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PubMed1997

Estimating the exposure and fatal crash rates of suspended/revoked and unlicensed drivers in California.

There have been a number of studies conducted during the past three decades which show that most suspended/revoked (S/R) drivers violate their license action and continue to drive during their period of disqualification. Traffic safety researchers also suspect that S/R drivers are overinvolved in traffic crashes, but this is difficult to demonstrate because of the lack of good data on their prevalence among all road users. This paper applies the quasi-induced exposure method to fatal crash data obtained from the National Highway Traffic Safety Administration's Fatal Accident Reporting System, to generate exposure and crash rate estimates for S/R drivers in California. The results show exposure rates of 8.8% and 3.3% for suspended/revoked and unlicensed drivers, respectively, and that, compared to validly licensed drivers, the former are overinvolved in fatal crashes by a factor of 3.7:1, and the latter 4.9:1. These findings provide support for efforts to better control S/R and unlicensed drivers. The paper also discusses serious limitations to using quasi-induced exposure to estimate the numbers of such drivers on California roads, and concludes that it is not suited to this task.

Accidents, Traffic↗
PubMed1996

Potential cost savings for Medi-Cal, AFDC, food stamps, and WIC programs associated with increasing breast-feeding among low-income Hmong women in California.

OBJECTIVE: To determine the potential cost savings for four social service programs if breast-feeding rates increased among Hmong women in California. DESIGN: Cost-savings analysis. SUBJECTS/SETTING: Hmong women in California. In this population, breast-feeding is currently uncommon, and use of contraceptives is minimal. MAIN OUTCOME MEASURES: Savings were based on estimates of the resulting decrease in infant morbidity, maternal fertility, and formula purchases (Special Supplemental Nutrition Program for Women, Infants, and Children) if women breast-fed each child for at least 6 months. Costs were projected over a 7.5-year period and future values were discounted with annual interest rates of 2% or 4%. RESULTS: Substantial savings estimates were associated with breast-feeding for all four programs. The total projected savings over the 7.5-year period ranges from $3,442 to $4,944 (4% discount) to $4,475 to $6,0960 (0% discount) per family enrolled in all four programs. This translates into an estimated yearly savings of between $459 and $659 (4% discount) and $597 and $808 (0% discount) per family. APPLICATIONS: Although health care providers generally accept that breast-feeding is the preferred method for feeding infants, many still view the choice as a neutral one; that is, they consider low breast-feeding rates in the United States a cultural choice with no cost to society. This analysis provides evidence that breast-feeding is economically advantageous for individuals and society.

Aid to Families with Dependent Children↗
PubMed2003

Analysis of the institutional volume-outcome relations for balloon angioplasty and stenting in the stent era in California.

BACKGROUND: Coronary artery stenting has become the predominant form of percutaneous coronary intervention. However, it is not clear whether a better outcome is conferred by stent placement in high-volume, more experienced centers as has been shown with balloon angioplasty. Furthermore, as stent procedures become more common, balloon angioplasty becomes less frequent. Thus, we separately analyzed the outcomes after coronary angioplasty and stenting in a large, unselected population to determine the effect of annual institutional angioplasty or stent volume on in-hospital outcomes after balloon angioplasty or stenting. METHODS: The California Office of Statewide Health Planning and Development database was queried to obtain discharge data on all patients in 1997 treated with percutaneous transluminal coronary angioplasty (PTCA) or a stent procedure. Hospitals were divided into low-volume (<200 procedures), intermediate-volume (200 to 400 procedures), and high-volume (>400 procedures) institutions as a function of their 1997 PTCA or stent volumes to assess the effect of volume on outcome. RESULTS: There were 44,276 percutaneous revascularization procedures performed in California in 1997, of which 57% involved coronary stent placement. Mortality rates after PTCA were 2.6%, 1.9%, and 1.4% in low-, intermediate- and high-volume PTCA hospitals, respectively (P <.001). The need for same-day coronary artery bypass grafting (CABG) after PTCA was 2.4%, 2.1%, and 1.2% in low-, intermediate- and high-volume PTCA hospitals, respectively (P <.001). Mortality rates after stent placement were 1.6%, 1.5%, and 1.1% in low-, intermediate-, and high-volume stent hospitals, respectively (P =.022). The need for same-day CABG after stent placement was 1.1%, 1.2%, and 0.8% in low-, intermediate-, and high-volume stent hospitals, respectively (P =.014). CONCLUSIONS: Short-term results of balloon angioplasty and stent procedures are improved when performed in high-volume hospitals.

