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4.  Defining and Measuring Chronic Conditions: Imperatives for Research, Policy, Program, and Practice 
Current trends in US population growth, age distribution, and disease dynamics foretell rises in the prevalence of chronic diseases and other chronic conditions. These trends include the rapidly growing population of older adults, the increasing life expectancy associated with advances in public health and clinical medicine, the persistently high prevalence of some risk factors, and the emerging high prevalence of multiple chronic conditions. Although preventing and mitigating the effect of chronic conditions requires sufficient measurement capacities, such measurement has been constrained by lack of consistency in definitions and diagnostic classification schemes and by heterogeneity in data systems and methods of data collection. We outline a conceptual model for improving understanding of and standardizing approaches to defining, identifying, and using information about chronic conditions in the United States. We illustrate this model’s operation by applying a standard classification scheme for chronic conditions to 5 national-level data systems.
PMCID: PMC3652713  PMID: 23618546
5.  Co-Occurrence of Leading Lifestyle-Related Chronic Conditions Among Adults in the United States, 2002-2009 
Public health and clinical strategies for meeting the emerging challenges of multiple chronic conditions must address the high prevalence of lifestyle-related causes. Our objective was to assess prevalence and trends in the chronic conditions that are leading causes of disease and death among adults in the United States that are amenable to preventive lifestyle interventions.
We used self-reported data from 196,240 adults aged 25 years or older who participated in the National Health Interview Surveys from 2002 to 2009. We included data on cardiovascular disease (coronary heart disease, angina pectoris, heart attack, and stroke), cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), diabetes, and arthritis.
In 2002, an unadjusted 63.6% of participants did not have any of the 5 chronic conditions we assessed; 23.9% had 1, 9.0% had 2, 2.9% had 3, and 0.7% had 4 or 5. By 2009, the distribution of co-occurrence of the 5 chronic conditions had shifted subtly but significantly. From 2002 to 2009, the age-adjusted percentage with 2 or more chronic conditions increased from 12.7% to 14.7% (P < .001), and the number of adults with 2 or more conditions increased from approximately 23.4 million to 30.9 million.
The prevalence of having 1 or more or 2 or more of the leading lifestyle-related chronic conditions increased steadily from 2002 to 2009. If these increases continue, particularly among younger adults, managing patients with multiple chronic conditions in the aging population will continue to challenge public health and clinical practice.
PMCID: PMC3652715  PMID: 23618540
7.  Complications of Common Gynecologic Surgeries among HIV-Infected Women in the United States 
Objective. To compare frequencies of complications among HIV-infected and-uninfected women undergoing common gynecological surgical procedures in inpatient settings. Methods. We used 1994–2007 data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, a nationally representative sample of inpatient hospitalizations. Our analysis included discharge records of women aged ≥15 undergoing hysterectomy, oophorectomy, salpingectomy for ectopic pregnancy, bilateral tubal sterilization, or dilation and curettage. Associations between HIV infection status and surgical complications were evaluated in multivariable logistic regression models, adjusting for key covariates. Results. For each surgery, HIV infection was associated with experiencing ≥1 complication. Adjusted ORs ranged from 2.0 (95% confidence interval (CI): 1.7, 2.2) for hysterectomy with oophorectomy to 3.1 (95% CI: 2.4, 4.0) for bilateral tubal sterilization with no comorbidity present. HIV infection was positively associated with extended length of stay and infectious complications of all of the surgeries examined. For some surgeries, it was positively associated with transfusion and anemia due to acute blood loss. Among HIV-infected women, the odds of infectious and other complications did not decrease between 1994–2000 and 2001–2007. Conclusion. HIV infection was associated with elevated frequencies of complications of gynecologic surgeries in the US, even in the era of HAART.
PMCID: PMC3362831  PMID: 22675242
11.  Diabetes Trends Among Delivery Hospitalizations in the U.S., 1994–2004 
Diabetes Care  2010;33(4):768-773.
To examine trends in the prevalence of diabetes among delivery hospitalizations in the U.S. and to describe the characteristics of these hospitalizations.
