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PubMed2006

Patient safety in surgery.

BACKGROUND: Improving patient safety is an increasing priority for surgeons and hospitals since sentinel events can be catastrophic for patients, caregivers, and institutions. Patient safety initiatives aimed at creating a safe operating room (OR) culture are increasingly being adopted, but a reliable means of measuring their impact on front-line providers does not exist. METHODS: We developed a surgery-specific safety questionnaire (SAQ) and administered it to 2769 eligible caregivers at 60 hospitals. Survey questions included the appropriateness of handling medical errors, knowledge of reporting systems, and perceptions of safety in the operating room. MANOVA and ANOVA were performed to compare safety results by hospital and by an individual's position in the OR using a composite score. Multilevel confirmatory factor analysis was performed to validate the structure of the scale at the operating room level of analysis. RESULTS: The overall response rate was 77.1% (2135 of 2769), with a range of 57% to 100%. Factor analysis of the survey items demonstrated high face validity and internal consistency (alpha = 0.76). The safety climate scale was robust and internally consistent overall and across positions. Scores varied widely by hospital [MANOVA omnibus F (59, 1910) = 3.85, P < 0.001], but not position [ANOVA F (4, 1910) = 1.64, P = 0.16], surgeon (mean = 73.91), technician (mean = 70.26), anesthesiologist (mean = 71.57), CRNA (mean = 71.03), and nurse (mean = 70.40). The percent of respondents reporting good safety climate in each hospital ranged from 16.3% to 100%. CONCLUSIONS: Safety climate in surgical departments can be validly measured and varies widely among hospitals, providing the opportunity to benchmark performance. Scores on the SAQ can serve to evaluate interventions to improve patient safety.

Analysis of Variance↗
PubMed1999

A multiplicative-epistatic model for analyzing interspecific differences in outcrossing species.

Epistasis may play an important role in evolution and speciation. Under multiplicative interactions between different loci, an analytical model is proposed to estimate genetic parameters at the individual locus level that contribute to interspecific differences in outcrossing species. The multiplicative epistasis model, inferred from a number of animal and plant experiments, suggests that genotypes at a pair of loci have genotypic values equal to the product of genotypic values at the two different loci. By considering the genetic property of outcrossing species (i.e., high polymorphisms) in the multilevel family structure analysis for an intra- and interspecific factorial mating design, a method is developed to provide estimates for allele frequencies and additive and dominant effects at individual loci in each of the two parental populations, the genotypic values of newly formed heterozygotes through species combination each with one allele from a parental population and the second from the other parental population, and the numbers of genetic factors that lead to species differentiation. Use of clones offers a tremendous power to test the adequacy of the model. However, the utilization of the model with species that cannot be cloned is also discussed. An example with interspecific hybrids of two forest tree species is used to demonstrate the model.

Alleles↗
PubMed2004

Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.

AIMS: To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels. METHODS: Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines. RESULTS: Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse. DISCUSSION: More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.

Body Mass Index↗
PubMed2005

The social determinants of oral health: new approaches to conceptualizing and researching complex causal networks.

Oral epidemiological research into the social determinants of oral health has been limited by the absence of a theoretical framework which reflects the complexity of real life social processes and the network of causal pathways between social structure and oral health and disease. In the absence of such a framework, social determinants are treated as isolated risk factors, attributable to the individual, having a direct impact on oral health. There is little sense of how such factors interrelate over time and place and the pathways between the factors and oral health. Features of social life which impact on individuals' oral health but are not reducible to the individual remain under-researched. A conceptual framework informing mainstream epidemiological research into the social determinants of health is applied to oral epidemiology. The framework suggests complex causal pathways between social structure and health via interlinking material, psychosocial and behavioural pathways. Methodological implications for oral epidemiological research informed by the framework, such as the use of multilevel modelling, path analysis and structural equation modelling, combining qualitative and quantitative research methods, and collaborative research, are discussed.

Causality↗
PubMed2002

Contextual influences on reproductive health service use in Uttar Pradesh, India.

