Excessive Hospitalizations and Its Associated Economic Burden among People with Diabetes in the United States

AbstractObjectivesWe conducted this study to estimate the excessive hospital admission among people with diabetes and the associated economic burden in the USA.MethodsThe study was based on the 2005 Nationwide Inpatient Sample (NIS), a nationally representative probability sample conducted annually by the Agency of Health Research and Quality. Nearly 8 million records were sampled from over 1000 community hospitals in the 2005 NIS.ResultsExcluding childbirth-related admissions, the estimated US hospitalizations numbered approximately 30.8 million; individuals with diabetes accounted for over 6.4 million (20.9%) of these admissions. For every 1000 individuals without diabetes, with type 1 diabetes, and with type 2 diabetes, the numbers of hospitalizations were 89, 418, and 303, respectively. The rates of hospitalization increased greatly by the presence of diabetes for all age groups and sex. During 2005, the national bill of hospital charges and costs for individuals with diabetes exceeded US$171 billion and US$90 billion, respectively. If the prevalence of diabetes increases to 7.5% from 7.0%, the total number of hospitalizations made by individuals with diabetes will be 7.5 million in 2015.ConclusionsAlthough approximately 7% of the population had diabetes in the USA, nearly 20.9% of hospitalizations were made by individuals with this condition. Due to the excessive hospitalizations incurred by patients with diabetes, a small increase in the number of people with diabetes will amplify the number of hospitalizations. Health-care communities should anticipate this possible increased demand of hospitalizations and the associated economic burden

How do programs work to improve child nutrition?: Program impact pathways of three nongovernmental organization intervention projects in the Peruvian highlands

This paper examines the program logic of three nongovernmental, community-based programs with different intervention models to reduce childhood stunting. Two programs, Child Nutrition Program (PNI) and Good Start, focused directly on education and behavior change among caregivers, or the short routes to achieve impact, while one program, Sustainable Networks for Food Security (REDESA), focused on upstream factors, such as improving local governance and coordination, improving water and sanitation, and increasing family incomes, or the long routes to achieve impact. We compared the logic of each program as it was explicitly documented to the logic as perceived by the implementers. We elucidated the program impact pathways (PIPs) of key activities by actors at different operational levels in each program to identify congruencies and gaps in the perceptions of causal mechanisms between program activities and their intended outcomes, and analyzed them with the simple program models and logical frameworks to highlight the methodology and utility of PIPs. In a desire to move beyond static input-out models of the three programs, we designed and conducted data collection activities (document review, semi-structured interviews, and observations) with the intention of gaining insights about those aspects of the program that brought causal mechanisms of a given program into clearer focus. We propose that different methods for eliciting PIPs may be necessary at different operational levels. The interview method elicited more complete responses among those who are familiar with programmatic concepts, whereas actors at the local operational level provided sparse and fragmentary responses, even when simple, common language was used during the interviews. Group participatory processes, using visual aids, may be more effective for mapping the perceptions of those who are not accustomed to articulating information about programs. To reduce the length and frequency of interviews with program actors, initial PIPs could also be constructed from program documents, then discussed and revised iteratively with program actors. Although program logic models and the logical frameworks provide a succinct overview of the program (for communication, strategic planning, and management), we found that PIPs provide a better representation of the causal connections between program activities and results, particularly when both upstream and direct intervention activities were part of the same program. PIPs provide a visual tool for tracking how activities were perceived to work and make an impact, bringing into focus the different pathways of the activities and influences along the way. Beyond the logical sequence of program inputs, outputs, and outcomes, the conceptualization of impact pathways is a useful approach for understanding the causal connections required for impact and for identifying where attention and reinforcements may be required within program operation. The utility of this tool warrants its use not only during final evaluation but also during mid-program monitoring and relevant assessments. National- and regional-level program actors had good understanding of the overarching frameworks and principles of their respective programs as well as the program components and activities. They demonstrated a strong coherence to the program documents, provided similar cohesive responses, and were able to articulate the impact pathways. However, program actors at the national level identified fewer facilitators and barriers along the impact pathways than did the local actors, revealing that the practical dimensions of the impact pathways were not as evident to planners and managers farther from the communities. Although program actors at the local level were more apt to provide practical examples of influencing factors or incidents that occur during implementation, they had difficulty fully articulating their perceived PIPs and provided fragmented views of how the activities linked to their outcomes. Similar patterns were found across the three programs. This finding raises the question of desirability of a common understanding of the goals and pathways by which these outcomes are achieved or the acceptability of diversity of perspectives. It is still unclear whether program effectiveness may be improved through greater congruency in the PIPs. Future research should elucidate how congruency of PIPs among program actors across operational levels could be increased, and whether greater congruency would improve program implementation and effectiveness.program impact pathway, program logic model, logical framework, childhood stunting, child nutrition programs,

