Multilevel Regression Models Research Articles

COVID-19 inpatient care performance in the unified health system, São Paulo state, Brazil: an application of standardized mortality ratio for hospitals’ comparisons

ObjectiveTo evaluate the variation in COVID-19 inpatient care mortality among hospitals reimbursed by the Unified Health System (SUS) in the first two years of the pandemic in São Paulo state and make performance comparisons within periods and over time.MethodsObservational study based on secondary data from the Hospital Information System. The study universe consisted of 289,005 adult hospitalizations whose primary diagnosis was COVID-19 in five periods from 2020 to 2022. A multilevel regression model was applied, and the death predictive variables were sex, age, Charlson Index, obesity, type of admission, Brazilian Deprivation Index (BrazDep), the month of admission, and hospital size. Then, the total observed deaths and total deaths predicted by the model’s fixed effect component were aggregated by each hospital, estimating the Standardized Mortality Ratio (SMR) in each period. Funnel plots with limits of two standard deviations were employed to classify hospitals by performance (higher-than-expected, as expected, and lower-than-expected) and determine whether there was a change in category over the periods.ResultsA positive association was observed between hospital mortality and size (number of beds). There was greater variation in the percentage of hospitals with as-expected performance (39.5 to 76.1%) and those with lower-than-expected performance (6.6 to 32.3%). The hospitals with higher-than-expected performance remained at around 30% of the total, except in the fifth period. In the first period, 64 hospitals (18.3%) had lower-than-expected performance, with standardized mortality ratios ranging from 1.2 to 4.4, while in the last period, only 23 (6.6%) hospitals were similarly classified, with ratios ranging from 1.3 to 2.8. A trend of homogenization and adjustment to expected performance was observed over time.ConclusionDespite the study’s limitations, the results suggest an improvement in the COVID-19 inpatient care performance of hospitals reimbursed by the SUS in São Paulo over the period studied, measured by the standardized mortality ratio for hospitalizations due to COVID-19. Moreover, the methodological approach adapted to the Brazilian context provides an applicable tool to follow-up hospital’s performance in caring all or specific-cause hospitalizations, in regular or exceptional emergency situations.

Specific growth velocity reference charts for monochorionic twin pregnancies.

We aimed to create specific growth velocity reference charts for monochorionic (MC) twin pregnancies and provide additional information for assessing fetal growth in MC twins. This retrospective study collected data from uncomplicated MC twins with serial ultrasound parameters. The four ultrasound parameters, including biparietal diameter, femur length, head circumference, and abdominal circumference, were used to calculate the estimated fetal weight (EFW). Multilevel linear regression models were applied to fit growth velocity charts for each biometric parameter and EFW. Analysis of variance was used to examine differences in birthweight by whether EFW velocity and EFW values were <10th or ≥10th percentiles. The final analysis encompassed a total of 5956 ultrasound examinations conducted on 487 MC twins. The growth velocity of four biparietal diameters exhibited a gradual decrease in a nearly linear fashion progressing from 18 to 37 gestational weeks. The EFW velocity increased steadily from 18 to 36 gestational weeks, reaching a peak of 178.2 g/week, and then the velocity gradually decreased until delivery. At 32 weeks for illustration, the lightest birth weight was observed when both EFW and EFW velocity were <10th percentile (1899 g). The study also found that birth weight was higher when EFW velocity was ≥10th percentile compared with <10th percentile, regardless of EFW being below or above the 10th percentile (2263 and 1906 g, respectively; P < 0.001). We developed specific growth velocity reference charts for MC twins, which could provide a valuable reference point for a more precise evaluation of fetal growth in MC twins. Preliminary findings indicate that the inclusion of fetal growth velocity in monitoring fetal growth provides additional information beyond EFW alone.

Adoption of Chinese cars and the shift to electric vehicles: Early evidence from Norway

Chinese auto manufacturers have started exporting electric cars to developed markets. I study data from the world’s leading market for electric vehicles, Norway, to provide some early descriptive evidence on the patterns of Chinese-brand new car sales. Using a Bayesian multilevel regression model, I find evidence of local peer effects: A higher proportion of sales of a Chinese branded car in a postal code increases the probability of a new car sale being Chinese. I also hypothesize that municipalities with high penetrations of electric cars will be associated with higher penetrations of Chinese-branded new car sales. I do not find evidence for this.

