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1.  Defining Incident Cases of Epilepsy in Administrative Data 
Epilepsy research  2013;106(0):273-279.
To determine the minimum enrollment duration for identifying incident cases of epilepsy in administrative data.
We performed a retrospective dynamic cohort study using Ohio Medicaid data from 1992–2006 to identify a total of 5,037 incident epilepsy cases who had at least 1 year of follow-up prior to epilepsy diagnosis (epilepsy-free interval). The incidence for epilepsy-free intervals from 1 to 8 years, overall and stratified by pre-existing disability status, was examined. The graphical approach between the slopes of incidence estimates and the epilepsy-free intervals was used to identify the minimum epilepsy-free interval that minimized misclassification of prevalent as incident epilepsy cases.
As the length of epilepsy-free interval increased, the incidence rates decreased. A graphical plot showed that the decline in incidence of epilepsy became nearly flat beyond the third epilepsy-free interval.
The minimum of 3-year epilepsy-free interval is needed to differentiate incident from prevalent cases in administrative data. Shorter or longer epilepsy-free intervals could result in over- or under-estimation of epilepsy incidence.
PMCID: PMC3759552  PMID: 23791310
Incidence; Administrative data; Epilepsy
Cancer  2011;118(17):4271-4279.
Study Objective
To compare survival and 5-year mortality, by Medicaid status, in adults diagnosed with 8 select cancers.
Linking records from the Ohio Cancer Incidence Surveillance System (OCISS) with Ohio Medicaid enrollment data, we identified Medicaid and non-Medicaid patients aged 15–54 years and diagnosed with the following incident cancers in the years 1996–2002: cancer of the testis; Hodgkin’s and non-Hodgkin’s lymphoma; early-stage melanoma, colon, lung, and bladder cancer; or pediatric malignancies (n=12,703). Medicaid beneficiaries were identified in the pre-diagnosis group if they were enrolled in Medicaid at least 3 months before cancer diagnosis, and in the peri/post-diagnosis group if they enrolled in Medicaid upon or after being diagnosed with cancer. We also linked the OCISS with death certificates and data from the U.S. Census. Using Cox and logistic regression analysis, we examined the association between Medicaid status and each of survival and 5-year mortality, respectively, after adjusting for patient covariates.
Nearly 11% of the study population were Medicaid beneficiaries. Of those, 45% were identified in the peri/post-diagnosis group. Consistent with higher mortality, findings from the Cox regression model indicated that compared to non-Medicaid, patients in the Medicaid pre-diagnosis and peri/post-diagnosis groups experienced unfavorable survival outcomes (adjusted hazard ratio (AHR): 1.52, 95% confidence interval (1.27, 1.82), and 2.01 (1.70, 2.38), respectively).
Medicaid status was associated with unfavorable survival, even after adjusting for confounders.
The findings reflect the vulnerability of Medicaid beneficiaries and possible inadequacies in the process of care.
PMCID: PMC3323683  PMID: 22213271
Curable Cancers; Survival Outcomes; Medicaid Status; Linked Databases
3.  Incidence and prevalence of treated epilepsy among poor health and low-income Americans 
Neurology  2013;80(21):1942-1949.
To determine the incidence and prevalence of treated epilepsy in an adult Medicaid population.
We performed a retrospective, dynamic cohort analysis using Ohio Medicaid claims data between 1992 and 2006. Individuals aged 18–64 years were identified as prevalent cases if they had ≥2 claims of epilepsy (ICD-9-CM: 345.xx) or ≥3 claims of convulsion (ICD-9-CM: 780.3 or 780.39) and ≥2 claims of antiepileptic drugs. Incident cases were required to have no epilepsy or convulsion claims for ≥5 years before epilepsy diagnosis. Subjects were determined as having preexisting disability and/or comorbid conditions, including brain tumor, depression, developmental disorders, migraine, schizophrenia, stroke, and traumatic brain injury, when at least one of these conditions occurred before epilepsy onset.
There were 9,056 prevalent cases of treated epilepsy in 1992–2006 and 1,608 incident cases in 1997–2006. The prevalence was 13.2/1,000 (95% confidence interval, 13.0–13.5/1,000). The incidence was 362/100,000 person-years (95% confidence interval, 344–379/100,000 person-years). The incidence and prevalence were significantly higher in men, in older people, in blacks, and in people with preexisting disability and/or comorbid conditions. The most common preexisting conditions in epilepsy subjects were depression, developmental disorders, and stroke, whereas people with brain tumor, traumatic brain injury, and stroke had the higher risk of developing epilepsy.
