Major US Metropolitan Research Articles

Residents' Perspectives on Patient Safety in University and Community Teaching Hospitals.

Patient safety is an important concept in resident education. To date, few studies have assessed resident perceptions of patient safety across different specialties. The study explored residents' views on patient safety across the specialties of internal medicine, general surgery, and diagnostic radiology, focusing on common themes and differences. In fall 2012, interviews of small groups of senior residents in internal medicine, general surgery, and diagnostic radiology were conducted at 3 academic medical centers and 3 community teaching hospitals in 3 major US metropolitan areas. In total, 33 residents were interviewed. Interviews used interactive discussion to explore multiple facets of patient safety. Residents identified lack of information, common errors, volume and acuity of patients, and inadequate supervision as major risks to patient safety. Specific threats to patient safety included communication problems, transitions of care, information technology interface issues, time constraints, and work flow. Residents disclosed that reporting safety issues was viewed as burdensome and carrying some degree of risk. There was variability as to whether residents would report safety threats they encountered. Residents are aware of threats to patient safety and have a unique perspective compared with other health care professionals. Transitions of care and communication problems were the most common safety threats identified by the residents interviewed.

Proton Therapy Expansion Under Current United States Reimbursement Models

To determine whether all the existing and planned proton beam therapy (PBT) centers in the United States can survive on a local patient mix that is dictated by insurers, not by number of patients. We determined current and projected cancer rates for 10 major US metropolitan areas. Using published utilization rates, we calculated patient percentages who are candidates for PBT. Then, on the basis of current published insurer coverage policies, we applied our experience of what would be covered to determine the net number of patients for whom reimbursement is expected. Having determined the net number of covered patients, we applied our average beam delivery times to determine the total number of minutes needed to treat that patient over the course of their treatment. We then calculated our expected annual patient capacity per treatment room to determine the appropriate number of treatment rooms for the area. The population of patients who will be both PBT candidates and will have treatments reimbursed by insurance is significantly smaller than the population who should receive PBT. Coverage decisions made by insurers reduce the number of PBT rooms that are economically viable. The expansion of PBT centers in the US is not sustainable under the current reimbursement model. Viability of new centers will be limited to those operating in larger regional metropolitan areas, and few metropolitan areas in the US can support multiple centers. In general, 1-room centers require captive (non-PBT-served) populations of approximately 1,000,000 lives to be economically viable, and a large center will require a population of >4,000,000 lives. In areas with smaller populations or where or a PBT center already exists, new centers require subsidy.

Abstract 199: Automated External Defibrillator Awareness and Knowledge Among the Lay Public in a Busy Urban Transportation System

Background: The prompt utilization of automatic external defibrillators (AEDs) by bystanders can greatly improve survival from sudden cardiac arrest occurring in public locations. A recent study of laypersons in a European transportation hub has suggested public knowledge and surrounding AED use is lacking; we sought to confirm and extend these findings in similar settings in the US. We hypothesized that awareness of AEDs and who can use them will be low among the general public. Objectives: To characterize layperson knowledge about AED use and emergency response in a major US metropolitan area transportation system. Methods: A survey instrument was adapted from a prior investigation performed in Europe. Trained survey personnel administered this oral survey (approx. five minute duration) to adult laypersons at two public transportation centers in a large US city during May 2012. The participants were asked questions relating to their knowledge of AEDs and who is permitted to use them, as well as their willingness to utilize an AED in an emergency. Results: Surveys were completed by 222 individuals. Mean age of respondents was 49.4±17.1 y, 44% were female and 25% reported prior CPR training within the past 5 years. When presented with a hypothetical cardiac arrest scenario, 63% said they would call for help and/or dial 911, but only 8% of respondents spontaneously suggested using an AED when prompted for other actions. When an AED was described, 59% of participants were aware that AEDs are available in public places, but only 38% were aware that AEDs can be used by laypersons. When informed regarding the availability for layperson use, 60% of respondents said that they would be willing to use an AED in an emergency situation. Conclusions: Though the majority of layperson respondents were willing to use an AED in an emergency when educated, few respondents considered an AED in their immediate response and the minority were aware that AEDs could be accessed by the general public. Additional broad efforts to educate the US public about AED availability and use should be prioritized.