What are escapists made of, and what does it have to do with excessive gambling and gaming?

AbstractResearch shows that escapism and frustration of basic psychological needs are linked with gambling and gaming problems, but an effect of escapism combined with restricted autonomy, competence, and relatedness on excessive gambling and gaming remains unclear. The purpose of this study is to identify shared characteristics of people who engage in escapist behavior and analyze to what extent the interaction of escapism and basic psychological need frustration predicts excessive gambling and gaming. We conducted a five-wave longitudinal survey with Finnish residents aged 18–75 years (n = 1530, 50.33% male) from April 2021 (T1) to April–May 2023 (T5). Measures included the Problem Gambling Severity Index, the ten-item Internet Gaming Disorder Test, and three escapism-specific questions. We analyzed the Basic Psychological Need Satisfaction and Frustration Scale, sociodemographic controls, and personality traits using multilevel regression models. We found that escapism was related to autonomy frustration, competence frustration, male gender, impulsivity, openness, and having a significant other who has experienced gambling problems. Escapism predicted excessive gambling, and competence frustration moderated this association. Escapism also predicted excessive gaming, and autonomy frustration and competence frustration moderated this association. Research on and treatment of excessive gambling and gaming should consider these underlying factors driving escapism.

What an Instrumentalist Perspective Adds to Cultural-Modernization Theory: Support for Democracy and Gender Equality in the Middle East

The comparative MENA literature on democratic support and the role of gender equality attitudes show mixed results despite the dominant cultural-modernization perspective predicting a positive interrelationship. Building on recent work, this paper derives and formulates the instrumentalist approach to democratic support as a supplement to the culturalist-modernization approach. It argues that people’s policy preferences and expectations of democracy are crucial to understand how democratic support is gendered, and part of these expectations are shaped by the political-institutional variations across the MENA region. Empirically, survey data from 47 AB and WVS surveys covering 13 MENA countries (2001–2014), are analysed. These data include information on support for gender equality, democracy, and the degree to which respondents link women’s rights to democracy. They are complemented with institutional information on the extent to which elections can form a threat to gender equality through empowering conservative Islamic forces via these elections. The multilevel regression models show initial support for cultural-modernization theory as the support for democracy and for gender equality correlate positively. This relationship is conditional to the risk elections pose to women’s position and whether people think democracy will bring gender equality thus illustrating the importance of adding an instrumentalist perspective. The support for democracy not only depends on the how much MENA citizens value democracy as a good in itself, it also depends on whether they expect democracy to be an instrument that helps further their other policy goals.

Abstract A089: Intersecting burdens: The role of social barriers and perceived stress in moderating cortisol reactivity among African American breast cancer survivors

Abstract Background: Disparities in breast cancer morbidity and mortality persist in African Americans. Social determinants and their subsequent effect on stress reactivity may impact the biological mechanisms associated with the onset and progression of cancer. However, stress reactivity has not been examined specifically among African American breast cancer survivors. Objective: To evaluate within-subject variation in stress reactivity among African American breast cancer survivors and determine whether this reactivity is influenced by social stressors, such as financial strain and social isolation, known to be associated with cancer outcomes. Methods: We conducted a laboratory intervention study using the Trier Social Stress Test on African American breast cancer survivors. We measured stress reactivity using salivary cortisol levels; socioeconomic, social, and psychological stressors were estimated by self-report. We performed multi-level random effect repeated-measures linear regression models to estimate within-subject changes in cortisol levels. We tested the moderating effects of social factors and cumulative social stressors on reactivity outcomes. Results: Sixty African American breast cancer survivors were included in the study. There were significant increases in mean cortisol levels at 30 minutes (beta=0.054, 95%CI=0.026, 0.082; p&amp;lt;0.001) and 40 minutes (beta=0.040, 95% CI=0.015, 0.065; p=.002) post-stress during the recovery period. We identified significant interactions between time and social stressors on cortisol levels for financial strain (χ2/df=15.83/4, p=.003), social isolation (χ2/df=9.67/4, p=.04), negative life events (χ2/df=12.75/4, p=.01), perceived stress (χ2/df=11.93/4, p=.02), and cumulative index of social stressors (χ2/df=11.14/4, p=.03). Conclusion: Social risk factors moderate the effects of stressors on cortisol reactivity among African American breast cancer survivors. There is a need to understand the lived experiences of Black women and develop interventions that mitigate the impact of social stressors on stress responses. Citation Format: Dr. Fatimata Sanogo, Dr. Junhan Cho, Dr. Trista Beard, Dr. Chanita Hughes Halbert. Intersecting burdens: The role of social barriers and perceived stress in moderating cortisol reactivity among African American breast cancer survivors [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A089.