The Medicaid population has a high incidence and prevalence of epilepsy, in an order of magnitude greater than that reported in the US general population. This indigent population carries a disproportionate amount of the epilepsy burden and deserves more attention for its health care needs and support services.
PMCID: PMC3716344  PMID: 23616158
Journal of geriatric oncology  2011;2(3):200-208.
To examine the effects of the occurrence and co-occurrence of comorbidities (COM), functional limitations (FL), and geriatric syndromes (GS) on treatment and outcomes in older cancer patients.
Materials and Methods
We used records from the Ohio Cancer Incidence Surveillance System linked with Medicare data, clinical assessment data from the home health care Outcomes and Assessment Information Set, and death certificate data. Our patient population included fee-for-service HHC Medicare beneficiaries diagnosed with incident loco-regional breast or colorectal cancer in years 1999–2001 (n=1236). We grouped patients according to the presence of multimorbidity: (0): none of COM, FL, or GS; (1): occurrence – but no co-occurrence – of COM, FL, or GS; (2): co-occurrence of any two of COM, FL, and GS; and (3): co-occurrence of all three of COM, FL, and GS. Our outcomes were receipt of standard treatment, as well as overall survival (OS) and disease-specific survival (DSS) through 2005. Multivariable regression models were developed to analyze the independent association between multimorbidity and the outcomes, before and after adjusting for age.
The effect of multimorbidity on our outcomes was attenuated considerably by age. Adjusting for age and compared with no multimorbidity (0), high multimorbidity (3) remained significantly and negatively associated with receipt of standard treatment (adjusted odds ratio: 0.57, 95% Confidence Interval (CI): 0.33, 0.97). Furthermore, high multimorbidity (3) was associated with increased hazard for OS, but not for DSS (adjusted hazard ratio and 95% CI: 2.15 (1.58, 2.93) for three entities).
Multimorbidity is significantly and independently associated with cancer treatment and OS, but not DSS.
PMCID: PMC3140210  PMID: 21785664
Comorbidity; Functional Limitations; Geriatric Syndromes; Multimorbidity; Colorectal Cancer; Breast Cancer; Standard Treatment; Survival
5.  Mental Illness and Use of Screening Mammography Among Medicaid Beneficiaries 
Disparities in receipt of preventive services by people with mental illness have been previously documented. However, whether these disparities extend to screening mammography among individuals experiencing comparable barriers to accessing care has not been fully examined.
To determine whether disparities exist in receipt of screening mammography between women with and without mental illness enrolled in Medicaid, a program with documented potential to reduce healthcare disparities.
Receipt of screening mammography was examined among women aged 50–64 years enrolled in Ohio’s Medicaid program during the years 2002–2008 (n=130,088). Receipt of annual screening mammography was examined among those with at least one screening mammography during the study period. Mental illness was identified through diagnostic, service, and pharmacotherapy codes (n=61,661).
Compared to women without mental illness, more women with mental illness received at least one screening mammography during the study period (38.1% vs 31.7%, p<0.001). However, after adjusting for potential confounders, including the presence of comorbid conditions and length of enrollment in Medicaid, women with mental illness were 32% less likely to undergo at least one screening mammography (AOR 0.68, 95% CI= 0.66, 0.70). Among those who received at least one screening mammography, fewer women with mental illness received screening mammography on an annual basis (5.9% vs 12.7%, p< 0.001; AOR 0.53 (95% CI= 0.49, 0.56)). For all beneficiaries, each year of enrollment in Medicaid increased the likelihood of screening mammography use by at least 50%.
Medicaid beneficiaries with mental illness constitute a particularly vulnerable population for suboptimal breast cancer screening.
PMCID: PMC3631560  PMID: 22608377
6.  Cancer Outcomes in Low-Income Elders: Is There An Advantage to Being on Medicaid? 
Medicare & Medicaid Research Review  2012;2(2):mmrr.002.02.a06.
Because of reduced financial barriers, dual Medicare-Medicaid enrollment of low-income Medicare beneficiaries may be associated with receipt of definitive cancer treatment and favorable survival outcomes.
