Testing the added value of self-reported health and well-being in understanding healthcare utilization and costs.

PURPOSE: We investigated the relationship between measures of self-reported health and well-being and concurrent and prospective healthcare utilization and costs to assess the added value of these self-reported measures in understanding utilization and cost. METHODS: Kaiser Permanente members (N = 6752) completed a 9-item survey measuring life evaluation, financial situation, social support, meaning and purpose, physical health, and mental health. Responses were linked to medical record information during the period 12 months before and after the survey. RESULTS: Correlations between health and well-being measures and healthcare utilization and cost variables were generally weak, with stronger correlations for future life evaluation and selected health measures (ρ = .20-.33, ps < .001). Better overall life evaluation had a significant but weak association with lower total cost and hospital days in the following year after controlling for age, sex, and race/ethnicity (p < .001). Full multivariate models, adjusting for age, sex, race/ethnicity, prior utilization, and relative risk models, showed weak associations between health and well-being measures and following year total healthcare cost and utilization, though the associations were relatively stronger for the health variables than the well-being variables. CONCLUSION: Overall, the health and well-being variables added little to no predictive utility for future utilization and cost beyond prior utilization and cost and the inclusion of predictive models based on clinical information. Perceptions of well-being may be associated with factors beyond healthcare utilization. When information about prior use is unavailable, self-reported health items have some predictive utility.

Vaccine adverse events in a safety net healthcare system and a managed care organization.

BACKGROUND: The Institute of Medicine, in a 2013 report, recommended that the Vaccine Safety Datalink (VSD) expand collaborations to include more diversity in the study population. Kaiser Permanente Colorado (KPCO), an established VSD site, partnered with Denver Health (DH), an integrated safety net healthcare system, to demonstrate the feasibility of integrating DH data within the VSD. Prior to incorporating the data, we examined the identification of specific vaccine associated adverse events (VAEs) in these two distinct healthcare systems. METHODS: We conducted retrospective cohort analyses within KPCO and DH to compare select VAEs between the two populations. We examined the following associations between January 1, 2004 and December 31, 2013: Measles, Mumps, and Rubella (MMR) vaccine and febrile seizures in children 2years and younger, intussusception after rotavirus vaccine in infants 4-34weeks, syncope after adolescent vaccines (Tetanus, Diphtheria, acellular Pertussis; Meningococcal and Human Papillomavirus) in adolescents 13-17years and medically attended local reactions after pneumococcal polysaccharide (PPSV23) vaccine in adults 65years and older. Both sites used similar data procurement methods and chart review processes. RESULTS: For seizures after MMR vaccine (KPCO - 3.15vs. DH - 2.97/10,000 doses) and syncope after all adolescent vaccines (KPCO - 3.0vs. DH - 2.37/10,000 doses), the chart confirmed rates were comparable at the two sites. However, for medically attended local reactions after PPSV23, there were differences in chart confirmed rates between the sites (KPCO - 31.65vs. DH - 14.90/10,000 doses). For intussusception after rotavirus vaccine, the number of cases was too low to make a valid comparison (KPCO - 0vs. DH - 0.13/10,000 doses). CONCLUSION: We demonstrated that data on important targeted VAEs can be captured at DH and rates appear similar to those at KPCO. Work is ongoing on the optimal approach to assimilate DH data as a potential safety net healthcare system in the VSD.

Gender differences in the prognostic value of exercise treadmill test characteristics.

BACKGROUND: Although exercise treadmill testing (ETT) is less sensitive and specific for diagnosis of coronary disease in women, little is known about gender differences in the prognostic importance of ETT variables. METHODS: We studied 9,569 consecutive patients (46.8% women) referred for ETT between July 2001 and June 2004 in a community-based system. We assessed the association between ETT variables (exercise capacity, symptoms, ST-segment deviations, heart rate recovery, and chronotropic response) and time to all-cause death and myocardial infarction (MI), adjusting for patient and stress test characteristics. Models were stratified by gender to determine the relationship between ETT variables and outcomes. RESULTS: In the entire population, exercise capacity and heart rate recovery were significantly associated with all-cause death, whereas exercise capacity, chest pain, and ST-segment deviations were significantly associated with subsequent MI. The relationship between ETT variables and outcomes were similar between men and women, except for abnormal exercise capacity, which had a significantly stronger association with death in men (men: hazard ratio [HR] 2.89 and 95% CI 1.89-4.44, women: HR 0.99 and 95% CI 0.52-1.93, and interaction P = .01), and chronotropic incompetence, which had a significantly stronger relationship with MI in women (men: HR 1.29 and 95% CI 0.74-2.20, women: HR 2.79 and 95% CI 0.94-8.27, and interaction P = .04). CONCLUSIONS: Although many traditional ETT variables had similar prognostic value in both men and women, exercise capacity was more prognostically important in men, and chronotropic incompetence was more important in women. Future studies should confirm these findings in additional populations.

The relationship between gender and clinical management after exercise stress testing.

