Early detection of new outbreak waves is critical for effective and sustained response to the COV... more Early detection of new outbreak waves is critical for effective and sustained response to the COVID-19 pandemic. We conducted a growth rate analysis using local community and inpatient records from seven hospital systems to characterize distinct phases in SARS-CoV-2 outbreak waves in the Greater Houston area. We determined the transition times from rapid spread of infection in the community to surge in the number of inpatients in local hospitals. We identified 193,237 residents who tested positive for SARS-CoV-2 via molecular testing from April 8, 2020 to June 30, 2021, and 30,031 residents admitted within local healthcare institutions with a positive SARS-CoV-2 test, including emergency cases. We detected two distinct COVID-19 waves: May 12, 2020–September 6, 2020 and September 27, 2020–May 15, 2021; each encompassed four growth phases: lagging, exponential/rapid growth, deceleration, and stationary/linear. Our findings showed that, during early stages of the pandemic, the surge in...
Journal of Primary Care & Community Health, 2020
Introduction Mobile clinics provide an efficient manner for delivering healthcare services to at-... more Introduction Mobile clinics provide an efficient manner for delivering healthcare services to at-risk populations, and there is a need to understand their economics. This study analyzes the costs of operating selected mobile clinic programs representing service categories in dental, dental/preventive, preventive care, primary care/preventive, and mammography/primary care/preventive. Methods The methodology included a self-reported survey of 96 mobile clinic programs operating in Texas, North Carolina, Georgia, and Florida; these states did not expand Medicaid and have a large proportion of uninsured individuals. Data were collected over an 8-month period from November 2016 to July 2017. The cost analyses were conducted in 2018, and were analyzed from the provider perspective. The average annual estimated costs; as well the costs per patient in each mobile clinic program within different service delivery types were assessed. Costs reported in the study survey were classified into rec...
Introduction. Wound care practices for neonatal and pediatric patients have created a lack of sta... more Introduction. Wound care practices for neonatal and pediatric patients have created a lack of standardized evidence-based guidelines for treatments in clinical practices. Unfortunately, published clinical guidelines for the evaluation and management of wounds in pediatric populations is limited. Consensus groups are used to develop clinical guidelines which define key aspects of the quality of health care, particularly appropriate indications for interventions. The aim of this initiative was to conduct the first two steps of the guideline development process, and to report on the findings from the expert consensus group for pediatric wound care. Methods. The goal was to recruit a multidisciplinary team that consisted of board certified Pediatric Plastic and Pediatric General Surgeons, WOCN, and research specialists active in the International Society of Pediatric Wound Care (ISPEW). All recruited individuals were emailed and invited to participate. For this study, an adapted questio...
International Archives of Public Health and Community Medicine, 2018
We describe a novel procedure for estimating population-level vulnerability to type 2 diabetes an... more We describe a novel procedure for estimating population-level vulnerability to type 2 diabetes and then demonstrate how differences in social and cultural factors among vulnerable subgroups translate into design considerations for prevention-oriented community interventions. Our study adopted a mixed method approach combining a quantitative evaluation of population data with a qualitative vulnerability assessment that centered around in-depth interviews. Harris County, Texas serves as the setting. Four distinct subgroups were identified within neighborhoods considered vulnerable to diabetes, based on clinical predictors of diabetes and on economic disadvantage. Differences among these groups were then characterized by their prominent social and cultural factors. Understanding these differences offers a critical refinement important for designing effective local policies and targeted community interventions to prevent type 2 diabetes. This paper emphasizes the qualitative analysis and its implications.
To evaluate dietary intake of toxic metals as a source of increased biomarker levels of metals am... more To evaluate dietary intake of toxic metals as a source of increased biomarker levels of metals among US Asians. We estimated daily food consumption and dietary intake of arsenic, cadmium, lead, and mercury by combining 24-hour dietary intake recall data from the 2011-2012 National Health and Nutrition Examination Survey (NHANES) with data from the USDA Food Composition Intake Database and FDA Total dietary study. We analyzed associations between dietary metal intake and biomarker levels of the metals using linear regression. Further, estimated food consumption and metal intake levels were compared between Asians and other racial/ethnic groups (white, black, Mexican American, and other Hispanic) and within three Asian subgroups (Chinese, Indian Asian, and other Asians). Significant associations (p<0.05) were found between biomarker levels and estimated dietary metal intake for total and inorganic arsenic and mercury among Asians. Asians had the highest daily fish and rice consumpt...
