion and causes of hospitalizations preventable through optimizing care continuum (HPOCC). We aim to identify the incidence and causes of HPOCC through clinician-adjudicated chart review. METHODS: A retrospective review was performed for inpatient admissions from the emergency department (ED) over 1 week. Each admission was reviewed by a clinician to determine whether it is an HPOCC defined as not requiring inpatient care with the assumption of idealized outpatient care and social support. RESULTS: Of the 515 patients admitted from the ED, 31 (6.0%) patients were judged to have had an HPOCC. Causes of HPOCC include urgent diagnostics (9, 29.0%), unnecessary transfer from a long-term facility (7, 23.0%), needing IV therapy (5, 16.0%), benign incidental finding (5, 16.0%), diagnostic uncertainty in complex chronic illness (3, 10.0%), and lack of access to care for disposition (2, 6.0%). CONCLUSION: Hospitalizations preventable through optimizing care continuum account for about 1 in every 15 hospitalizations in an urban academic medical center. The need for urgent diagnostics accounts for a plurality of HPOCC and could be an important target for quality improvement.

Behavioral Health Factors as Predictors of Emergency Department Use in the High-Risk, High-Cost Medicare Population.

OBJECTIVE: This study measured the presence, extent, and type of behavioral health factors in a high-cost Medicare population and their association with the probability and intensity of emergency department (ED) use. METHODS: Retrospective claims analysis and a comprehensive electronic medical record-based review were conducted for patients enrolled in a 65-month prospective care management program at an academic tertiary medical center (N=3,620). A two-part model used multivariable logistic regression to evaluate the effect of behavioral health factors on the probability of ED use, complemented by a Poisson model to measure the number of ED visits. Control variables included demographic characteristics, poststudy survival, and hierarchical condition category risk score. RESULTS: After analyses controlled for comorbidities and other relevant variables, patients with two or more behavioral health diagnosis categories or two or more behavioral health medications were about twice as likely as those without such categories or medications to use the ED. Patients with a diagnosis category of psychosis, neuropsychiatric disorders, sleep disorders, or adjustment disorders were significantly more likely than those without these disorders to use the ED. Most primary ED diagnoses were not of behavioral health conditions. CONCLUSIONS: Behavioral health factors had a substantial and significant effect on the likelihood and number of ED visits in a population of high-cost Medicare patients. Attention to behavioral health factors as independent predictors of ED use may be useful in influencing ED use in high-cost populations.

Utilization Management of High-Cost Imaging in an Outpatient Setting in a Large Stable Patient and Provider Cohort over 7 Years.

Purpose To quantify the effect of a comprehensive, long-term, provider-led utilization management (UM) program on high-cost imaging (computed tomography, magnetic resonance imaging, nuclear imaging, and positron emission tomography) performed on an outpatient basis. Materials and Methods This retrospective, 7-year cohort study included all patients regularly seen by primary care physicians (PCPs) at an urban academic medical center. The main outcome was the number of outpatient high-cost imaging examinations per patient per year ordered by the patient's PCP or by any specialist. The authors determined the probability of a patient undergoing any high-cost imaging procedure during a study year and the number of examinations per patient per year (intensity) in patients who underwent high-cost imaging. Risk-adjusted hierarchical models were used to directly quantify the physician component of variation in probability and intensity of high-cost imaging use, and clinicians were provided with regular comparative feedback on the basis of the results. Observed trends in high-cost imaging use and provider variation were compared with the same measures for outpatient laboratory studies because laboratory use was not subject to UM during this period. Finally, per-member per-year high-cost imaging use data were compared with statewide high-cost imaging use data from a major private payer on the basis of the same claim set. Results The patient cohort steadily increased in size from 88 959 in 2007 to 109 823 in 2013. Overall high-cost imaging utilization went from 0.43 examinations per year in 2007 to 0.34 examinations per year in 2013, a decrease of 21.33% (P < .0001). At the same time, similarly adjusted routine laboratory study utilization decreased by less than half that rate (9.4%, P < .0001). On the basis of unadjusted data, outpatient high-cost imaging utilization in this cohort decreased 28%, compared with a 20% decrease in statewide utilization (P = .0023). Conclusion Analysis of high-cost imaging utilization in a stable cohort of patients cared for by PCPs during a 7-year period showed that comprehensive UM can produce a significant and sustained reduction in risk-adjusted per-patient year outpatient high-cost imaging volume. © RSNA, 2017.

