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PubMed2000

Improving patient outcomes by pooling resources (the Texas Heart Care Partnership experience).

The morbidity and mortality associated with cardiovascular disease presents an enormous humanistic and economic burden in the United States. In Texas, cardiovascular disease has been the leading cause of death since 1950. Risk-factor modification has been targeted in the secondary prevention of cardiovascular disease, including lipid management, smoking cessation, improved control of blood pressure, physical activity, weight management, the use of antiplatelet agents/anticoagulants, angiotensin-converting enzyme (ACE) inhibitors in congestive heart failure, beta blockers after myocardial infarction, and estrogen replacement therapy. The Heart Care Partnership (HCP) is a multifaceted interactive program designed to improve risk-factor management in the secondary prevention of cardiovascular disease through physician education, participation, and consensus development in addition to practice improvement processes and patient education. Development and implementation of the Texas HCP was a joint effort of the Texas Medical Association, the Texas Affiliate of the American Heart Association, and Merck & Co. This program helps hospitals improve the quality of care and outcomes for patients with heart disease. Program resources include educational workshops, quality improvement processes, and patient educational materials. HCP workshops address the treatment gap, define optimal care, and help define institution-specific plans for treating heart disease. Quality-improvement processes provide hospitals with baseline data and tools to improve and measure outcomes over time. The HCP workshops are provided as a combination of lectures, interactive discussions, and small group planning sessions designed to encourage audience participation. Upon completing the HCP program, participants are able to (1) describe the evidence-based medicine supporting secondary prevention of cardiovascular disease; (2) identify and prioritize cardiovascular disease risk factors for secondary prevention; (3) identify barriers to and solutions for implementing secondary prevention; and (4) develop site-based plans for cardiovascular risk-factor modification with definite time lines for implementation ("care maps"). The HCP's initial audit of medical practices indicates that Texas appears to share the same deficiencies in the secondary prevention of cardiovascular disease as the rest of the country. However, improvements can be demonstrated in both the hospital and physician office settings through the HCP. The HCP facilitated the cooperation of the medical community in the state of Texas to work together in a synchronized, communicative manner to decrease coronary events. This partnership represents a watershed event in the history of Texas medicine. It is the first time that such a statewide team approach to address a public health issue has been initiated. In the past, medical organizations within the state have had disparate goals and multiple strategies for achieving them.

Cardiology↗
PubMed1999

Neural tube defects along the Texas-Mexico border, 1993-1995.

In response to a 1991 anencephaly cluster in Cameron County, Texas, a surveillance and neural tube defect (NTD) recurrence prevention project for NTDs was implemented in the 14 Texas-Mexico border counties. For 1993-1995, NTD-affected pregnancies were identified at all gestational ages through active surveillance of multiple case-ascertainment sources. There were 87 cases of anencephaly, 96 cases of spina bifida, and 14 cases of encephalocele for respective rates of 6.4, 7.1, and 1.1 per 10,000 live births. Of the 197 NTD case-women, 93% were Hispanic. The overall, Hispanic, and Anglo NTD rates were, respectively, 14.6, 14.9, and 10.6 per 10,000 live births. The NTD rate for El Paso County (9.8 per 10,000), the most northwestern Texas county, was significantly lower (p = 0.001) than the aggregate rate for the rest of the Texas border (17.1 per 10,000). The overall Texas border rate was significantly higher (p < 0.001) than a recently estimated rate of 9.3 for California and minimally higher than a recently adjusted rate of 11.3 for the Metropolitan Atlanta Congenital Defects Program counties (p = 0.052), both of which now reflect all gestational ages. Of the 197 Texas border cases, 85% (168 cases) reached a gestational age of > or =20 weeks. Excluding cases of <20 weeks' gestation in the rate had a more marked effect on reducing the anencephaly rate (4.9 per 10,000) than the spina bifida rate (6.7 per 10,000). A country of birth was known for 153 (83%) of the 184 Hispanic case-women: 63% were born in Mexico; 24%, in Texas; and 11%, elsewhere in the United States. Rates for Mexico-born Hispanic women (15.1 per 10,000) were significantly higher than rates for United States-born Hispanic women (9.5 per 10,000) (p = 0.006).

