Reoperation for inguinal hernia recurrence in Ontario: a population-based study.

PURPOSE: Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures. METHODS: We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates. RESULTS: We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26). CONCLUSION: Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.

Impact of diabetes on healthcare costs in a population-based cohort: a cost analysis.

AIMS: To estimate the healthcare costs attributable to diabetes in Ontario, Canada using a propensity-matched control design and health administrative data from the perspective of a single-payer healthcare system. METHODS: Incident diabetes cases among adults in Ontario were identified from the Ontario Diabetes Database between 2004 and 2012 and matched 1:3 to control subjects without diabetes identified in health administrative databases on the basis of sociodemographics and propensity score. Using a comprehensive source of administrative databases, direct per-person costs (Canadian dollars 2012) were calculated. A cost analysis was performed to calculate the attributable costs of diabetes; i.e. the difference of costs between patients with diabetes and control subjects without diabetes. RESULTS: The study sample included 699 042 incident diabetes cases. The costs attributable to diabetes were greatest in the year after diagnosis [C$3,785 (95% CI 3708, 3862) per person for women and C$3,826 (95% CI 3751, 3901) for men], increasing substantially for older age groups and patients who died during follow-up. After accounting for baseline comorbidities, attributable costs were primarily incurred through inpatient acute hospitalizations, physician visits and prescription medications and assistive devices. CONCLUSIONS: The excess healthcare costs attributable to diabetes are substantial and pose a significant clinical and public health challenge. This burden is an important consideration for decision-makers, particularly given increasing concern over the sustainability of the healthcare system, aging population structure and increasing prevalence of diabetic risk factors, such as obesity.

The association of hospital prevention processes and patient risk factors with the risk of Clostridium difficile infection: a population-based cohort study.

BACKGROUND: Clostridium difficile is the most common cause of healthcare-acquired infection; the real-world impacts of some proposed C. difficile prevention processes are unknown. METHODS: We conducted a population-based retrospective cohort study of all patients admitted to acute care hospitals between April 2011 and March 2012 in Ontario, Canada. Hospital prevention practices were determined by survey of infection control programmes; responses were linked to patient-level risk factors and C. difficile outcomes in Ontario administrative databases. Multivariable generalised estimating equation (GEE) regression models were used to assess the impact of selected understudied hospital prevention processes on the patient-level risk of C. difficile infection, accounting for patient risk factors, baseline C. difficile rates and structural hospital characteristics. RESULTS: C. difficile infections complicated 2341 of 653 896 admissions (3.6 per 1000 admissions). Implementation of the selected C. difficile prevention practices was variable across the 159 hospitals with isolation of all patients at onset of diarrhoea reported by 43 (27%), auditing of antibiotic stewardship compliance by 26 (16%), auditing of cleaning practices by 115 (72%), on-site diagnostic testing by 74 (47%), vancomycin as first-line treatment by 24 (15%) and reporting rates to senior leadership by 52 (33%). None of these processes were associated with a significantly reduced risk of C. difficile after adjustment for baseline C. difficile rates, structural hospital characteristics and patient-level factors. Patient-level factors were strongly associated with C. difficile risk, including age, comorbidities, non-elective and medical admissions. CONCLUSIONS: In the largest study to date, selected hospital prevention strategies were not associated with a statistically significant reduction in patients' risk of C. difficile infection. These prevention strategies have either limited effectiveness or were ineffectively implemented during the study period.

Estimating gestational age at birth: a population-based derivation-validation study.

INTRODUCTION: Information on newborn gestational age (GA) is essential in research on perinatal and infant health, but it is not always available from administrative databases. We developed and validated a GA prediction model for singleton births for use in epidemiological studies. METHODS: Derivation of estimated GA was calculated based on 130 328 newborn infants born in Ontario hospitals between 2007 and 2009, using linear regression analysis, with several infant and maternal characteristics as the predictor (independent) variables. The model was validated in a separate sample of 130 329 newborns. RESULTS: The discriminative ability of the linear model based on infant birth weight and sex was reasonably approximate for infants born before the 37th week of gestation (r2 = 0.67; 95% CI: 0.65-0.68), but not for term births (37-42 weeks; r2 = 0.12; 95% CI: 0.12-0.13). Adding other infant and maternal characteristics did not improve the model discrimination. CONCLUSION: Newborn gestational age before 37 weeks can be reasonably approximated using locally available data on birth weight and sex.

A pooled analysis of 10 case-control studies of melanoma and oral contraceptive use.