Dietary intake patterns of low-income urban african-american adolescents.

Unhealthy eating increases risks for chronic disease. Few studies have examined the multifaceted aspects of dietary intake of low-income, urban African-American adolescents. This study aimed to describe dietary patterns including energy, nutrients, food groups, and diet quality and to identify areas to guide future interventions. Baseline data for a school-based obesity prevention study were collected from 382 African-American adolescents (10- to 14-year-olds) from four Chicago, IL, public schools in 2003. Diet was assessed using a 152-item food frequency questionnaire. Diet quality was measured using a modified version of the US Department of Agriculture Healthy Eating Index (HEI) and compared to published estimates for a nationwide sample. Participants reported high energy intakes and several unhealthy eating patterns: 58.6% consumed one or more servings of sweetened beverages per day and 15.7% consumed three or more servings per day; average fried food consumption was high (1.4 servings/day), 58.4% consumed one or more serving per day; and 75% consumed three or more three snacks per day. Only 49% of participants met the recommended three servings of dairy foods per day. Compared to a national, mostly white sample, participants had lower HEI scores (P<0.05); mean score was 66.0+/-12.8 (100=maximum HEI score) vs 70.3+/-13.0 in boys vs girls, one third had scores <60 ("needs improvement") and only 15% scored >80 ("good"). This study reveals key areas of problematic dietary patterns for future interventions targeting low-income African-American adolescents, including frequent intakes of calorie-dense, low nutrient-rich foods, such as fried foods, snacks, and sweetened beverages.

Prospective study of adolescent alcohol consumption and risk of benign breast disease in young women.

OBJECTIVE: To investigate prospectively, using alcoholic beverage consumption data collected in real time, the association between adolescent drinking and risk of biopsy-confirmed benign breast disease (BBD) in young women. PARTICIPANTS AND METHODS: The Growing Up Today Study is a prospective cohort study of US girls, aged 9 to 15 years at baseline, with annual questionnaires from 1996 through 2001, followed by questionnaires in 2003, 2005, and 2007. On the 2003 survey, the participants (then aged 16-23 years) provided information about their alcoholic beverage consumption in the previous year. On the 2005 and 2007 surveys, a total of 6899 women (aged 18-27 years) reported whether a health care provider had ever diagnosed them with BBD (n = 147 cases) and whether it was confirmed by biopsy (n = 67 cases); 6752 women reported never being diagnosed with BBD. RESULTS: Adjusted for age and BMI, quantity of alcohol consumed was associated with increased risk of biopsy-confirmed BBD (odds ratio: 1.50 per drink per day [95% confidence interval: 1.19-1.90]). Girls who typically drank 6 or 7 days/week were at higher risk (odds ratio: 5.50 [95% confidence interval: 1.23-24.53]) compared with those who never drank or who drank less than once per week. CONCLUSIONS: Higher amounts consumed, and more frequent consumption, of alcoholic beverages in adolescence may increase the occurrence of BBD in young women. Advising teenagers to avoid alcoholic beverages, along with smoking and sun exposure, may reduce cancer incidence in adulthood.

Dairy consumption and female height growth: prospective cohort study.

