A new universal, standardized implant database for product identification: a unique tool for arthroplasty registries.

INTRODUCTION Every joint registry aims to improve patient care by identifying implants that have an inferior performance. For this reason, each registry records the implant name that has been used in the individual patient. In most registries, a paper-based approach has been utilized for this purpose. However, in addition to being time-consuming, this approach does not account for the fact that failure patterns are not necessarily implant specific but can be associated with design features that are used in a number of implants. Therefore, we aimed to develop and evaluate an implant product library that allows both time saving barcode scanning on site in the hospital for the registration of the implant components and a detailed description of implant specifications. MATERIALS AND METHODS A task force consisting of representatives of the German Arthroplasty Registry, industry, and computer specialists agreed on a solution that allows barcode scanning of implant components and that also uses a detailed standardized classification describing arthroplasty components. The manufacturers classified all their components that are sold in Germany according to this classification. The implant database was analyzed regarding the completeness of components by algorithms and real-time data. RESULTS The implant library could be set up successfully. At this point, the implant database includes more than 38,000 items, of which all were classified by the manufacturers according to the predefined scheme. Using patient data from the German Arthroplasty Registry, several errors in the database were detected, all of which were corrected by the respective implant manufacturers. CONCLUSIONS The implant library that was developed for the German Arthroplasty Registry allows not only on-site barcode scanning for the registration of the implant components but also its classification tree allows a sophisticated analysis regarding implant characteristics, regardless of brand or manufacturer. The database is maintained by the implant manufacturers, thereby allowing registries to focus their resources on other areas of research. The database might represent a possible global model, which might encourage harmonization between joint replacement registries enabling comparisons between joint replacement registries.

Comparison of 2.5D and 3D Quantification of Femoral Head Coverage in Normal Control Subjects and Patients with Hip Dysplasia.

Hip dysplasia is characterized by insufficient femoral head coverage (FHC). Quantification of FHC is of importance as the underlying goal of the surgery to treat hip dysplasia is to restore a normal acetabular morphology and thereby to improve FHC. Unlike a pure 2D X-ray radiograph-based measurement method or a pure 3D CT-based measurement method, previously we presented a 2.5D method to quantify FHC from a single anteriorposterior (AP) pelvic radiograph. In this study, we first quantified and compared 3D FHC between a normal control group and a patient group using a CT-based measurement method. Taking the CT-based 3D measurements of FHC as the gold standard, we further quantified the bias, precision and correlation between the 2.5D measurements and the 3D measurements on both the control group and the patient group. Based on digitally reconstructed radiographs (DRRs), we investigated the influence of the pelvic tilt on the 2.5D measurements of FHC. The intraclass correlation coefficients (ICCs) for absolute agreement was used to quantify interobserver reliability and intraobserver reproducibility of the 2.5D measurement technique. The Pearson correlation coefficient, r, was used to determine the strength of the linear association between the 2.5D and the 3D measurements. Student's t-test was used to determine whether the differences between different measurements were statistically significant. Our experimental results demonstrated that both the interobserver reliability and the intraobserver reproducibility of the 2.5D measurement technique were very good (ICCs > 0.8). Regression analysis indicated that the correlation was very strong between the 2.5D and the 3D measurements (r = 0.89, p < 0.001). Student's t-test showed that there were no statistically significant differences between the 2.5D and the 3D measurements of FHC on the patient group (p > 0.05). The results of this study provided convincing evidence demonstrating the validity of the 2.5D measurements of FHC from a single AP pelvic radiograph and proved that it could serve as a surrogate for 3D CT-based measurements. Thus it may be possible to use this method to avoid a CT scan for the purpose of estimating 3D FHC in diagnosis and post-operative treatment evaluation of patients with hip dysplasia.

The Economics of Incentive-Based Health Care Plans

Medical savings accounts (MSAs) belong to a larger class of incentive-based health care plans. Using a model that allows the consumer to invest in healthy activities, we examine the efficiency properties of incentive plans and compare them to traditional full- coverage and deductible plans, under both experience rating and community rating. The model also is extended to include utilization of preventive health care. Properly constructed incentive plans have the capacity to induce socially efficient levels of healthy activities and preventive care, raising the expected wealth of consumers without reducing insurers' profits.

