Hospital and environmental variation in Texas nonprofit hospital organizational policies regarding charity care

The 2005 Annual Statement of Community Benefits Standard (ASCBS) and the annual report of the Community Benefits Plan, Summary of Current Hospital Charity Care Policy and Community Benefits, were used to identify various environmental and policy relationships with regard to eligibility for charity care requirements, a component for meeting the nonprofit requirements established by the Texas Legislature for nonprofit tax exemption (Texas Health and Safety Code, §311.04610). ^ Charity care policies are established by the individual hospital (or systems) and are generally defined as rules concerning care provided by the institution without the expectation of payment. This study has been undertaken to provide specific information about the charity care eligibility requirement policies of nonprofit hospitals. These hospitals are the part of the safety net for those persons who are indigent, low-income and uninsured. This study examines nonprofit hospitals by physical location, bed size, religious affiliation, trauma level, disproportionate share, and teaching designations. County information includes population, percentage of residents eligible for Medicaid benefits, ethnic makeup of county residents, poverty level, designation of a hospital district or operators of a public hospital, and the number of nonprofit and for-profit hospitals located in the county. Although this information has been collected by the Texas Department of State Health Services (DSHS), no other analysis has been conducted. ^

An evaluation of the Cypress Creek watershed for inorganic chemical load as it flows into Lake Houston

Background. The Cypress Creek is one of the main tributaries of Lake Houston, which provides drinking water to 21.4 million customers. Furthermore, the watershed is being utilized for contact and non-contact recreation, such as canoeing, swimming, hiking trail, and picnics. Water along the creek is impacted by numerous wastewater outfalls from both point and non-point sources. As the creek flows into Lake Houston, it carries both organic and inorganic contaminants that may affect the drinking water quality of this important water source reservoir. Objective. This study was carried out to evaluate the inorganic chemical load of the water in Cypress Creek along its entire length, from the headwaters in Waller County and up to the drainage into Lake Houston. The purpose was to determine whether there are hazardous concentrations of metals in the water and what would be the likely sources. Method. Samples were collected at 29 sites along the creek and analyzed for 29 metals, 17 of which were on the Environmental Protection Agency priority pollution list. Public access sites primarily at bridges were used for sample collection. Samples were transported on ice to the University Of Texas School Of Public Health laboratory, spiked with 2 ml HNO3 kept overnight in the refrigerator, and the following day transported to the EPA laboratory for analysis. Analysis was done by EPA Method 200.7-ICP, Method 200.8ICP/MS and Method 245.1-CVAAS. Results. Metals were present above the detection limits at 65% of sites. Concentrations of aluminum, iron, sodium, potassium, magnesium, and calcium, were particularly high at all sites. Aluminum, sodium, and iron concentrations greatly exceeded the EPA secondary drinking water standards at all sites. ^ Conclusion. The recreational water along Cypress Creek is impacted by wastewater from both permitted and non-permitted outfalls, which deposit inorganic substances into the water. Although a number of inorganic contaminants were present in the water, toxic metals regulated by the EPA were mostly below the recommended limits. However, high concentrations of aluminum, sodium, and iron in the Cypress Creek bring forward the issue of unauthorized discharges of salt water from mining, as well as industrial and domestic wastewater.^

Environmental influences on self-reported leisure-time physical activity in the Austin/Travis County STEPS survey 2005--2009

This study was an examination of environmental and social correlates of physical inactivity in a socio-economically disadvantaged community. This study was a secondary analysis of data collected by the Austin/Travis County Department of Health and Human Services. The study included an analysis of perceived environmental influences (e.g. access to physical support features like sidewalks and streetlights). This study also investigated several features of the social environment (e.g. perceived neighborhood crime and social influence). Participants’ beliefs and attitudes about the neighborhood were investigated. Results included estimates of the association between neighborhood factors and physical inactivity controlling for age, gender and education. This study found significant associations for social and environmental variables with physical inactivity. The goal of this work was to identify factors that contribute to inactivity and address a number of environmental and neighborhood risk factors that contribute to sedentary behaviors in a population of relative social and economic disadvantage.^

Health significance of chlorination byproducts in drinking water: The Houston experience: A continuation study