This study examines the determinants of the use of four types of reproductive health-care services in Uttar Pradesh, India: contraceptive services, antenatal care, delivery in a medical institution, and services dealing with reproductive tract and sexually transmitted infections. The analysis uses a multilevel modeling strategy to assess the presence of household- and community-level variation in service use. The influence of community-level characteristics and reproductive health-care service attributes on service use is examined. The results highlight strong community-level influences on service use, although the type of community effect varies by service type. The role of some individual and household factors in determining a person's use of services is mediated by the characteristics of the community in which the individual lives. The results demonstrate the need to look beyond individual factors when examining health-care-seeking behavior, and illustrate that there is no singular "community" effect on service use.

Adolescent↗
PubMed2003

Who's dragging their feet? Husbands and wives seeking marital therapy.

Despite its demonstrated efficacy, marital therapy's impact has been limited by couples' general reluctance to seek help until their problems become severe. To understand this delay, 147 married couples (294 individuals) in the process of seeking marital therapy were surveyed. Using multilevel confirmatory factor analysis, three relatively independent steps (problem recognition, treatment consideration, and treatment seeking) were identified. On average, wives were rated as completing all three steps before their husbands. Gender-role orientation, demographics, relationship satisfaction, and specific relationship problems (especially husbands' dissatisfaction with sex) were also predictive of the steps toward therapy. Implications for marital therapy are discussed.

Adult↗
PubMed2005

First line treatment of knee osteoarthritis in outpatients in France: adherence to the EULAR 2000 recommendations and factors influencing adherence.

OBJECTIVES: To document adherence to two parts of the EULAR 2000 recommendations for knee osteoarthritis, concerning non-pharmacological and pharmacological first line management; and to identify factors influencing adherence to the recommendations. METHODS: In a prospective study, 1030 randomly selected French general practitioners completed questionnaires about three unselected outpatients with osteoarthritis, and about their own practice, knowledge, and agreement with the EULAR 2000 recommendations. Percentages of adherence of their prescriptions to both parts of the recommendation were calculated, and probabilities of non-adherence analysed in relation to patient and physician related characteristics, using multilevel logistic regression analysis. RESULTS: Data were obtained from 967 physicians and 2430 patients. The EULAR 2000 recommendations were familiar to 79% of the GPs; 99% agreed with the non-pharmacological part and 97% with the pharmacological part. Adherence to the two parts was 74.8% and 73.6%, but 54.2% for both together. Factors increasing adherence to the non-pharmacological recommendation were patient body mass index >35 kg/m(2) (odds ratio 0.11 (95% confidence interval, 0.06 to 0.21)), patient's stated preference for a treatment (OR 0.43 (0.55 to 0.97)), and physician's regular continuance of medical education (OR 0.76 (0.59 to 0.98)); patient's age and duration of symptoms decreased adherence. Factors increasing adherence to the pharmacological recommendation were gastrointestinal disease (OR 0.50 (0.35 to 0.72)) and physician's knowledge of the EULAR recommendations (OR 0.75 (0.60 to 0.93)). CONCLUSIONS: Although most physicians agreed with the EULAR 2000 recommendations, adherence was only approximately 75% for each of the non-pharmacological and pharmacological recommendations and 54% for both together.

Adult↗
PubMed2004

Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998-9 national family health survey.

OBJECTIVE: To investigate the demographic, socioeconomic, and geographical distribution of tobacco consumption in India. DESIGN: Multilevel cross sectional analysis of the 1998-9 Indian national family health survey of 301 984 individuals in 92 447 households in 3215 villages in 440 districts in 26 states. SETTING: Indian states. PARTICIPANTS: 301 984 adults (> or = 18 years). MAIN OUTCOME MEASURES: Dichotomous variable for smoking and chewing tobacco for each respondent (1 if yes, 0 if no) as well as a combined measure of whether an individual smokes, chews tobacco, or both. RESULTS: Smoking and chewing tobacco are systematically associated with socioeconomic markers at the individual and household level. Individuals with no education are 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. Households belonging to the lowest fifth of a standard of living index were 2.54 times more likely to consume tobacco than those in the highest fifth. Scheduled tribes (odds ratio 1.23, 95% confidence interval 1.18 to 1.29) and scheduled castes (1.19, 1.16 to 1.23) were more likely to consume tobacco than other caste groups. The socioeconomic differences are more marked for smoking than for chewing tobacco. Socioeconomic markers and demographic characteristics of individuals and households do not account fully for the differences at the level of state, district, and village in smoking and chewing tobacco, with state accounting for the bulk of the variation in tobacco consumption. CONCLUSION: The distribution of tobacco consumption is likely to maintain, and perhaps increase, the current considerable socioeconomic differentials in health in India. Interventions aimed at influencing change in tobacco consumption should consider the socioeconomic and geographical determinants of people's susceptibility to consume tobacco.