Identifying Cities for Enhanced Fine Particulate Matter Speciation Monitoring

PP-30-018 Background/Aims: Epidemiologic studies have demonstrated adverse human health effects of particulate matter (PM2.5); PM2.5 constituents; and gaseous criteria air pollutants including CO, NO2, SO2, and O3. The current monitoring network covers most major US metropolitan areas. However, most PM constituents collected at Speciation Trend Network monitors are measured only 1 in 3 days or 1 in 6 days, complicating time-series analyses. Since limited resources will support daily monitoring at only a few locations, the major metropolitan areas selected should maximize the pollutant concentration levels and variances, and minimize the covariance between pollutants. Methods: We focused on 48 cities with Speciation Trend Network monitors from 2001 to 2005. We examined the concentration and variability for the gaseous criteria air pollutants and fine particle components, determined their correlations with PM2.5 mass, and evaluated regional and seasonal patterns. We chose PM2.5 species based on their potential to be markers for a particular source including coal combustion, residual oil fly ash, wood smoke, mobile sources, crustal elements, and road salt. Results: Regardless of season or region, markers of coal combustion (S and SO4) were strongly (>0.7)-to-moderately (>0.5) correlated with PM2.5 mass. Strong correlations with wood smoke (K, Br, and Ca) were seen in some cities, usually in the western part of the US during the winter. Elements associated with mobile sources (EC, OC, Zn, and NO3) were at least moderately correlated with PM2.5 in most cities, exhibiting different geographical and seasonal patterns. The correlations between PM2.5 and O3 were negative in the winter and positive in the summer, and showed some regional differences. Finally, markers of residual oil fly ash, crustal sources, and road salt were moderately correlated with PM2.5 in a small percentage of cities. Conclusion: Concentrations, variability, and relationships with PM2.5 differed by pollutant, region, and season. These factors can help identify the metropolitan areas for daily speciation monitoring.

Water use and acute diarrhoeal illness in children in a United States metropolitan area

We examined the association between water exposures and acute diarrhoeal illness (ADI) in children under non-outbreak conditions in a major US metropolitan area. We used a nested case-control study of children seen in an urban/suburban emergency department. Cases were those seen for a complaint of diarrhoea, while controls were age-matched children with a non-gastrointestinal complaint. Parents of subjects completed a validated water-use survey. Stratum-specific adjusted odds ratios (aOR) were calculated for the three main water effects: water source [surface vs. ground (well)], drinking-water type (tap vs. bottled), and use of water filters. Of 2472 subjects, 45% drank mostly or only bottled water. Well-water use was associated with increased odds of ADI compared to surface water [aOR 1·38, 95% confidence interval (CI) 1·01-1·87]. Use of bottled water did not affect the odds of ADI in well-water users, but increased the odds of ADI for surface-water users (aOR 1·27, 95% CI 1·02-1·57). We conclude that well-water use and bottled-water use are associated with increased odds of ADI in children.

Metropolitan Geographies of US Climate Action: Cities, Suburbs, and the Local Divide in Global Responsibilities

Planning for climate change is now occurring at multiple, sometimes interlocking scales of ecological governance and policy formulation. Within the context of this journal's past calls for fresh work on the ‘spatialities of (un)sustainability’, particularly around climate action, this paper examines new geographies of local climate policy within six major US metropolitan regions located in six different smart growth states. The methodological assumption of the paper is that these putatively pro-planning states in the USA should provide a particularly fertile legal and policy arena within which metropolitan-scale action might emerge. Focusing empirically on the US Mayors Climate Action Agreement, though, the discussion highlights an uneven local geography of planning for global climate change, with central cities apparently accepting responsibility and, in general, suburban municipalities concomitantly free-riding. Policy and research implications of these metropolitan geographies of (in) action are discussed in light of the extant literature on cities, planning, and the governance of climate action.

