Process Evaluation of the Los Angeles Unified School District Nutrition Network

IntroductionThis study evaluated the Los Angeles Unified School District Nutrition Network, a large multicomponent nutrition and physical activity program in an ethnically diverse school district, launched in 2000.MethodsWe calculated descriptive statistics and performed hierarchical logistic regression on school-level demographic and implementation data.ResultsThirty-six percent of eligible schools participated in 2001, and 79% of participating schools reapplied the following year. Elementary schools and schools that applied for grant money were more likely to re-apply. Produce sampling was the most frequently cited program highlight, and making purchases with program grant money was the most frequently cited challenge.ConclusionOur findings suggest that schools serving students of low socioeconomic status and diverse ethnicities can be recruited into a large program to promote healthy dietary choices and physical activity, especially elementary schools. Effectiveness and institutionalization of the program might be positively affected by fostering local ownership, allowing school personnel who apply for the grant to tailor the program to their individual schools

Population-based Interventions Engaging Communities of Color in Healthy Eating and Active Living: A Review

INTRODUCTION: The U.S. obesity epidemic is escalating, particularly among communities of color. Obesity control efforts have shifted away from individual-level approaches toward population-based approaches that address socio-cultural, political, economic, and physical environmental factors. Few data exist for ethnic minority groups. This article reviews studies of population-based interventions targeting communities of color or including sufficient samples to permit ethnic-specific analyses. METHODS: Inclusion criteria were established, an electronic database search conducted, and non-electronically catalogued studies retrieved. Findings were aggregated for earlier (early 1970s to early 1990s) and later (mid-1990s to present) interventions. RESULTS: The search yielded 23 ethnically inclusive intervention studies published between January 1970 and May 2003. Several characteristics of inclusive interventions were consistent with characteristics of community-level interventions among predominantly white European-American samples: use of non-interpersonal channels for information dissemination directed at broad spheres of influence (e.g., mass media), promotion of physical activity, and incorporation of social marketing principles. Ethnically inclusive studies, however, also placed greater emphasis on involving communities and building coalitions from study inception; targeting captive audiences; mobilizing social networks; and tailoring culturally specific messages and messengers. Inclusive studies also focused more on community than individual norms. Later studies used "upstream" approaches more than earlier studies. Fewer than half of the inclusive studies presented outcome evaluation data. Statistically significant effects were few and modest, but several studies demonstrated better outcomes among ethnic minority than white participants sampled. CONCLUSION: The best data available speak more about how to engage and retain people of color in these interventions than about how to create and sustain weight loss, regular engagement in physical activity, or improved diet. Advocacy should be directed at increasing the visibility and budget priority of interventions, particularly at the state and local levels

Minimum wage and overweight and obesity in adult women: a multi-level analysis of low and middle-income countries

Objectives: To describe the relationship between minimum wage and overweight and obesity across countries at different levels of development. Methods: A cross-sectional analysis of 27 countries with data on the legislated minimum wage level linked to socio-demographic and anthropometry data of non-pregnant 190,892 adult women (24–49 y) from the Demographic and Health Survey. We used multilevel logistic regression models to condition on country- and individual-level potential confounders, and post-estimation of average marginal effects to calculate the adjusted prevalence difference. Results: We found the association between minimum wage and overweight/obesity was independent of individual-level SES and confounders, and showed a reversed pattern by country development stage. The adjusted overweight/obesity prevalence difference in low-income countries was an average increase of about 0.1 percentage points (PD 0.075 [0.065, 0.084]), and an average decrease of 0.01 percentage points in middle-income countries (PD -0.014 [-0.019, -0.009]). The adjusted obesity prevalence difference in low-income countries was an average increase of 0.03 percentage points (PD 0.032 [0.021, 0.042]) and an average decrease of 0.03 percentage points in middle-income countries (PD -0.032 [-0.036, -0.027])

The association between advanced diagnostic imaging and ED length of stay

ObjectiveThere has been a rise in advanced diagnostic imaging (ADI) use in the emergency department (ED). Increased utilization may contribute to longer length of stay (LOS), but prior reports have not considered improved methods for modeling skewed LOS data.MethodsThe 2010 National Hospital Ambulatory Medical Care Survey data were analyzed by 5 common ED chief complaints. Generalized linear model (GLM) was compared to quantile and ordinary least squares (OLS) regression to evaluate the association between ADI and ED LOS. Receipt of computed tomography or magnetic resonance imaging was the primary exposure. Emergency department LOS was the primary outcome.ResultsOf the 33,685 ED visits analyzed, 17% involved ADI. The median LOS for patients without ADI was 138 minutes compared to 252 minutes for those who received ADI. Overall, GLM offered the most unbiased estimates, although it provided similar adjusted point estimates to OLS for the marginal change in LOS associated with ADI. The effect of imaging differed by LOS quantile, especially for patients with abdominal pain, fever, and back symptoms.ConclusionsGeneralized linear model offered an improved modeling approach compared to OLS and quantile regression. Consideration of such techniques may facilitate a more complete view of the effect of ADI on ED LOS

Segmentation of High-Cost Adults in an Integrated Healthcare System Based on Empirical Clustering of Acute and Chronic Conditions

BackgroundHigh-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population.ObjectiveTo define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending.DesignRetrospective observational cohort study.ParticipantsWithin a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010.Main measuresWe used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients.ResultsAmong 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4 years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups.ConclusionsData-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4 years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly