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PubMed1991

Small area analysis shows differences in utilization.

Adjusted admission rates for respiratory distress (COPD, asthma, bronchitis, and pneumonia) varied up to 3.09-fold between the highest and lowest hospital market areas in 1986 for the state of Ohio. Reasons for the variability can be determined through small area analysis techniques with the help of area physicians. Substantial improvements in the availability, delivery, and cost of respiratory care would reasonably be anticipated as a result of such analysis and feedback.

Aged↗
PubMed1994

A small area analysis of psychiatric hospitalizations to general hospitals. Effects of community mental health centers.

Population-based psychiatric admission rates vary across geographic areas, but reasons for this variation are unknown. Insofar as Community Mental Health Centers (CMHCs) provide outpatient services that may deter the need for hospitalization, the presence and structural characteristics of CMHCs may have an impact on a population's psychiatric admission rates. This study uses small area analysis to examine how general hospital psychiatric admission rates are associated with CMHC characteristics. Based on a survey of all CMHCs in Iowa and corresponding small area variation data, it was found that population admission rates were higher in areas closer to the CMHC and lower in outlying catchment areas, adjusting for age, sex, and urban/rural differences in populations. There was little evidence that differences in staffing and service variables influenced admission rates, although greater CMHC staff coverage by social workers and psychiatric residents was associated with lower admission rates. The results suggest that CMHCs do not lower an area's hospitalization rate, and in fact, the presence of CMHCs may promote a "supplier-induced demand" phenomenon of higher admissions.

Community Mental Health Centers↗
PubMed1998

Objective scaling of facial nerve function based on area analysis (OSCAR).

An objective scaling of facial nerve function based on area analysis (OSCAR) was developed using the variations of luminance produced by changes of facial expression. The presented method of scaling facial motions has the advantage of being continuous, objective, and reproducible. It is fast and simple to use.

Adult↗
PubMed1994

Low-income neighborhoods and the risk of severe pediatric injury: a small-area analysis in northern Manhattan.

OBJECTIVES: The purpose of this study was to investigate the relationship between socioeconomic disadvantage and the incidence of severe childhood injury. METHODS: Small-area analysis was used to examine socioeconomic risk factors for pediatric injury resulting in hospitalization or death in Northern Manhattan, New York, NY, during a 9-year period (1983 through 1991). RESULTS: The average annual incidence of all causes of severe pediatric injury was 72.5 per 10,000 children; the case-fatality rate was 2.6%. Census tract proportions of low-income households, single-parent families, non-high school graduates, and unemployment were significant predictors of risk for both unintentional and intentional injury. Among the socioeconomic factors considered, low income was the single most important predictor of all injuries; other socioeconomic variables were not independent contributors once income was included in the model. Compared with children living in areas with few low-income households, children in areas with predominantly low-income households were more than twice as likely to receive injuries from all causes and four and one half times as likely to receive assault injuries. The effect of neighborhood income disparities on injury risk persisted after race was controlled. CONCLUSIONS: These results illuminate the impact of socioeconomic disparities on child health and point to the need for injury prevention efforts targeting low-income neighborhoods.

Adolescent↗
PubMed1995

Poverty, race, and medication use are correlates of asthma hospitalization rates. A small area analysis in Boston.