Birth Defects Research Part A: Clinical and Molecular Teratology, 2013
ABSTRACTBACKGROUNDThere is evidence from previous studies that maternal occupational exposure to ... more ABSTRACTBACKGROUNDThere is evidence from previous studies that maternal occupational exposure to hazardous air pollutants (HAPs) is positively associated with oral clefts; however, studies evaluating the association between residential exposure to these toxicants and oral clefts are lacking. Therefore, our goal was to conduct a case‐control study examining the association between estimated maternal residential exposure to benzene, toluene, ethyl benzene, and xylene (BTEX) and the risk of oral clefts among offspring.METHODSData on 6045 nonsyndromic isolated oral cleft cases (3915 cleft lip with or without cleft palate [CL ± P] and 2130 nonsyndromic isolated cleft palate [CP] cases) delivered between 1999 and 2008 were obtained from the Texas Birth Defects Registry. The control group was a sample of unaffected live births, frequency matched to cases on year of birth. Census tract‐level estimates of annual average exposures were obtained from the U.S. Environmental Protection Agency 20...
Background: Faith-based health promotion has shown promise for supporting healthy lifestyles, but... more Background: Faith-based health promotion has shown promise for supporting healthy lifestyles, but has limited evidence of reaching scale or sustainability. In one recent such effort, volunteers from a diverse range of faith organizations were trained as peer educators to implement diabetes self-management education (DSME) classes within their communities. The purpose of this study was to identify factors associated with provision of these classes within six months of peer-educator training. Methods: This study used the Consolidated Framework for Implementation Research (CFIR) to identify patterns from interviews, observations, attendance records, and organizational background information. Two research team members thematically coded interview transcripts and observation memos to identify patterns distinguishing faith organizations that did, versus did not, conduct DSME classes within six months of peer-educator training. Bivariate statistics were also used to identify faith organizational characteristics associated with DSME class completion within this time frame. Results: Volunteers from 24 faith organizations received peer-educator training. Of these, 15 led a DSME class within six months, graduating a total of 132 participants. Thematic analyses yielded two challenges experienced disproportionately by organizations unable to complete DSME within six months: [1] Their peer educators experienced DSME as complex, despite substantial planning efforts at simplification, and [2] the process of engaging peer educators and leadership within their organizations was often more difficult than anticipated, despite initial communication by Faith and Diabetes organizers intended to secure informed commitments by both groups. Many peer educators were overwhelmed by training content, the responsibility required to start and sustain DSME classes, and other time commitments. Other priorities competed for time in participants' lives and on organizational calendars, and scheduling processes could be slow. In an apparent dynamic of "crowding out," coordination was particularly difficult in larger organizations, which were less likely than smaller organizations to complete DSME classes despite their more substantial resources.
The US National Research Council recently released a report promoting sustainability assessment a... more The US National Research Council recently released a report promoting sustainability assessment as the future of environmental regulation. Thirty years earlier, this organization (under the same senior author) had issued a similar report promoting risk assessment as a new method for improving the science behind regulatory decisions. Tools for risk assessment were subsequently developed and adopted in state and federal agencies throughout the US. Since then, limitations of the traditional forms of risk assessment have prompted some dramatic modifications toward cumulative assessments that combine multiple chemical and non-chemical stressors in community settings. At present, however, there is little momentum within the risk assessment community for abandoning this evolved system in favor of a new sustainability-based one. The key question is, how best to proceed? Should sustainability principles be incorporated into current risk assessment procedures, or vice versa? Widespread recognition of the importance of sustainability offers no clear guidance for the risk assessment community, especially in light of institutional commitments to sustainability tools and definitions that appear to have little in common with cumulative risk notions. The purpose of this paper is to reframe the sustainability challenge for risk assessors by offering analytical guidance to chart a way out. We adopt a decision analysis framework to
International Journal of Environmental Research and Public Health, 2010
There is strong presumptive evidence that people living in poverty and certain racial and ethnic ... more There is strong presumptive evidence that people living in poverty and certain racial and ethnic groups bear a disproportionate burden of environmental health risk. Many have argued that conducting formal assessments of the health risk experienced by affected communities is both unnecessary and counterproductive-that instead of analyzing the situation our efforts should be devoted to fixing obvious problems and rectifying observable wrongs. We contend that formal assessment of cumulative health risks from combined effects of chemical and nonchemical stressors is a valuable tool to aid decision makers in choosing risk management options that are effective, efficient, and equitable. If used properly, cumulative risk assessment need not impair decision makers' discretion, nor should it be used as an excuse for doing nothing in the face of evident harm. Good policy decisions require more than good intentions; they necessitate analysis of risk-related information along with careful consideration of economic issues, ethical and moral principles, legal precedents, political realities, cultural beliefs, societal values, and bureaucratic impediments. Cumulative risk assessment can provide a systematic and impartial means for informing policy decisions about environmental justice.