We used a database developed by linking records from the Ohio Cancer Incidence Surveillance System with Medicare and Medicaid files, death certificates, and U.S. Census data. The study population included community-dwelling Medicare fee-for-service beneficiaries, age 66 years or older, with low incomes, residing in Ohio, and diagnosed with incident loco-regional breast (n=838), colorectal (n=784), or prostate cancer (n=946) in years 1997–2001. We identified as “duals” Medicare beneficiaries who were enrolled in Medicaid at least three months prior to cancer diagnosis. Multivariable logistic regression and survival models were developed to analyze the association between dual status and (1) receipt of definitive treatment; and (2) overall and disease-specific survival, after adjusting for tumor stage and patient covariates.
Dual status was associated with a significantly lower likelihood to receive definitive treatment among colorectal cancer patients (Adjusted Odds Ratio: 0.60, 95% Confidence Interval, or CI, [0.38, 0.95]), but not among breast or prostate cancer patients. Furthermore, dual status was associated with decreased overall survival among prostate cancer patients (Adjusted Hazard Ratio, or AHR, 1.45, 95% CI [1.05, 2.02]), and decreased disease-specific survival among colorectal cancer patients (AHR: 1.52 [1.05, 2.19]).
Enrollment of low-income Medicare beneficiaries in Medicaid is not associated with favorable treatment patterns or survival outcomes. Differences in health and functional status between community-dwelling duals and non-duals might help explain the observed disparities.
PMCID: PMC4006380  PMID: 24800139
Dually Eligible; Low-Income Medicare-Medicaid Beneficiaries; Cancer-Related Outcomes; Breast Cancer; Colorectal Cancer; Prostate Cancer; Cancer treatment; Linked Databases
7.  Analysis of HIV tropism in Ugandan infants 
Current HIV research  2010;8(7):498-503.
HIV-infected infants may have CXCR4-using (X4-tropic) HIV, CCR5-using (R5-tropic) HIV, or a mixture of R5-tropic and X4-tropic HIV (dual/mixed, DM HIV). The level of infectivity for R5 virus (R5-RLU) varies among HIV-infected infants. HIV tropism and R5-RLU were measured in samples from HIV-infected Ugandan infants using a commercial assay. DM HIV was detected in 7/72 (9.7%) infants at the time of HIV diagnosis (birth or 6–8 weeks of age, 4/15 (26.7%) with subtype D, 3/57 (5.3 %) with other subtypes, P=0.013). A transition from R5-tropic to DM HIV was observed in only two (6.7%) of 30 infants over 6–12 months. Six (85.7%) of seven infants with DM HIV died, compared to 21/67 (31.3%) infants with R5-tropic HIV (p=0.09). Higher R5-RLU at 6–8 weeks was not associated with decreased survival. Infants with in utero infection had a higher median R5-RLU than infants who were HIV-uninfected at birth (p=0.025).
PMCID: PMC3075545  PMID: 21073438
CCR5; CXCR4; HIV-1; infant; survival; transmission; tropism
8.  Emergence and persistence of nevirapine (NVP) resistance in breast milk after single-dose NVP administration 
AIDS (London, England)  2010;24(4):557-561.
Single-dose nevirapine (sdNVP) can reduce the risk of HIV vertical transmission. We assessed risk factors for NVP resistance in plasma and breast milk from sdNVP-exposed Ugandan women.
Samples were analyzed using the Roche AMPLICOR HIV-1 Monitor Test Kit, v1.5, and the ViroSeq HIV-1 Genotyping System. NVP concentrations were determined by liquid chromatography with tandem mass spectroscopy.
HIV genotypes (plasma and breast milk) were obtained for 30 women 4 weeks after sdNVP (HIV subtypes: 15A, 1C, 12D, 2 recombinant). NVP resistance was detected in 12 (40%) of 30 breast milk samples. There was a non-significant trend between detection of NVP resistance in breast milk and plasma (p=0.06). There was no association of HIV resistance in breast milk with median maternal pre-NVP viral load or CD4 cell count, median breast milk viral load at 4 weeks, breast milk sodium >10 mmol/L, HIV subtype, or concentration of NVP in breast milk or plasma.
NVP resistance was frequently detected in breast milk 4 weeks after sdNVP exposure. In this study, we were unable to identify specific factors associated with breast milk NVP resistance.