Hospitalization rates for asthma in New York City are highest in poor urban neighborhoods, although the reasons for this are unknown. We performed a small area analysis of asthma hospitalization rates in Boston, to determine whether this pattern of asthma hospitalization also obtained in a medium-sized city and to identify characteristics of neighborhoods with high hospitalization rates, including the relative use of inhaled anti-inflammatory medication. Zip codes were used to define 22 small areas within Boston. The number of asthma hospitalizations for residents of each area in 1992 was obtained from the Codman Research Group. Population and demographic characteristics of each area were obtained from the 1990 US Census. Estimates of inhaled asthma medications (beta-agonists, steroids, and cromolyn) dispensed in each area in 1992 were obtained from IMS America. Asthma hospitalization rates for each of the six areas with the highest rates (5.3 to 9.8 per 1,000 persons) were significantly greater than the city-wide average of 4.2 hospitalizations per thousand persons (p < 0.001 for each comparison). Asthma hospitalization rate was positively correlated with poverty rate and with the proportion of nonwhite residents and inversely correlated with income and educational attainment. Asthma hospitalization rate was inversely correlated with the ratio of inhaled anti-inflammatory to beta-agonist medication use (r = -0.55, p = 0.008). We conclude that asthma hospitalization rates in Boston are highest in poor inner city neighborhoods, and that these high rates affect both genders and all age groups. Underuse of inhaled anti-inflammatory medication may be one of the many factors that contributes to this excess hospitalization.

Adolescent↗
PubMed1992

Problems in the interpretation of small area analysis of epidemiological data: the case of cancer incidence in the West of Scotland.

STUDY OBJECTIVE: The aim was to examine the extent to which random variation alone will produce differences in observed incidence rates between small areas which will affect measures of spatial clustering and estimates of relative risk. DESIGN: This was a study of changes in the pattern of spatial concentration of cancer incidence over a five year time period. A comparison was made of observed incidence rates for 34 tumour sites with randomly generated values and, where possible, with expected values derived from known relative risks. SETTING: Twenty six local government districts in the West of Scotland. MAIN RESULTS: A statistically significant relationship was observed between sample size and the stability of a summary measure of spatial concentration. Almost all observed highest:mean rate ratios were within the 95% confidence interval of the simulated distribution of these values. In three cases examined, both observed and simulated highest:lowest rate ratios were larger than those expected on the basis of known exposures to risk. CONCLUSIONS: In the absence of a prior hypothesis, small area analysis of epidemiological data for periods of less than 10 years will almost always give misleading results for all but the most common diseases.

Analysis of Variance↗
PubMed1994

Constructing regions for small area analysis: material deprivation and colorectal cancer.

BACKGROUND: This paper is about constructing small areas for the analysis of health data with the aims of health service delivery in mind. The areal framework should enable the analyst to link health data and census data and the areas should have large enough populations to ensure that rates are reliable and be homogeneous with respect to important socio-economic attributes. METHODS: An information-based statistic is used for the construction of regions in Sheffield based on the Townsend deprivation index. Enumeration districts are used as the geographical building blocks for the regions. The new regional framework is used for computing Bayes adjusted standardized incidence rates for colorectal cancer (CRC) across Sheffield. The paper then examines the statistical relationship between CRC incidence and deprivation across the set of regions using bivariate regression. RESULTS: The method yields regions that are considerably more homogeneous in terms of deprivation than wards, and using this framework it is shown that there is a (weak) statistical association at the regional scale between deprivation and CRC. CONCLUSION: We conclude that statistical tools can be employed to provide regions that meet the criteria for small area analysis of health data and the analyst does not have to be tied to large administrative units such as wards. There are some benefits to executing this work within a Geographic Informative System. The method should be of interest to those concerned with health service delivery and the identification of 'problem regions'.

Bayes Theorem↗
PubMed2004

Comparison of small-area analysis techniques for estimating county-level outcomes.

BACKGROUND: Since many health data are unavailable at the county level, policymakers sometimes rely on state-level datasets to understand the health needs of their communities. This can be accomplished using small-area estimation techniques. However, it is unknown which small- area technique produces the most valid and precise results. METHODS: The reliability and accuracy of three methods used in small-area analyses were examined, including the synthetic method, spatial smoothing, and regression. To do this, severe work disability measures were first validated by comparing the 2000 Behavioral Risk Factor Surveillance System (BRFSS) and Census 2000 measures (used as the gold standard). The three small-area analysis methods were then applied to 2000 BRFSS data to examine how well each technique predicted county-level disability prevalence. RESULTS: The regression method produces the most valid and precise estimates of county-level disability prevalence over a large number of counties when a single year of data is used. CONCLUSIONS: Local health departments and policymakers who need to track trends in behavioral risk factors and health status within their counties should utilize the regression method unless their county is large enough for direct estimation of the outcome of interest.

