A study in nursing home effectiveness in Texas

This exploratory study was conducted to examine the relationship between nursing home organizational variables and variations in financial efficiency and effectiveness in Texas nursing homes. Efficiency was defined in terms of nursing home profit, contribution margin, and administrative costs. Effectiveness was defined as the level of the quality of care measured by Texas Department of Health annual surveys of Medicaid certified facilities.^ A sample of 318 intermediate care facilities was selected from a population of 1,026 Texas nursing homes operating in 1987. Location was not found to be related to nursing home effectiveness. Nursing home ownership was positively related to financial efficiency. A moderate amount of quality of care variation was explained by examining nursing home size, employee turnover rate, labor hours per patient day and occupancy rate.^ The number of labor hours per patient day and employee turnover rate were significantly related negatively to both measures of profitability and quality of care. ^

Linkage and association of candidate obesity genes in Mexican-Americans from Starr County, Texas

Obesity and related chronic diseases represent a tremendous public health burden among Mexican Americans, a young and rapidly-expanding population. This study investigated the impact of variation within eight candidate obesity genes, which include leptin (LEP), leptin receptor (LEPR), neuropeptide Y (NPY), NPYY1 receptor (NPYY1), glucagon-like peptide-1 (GLP-1), GLP-1 receptor (GLP1R), beta-3 adrenergic receptor (β3AR), and uncoupling protein (UCP1), on variation in human obesity status and/or quantitative traits related to obesity in Mexican Americans from Starr County, Texas. The Trp64Arg polymorphism within β3AR was typed in 820 random individuals and 240 pedigrees (N = 2,044). The Arg allele frequency was significantly greater in obese versus non-obese individuals (0.20 versus 0. 15, respectively). In addition, within the random sample, the Arg allele was associated with significantly greater body weight (p = 0.031) and body mass index (BMI, p = 0.008) than the Trp allele. In the family sample, the Trp64Arg locus was also linked to percent fat (p = 0.045) but not to body weight or BMI. No linkage between obesity, diabetes, hypertension, or gallbladder disease and the Trp64Arg mutation was observed in families using affected sib pair linkage analysis or the transmission disequilibrium test. Microsatellite markers proximate to the remaining seven genes were typed in 302 individuals from 59 families. Sib pair linkage analysis provided evidence for linkage between obesity and NPY within affected sibling pairs (p = 0.042; n = 170 pairs). NPY was also linked to weight (p = 0.020), abdominal circumference (p = 0.031), hip circumference (p = 0.012), DBP (p ≤ 0.005), and a composite measure of body mass/fat (p ≤ 0.048) in all sibling pairs (n = 545 pairs). Additionally, LEP was linked to waist/hip ratio (p ≤ 0.009), total cholesterol (p ≤ 0.030), and HDL cholesterol (p ≤ 0.026), and LEPR was linked to fasting blood glucose (p ≤ 0.018) and DBP (p ≤ 0.003). Subsequent to the linkage analyses, the NPY gene was sequenced and eight variant sites identified. Two variant sites (-880I/D and 69I/D) were typed in a random sample of 914 individuals. The 880I/D variant was significantly associated with waist/hip ratio (p = 0.035) in the entire sample (N = 914) and with BMI (p = 0. 031), abdominal circumference (p = 0.044), and waist/hip ratio (p = 0.041) in a non-obese subsample (BW < 30 kg/m2, n = 594). The 69I/D variant was a rare mutation observed in only one pedigree and was not associated with obesity or body size/mass within this pedigree. Results of this study indicate that variation at or near β3AR, LEP, LEPR, and NPY may exert effects which increase obesity susceptibility and influence obesity-related measures in this population. ^

Fasting blood glucose and 8-year mortality in the hypertension detection follow-up program population