Adult↗
PubMed2001

Physician assistants in Texas.

Understanding the health requirements of a state begins with identifying the population at need and the workforce available to meet those needs. A descriptive study was undertaken to examine the physician assistant (PA) workforce in Texas as part of an ongoing effort to meet the health needs of Texas residents. In September 2000, Texas had 2237 licensed PAs practicing in 186 counties. Education for PAs in Texas began in 1970 and currently includes one private, one military, and six public programs. Most practicing PAs in Texas graduate from in-state programs and tend to locate within the state. Preparations are under way to shift the public undergraduate programs to graduate degree programs. Although barriers to health care access in Texas remain a substantial public health issue, PAs have helped reduce these barriers, especially in many rural communities. The supply of and demand for Texas PAs appear to be in equilibrium. Policy implications are discussed.

Delivery of Health Care↗
PubMed2003

Female suicides in major Texas cities, 1994 through 1998.

From 1976 to 1985, Texas ranked first among states in the proportion of injury deaths caused by firearms, with an annual rate of 21.2 per 100,000. From 1995 to 1997, suicide was the eighth leading cause of death in Texas, claiming 2137 lives and accounting for 20% of all injury deaths in Texas. Firearm injuries significantly affect mortality rates in many states. The rates of suicide have continued to rise, particularly in young adults, and the rate of suicide by firearms has also increased significantly throughout the United States. We have focused on the most common method of suicide by age and race among women in Texas from 1994 through 1998. This work extended that of Li et al on suicide in Austin, Travis County, Texas, from 1994 through 1998. Those investigators found that the most common method of suicide in females was by firearms. In this current study, we asked whether the Austin data for females were unique or were representative of other major cities in Texas, including Dallas, El Paso, Houston, and San Antonio. Our major finding was that the use of firearms was the most common method of suicide among women in all of these cities. Women aged from 35 to 44 years had the highest incidence of deaths, followed by those aged from 45 to 54 years. Hispanic women had the lowest rate of suicide compared with African American and white women. Overall, rates of suicide among white males and females are at or higher than the US average in all Texas cities examined, except Dallas. Suicide rates among African-American males are at or below the US average, whereas the suicide rate for African-American females exceeds the national average. Nationwide rates for Hispanics were not available.

Adolescent↗
PubMed2005

Texas' community health workforce: from state health promotion policy to community-level practice.

BACKGROUND: Imagine yourself in Texas as a newly arrived immigrant who does not speak English. What would you do if your child became ill? How would you find a doctor? When you find one, will the doctor speak your native language or understand your culture? In a state of approximately 22 million people, many Texas residents, marginalized by poverty and cultural traditions, find themselves in this situation. To help them, some communities across Texas offer the services of promotores, or community health workers, who provide health education and assist with navigating the health care system. CONTEXT: In 1999, Texas became the first state in the nation to recognize these workers and their contributions to keeping Texans healthy. This paper examines a state health promotion policy that culminated in a training and certification program for promotores and the impact of this program on the lay health education workforce in Texas. METHODS: In 1999, the Texas legislature established the 15-member Promotor(a) Program Development Committee to study issues involved in developing a statewide training and certification program. During its 2-year term, the committee met all six of its objectives toward establishing and maintaining a promotor(a) certification program. CONSEQUENCES: By the end of December 2005, it is estimated that there will be more than 700 certified promotores in Texas. State certification brings community health workers into the public health mainstream as never before. INTERPRETATION: Promotores, a community health safety net and a natural extension of the health and human services agencies, improve health at the neighborhood level. Certification brings renewed commitment to serving others and a distinction to those who have been the unsung heroes of public health for decades.

Community Health Services↗
PubMed2006

Spread of equine West Nile virus encephalomyelitis during the 2002 Texas epidemic.