BACKGROUND: Because of its nutrients and anabolic hormones, cow's milk may promote height growth, which in turn has been related to breast cancer risk. We prospectively investigated associations between dairy intakes and height growth. METHODS: A cohort of 5,101 girls from throughout the United States completed annual surveys (1996-2001, 2003), providing height, weight, and past-year diet. At baseline, all were premenarchal, ages 9 years and above, with no serious medical conditions. We studied three outcomes: annual height growth, peak growth velocity, and adult height. Multivariate models estimated the effects of milk, cheese, yogurt, and energy on subsequent growth, adjusted for race/ethnicity, age, prior height, and body mass index. Other models studied fats and proteins. RESULTS: Premenarchal girls who drank >3 servings per day of milk grew 0.11 in. (P = 0.02) more the following year than girls consuming <1 serving per day. Yogurt (+0.13 in./cup; P = 0.02), but not cheese or total calories, predicted height growth. In a separate model, dairy protein (+0.034 in./10 g; P < 0.001) predicted height growth. Larger peak velocities were seen among girls reporting, at baseline, more milk (>3 glasses per day versus <1; +0.14 in., P = 0.01), more yogurt (+0.17 in./cup, P = 0.02), and, in a separate model, more dairy protein (+0.039 in./10 g; P = 0.003). Baseline milk and dairy protein predicted taller adults. Dairy protein was more important than dairy fat, for all outcomes. Nondairy animal protein and vegetable protein were never significant, nor were nondairy animal fat and vegetable fat. CONCLUSION: Of the foods/nutrients studied, dairy protein had the strongest association with height growth. These findings suggest that a factor in the nonlipid phase of milk, but not protein itself, has growth-promoting action in girls.

Sexual orientation disparities in weight status in adolescence: findings from a prospective study.

A growing number of studies among adult women have documented disparities in overweight adversely affecting lesbian and bisexual women, but few studies have examined sexual orientation-related patterns in weight status among men or adolescents. We examined sexual orientation group trends in BMI (kg/m(2)), BMI Z-scores, and overweight using 56,990 observations from 13,785 adolescent females and males in the Growing Up Today Study (GUTS), a large prospective cohort of US youth. Participants provided self-reported information from six waves of questionnaire data collection from 1998 to 2005. Gender-stratified linear regression models were used to estimate BMI and BMI Z-scores and modified Poisson regression models to estimate risk ratios for overweight, controlling for age and race/ethnicity, with heterosexuals as the referent group. Among females, we observed fairly consistently elevated BMI in all sexual orientation minority groups relative to heterosexual peers. In contrast, among males we documented a sexual-orientation-by-age interaction indicating steeper increases in BMI with age from early-to-late adolescence in heterosexuals relative to sexual orientation minorities. Additional prospective research is needed to understand the determinants of observed sexual orientation disparities and to inform appropriate preventive and treatment interventions. The long-term health consequences of overweight are well-documented and over time are likely to exact a high toll on populations with elevated rates.

Weight gain in older adolescent females: the internet, sleep, coffee, and alcohol.

OBJECTIVES: To examine whether excessive recreational Internet time, insufficient sleep, regular coffee consumption, or alcoholic beverages promote weight gain. STUDY DESIGN: A longitudinal cohort of >5000 girls (Growing Up Today Study), from all over the United States and aged 14 to 21 years, returned surveys in 2001 reporting typical past-year recreational Internet time, sleep, coffee (with caffeine), and alcohol consumption. We estimated correlations among these 4 exposures. Each girl also reported her height and weight in 2000 and again in 2001. Multivariate models investigated associations between 1-year change in body mass index and same-year exposures, adjusted for adolescent growth/development, activity, and inactivity. RESULTS: The exposures were highly (P < .0001) correlated with each other, except for coffee with Internet time (P > .50). More Internet time, more alcohol, and less sleep were all associated (P < .05) with same-year increases in body mass index. Females, aged 18+ years, who slept

Milk consumption and acne in teenaged boys.