In the absence of scientific consensus on an appropriate theoretical framework, cumulative risk a... more In the absence of scientific consensus on an appropriate theoretical framework, cumulative risk assessment and related research have relied on speculative conceptual models. We argue for the importance of theoretical backing for such models and discuss 3 relevant theoretical frameworks, each supporting a distinctive “family” of models. Social determinant models postulate that unequal health outcomes are caused by structural inequalities; health disparity models envision social and contextual factors acting through individual behaviors and biological mechanisms; and multiple stressor models incorporate environmental agents, emphasizing the intermediary role of these and other stressors. The conclusion is that more careful reliance on established frameworks will lead directly to improvements in characterizing cumulative risk burdens and accounting for disproportionate adverse health effects.
International Journal of Environmental Research and Public Health, 2018
Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and... more Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and synergistic effects of multiple chemical, physical and social stressors on human health, with the goal of informing policy and decision-making, and protecting public health. Routine application of CRA to environmental regulatory and policy decision making, however, has been limited due to a perceived lack of appropriate quantitative approaches for assessing combined effects of chemical and nonchemical exposures. Seven research projects, which represented a variety of disciplines, including population health science, laboratory science, social sciences, geography, statistics and mathematics, were funded by the US Environmental Protection Agency (EPA) to help address this knowledge gap. We synthesize key insights from these unique studies to determine the implications for CRA practice and priorities for further research. Our analyses of these seven projects demonstrate that the necessary ...
International Journal of Environmental Research and Public Health, 2018
Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and... more Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and synergistic effects of multiple chemical, physical and social stressors on human health, with the goal of informing policy and decision-making, and protecting public health. Routine application of CRA to environmental regulatory and policy decision making, however, has been limited due to a perceived lack of appropriate quantitative approaches for assessing combined effects of chemical and nonchemical exposures. Seven research projects, which represented a variety of disciplines, including population health science, laboratory science, social sciences, geography, statistics and mathematics, were funded by the US Environmental Protection Agency (EPA) to help address this knowledge gap. We synthesize key insights from these unique studies to determine the implications for CRA practice and priorities for further research. Our analyses of these seven projects demonstrate that the necessary ...
2045 Background: Cancer care is changing rapidly with more detailed understanding of disease and ... more 2045 Background: Cancer care is changing rapidly with more detailed understanding of disease and more numerous therapeutic choices. As treatment choice is more complex, mechanisms to improve compliance with evidence based treatment can improve the quality of cancer care. Methods: A retrospective cohort study was conducted from January 2014-May 2016 evaluating the impact of a clinical decision support system (CDSS) on compliance with evidence based pathways (EBP) across 9 statewide community based oncology practices. These EBP are developed with physician input on efficacy toxicity and value and incorporated in to a CDSS that is used within the Electronic Health Record (EHR) at point of care to alter the choice architecture a clinician sees when prescribing therapy. A multi-level logistic regression model was used to adjust for group effects on physician or practice behavior. SAS 9.4 software was used and GLIMMIX was applied. Individual physician benchmark compliance was evaluated us...
The fiscal pool that funds Delivery System Reform Incentive Payment (DSRIP) projects has four int... more The fiscal pool that funds Delivery System Reform Incentive Payment (DSRIP) projects has four interlinking categories, Categories I – IV. DSRIP that was adopted in nine counties of southeast Texas detected a decrease in Preventable Hospitalization (PH) rates formulating the problem statement: What were the proposed factors that influenced the detected decrease? The article is a delineation of the presumable influencers within DSRIP that may have resulted in decrease in PH rates, those likely being physician-hospital collaboration, mechanisms of reimbursements, types of measures leveraged to report quality initiatives and interplaying healthcare externalities within the implemeted counties. The paper explains functioning of the four aforementioned influencers, examines how those may have impacted DSRIP and thereafter elucidates mechanisms these influencers in a detailed discussion. Physician-hospital collaboration propagated relationship centered care geared towards patients. State reimbursements provided a fiscal ballast to initiate and continue DSRIP activities. DSRIP’s Categories itself were designed in a systematic way so as to procure health outcomes in a continual process. And lastly, interplaying healthcare externalities such as the presence of Medicaid Managed Care/Health Maintanence Organizations may have impacted patient health in the implemented areas. At large, DSRIP may have exemplified coordination of physicians, administrators and the state so as to likely procure outcomes in healthcare quality as described in the paper.