Background. Houston, Texas, once obtained all its drinking water from underground sources. However, in 1853, the city began supplementing its water from the surface source Lake Houston. This created differences in the exposure to disinfection byproducts (DBPs) in different parts of Houston. Trihalomethanes (THMs) are the most common DBP and are useful indicators of DBPs in treated drinking water. This study examines the relationship between THMs in chlorinated drinking water and the incidence of bladder cancer in Houston. ^ Methods. Individual bladder cancer deaths, from 1975 to 2004, were assigned to four surface water exposure areas in Houston utilizing census tracts—area A used groundwater the longest, area B used treated lake water the longest, area C used treated lake water the second longest, and area D used a combination of groundwater and treated lake water. Within each surface water exposure area mortality rates were calculated in 5 year intervals by four race-gender categories. Linear regression models were fitted to the bladder cancer mortality rates over the entire period of available data (1990–2004). ^ Results. A decrease in bladder cancer mortality was observed amongst white males in area B (p = 0.030), white females in area A (p = 0.008), non-white males in area D (p = 0.003), and non-white females in areas A and B (p = 0.002 & 0.001). Bladder cancer mortality differed by race-gender and time (p ≤ 0.001 & p ≤ 0.001), but not by surface water exposure area (p = 0.876). ^ Conclusion. The relationship between bladder cancer mortality and the four surface water exposure areas (signifying THM exposure) was insignificant. This result could be attributable to Houston controlling for THMs starting in the early 1980’s by using chloramine as a secondary disinfectant in the drinking water purification process.^

Integrated pest management in multi-story public housing for the elderly in Houston, Texas

Integrated pest management is a viable alternative to traditional pest control methods. A paired sample design was utilized to measure the effect of IPM education on the number of cockroaches in a 200 unit, seven story public housing building for the elderly in Houston, TX. Glue traps were placed in 71 randomly selected apartments (5traps/unit) and left in place for two nights. Baseline cockroach counts were shared with the property manager, maintenance/janitorial staff, service coordinator, pest control professional and tenant representatives at the end of a one day “Integrated Pest Management in Multi-Family Housing” training course.^ There was a significant decrease in the average number of cockroaches after IPM education and implementation of IPM principles (P < 0.0003). Positive changes in behavior by members of the IPM team and changes in the housing authority operational plan were also found. Paired t-tests comparing the difference between mean cockroach counts at baseline and follow-up by location within the apartment all demonstrated a significant decrease in the number of cockroaches.^ Results supported the premise that IPM education and the implementation of IPM principles are effective measures to change pest control behaviors and control cockroaches. Cockroach infestations in multi-story housing are not solely determined by the actions of individual tenants. The actions of other residents, property managers and pest control professionals are also important factors in pest control.^ Findings support the implementation of IPM education and the adoption of IPM practices by public housing authorities. This study adds to existing evidence that clear communication of policies, a team approach and a commitment to ongoing inspection and monitoring of pests combined with corrective action to eliminate food, water and harborage and the judicial use of low risk pesticides have the potential to improve the living conditions of elderly residents living in public housing.^

The relationship between enterotoxigenic {\it Escherichia coli\/} infection and environmental risk factors in Bilbeis, Egypt, 1981--1983

Diarrheal disease associated with enterotoxigenic Escherichia coli (ETEC) infection is one of the major public health problems in many developing countries, especially in infants and young children. Because tests suitable for field laboratories have been developed only relatively recently, the literature on the environmental risk factors associated with ETEC is not as complete as for many other pathogens or for diarrhea of unspecified etiology.^ Data from a diarrheal disease surveillance project in rural Egypt in which stool samples were tested for a variety of pathogens, and in which an environmental questionnaire was completed for the same study households, provided an opportunity to test for an association between ETEC and various risk factors present in those households. ETEC laboratory-positive specimens were compared with ETEC laboratory-negative specimens for both symptomatic and asymptomatic children less than three years of age at the individual and household level using a case-comparison design.^ Individual children more likely to have LT infection were those who lived in HHs that had cooked food stored for subsequent consumption at the time of the visit, where caretakers used water but not soap to clean an infant after a diarrheal stool, and that had an indoor, private water source. LT was more common in HHs where the caretaker did not clean an infant with soap after a diarrheal stool, and where a sleeping infant was not covered with a net. At both the individual and HH level, LT was significantly associated with good water supply in terms of quantity and storage.^ ST was isolated more frequently at the individual level where a sleeping infant was covered with a net, where large animals were kept in or around the house, where water was always available and was not potable, and where the water container was not covered. At the HH level, the absence of a toilet or latrine and the indiscriminate disposal of animal waste decreased risk. Using animal feces for fertilizer, the presence of large animals, and poor water quality were associated with ST at both the individual and HH level.^ These findings are mostly consistent with those of other studies, and/or are biologically plausible, with the obvious exception of those from this study where poorer water supplies are associated with less infection, at least in the case of LT. More direct observation of how animal ownership and feces disposal relates to different types of water supply and usage might clarify mechanisms through which some ETEC infection could be prevented in similar settings. ^