Adolescent↗
PubMed1997

The internal burden of lead among children in a smelter town--a small area analysis.

Hettstedt, a city in former East Germany with a history of mining and smelting of nonferrous ores, has multiple lead waste deposits and the remains of a former lead and copper-silver smelter. A small-area analysis of lead concentrations in blood and in household dust was undertaken in a cross-sectional study to determine if children living near the sources had particularly high burdens of lead. The overall geometric mean of the region was 38.0 micrograms Pb/liter blood with a 95% confidence interval (CI) of 36.5-39.5. The burden of lead among children living in the region containing the lead tailings piles and adjacent smelters was almost twice as high (77.4 micrograms Pb/liter blood; 95% CI 65.0-92.0). It decreased in the areas farther northeast from the smelter. Lead levels in the children residing in areas southwest of the smelters were not appreciably elevated. The same pattern was found in house dust lead concentrations. This analysis helped target areas where follow-up is needed and found that not only distance from lead sources, but also meteorological factors played an important role in lead exposure.

Adolescent↗
PubMed2006

Higher incidence of childhood-onset type 1 diabetes mellitus in remote areas: a UK regional small-area analysis.

AIMS/HYPOTHESIS: We investigated the association between the incidence of type 1 diabetes mellitus and remoteness (a proxy measure for exposure to infections) using recently developed techniques for statistical analysis of small-area data. SUBJECTS, MATERIALS AND METHODS: New cases in children aged 0 to 14 years in Northern Ireland were prospectively registered from 1989 to 2003. Ecological analysis was conducted using small geographical units (582 electoral wards) and area characteristics including remoteness, deprivation and child population density. Analysis was conducted using Poisson regression models and Bayesian hierarchical models to allow for spatially correlated risks that were potentially caused by unmeasured explanatory variables. RESULTS: In Northern Ireland between 1989 and 2003, there were 1,433 new cases of type 1 diabetes, giving a directly standardised incidence rate of 24.7 per 100,000 person-years. Areas in the most remote fifth of all areas had a significantly (p=0.0006) higher incidence of type 1 diabetes mellitus (incidence rate ratio=1.27 [95% CI 1.07, 1.50]) than those in the most accessible fifth of all areas. There was also a higher incidence rate in areas that were less deprived (p<0.0001) and less densely populated (p=0.002). After adjustment for deprivation and additional adjustment for child population density the association between diabetes and remoteness remained significant (p=0.01 and p=0.03, respectively). CONCLUSIONS/INTERPRETATION: In Northern Ireland, there is evidence that remote areas experience higher rates of type 1 diabetes mellitus. This could reflect a reduced or delayed exposure to infections, particularly early in life, in these areas.

Adolescent↗
PubMed1992

Arm pain in the workplace. A small area analysis.

In the mid-1980s, use-related arm pain was recognized as a major issue for worker health and workplace safety. National policy targeted these "cumulative trauma disorders," "overuse syndromes," and "motion illnesses" for a "special emphasis program" by the Occupational Safety and Health Administration, a federal regulatory agency. The program begins with case recognition to identify the responsible ergonomic hazards with the goal of mandating ergonomic remedies. This report is a small area analysis of the impact of this process on the US West Communications, Inc work force. US West employs some 55,000 workers in 14 states. Commencing in the mid-1980s, workers in four of these states complained of upper extremity pain and were diagnosed as suffering from conditions encompassed by the "cumulative trauma disorders" rubric. The incidence was tenfold higher in one task category, directory assistance operators. No ergonomic descriptor can account for the four endemics of arm pain in directory assistance operators. The response of the medical communities to the plight of these injured claimants varied considerably from community to community. Denver represents one extreme where the clinical judgments led to multiple surgical interventions, generated a total direct cost of some $1.5 million, and left many permanently disabled workers in their wake. This analysis raises many reservations about the validity of the "cumulative trauma disorder" hypothesis and provides an object lesson in the potential for untoward outcomes from the premature introduction of clinical hypotheses into the arena of health policy.