Aged↗
PubMed1999

Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity.

BACKGROUND: Congestive heart failure (CHF) disproportionately affects African Americans, but data are limited concerning CHF hospitalization patterns among Hispanic and Asian populations, the 2 fastest growing ethnic groups in the United States, and race/ethnic patterns of rehospitalization and survival among patients with CHF are unknown. We conducted a study to assess rates of CHF hospitalization, readmission, and survival among diverse populations in California. METHODS AND RESULTS: We used 2 study designs. First, we calculated the population-based incidence of CHF hospitalization in California in 1991. Next we conducted a retrospective cohort study that identified patients initially hospitalized for CHF in 1991 or 1992 and followed these patients for 12 months after their index hospitalization to determine their likelihood of rehospitalization or death. Data were analyzed with Cox proportional hazards models. African Americans had the highest rate of CHF hospitalization. Age-adjusted hospitalization rates were comparable among whites, Latinos, and Asian women and all lower than those in African American, whereas Asian men had the lowest rates. On adjusted analyses, African Americans were more likely than whites and Asians to be rehospitalized (relative risk 1.07; 95% confidence interval 1.04 to 1.10). However, they were less likely to die within the 12-month follow-up period (relative risk 0.86; 95% confidence interval 0.82 to 0.90). Whites, conversely, had the highest posthospitalization mortality rates. CONCLUSIONS: These findings demonstrate important racial-ethnic differences in CHF morbidity and mortality rates. The disparate findings of higher hospitalization and rehospitalization rates and lower mortality rates among African Americans than whites may represent differences in the underlying pathophysiology of CHF in these groups or differences in access to quality care. Further studies are needed to explain these seemingly paradoxical outcomes.

Black or African American↗
PubMed2002

Effects of the September 11th attacks on urgent and emergent medical evaluations in a Northern California managed care plan.

PURPOSE: To determine whether the terrorist attacks on September 11, 2001, affected the health of persons far from the attacks, we studied rates of urgent and emergency medical evaluations among the 3 million persons enrolled in a managed care plan in Northern California. METHODS: Using a computerized database of all urgent care and emergency department evaluations, we monitored physician diagnoses made during the 6 weeks before and after September 11, 2001, at 16 hospitals in the Kaiser Permanente Medical Care Program. Actual rates of evaluations and diagnoses were compared with expected rates based on similar periods in 1998, 1999, and 2000. RESULTS: There were 4260 fewer urgent and emergent medical evaluations than expected during the 6 weeks beginning September 11, 2001 (-4%; 95% confidence interval [CI]: -3% to -5%; P <0.0001; N = 95,603). Emergency department visits occurred at the expected rate (-1%; 95% CI: -2% to 1%; P = 0.34), but urgent care visits were reduced (-9%; 95% CI: -8% to -11%; P <0.0001). Evaluations were particularly less frequent during the week beginning September 11 (-7%; 95% CI: -4% to -9%; P <0.0001), but a decrease persisted afterwards. Compared with expected rates, injuries (P <0.0001) and ill-defined/symptom-related diagnoses (P <0.0001) were less frequent, while gastrointestinal diagnoses (P = 0.01) were more frequent, during the 6 weeks after the attacks. Total urgent and emergent evaluations were mostly unchanged on September 11; only diagnoses associated with cardiac ischemia were more frequent (+70%; 95% CI: 10% to 163%; P = 0.02). CONCLUSION: Total urgent and emergent medical evaluations in a California managed care plan were reduced during the 6 weeks after the September 11th attacks. These results may help in allocation of resources during national disasters.

California↗
PubMed2003

Differences in mortality among patients with community-acquired pneumonia in California by ethnicity and hospital characteristics.