Measurement of isotopic uranium in water for compliance monitoring by liquid scintillation counting with alpha/beta discrimination

A simple and inexpensive method is described for analysis of uranium (U) activity and mass in water by liquid scintillation counting using $\alpha$/$\beta$ discrimination. This method appears to offer a solution to the need for an inexpensive protocol for monitoring U activity and mass simultaneously and an alternative to the potential inaccuracy involved when depending on the mass-to-activity conversion factor or activity screen.^ U is extracted virtually quantitatively into 20 ml extractive scintillator from a 1-$\ell$ aliquot of water acidified to less than pH 2. After phase separation, the sample is counted for a 20-minute screening count with a minimum detection level of 0.27 pCi $\ell\sp{-1}$. $\alpha$-particle emissions from the extracted U are counted with close to 100% efficiency with a Beckman LS6000 LL liquid scintillation counter equipped with pulse-shape discrimination electronics. Samples with activities higher than 10 pCi $\ell\sp-1$ are recounted for 500-1000 minutes for isotopic analysis. Isotopic analysis uses events that are automatically stored in spectral files and transferred to a computer during assay. The data can be transferred to a commercially available spreadsheet and retrieved for examination or data manipulation. Values for three readily observable spectral features can be rapidly identified by data examination and substituted into a simple formula to obtain $\sp{234}$U/$\sp{238}$U ratio for most samples. U mass is calculated by substituting the isotopic ratio value into a simple equation.^ The utility of this method for the proposed compliance monitoring of U in public drinking water supplies was field tested with a survey of drinking water from Texas supplies that had previously been known to contain elevated levels of gross $\alpha$ activity. U concentrations in 32 samples from 27 drinking water supplies ranged from 0.26 to 65.5 pCi $\ell\sp{-1}$, with seven samples exceeding the proposed Maximum Contaminant Level of 20 $\mu$g $\ell\sp{-1}$. Four exceeded the proposed activity screening level of 30 pCi $\ell\sp{-1}$. Isotopic ratios ranged from 0.87 to 41.8, while one sample contained $\sp{234}$U activity of 34.6 pCi $\ell\sp{-1}$ in the complete absence of its parent, $\sp{238}$U. U mass in the samples with elevated activity ranged from 0.0 to 103 $\mu$g $\ell\sp{-1}$. A limited test of screening surface and groundwaters for contamination by U from waste sites and natural processes was also successful. ^

FEASIBILITY OF CORRELATING INCIDENCE OF DIARRHEA WITH CHARACTERISTICS OF RURAL EGYPTIAN HOUSEHOLDS BY MEANS OF AN ENVIRONMENTAL SURVEY

Few, if any studies, have attempted to identify the specific environmental factors associated with the incidence of diarrheal disease and to rank these by their contribution to the total incidence of diarrheal illness. Potentially those factors with the greatest contribution are the variables on which intervention could be expected to have the greatest impact on the incidence of diarrhea.^ In 317 rural Egyptian households participating in a longitudinal study of diarrheal disease, selected environmental characteristics were observed and recorded on a questionnaire. Characteristics of the environment were classified into seven categories including water usage, proximity of animals to the house, waste management, food preparation area, toilet area, the household structure and hygiene. The variables from each of the seven major groupings most associated with the incidence of diarrhea in infants were selected through the application of stepwise multiple regression. Each area was then ranked by the portion of the incidence of diarrhea in infants that each composite group of area-specific variables alone would explain. The groups of household structure and water usage variables were found to be more associated with the incidence of diarrhea in infants than variables describing the toilet area, proximity to animals or others. It was also found that 24.7% of the total variance in incidence of diarrheal illness was explained by environmental variables. ^

SOCIO-ENVIRONMENTAL FACTORS ASSOCIATED WITH THE DISTRIBUTION OF DRACUNCULUS MEDINENSIS (GUINEA WORM DISEASE) AND SUGGESTED METHODS FOR CONTROL, IBARAPA, NIGERIA, 1982 (AFRICA)