Abstract B166: Impact of rurality on early-onset colorectal cancer outcomes: Age, geographic disparities, and the need for improved access and awareness in the United States

Abstract BACKGROUND: While overall colorectal cancer (CRC) rates have stabilized or declined in the United States (U.S.), early-onset CRC (EO-CRC), diagnoses before age 50, has increased. Rural U.S. residents face a higher CRC incidence (43.9 vs. 40.1 per 100,000) than urban residents. CRC mortality, once highest in the Northeast, is now most prevalent in the South and Midwest, particularly among Non-Hispanic Black populations. This geographic shift is also evident in EO-CRC. Existing literature lacks comprehensive analysis on the influence of rurality and age at CRC diagnosis. In this study, we sought to elucidate the relationships between age at diagnosis with CRC outcomes, while examining the moderating role of rurality. Methods: We used data from the 2006-2020 Surveillance, Epidemiology, and End Results (SEER) Program. Rurality was defined using census tract level U.S. Department of Agriculture (USDA)’s 2010 Rural Urban Commuting Area (RUCA) codes: rural (codes 8, 9, 10) and urban (all other listed codes). We conducted multilevel regression modeling (logistic and Cox proportional hazards) to examine the associations between age at diagnosis, rurality, and CRC outcomes (late-stage diagnosis and survival), adjusting for race, marital status, sex, and year of diagnosis. Results: We identified 835,907 patients aged 20-79 from the 2006-2020 SEER program. Most patients lived in urban areas (86%), were non-Hispanic white (66%), and married (41%). After adjusting for marital status, race, sex, and diagnosis year, we found that patients aged 30-39 (aOR: 1.49, 95% CI: 1.44–1.55) and 40-49 (aOR: 1.43, 95% CI: 1.39–1.46) had over a 40% increased likelihood of late-stage CRC compared to patients aged 50-59. Urban patients aged 30-39 had a 52% higher likelihood of late-stage CRC (aOR: 1.52, 95% CI: 1.46–1.58). Patients aged 20-29 (aOR: 0.81, 95% CI: 0.77–0.86) had a reduced risk of CRC death compared to those aged 50-59. Conversely, patients aged 40-49 (aOR: 1.09, 95% CI: 1.07–1.11), 60-69 (aOR: 1.16, 95% CI: 1.14–1.17), and 70-79 (aOR: 1.39, 95% CI: 1.28–1.36) had increased risks of CRC death compared to patients aged 50-59. Rural patients aged 20-29 (aOR: 0.79, 95% CI: 0.68–0.94) and 30-39 (aOR: 0.95, 95% CI: 0.87–1.03) had a reduced risk of CRC death compared to rural patients aged 50-59. Conclusion: We observed that patients aged 30-49 were more likely to be diagnosed with late- stage CRC compared to those aged 50-59, particularly in urban areas. To reduce the burden of EO-CRC and prevent advanced-stage diagnoses in young adults, it is essential to enhance access to care and raise awareness of CRC symptoms among younger Americans. Future research should explore urban -rural barriers to healthcare access, including the role of healthcare infrastructure, transportation, and provider availability, to develop strategies for improving EO-CRC early detection and treatment outcomes. Citation Format: Meng-Han Tsai, Justin X. Moore, Caitlyn Grunert. Impact of rurality on early-onset colorectal cancer outcomes: Age, geographic disparities, and the need for improved access and awareness in the United States [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B166.