PURPOSE: To determine ethnic disparities in mortality for patients with community-acquired pneumonia, and the potential effects of hospital characteristics on disparities, we compared the risk-adjusted mortality of white, African American, Hispanic, and Asian American patients hospitalized for community-acquired pneumonia. METHODS: We studied patients discharged with community-acquired pneumonia in 1996 from an acute care hospital in California (n = 54,874). Logistic regression models were used to examine the association between ethnicity and hospital characteristics and 30-day mortality after adjusting for clinical characteristics. RESULTS: The overall 30-day mortality was 12.2%. After adjustment for demographic, clinical, and hospital characteristics, Hispanic (odds ratio [OR] = 0.81; 95% confidence interval [CI]: 0.73 to 0.90) and Asian American patients (OR = 0.88; 95% CI: 0.77 to 1.00) had lower mortality than did white patients, whereas African Americans had a similar mortality to whites (OR = 0.93; 95% CI: 0.83 to 1.06). There were no overall differences in mortality by hospital characteristics (i.e., teaching status, rural location, and public or district hospital). CONCLUSION: Hispanics and Asian Americans have a lower risk of death from community-acquired pneumonia than whites in California. No overall differences in mortality were observed by hospital characteristics.

Black or African American↗
PubMed1999

The effect of hospital experience on mortality among patients hospitalized with acquired immunodeficiency syndrome in California.

BACKGROUND: Several studies in the 1980s suggested that mortality rates for patients hospitalized with the acquired immunodeficiency syndrome (AIDS) were lower in hospitals that cared for greater numbers of AIDS patients. We sought to determine whether this observation persisted in the mid-1990s in California. SUBJECTS AND METHODS: We performed an analysis of hospital discharge data for 7,901 adults discharged with human immunodeficiency virus (HIV) or AIDS-related diagnoses from all acute care hospitals (n = 333) in California during 1994. The main outcome measure was in-hospital mortality, adjusted for severity of illness, comorbidity, prior hospitalizations, and other patient and hospital characteristics. RESULTS: Among 7,901 persons hospitalized with AIDS, the unadjusted inpatient mortality was 9.0%. The adjusted mortality rate varied significantly (P <0.0001) from 12.4% among institutions with the lowest quartile of AIDS experience to 10.3%, 6.3%, and 7.6% by quartile of greater AIDS experience. Increasing severity of illness, comorbidity, and previous hospitalizations were also significant predictors of increased mortality. Sex, race, and insurance status were not associated with hospital mortality. CONCLUSIONS: Hospital mortality for AIDS patients was greater among less experienced hospitals. The difference in mortality rate was equivalent to more than four additional deaths per 100 patients with AIDS admitted to the least experienced hospitals. This finding was not explained by severity of illness, comorbidity, or other case-mix variables.

Acquired Immunodeficiency Syndrome↗
PubMed2000

Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis.

OBJECTIVE: We compared the perinatal outcomes and costs of undocumented women with and without prenatal care and inferred the impact of denial of prenatal benefits to undocumented immigrants in California. STUDY DESIGN: We retrospectively reviewed the delivery records of a cohort of 970 undocumented immigrants. The effects of prenatal care on low birth weight and prematurity were evaluated by means of logistic regression. The difference in the costs of postnatal care between neonates with and without prenatal care was compared with the cost of prenatal care. This ratio was extrapolated to calculate the net cost to the state. Long-term morbidity costs were also considered. RESULTS: Nearly 10% of undocumented women had no prenatal care. These women were nearly 4 times as likely to be delivered of low birth weight infants (relative risk, 3.8; 95% confidence interval, 2.03-7.05) and >7 times as likely to be delivered of premature infants (relative risk, 7.4; 95% confidence interval, 4.35-12.59) as were undocumented women who had prenatal care. The cost of postnatal care for a neonate without prenatal care was $2341 more initially and $3247 more when incremental long-term morbidity cost was added than that for a neonate with prenatal care. For every dollar cut from prenatal care we expect an increase of $3. 33 in the cost of postnatal care and $4.63 in incremental long-term cost. Elimination of publicly funded prenatal care for undocumented women could save the state $58 million in direct prenatal care costs but could cost taxpayers as much as $194 million more in postnatal care, resulting in a net cost of $136 million initially and $211 million in long-term costs. CONCLUSIONS: Elimination of public funding of prenatal care for undocumented immigrants in California could substantially increase low birth weight, prematurity, and postnatal costs.