PMCID: PMC3065236  PMID: 20057308
nevirapine; HIV-1; breast milk; Uganda; vertical transmission; nevirapine resistance
9.  Comorbidities, Functional Limitations, and Geriatric Syndromes in Relation to Treatment and Survival Patterns Among Elders With Colorectal Cancer 
To examine patterns of colorectal cancer (CRC) treatment and survival in relation to comorbidities (COM), functional limitations (FL), and geriatric syndromes (GS).
Our study population consisted of Ohio elders diagnosed with incident invasive CRC in the period August 1999 to November 2001 and admitted to home health care (HHC) in the 30 days before or after cancer diagnosis (n = 1009). We used data from the Ohio Cancer Incidence Surveillance System, vital records, and Medicare administrative data, including the HHC Outcome and Assessment Information Set (OASIS), which includes detailed clinical data for HHC patients. Counts of COM, FL, and GS at baseline were retrieved from the OASIS. Multivariable logistic and survival models were developed to examine the association between clinical attributes and outcomes, adjusting for demographic covariates and cancer stage.
Comorbidities were associated with increased likelihood of surgery-only, but not with surgery + chemotherapy. Both FL and GS were associated with lower likelihood to undergo surgery-only or surgery + chemotherapy. Two or more GS was associated with disease-specific mortality (adjusted hazard ratio [AHR]: 2.71; 95% confidence interval [CI]: 1.80–4.07) and overall mortality (AHR: 2.34; 95% CI: 1.74–3.15). Two or more FL was associated with overall mortality (AHR: 1.33; 95% CI: 1.10–1.62), but not with disease-specific mortality. COM was not associated with overall mortality, but was negatively associated with disease-specific mortality at borderline level of significance (AHR: 0.78; 95% CI: 0.61–1.00).
Our findings demonstrate the importance of accounting for FL and GS, in addition to COM, when studying cancer-related outcomes in elders.
PMCID: PMC2904594  PMID: 20018824
Comorbidities; Functional limitations; Geriatric syndromes; Colorectal cancer
10.  HLA polymorphisms and detection of kaposi sarcoma-associated herpesvirus DNA in saliva and peripheral blood among children and their mothers in the uganda sickle cell anemia KSHV Study 
Kaposi sarcoma-associated herpesvirus (KSHV, also called Human herpesvirus 8 or HHV8) is a γ-2 herpesvirus that causes Kaposi sarcoma. KSHV seroprevalence rates vary geographically with variable rates recorded in different sub Sahara African countries, suggesting that effects of genetic and/or environmental factors may influence the risk of infection. One study conducted in South Africa, where KSHV seroprevalence is relatively low, found that carriage of human leukocyte antigen (HLA) alleles HLA-A*6801, HLA-A*30, HLA-A*4301, and HLA-DRB1*04 was associated with increased shedding of KSHV DNA in saliva. Confirmation of those results would strengthen the hypothesis that genetic factors may influence KSHV distribution by modulating KSHV shedding in saliva. To explore these associations in another setting, we used high resolution HLA-A, B, and DRB1 typing on residual samples from the Uganda Sickle Cell Anemia KSHV study, conducted in a high KSHV seroprevalence region, to investigate associations between HLA and KSHV shedding in saliva or peripheral blood among 233 children and their mothers. HLA-A and HLA-DRB1 alleles were not associated with KSHV shedding in our study, but our study was small and was not adequately powered to exclude small associations. In exploratory analyses, we found marginal association of KSHV DNA shedding in saliva but not in peripheral blood among children carrying HLA- B*4415 and marginal association of KSHV DNA shedding in peripheral blood but not in saliva among children carrying HLA- B*0801 alleles. The contribution of individual HLA polymorphisms to KSHV shedding is important but it may vary in different populations. Larger population-based studies are needed to estimate the magnitude and direction of association of HLA with KSHV shedding and viral control.
PMCID: PMC2995779  PMID: 21087485
11.  Hepatitis C Virus Genotype 4 in Ugandan Children and Their Mothers 
Emerging Infectious Diseases  2006;12(9):1440-1443.
In Kampala, Uganda, in 2001, hepatitis C virus antibodies were found in 27 (4%) of 603 children and in 62 (12%) of 525 of their mothers. However, only ≈10% of positive results were confirmed by reverse transcription–PCR, which suggests frequent false-positive results or viral clearance. All sequenced types were genotype 4.
PMCID: PMC3294722  PMID: 17073099
hepatitis C virus; genotype 4; Africa; epidemiology; phylogeny; sequencing; sickle cell anemia; transmission

Results 1-11 (11)