The association of solid fuel use in households for cooking with elevated blood pressure among reproductive-aged married women in Bangladesh.

Bangladesh is experiencing a rapid increase in hypertension prevalence, particularly in socio-economically disadvantaged communities. The higher use of solid fuel in these communities could be one of the significant factors contributing to this trend, but evidence supporting this hypothesis is limited in Bangladesh. Therefore, this study aims to investigate the associations of household solid fuel use and its exposure level with systolic and diastolic blood pressure (DBP) and hypertension. We analysed 7,320 women's data from 2017/18 Bangladesh Demographic and Health Survey. We considered three outcome variables: (i) systolic blood pressure (BP) (continuous response), (ii) DBP (continuous response), and (iii) hypertension status (yes, no). Our primary exposures of interest were fuel type (clean vs solid) and the potential level of household air pollution exposure through solid fuel use (unexposed, moderately exposed, and highly exposed). We used a multilevel mixed-effects Poisson regression model with robust variance to determine association between exposure and outcome variables while adjusting for confounders. Of the total respondents analysed, approximately 82% used solid fuel for cooking. The age-standardised prevalence of hypertension was 28%. Respondents using solid fuel were found to be 1.44 times (95% confidence interval [CI], 1.04-1.89) more likely to develop hypertension compared to clean fuel users. Compared to women using clean fuel, the likelihood of hypertension was found to be 1.61 times (95% CI, 1.07-2.20) higher among the moderately exposed group and 1.80 times (95% CI, 1.27-2.32) higher among the highly exposed group. Similar associations were reported for systolic and DBP. The use of solid fuel increases the risk of becoming hypertensive and elevates systolic and DBP. Policies and programmes are necessary to increase awareness of the adverse effects of solid fuel use on health, including hypertension. Efforts should be made to reduce solid fuel use and ensure proper ventilation systems in households where solid fuel is used.

Spatial patterns and associated factors of HIV testing and counselling (HTC) as a component of antenatal care services in Ethiopia

Background While HIV testing and counselling play a crucial role in preventing mother-to-child transmission, numerous pregnant women did not receive these services. Understanding the spatial variation of HIV testing and counselling and its associated factors during antenatal care in Ethiopia remains limited. Thus, this study was aimed at assessing the spatial patterns and factors associated with HIV testing and counselling during antenatal care visits in Ethiopia. Methods A cross-sectional study design was employed with a two-stage stratified cluster sampling technique. A total of 2,789 women who gave birth in the two years prior to the survey and had at least one antenatal care visit were included in the study. Stata version 16 and ArcGIS version 10.8 software were used for analysis. A multilevel robust Poisson regression model was fitted to identify significantly associated factors since the prevalence of HIV testing and counselling was higher than 10%. A statistically significant association was declared based on multivariable multilevel robust Poisson regression analysis using an adjusted prevalence ratio with its 95% confidence interval at a p-value &lt; 0.05. Spatial regression analysis was conducted, and the local coefficients of statistically significant spatial covariates were visualised. Results In Ethiopia, the overall prevalence of HIV testing and counselling during antenatal care visits was 29.5% (95% CI: 27.8%, 31.2%). Significant spatial clustering was observed (Global Moran’s I = 0.138, p-value &lt;0.001). In the spatial regression analysis, high and comprehensive knowledge related to HIV, and comprehensive knowledge on the prevention of mother-to-child transmission were significant explanatory variables for the spatial variation of HIV testing and counselling. In the multivariable multilevel robust Poisson regression analysis, education, household wealth, media exposure, number of antenatal care visits, comprehensive knowledge on mother-to-child transmission, comprehensive knowledge on prevention of mother-to-child transmission, and region were significantly associated factors. Conclusion The prevalence of HIV testing and counselling during antenatal care visits was low. Empowering women through education, promoting mass media exposure, increasing numbers of antenatal care visits, and enhancing women’s knowledge related to HIV and mother-to-child transmission by targeting cold spot areas could improve HIV testing and counselling service uptake among pregnant women in Ethiopia.