Residential air exchange rates in three major US metropolitan areas: results from the Relationship Among Indoor, Outdoor, and Personal Air Study 1999–2001

We report approximately 500 indoor-outdoor air exchange rate (AER) calculations based on measurements conducted in residences in three US metropolitan areas in 1999-2001: Elizabeth, New Jersey; Houston, Texas; and Los Angeles County, California. Overall, a median AER across these urban areas and seasons was 0.71 air changes per hour (ACH, or per hour; n = 509) while median AERs measured in California (n = 182), New Jersey (n = 163), and Texas (n = 164) were 0.87, 0.88, and 0.47 ACH, respectively. In Texas, the measured AERs were lower in the summer cooling season (median = 0.37 ACH) than in the winter heating season (median = 0.63 ACH), likely because of the reported use of room air conditioners as Houston is typically hot and humid during the summer. The measured AERs in California were higher in summer (median = 1.13 ACH) than in winter (median = 0.61 ACH). Because the summer cooling season in Los Angeles County is less humid than in New Jersey or Texas, natural ventilation through open windows and screened doors likely increased measured AER in California study homes. In New Jersey, AER were similar across heating and cooling seasons, although the median AER was relatively lower during the spring. Adequate ventilation or air exchange rate (AER) for an indoor environment is important for human health and comfort, and relevant to building design and energy conservation and efficiency considerations. However, residential AER data, especially measured by more accurate non-toxic tracer gas methodologies, are at present quite limited worldwide, and are insufficient to represent the variations across regions and seasons within and between homes, including apartments and condominiums in more densely populated urban areas. The present paper presents quantitative and qualitative data to characterize residential AERs in three US urban areas with different climate attributes.

Laypersons' Responses to the Communication of Uncertainty Regarding Cancer Risk Estimates

To explore laypersons' responses to the communication of uncertainty associated with individualized cancer risk estimates and to identify reasons for individual differences in these responses. A qualitative study was conducted using focus groups. Participants were informed about a new colorectal cancer risk prediction model, and presented with hypothetical individualized risk estimates using presentation formats varying in expressed uncertainty (range v. point estimate). Semistructured interviews explored participants' responses to this information. Eight focus groups were conducted with 48 adults aged 50 to 74 residing in 2 major US metropolitan areas, Chicago, IL and Washington, DC. Purposive sampling was used to recruit participants with a high school or greater education, some familiarity with information technology, and no personal or immediate family history of cancer. Participants identified several sources of uncertainty regarding cancer risk estimates, including missing data, limitations in accuracy and source credibility, and conflicting information. In comparing presentation formats, most participants reported greater worry and perceived risk with the range than with the point estimate, consistent with the phenomenon of "ambiguity aversion.'' However, others reported the opposite effect or else indifference between formats. Reasons suggested by participants' responses included individual differences in optimism and motivations to reduce feelings of vulnerability and personal lack of control. Perceptions of source credibility and risk mutability emerged as potential mediating factors. Laypersons' responses to the communication of uncertainty regarding cancer risk estimates differ, and include both heightened and diminished risk perceptions. These differences may be attributable to personality, cognitive, and motivational factors.

Conceptual problems in laypersons' understanding of individualized cancer risk: a qualitative study.