Adult↗
PubMed1986

A primer on small area analysis.

As hospitals become more accountable to purchasers and consumers, they will need to be more responsive to legitimate questions about hospital use, costs, and quality. Small area analysis, because of its simplicity and ease of understanding, will be at the center of many of these discussions.

Catchment Area, Health↗
PubMed1977

Social area analysis in community medicine.

There is an acknowledged need for better information to guide resource allocation and service planning in the health services. Despite the recognition of the important role of socioeconomic factors, difficulties with the appropriate presentation of daya have so far proved insuperable. Social area analysis (SAA), which is a generic name for a number of methods employing census and other data to classify small areas into similar socioeconomic groups, is an approach which quantifies data in a useful fashion and has important applications in medical, epidemiological and health services research. Most previous British exercises in SAA have been in the field of town planning. The potentialities of the approach for community medicine are evaluated, by the use of information from two existing studies. This is shown to discriminate more effectively than does existing health information between hypotheses concerning geographical variations in mortality, and it provides adequate explanations for urban area differentials in infant mortality, the uptake of vaccination, and the incidence of infectious disease. Specific applications of SAA in health planning and research are discussed.

Community Health Services↗
PubMed1998

Race, income, urbanicity, and asthma hospitalization in California: a small area analysis.

STUDY OBJECTIVES: To explicate the interrelationship between asthma hospitalization and race/ethnicity and income. DESIGN: Small area ecologic analysis using census and administrative data. SETTING AND PARTICIPANTS: All asthma hospitalizations in California were identified using the 1993 California Hospital Discharge file. Small area analyses of Los Angeles (LA) were compared with published rates in New York City (NYC). RESULTS: In 1993, the age-adjusted asthma hospitalization rate in California for nonelderly blacks was 42.5/10,000-approximately four times higher than other populations. Black rates remained fourfold higher after stratification by age, income, and urbanicity. Multivariate analyses suggest that the association between black race and asthma hospitalization is independent of income. Regardless of race, children and persons living in poverty were at increased risk for asthma hospitalization. Urbanicity was not a predictor for asthma hospitalization. Overall, asthma hospitalization rates in NYC were 2.8 times higher compared with rates in LA; while rates were similar among blacks (60 vs 40/10,000, respectively), Puerto Rican Hispanics in NYC had dramatically higher rates compared with Mexican Hispanics in LA (63 vs 14/10,000, respectively). CONCLUSIONS: After controlling for socioeconomic status, notable differences in asthma hospitalization by race and ethnicity persist. The reasons for the significantly elevated risk of asthma morbidity among blacks remain unclear.

Adolescent↗
PubMed2004

Homicide risk across race and class: a small-area analysis in Massachusetts and Rhode Island.

Areas with higher absolute poverty and higher income inequality have been associated with higher risk of homicide victimization. In addition, studies of differential homicide rates have indicated that black persons are at a higher risk of homicide compared to white persons. However, few studies directly compared risk of homicide offending or victimization between Hispanic persons and non-Hispanic white persons, and few studies have attempted to examine the interaction between race and residential neighborhood socioeconomic measures on homicide risk. This population-based retrospective study comprised all white, black, and Hispanic 15- to 44-year-old men included in the 1990 US Census as Rhode Island or Massachusetts residents. Vital statistics registries were linked to 1990 US Census data to provide information on small-area characteristics. Overall, we observed a trend of increasing homicide risk as block-group socioeconomic position descended. The data indicated that block-group poverty, female-headed households, home ownership, and higher education were all strongly associated with homicide risk after stratifying by race and age of victim and adjusting for other block-group socioeconomic characteristics. Race was a strong modifier for absolute risk difference for the relation between risk of homicide and socioeconomic surroundings. Our analyses suggested that area-based interventions that would improve neighborhood social and economic conditions would be effective in decreasing risk of homicide for men.

