National Dataset Research Articles

Not-so-random forests: Comparing voting and decision tree ensembles for characterizing partial harvest events

Ensemble-based change detection can improve map accuracies by combining information from multiple datasets. There is a growing literature investigating ensemble inputs and applications for forest disturbance detection and mapping. However, few studies have evaluated ensemble methods other than Random Forest classifiers, which rely on uninterpretable “black box” algorithms with hundreds of parameters. Additionally, most ensemble-based disturbance maps do not utilize independently and systematically collected field-based forest inventory measurements. Here, we compared three approaches for combining change detection results generated from multi-spectral Landsat time series with forest inventory measurements to map forest harvest events at an annual time step. We found that seven-parameter degenerate decision tree ensembles performed at least as well as 500-tree Random Forest ensembles trained and tested on the same LandTrendr segmentation results and both supervised decision tree methods consistently outperformed the top-performing voting approach (majority). Comparisons with an existing national forest disturbance dataset indicated notable improvements in accuracy that demonstrate the value of developing locally calibrated, process-specific disturbance datasets like the harvest event maps developed in this study. Furthermore, by using multi-date forest inventory measurements, we are able to establish a lower bound of 30% basal area removal on detectable harvests, providing biophysical context for our harvest event maps. Our results suggest that simple interpretable decision trees applied to multi-spectral temporal segmentation outputs can be as effective as more complex machine learning approaches for characterizing forest harvest events ranging from partial clearing to clear cuts, with important implications for locally accurate mapping of forest harvests and other types of disturbances.

A National Assessment of EMS Performance at the Response and Agency Level

Background In 2019, the National EMS Quality Alliance (NEMSQA) established a suite of 11 evidence-based EMS quality measures, yet little is known regarding EMS performance on a national level. Our objective was to describe EMS performance at a response and agency level using the National EMS Information System (NEMSIS) dataset. Methods The 2019 NEMSIS research dataset of all EMS 9-1-1 responses in the United States was utilized to calculate 10 of 11 NEMSQA quality measures. Measure criteria and pseudocode was implemented to calculate the proportion meeting measure criteria and 95% confidence intervals across all encounters and for each anonymized agency. We omitted Pediatrics-03b because the NEMSIS national dataset does not report patient weight. Agency level analysis was subsequently stratified by call volume and urbanicity. Results Records from 9,679 agencies responding to 26,502,968 9-1-1 events were analyzed. Run-level average performance ranged from 12% for Safety-01 (encounter documented as initial response without the use of lights and siren to 82% for Pediatrics-02 (documented respiratory assessment in pediatric patients with respiratory distress) At the agency level, significant variation in measure performance existed by agency size and by urbanicity. At the individual agency performance analysis, Trauma-04 (trauma patients transported to trauma center) had the lowest agency-level performance with 47% of agencies reporting 0% of eligible runs with documented transport to a trauma center. Conclusion There is a wide range of performance in key EMS quality measures across the United States that demonstrate a need to identify strategies to improve quality and equity of care in the prehospital environment, system performance and data collection.

Canada Source Watershed Polygons (Can-SWaP): A dataset for the protection of Canada’s municipal water supply

Over 80% of municipal (i.e., excluding industrial and agricultural) water use in Canada comes from streams, lakes, and reservoirs. These freshwater bodies and their catchments require adequate protection to secure drinking water supply for Canadians. Canada, like most countries, lacks a consolidated national dataset of municipal catchments, arguably due to gaps in data availability. Against this backdrop, we present the Canada Source Watershed Polygons dataset, or Can-SWaP. Can-SWaP was created using point locations of more than 3,300 municipal water licences defining rights to surface water withdrawal. Where possible, the resulting 1,574 catchments were assessed for accuracy in spatial coverage against provincial and local datasets. Each watershed in Can-SWaP has an estimated water volume used for municipal water purposes derived from licencing data, and several variables from RiverATLAS for investigating the integrity of surface drinking water sources in Canada. Furthermore, basing our method on the HydroSHEDS suite of global products offers a robust framework for the production of other national datasets following an established international standard.

The metropolitan and neighborhood geographies of REIT- and private equity–owned single-family rentals

ABSTRACT After the U.S. foreclosure crisis, institutional investors purchased thousands of homes and converted them into rental properties. Past research links these entities to a number of negative outcomes, including rent increases and eviction filings. This paper examines a larger variety of investors, including private equity firms and contract sellers. Using a national dataset of real estate transactions from 2010 to mid-2017, we examine the inter- and intra-metropolitan geography of institutional investors. Consistent with prior research, we find that large publicly traded entities purchased homes in growing Sunbelt metros, yet some specific firms target weaker-market metros. Large, publicly traded firms have concentrated investment in higher-value neighborhoods with larger shares of white residents. In contrast, private equity firms and contract sellers tend to invest in relatively lower-value neighborhoods with larger shares of Black residents. Results suggest different potential implications for these diverse actors’ investments, from crowding out prospective homebuyers to racial targeting.