To explore laypersons' understanding of individualized cancer risk estimates, and to identify conceptual problems that may limit this understanding. Risk prediction models are increasingly used to provide people with information about their individual risk of cancer and other diseases. However, laypersons may have difficulty understanding individualized risk information, because of conceptual as well as computational problems. A qualitative study was conducted using focus groups. Semi-structured interviews explored participants' understandings of the concept of risk, and their interpretations of a hypothetical individualized colorectal cancer risk estimate. Eight focus groups were conducted with 48 adults aged 50-74 years residing in two major US metropolitan areas. Participants had high school or greater education, some familiarity with information technology, and no personal or family history of cancer. Several important conceptual problems were identified. Most participants thought of risk not as a neutral statistical concept, but as signifying danger and emotional threat, and viewed cancer risk in terms of concrete risk factors rather than mathematical probabilities. Participants had difficulty acknowledging uncertainty implicit to the concept of risk, and judging the numerical significance of individualized risk estimates. The most challenging conceptual problems related to conflict between subjective and objective understandings of risk, and difficulties translating aggregate-level objective risk estimates to the individual level. Several conceptual problems limit laypersons' understanding of individualized cancer risk information. These problems have implications for future research on health numeracy, and for the application of risk prediction models in clinical and public health settings.

On Local Housing Supply Elasticity

Housing markets have been established as fundamental to understanding business cycles, financial market stability, labor mobility, household wealth, individual portfolio allocation, and urban dynamics. What determines local housing supply elasticities and prices? In this paper I give empirical content to the concept of land availability by processing satellite-generated data on elevation and presence of water bodies to precisely estimate the amount of developable land in each metro area. I demonstrate that development is effectively curtailed by the presence of slopes above 15% and that most areas that are widely regarded as supply-inelastic are, in fact, severely land-constrained by their topography. Furthermore, the extent of topographical constraints correlates positively and strongly with regulatory barriers to development. Immigration, high taxes, politics, and communitarian social capital are also predictive of more restrictive residential land regulations. I estimate a system of equations where housing prices, construction, and regulations are all determined endogenously. Housing supply elasticities can be well-characterized as functions of both physical and regulatory constraints, which in turn are endogenous to prices and past growth. The results provide operational estimates of local supply elasticities in all major US metropolitan areas.

Importance of Travel in Domestically Acquired Typhoid Fever Infections: Opportunities for Prevention and Early Detection

Approximately 25% of Salmonella typhi infections in the US occur among nontravelers. Two S. typhi infections in a major US metropolitan city acquired domestically in 2005 were epidemiologically linked to a S. typhi-infected Haitian traveler through their congregation meetings. This investigation highlighted the importance of integrating multiple methods of obtaining epidemiologic information, including laboratory evidence and multiple individual and group interviews. Physicians should consider typhoid fever in their differential diagnosis in communities with close ties to endemic areas. Education of communities whose residents travel regularly to typhoid-endemic areas can reduce infection and transmission risk.

Prediction Modeling to Determine the Adequacy of Medical Response to Urban Nuclear Attack

Government reports have persistently indicated the intent of terrorists and hostile nations to acquire and "weaponize" nuclear materials for deliberate attack on a major US metropolitan city. A modeling analysis of the effects of 20- and 550-kiloton nuclear detonations on the 2 major metropolitan centers of Los Angeles and Houston is presented with a focus on thermal casualties. Brode's work as modified by Binninger was used to calculate thermal fluence, using thermal fractions. The EM-1 and WE programs were used to calculate blast effects. Fallout radiation was calculated using the Defense Threat Reduction Agency's Hazard Prediction and Assessment Capability V404SP4 with "urban effects" turned on. The ESRI ArcView program calculated affected populations from 2000 US Census block-level data for areas affected by thermal effects. The population affected by a 550-kiloton nuclear weapon detonated in Los Angeles and Houston is staggering: surviving thermal casualties are estimated at 185,000 and 59,000, respectively. Even the 20-kiloton detonations in Los Angeles and Houston are significant: the numbers of surviving thermal casualties requiring care exceed 28,000 and 10,000, respectively. The surviving health care community postdetonation would be faced with an unprecedented burden of care for thermal casualties. A great expansion of personnel involved in emergency burn care response is critical. Bold, new approaches such as regionalization and predetermined medical air transport need to be considered.