California↗
PubMed1998

Declining cesarean delivery rates in California: an effect of managed care?

OBJECTIVES: We hypothesized that movement from traditional indemnity insurance to managed care in California between 1983 and 1994 would lead to reductions in the rate of cesarean delivery. STUDY DESIGN: We decomposed the frequency of cesarean delivery with each primary diagnosis into the product of the diagnosis rate among all women and the cesarean delivery rate among women with the given diagnosis (conditional cesarean delivery rate). We used logistic regression to estimate the diagnosis and conditional cesarean delivery rates. RESULTS: Adjusted and observed cesarean delivery rates are indistinguishable. Both the diagnosis rates and the conditional cesarean delivery rates contributed to the increase in the cesarean delivery rate between 1983 and 1987. The subsequent decline is attributable to the decline in the repeated cesarean delivery rate. CONCLUSIONS: The increase in managed care in California played no apparent role in the decline in the cesarean delivery rate. With the exception of Kaiser health maintenance organizations, managed care providers and indemnity insurers managed deliveries similarly.

Adult↗
PubMed2001

New challenges: residential pesticide exposure assessment in the California Department of Pesticide Regulation, USA.

Residential exposure assessment is in an early stage of development within many of the regulatory agencies responsible for pesticides. Some of the impetus for residential assessment comes from the Food Quality Protection Act (FQPA), a federal law adopted in 1996 in the USA. The FQPA mandates that the aggregate and cumulative risks from all nonoccupational sources of exposure to similarly acting pesticides be assessed. The development of methods for residential exposure assessment is therefore proceeding in tandem with methods for aggregate risk assessment. The California Department of Pesticide Regulation (Cal DPR) regulates pesticides in the state of California much as the US EPA does at the national level. While Cal DPR is not explicitly bound by the federal law, it recognizes the importance of residential exposure and of cumulative risk, and tries to harmonize its methods with those of US EPA. Accordingly, Cal DPR is developing guidance for residential exposure assessment. Some factors to consider are the following: (1) although the end goal may be total exposure from all sources, in order to regulate the use of products it is necessary to have separate estimates of exposure from individual sources and routes; (2) probabilistic approaches will be used increasingly, and they must separate variability and uncertainty; (3) there is a critical need for data on residential use of pesticides, including the frequency of mishaps and improper handling; (4) data are needed on long-term activity patterns of individuals, including residential and occupational history; (5) regulatory agencies need a way to identify and screen potential exposure scenarios, in order to streamline the risk assessment process.

California↗
PubMed1997

Acid leaching studies of chrysotile asbestos from mines in the Coalinga region of California and from Quebec and British Columbia.

The dissolution of magnesium (Mg) and silicon (Si) from various samples of chrysotile asbestos was measured in N HCl at 25 degrees C. Nine samples were used, five from Canada and four from the Coalinga deposit in California. With milled samples from Quebec, the fraction of Mg dissolving was linearly related to the square root of the leaching time until at least 65% had dissolved. With a hand-picked sample of ore from Quebec, the sample from British Columbia and all the Californian samples, the Mg leaching patterns were sigmoid. The leaching patterns for Si were sigmoid in shape for all the materials tested. Mean Mg dissolution rates were calculated for each leaching period. Considerable differences were observed between samples from the different mining regions and also between hand-picked and milled samples from the same mine. Initially, Mg dissolved more rapidly from milled Quebec chrysotiles than from the Coalinga samples. This difference is due in part to the rapid dissolution of non-structural brucite, present in all the samples from Quebec but not in those from California. An additional cause is greater damage to the fibre surfaces resulting from the milling to which the less readily-opened fibres, typical of the Quebec mining area, were subjected. Once this readily-available Mg had dissolved, there was little difference in leaching rates between milled and unmilled samples from the different regions. When the fraction of Mg dissolving is plotted against that of Si, all the materials follow a similar pattern, suggesting that the dissolution of Si (as silica) is the rate-controlling step in the dissolution of Mg.