OBJECTIVE: We sought to examine the association between dietary dairy intake and teenaged acne among boys. METHODS: This was a prospective cohort study. We studied 4273 boys, members of a prospective cohort study of youths and of lifestyle factors, who reported dietary intake on up to 3 food frequency questionnaires from 1996 to 1998 and teenaged acne in 1999. We computed multivariate prevalence ratios and 95% confidence intervals for acne. RESULTS: After adjusting for age at baseline, height, and energy intake, the multivariate prevalence ratios (95% confidence interval; P value for test of trend) for acne comparing highest (>2 servings/d) with lowest (<1/wk) intake categories in 1996 were 1.16 (1.01, 1.34; 0.77) for total milk, 1.10 (0.94, 1.28; 0.83) for whole/2% milk, 1.17 (0.99, 1.39; 0.08) for low-fat (1%) milk, and 1.19 (1.01, 1.40; 0.02) for skim milk. LIMITATIONS: Not all members of the cohort responded to the questionnaire. Acne assessment was by self-report and boys whose symptoms might have been part of an underlying disorder were not excluded. We did not adjust for steroid use and other lifestyle factors that may affect occurrence of acne. CONCLUSION: We found a positive association between intake of skim milk and acne. This finding suggests that skim milk contains hormonal constituents, or factors that influence endogenous hormones, in sufficient quantities to have biological effects in consumers.

Comparison of a short food frequency questionnaire with the Youth/Adolescent Questionnaire in the Growing Up Today Study.

INTRODUCTION: Our purpose was to design and evaluate a shorter version of our 126-item food frequency questionnaire (long FFQ) for use with adolescents. A shorter FFQ is needed that can reliably rank research subjects according to their intakes of energy, macronutrients and selected micronutrients. METHODS: Dietary data were collected annually, for 3 years, using the full-list FFQ from 16 882 participants of the Growing Up Today Study (GUTS). From this full-list FFQ data, the top ten food contributors for energy and each macronutrient, and the top five food contributors for eight other selected micronutrients were compiled to create a 26-item (short-list) FFQ. Arithmetic means and Pearson correlations were computed to assess relationships between nutrient intakes estimated from the short- and full-list FFQs. We further compared both FFQs with three 24-hour recalls (approximately every 4 months over a 1-year period). Linear regression models were fitted, using energy and nutrients estimated from the short-list FFQ and separately from the full-list FFQ, to see how results may differ. RESULTS: As expected, mean nutrient values from the short-list FFQ were substantially below those from the full-list FFQ. Pearson correlations >0.85 between the short- and full-list FFQs were found for most nutrients. However, correlations between nutrients from the short-list FFQ and the three 24-hour recalls were lower (mean correlation =0.40) than the full-list FFQ. Linear regression models suggested that the short-list FFQ performed nearly as well as the full-list FFQ, for studying associations between energy and several nutrients (trans fatty acids, saturated fat, and glycemic load) and the non-dietary factor, TV viewing. Model betas for energy and nutrients from the short-list FFQ were slightly smaller than betas obtained from the full-list FFQ, but all were statistically significant. CONCLUSION: The short-list FFQ can assess nutrient values of a population for analytic research purposes, such as studying associations between certain dietary intakes and non-dietary factors.

Office-based motivational interviewing to prevent childhood obesity: a feasibility study.