Providing quality healthcare is one of the topmost priorities of the care delivery system. Qualit... more Providing quality healthcare is one of the topmost priorities of the care delivery system. Quality is recognized as value added to the healthcare system. Healthcare policies and programs are innovated and designed to reform delivery of patient care, an example of which is the Delivery System Reform Incentive Payment (DSRIP) program. In this paper, we leverage three assessment models in healthcare quality namely, Donabedian’s model, the Institute of Medicine’s Patient Care Aim model and the Institute of Healthcare Improvement’s Triple Aim model. The paper exhibits how DSRIP likely interrelates with and is congruent to the aforementioned assessment models. DSRIP’s goals are likely designed in such a way that they supposedly intertwine with the goals of these models. The article aims at showing how DSRIP is attempting to operationalize its own goals with those of the above models. Nonetheless, the article explains DSRIP’s inner workings and conclusively analyzes how its systemic design aligns with and conforms to these models. Lastly, the paper explains DSRIP’s logistics, project cohorts and categories, outcome reporting techniques and state reimbursement methods as parts of its systemic design so as to prospectively assist/serve policymakers and analysts whilst designing new policies for procuring outcomes in quality and health in the future.
International journal of environmental research and public health, Oct 2, 2018
Of the 382 million people worldwide with diabetes, and if current trends continue, nearly half a ... more Of the 382 million people worldwide with diabetes, and if current trends continue, nearly half a billion people worldwide will have diabetes by 2035. Two-thirds of current diabetics are living in urban centers and the urban concentration of individuals with diabetes is on the rise. The problem is that in the absence of widespread clinical testing, there is no reliable way to predict which segments of the population are the most vulnerable to the onset of diabetes. Knowing who the most vulnerable are, and where they live, can guide the efficient allocation of prevention resources. Toward this end, we introduce the concept of composite vulnerability, which includes both group and individual-level attributes, and we provide a demonstration of its application to a large urban setting. The components of composite vulnerability are estimated using a novel, population-based, procedure that relies on sample survey data and nonparametric statistical techniques. First, cluster analysis identi...
According to some estimates, the United States wastes as much as 30% of health care dollars. Some... more According to some estimates, the United States wastes as much as 30% of health care dollars. Some of that waste can be mitigated by reducing certain costs associated with Medicaid. We chose 5 areas of savings applicable to Medicaid: (1) modification of physician payment models to reduce unnecessary care, (2) development of a medication adherence program for patients dually eligible for Medicaid and Medicare support ("dual eligibles"), (3) improvement in unnecessary admissions and readmissions for dual eligibles, (4) reduction in emergency department visits among children in Medicaid and dual-eligible beneficiaries, and (5) improvement in adoption of endof-life advance directives. We chose the states from both ends of the spending spectrum: the 5 with the lowest annual Medicaid expenditures:
International journal of environmental health research, 2018
This study represents an analysis of the effect of exposure to ambient ozone and toxic air releas... more This study represents an analysis of the effect of exposure to ambient ozone and toxic air releases on hospitalization for asthma among children in Harris County, Texas. Our study identified temporal and spatial variations in asthma hospitalization across the study region and explored the combined effect of exposure to ambient ozone and air toxics on asthma hospitalization. Asthma hospitalization hot spots and clusters were mostly not located on zip codes with reported high quantities of total air releases of chemical pollutants. There was no significant interaction between ambient ozone exposure and toxic air releases relative to asthma hospitalization. The major predictor of asthma hospitalization was season, with hospitalization rate per 10,000 people for asthma being highest in winter period when ozone levels are usually lowest.
International journal for equity in health, Feb 5, 2018
Interventions that promote healthier lifestyles among Latinos often involve community health work... more Interventions that promote healthier lifestyles among Latinos often involve community health workers (CHWs). CHWs can effectively advocate for healthier lifestyles and may be pivotal in addressing such mental health conditions as depression and anxiety. The goal of this study was to characterize the relationship dynamics between Latino participants and CHWs, from the participant's perspective. We aimed to determine if CHW-delivered community interventions effected behavior change, especially among participants who reported anxiety and depression. Semi-structured interviews were conducted with a purposive sample of 28 Latino participants that was based on a mental health scoring strata. Participants completed a lifestyle intervention that included multiple home visits from CHWs to promote physical activity and healthful food choice. Interviews were conducted in the participant's preferred language (English or Spanish). Transcribed interviews were analyzed using a grounded the...