Intervention Design Elements Are Associated with Frontline Health Workers\u27 Performance to Deliver Infant and Young Child Nutrition Services in Bangladesh and Vietnam

Background: Frontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance.Objectives: We examined whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services.Methods: Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in non-intensive (A&T-NI) areas received standard government training and supervision. There was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the 2 program areas. Path analyses were conducted to examine the paths from exposure to performance outcomes measured at FLW and end-user levels.Results: Compared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3-3.6 of 10 points), supportive supervision (0.3-3.5 points), and mass media exposure (0.3-3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service received (beta = 0.12-1.04 in Bangladesh and 0.11-0.96 in Vietnam) and maternal knowledge (beta = 0.12-0.17 in Bangladesh and 0.04-0.21 in Vietnam).Conclusions: Training, supervision, and mass media exposure can be implemented at large scale and contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother\u27s service utilization and IYCF knowledge. Training, supervision, and mass media to enhance service provision should be considered when designing interventions. This trial was registered at clinicaltrials.gov as NCT01678716 (Bangladesh) and NCT01676623 (Vietnam)

Understanding the role of intersectoral convergence in the delivery of essential maternal and child nutrition interventions in Odisha, India: a qualitative study.

BACKGROUND: Convergence of sectoral programs is important for scaling up essential maternal and child health and nutrition interventions. In India, these interventions are implemented by two government programs - Integrated Child Development Services (ICDS) and National Rural Health Mission (NRHM). These programs are designed to work together, but there is limited understanding of the nature and extent of coordination in place and needed at the various administrative levels. Our study examined how intersectoral convergence in nutrition programming is operationalized between ICDS and NRHM from the state to village levels in Odisha, and the factors influencing convergence in policy implementation and service delivery. METHODS: Semi-structured interviews were conducted with state-level stakeholders (n = 12), district (n = 19) and block officials (n = 66), and frontline workers (FLWs, n = 48). Systematic coding and content analysis of transcripts were undertaken to elucidate themes and patterns related to the degree and mechanisms of convergence, types of actions/services, and facilitators and barriers. RESULTS: Close collaboration at state level was observed in developing guidelines, planning, and reviewing programs, facilitated by a shared motivation and recognized leadership for coordination. However, the health department was perceived to drive the agenda, and different priorities and little data sharing presented challenges. At the district level, there were joint planning and review meetings, trainings, and data sharing, but poor participation in the intersectoral meetings and limited supervision. While the block level is the hub for planning and supervision, cooperation is limited by the lack of guidelines for coordination, heavy workload, inadequate resources, and poor communication. Strong collaboration among FLWs was facilitated by close interpersonal communication and mutual understanding of roles and responsibilities. CONCLUSIONS: Congruent or shared priorities and regularity of actions between sectors across all levels will likely improve the quality of coordination, and clear roles and leadership and accountability are imperative. As convergence is a means to achieving effective coverage and delivery of services for improved maternal and child health and nutrition, focus should be on delivering all the essential services to the mother-child dyads through mechanisms that facilitate a continuum of care approach, rather than sectorally-driven, service-specific delivery processes

Early Breastfeeding Practices Contribute to Exclusive Breastfeeding in Bangladesh, Vietnam and Ethiopia