Using reports of clinical West Nile virus (WNV) encephalomyelitis in Texas equids during 2002, the distribution of disease was analyzed using cluster statistics and spatial modeling to develop hypotheses of disease spread during the first year of its detection. Significant (P < 0.05) clusters of cases reported early during the outbreak were identified in east, northcentral, and north Texas, and significant (P < 0.05) clusters late during the outbreak were detected in central, south, and west Texas. Two counties on the south Texas coast first reported disease significantly (P < 0.05) earlier than their 10 nearest neighboring counties. The estimated incidence of disease was greatest in the high plains of north Texas and in northcentral Texas. Higher rates were also estimated in eastern and southern areas of the Gulf Coast. The spatial and temporal distribution observed indicates that the equine WNV epidemic began in two parts of Texas and spread elsewhere throughout the state. The mechanism of introduction and spread remains speculative.

Animals↗
PubMed1991

Cache Valley virus infection in Texas sheep flocks.

Cache Valley virus (CVV), an arbovirus indigenous to the United States, has been implicated as an important teratogenic agent in sheep. The prevalence and distribution of Texas sheep with CVV-specific antibody were investigated. In 1981, 19.1% of 366 sheep located in 22 counties of Texas had antibodies specific for CVV. Of 50 flocks examined in the major sheep-producing counties in Texas, 34 had sheep with antibodies that reacted with CVV, including all sheep tested in 6 flocks that were seropositive. Sera obtained from sheep at the Texas Agricultural Experiment Station at San Angelo between 1986 and 1989 were also examined for CVV-specific antibody because this flock was the subject of the episode of CVV-associated congenital malformations during the 1986 and 1987 lambing season. Approximately 8.6% of 104 sheep in 1986, 63.4% of 164 in 1987, 11.3% of 44 in 1988, and 71.9% of 89 in 1989 from the Texas Agricultural Experiment Station at San Angelo tested were seropositive. The data indicate that CVV infections in sheep were widespread in Texas in 1981 and that the virus is enzootic in sheep at the Texas Agricultural Experiment Station in San Angelo, where the episode of congenital malformations had initially been reported in 1987.

Animals↗
PubMed1991

Firearm mortality in Texas, 1976-1985: how far is Fort Smith?

Firearm injuries significantly affect mortality rates in many states throughout the United States. We reviewed all deaths due to injuries in all state for 1985 to determine deaths from firearm injury in proportion to deaths from all injuries in each state. We then compared Texas data with those of other states. Death certificate data for Texas from 1976 through 1985 were used to describe Texas firearm mortality rates by age, gender, and race and to compare firearm injury with other causes of mortality in Texas. Texas ranked first among states in the proportion of injury deaths caused by firearms, with an annual firearm death rate of 21.2 per 10,000. Of the 30,906 firearm deaths recorded in Texas during the 10-year study period, 650 involved children. Black males had the highest firearm homicide rate (53.9 per 100,000 per year), and white males had the highest firearm suicide rate (15.7 per 100,000 per year). Firearms accounted for 11% of the total years of productive life lost. The economic cost of firearm deaths in Texas was estimated to be $40.7 billion per year. Strategies for preventing these deaths are discussed.

Female↗
PubMed1989

Are Texas dentists burned out?

Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do "people work" of some kind. Health care providers, including dentists, are at high risk for burnout because their occupation often requires intense interaction with fearful, demanding patients on a daily basis. The purpose of this study was to assess the prevalence of burnout among Texas dentists using a standardized measurement device, the Maslach Burnout Inventory (MBI). Dentists attending the 1989 Texas Dental Association Annual Session were surveyed using the MBI. The respondents' results were analyzed and compared to each other as well as to the norms of medicine and to society (human service workers nationwide). Among the Texas sample, male dentists scored significantly higher for emotional exhaustion and depersonalization than did female dentists. When compared to the norms of medical workers, Texas dentists scored higher burnout in the depersonalization subscale, but lower burnout for personal accomplishment. The Texas sample again scored lower for burnout in the personal accomplishment subscale when compared to societal norms. At no time did the Texas sample fall into the high range of experienced burnout as defined by the survey instrument. Texas dentists did not appear "burned out" as a group and actually demonstrated an increased sense of personal accomplishment in their profession.