Hospital discharge data from 1994 through 2004 were obtained from the Nationwide Inpatient Sample. Diagnosis codes were selected for gestational diabetes mellitus (GDM), type 1 diabetes, type 2 diabetes, and unspecified diabetes. Rates of delivery hospitalization with diabetes were calculated per 100 deliveries.
Overall, an estimated 1,863,746 hospital delivery discharges contained a diabetes diagnosis, corresponding to a rate of 4.3 per 100 deliveries over the 11-year period. GDM accounted for the largest proportion of delivery hospitalizations with diabetes (84.7%), followed by type 1 (7%), type 2 (4.7%), and unspecified diabetes (3.6%). From 1994 to 2004, the rates for all diabetes, GDM, type 1 diabetes, and type 2 diabetes significantly increased overall and within each age-group (15–24, 25–34, and ≥35 years) (P < 0.05). The largest percent increase for all ages was among type 2 diabetes (367%). By age-group, the greatest percent increases for each diabetes type were among the two younger groups. Significant predictors of diabetes at delivery included age ≥35 years vs. 15–24 years (odds ratio 4.80 [95% CI 4.72–4.89]), urban versus rural location (1.14 [1.11–1.17]), and Medicaid/Medicare versus other payment sources (1.29 [1.26–1.32]).
Given the increasing prevalence of diabetes among delivery hospitalizations, particularly among younger women, it will be important to monitor trends in the pregnant population and target strategies to minimize risk for maternal/fetal complications.
PMCID: PMC2845025  PMID: 20067968
14.  Severe Obstetric Morbidity in the United States: 1998–2005 
Obstetrics and gynecology  2009;113(2 Pt 1):293-299.
To examine trends in the rates of severe obstetric complications and the potential contribution of changes in delivery mode and maternal characteristics to these trends.
We performed a cross-sectional study of severe obstetric complications identified from the 1998–2005 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regression was used to examine the effect of changes in delivery mode and maternal characteristics on rates of severe obstetric complications.
The prevalence of delivery hospitalizations complicated by at least of one severe obstetric complications increased from 0.64% (n=48,645) in 1998–99 to 0.81% (n=68,433) in 2004–05. Rates of complications per 1,000 which increased significantly during the study period included renal failure by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57). In logistic regression models, adjustment for maternal age had no effect on the increased risk for these complications in 2004–05 relative to 1998–99. However, after adjustment for mode of delivery, the increased risks for these complications in 2004–05 relative to 1998–99 were no longer significant, with the exception of pulmonary embolism (OR=1.30) and blood transfusion (OR=1.72). Further adjustment for payer, multiple births, and select comorbidites had little effect.
Rates of severe obstetric complications increased from 1998–99 to 2004–05. For many of these complications, these increases were associated with the increasing rate of cesarean delivery.
PMCID: PMC2743391  PMID: 19155897
17.  The National Summit on Preconception Care: A Summary of Concepts and Recommendations 
Maternal and Child Health Journal  2006;10(Suppl 1):199-207.
The Centers for Disease Control and Prevention (CDC) and 35 partner organizations have engaged in developing an agenda for Preconception Health. A summit was held in June 2005 to discuss the current state of knowledge regarding preconception care and convene a select panel to develop recommendations and action steps for improving the health of women, children, and families through advances in clinical care, public health, and community action. A Select Panel on Preconception Care, convened by CDC, deliberated critical related issues and created refined definition of preconception care. The panel also developed a strategic plan with goals, recommendations, and action steps for improving preconception health. The recommendations and action steps are specific to the implementation of health behavior, access, consumer demand, research, and surveillance activities for monitoring and improving the health of women, children and families. The outcome of the deliberations is the CDC publication of detailed recommendations and action steps in the Morbidity and Mortality Weekly Report series, Recommendations and Reports.
PMCID: PMC1592248  PMID: 16773451
Preconception care; Maternal health; Health behavior; Research and surviellance; Access to care
18.  A Perspective of Preconception Health Activities in the United States 
Maternal and Child Health Journal  2006;10(Suppl 1):13-20.