Asbestos, Amphibole↗
PubMed2002

An evaluation of the implementation of ignition interlock in California.

PROBLEM: This study evaluates the degree to which courts have implemented California's ignition interlock program, and surveys judges and district/city attorneys to identify barriers to implementing a successful interlock program. METHOD: There are three parts to the evaluation. In the first, a sample of drivers arrested for driving on a driving under the influence (DUI)-suspended driver license was examined to calculate the rate at which courts order interlocks for DUI-suspended drivers, as required by California law. The second part of the study used Department of Motor Vehicle (DMV) records to count the statewide rate of court-ignition interlock device (IID) orders across time and jurisdictions. The final part surveyed judges, district/city attorneys, and offenders installing an interlock to obtain information about their use of interlock, barriers to implementing an interlock program, and the effectiveness of the devices in preventing drinking and driving. RESULTS: It was found that conviction rates for driving while suspended are low; that judges order interlocks for only a fraction of the convicted driving-while-suspended (DWS) offenders who should receive such an order; and that the majority of offenders who are ordered by the court to install an ignition interlock in their vehicle do not do so. IMPACT ON INDUSTRY: Any successful interlock program will need to find a way to balance the inability of many offenders to pay for the devices, with the need for the industry to remain economically viable.

Alcohol Drinking↗
PubMed2002

Comparability of bioaccumulation within the sanddab guild in coastal Southern California.

Most assessments of fish contamination in Southern California use ecologically different species from different sites. Use of ecologically similar species (a guild) might provide better assessments of fish contamination across different sites and depths. In July-August 1997, we collected samples of four sanddab guild species at 22 sites where species pairs co-occurred and determined total DDT concentrations in homogenized whole fish composites. Log-transformed DDT concentrations were highly correlated among all species pairs within this guild. All relationships were linear over the range observed, with slopes not statistically different from unity. The variability in response among species was about four times the variability encountered among replicates within species, but 15 times smaller than the variability among sites. Together, these results suggest that the sanddab guild, widespread on soft bottoms of the Southern California coastal shelf, can be used as a "superspecies" in bathymetrically diverse regional assessments of fish tissue contamination.

Animals↗
PubMed2002

Decreased incidence of cervical cancer in medicare-eligible California women.

OBJECTIVE: To determine if the incidence of invasive cervical cancer relative to carcinoma in situ decreased in Medicare-eligible women. METHODS: A retrospective cohort was amassed from the California Cancer Registry database. The hypothesis was prospectively specified. Mean ratio of invasive (International Federation of Gynecology and Obstetrics Stages I-IV) to in situ cervical carcinoma in 1988-1990 versus 1991-1995 was stratified by age (24 or younger, 25-44, 45-64, 65 or older) and race (all races, whites, blacks, Hispanics, Asian/Pacific Islanders). RESULTS: The mean ratio of invasive to in situ cervical cancer incidence for women at least 65 years old was lower in 1991-1995 compared with 1988-1990 (P <.001, 95% confidence interval 0.893, 0.954); and had decreased more than observed for women aged 45-64 and 25-44, for all races combined, and for white women. The decreased ratio of invasive to in situ cancer for blacks, Hispanics, and Asian/Pacific Islanders at least 65 years old was no different than the decreased ratio in younger women. CONCLUSION: In California, in the 5 years after the 1990 change in Medicare funding statutes for cervical cytology screening, the ratio of invasive cervical cancer to in situ disease decreased more in Medicare-eligible patients than in younger women.

Adult↗
PubMed1998

Managed care in the Northern California Kaiser Permanente health care system.

Kaiser Permanente in Northern California is a group model health maintenance organization (HMO) that contracts with The Permanente Medical Group, Inc. (TPMG) to provide care for health plan members. TPMG is the largest (for-profit) private group practice in the world, with 3600 physicians in Northern California, including 62 urologists, providing care to 2.5 million health plan members. Recent changes in health care financing and delivery mandate an HMO-physician relationship which addresses issues of cost, quality of care, and the needs of physicians.