OBJECTIVE: To determine whether pediatricians and dietitians can implement an office-based obesity prevention program using motivational interviewing as the primary intervention. DESIGN: Nonrandomized clinical trial. Fifteen pediatricians belonging to Pediatric Research in Office Settings, a national practice-based research network, and 5 registered dietitians were assigned to 1 of 3 groups: (1) control; (2) minimal intervention (pediatrician only); or (3) intensive intervention (pediatrician and registered dietitian). SETTING: Primary care pediatric offices. PARTICIPANTS: Ninety-one children presenting for well-child care visits met eligibility criteria of being aged 3 to 7 years and having a body mass index (calculated as the weight in kilograms divided by the height in meters squared) at the 85th percentile or greater but lower than the 95th percentile for the age or having a normal weight and a parent with a body mass index of 30 or greater. INTERVENTIONS: Pediatricians and registered dietitians in the intervention groups received motivational interviewing training. Parents of children in the minimal intervention group received 1 motivational interviewing session from the physician, and parents of children in the intensive intervention group received 2 motivational interviewing sessions each from the pediatrician and the registered dietitian. MAIN OUTCOME MEASURE: Change in the body mass index-for-age percentile. RESULTS: At 6 months' follow-up, there was a decrease of 0.6, 1.9, and 2.6 body mass index percentiles in the control, minimal, and intensive groups, respectively. The differences in body mass index percentile change between the 3 groups were nonsignificant (P=.85). The patient dropout rates were 2 (10%), 13 (32%), and 15 (50%) for the control, minimal, and intensive groups, respectively. Fifteen (94%) of the parents reported that the intervention helped them think about changing their family's eating habits. CONCLUSIONS: Motivational interviewing by pediatricians and dietitians is a promising office-based strategy for preventing childhood obesity. However, additional studies are needed to demonstrate the efficacy of this intervention in practice settings.

Assessing diet quality in a population of low-income pregnant women: a comparison between Native Americans and whites.

OBJECTIVE: To assess diet quality of pregnant women in the WIC program in North Dakota and to compare Native Americans with whites, we used a DQI-P (diet quality index for pregnancy) among low-income pregnant women enrolled in WIC, a special supplemental program for women, infants, and children. METHODS: Dietary information was collected for all participants using the Harvard Service Food Frequency Questionnaire (HSFFQ). DQI-P scores were based on 10 components previously used in other diet quality indices: percent recommended intake of grains, vegetables, fruits, folate, calcium, and iron; total fat, saturated fat, and cholesterol; and dietary diversity. Each component contributed 10 points to the total possible DQI-P score of 100. RESULTS: The mean DQI-P score was 53.9. Native Americans (51.8) had significantly lower DQI-P scores (51.8 vs. 54.2; p<0.0001); significantly higher scores for iron and folate; and significantly lower scores for cholesterol, total fat intake, and saturated fat components than did whites. As DQI-P scores increased, diet improved and scores for individual components increased. CONCLUSION: While there were significant differences between the diet quality of Native American and white pregnant women, the differences were minimal. The DQI-P scores for all women in this population indicate that their diets are not meeting dietary recommendations. Interventions should focus on decreasing fat intake and increasing iron and folate intake to meet national dietary recommendations. More emphasis should be placed on eating whole fruit and vegetables.

Milk consumption and acne in adolescent girls.

There has been a remarkable paucity of evidence for an association between diet and acne. Our previous studies suggest that there is an association between milk intake and teenage acne. This is a prospective cohort study to evaluate that relationship. We studied 6,094 girls, aged 9-15 years in 1996, who reported dietary intake on up to three food frequency questionnaires from 1996 to 1998. Presence and severity of acne was assessed by questionnaire in 1999. We computed multivariate prevalence ratios (PR) and 95 percent confidence intervals for acne. After accounting for age at baseline, height and energy intake, the multivariate PRs (95 % CI; p-value for test of trend) for acne comparing highest (2 or more servings per day) to lowest (<1 per week) intake categories in 1996, were 1.20 (1.09, 1.31; <0.001) for total milk, 1.19 (1.06, 1.32; <0.001) for whole milk, 1.17 (1.04, 1.31; 0.002) for low fat milk and 1.19 (1.08, 1.31; <0.001) for skim milk. This result did not change appreciably when we excluded girls who reported use of contraceptives and when we restricted our analysis to those younger than 11 years of age at baseline. We found a positive association between intake of milk and acne. This finding supports earlier studies and suggests that the metabolic effects of milk are sufficient to elicit biological responses in consumers.

Validation of adolescent diet recalled by adults.