Data regarding the effects of oral contraceptive use on women's risk of melanoma have been difficult to resolve. We undertook a pooled analysis of all case-control studies of melanoma in women completed as of July 1994 for which electronic data were available on oral contraceptive use along with other melanoma risk factors such as hair colour, sun sensitivity, family history of melanoma and sun exposure. Using the original data from each investigation (a total of 2391 cases and 3199 controls), we combined the study-specific odds ratios and standard errors to obtain a pooled estimate that incorporates inter-study heterogeneity. Overall, we observed no excess risk associated with oral contraceptive use for 1 year or longer compared to never use or use for less than 1 year (pooled odds ratio (pOR)=0.86; 95% CI=0.74-1.01), and there was no evidence of heterogeneity between studies. We found no relation between melanoma incidence and duration of oral contraceptive use, age began, year of use, years since first use or last use, or specifically current oral contraceptive use. In aggregate, our findings do not suggest a major role of oral contraceptive use on women's risk of melanoma.

The uneven landscape of newborn intensive care services: variation in the neonatology workforce.

CONTEXT: In the past 30 years, the number of neonatologists has increased while total births have remained nearly constant. It is not known how equitably this expanded workforce is distributed. OBJECTIVE: To determine the geographic distribution of neonatologists in the United States. DATA SOURCES: 1996 American Medical Association physician masterfiles; 1999 survey of all U.S. neonatal intensive care units; 1995 American Hospital Association hospital survey; and 1995 U.S. vital records. MEASURES: The number of neonatologists and neonatal mid-level providers per live birth within 246 market-based regions. RESULTS: The neonatology workforce varied substantially across neonatal intensive care regions. The number of neonatologists per 10,000 live births ranged from 1.2 to 25.6 with an interquintile range of 3.5 to 8.5. The weakly positive correlation between neonatologists and neonatal mid-level providers per live birth is not consistent with substitution of neonatal mid-level providers for neonatologists (Spearman rank-correlation coefficient, 0.17; P < 0.01). There was no difference in the percentage of neonatal fellows in the lowest and highest workforce quintile (14% vs. 16%) or in the percentage of neonatologists engaged predominantly in research, teaching, or administration (14% in lowest and highest quintiles). CONCLUSIONS: The regional supply of neonatologists varies dramatically and cannot be explained by the substitution of neonatal mid-level providers or by the presence of academic medical centers. Further research is warranted to understand whether neonatal intensive care resources are located in accordance with risk and whether more resources improve newborn outcomes.

Panel-based pain management in primary care. a pilot study.

Although pain is an extremely common symptom presenting to primary care physicians, it frequently is not optimally managed. The purpose of this feasibility study was to develop and pilot-test an efficient, rapid assessment and management approach for pain in busy community practices. The intervention utilized the Dartmouth COOP Clinical Improvement System (DCCIS) and a telephone-based, nurse-educator intervention. Patients from four primary care practices in rural New Hampshire and Vermont were screened by mail for the presence of persistent pain. Patients with mild to severe pain were randomized to either the usual care control group (n = 383) or the intervention group (n = 320). Patients who reported pain but no psychosocial problems received a summary of identified problems and targeted educational material via mail (DCCIS). Patients who reported pain and psychosocial problems received the DCCIS intervention and calls from a nurse-educator who provided pain self-management strategies and a problem-solving approach for psychosocial problems. Post-treatment evaluation revealed that patients in the intervention group scored significantly better on the Pain, Physical, Emotional, and Social subscales of the SF-36 and on the total score of the Functional Interference Scale, as compared to a usual care control group. Feasibility and acceptability of the approach were demonstrated; however, the conclusions based on analyses of the post-treatment outcomes were tempered by baseline imbalances across groups.

Are neonatal intensive care resources located according to need? Regional variation in neonatologists, beds, and low birth weight newborns.