California↗
PubMed1995

Association between Vogt-Koyanagi-Harada syndrome and HLA-DR1 and -DR4 in Hispanic patients living in southern California.

BACKGROUND: Vogt-Koyanagi-Harada (VKH) syndrome is associated with human leukocyte antigen (HLA)-B54, -DR4, -DR beta 1*0405, -DQ4, and -DR53 in Japanese patients. Disease-associated HLA specificities may differ among races. This study examined HLA associations with VKH syndrome in Hispanic patients living in southern California, a racial subgroup at increased risk for the disease. METHODS: Human leukocyte antigen specificities were determined on 25 Hispanic patients with VKH syndrome and compared with HLA specificities of 217 healthy Hispanic control subjects. Inclusion criteria for study patients were nontraumatic panuveitis with exudative retinal detachments, with or without extraocular manifestations. Tests were performed using standard cytotoxic assays. RESULTS: HLA-DR4 was present in 14 (56%) patients with VKH syndrome and in 62(29%) control subjects (relative risk = 1.96). HLA-DR1 was present in 9 (36%) patients with VKH syndrome and in 19 (9%) control subjects (relative risk = 4.11). HLA-DR1 and DR4 share a common epitope within the DR beta 1 gene. HLA-DR1 and/or DR4 were present in 21 (84%) patients with VKH syndrome and in 76 (35%) control subjects (relative risk = 2.40). CONCLUSIONS: HLA-DR1 and -DR4 were found in a significantly disproportionate number of Hispanic patients with VKH syndrome living in southern California. HLA-DR4, although not HLA-DR1, has been previously associated with VKH syndrome in other groups. These associations suggest a common immunogenic predisposition to VKH among different racial groups, and suggest that a common epitope shared by DR1 and DR4 may be involved in the pathogenesis of the disease.

California↗
PubMed2003

Spatial analysis of Yersinia pestis and Bartonella vinsonii subsp. berkhoffii seroprevalence in California coyotes (Canis latrans).

Zoonotic transmission of sylvatic plague caused by Yersinia pestis occurs in California, USA. Human infections with various Bartonella species have been reported recently. Coyotes (Canis latrans) are ubiquitous throughout California and can become infected with both bacterial agents, making the species useful for surveillance purposes. This study examined the geographic distribution of 863 coyotes tested for Y. pestis and Bartonella vinsonii subsp. berkhoffii serologic status to gain insight into the natural history of B. vinsonii subsp. berkhoffii and to characterize the spatial distribution of the two agents. We found 11.7% of specimens positive to Y. pestis and 35.5% positive to B. vinsonii subsp. berkhoffii. The two pathogens had distinct spatial clusters: Y. pestis was more prevalent in eastern portions of the state and B. vinsonii subsp. berkhoffii in coastal regions. Prevalence of Y. pestis increased with increasing elevation, whereas prevalence of B. vinsonii subsp. berkhoffii decreased with increasing elevation. There were differences in the proportions of positive animals on a yearly basis to both pathogens.

Animals↗
PubMed2003

Seroprevalence of Johne's-disease infection in dairy cattle in California, USA.

A total of 1,950 serum samples from dairy cattle in California, USA were tested for the presence of antibodies to Mycobacterium avium subspecies paratuberculosis (MAP) using a commercial enzyme-linked immunosorbent assay (ELISA) kit. The sampled animals came from 65 herds and were sampled to reflect the relative numbers and distribution of dairy herds within three geographic regions in the state. Using the manufacturers suggested cut-off for a positive test, 89 animals (4.6%) were positive. The seroprevalence was 6.9% in the northern region of the state, 3.7% in the central region and 5.2% in the southern region. Using the sensitivity and specificity claimed by the manufacturer of the ELISA kit, the true prevalence in California dairy cattle overall was calculated as 9.4% (99% CI, 7.7%, 11.1%) and the true prevalences for the northern, central and southern regions were 14.1% (99% CI, 9.6%, 18.65%), 7.5% (99% CI, 5.6%, 9.4%), and 10.6% (99% CI, 5.9%, 15.6%), respectively.

Animal Husbandry↗