Telecommuting and environmental policy: Lessons from the ecommute program

In 1999 the National Air Quality and Telecommuting Act established pilot telecommuting programs (ecommute) in five major US metropolitan areas. The major goal of the ecommute program was to examine whether a particular type of economic incentive, tradable emissions credits from telecommuting, represents a viable strategy for reducing vehicle miles traveled and improving air quality. A context is established for evaluating whether the envisioned trading scheme represents a feasible approach to reducing mobile source emissions and promoting telecommuting and a review of the limited experience with mobile source emissions trading programs is provided. Using two-and-one-half years of data collected in the ecommute program, telecommuting frequency, mode choice, and emissions reductions are examined. It is found that from a regulatory perspective, the most substantial drawback to such a program is its questionable environmental integrity, resulting from difficulties in designing sufficiently rigorous quantification protocols to accurately measure the emissions reductions from telecommuting. Such a program is not likely to be cost-effective because the emissions reductions from a single telecommuter are very small.

Factors associated with colorectal cancer screening among the US urban Japanese population.

The author examined the prevalence and predictors of colorectal cancer screening among the urban Japanese population of the United States. A sample of Japanese residents of major US metropolitan areas completed a self-administered mailed survey. Physician recommendation, acculturation, and perceived psychological costs were consistent predictors of screening for colorectal cancer. Gender and marital status were related to screening via fecal occult blood testing; age, susceptibility, and health insurance were related to sigmoidoscopy/colonoscopy screening. Colorectal cancer screening among the urban Japanese population could be increased with interventions seeking to promote physician recommendations for screening, alleviate perceived psychological costs among patients, and improve physician-patient communication.

Drug testing the police: some results of urinalysis and hair analysis in a major US metropolitan police force

This article presents the results of drug screening done between 1985 and 1999 by a police department in a major eastern American city. Drug testing data is presented for civilians applying for the position of police officer in response to public solicitations, officers-in-training who are tested at the end of a two year training period, and “sworn” – i.e., working officers in the field. The data includes test results for both urinalysis and hair analysis. The article compares the outcome in relationship to the intrinsic differences in time windows that the two testing technologies address, and assesses the efficacy of the technologies for detection of drug use, and the differences in detection rates attributable to each. The urinalysis findings show that of the three categories (police applicants, in-training officers, and working officers) applicants have drug-positive urinalyses about 2.8 times the rate of working police officers and at 16 times the rate for probationary officers. This pattern apparently holds true regardless of the size of the tested pool of personnel. Probationary officers in every case have the lowest rates of positive urine test results, applicants have the highest, and working officers occupy the middle ground. Hair analysis, which examines a larger time “window” than urinalysis, shows a higher prevalence rate than does urinalysis. The mean rate for hair analysis drug positive specimens was found to be 1.36 times that for urinalysis. Consistent with the urinalysis results, the applicant pool tested at rates 2–3 times higher when using hair analysis than the probationary officers.

Prevalence of autism in a US metropolitan area.

Concern has been raised about possible increases in the prevalence of autism. However, few population-based studies have been conducted in the United States. To determine the prevalence of autism among children in a major US metropolitan area and to describe characteristics of the study population. Study of the prevalence of autism among children aged 3 to 10 years in the 5 counties of metropolitan Atlanta, Ga, in 1996. Cases were identified through screening and abstracting records at multiple medical and educational sources, with case status determined by expert review. Autism prevalence by demographic factors, levels of cognitive functioning, previous autism diagnoses, special education eligibility categories, and sources of identification. A total of 987 children displayed behaviors consistent with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for autistic disorder, pervasive developmental disorder-not otherwise specified, or Asperger disorder. The prevalence for autism was 3.4 per 1000 (95% confidence interval [CI], 3.2-3.6) (male-female ratio, 4:1). Overall, the prevalence was comparable for black and white children (black, 3.4 per 1000 [95% CI, 3.0-3.7] and white, 3.4 per 1000 [95% CI, 3.2-3.7]). Sixty-eight percent of children with IQ or developmental test results (N = 880) had cognitive impairment. As severity of cognitive impairment increased from mild to profound, the male-female ratio decreased from 4.4 to 1.3. Forty percent of children with autism were identified only at educational sources. Schools were the most important source for information on black children, children of younger mothers, and children of mothers with less than 12 years of education. The rate of autism found in this study was higher than the rates from studies conducted in the United States during the 1980s and early 1990s, but it was consistent with those of more recent studies.