Using multi-level regression to determine associations and estimate causes and effects in clinical anesthesia due to patient, practitioner and hospital or health system practice variability.

In this research methods tutorial of clinical anesthesia, we will explore techniques to estimate the influence of a myriad of factors on patient outcomes. Big data that contain information on patients, treated by individual anesthesiologists and surgical teams, at different hospitals, have an inherent multi-level data structure (Fig.1). While researchers often attempt to determine the association between patient factors and outcomes, that does not provide clinicians with the whole story. Patient care is clustered together according to clinicians and hospitals where they receive treatment. Therefore, multi-level regression models are needed to validly estimate the influence of each factor at each level. In addition, we will explore how to estimate the influence that variability-for example, one anesthesiologist deciding to do one thing, while another takes a different approach-has on outcomes for patients, using the intra-class correlation coefficient for continuous outcomes and the median odds ratio for binary outcomes. From this tutorial, you should acquire a clearer understanding of how to perform and interpret multi-level regression modeling and estimate the influence of variable clinical practices on patient outcomes in order to answer common but complex clinical questions. Fig.1 Infographics.

Exploring the impact of perceived early marriage on women’s education and employment in Bangladesh through a mixed-methods study

Child marriage negatively affects women’s socio-economic empowerment, particularly in education and employment. This study aimed to explore women’ perspectives on the timing of their marriages, considering their educational and employment status at the time. It also sought to identify factors influencing early married women’s perception of their marriages as timely. We analyzed both quantitative and qualitative data. The quantitative data included a sample of 5,596 women aged 15–24 from the 2017/18 Bangladesh Demographic and Health Survey. Additionally, we collected qualitative data through six in-depth interviews, two focus group discussions, and 13 key informant interviews. We used a multilevel mixed-effects Poisson regression model to examine the relationship between women’s formal employment, education, and child marriage. Thematic analysis was employed for the qualitative data. Around 62% of the total women analysed reported their married occurred early with the mean age at marriage was 15.2 years. Approximately 55% of the total early married women believed their marriages occurred at the right time, especially among those who were employed at the time of their marriage. Among this subset, we also noticed a higher likelihood of discontinuing work and education following marriage. Qualitative findings revealed reasons behind this perception, such as escaping poverty, safety concerns, limited job prospects, and the impact of non-marital relationship and societal norms. While many early-married women perceived their marriage as timely, particularly those initially employed, this decision often coincides with a subsequent withdrawal from work and education. This underscores the pressing need for policies and programs aimed at educating women about the legal age for marriage and the negative consequences associated with early marriage while also equipping them with knowledge and resources for informed decision-making.

Escalation of Human Resource Quality in National Health Resilience Through Estimating Multilevel Model Parameters with the Restricted Maximum Likelihood Approach to The 2019 UTBK Average

Multilevel modeling or Hierarchical Linear Modeling (HLM) is a statistical approach specifically used to analyze data with a two-level structure. This approach allows an understanding of the contribution of factors at both the individual and group levels to the response variable. One method commonly used in HLM is Restricted Maximum Likelihood (REML). REML is a parameter estimation method that is often applied in statistical models, especially linear models that incorporate random components. This allows more efficient parameter assessment compared to conventional estimation methods. In this research, multilevel model parameter estimation analysis was carried out using the limited maximum likelihood approach. The aim is to determine the multilevel linear regression model on the average UTBK score for health cluster study programs in 2019. This involves selecting the optimal node point based on the minimum Generalized Cross Validation (GCV) and identifying the factors that influence it. Predictor variables considered include interest and capacity of study programs at university level (Level-1), as well as the average UNBK and HDI scores at provincial level (Level-2). The findings of this research indicate that the most appropriate multilevel regression model is formed with three nodes with a minimum GCV value at Level-1 of 864.6593 and at Level-2 of 3.1816. At Level-1, the influencing factor is the interest variable and at Level-2 is the average provincial UNBK score in 2019 and the Human Development Index (HDI).