The NORDeHEALTH 2022 Patient Survey: Cross-Sectional Study of National Patient Portal Users in Norway, Sweden, Finland, and Estonia.

Although many surveys have been conducted on patients accessing their own health records in recent years, there is a limited amount of nationwide cross-country data available on patients' views and preferences. To address this gap, an international survey of patient users was conducted in the Nordic eHealth project, NORDeHEALTH. We aimed to investigate the sociodemographic characteristics and experiences of patients who accessed their electronic health records (EHRs) through national patient portals in Norway, Sweden, Finland, and Estonia. A cross-sectional web-based survey was distributed using the national online health portals. The target participants were patients who accessed the national patient portals at the start of 2022 and who were aged ≥15 years. The survey included a mixture of close-ended and free-text questions about participant sociodemographics, usability experience, experiences with health care and the EHR, reasons for reading health records online, experience with errors, omissions and offense, opinions about security and privacy, and the usefulness of portal functions. In this paper, we summarized the data on participant demographics, past experience with health care, and the patient portal through descriptive statistics. In total, 29,334 users completed the survey, of which 9503 (32.40%) were from Norway, 13,008 (44.35%) from Sweden, 4713 (16.07%) from Finland, and 2104 (7.17%) from Estonia. National samples were comparable according to reported gender, with about two-thirds identifying as women (19,904/29,302, 67.93%). Age distributions were similar across the countries, but Finland had older users while Estonia had younger users. The highest attained education and presence of health care education varied among the national samples. In all 4 countries, patients most commonly rated their health as "fair" (11,279/29,302, 38.48%). In Estonia, participants were more often inclined to rate their health positively, whereas Norway and Sweden had the highest proportion of negative health ratings. Across the whole sample, most patients received some care in the last 2 years (25,318/29,254, 86.55%). Mental health care was more common (6214/29,254, 21.24%) than oncological care (3664/29,254, 12.52%). Overall, most patients had accessed their health record "2 to 9 times" (11,546/29,306, 39.4%), with the most frequent users residing in Sweden, where about one-third of patients accessed it "more than 20 times" (4571/13,008, 35.14%). This is the first large-scale international survey to compare patient users' sociodemographics and experiences with accessing their EHRs. Although the countries are in close geographic proximity and demonstrate similar advancements in giving their residents online records access, patient users in this survey differed. We will continue to investigate patients' experiences and opinions about national patient-accessible EHRs through focused analyses of the national and combined data sets from the NORDeHEALTH 2022 Patient Survey.

Health implications of urban tree canopy policy scenarios in Denver and Phoenix: A quantitative health impact assessment

Background: Urban tree canopy (UTC) goals are a popular policy to increase urban vegetation, support climate strategies, and encourage a healthy environment. Health studies related to UTC are needed across cities to support evidence-based decision-making.Methods: We used a quantitative Health Impact Assessment (HIA) to model the annual number of premature deaths prevented, and the number of stroke and dementia cases, under UTC goals in Denver, Colorado, and Phoenix, Arizona, USA, using standing policy goals (20% and 25% UTC, respectively) and 50% (“half-way”) attainment scenarios from current levels (16.5% and 13% UTC, respectively), using publicly accessible national datasets, and a proportional representation of UTC change to standardize across methodologies. We estimated UTC health impacts by relating UTC with scenario-based changes in the Normalized Difference Vegetation Index (NDVI) and considered health equity in UTC distributions and benefits.Results: We projected that at 2020 populations, uniform 20% UTC attainment across Denver block groups would avert 200 (95% uncertainty interval: (UI) 100, 306) annual premature deaths among adults 18 and older, along with 4.1 (95% UI: 2.2, 6.7) annual cases of stroke (adults ≥35), and 2.6 (95% UI: 1.5, 4.1) cases of dementia (adults ≥65), with “halfway” attainment from current levels (16.5% UTC) capturing ∼64% of these benefits. In Phoenix, uniform 25% UTC would annually prevent 368 (95% UI: 181, 558) premature deaths, 8.7 (95% UI: 4.7, 13.9) cases of stroke, and 5,1 (95% UI: 2.9, 8.0) of dementia, with the “halfway” scenario (17% UTC) achieving ∼44% of these results. Both cities saw significantly different greenspace exposures and health outcomes by socioeconomic vulnerability. Denver had more spatially and socioeconomically heterogeneous projected health benefits than Phoenix.Conclusions: Implementing UTC goals can prevent excess mortality and chronic diseases among urban residents. UTC goals can be used as a health promotion and prevention tool.