Objectives: Information regarding the type and scope of preconception care programs in the United States is scant. We evaluated State Title V measurement and indicator data and abstracts presented at the National Summit on Preconception Care (June 2005) in order to identify existing programs and innovative strategies for preconception health promotion.
Methods: We used the web-based Title V Information System to identify state Performance Measures and Priority Needs pertaining to preconception health as reported for the 2005–2010 Needs Assessment Cycle. We also present a detailed summary of the abstracts presented at the National Summit on Preconception Care.
Results: A total of 23 states reported a Priority Need that focused on preconception health and health care. Forty-two states and jurisdictions identified a Performance Measure associated with preconception health or a related indicator (e.g., folic acid, birth spacing, family planning, unintended pregnancy, and healthy weight). Nearly 60 abstracts pertaining to preconception care were presented at the National Summit and included topics such as research, programs, patient or provider toolkits, clinical practice strategies, and public policy.
Conclusions: Strategies for improving preconception health have been incorporated into numerous programs throughout the United States. Widespread recognition of the benefits of preconception health promotion is evidenced by the number of states identifying related indicators.
PMCID: PMC1592247  PMID: 16231108
Preconception care; Reproductive health; Pregnancy
19.  National estimates for maternal mortality: an analysis based on the WHO systematic review of maternal mortality and morbidity 
BMC Public Health  2005;5:131.
Despite the worldwide commitment to improving maternal health, measuring, monitoring and comparing maternal mortality estimates remain a challenge. Due to lack of data, international agencies have to rely on mathematical models to assess its global burden. In order to assist in mapping the burden of reproductive ill-health, we conducted a systematic review of incidence/prevalence of maternal mortality and morbidity.
We followed the standard methodology for systematic reviews. This manuscript presents nationally representative estimates of maternal mortality derived from the systematic review. Using regression models, relationships between study-specific and country-specific variables with the maternal mortality estimates are explored in order to assist further modelling to predict maternal mortality.
Maternal mortality estimates included 141 countries and represent 78.1% of the live births worldwide. As expected, large variability between countries, and within regions and subregions, is identified. Analysis of variability according to study characteristics did not yield useful results given the high correlation with each other, with development status and region. A regression model including selected country-specific variables was able to explain 90% of the variability of the maternal mortality estimates. Among all country-specific variables selected for the analysis, three had the strongest relationships with maternal mortality: proportion of deliveries assisted by a skilled birth attendant, infant mortality rate and health expenditure per capita.
With the exception of developed countries, variability of national maternal mortality estimates is large even within subregions. It seems more appropriate to study such variation through differentials in other national and subnational characteristics. Other than region, study of country-specific variables suggests infant mortality rate, skilled birth attendant at delivery and health expenditure per capita are key variables to predict maternal mortality at national level.
PMCID: PMC1351170  PMID: 16343339
21.  Knowledge of, attitudes toward, and stage of change for female and male condoms among denver inner-city women 
Despite availability for a decade and documented acceptability among some groups of women for the method, female condom use is still rare. We surveyed 198 young women (15–25 years old) living in the inner city of Denver about their knowledge of, attitudes toward, and practices regarding female and male condoms. Most (75%) women had ever considered using male condoms; 32% had ever considered using female condoms; and use of either was sporadic. We examined predictors for being in either precontemplation or a later stage along the change continuum at both the bivariate and multivariate levels. Our findings suggest that African Americans and younger women are more likely to contemplate using female condoms. Both lack of knowledge and positive attitudes toward female condoms in this sample suggest that programs designed to raise awareness and knowledge of female condoms while improving their image are needed.
PMCID: PMC3456220  PMID: 14709713
Female condoms; STD prevention; Pregnancy prevention
22.  Ethnic Differences in Hormone Replacement Prescribing Patterns 
To determine whether prescription patterns of hormone replacement therapy (HRT) differ in African-American, Asian, Latina, Soviet immigrant, and white women.
Retrospective review of computerized medical records.
The general internal medicine, family medicine, and gynecology practices of an academic medical center.
Women aged 50 years or older with at least one outpatient visit from January 1, 1992, to November 30, 1995.