OBJECTIVE: Despite marked growth in neonatal intensive care during the past 30 years, it is not known if neonatologists and beds are preferentially located in regions with greater newborn risk. This study reports the relationship between regional measures of intensive care capacity and low birth weight infants using newly developed market-based regions of neonatal intensive care. DESIGN: Cross-sectional small-area analysis of 246 neonatal intensive care regions (NICRs). DATA SOURCES: 1996 American Medical Association and American Osteopathic Association masterfiles data of clinically active neonatologists; 1999 American Academy of Pediatrics Section on Perinatal Pediatrics survey of directors of neonatal intensive care units in the United States with 100% response rate; 1995 linked birth/death data. RESULTS: The number of total births per neonatologist across NICRs ranged from 390 to 8197 (median: 1722) and the number of total births per intensive care bed ranged from 72 to 1319 (median: 317). The associations between capacity measures and low birth weight rates across NICRs were statistically significant but negligible (R(2): 0.04 for neonatologists; 0.05 for beds). NICRs in the quintile with the greatest neonatologist capacity (average of only 863 births per neonatologist) had very low birth weight (VLBW) rates of 1.5% while those in the quintile of lowest neonatologist capacity (average of 3718 births per neonatologist) had VLBW rates of 1.3%; a similar lack of meaningful difference in VLBW rates was noted across quintiles of intensive care bed capacity. Including midlevel providers and intermediate care beds to the analyses did not alter the findings. CONCLUSIONS: Neonatal intensive care capacity is not preferentially located in regions with greater newborn need as measured by low birth weight rates. Whether greater capacity affords benefits to the newborns remains unknown.

Two-stage methods for the analysis of pooled data.

Epidemiologic studies of disease often produce inconclusive or contradictory results due to small sample sizes or regional variations in the disease incidence or the exposures. To clarify these issues, researchers occasionally pool and reanalyse original data from several large studies. In this paper we explore the use of a two-stage random-effects model for analysing pooled case-control studies and undertake a thorough examination of bias in the pooled estimator under various conditions. The two-stage model analyses each study using the model appropriate to the design with study-specific confounders, and combines the individual study-specific adjusted log-odds ratios using a linear mixed-effects model; it is computationally simple and can incorporate study-level covariates and random effects. Simulations indicate that when the individual studies are large, two-stage methods produce nearly unbiased exposure estimates and standard errors of the exposure estimates from a generalized linear mixed model. By contrast, joint fixed-effects logistic regression produces attenuated exposure estimates and underestimates the standard error when heterogeneity is present. While bias in the pooled regression coefficient increases with interstudy heterogeneity for both models, it is much smaller using the two-stage model. In pooled analyses, where covariates may not be uniformly defined and coded across studies, and occasionally not measured in all studies, a joint model is often not feasible. The two-stage method is shown to be a simple, valid and practical method for the analysis of pooled binary data. The results are applied to a study of reproductive history and cutaneous melanoma risk in women using data from ten large case-control studies.

Skin cancer risk in relation to toenail arsenic concentrations in a US population-based case-control study.

Arsenic is a known carcinogen specifically linked to skin cancer occurrence in regions with highly contaminated drinking water or in individuals who took arsenic-containing medicines. Presently, it is unknown whether such effects occur at environmental levels found in the United States. To address this question, the authors used data collected on 587 basal cell and 284 squamous cell skin cancer cases and 524 controls interviewed as part of a case-control study conducted in New Hampshire between 1993 and 1996. Arsenic was determined in toenail clippings using instrumental neutron activation analysis. The odds ratios for squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) were close to unity in all but the highest category. Among individuals with toenail arsenic concentrations above the 97th percentile, the adjusted odds ratios were 2.07 (95% confidence interval (CI): 0.92, 4.66) for SCC and 1.44 (95% CI: 0.74, 2.81) for BCC, compared with those with concentrations at or below the median. While the risks of SCC and BCC did not appear elevated at the toenail arsenic concentrations detected in most study subjects, the authors cannot exclude the possibility of a dose-related increase at the highest levels of exposure experienced in the New Hampshire population.

Therapeutic ionizing radiation and the incidence of basal cell carcinoma and squamous cell carcinoma. The New Hampshire Skin Cancer Study Group.

OBJECTIVE: To estimate the relative risk of developing basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) after receiving therapeutic ionizing radiation. DESIGN: Population-based case-control study. SETTING: New Hampshire. PATIENTS: A total of 592 cases of BCC and 289 cases of SCC identified through a statewide surveillance system and 536 age- and sex-matched controls selected from population lists. MAIN OUTCOME MEASURES: Histologically confirmed BCC and invasive SCC diagnosed between July 1, 1993, through June 30, 1995, among New Hampshire residents. RESULTS: Information regarding radiotherapy and other factors was obtained through personal interviews. An attempt was made to review the radiation treatment records of subjects who reported a history of radiotherapy. Overall, an increased risk of both BCC and SCC was found in relation to therapeutic ionizing radiation. Elevated risks were confined to the site of radiation exposure (BCC odds ratio, 3. 30; 95% confidence interval, 1.60-6.81; SCC odds ratio, 2.94; 95% confidence interval, 1.30-6.67) and were most pronounced for those irradiated for acne exposure. For SCC, an association with radiotherapy was observed only among those whose skin was likely to sunburn with sun exposure. CONCLUSIONS: These results largely agree with those of previous studies on the risk of BCC in relation to ionizing radiation exposure. In addition, they suggest that the risk of SCC may be increased by radiotherapy, especially in individuals prone to sunburn with sun exposure. Arch Dermatol. 2000;136:1007-1011

Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors.