A population-based cross-sectional survey of socio-environmental factors associated with the prevalence of Dracunculus medinensis (guinea worm disease) was conducted in Idere, a rural agricultural community in Ibarapa, Oyo state, Nigeria, during 1982.^ The epidemiologic data were collected by household interview of all 501 households. The environmental data were collected by analysis of water samples collected from all domestic water sources and rainfall records.^ The specific objectives of this research were to: (a) Describe the prevalence of guinea worm disease in Idere during 1982 by age, sex, area of residence, drinking water source, religion and weekly amount of money spent by the household to collect potable drinking water. (b) Compare the characteristics of cases with non-cases of guinea worm in order to identify factors associated with high risk of infection. (c) Investigate domestic water sources for the distribution of Cyclops. (d) Determine the extent of potable water shortage with a view to identifying factors responsible for such shortage in the community. (e) Describe the effects of guinea worm on school attendance during 1980/1982 school years by class and location of school from piped water supply.^ The findings of this research indicate that during 1982, 31.8 percent of Idere's 6,527 residents experienced guinea worm infection, with higher prevalence of infection recorded in males in their most productive years and females in their teenage years. The role of sex and age to risk of higher infection rate was explained in the context of water related exposure and water intake due to dehydration from physical occupational actitives of subgroups.^ Potable water available to residents was considerably below the minimum recommended by WHO for tropical climates, with sixty-eight percent of water needs of the residents coming from unprotected surface water which harbour Cyclops, the obligatory intermediate host of Dracunculus medinensis. An association was found between periods of relative high density of Cyclops in domestic water and rainfall.^ Impact of guinea worm infection on educational activities was considerable and its implications were discussed, including the implications of the research findings in relation to control of guinea worm disease in Ibarapa. ^

ENVIRONMENTAL EXPOSURES AND LUNG CANCER RISK AMONG WOMEN IN HARRIS COUNTY, TEXAS, 1977-1980 (OCCUPATION, SMOKING, BYSTANDER)

Excessively high, accelerating lung cancer rates among women in Harris County, Texas, prompted this case-comparison study. Objectives were to compare patterns of employment, indirect exposures, and sociodemographic variables of lung cancer cases with comparison subjects (compeers) after standardizing for possible confounders, such as age and cigarette smoking. Lung cancer cases were microscopically confirmed, white, Harris County residents. Compeers, chosen from Medicare records and Texas Department of Public Safety records, were matched on gender, race, age, resident and vital status. Personal interviews were conducted with study subjects or next-of-kin. Industries and occupations were categorized as high risk, based on previous studies.^ Almost all cases (95.0%) and 60.0% of compeers smoked cigarettes. The odds ratio for lung cancer and smoking is 13.9. Stopping smoking between ages 30-50 years carries a lower risk than stopping at age 58 or more years. Women's employment in a high risk industry or occupation results in consistently elevated, smoking-adjusted odds ratios. Frequency and duration of employment demonstrate a moderate dose-response effect. A temporal association exists with employment in a high risk occupation during 1940-1949.^ No increased risk appeared with passive smoking. Husband's employment in a construction industry or a structural occupation significantly increased the smoking-adjusted odds ratios among cases and compeers (O.R. = 2.9, 2.2). Smoking-adjusted odds ratios increased significantly when women had resided with persons employed in cement (O.R. = 3.2) or insulation (O.R. = 5.5) manufacturing, or a high rise construction industry (O.R. = 2.4). A family history of lung cancer resulted in a two-fold increase in smoking-adjusted odds ratios. Vital status of compeers affected the odds ratios.^ Work-related exposures appear to increase the risk of lung cancer in women although cigarette smoking has the single highest odds ratio. Indirect exposure to certain employment also plays a significant role in lung cancer in women. Investigations of specific direct and indirect hazardous exposures in the workplace and home are needed. Cigarette smoking is as hazardous for women as for men. Smoking should be prevented and eliminated. ^

The role of environmental tobacco smoke in the development and exacerbation of asthma among children in developing countries: A systematic review

Environmental tobacco smoke (ETS) is an important indoor air pollutant associated with adverse effects on the respiratory health of the general population, especially people with asthma. ETS consists mainly of sidestream smoke from burning cigarettes and a smaller quantity of mainstream smoke which is exhaled by the smoker. At least one out of every three children is frequently exposed to ETS. ^ This paper reviewed the literature for studies on the role of ETS in the development and exacerbation of asthma among children in developing countries, specifically the low and middle income countries from the year 1980 to the present. The databases searched in this systematic review were: Ovid Medline; PubMed (National Library of Medicine); and Cumulative Index to Nursing and Allied Health (CINAHL) (EBSCOhost). Out of a total of 197 articles initially identified, only four studies (two from China, one from Macedonia and one from Brazil) were rated by two independent raters as being of high quality, and were selected for final abstraction, synthesis and evidence weighting. Results from these four studies suggests that, in developing countries, ETS exposure is associated with childhood asthma, and that asthma prevalence increases with an increase in the amount and duration of exposure to ETS. Similarly, exposure to ETS is associated with persistent cough, current night dry cough, and exacerbation of asthma symptoms. ^ Therefore, as is the case in developed nations, there is suggestive evidence in the literature that ETS exposure plays substantial role in the development and/or exacerbation of asthma among children in developing countries. To decrease the likelihood of new asthma development, enhance asthma control, and reduce the rate of medical service utilization in children exposed to ETS, smoking should be eliminated at home and in public places.^