Effects of health disparities on Helicobacter pylori infection among children on the US-Mexico border

The objective of this study is to determine whether health disparities influence the odds of developing H. pylori infections among the children enrolled in the Pasitos Cohort Study on the US-Mexico border. The study variables were the number of prenatal care visits, ways of transportation, car in household, location of health services and insurance coverage. The study recruited eligible pregnant women to complete baseline questionnaires. Every six months after the birth of the child, infection status is measure by the 13-C urea breath test. Results indicate that having medical insurance consistently decreases the odds of being infected. Children with mothers who went to a private physician had decreased odds of infection compared to those utilizing public clinics, and having a car in the household increased the odds of infection. Limitations include bias due to loss to follow-up and the transient nature of the infection.^

Access to health care among children in the U.S.: Use of health inequalities measures to evaluate progress in reduction of disparities from 1997 to 2005

Much of the literature on disparities in access to health care among children has focused on measuring absolute and relative differences experienced by race/ethnic groups and, to a lesser extent, socioeconomic groups. However, it is not clear from existing literature how disparities in access to care may have changed over time for children, especially following implementation of the State Children’s Health Insurance Program (SCHIP). The primary objective of this research was to determine if there has been a decrease in disparities in access to care for children across two socioeconomic groups and race/ethnicity groups after SCHIP implementation. Methods commonly used to measure ‘health inequalities’ were used to measure disparities in access to care including population-attributable risk (PAR) and the relative index of inequality (RII). Using these measures there is evidence of a substantial decrease in socioeconomic disparities in health insurance coverage and to a lesser extent in having a usual source of care since the SCHIP program began. There is also evidence of a considerable decrease in non-Hispanic Black disparities in access to care. However, there appears to be a slight increase in disparities in access to care among Hispanic compared to non-Hispanic White children. While there were great improvements in disparities in access to care with the introduction of the SCHIP program, continuing progress in disparities may depend on continuation of the SCHIP program or similar targeted health policy programs. ^

Crossing the border for dental care: Factors related to dental health among the south Texas border region

Objectives. The purpose of this thesis is to understand the underlying socioeconomic characteristics affecting dental insurance coverage, yearly dental visits, and factors related to visiting a dentist in Mexico among border region residents. Methods. Using data from the Border Epidemiological Study of Aging, dental utilization in the previous 12 months, dental visits to Mexico, and dental insurance (proxy) were calculated utilizing logistic regression. Three different models were utilized for the dependent variables adjusting for diverse socioeconomic characteristics such as gender, age, marital status, income, education, years of residence in the United States (for immigrants), English proficiency, general health status, employment and dental insurance. Results. After adjustment, diverse variables were significant for the three different models calculated. Conclusion. Although the Mexican health market constitutes a viable option for dental services for border residents, dental insurance and dental yearly visits were lower in this region when compared to national averages. ^

Physician coding for mental illness reimbursement and the need for mental health parity

Many patients with anxiety and depression initially seek treatment from their primary care physicians. Changes in insurance coverage and current mental parity laws, make reimbursement for services a problem. This has led to a coding dilemma for physicians seeking payment for their services. This study seeks to determine first the frequency at which primary care physicians use alternative coding, and secondly, if physicians would change their coding practices, provided reimbursement was assured through changes in mental parity laws. A mail survey was sent to 260 randomly selected primary care physicians, who are family practice, internal medicine, and general practice physicians, and members of the Harris County Medical Society. The survey evaluated the physicians' demographics, the number of patients with psychiatric disorders seen by primary care physicians, the frequency with which physicians used alternative coding, and if mental parity laws changed, the rate at which physicians would use a psychiatric illness diagnosis as the primary diagnostic code. The overall response rate was 23%. Only 47 of the 59 physicians, who responded, qualified for the study and of those 45% used a psychiatric disorder to diagnose patients with a primary psychiatric disorder, 47% used a somatic/symptom disorder, and 8% used a medical diagnosis. From the physicians who would not use a psychiatric diagnosis as a primary ICD-9 code, 88% were afraid of not being reimbursed and 12% were worried about stigma or jeopardizing insurability. If payment were assured using a psychiatric diagnostic code, 81% physicians would use a psychiatric diagnosis as the primary diagnostic code. However, 19% would use an alternative diagnostic code in fear of stigmatizing and/or jeopardizing patients' insurability. Although the sample size of the study design was adequate, our survey did not have an ideal response rate, and no significant correlation was observed. However, it is evident that reimbursement for mental illness continues to be a problem for primary care physicians. The reformation of mental parity laws is necessary to ensure that patients receive mental health services and that primary care physicians are reimbursed. Despite the possibility of improved mental parity legislation, some physicians are still hesitant to assign patients with a mental illness diagnosis, due to the associated stigma, which still plays a role in today's society. ^