BACKGROUND: Controversy remains regarding whether gender differences exist in clinical management after exercise treadmill testing (ETT). METHODS: We studied 7,506 patients (49.8% women) without documented coronary heart disease referred for ETT from July 2001 to June 2004 in a community-based setting. We assessed the relationship between gender and subsequent diagnostic testing (secondary stress testing or coronary angiography) within 6 months after ETT. Secondary outcomes included subsequent stress testing, coronary angiography, and new cardiology visits in the 6-month interval. Multivariable analyses assessed the relationship between gender and these outcomes adjusting for demographic, clinical, and stress test characteristics. In subsequent analyses, patients were stratified by Duke Treadmill Scores (Duke University, Durham, NC). RESULTS: Compared with men, women referred for ETT were older, had a higher prevalence of some cardiac risk factors, achieved lower peak workloads, and, more often, experienced chest pain or ST-segment changes. After accounting for differences in clinical and ETT parameters, gender was not associated with any subsequent diagnostic testing in the 6 months after ETT (OR 1.0, 95% CI 0.85-1.18). In secondary analyses, women were less likely to undergo angiography (OR 0.63, 95% CI 0.47-0.83) with a trend toward more subsequent stress testing. Stratified analyses revealed less subsequent testing in high-to-intermediate Duke Treadmill Score women compared with men (OR 0.61, 95% CI 0.48-0.79). Women and men were equally likely to die (hazards ratio 0.93, 95% CI 0.61-1.44) in the adjusted survival analysis. CONCLUSIONS: Overall, women and men equally underwent subsequent diagnostic testing after ETT. Although women were less likely to undergo angiography and higher-risk women were less likely to undergo subsequent testing, adverse events were not higher in women. Given these findings, assumptions regarding gender disparities in clinical management after ETT should be reevaluated in other settings.

Comparison of children's diets as reported by the child via the Youth/Adolescent Questionnaire and the parent via the Willett food-frequency questionnaire.

OBJECTIVE: A comparison of a parent-completed Willett food-frequency questionnaire (FFQ) and a self-completed Youth/Adolescent Questionnaire (YAQ) has not yet been conducted. SETTING: In the Diabetes Autoimmunity Study in the Young (DAISY), parents report their child's diet on the FFQ annually from birth until age 10 years, when the child begins to report their own diet using the YAQ. SUBJECTS: To determine the comparability of these collection methods, 89 children aged 10-17 years and their parents completed the YAQ and FFQ, respectively, for the child's previous year's diet. DESIGN: We compared reported intakes for energy, the macronutrients and a variety of micronutrients of interest to the DAISY study. RESULTS: Bland-Altman plots of energy-adjusted differences between questionnaire responses against their means suggested that the two collection methods gave similar results. The average Spearman correlation coefficient of all energy-adjusted nutrient intakes was 0.50, and did not differ significantly by gender (males, r=0.48; females, r=0.46) or age (10-11 years, r=0.49; 12-17 years, r=0.51). While correlated, the nutrient values from the FFQ were higher than the nutrient values from the YAQ. CONCLUSIONS: While reported nutrient intakes are correlated, an indicator variable defining which survey method a nutrient was collected with should be included in any longitudinal data analyses examining nutrient intakes collected with the YAQ and the FFQ as independent predictors of a disease outcome.

Plasma micronutrients are associated with dietary intake and environmental tobacco smoke exposure in a paediatric population.

BACKGROUND: While adult populations have been well described in terms of nutritional status, such as the concentration of nutrient biomarkers, little work has been done in healthy paediatric populations. OBJECTIVE: The primary objective of this analysis was to explore the determinants of plasma micronutrients in a group of healthy infants and children. DESIGN: The Diabetes Autoimmunity Study in the Young (DAISY) has enrolled 1433 newborns at increased risk for type 1 diabetes in Denver, Colorado. A representative random sample of 257 children from the DAISY cohort between the ages of 9 months and 8 years with a total of 815 clinic visits over time was used in this analysis. Annual dietary intake was assessed over time with Willett food-frequency questionnaires that were validated in this population. Environmental tobacco smoke (ETS) was assessed using a validated survey. Plasma samples were tested for vitamins, carotenoids and total lipids. Predictors of plasma micronutrients were evaluated using mixed models for longitudinal data, while adjusting for age, human leukocyte antigen genotype, type 1 diabetes family history and other potential confounders and covariates. RESULTS: Increased micronutrient intake was associated with increased levels of their respective plasma nutrient, with the exception of gamma-tocopherol. Independent of dietary intake, levels of alpha- and beta-carotene and beta-cryptoxanthin were significantly lower, and gamma-tocopherol was significantly higher, in children who were exposed to ETS. CONCLUSION: Dietary intake predicts plasma micronutrient levels. Exposure to ETS potentially could have negative health effects in this young population.

Validating methods of urine collection: a pilot study.

In this pilot study of 21 adults, direct collection versus cotton-ball collection of urine was studied. Results showed the use of cotton balls for collecting urine is a safe and effective method for measuring antioxidants and markers of oxidative stress for clinical and research use.

Validation of a five-question survey to assess a child's exposure to environmental tobacco smoke.

PURPOSE: To study the potentially adverse health effects of environmental tobacco smoke (ETS) exposure in young children, a short five-question survey was developed to identify routine exposure to ETS in a large epidemiological study. METHODS: The survey is administered to parents of a healthy cohort of children starting at age 3 months. To validate the survey, urinary cotinine levels were measured on 50 children from this cohort who were selected based on ETS exposure as reported in the survey: 24 with no exposure and 26 with exposure. Cotinine was adjusted for creatinine. RESULTS: Overall, children with some form of reported ETS exposure had urinary cotinine levels 7.5 times higher than those who were not exposed. Analysis of variance shows that mean levels of log transformed cotinine in children whose parent(s) smoke in the home, parent(s) who smoke but not in the home, and non-smoking parents are 137.13, 75.60, and 43.28 respectively (p = 0.0009), indicating decreasing levels of cotinine as reported exposure decreases. Using a cut-point of 30 ng/mg of cotinine to differentiate unexposed and exposed to ETS, we found 80% agreement with our survey. A Spearman's ranked correlation coefficient of 0.62 indicates a direct relationship between cotinine and an ETS exposure intensity score (p < 0.0001). CONCLUSIONS: These results suggest that the 5-question survey reflects the child's exposure to passive smoke and that the survey is sensitive to varying levels of exposure.