This study analyzed the relationship between fasting blood glucose (FBG) and 8-year mortality in the Hypertension Detection Follow-up Program (HDFP) population. Fasting blood glucose (FBG) was examined both as a continuous variable and by specified FBG strata: Normal (FBG 60–100 mg/dL), Impaired (FBG ≥100 and ≤125 mg/dL), and Diabetic (FBG>125 mg/dL or pre-existing diabetes) subgroups. The relationship between type 2 diabetes was examined with all-cause mortality. This thesis described and compared the characteristics of fasting blood glucose strata by recognized glucose cut-points; described the mortality rates in the various fasting blood glucose strata using Kaplan-Meier mortality curves, and compared the mortality risk of various strata using Cox Regression analysis. Overall, mortality was significantly greater among Referred Care (RC) participants compared to Stepped Care (SC) {HR = 1.17; 95% CI (1.052,1.309); p-value = 0.004}, as reported by the HDFP investigators in 1979. Compared with SC participants, the RC mortality rate was significantly higher for the Normal FBG group {HR = 1.18; 95% CI (1.029,1.363); p-value = 0.019} and the Impaired FBG group, {HR = 1.34; 95% CI (1.036,1.734); p-value = 0.026,}. However, for the diabetic group, 8-year mortality did not differ significantly between the RC and SC groups after adjusting for race, gender, age, smoking status among Diabetic individuals {HR = 1.03; 95% CI (0.816,1.303); p-value = 0.798}. This latter finding is possibly due to a lack of a treatment difference of hypertension among Diabetic participants in both RC and SC groups. The largest difference in mortality between RC and SC was in the Impaired subgroup, suggesting that hypertensive patients with FBG between 100 and 125 mg/dL would benefit from aggressive antihypertensive therapy.^

Effects of overweight and obesity on economic outcomes among U.S. adults with kidney disease

Background. Kidney disease is a growing public health phenomenon in the U.S. and in the world. Downstream interventions, dialysis and renal transplants covered by Medicare's renal disease entitlement policy in those who are 65 years and over have been expensive treatments that have been not foolproof. The shortage of kidney donors in the U.S. has grown in the last two decades. Therefore study of upstream events in kidney disease development and progression is justified to prevent the rising prevalence of kidney disease. Previous studies have documented the biological route by which obesity can progress and accelerate kidney disease, but health services literature on quantifying the effects of overweight and obesity on economic outcomes in the context of renal disease were lacking. Objectives . The specific aims of this study were (1) to determine the likelihood of overweight and obesity in renal disease and in three specific adult renal disease sub-populations, hypertensive, diabetic and both hypertensive and diabetic (2) to determine the incremental health service use and spending in overweight and obese renal disease populations and (3) to determine who financed the cost of healthcare for renal disease in overweight and obese adult populations less than 65 years of age. Methods. This study was a retrospective cross-sectional study of renal disease cases pooled for years 2002 to 2009 from the Medical Expenditure Panel Survey. The likelihood of overweight and obesity was estimated using chi-square test. Negative binomial regression and generalized gamma model with log link were used to estimate healthcare utilization and healthcare expenditures for six health event categories. Payments by self/family, public and private insurance were described for overweight and obese kidney disease sub-populations. Results. The likelihood of overweight and obesity was 0.29 and 0.46 among renal disease and obesity was common in hypertensive and diabetic renal disease population. Among obese renal disease population, negative binomial regression estimates of healthcare utilization per person per year as compared to normal weight renal disease persons were significant for office-based provider visits and agency home health visits respectively (p=0.001; p=0.005). Among overweight kidney disease population health service use was significant for inpatient hospital discharges (p=0.027). Over years 2002 to 2009, overweight and obese renal disease sub-populations had 53% and 63% higher inpatient facility and doctor expenditures as compared to normal weight renal disease population and these result were statistically significant (p=0.007; p=0.026). Overweigh renal disease population had significant total expenses per person per year for office-based and outpatient associated care. Overweight and obese renal disease persons paid less from out-of-pocket overall compared to normal weight renal disease population. Medicare and Medicaid had the highest mean annual payments for obese renal disease persons, while mean annual payments per year were highest for private insurance among normal weight renal disease population. Conclusion. Overweight and obesity were common in those with acute and chronic kidney disease and resulted in higher healthcare spending and increased utilization of office-based providers, hospital inpatient department and agency home healthcare. Healthcare for overweight and obese renal disease persons younger than 65 years of age was financed more by private and public insurance and less by out of pocket payments. With the increasing epidemic of obesity in the U.S. and the aging of the baby boomer population, the findings of the present study have implications for public health and for greater dissemination of healthcare resources to prevent, manage and delay the onset of overweight and obesity that can progress and accelerate the course of the kidney disease.^