BACKGROUND: Few studies have examined the validity of adolescent diet as recalled by adults many years later. METHODS: In this investigation, we examined the validity of a 124-item food frequency questionnaire (HS-FFQ) completed by 80 young adults in the United States about their diet during high school. We compared the HS-FFQ with 3 24-hour recalls and 2 food-frequency questionnaires (YAQ) collected 10 years earlier in 1993, when the participants were in high school. We calculated Pearson correlation coefficients for 20 to 25 nutrients and corrected these correlations for within-person variation. RESULTS: The average corrected correlation for energy-adjusted nutrient intakes calculated from the HS-FFQ and the 24-hour recalls was 0.45 (range = 0.16-0.68). The mean corrected correlation between the HS-FFQ and YAQs was 0.58 (range = 0.40-0.88). CONCLUSION: Taken together with the results of our earlier work, this analysis suggests that the HS-FFQ can reasonably capture adolescent diet recalled by young adults.

Breast-feeding and overweight in adolescence: within-family analysis [corrected].

BACKGROUND: Previous reports have found associations between having been breast-fed and a reduced risk of being overweight. These associations may be confounded by sociocultural determinants of both breast-feeding and obesity. We addressed this possibility by assessing the association of breast-feeding duration with adolescent obesity within sibling sets. METHODS: We surveyed 5,614 siblings age 9 to 14 years and their mothers. These children were a subset of participants in the Growing Up Today Study, in which we had previously reported an inverse association of breast-feeding duration with overweight. We compared the prevalence of overweight (body mass index exceeding the age-sex-specific 85th percentile) in siblings who were breast-fed longer than the mean duration of their sibship with those who were breast-fed for a shorter period. Then we compared odds ratios from this within-family analysis with odds ratios from an overall (ie, not within-family) analysis. RESULTS: Mean +/- standard deviation breast-feeding duration was 6.4 +/- 4.0 months, and crude prevalence of overweight was 19%. On average, siblings who were breast-fed longer than their family mean had breast-feeding duration 3.7 months longer than their shorter-duration siblings. The adjusted odds ratio (OR) for overweight among siblings with longer breast-feeding duration, compared with shorter duration, was 0.92 (95% confidence interval = 0.76-1.11). In overall analyses, the adjusted OR was 0.94 (0.88-1.00) for each 3.7-month increment in breast-feeding duration. CONCLUSION: The estimated OR for the within-family analysis was close to the overall estimate, suggesting that the apparent protective effect of breast-feeding on later obesity was not highly confounded by unmeasured sociocultural factors. A larger study of siblings, however, would be needed to confirm this conclusion.

Use of a food frequency questionnaire in American Indian and Caucasian pregnant women: a validation study.

BACKGROUND: Food frequency questionnaires (FFQs) have been validated in pregnant women, but few studies have focused specifically on low-income women and minorities. The purpose of this study was to examine the validity of the Harvard Service FFQ (HSFFQ) among low-income American Indian and Caucasian pregnant women. METHODS: The 100-item HSFFQ was administered three times to a sample of pregnant women, and two sets of 24-hour recalls (six total) were collected at approximately 12 and 28 weeks of gestation. The sample included a total of 283 pregnant women who completed Phase 1 of the study and 246 women who completed Phase 2 of the study. Deattenuated Pearson correlation coefficients were used to compare intakes of 24 nutrients estimated from the second and third FFQ to average intakes estimated from the week-12 and week-28 sets of diet recalls. RESULTS: Deattenuated correlations ranged from 0.09 (polyunsaturated fat) to 0.67 (calcium) for Phase 1 and from 0.27 (sucrose) to 0.63 (total fat) for Phase 2. Average deattenuated correlations for the two phases were 0.48 and 0.47, similar to those reported among other groups of pregnant women. CONCLUSION: The HSFFQ is a simple self-administered questionnaire that is useful in classifying low-income American Indian and Caucasian women according to relative dietary intake during pregnancy. Its use as a research tool in this population may provide important information about associations of nutrient intakes with pregnancy outcomes and may help to identify groups of women who would benefit most from nutritional interventions.