Use of HRT was defined as documentation of systemic estrogen use. The main predictor variable was self-identified ethnicity. Age, diagnosis (coronary heart disease, hypertension, diabetes, osteoporosis, or breast cancer), and median income were included in the analysis. Of the 8,968 women (mean age, 65.4 years) included, 50% were white, 20% Asian, 15% African American, 9% Latina, and 6% Soviet immigrants. Whites (33%) were significantly more likely to be prescribed HRT than Asians (21%), African Americans (25%), Latinas (23%), or Soviet immigrants (6.6%), p < 0.01 for each. Multivariate analysis, comparing ethnic groups and controlling for confounding variables, showed that Asians (odds ratio [OR] 0.56; 95% confidence interval [CI] 0.49, 0.64), African Americans (OR 0.70; 95% CI 0.60, 0.81), Latinas (OR 0.70; 95% CI 0.58, 0.84), and Soviet immigrants (OR 0.14; 95% CI 0.10, 0.20) were each less likely to be prescribed HRT than were white women. Although women with osteoporosis were more likely to receive HRT (OR 2.28; 95% CI 1.71, 2.99), those with coronary heart disease were not (OR 0.88; 95% CI 0.68, 1.09).
Physicians at this medical center were more likely to prescribe HRT for white women and women with osteoporosis. Further study is needed to address whether these differences in HRT prescribing result in different health outcomes.
PMCID: PMC1496759  PMID: 10571714
hormone replacement therapy; postmenopausal women; ethnicity; physician prescribing; prevention
23.  Ethnic Comparison of Attitudes and Beliefs About Cigarette Smoking 
To determine if hypothesized differences in attitudes and beliefs about cigarette smoking between Latino and non-Latino white smokers are independent of years of formal education and number of cigarettes smoked per day.
Cross-sectional survey using a random digit dial telephone method.
San Francisco census tracts with at least 10% Latinos in the 1990 Census.
Three hundred twelve Latinos (198 men and 114 women) and 354 non-Latino whites (186 men and 168 women), 18 to 65 years of age, who were current cigarette smokers participated.
Self-reports of cigarette smoking behavior, antecedents to smoking, reasons to quit smoking, and reasons to continue smoking were the measures. Latino smokers were younger (36.6 vs 39.6 years, p < .01), had fewer years of education (11.0 vs 14.3 years, p < .001), and smoked on average fewer cigarettes per day (9.7 vs 20.1, p < .001). Compared with whites, Latino smokers were less likely to report smoking “almost always or often” after 13 of 17 antecedents (each p < .001), and more likely to consider it important to quit for 12 of 15 reasons (each p < .001). In multivariate analyses after adjusting for gender, age, education, income, and number of cigarettes smoked per day, Latino ethnicity was a significant predictor of being less likely to smoke while talking on the telephone (odds ratio [OR] 0.41; 95% confidence interval [CI] 0.26, 0.64), drinking alcoholic beverages (OR 0.66; 95% CI 0.44, 0.99), after eating (OR 0.55, 95% CI 0.37, 0.81), or at a bar (OR 0.62, 95% CI 0.41, 0.94), and a significant predictor of being more likely to smoke at a party (OR 1.72; 95% CI 1.14, 2.60). Latino ethnicity was a significant predictor of considering quitting important because of being criticized by family (OR 1.93; 95% CI 1.26, 2.98), burning clothes (OR 1.57; 95% CI 1.02, 2.42), damaging children's health (OR 1.67; 95% CI 1.08, 2.57), bad breath (OR 2.07; 95% CI 1.40, 3.06), family pressure (OR 1.67; 95% CI 1.10, 2.60), and being a good example to children (OR 1.83; 95% CI 1.21, 2.76).
Differences in attitudes and beliefs about cigarette smoking between Latinos and whites are independent of education and number of cigarettes smoked. We recommend that these ethnic differences be incorporated into smoking cessation interventions for Latino smokers.
PMCID: PMC1496925  PMID: 9541373
cigarette smoking; Latinos; Hispanics; culture

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