Adolescent↗
PubMed2006

Does gender modify associations between self rated health and the social and economic characteristics of local environments?

OBJECTIVES: To examine whether area level socioeconomic disadvantage and social capital have different relations with women's and men's self rated health. METHODS: The study used data from 15 112 respondents to the 1998 Tasmanian (Australia) healthy communities study (60% response rate) nested within 41 statistical local areas. Gender stratified analyses were conducted of the associations between the index of relative socioeconomic disadvantage (IRSD) and social capital (neighbourhood integration, neighbourhood alienation, neighbourhood safety, political participation, social trust, trust in institutions) and individual level self rated health using multilevel logistic regression analysis before (age only) and after adjustment for individual level confounders (marital status, indigenous status, income, education, occupation, smoking). The study also tested for interactions between gender and area level variables. RESULTS: IRSD was associated with poor self rated health for women (age adjusted p<0.001) and men (age adjusted p<0.001), however, the estimates attenuated when adjusted for individual level variables. Political participation and neighbourhood safety were protective for women's self rated health but not for men's. Interactions between gender and political participation (p = 0.010) and neighbourhood safety (p = 0.023) were significant. CONCLUSIONS: These finding suggest that women may benefit more than men from higher levels of area social capital.

Adolescent↗
PubMed2005

The relationship between student smoking in the school environment and smoking onset in elementary school students.

This study examined how perceptions of student smoking in the school environment and the actual smoking rate among senior students at a school are related to smoking onset. Multilevel logistic regression analysis was used to examine correlates of ever smoking in a sample of 4,286 grade 6 and 7 students from 57 elementary schools in Ontario, Canada. Students are at increased risk for smoking if they (a) often see students smoking near their school, (b) report that students at their school smoke where they are not allowed, and (c) attend a school with a relatively high senior student smoking rate. Each 1% increase in the smoking rate among grade 8 students increased the odds that a student in grades 6 or 7 was an ever smoker versus never smoker (odds ratio, 1.05; 95% confidence interval, 1.02-1.08). A low-risk student (no family or friends who smoke) was over twice as likely to try smoking if he/she attended a high-risk school. Prevention programs should target both at-risk schools and at-risk students, and strongly enforced policies preventing students from smoking on or near school property should be implemented.

Adolescent↗
PubMed2005

A multilevel study of socioeconomic predictors of regular mammography use among African-American women.

BACKGROUND: Little is known about the predictors of adherence to mammography guidelines by African-American women. We assessed individual-level and group-level socioeconomic predictors of regular mammography use in a large cohort of African-American women. METHODS: We included 14,706 participants in the Black Women's Health Study who were 40 to 69 years of age at baseline in 1995. Data were obtained through mail questionnaires at entry and biennially during three 2-year follow-up periods until 2001. We linked the women's addresses to census block (neighborhood) socioeconomic data. With multilevel multivariable regression analysis, we assessed the relation of individual-level and neighborhood socioeconomic factors to "regular" mammography use (use in all three follow-up periods) relative to nonregular use, with control for other predictors. RESULTS: Most participants had health insurance and almost half had graduated college. Having health insurance was the socioeconomic variable most strongly associated with regular mammography use (odds ratio, 3.59; 95% confidence interval 3.02-4.28); the association was present at all levels of educational attainment, household income, and neighborhood socioeconomic status. Regular mammography use increased with individual household income: odds ratio, 2.00 (95% confidence interval, 1.58-2.53) for household income > USD $100,000 relative to < USD $15,001. Regular mammography use did not vary across level of education. Higher neighborhood socioeconomic status was significantly associated with regular mammography use before, but not after, control for household income. CONCLUSIONS: Access to health insurance is strongly associated with regular mammography use among African-American women, even at higher levels of educational attainment and socioeconomic status. Neighborhood socioeconomic characteristics do not materially influence regular use.