Limited evidence exists on the complex relationship among interventions, early initiation of breastfeeding (EIBF), prelacteal feeding and exclusive breastfeeding (EBF). We examined whether early breastfeeding practices are associated with EBF and how much improving EIBF and non-prelacteal feeding contributes to increased prevalence of EBF. Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh, Vietnam and Ethiopia. Multivariable logistic regression analyses were used to examine effects of interventions and early breastfeeding practices on EBF. Structural equation modelling quantified the direct and indirect effects of interventions (via improving EIBF and non-prelacteal feeding) on EBF. Although breastfeeding is nearly universal in all three countries (≥98%), delayed initiation of breastfeeding is prevalent (\u3e60%) and prelacteal feeding is common. EIBF alone was not associated with EBF, whereas non-prelacteal feeding was associated with 1.6-3.5 higher odds of EBF. Intervention exposure affected breastfeeding practices in all three countries; these impacts were amplified among those who practiced EIBF or non-prelacteal feeding [odds ratio (OR) = 11 and 27.5 in Bangladesh and 6.5 and 11.5 in Vietnam, respectively]. The paths through EIBF and non-prelacteal feeding explained 13%-18% of the effect of the interventions on EBF. Early breastfeeding practices influence EBF, but interventions aimed only at the initiation and early days of breastfeeding will be inadequate to promote EBF. Social and behaviour change interventions should simultaneously target EIBF, non-prelacteal feeding and EBF to support optimal breastfeeding practices

Ganglionated Plexi Modulate Extrinsic Cardiac Autonomic Nerve Input Effects on Sinus Rate, Atrioventricular Conduction, Refractoriness, and Inducibility of Atrial Fibrillation

ObjectivesThis study sought to systematically investigate the interactions between the extrinsic and intrinsic cardiac autonomic nervous system (ANS) in modulating electrophysiological properties and atrial fibrillation (AF) initiation.BackgroundSystematic ganglionated plexi (GP) ablation to evaluate the extrinsic and intrinsic cardiac ANS relationship has not been detailed.MethodsThe following GP were exposed in 28 dogs: anterior right GP (ARGP) near the sinoatrial node, inferior right ganglionated plexi (IRGP) at the junction of the inferior vena cava and atria, and superior left ganglionated plexi (SLGP) near the junction of left superior pulmonary vein and left pulmonary artery. With unilateral vagosympathetic trunk stimulation (0.6 to 8.0 V, 20 Hz, 0.1 ms in duration), sinus rate (SR), and ventricular rate (VR) during AF were compared before and after sequential ablation of SLGP, ARGP, and IRGP.ResultsThe SLGP ablation significantly attenuated the SR and VR slowing responses with right or left vagosympathetic trunk stimulation. Subsequent ARGP ablation produced additional effects on SR slowing but not VR slowing. After SLGP + ARGP ablation, IRGP ablation eliminated VR slowing but did not further attenuate SR slowing with vagosympathetic trunk stimulation. Unilateral right and left vagosympathetic trunk stimulation shortened the effective refractory period and increased AF inducibility of atrium and pulmonary vein near the ARGP and SLGP, respectively. The ARGP ablation eliminated ERP shortening and AF inducibility with right vagosympathetic trunk stimulation, whereas SLGP ablation eliminated ERP shortening but not AF inducibility with left vagosympathetic trunk stimulation.ConclusionsThe GP function as the “integration centers” that modulate the autonomic interactions between the extrinsic and intrinsic cardiac ANS. This interaction is substantially more intricate than previously thought

Exposure to Mass Media and Interpersonal Counseling Has Additive Effects on Exclusive Breastfeeding and Its Psychosocial Determinants Among Vietnamese Mothers

The pathways through which behavior change interventions impact breastfeeding practices have not been well studied. This study aimed to examine: (1) the effects of exposure to mass media and interpersonal counseling on exclusive breastfeeding (EBF) and hypothesized psychosocial determinants (i.e. knowledge, intention, beliefs, social norms, and self-efficacy); and (2) the pathways through which exposure to mass media and interpersonal counseling are associated with EBF. We used survey data from mothers with children\u3c 2 year (n = 2045) from the 2013 process evaluation of Alive & Thrive’s program in Viet Nam. Multiple linear regression analyses and structural equation modeling were used to estimate effects. Exposure to mass media only, interpersonal counseling only, both or neither was 51%, 5%, 19% and 25%, respectively. Exposure to both mass media and interpersonal counseling had additive effects on EBF as well as on related psychosocial factors, compared with no exposure. For example, EBF prevalence was 26.1 percentage points (pp) higher in the group that received interpersonal counseling only, 3.9 pp higher in the mass media group and 31.8 pp higher in the group that received both interventions. As hypothesized, more than 90% of the total effect of the two interventions on EBF was explained by the psychosocial factors measured. Our findings suggest that combining different behavior change interventions leads to greater changes in psychosocial factors, which in turn positively affects breastfeeding behaviors