The success of worksite nutrition and physical activity interventions with environmental modifications A systematic review

Background: As obesity increases among U.S. workers, employers are implementing programs to increase physical activity and improve diets. Although programs to address individual determinants of obesity have been evaluated, less is known about the effects of workplace programs that change environmental factors, because most reviews have not isolated environmental programs; the one that did was published in 2005. ^ Objective: To update the 2005 review to determine the effectiveness of workplace environmental interventions. ^ Methods: The Medline database was searched for published English language reports (2003-2011) of randomized controlled (RCTs) or quasi-experimental trials (NRCTs) that evaluated strategies to modify physical activity opportunities or food services, targeting employees at least 18 years, not including retirees and that provided data for at least one physical activity, dietary, or health risk indicator. Three coders independently extracted study characteristics and scored the quality of study methods. Program effectiveness was determined using the 2005 review's best evidence approach. ^ Results: Seven studies represented in nine reports met eligibility criteria; three focused on diet and the remainder targeted diet and physical activity interventions. All but one study received a high quality score for internal validity. The evidence for the effectiveness of workplace environmental interventions was at best, inconclusive for diet and physical activity and limited for health risk indicators. The outcome constructs were inconsistent across the studies. ^ Conclusions: Limitations in the methods of the 2005 review made it challenging to draw conclusions about findings for this review that include: variation in outcome measures, reliance on distal measures without proximal behavior change measures, no distinction between changes at the workplace versus outside the workplace, and inappropriate analyses of cluster designs that biased findings toward statistical significance. The best evidence approach relied on vote-counting, using statistical significance alone rather than effect size and confidence intervals. Future research should address these limitations and use more rigorous methods; systematic reviews should use methods of meta-analysis to summarize study findings. These recommendations will help employers to better understand how environmental modifications in the workplace can support their efforts to combat the effects of obesity among employees.^

Baseline evaluation of environmental physical activity and nutrition support of Texas Medical Center hospital worksites

Background: Obesity is a major health problem in the United States that has reached epidemic proportions. With most U.S adults spending the majority of their waking hours at work, the influence of the workplace environment on obesity is gaining in importance. Recent research implicates worksites as providing an 'obesogenic' environment as they encourage overeating and reduce the opportunity for physical activity. Objective: The aim of this study is to describe the nutrition and physical activity environment of Texas Medical Center (TMC) hospitals participating in the Shape Up Houston evaluation study to develop a scoring system to quantify the environmental data collected using the Environmental Assessment Tool (EAT) survey and to assess the inter-observer reliability of using the EAT survey. Methods: A survey instrument that was adapted from the Environmental Assessment Tool (EAT) developed by Dejoy DM et al in 2008 to measure the hospital environmental support for nutrition and physical activity was used for this study. The inter-observer reliability of using the EAT survey was measured and total percent agreement scores were computed. Most responses on the EAT survey are dichotomous (Yes and No) and these responses were coded with a '0' for a 'no' response and a '1' for a 'yes' response. A summative scoring system was developed to quantify these responses. Each hospital was given a score for each scale and subscale on the EAT survey in addition to a total score. All analyses were conducted using Stata 11 software. Results: High inter-observer reliability is observed using EAT. The percentage agreement scores ranged from 94.4%–100%. Only 2 of the 5 hospitals had a fitness facility onsite and scores for exercise programs and outdoor facilities available for hospital employees ranged from 0–62% and 0–37.5%, respectively. The healthy eating percentage for hospital cafeterias range from 42%–92% across the different hospitals while the healthy vending scores were 0%–40%. The total TMC 'healthy hospital' score was 49%. Conclusion: The EAT survey is a reliable instrument for measuring the physical activity and nutrition support environment of hospital worksites. The study results showed a large variability among the TMC hospitals in the existing physical activity and nutrition support environment. This study proposes cost effective policy changes that can increase environmental support to healthy eating and active living among TMC hospital employees.^