Racial differences in homeownership: the effect of residential location

The rate of homeownership among African–American households is considerably lower than white households in American urban areas. This paper examines whether racial differences in residential location outcomes are among the factors that contribute to the large racial differences in homeownership rates in major US metropolitan areas. Based on the 1985 metropolitan sample of the American Housing Survey for Philadelphia, the paper does not find any evidence that existing racial differences in residential location in Philadelphia decrease the homeownership rate among African Americans. Rather, the empirical evidence suggests that African–American residential location outcomes are associated with lower than expected racial differences in homeownership. Therefore, after controlling for neighborhood, racial differences in homeownership are larger than originally believed, and the ability of racial differences in endowments to explain homeownership differences is more limited.

Large format retailing in the US: a consumer experience perspective

Proponents of relationship marketing seek to develop and maintain long-term ties to their customers in the hope of having a loyal customer base. In this paper we examined large format retailing from the perspective of consumers’ experiences in these stores. Focus group interviews were conducted in two major US metropolitan areas and one medium size market. After analyzing the focus group content, several themes emerged related to patronage of large format retailers. These included the accuracy of prices when products were scanned and loyalty to store personnel based on familiarity. Large format supercenters were especially chided for their bigness and potential negative impact on smaller retailers. Attending to the details of the food retail business (accurate pricing, product availability, continuity of personnel) are ways in which consumers’ experiences in retail stores might be improved. Numerous choices and a diverse array of retail formats are available to consumers in the US market. Managerial implications are discussed in the light of a changing retail landscape.

Penetrating craniocerebral injuries in a civilian population in mid-Europe

Our current neurosurgical understanding of civilian penetrating craniocerebral injuries is based on US metropolitan series. It is unknown whether all principles applied to these patients are relevant in the Mid-European setting with its distinct epidemiology. The objective of this study was to characterize our patients with penetrating craniocerebral injuries, to analyze their outcome, and to identify relevant prognostic factors. Thirty-two patients with penetrating craniocerebral injuries were entered into the study. Patient evaluation comprised neurological, laboratory and radiographic analyses. Motivating factors were suicide (75%), assault (13%), and accident (9%). Initial GCS score, coagulopathy on admission, and radiographic extent of injury could be identified as outcome predictors ( P<0.001). An aggressive therapeutic approach to patients with GCS 3-7 reduced mortality when compared to a conservative management (67 vs. 91%). Due to major differences in epidemiology and outcome of our penetrating craniocerebral injury patients when compared to major US metropolitan series, current therapeutic strategies applied to this patient population in mid-Europe should be reconsidered. The results of our study justify an aggressive neurosurgical approach even in those patients that are thought to have a deleterious prognosis. Predictive variables identified in this study and a novel CT-grading algorithm may help in decision making.

Promotional products vs price promotion in fostering customer loyalty: a report of two controlled field experiments

Winning customer loyalty and repeat business and eliminating or reducing their reliance on coupons and other forms of price promotion is the goal of many service businesses today. The effectiveness of using advertising specialties (imprinted items given away for free) and price promotions was directly compared by way of two controlled field experiments involving customers of a Chinese food delivery service and a drycleaner in a major US metropolitan area. The studies used a controlled field experiment with a behavioral measure. The experiments offered support, in the business‐to‐business and consumer settings, that ad specialties can serve as inducements for a larger dollar volume of repeat business than the use of no promotion, and in some cases more than was generated by price promotion. Results suggest that goodwill engendered among customers by the ad. specialty “gifts”, coupled with the repeated brand exposure opportunities afforded by imprinted items, can exert a considerable impact on purchase behavior.