Different Combinations of Behavior Change Interventions and Frequencies of Interpersonal Contacts Are Associated With Infant and Young Child Feeding Practices in Bangladesh, Ethiopia, and Vietnam

Background: Social and behavior change communication interventions are integral to improving dietary and care practices, but evidence on the impact of the combination and intensity of these interventions in different contexts is scarce. Objectives: We examined the extent of and factors associated with intervention exposure: interpersonal communication (IPC) alone or with other interventions (i.e., mass media, community mobilization, or nutrition-sensitive agricultural activities), number of and factors associated with IPC contacts, and combinations of intervention components and number of contacts associated with infant and young child feeding (IYCF) practices. Methods: We used endline survey data from impact evaluations in Bangladesh, Ethiopia, and Vietnam ( = 1001, 1720, and 1001 mothers with children agedy, respectively). Multivariable regression models were used for analyses. Results: Exposure to the interventions varied in all 3 countries. On average, mothers received 8 visits in the last 6 mo in Bangladesh, 2 visits in the last 3 mo in Ethiopia, and 1 visit in the last 6 mo in Vietnam. Across countries, the factors associated with intervention exposure and number of IPC contacts differed. In Ethiopia, exposure to IPC with other interventions was associated with higher odds of achieving minimum meal frequency (OR: 1.6), minimum dietary diversity (OR: 1.8), and consumption of iron-rich foods (OR: 4.7). In Vietnam, exposure to IPC alone or with mass media was associated with higher odds of exclusive breastfeeding (EBF; OR: 2.8-3.7). Near-monthly visits were associated with 2-3 times higher odds of IYCF practices in Bangladesh and Ethiopia. In Vietnam, even 1 IPC visit was associated with 2 times higher odds of EBF. Conclusions: Exposure matters for impact, but the combination of behavior change interventions and number of IPC contacts required to support IYCF behavior change are context specific. This trial was registered at www.clinicaltrials.gov as NCT01678716 (Bangladesh), NCT02775552 (Ethiopia), and NCT01676623 (Vietnam)

Development of a methods repository for food choice behaviors and drivers at the household and individual levels

This brief identifies important constructs for assessing drivers of food choice behaviors and describes progress on the development of a repository of instruments and measures for assessing these constructs. OBJECTIVES 1. List constructs that can be assessed to understand drivers of household and individual food choice behaviors. 2. Identify instruments and measures to assess each food choice construct and organize these into a searchable repository. 3. Illustrate the use of the Food Choice Repository

Information Diffusion and Social Norms Are Associated With Infant and Young Child Feeding Practices in Bangladesh

Background Interaction within mothers’ social networks can theoretically diffuse messages from interventions and campaigns into norms and practices for infant and young child feeding (IYCF). Objectives We hypothesized that mothers’ social networks, diffusion of information, and social norms differed in intensive [intensive interpersonal counseling (IPC), community mobilization (CM), and mass media (MM)] compared with nonintensive (standard IPC and less-intensive CM and MM) intervention areas, were associated with IYCF practices, and partly explained practice improvement. Methods We conducted household surveys at endline in 2014 and follow-up in 2016 (n = ∼2000 each round). We used multiple regression to test differences and changes in networks, diffusion, and norms within intervention areas. We analyzed paths from intervention exposure to IYCF practices through networks, diffusion, and norms. Results Mothers’ networks were larger in intensive than in nonintensive areas in 2014 and increased in both areas over time [25–38 percentage points (pp)]. The prevalence of receipt of IYCF information was high, with no changes over time in intensive areas but an increase in nonintensive areas (8–16 pp). In both areas, more family members and health workers provided IYCF information over time. Sharing of information increased 17–23 pp in intensive and 11–41 pp in nonintensive areas over time. Perceived descriptive norms improved 8–16 pp in intensive and 17–28 pp in nonintensive areas. Perceived injunctive norms were high in both areas. Breastfeeding practices were associated with networks, diffusion, and norms (OR: 1.6–4.4 times larger comparing highest with lowest quartile). Minimum dietary diversity was associated with larger networks and diffusion (OR: 1.5–2.2) but not with social norms. Indirect paths from intervention exposure to practices explained 34–78% of total effects. Conclusions Diffusion of IYCF information through social networks, reinforced by positive social norms for messages promoted over time, will contribute to positive changes in IYCF practices that may be achieved and sustained through large-scale social and behavior change interventions. This trial was registered at clinicaltrials.gov as NCT0274084