Early detection of new outbreak waves is critical for effective and sustained response to the COV... more Early detection of new outbreak waves is critical for effective and sustained response to the COVID-19 pandemic. We conducted a growth rate analysis using local community and inpatient records from seven hospital systems to characterize distinct phases in SARS-CoV-2 outbreak waves in the Greater Houston area. We determined the transition times from rapid spread of infection in the community to surge in the number of inpatients in local hospitals. We identified 193,237 residents who tested positive for SARS-CoV-2 via molecular testing from April 8, 2020 to June 30, 2021, and 30,031 residents admitted within local healthcare institutions with a positive SARS-CoV-2 test, including emergency cases. We detected two distinct COVID-19 waves: May 12, 2020–September 6, 2020 and September 27, 2020–May 15, 2021; each encompassed four growth phases: lagging, exponential/rapid growth, deceleration, and stationary/linear. Our findings showed that, during early stages of the pandemic, the surge in...
Journal of Primary Care & Community Health, 2020
Introduction Mobile clinics provide an efficient manner for delivering healthcare services to at-... more Introduction Mobile clinics provide an efficient manner for delivering healthcare services to at-risk populations, and there is a need to understand their economics. This study analyzes the costs of operating selected mobile clinic programs representing service categories in dental, dental/preventive, preventive care, primary care/preventive, and mammography/primary care/preventive. Methods The methodology included a self-reported survey of 96 mobile clinic programs operating in Texas, North Carolina, Georgia, and Florida; these states did not expand Medicaid and have a large proportion of uninsured individuals. Data were collected over an 8-month period from November 2016 to July 2017. The cost analyses were conducted in 2018, and were analyzed from the provider perspective. The average annual estimated costs; as well the costs per patient in each mobile clinic program within different service delivery types were assessed. Costs reported in the study survey were classified into rec...
Introduction. Wound care practices for neonatal and pediatric patients have created a lack of sta... more Introduction. Wound care practices for neonatal and pediatric patients have created a lack of standardized evidence-based guidelines for treatments in clinical practices. Unfortunately, published clinical guidelines for the evaluation and management of wounds in pediatric populations is limited. Consensus groups are used to develop clinical guidelines which define key aspects of the quality of health care, particularly appropriate indications for interventions. The aim of this initiative was to conduct the first two steps of the guideline development process, and to report on the findings from the expert consensus group for pediatric wound care. Methods. The goal was to recruit a multidisciplinary team that consisted of board certified Pediatric Plastic and Pediatric General Surgeons, WOCN, and research specialists active in the International Society of Pediatric Wound Care (ISPEW). All recruited individuals were emailed and invited to participate. For this study, an adapted questio...
International Archives of Public Health and Community Medicine, 2018
We describe a novel procedure for estimating population-level vulnerability to type 2 diabetes an... more We describe a novel procedure for estimating population-level vulnerability to type 2 diabetes and then demonstrate how differences in social and cultural factors among vulnerable subgroups translate into design considerations for prevention-oriented community interventions. Our study adopted a mixed method approach combining a quantitative evaluation of population data with a qualitative vulnerability assessment that centered around in-depth interviews. Harris County, Texas serves as the setting. Four distinct subgroups were identified within neighborhoods considered vulnerable to diabetes, based on clinical predictors of diabetes and on economic disadvantage. Differences among these groups were then characterized by their prominent social and cultural factors. Understanding these differences offers a critical refinement important for designing effective local policies and targeted community interventions to prevent type 2 diabetes. This paper emphasizes the qualitative analysis and its implications.
To evaluate dietary intake of toxic metals as a source of increased biomarker levels of metals am... more To evaluate dietary intake of toxic metals as a source of increased biomarker levels of metals among US Asians. We estimated daily food consumption and dietary intake of arsenic, cadmium, lead, and mercury by combining 24-hour dietary intake recall data from the 2011-2012 National Health and Nutrition Examination Survey (NHANES) with data from the USDA Food Composition Intake Database and FDA Total dietary study. We analyzed associations between dietary metal intake and biomarker levels of the metals using linear regression. Further, estimated food consumption and metal intake levels were compared between Asians and other racial/ethnic groups (white, black, Mexican American, and other Hispanic) and within three Asian subgroups (Chinese, Indian Asian, and other Asians). Significant associations (p<0.05) were found between biomarker levels and estimated dietary metal intake for total and inorganic arsenic and mercury among Asians. Asians had the highest daily fish and rice consumpt...