Adult↗
PubMed1996

Incidence of childhood and adolescent cancer in Texas.

Population-based data from the Texas Cancer Registry were used to describe the incidence of cancer in 1990 among Texas residents younger than 20 years. A total of 788 primary malignant neoplasms were diagnosed. Higher incidence of all cancers was observed among Texas Anglo children compared with Hispanics or African-Americans, and lower rates of central nervous system (CNS) neoplasms were seen among Hispanics. Compared with national data, significantly fewer cases of all cancers combined, non-Hodgkin's lymphoma, neuroblastoma, and CNS neoplasms were seen in Texas Hispanics. The overall incidence of leukemia and acute nonlymphocytic leukemia (ANLL) was highest in Hispanics compared with other Texas children, and a three-fold statistically significant excess of ANLL was evident in Hispanic females compared with national whites. In summary, the incidence of cancer in Texas Hispanic children and adolescents differs from that seen in other racial and ethnic groups. Incidence data for Texas provide additional insight into the descriptive nature of childhood and adolescent cancers.

Adolescent↗
PubMed1997

Middle digestive cancers in Texas Hispanics: a New World syndrome?

To test the hypothesis that middle digestive cancers in Texas Hispanics follow the patterns predicted by the New World Syndrome (1984), cancer incidence rates and relative risks for middle digestive cancers were estimated for 1944-1992. The relative risk for all middle digestive cancers is significantly elevated in Texas Hispanics compared with Anglos, and this risk has increased over time. Elevated risks of these cancers in Texas Hispanics have been explained as resulting from the evolutionary history of Native Americans (American Indians), their genetic relation to Texas Hispanics, and a changing diet and lifestyle. Recent Texas cancer incidence data add further support to the hypothesis. Other current disease prevalence data in Texas Hispanics, percent of the population which is diabetic and percent which is overweight, are also consistent with the New World Syndrome. Expected patterns of disease in males vs females are also confirmed. Factors that do not support the New World Syndrome hypothesis and can be examined by future studies are described. This is the first report since the original describing and updating patterns of middle digestive cancers in Texas Hispanics as resulting from the New World Syndrome. Application of these findings to contemporary medical practice and to cancer prevention are reviewed.

Asian People↗
PubMed2002

Report of the Texas Consensus Conference Panel on medication treatment of bipolar disorder 2000.

BACKGROUND: The process and outcome of a consensus conference to develop revised algorithms for treatment of bipolar disorder to be implemented in the public mental health system of Texas are described. These medication algorithms for bipolar disorder are an update of those developed for the Texas Medication Algorithm Project, a research study that tested the clinical and economic impact of treatment guidelines for major psychiatric illnesses treated in the Texas public mental health system (Texas Department of Mental Health and Mental Retardation [TDMHMR]). METHOD: Academic clinicians and researchers, practicing clinicians in the TDMHMR system, administrators, advocates, and consumers participated in a consensus conference in August 2000. Participants attended presentations reviewing new evidence in the pharmacologic treatment of bipolar disorder and discussed the needs of consumers in the TDMHMR system. Principles were enumerated, including balancing of evidence for efficacy, tolerability, and safety in medication choices. A set of 7 distinct algorithms was drafted. In the following months, a subcommittee condensed this product into 2 primary algorithms. RESULTS: The panel agreed to 2 primary algorithms: treatment of mania/hypomania, including 3 pathways for treatment of euphoric symptoms, mixed or dysphoric symptoms, and psychotic symptoms; and treatment of depressive symptoms. General principles to guide algorithm implementation were discussed and drafted. CONCLUSION: The revised algorithms are currently being disseminated and implemented within the Texas public mental health system. The goals of the Texas initiative include increasing the consistency of appropriate treatment of bipolar disorder, encouraging systematic and optimal use of available pharmacotherapies, and improving the outcomes of patients with bipolar disorder.

Algorithms↗
PubMed2004

Projected economic costs due to health consequences of teenagers' loss of confidentiality in obtaining reproductive health care services in Texas.