Adolescent↗
PubMedDate not supplied

Toward congruence between theory and practice in small area analysis and local public health data.

Advances in computer hardware, software and database interfaces have provided opportunities for collation, manipulation, analysis and display of spatial data on an unprecedented scale. Demands for small area data in public health, fuelled in part by an increasing emphasis on benchmarking in relation to Year 2000 objectives but also in response to state and federal programmes to involve local communities in the assessment and planning process have simultaneously generated an unprecedented demand for these analyses and data presentations. This paper discusses four areas where geographic, cartographic and statistical theory and methodology need to be brought to bear on the development of applications involving small area health data. These areas are: (i) the theoretical conceptions of space; (ii) managing the inherent variability of rates and frequencies; (iii) attribution of events or cases to areas or to points; and (iv) the application of sound principles of cartographic design to the presentation of results.

Censuses↗
PubMed1999

Asthma prevalence and deprivation: a small area analysis.

STUDY OBJECTIVE: To investigate the relation between the prevalence of asthma symptoms in adults and deprivation in the area of residence. DESIGN: Two complementary surveys carried out between 1991-1993 yielding adult asthma symptom prevalence throughout New Zealand. Deprivation is measured by the NZDep91 index of deprivation for small areas. SETTING: New Zealand. PARTICIPANTS: A random sample of 25,042 adults aged 20-50 years. MAIN RESULTS: After controlling for possible confounding by age, gender, and ethnicity, the 12 month period prevalence rates of asthma in this representative sample of New Zealand adults are significantly higher in the three most deprived area categories than in the least deprived (tenth) category. The prevalence ratio for the most deprived category compared with the least deprived category is 1.29 with 95% confidence intervals (CI) 1.14, 1.47. There is a linear increase in asthma prevalence with increasing area deprivation (chi 2(1) = 32.20, p < 0.001). Independently, the rates are also 1.41 (95% CI 1.29, 1.54) times higher among Maori and 1.29 (95% CI 1.10, 1.52) times higher among the Pacific Island group than among the remaining, mostly European, respondents. CONCLUSIONS: The relation between asthma in adults and area deprivation is unlikely to be attributable to study biases or confounding. Further work should examine the possible role of modifiable deprivation factors in this relation.

Adolescent↗
PubMed1997

Plastic surgery in irradiated areas: analysis of 200 consecutive cases.

Reconstructive surgery in previously irradiated areas is more difficult than in non-irradiated cases. A retrospective analysis of the outcome of 200 previously irradiated patients who had skin graft or flap reconstruction performed by the same surgeon is presented, and the most suitable surgical technique in irradiated areas is discussed. One hundred and fifty-six patients had skin and oral cavity cancer, and were operated on after local recurrence. Twenty patients had breast cancer; 15 were operated on for local recurrence and five for breast reconstruction. Twenty-four patients had soft tissue sarcomas. Eighty-five patients had a skin graft (group 1), 35 had a skin flap (group 2), 10 had a fascia/muscle flap plus skin graft and 70 had a myocutaneous flap (group 3). Analysis of complications revealed statistically significant differences in terms of incomplete graft/flap necrosis between group 1 and 2 (P < 0.001) and groups 1 and 3 (P < 0.001), and in terms of infection between groups 1 and 3 (P < 0.01). We conclude that the method of reconstruction is determined by the characteristics of the defect such as size and localization; the quality, fractionation, total dose, and energy of radiation used; skin and subcutaneous tissue changes due to radiation; and operation time. However, it is reasonable to choose fascia/muscle or myocutaneous flaps for reconstruction in previously irradiated areas. These methods are more resistant to bacterial inoculation, more prone to clean residual infection, and provide better vascularized tissue and volume replacement for contour defects.

Adolescent↗