Birth Defects Research Part A: Clinical and Molecular Teratology, 2013
ABSTRACTBACKGROUNDThere is evidence from previous studies that maternal occupational exposure to ... more ABSTRACTBACKGROUNDThere is evidence from previous studies that maternal occupational exposure to hazardous air pollutants (HAPs) is positively associated with oral clefts; however, studies evaluating the association between residential exposure to these toxicants and oral clefts are lacking. Therefore, our goal was to conduct a case‐control study examining the association between estimated maternal residential exposure to benzene, toluene, ethyl benzene, and xylene (BTEX) and the risk of oral clefts among offspring.METHODSData on 6045 nonsyndromic isolated oral cleft cases (3915 cleft lip with or without cleft palate [CL ± P] and 2130 nonsyndromic isolated cleft palate [CP] cases) delivered between 1999 and 2008 were obtained from the Texas Birth Defects Registry. The control group was a sample of unaffected live births, frequency matched to cases on year of birth. Census tract‐level estimates of annual average exposures were obtained from the U.S. Environmental Protection Agency 20...
Background: Faith-based health promotion has shown promise for supporting healthy lifestyles, but... more Background: Faith-based health promotion has shown promise for supporting healthy lifestyles, but has limited evidence of reaching scale or sustainability. In one recent such effort, volunteers from a diverse range of faith organizations were trained as peer educators to implement diabetes self-management education (DSME) classes within their communities. The purpose of this study was to identify factors associated with provision of these classes within six months of peer-educator training. Methods: This study used the Consolidated Framework for Implementation Research (CFIR) to identify patterns from interviews, observations, attendance records, and organizational background information. Two research team members thematically coded interview transcripts and observation memos to identify patterns distinguishing faith organizations that did, versus did not, conduct DSME classes within six months of peer-educator training. Bivariate statistics were also used to identify faith organizational characteristics associated with DSME class completion within this time frame. Results: Volunteers from 24 faith organizations received peer-educator training. Of these, 15 led a DSME class within six months, graduating a total of 132 participants. Thematic analyses yielded two challenges experienced disproportionately by organizations unable to complete DSME within six months: [1] Their peer educators experienced DSME as complex, despite substantial planning efforts at simplification, and [2] the process of engaging peer educators and leadership within their organizations was often more difficult than anticipated, despite initial communication by Faith and Diabetes organizers intended to secure informed commitments by both groups. Many peer educators were overwhelmed by training content, the responsibility required to start and sustain DSME classes, and other time commitments. Other priorities competed for time in participants' lives and on organizational calendars, and scheduling processes could be slow. In an apparent dynamic of "crowding out," coordination was particularly difficult in larger organizations, which were less likely than smaller organizations to complete DSME classes despite their more substantial resources.
The US National Research Council recently released a report promoting sustainability assessment a... more The US National Research Council recently released a report promoting sustainability assessment as the future of environmental regulation. Thirty years earlier, this organization (under the same senior author) had issued a similar report promoting risk assessment as a new method for improving the science behind regulatory decisions. Tools for risk assessment were subsequently developed and adopted in state and federal agencies throughout the US. Since then, limitations of the traditional forms of risk assessment have prompted some dramatic modifications toward cumulative assessments that combine multiple chemical and non-chemical stressors in community settings. At present, however, there is little momentum within the risk assessment community for abandoning this evolved system in favor of a new sustainability-based one. The key question is, how best to proceed? Should sustainability principles be incorporated into current risk assessment procedures, or vice versa? Widespread recognition of the importance of sustainability offers no clear guidance for the risk assessment community, especially in light of institutional commitments to sustainability tools and definitions that appear to have little in common with cumulative risk notions. The purpose of this paper is to reframe the sustainability challenge for risk assessors by offering analytical guidance to chart a way out. We adopt a decision analysis framework to
International Journal of Environmental Research and Public Health, 2010
There is strong presumptive evidence that people living in poverty and certain racial and ethnic ... more There is strong presumptive evidence that people living in poverty and certain racial and ethnic groups bear a disproportionate burden of environmental health risk. Many have argued that conducting formal assessments of the health risk experienced by affected communities is both unnecessary and counterproductive-that instead of analyzing the situation our efforts should be devoted to fixing obvious problems and rectifying observable wrongs. We contend that formal assessment of cumulative health risks from combined effects of chemical and nonchemical stressors is a valuable tool to aid decision makers in choosing risk management options that are effective, efficient, and equitable. If used properly, cumulative risk assessment need not impair decision makers' discretion, nor should it be used as an excuse for doing nothing in the face of evident harm. Good policy decisions require more than good intentions; they necessitate analysis of risk-related information along with careful consideration of economic issues, ethical and moral principles, legal precedents, political realities, cultural beliefs, societal values, and bureaucratic impediments. Cumulative risk assessment can provide a systematic and impartial means for informing policy decisions about environmental justice.