BACKGROUND: We wanted to focus on the potential consequences of recently enacted legislation in Texas that limits adolescents' ability to obtain confidential reproductive health care services. OBJECTIVE: To assess the potential economic costs that result when adolescents do not seek reproductive health care services because their confidentiality is compromised. DESIGN: We developed a cost model to estimate the projected costs of parental consent and law enforcement reporting requirements based on data from the literature, the Texas Department of Health, and publicly funded family planning clinics in Texas. Univariate and multivariate sensitivity analyses explored different scenarios. SETTING: The state of Texas. PARTICIPANTS: Projected costs were estimated for all girls younger than 18 years using publicly funded reproductive health care services in Texas. MAIN OUTCOME MEASURES: We determined the projected number of additional pregnancies, births, abortions, and untreated sexually transmitted infections and resulting pelvic inflammatory disease and calculated the associated economic costs of these projected outcomes. RESULTS: The potential costs of parental consent and law enforcement reporting requirements in Texas were estimated at 43.6 million dollars (range, 11.8 million dollars to 56.6 million dollars) for girls younger than 18 years currently using publicly funded services. CONCLUSIONS: As policymakers throughout the United States search for ways to curtail adolescent sexual activity and its adverse consequences, this analysis suggests that the limiting of medical confidentiality and the resulting restricted use of reproductive health care services potentially have serious health and economic consequences.

Adolescent↗
PubMed1999

Adolescent occupational injuries: Texas, 1990-1996.

BACKGROUND: A comprehensive surveillance system for occupational injuries to adolescents does not exist in Texas, as in most states. Therefore, the magnitude, severity, nature, and source of injuries to working adolescents have not been well described in Texas. METHODS: The investigators used three data sources to investigate work-related injuries and deaths in Texas: (1) Texas Workers' Compensation Commission (TWCC) claims data from 1991 through April 1996; (2) 1993 TWCC/Bureau of Labor Statistics (BLS) Annual Survey of Occupational Injuries and Illnesses; and (3) work-related fatalities identified from Texas death certificates from 1990-1995. RESULTS: There were 9,027 injuries reported to the TWCC for adolescents 14-17 years of age during slightly more than 5 years. Injuries for which indemnity payments were made (more than 7 days out of work) occurred among 21.7% of the adolescents. Based on BLS data in 1993, of 992 non-fatal injuries involving days away from work, 35% were caused by contact with objects, 27% by bodily reaction, and 24% by falls. Two-thirds of these injuries occurred while working in eating and drinking places and grocery stores. Three-quarters of the 30 deaths from 1990-1995 were accounted for equally by motor vehicle and homicide. CONCLUSIONS: In conclusion, a substantial number of adolescents are injured or killed in the workplace each year in Texas. Although improved population-based surveillance is needed, sufficient knowledge exists to begin prevention efforts now.

Accidents, Occupational↗
PubMed2001

A comparative assessment of contaminants in fish from four resacas of the Texas, USA-Tamaulipas, Mexico border region.

A recent survey of contaminant information for the Lower Rio Grande Valley (LRGV), Texas, has shown that little is known about contaminants and their impacts on biota of resacas (oxbows) along the US-Mexico border. In 1996, fish were collected from four resacas in the Texas-Tamaulipas border region to assess contaminant loadings and their impacts on fish and birds. Tissue residue concentrations in fish were analyzed and also compared to two histopathological bioindicators of unhealthy environmental conditions. Of the organochlorine insecticides measured, DDE was the most common and was present at relatively high concentrations (10 microg/g w/w) at some sites. DDE concentrations were nearly 20 times greater in fish from resacas in Texas than from resacas in Tamaulipas, although the limited sample sizes obtained precluded statistical comparisons. DDE concentrations in fish from the two Texas resacas were also greater than those reported in fish from nearby areas during the 1980s and 1990s. Most trace element concentrations were similar among resacas from Texas and Tamaulipas. Arsenic, however, was two to six times greater in fish from a downtown resaca in Matamoros than in fish from other resacas in Tamaulipas and Texas. The bioindicators, pigment accumulation, and macrophage aggregates (MAs), in general, reflected the contamination indicated by the tissue residues for each site. Overall, it appears that some resacas of the US-Mexico border region are contaminant sinks and could pose potential health or reproductive problems for fish and wildlife, and humans that consume fish from those sites.