COVID-19, school closures and the retreat from educational aspirations.

As a shared external shock, the coronavirus pandemic (COVID-19) impacted health and well-being around the world. Mitigation strategies employed in many locations included school closures and travel restrictions. These strategies directly impacted educational access and opportunities and created economic stressors for families. This study examines how these direct impacts also altered educational aspirations for children and adolescents, an important predictor of educational attainment. We estimate multilevel regression models using two waves of data, collected in 2017-18 and 2020-21, from 1294 children and adolescents (Mean age = 13.1, SD = 2.8; 50.3% female) in Jalisco, Mexico, and 2201 children and adolescents (Mean age = 14.7, SD = 2.6; 49.1% female) in Chitwan Nepal. We examine changes in educational aspirations between the two waves (pre- and post-COVID-19 onset). Initial aspirations are positively associated with household wealth, caregiver education, and prior commitment to education. Multilevel regression models predicting changes in educational aspirations demonstrate these resources are important for maintaining high educational aspirations. But children and adolescents in households that experienced more economic loss following the external shock of the pandemic had lowered aspirations over time. Disruptions to schooling and economic shocks to households curtailed educational aspirations among children and adolescents in a similar way in two disparate settings. These results raise concerns about the educational attainment of children in the face of external shocks and the possibility that educational progress will stall in low resourced environments among the most vulnerable youth.

Determinants of Stunting in The Under-five in West Nusa Tenggara Province with Multilevel Binary Logistic Regression

Stunting is a form of malnutrition in children that is still a health problem in Indonesia, especially in NTB Province. Based on the results of the SSGI, the prevalence of stunting in children under five years of age in NTB Province was 32.7 percent, up 1.3 percent compared to the previous year. This value has not reached the threshold of 20 percent and the national target of 18.4 percent. This puts NTB Province in the fourth highest position in Indonesia. In 2022, NTB Province recorded the highest percentage in Indonesia for children under six months who received exclusive breastfeeding, which was 79.69 percent. However, the prevalence of stunting in toddlers in NTB Province is still very high. Between districts/cities in NTB Province, there is a fairly high disparity in the prevalence of stunting in children under five years of age. This shows the influence of regions or households so that there is a disparity in the prevalence of stunting in children under five years of age. This study aims to describe the incidence of stunting in toddlers in general and analyze the variables that influence it and its tendencies in NTB Province in 2022 using a multilevel binary regression model. The results of the study showed that the variables of toddler gender, toddler age, history of toddler pneumonia, maternal education level, access to clean drinking water sources, access to proper sanitation, and GRDP per capita had a significant effect

Genome-Derived Ampullary Adenocarcinoma Classifier and Postresection Prognostication

Ampullary adenocarcinoma (AA) is characterized by clinical and genomic heterogeneity. A previously developed genomic classifier defined biologically distinct phenotypes with greater accuracy than standard histologic classification. External validation is needed before routine clinical use. To test external validity of the prognostic value of the hidden genome classifier of AA. This retrospective cohort study took place at 6 international academic institutions. Consecutive patients (n = 192) who underwent curative-intent resection of histologically confirmed AA were included. The data were analyzed from January 2005 through July 2020. The multilevel meta-feature regression model previously trained on a prospectively sequenced cohort of 3411 patients (1001 pancreatic adenocarcinoma, 165 distal bile duct adenocarcinoma, and 2245 colorectal adenocarcinoma) was applied to AA sequencing data to quantify the relative proportions of parental cell of origin. Genomic classification was correlated with immunohistologic subtype (intestinal [INT] or pancreatobiliary [PB]) and with overall survival (OS), using the log-rank test and Cox proportional hazard models. Among 192 patients with AA (median age, 69.0 [IQR, 60.0-74.0] years and 134 were male [64%]), concordance between immunohistologic and genomic subtypes was 55%. Most INT subtype tumors were categorized into the colorectal genomic subtype (43 of 57 [72.9%]). Of the 114 PB subtype tumors, 29 had a pancreatic genomic profile (25.4%) and 24 had a distal bile duct genomic profile (21.1%). Whereas the standard immunohistologic subtypes were not associated with survival (log rank P = .26), predicted genomic probabilities were correlated with survival probability. Genomic scores with higher colorectal probability were associated with higher survival probability; higher pancreatic and distal bile duct probabilities were associated with lower survival probability. The AA genomic classifier is reproducible with available molecular testing in a diverse international cohort of patients and improves stratification of the divergent clinical outcomes beyond standard immunohistologic classification. These data provide a molecular classification that may be incorporated into clinical trials for prospective validation.