Adult↗
PubMed2006

Variation in long-term care needs assessors' willingness to support clients' requests for admission to a residential home: a vignette study.

OBJECTIVE: The purpose of this study is to determine what client, needs assessor, and agency factors explain variation in decision making by long-term care needs assessors concerning clients requesting admission to a residential home. METHOD: Hypothetical case vignettes were sent to needs assessors allocating services for the elderly. Multilevel logistic regression analysis provided random and fixed effects. RESULTS: The authors found random effects of the level of needs assessors are negligible, of the level of agencies small though statistically significant, clients receiving largest relative share of the variance. The amount of care already present appeared most important in the decision. Needs assessors were willing to support their clients' wishes only when they were clearly motivated. Policy implications considering the tension between clients' preferences and equity are discussed.

Activities of Daily Living↗
PubMed2006

The wider social environment and changes in self-reported quality of life in the transition from late childhood to early adolescence: a cohort study.

BACKGROUND: Neighbourhood socioeconomic disadvantage and social capital have been associated with adolescent well-being, but the majority of studies were cross-sectional, and the time window over which the neighbourhood may impact on development is unknown. Therefore, the contribution of the neighbourhood environment to adolescents' quality of life and the course of these effects during the period of transition from childhood to early adolescence was examined. METHODS: A cohort of adolescents living in Maastricht (The Netherlands), with a mean age of 11.2 years at baseline and of 13.5 years at follow-up was followed. Adolescents who responded both at baseline and at follow-up were included in the analysis (n = 475). Multilevel regression analyses estimated neighbourhood effects while controlling for individual-level effects. Neighbourhood-level socioeconomic and social capital variables, individual-level confounders, and baseline values of the outcome measures were included in the models. RESULTS: None of the neighbourhood factors was associated with changes in general health or mental health over the two-year period. However, two-year exposure to greater disparity between individual level socioeconomic status on the one hand and neighbourhood level of socioeconomic status on the other (e.g. high socioeconomic status adolescents living in deprived neighbourhoods and vice versa) negatively impacted on self-esteem and satisfaction. CONCLUSION: The neighbourhood environment per se does not contribute to change in quality of life during the transition to early adolescence. However, adolescents living in families whose socioeconomic status deviates from the mean level of neighbourhood socioeconomic deprivation may be negatively affected.

Adolescent↗
PubMed2006

Social capital and health: does egalitarianism matter? A literature review.

The aim of the paper is to critically review the notion of social capital and review empirical literature on the association between social capital and health across countries. The methodology used for the review includes a systematic search on electronic databases for peer-reviewed published literature. We categorize studies according to level of analysis (single and multilevel) and examine whether studies reveal a significant health impact of individual and area level social capital. We compare the study conclusions according to the country's degrees of economic egalitarianism. Regardless of study design, our findings indicate that a positive association (fixed effect) exists between social capital and better health irrespective of countries degree of egalitarianism. However, we find that the between-area variance (random effect) in health tends to be lower in more egalitarian countries than in less egalitarian countries. Our tentative conclusion is that an association between social capital and health at the individual level is robust with respect to the degree of egalitarianism within a country. Area level or contextual social capital may be less salient in egalitarian countries in explaining health differences across places.

Journal Article↗
PubMed2006

Neighborhood Environment Walkability Scale: validity and development of a short form.

PURPOSE: The aim of this study was to examine the factorial and criterion validity of the Neighborhood Environment Walkability Scale (NEWS) and to develop an abbreviated version (NEWS-A). METHODS: A stratified two-stage cluster sample design was used to recruit 1286 adults. The sample was drawn from residential addresses within eight high- and eight low-walkable neighborhoods matched for socioeconomic status. Subjects completed the NEWS and reported weekly minutes of walking for transport and recreation using items from the International Physical Activity Questionnaire. RESULTS: Multilevel confirmatory factor analysis was used to develop measurement models of the NEWS and NEWS-A. Six individual-level and five blockgroup-level factors were identified. Factors/scales gauging presence of diversity of destinations, residential density, walking infrastructure, aesthetics, traffic safety, and crime were positively related to walking for transport. Aesthetics, mixed destinations, and residential density were associated with walking for recreation. CONCLUSIONS: The NEWS and NEWS-A possess adequate levels of factorial and criterion validity. Alternative methods of scoring for different purposes are presented.