OBJECTIVE: To explore whether geographic variations in Medicare hospital utilization rates are due to differences in local hospital capacity, after controlling for socioeconomic status and disease burden, and to determine whether greater hospital capacity is associated with lower Medicare mortality rates. DATA SOURCES/STUDY SETTING: The study population: a 20 percent sample of 1989 Medicare enrollees. Measures of resources were based on a national small area analysis of 313 Hospital Referral Regions (HRR). Demographic and socioeconomic data were obtained from the 1990 U.S. Census. Measures of local disease burden were developed using Medicare claims files. STUDY DESIGN: The study was a cross-sectional analysis of the relationship between per capita measures of hospital resources in each region and hospital utilization and mortality rates among Medicare enrollees. Regression techniques were used to control for differences in sociodemographic characteristics and disease burden across areas. DATA COLLECTION/EXTRACTION METHODS: Data on the study population were obtained from Medicare enrollment (Denominator File) and hospital claims files (MedPAR) and U.S. Census files. PRINCIPAL FINDINGS: The per capita supply of hospital beds varied by more than twofold across U.S. regions. Residents of areas with more beds were up to 30 percent more likely to be hospitalized, controlling for ecologic measures of socioeconomic characteristics and disease burden. A greater proportion of the population was hospitalized at least once during the year in areas with more beds; death was also more likely to take place in an inpatient setting. All effects were consistent across racial and income groups. Residence in areas with greater levels of hospital resources was not associated with a decreased risk of death. CONCLUSIONS: Residence in areas of greater hospital capacity is associated with substantially increased use of the hospital, even after controlling for socioeconomic characteristics and illness burden. This increased use provides no detectable mortality benefit.

Has asthma medication use in children become more frequent, more appropriate, or both?

OBJECTIVE: Despite national initiatives to improve asthma medical treatment, the appropriateness of physician prescribing for children with asthma remains unknown. This study measures trends and recent patterns in the pediatric use of medications approved for reversible obstructive airway disease (asthma medications). DESIGN: Population-based longitudinal and cross-sectional analyses. Setting. A nonprofit staff model health maintenance organization located in the Puget Sound area of Washington state. PARTICIPANTS: Children 0 to 17 years of age enrolled continuously during any one of the years from 1984 to 1993 (N = 83 232 in 1993). PRIMARY OUTCOME MEASURES. Percent of enrollees filling prescriptions for asthma medications and fill rates by medication class and estimated duration of inhaled antiinflammatory medication use. RESULTS: Between 1984 and 1993, the frequency of asthma medication use increased: the percent of children filling any asthma medication prescription increased from 4. 0% to 8.1%, whereas the percent filling an inhaled antiinflammatory inhaler rose from 0.4% to 2.4%. In contrast, the intensity of inhaled antiinflammatory use decreased among users; 37% of users filled more than two inhalers during the year in 1984, and 29% in 1993. In high beta-agonist users (filling more than two beta-agonist inhalers each quarter per year), the estimated duration of inhaled antiinflammatory use increased slightly from a mean of 4.1 months per year in 1984-1986 to 5.0 months in 1991-1993; estimated duration of use in adolescents 10 to 17 years of age was approximately half that of children 5 to 9 years of age. CONCLUSIONS: The proportion of children using asthma medications increased substantially during the study period, but the use of inhaled antiinflammatory medication per patient remained low even for those using large amounts of inhaled beta-agonists. These findings suggest that most asthma medications were used by children with mild lower airway symptoms and that inhaled antiinflammatory medication use in children with more severe disease fell short of national guidelines.

Increase in incidence rates of basal cell and squamous cell skin cancer in New Hampshire, USA. New Hampshire Skin Cancer Study Group.