Maternal immigrant status and survival among children with congenital heart disease

ObjectiveTo examine associations between maternal immigrant status and survival of children with congenital heart disease (CHD). ApproachA retrospective population-based cohort study of hospital live births between April 2002 to September 2020 in Ontario, Canada was conducted at ICES. We identified children aged 0-17 years with a diagnosis of CHD from inpatient and health services datasets. The exposure was maternal immigrant status obtained from the IRCC permanent resident database. The outcome was time-to-death from after birth to &lt;18 years olds. Multilevel Cox hazard regression models generated hazard ratios (HR) for associations between maternal immigrant status and children’s deaths while accounting for hospitals as a cluster factor and adjusting for maternal age at birth, neighbourhood income and education quantiles, comorbidities, a composite of severe maternal morbidity, gestational age at birth, birth weight, and infant sex. ResultsRelative to children born to non-immigrant mothers, the adjusted HR for death was 1.17 (95% CI:1.06-1.30) in children whose mothers were immigrants, and 1.33 (95% CI:1.07-1.65) in those from refugees. Moreover, compared to children residing in neighbourhoods with the highest income and educational levels, the adjusted HR of death for children who lived in neighbourhoods with the lowest income and educational level was 1.52 (95% CI: 1.24-1.88) and 1.47 (95% CI: 1.18-1.83) respectively. ConclusionChildren with CHD born to immigrant and refugee mothers, and those living in low socioeconomic status neighbourhoods had worse mortality. Health policy decision makers should target children with CHD from immigrant/refugee families and disadvantaged neighbourhoods to improve their survival.

Temporal trends and practice variation in early repair of the ruptured aneurysm among patients with aneurysmal subarachnoid hemorrhage in the United States, 2012-2019.

Early repair of the ruptured cerebral aneurysm (RRCA), preferably within 24 h of onset, is endorsed by clinical guideline as the preferred management strategy for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, a comprehensive picture of this guideline-recommended usage in contemporary clinical practice is not available. This study aimed to characterize trends over time and practice variation in the implementation of an early RRCA strategy among patients with aSAH in a large, national representative data. Using data from the 2012-2019 National Inpatient Sample, we measured trends in the proportion of early RRCA, defined as within day 1 of admission, overall, and by demographic and geographical subgroups. In addition, we created multilevel regression models to quantify hospital-level variation in the early RRCA rates. We identified 82,615 aSAH hospitalizations (mean age = 56.1 years; 68.9% women) undergoing RRCA and, among these, 84.0% (95% confidence interval (CI) = 83.4-84.7%) receiving early RRCA. The proportion of early RRCA increased steadily from 82.5% in 2012 to 85.8% in 2019 (p for trend <0.001). The proportion of patients receiving early RRCA across geographic regions ranged from 78.7% to 87.9%, with a median (interquartile range (IQR)) of 84.2% (83.0-86.1%). In contrast, the delivery of early RRCA varied widely among hospitals, with a median (IQR) rate of 86.1% (75.0-100.0%) and a range from 0% to 100.0%. The median odds ratio for the early use of RRCA treatment was 1.24 (95% CI = 1.21-1.27) in 2019, indicating 24% increased odds of implementing early RRCA if moving from a lower-use to a higher-use hospital. Most patients in the United States with aSAH received early RRCA treatment and exhibited an upward trend over the recent 8-year period. However, substantial variation in access to early RRCA was observed across population subgroups, particularly at the hospital level. Future efforts are necessary to identify further sources of this variation and to develop initiatives that could represent an opportunity to optimize guideline-based quality of care in aSAH management. The data are available from the corresponding author upon reasonable request following completion of onboarding and verification procedures as specified by the HCUP.