An overview of China's one child policy and health consequences on society

In 1979, China implemented the one child policy to stifle the burden of the massive demographic growth cast on the future economic development and quality of living conditions. At the time, a quarter of the world's population resided in China and occupied only 7 percent of the world's arable land (The World Factbook, 2006). The government set the target total population to about 1.4 billion for the year 2010 and to significantly reduce the natural increase rate. First this overview paper will describe population demographics and economy of China's society. This paper will also investigate what the one child policy entails and how it is implemented. Furthermore, the consequences of the policy in regard to population growth, sex ratio, marital discrepancies, adverse health of mother and child, aging population, and pension coverage will be examined. Finally, future recommendations and an alternative policy will be postulated to increase the effectiveness of the policy and improve its effects on health. ^

How health care delay and avoidance decisions are affected by finances and health insurance

Objective. To identify how an individual's finances and health insurance coverage affects their decision whether to avoid or delay medical care. Methods. Secondary data analysis of The Effects of Financial and Insurance Considerations on Health Care Utilization 2007 telephone survey data. Study inclusion criteria. 18 years old, Harris County resident, and had a need for medical care within the past year. Post weighing was done to correct for non-response bias. Results. Survey decision makers were predominately minorities (60%), Female (70%), and insured (71%). Ninety-two percent of participants sought care when needed, however, of this population 39% delayed medical care. Fifty-six percent of participants who delayed medical care sought care in the Doctor's office. For those who replied "Yes" to considering health insurance and finances in deciding to avoid medical care, 61% stated that they were confused about their insurance coverage as the explanation why. Fifty-five percent of Respondents indicated that delaying medical care was due to not knowing whether medical care was necessary. Conclusion. Additional research needs to be conducted to examine the relationship between onset of medical symptoms and final medical diagnosis to identify whether survey participants who delayed or avoided medical care actions were appropriate responses to their initial medical symptoms and final diagnosis. ^

Factors associated with smoking cessation using the 2005 National Health Interview Survey

Objectives. The objective of this study is to compare the socio-demographic, behavioral, and access to care characteristics of smokers who have quit smoking for one or more years and current smokers who have made an attempt to quit smoking within the last year. ^ Methods. Data from the 2005 National Health Interview Survey (NHIS) were used to compare current smokers who have tried to quit (n=2747) and former smokers who have quit for one or more years (n=6194). The data was analyzed using STATA 9.0 to perform statistical calculations. ^ Results. Age, education, race and income were associated with smoking status. Respondents aged 65 and older were 36 times more likely to have quit smoking. Education and income had higher odds ratios among quitters (OR=1.27 and OR=1.21) and Non-Hispanic Whites were the most likely to have quit smoking compared to Hispanics and Blacks. Adults with health insurance coverage were 3.44 times more likely to have quit smoking. ^ Discussion. Existing research suggests that individual factors relating to demographics behavior and access to care can impact a smoker's ability to quit smoking. This paper discusses the factors that affect cessation and which populations would benefit from additional research and targeted smoking cessation programs. ^

News media coverage of policies surrounding the HPV vaccine before and after Texas Governor Rick Perry's executive order, February 2006-February 2008