We conducted a study to estimate the current incidence rates of basal-cell carcinoma (BCC) and squamous-cell carcinoma (SCC) of the skin in the population of New Hampshire (NH), USA, and to quantify recent changes in the incidence rates of these malignancies. BCCs and SCCs diagnosed among NH residents were identified through physician practices and central pathology laboratories in NH and bordering regions from June 1979 through May 1980 and from July 1993 through June 1994. For each diagnosis period, we estimated the age-adjusted incidence rates for both BCC and SCC among both men and women and for separate anatomic sites. Between 1979-1980 and 1993-1994, incidence rates of SCC increased by 235% in men and by 350% in women. Incidence rates of BCC increased by more than 80% in both men and women. While the absolute increase was greatest for tumors of the head and neck, the relative change was most pronounced for tumors on the trunk in men and on the lower limb in women. Thus, there has been a marked rise in the incidence rates of BCC and SCC skin cancers in NH in recent years. The anatomic pattern of increase in BCC and SCC incidence is consistent with an effect of greater sunlight exposure. Studies of BCC and SCC occurrence are needed to identify possible behavioral and environmental factors and to assess possible changes in diagnostic practices that might account for the rise in incidence of these common malignancies.

A randomized trial of the use of patient self-assessment data to improve community practices.

OBJECTIVE: Because of time constraints in the office environment, problems of concern to elderly patients may not be raised during clinic visits. To facilitate communication about geriatric health problems, we examined the impact of a strategy that used patient self-assessment data to improve community practices. DESIGN: Twenty-two primary care practices were randomized to participate in the intervention strategy (intervention practices) or to provide usual care (usual care practices). SETTING: Primary care practices in 16 towns in New Hampshire (total, 45 physicians). PATIENTS: 1651 patients 70 years of age or older. INTERVENTION: All patients received a mailed survey that asked about their health problems and about how well these problems were being addressed by their physicians. In the intervention practices, these data were used to generate a customized letter that directed the patient to specific sections in an 80-page modified version of the National Institute on Aging's Age Pages and were summarized and communicated to the patient's physician. MAIN OUTCOME MEASURE: Change from baseline in patients' overall assessment of health care. RESULTS: In 8 of 11 intervention practices, patients felt that their care had improved over the 2-year study period. This improvement occurred in only 1 of 11 usual care practices (P = 0.003). Patients in intervention practices reported receiving significantly more help with physical function, fall prevention, and assistance for memory problems. Self-assessed health status did not differ in the two groups. CONCLUSION: A standard, easy-to-implement strategy to improve the quality of provider--patient interactions can improve the satisfaction of older patients cared for in community practices.

Physical symptom trajectories following trauma exposure: longitudinal findings from the normative aging study.

This study modeled physical symptom trajectories from ages 30 to 75 in 1079 older male military veterans who were assessed every 3 to 5 years since the 1960s. Combat exposure and noncombat trauma were used to define four groups: no trauma (N = 249), noncombat trauma only (N = 333), combat only (N = 152), and both combat and noncombat trauma (N = 345). Number of symptoms on the Cornell Medical Index physical symptom scale increased 29% per decade. Men who had experienced either combat or noncombat trauma did not differ from nonexposed men, but those who had experienced both combat and noncombat trauma had 16% more symptoms across all ages. There were no differences in age-related trajectories as a function of trauma history. In cross-sectional analysis, men with combat and noncombat trauma had more posttraumatic stress disorder symptoms, but not more depression symptoms, than men with either no trauma or noncombat trauma only. Discussion focuses on the importance of considering physical as well as psychological outcomes of exposure to traumatic events.

Brain size, head size, and intelligence quotient in monozygotic twins.

Many studies of monozygotic (MZ) twins have revealed evidence of genetic influences on intellectual functions and their derangement in certain neurologic and psychiatric diseases afflicting the forebrain. Relatively little is known about genetic influences on the size and shape of the human forebrain and its gross morphologic subdivisions. Using MRI and quantitative image analysis techniques, we examined neuroanatomic similarities in MZ twins and their relationship to head size and intelligence quotient (IQ). ANOVA were carried out using each measure as the dependent variable and genotype, birth order, and sex, separately, as between-subject factors. Pairwise correlations between measures were also computed. We found significant effects of genotype but not birth order for the following neuroanatomic measures: forebrain volume (raw, p < or = 0.0001; normalized by body weight, p = 0.0003); cortical surface area (raw, p = 0.002; normalized, p = 0.001); and callosal area (raw, p < or = 0.0001; normalized by forebrain volume, p = 0.02). We also found significant effects of genotype but not birth order for head circumference (raw, p = 0.0002; normalized, p < or = 0.0001) and full-scale IQ (p = 0.001). There were no significant sex effects except for raw head circumference (p = 0.03). Significant correlations were observed among forebrain volume, cortical surface area, and callosal area and between each brain measure and head circumference. There was no significant correlation between IQ and any brain measure or head circumference. These results indicate that: 1) forebrain volume, cortical surface area, and callosal area are similar in MZ twins; and 2) these brain measures are tightly correlated with one another and with head circumference but not with IQ in young, healthy adults.