In the absence of scientific consensus on an appropriate theoretical framework, cumulative risk a... more In the absence of scientific consensus on an appropriate theoretical framework, cumulative risk assessment and related research have relied on speculative conceptual models. We argue for the importance of theoretical backing for such models and discuss 3 relevant theoretical frameworks, each supporting a distinctive “family” of models. Social determinant models postulate that unequal health outcomes are caused by structural inequalities; health disparity models envision social and contextual factors acting through individual behaviors and biological mechanisms; and multiple stressor models incorporate environmental agents, emphasizing the intermediary role of these and other stressors. The conclusion is that more careful reliance on established frameworks will lead directly to improvements in characterizing cumulative risk burdens and accounting for disproportionate adverse health effects.
International Journal of Environmental Research and Public Health, 2018
Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and... more Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and synergistic effects of multiple chemical, physical and social stressors on human health, with the goal of informing policy and decision-making, and protecting public health. Routine application of CRA to environmental regulatory and policy decision making, however, has been limited due to a perceived lack of appropriate quantitative approaches for assessing combined effects of chemical and nonchemical exposures. Seven research projects, which represented a variety of disciplines, including population health science, laboratory science, social sciences, geography, statistics and mathematics, were funded by the US Environmental Protection Agency (EPA) to help address this knowledge gap. We synthesize key insights from these unique studies to determine the implications for CRA practice and priorities for further research. Our analyses of these seven projects demonstrate that the necessary ...
International Journal of Environmental Research and Public Health, 2018
Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and... more Cumulative risk assessment (CRA) has been proposed as a means of evaluating possible additive and synergistic effects of multiple chemical, physical and social stressors on human health, with the goal of informing policy and decision-making, and protecting public health. Routine application of CRA to environmental regulatory and policy decision making, however, has been limited due to a perceived lack of appropriate quantitative approaches for assessing combined effects of chemical and nonchemical exposures. Seven research projects, which represented a variety of disciplines, including population health science, laboratory science, social sciences, geography, statistics and mathematics, were funded by the US Environmental Protection Agency (EPA) to help address this knowledge gap. We synthesize key insights from these unique studies to determine the implications for CRA practice and priorities for further research. Our analyses of these seven projects demonstrate that the necessary ...
2045 Background: Cancer care is changing rapidly with more detailed understanding of disease and ... more 2045 Background: Cancer care is changing rapidly with more detailed understanding of disease and more numerous therapeutic choices. As treatment choice is more complex, mechanisms to improve compliance with evidence based treatment can improve the quality of cancer care. Methods: A retrospective cohort study was conducted from January 2014-May 2016 evaluating the impact of a clinical decision support system (CDSS) on compliance with evidence based pathways (EBP) across 9 statewide community based oncology practices. These EBP are developed with physician input on efficacy toxicity and value and incorporated in to a CDSS that is used within the Electronic Health Record (EHR) at point of care to alter the choice architecture a clinician sees when prescribing therapy. A multi-level logistic regression model was used to adjust for group effects on physician or practice behavior. SAS 9.4 software was used and GLIMMIX was applied. Individual physician benchmark compliance was evaluated us...
The fiscal pool that funds Delivery System Reform Incentive Payment (DSRIP) projects has four int... more The fiscal pool that funds Delivery System Reform Incentive Payment (DSRIP) projects has four interlinking categories, Categories I – IV. DSRIP that was adopted in nine counties of southeast Texas detected a decrease in Preventable Hospitalization (PH) rates formulating the problem statement: What were the proposed factors that influenced the detected decrease? The article is a delineation of the presumable influencers within DSRIP that may have resulted in decrease in PH rates, those likely being physician-hospital collaboration, mechanisms of reimbursements, types of measures leveraged to report quality initiatives and interplaying healthcare externalities within the implemeted counties. The paper explains functioning of the four aforementioned influencers, examines how those may have impacted DSRIP and thereafter elucidates mechanisms these influencers in a detailed discussion. Physician-hospital collaboration propagated relationship centered care geared towards patients. State reimbursements provided a fiscal ballast to initiate and continue DSRIP activities. DSRIP’s Categories itself were designed in a systematic way so as to procure health outcomes in a continual process. And lastly, interplaying healthcare externalities such as the presence of Medicaid Managed Care/Health Maintanence Organizations may have impacted patient health in the implemented areas. At large, DSRIP may have exemplified coordination of physicians, administrators and the state so as to likely procure outcomes in healthcare quality as described in the paper.