Objective. In June 2006, the first vaccine for human papillomavirus (HPV) was approved by the FDA and shortly after approval, the Advisory Committee on Immunization Practices (ACIP) voted to recommend the HPV vaccine for young girls. As a result of ACIP recommendations, state legislators introduced bills to mandate the vaccine. Policies related to public health issues, such as vaccination mandates, are often influenced by news coverage of these issues. News media, particularly in times of controversies, reinforce specific messages and plays an essential role in framing issues for the public. The objective of this study is to examine the quality, content, and scope of policies for the HPV vaccine before and after Texas Governor Rick Perry issued an executive order mandating the vaccine for middle school girls.^ Methods. The Lexis-Nexis database was used to identify 335 articles on HPV vaccination mandate policies that were published in U.S. newspapers from February 1, 2006 to February 2, 2008. The coding instrument captured information about article type, main news story concern, general information about HPV, HPV vaccine mandate policies, arguments for and against HPV vaccination mandates, arguments for and against the HPV vaccine, and sources of information.^ Results. Most news articles (82.4%) occurred after Governor Rick Perry issued an executive order mandating the HPV vaccine. Most articles mentioned that HPV is sexually transmitted (90.7%) and linked HPV infection to cervical cancer (96.1%). Only 63.9% of the articles reported that the HPV vaccine protects against types of HPV that cause cervical cancer and 18.8% of the articles reported that the vaccine protects against genital warts. Only 18.2% of the news articles presented a balanced argument regarding mandatory HPV vaccinations, and only 39.4% of the news articles presented a balanced argument for the HPV vaccine.^ Conclusions. Our study revealed that news coverage regarding mandating the HPV vaccine and issues related to the vaccine itself is biased, unbalanced, and incomplete. Since the public pays a great deal of attention to health in the media, it is essential that news stories are balanced, complete, and accurate. In order to ensure that future vaccination mandates are not covered in the same way the HPV vaccination was, public health officials, health care providers and scientists should work effectively with the media to ensure that balanced information is provided.^

Findings of the University of Texas Health Science Center at San Antonio's Dental School pilot mobile van program in Laredo, Texas

Lack of access to oral health care frequently affects those of lower socio-economic level; individuals in this group experience more dental decay, and the caries experience is more likely to be untreated. Inadequate dental care access may be attributed to exclusion that is due to income, geography, age, race or ethnicity. Objective: The present study aims were to: (1) determine how oral disease prevalence and access to dental services in four US-Mexico Border unincorporated low socioeconomic settlements identified as colonias compare to each other and Laredo, Texas, and (2) determine if insurance status affects dental care access and/or disease prevalence. Methods: A secondary analysis of data from a retrospective chart review of 672 patients attending a Mobile Dental Van Program in the Webb County colonias. Demographic information, (ethnicity, age, gender, insurance coverage and colonia site), dental visits within past year, insurance status, presence of dental sealants, prevalence of untreated dental decay (caries), and presence of gum disease (gingivitis and periodontitis) were extracted. Pearson's chi-square tests (χ2) were computed to compare the prevalence of these outcomes between colonias and Laredo and their potential association with insurance status. Results: For 6 - 11 year olds, dental visits in the past year were lower for colonias (39%), than Laredo (58.5%) (p<0.002). Caries prevalence was higher for colonias (56.6%), than Laredo (37.1%) (p<0.001). Gum disease prevalence was higher in colonias (73%), than in Laredo (21.4%) (p<0.001). No significant differences were noted for caries (χ2=1.73; p<0.188) and gum disease (χ2=0.0098; p<0.921) by patient's insurance status. For adults 36 - 64 years of age, dental visits in the past year were lower in colonias (22.4%), than Laredo (36.3%) (p<0.001). Caries prevalence was higher for colonias (78.3%), than Laredo (54.0%) (p<0.001). Gum disease prevalence was also higher among colonias (91.3%) than Laredo (61.3%) (p<0.001). No significant differences were noted for caries (χ2=0.0010; p<0.975) and gum disease (χ2=0.0607; p<0.805) by patient's insurance status. Conclusion: Colonia residents seeking dental care at a Mobile Dental Van Program in Webb County have significantly higher prevalence of oral disease regardless of insurance status.^

Parental acculturation and adolescent HPV uptake among Hispanics: Results from the California Health Interview Survey