Adult↗
PubMed2006

The contribution of diagnostic substitution to the growing administrative prevalence of autism in US special education.

OBJECTIVE: Growing administrative prevalence of autism has stirred public controversy and concern. The extent to which increases in the administrative prevalence of autism have been associated with corresponding decreases in the use of other diagnostic categories is unknown. The main objective of this study was to examine the relationship between the rising administrative prevalence of autism in US special education and changes in the use of other classification categories. METHODS: The main outcome measure was the administrative prevalence of autism among children ages 6 to 11 in US special education. Analysis involved estimating multilevel regression models of time-series data on the prevalence of disabilities among children in US special education from 1984 to 2003. RESULTS: The average administrative prevalence of autism among children increased from 0.6 to 3.1 per 1000 from 1994 to 2003. By 2003, only 17 states had a special education prevalence of autism that was within the range of recent epidemiological estimates. During the same period, the prevalence of mental retardation and learning disabilities declined by 2.8 and 8.3 per 1000, respectively. Higher autism prevalence was significantly associated with corresponding declines in the prevalence of mental retardation and learning disabilities. The declining prevalence of mental retardation and learning disabilities from 1994 to 2003 represented a significant downward deflection in their preexisting trajectories of prevalence from 1984 to 1993. California was one of a handful of states that did not clearly follow this pattern. CONCLUSIONS: Prevalence findings from special education data do not support the claim of an autism epidemic because the administrative prevalence figures for most states are well below epidemiological estimates. The growing administrative prevalence of autism from 1994 to 2003 was associated with corresponding declines in the usage of other diagnostic categories.

Autistic Disorder↗
PubMed1991

Effect of kernel density on the apparent and true metabolizable energy value of corn for chickens.

Five samples of corn selected to vary widely in kernel density (test weight per unit volume) were assayed for AMEn with male broiler chickens at 4 wk of age by regression analysis of a multilevel assay and for TMEn with adult White Leghorn roosters. The kernel densities (kilograms per hectoliter), AMEn, and TMEn (kilocalories per gram of DM) values of the corn were, respectively, 72, 3.68, and 3.96; 71, 3.72, and 3.95; 68, 3.66, and 3.90; 62, 3.64, and 3.88; 60, 3.54, and 3.68. Positive relationships were established between AMEn and TMEn (r = .974, P less than .01) or kernel density (r = .875, P less than .05). The assay for TMEn provided a simple, rapid and sensitive method for estimating the AMEn content of corn for chickens. The small (4%) variation in AMEn relative to a large (20%) variation in kernel density precludes the use of kernel density for estimating the AMEn content of corn.

Animal Feed↗
PubMed2005

Epidemiology of unintentional injuries in childhood: a population-based survey in general practice.

This study aimed to assess the incidence of unintentional injuries presented in general practice, and to identify children at risk from experiencing an unintentional injury. We used the data of all 0-17-year-old children from a representative survey in 96 Dutch general practices in 2001. We computed incidence rates and multilevel multivariate regression analysis in different age strata and identified patient and family characteristics associated with an elevated injury risk. Nine thousand four hundred and eighty-four new injury episodes were identified from 105 353 new health problems presented in general practice, giving an overall incidence rate of 115 per 1000 person years (95% confidence interval [CI] = 113 to 118). Sex and residence in rural areas are strong predictors of injury in all age strata. Also, in children aged 0-4 years, a higher number of siblings is associated with elevated injury risk (> or =3 siblings odds ratio [OR] = 1.57, 95% CI = 1.19 to 2.08) and in the 12-17-year-olds, ethnic background and socioeconomic class are associated with experiencing an injury (non-western children OR = 0.67, 95% CI = 0.54 to 0.81; low socioeconomic class OR = 1.39, 95% CI = 1.22 to 1.58). Unintentional injury is a significant health problem in children in general practice, accounting for 9% of all new health problems in children. In all age groups, boys in rural areas are especially at risk to experience an injury.

Accidents↗