Trends in pediatric asthma hospitalization rates: regional and socioeconomic differences.

OBJECTIVE: Asthma hospitalization rates continue to increase nationally for children despite efforts by the National Institutes of Health and specialty organizations to improve outcomes through the dissemination of practice guidelines. To understand the generalizability of national trends to regional populations, we studied childhood hospitalizations over a 10-year period in four northeastern states. DESIGN: Longitudinal analysis of hospitalization rates by patient residence and patient characteristics using state hospital discharge datasets. POPULATION: Age < 18 years residing in Maine, New Hampshire, Vermont, or New York state during the period 1985 to 1994. RESULTS: In multivariate analyses (controlling for age, sex, race/ethnicity, median household income, metropolitan status), we found that New York asthma hospitalization rates increased 3.8% per annum (95% confidence interval: 3.3, 4.2), whereas in New Hampshire, rates decreased 5.8% (95% confidence interval: 7.6, 4.1). Maine and Vermont rates did not change significantly during the study period. Increased asthma hospitalization rates were noted in black and Hispanic populations, in children residing in zip codes with lower median household incomes, and in those living in metropolitan areas. Hospitalization rates for nonasthma causes fell substantially. As a result, the proportion of hospital days attributed to childhood asthma increased in all population groups. CONCLUSIONS: Asthma discharge rates measured by the state of residence or socioeconomic characteristic do not necessarily parallel national trends. None of the current hypotheses offered to explain national trends in asthma hospitalization rates (changes in disease severity, diagnostic substitution, or differences in the supply and character of medical care) can be the sole explanation of these regional trends. Efforts intended to improve asthma outcomes may benefit a greater number of children by redirecting resources toward specific populations identified through state hospital discharge datasets.

A comparison of clomiphene citrate and human menopausal gonadotropin for use in conjunction with intrauterine insemination.

OBJECTIVE: To compare the outcome of superovulation using clomiphene citrate (CC) versus hMG in conjunction with IUI. DESIGN: Sequentially assigned, observational study. Couples initially were assigned to receive either CC or hMG for three cycles. SETTING: The Clinical Outpatient Department of the Dartmouth-Hitchcock Medical Center. PATIENT(S): Eighty-three infertile couples. INTERVENTION(S): IUI with hMG use. MAIN OUTCOME MEASURE(S): Conception rate, term pregnancy rate (PR), and pregnancy complications, such as spontaneous miscarriage and multiple gestation. RESULT(S): Of 83 couples who underwent at least one treatment cycle, 29 (35%) conceived during the study period. The relative rate of conception for hMG versus CC was 2.08 (95% confidence interval [CI], 0.93 to 4.68). The relative term PR was 2.10 (95% CI, 0.77 to 5.73) for hMG versus CC. There was no difference in the miscarriage rate for hMG versus CC. CONCLUSION(S): Both the conception rate and the term PR were higher using hMG, compared with CC, in combination with IUI, and showed a trend toward statistical significance.

The distance to community medical care and the likelihood of hospitalization: is closer always better?

OBJECTIVES: This study examined the influence that distance from residence to the nearest hospital had on the likelihood of hospitalization and mortality. METHODS: Hospitalizations were studied for Maine. New Hampshire, and Vermont during 1989 (adults) and for 1985 through 1989 (children) and for mortality (1989) in Medicare enrollees. RESULTS: After other known predictors of hospitalization (age, sex, bed supply, median household income, rural residence, academic medical center, and presence of nursing home patients) were controlled for, the adjusted rate ratio of medical hospitalization for residents living more than 30 minutes away was 0.85 (95% confidence interval [CI] = 0.82, 0.88) for adults and 0.78 (95% CI = 0.74, 0.81) for children, compared with those living in a zip code with a hospital. Similar effects were seen for the four most common diagnosis-related groups for both adults and children. The likelihood of hospitalization for conditions usually requiring hospitalization and for mortality in the elderly did not differ by distance. CONCLUSIONS: Distance to the hospital exerts an important influence on hospitalization rates that is unlikely to be explained by illness rates.