Providing quality healthcare is one of the topmost priorities of the care delivery system. Qualit... more Providing quality healthcare is one of the topmost priorities of the care delivery system. Quality is recognized as value added to the healthcare system. Healthcare policies and programs are innovated and designed to reform delivery of patient care, an example of which is the Delivery System Reform Incentive Payment (DSRIP) program. In this paper, we leverage three assessment models in healthcare quality namely, Donabedian’s model, the Institute of Medicine’s Patient Care Aim model and the Institute of Healthcare Improvement’s Triple Aim model. The paper exhibits how DSRIP likely interrelates with and is congruent to the aforementioned assessment models. DSRIP’s goals are likely designed in such a way that they supposedly intertwine with the goals of these models. The article aims at showing how DSRIP is attempting to operationalize its own goals with those of the above models. Nonetheless, the article explains DSRIP’s inner workings and conclusively analyzes how its systemic design aligns with and conforms to these models. Lastly, the paper explains DSRIP’s logistics, project cohorts and categories, outcome reporting techniques and state reimbursement methods as parts of its systemic design so as to prospectively assist/serve policymakers and analysts whilst designing new policies for procuring outcomes in quality and health in the future.
International journal of environmental research and public health, Oct 2, 2018
Of the 382 million people worldwide with diabetes, and if current trends continue, nearly half a ... more Of the 382 million people worldwide with diabetes, and if current trends continue, nearly half a billion people worldwide will have diabetes by 2035. Two-thirds of current diabetics are living in urban centers and the urban concentration of individuals with diabetes is on the rise. The problem is that in the absence of widespread clinical testing, there is no reliable way to predict which segments of the population are the most vulnerable to the onset of diabetes. Knowing who the most vulnerable are, and where they live, can guide the efficient allocation of prevention resources. Toward this end, we introduce the concept of composite vulnerability, which includes both group and individual-level attributes, and we provide a demonstration of its application to a large urban setting. The components of composite vulnerability are estimated using a novel, population-based, procedure that relies on sample survey data and nonparametric statistical techniques. First, cluster analysis identi...
According to some estimates, the United States wastes as much as 30% of health care dollars. Some... more According to some estimates, the United States wastes as much as 30% of health care dollars. Some of that waste can be mitigated by reducing certain costs associated with Medicaid. We chose 5 areas of savings applicable to Medicaid: (1) modification of physician payment models to reduce unnecessary care, (2) development of a medication adherence program for patients dually eligible for Medicaid and Medicare support ("dual eligibles"), (3) improvement in unnecessary admissions and readmissions for dual eligibles, (4) reduction in emergency department visits among children in Medicaid and dual-eligible beneficiaries, and (5) improvement in adoption of endof-life advance directives. We chose the states from both ends of the spending spectrum: the 5 with the lowest annual Medicaid expenditures:
International journal of environmental health research, 2018
This study represents an analysis of the effect of exposure to ambient ozone and toxic air releas... more This study represents an analysis of the effect of exposure to ambient ozone and toxic air releases on hospitalization for asthma among children in Harris County, Texas. Our study identified temporal and spatial variations in asthma hospitalization across the study region and explored the combined effect of exposure to ambient ozone and air toxics on asthma hospitalization. Asthma hospitalization hot spots and clusters were mostly not located on zip codes with reported high quantities of total air releases of chemical pollutants. There was no significant interaction between ambient ozone exposure and toxic air releases relative to asthma hospitalization. The major predictor of asthma hospitalization was season, with hospitalization rate per 10,000 people for asthma being highest in winter period when ozone levels are usually lowest.
International journal for equity in health, Feb 5, 2018
Interventions that promote healthier lifestyles among Latinos often involve community health work... more Interventions that promote healthier lifestyles among Latinos often involve community health workers (CHWs). CHWs can effectively advocate for healthier lifestyles and may be pivotal in addressing such mental health conditions as depression and anxiety. The goal of this study was to characterize the relationship dynamics between Latino participants and CHWs, from the participant's perspective. We aimed to determine if CHW-delivered community interventions effected behavior change, especially among participants who reported anxiety and depression. Semi-structured interviews were conducted with a purposive sample of 28 Latino participants that was based on a mental health scoring strata. Participants completed a lifestyle intervention that included multiple home visits from CHWs to promote physical activity and healthful food choice. Interviews were conducted in the participant's preferred language (English or Spanish). Transcribed interviews were analyzed using a grounded the...
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Papers by Stephen Linder