Background. The Centers for Disease Control and Prevention (CDC), the American Cancer Society (ACS), and the American College of Obstetricians and Gynecologists (ACOG) all recommend the HPV vaccine for girls 11-12. The vaccine has the potential to reduce cervical cancer disparities if it is used by populations that do not participate in screening. Evidence suggests that incidence and mortality are higher among Hispanic women compared to non-Hispanic white women because they do not participate in screening. Past literature has found that acculturation has a mixed effect on cervical cancer screening and immunization. Little is known about whether parental acculturation is associated with adolescent HPV vaccine uptake among Hispanics and the mechanisms through which acculturation may affect vaccine uptake.^ Aims. To examine the association between parental acculturation and adolescent HPV uptake among Hispanics in California and test the structural hypothesis of acculturation by determining if socioeconomic status (SES) and health care access mediate the association between acculturation and HPV vaccine uptake.^ Methods. Cross-sectional data from the 2007 California Health Interview Survey (CHIS) were used for bivariate and multivariate logistic regression analyses. The sample used for analysis included 1,090 Hispanic parents, with a daughter age 11-17, who answered questions about the HPV vaccine. Outcome variable of interest was HPV vaccine uptake (≥1dose). Independent variables of interest were language spoken at home (a proxy variable for acculturation), household income (percent of federal poverty level), education level, and health care access (combined measure of health insurance coverage and usual source of care).^ Results. Parents who spoke only English or English and Spanish in the home were more likely to get the HPV vaccine for their daughter than parents who only spoke Spanish (Odds Ratio [OR]: 0.55, 95% Confidence Interval [CI]: 0.31-0.98). When SES and health care access variables were added to the logistic regression model, the association between language acculturation and HPV vaccine uptake became non-significant (OR: 0.68, 95% CI: 0.35-1.29). Both income and health care access were associated with uptake. Parents with lower income or who did not have insurance and a usual source of care were less likely to have a vaccinated daughter.^ Discussion. Socioeconomic status and health care access have a more proximal effect on HPV vaccine uptake than parental language acculturation among Hispanics in California.^ Conclusion. This study found support for the structural hypothesis of acculturation and suggest that interventions focus on informing low SES parents who lack access to health care about programs that provide free HPV vaccines.^

HPV vaccine coverage in Texas counties: An application of multilevel, small area estimation

Health departments, research institutions, policy-makers, and healthcare providers are often interested in knowing the health status of their clients/constituents. Without the resources, financially or administratively, to go out into the community and conduct health assessments directly, these entities frequently rely on data from population-based surveys to supply the information they need. Unfortunately, these surveys are ill-equipped for the job due to sample size and privacy concerns. Small area estimation (SAE) techniques have excellent potential in such circumstances, but have been underutilized in public health due to lack of awareness and confidence in applying its methods. The goal of this research is to make model-based SAE accessible to a broad readership using clear, example-based learning. Specifically, we applied the principles of multilevel, unit-level SAE to describe the geographic distribution of HPV vaccine coverage among females aged 11-26 in Texas.^ Multilevel (3 level: individual, county, public health region) random-intercept logit models of HPV vaccination (receipt of ≥ 1 dose Gardasil® ) were fit to data from the 2008 Behavioral Risk Factor Surveillance System (outcome and level 1 covariates) and a number of secondary sources (group-level covariates). Sampling weights were scaled (level 1) or constructed (levels 2 & 3), and incorporated at every level. Using the regression coefficients (and standard errors) from the final models, I simulated 10,000 datasets for each regression coefficient from the normal distribution and applied them to the logit model to estimate HPV vaccine coverage in each county and respective demographic subgroup. For simplicity, I only provide coverage estimates (and 95% confidence intervals) for counties.^ County-level coverage among females aged 11-17 varied from 6.8-29.0%. For females aged 18-26, coverage varied from 1.9%-23.8%. Aggregated to the state level, these values translate to indirect state estimates of 15.5% and 11.4%, respectively; both of which fall within the confidence intervals for the direct estimates of HPV vaccine coverage in Texas (Females 11-17: 17.7%, 95% CI: 13.6, 21.9; Females 18-26: 12.0%, 95% CI: 6.2, 17.7).^ Small area estimation has great potential for informing policy, program development and evaluation, and the provision of health services. Harnessing the flexibility of multilevel, unit-level SAE to estimate HPV vaccine coverage among females aged 11-26 in Texas counties, I have provided (1) practical guidance on how to conceptualize and conduct modelbased SAE, (2) a robust framework that can be applied to other health outcomes or geographic levels of aggregation, and (3) HPV vaccine coverage data that may inform the development of health education programs, the provision of health services, the planning of additional research studies, and the creation of local health policies.^