Animals↗
PubMed2005

Spatial, temporal, and interspecies patterns in fine particulate matter in Texas.

The Big Bend Regional Aerosol and Visibility Observational (BRAVO) field study was conducted from July to October 1999 and was followed by several years of modeling and data analyses to examine the causes of haze at Big Bend National Park TX (BBNP). During BRAVO, daily speciated fine (diameter <2.5 microm) particulate concentrations were measured at 37 sites throughout Texas. At the primary receptor site, K-Bar Ranch, there were many additional measurements including a "high-sensitivity" version of the 24-hr fine particulate elemental data. The spatial, temporal, and interspecies patterns in these data are examined here to qualitatively investigate source regions and source types influencing the fine particulate concentrations in Texas with an emphasis on sources of sulfates, the largest contributor to fine mass and light extinction. Peak values of particulate sulfur (S) varied spatially and seasonally. Maximum S was in Northeast Texas during the summer, whereas peak S at BBNP was in the fall. Sulfate acidity at BBNP also varied by month. Sources of Se were evident in Northeast Texas and from the Carbón I and II plants. High S episodes at BBNP during BRAVO had several different trace element characteristics. Carbon concentrations at BBNP during BRAVO were probably mostly urban-related, with arrival from the Houston area likely. The Houston artificial tracer released during the second half of BRAVO was highly correlated with some carbon fractions. There was evidence of the influence of African dust at sites throughout Texas during the summer. Patterns in several trace elements were also examined. Vanadium was associated with air masses from Mexico. Lead concentrations in southern Texas have dropped dramatically over the past several years.

Air Pollutants↗
PubMed1995

Health hazards among working children in Texas.

This report represents the first attempt to assemble existing data from a variety of sources regarding children less than 18 years of age in the work force in Texas. These data include the frequency of detected violations of child labor laws, reports of injuries to the Texas Workers' Compensation Commission, and work-related deaths as ascertained from death certificates. More than 1,000 minors were detected as being illegally employed in Texas each year since 1986 and nearly 1,100 work-related injuries in children 18 years of age and younger were reported to the Texas Workers' Compensation Commission in 1991. A review of Texas death certificates from 1980 to 1990 revealed 125 work-related fatalities among children. The leading cause of death was motor vehicle injuries, followed by injuries from machinery (usually agricultural machinery). The magnitude and severity of occupational illnesses in working children are unknown. Because of physiologic differences in size, metabolism, and absorption, children may be especially susceptible to work-related injury and illness. Health and safety data on working children in Texas, as in most other places, are fragmented and incomplete. These data are needed to identify children at high risk of injuries and illnesses, to target prevention programs, and to identify areas for additional legislation. More rigorous enforcement of current legislation is also needed.

Accidents, Occupational↗
PubMed1982

A closer examination of neonatal mortality rates among the Texas Spanish surname population.

Considering the poor socioeconomic status of the Spanish surnamed population in Texas, the Spanish surname neonatal mortality rate seems surprisingly low. During five of the last 10 years, the neonatal mortality rate for Texas Spanish surnamed population was actually lower than for Anglos. It is often suggested that the low Spanish surname neonatal mortality rate is due in part to reporting problems peculiar to the Spanish surname population in Texas. Linked birth and neonatal death records of Texas residents are examined for evidence of underreporting or misreporting of Spanish surnamed neonatal deaths. It is found that discrepancies in coding race on the birth and death records cause a minor deflation of Spanish surname neonatal and infant mortality rates. Indirect evidence indicates that there may be a substantial amount of underreporting of Spanish surname neonatal deaths. This underreporting appears to be associated with the presence of a large number of Mexican nationals misidentified as Texas residents, and the greater reliance upon lay midwives by the Spanish surname population in Texas. Reasons proposed to explain a reluctance to report neonatal deaths include fear of contact with authorities, and fear that a reported death would diminish the value of the birth certificate.

Adult↗