Hospital and Physician Variability in Revascularization Decisions and Outcomes for Patients With 3-Vessel and Left Main Coronary Artery Disease: A Population-Based Cohort Study.

Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization. Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

Application of longitudinal multilevel zero inflated Poisson regression in modeling of infectious diseases among infants in Ethiopia

BackgroundIn sub-Saharan African countries, preventable and manageable diseases such as diarrhea and acute respiratory infections still claim the lives of children. Hence, this study aims to estimate the rate of change in the log expected number of days a child suffers from Diarrhea (NOD) and flu/common cold (NOF) among children aged 6 to 11 months at the baseline of the study.MethodologyThis study used secondary data which exhibit a longitudinal and multilevel structure. Based on the results of exploratory analysis, a multilevel zero-inflated Poisson regression model with a rate of change in the log expected NOD and NOF described by a quadratic trend was proposed to efficiently analyze both outcomes accounting for correlation between observations and individuals through random effects. Furthermore, residual plots were used to assess the goodness of fit of the model.ResultsConsidering subject and cluster-specific random effects, the results revealed a quadratic trend in the rate of change of the log expected NOD. Initially, low dose iron Micronutrient Powder (MNP) users exhibited a higher rate of change compared to non-users, but this trend reversed over time. Similarly, the log expected NOF decreased for children who used MNP and exclusively breastfed for six months, in comparison to their counterparts. In addition, the odds of not having flu decreased with each two-week increment for MNP users, as compared to non-MNP users. Furthermore, an increase in NOD resulted in an increase in the log expected NOF. Region and exclusive breastfeeding also have a significant relationships with both NOD and NOF.ConclusionThe findings of this study underscore the importance of commencing analysis of data generated from a study with exploratory analysis. The study highlights the critical role of promoting EBF for the first six months and supporting children with additional food after six months to reduce the burden of infectious diseases.

Association between City-Level Particulate Matter Exposure and Frailty among Middle-Aged and Older Adults in China

Introduction: The effects of exposure to particulate matter and frailty, as well as its exposure-response relationship, have not been effectively explored. This study aimed to explore the association between long-term exposure to particulate matter and frailty state and each dimension in Chinese middle-aged and older adults, in addition to the exposure-response relationship. Methods: The data were obtained from the National Urban Air Quality Real-Time Dissemination Platform and China Health and Retirement Longitudinal Study (CHARLS). Frailty was measured by a frailty index containing 39 indicators. Annual averages of seven pollutants were calculated from hourly monitoring data. We used multilevel regression modeling to explore the association between long-term exposure to particulate matter and frailty. Meanwhile, we explored the exposure-response relationship based on a multilevel generalized summation model. We performed a sensitivity analysis using a multi-pollution model and a quantile-based g-computation (QGC) model. Results: A total of 15,611 participants were included in the analysis. We find that long-term exposure to PM2.5 was associated with an increased risk of pre-frailty and frailty (all p < 0.05). PMc and PM10 exhibited similar associations. The exposure-response relationship between PM2.5 showed a linear relationship, whereas the exposure-response relationship between PM10, PMc showed a nonlinear relationship. Elevated PM2.5 concentrations showed significant positive associations with the number of chronic disease score, IADL score, and functional limitation status score (all p < 0.05). PM10 and PMc showed similar positive correlations. These results remained robust after sensitivity analyses using a multi-pollution model and QGC model. Conclusion: Chronic exposure to particulate matter was significantly associated with increased risk of frailty. The exposure-response relationship between PM2.5 concentration and frailty showed a linear relationship, and the exposure-response relationship between PM10 and PMc showed a nonlinear relationship. Exposure to a mixture of pollutants carried a higher risk of frailty than exposure to a single pollutant.