MRNA SARS-CoV-2 Vaccination Before vs During Pregnancy and Omicron Infection Among Infants

Infants younger than 6 months are at risk of severe SARS-CoV-2 infection. Data are lacking on the optimum timing for maternal vaccination and estimated effectiveness against Omicron variants, including XBB, for infants. To investigate maternal vaccination against Omicron variants, including XBB, and the association of vaccination timing during pregnancy vs prior to pregnancy and risks of SARS-CoV-2 infection among infants aged 6 months or younger. This population-based cohort study was conducted between January 1, 2022, and March 31, 2023. Singapore's national dataset was used to study infants born at greater than 32 weeks' gestation between January 1, 2022, and September 30, 2022. The study included infants whose parents had a confirmed SARS-CoV-2 infection from the date of birth up to 6 months of age. Of 21 609 infants born during this period, 7292 (33.7%) had at least 1 parent infected with SARS-CoV-2 before the age of 7 months. Statistical analysis was performed from April to July 2023. Infants' mothers were unvaccinated, vaccinated prior to pregnancy, or vaccinated with a messenger RNA (mRNA) SARS-CoV-2 vaccine during pregnancy. Infants were considered infected if they had a positive polymerase chain reaction test. Among 7292 infants included in this study, 4522 (62.0%) had mothers who were Chinese, 527 (7.2%) had mothers who were Indian, 2007 (27.5%) had mothers who were Malay, and 236 (3.2%) had mothers who were other ethnicity; 6809 infants (93.4%) were born at full term, and 1272 infants (17.4%) were infected during the study period. There were 7120 infants (97.6%) born to mothers who had been fully vaccinated or boosted as of 14 days prior to delivery. The crude incidence rate was 174.3 per 100 000 person-days among infants born to mothers who were unvaccinated, 122.2 per 100 000 person-days among infants born to mothers who were vaccinated before pregnancy, and 128.5 per 100 000 person-days among infants born to mothers who were vaccinated during pregnancy. The estimated vaccine effectiveness (VE) was 41.5% (95% CI, 22.8% to 55.7%) among infants born to mothers vaccinated during pregnancy. Infants of mothers who received vaccination prior to pregnancy did not have a lower risk for infection (estimated VE, 15.4% [95% CI, -17.6% to 39.1%]). A lower risk for Omicron XBB infection was only observed among mothers vaccinated with the third (booster) dose antenatally (estimated VE, 76.7% [95% CI, 12.8% to 93.8%]). In this population-based cohort study, maternal mRNA vaccination was associated with a lower risk of Omicron SARS-CoV-2 infection among infants up to 6 months of age only if the vaccine was given during the antenatal period. These findings suggest that mRNA vaccination during pregnancy may be needed for lower risk of SARS-CoV-2 infection among newborns.

Risk of self-harm in patients with eating disorders: English population-based national record-linkage study, 1999-2021.

Anorexia nervosa (AN) and bulimia nervosa (BN) are eating disorders associated with high rates of self-harm (SH). This is the first national study in England to quantify this association in a hospital population. A retrospective cohort study using a linked national dataset of Hospital Episode Statistics for 1999-2021. The exposure cohort included individuals aged <35 years admitted to hospital with a diagnosis of AN or BN. The reference cohort included hospital controls. We calculated the rate ratio (RR) of SH in each cohort. The individuals in the two cohorts were matched on multiple socio-demographic indicators. The main outcome was a subsequent hospitalization or death record with an SH diagnosis. We identified 15,004 females and 1411 males with AN, and 6055 females and 741 males with BN. The RR with 95% confidence intervals (95%CI) for a subsequent admission with intentional self-harm after admission with AN was 4.9 (95%CI 4.7-5.1) in females and 4.8 (95%CI 3.9-5.8) in males. For BN it was 9.0 (95%CI 8.4-9.6) in females and 9.8 (95%CI 7.7-12.2) in males. There were strong associations between AN and BN and other SH. Women and men admitted to English hospitals with AN or BN have a very high risk of a subsequent admission with SH. For some SH behaviors, such as alcohol intoxication, the RR was >10-fold elevated. The magnitude of risk was higher for BN than for AN. Clinicians should be aware of the scale of risk increase. Providing those at risk with appropriate support is required. This study is the first national study in an English hospital population that confirms and quantifies the association between eating disorders and self-harm. We have found that both women and men admitted to hospital with anorexia nervosa or bulimia nervosa are at an increased risk of subsequent admission with self-harm. It is important that clinicians are aware of this increased risk to support those at highest risk of self-harm.

Protocol for a mixed-methods investigation of quality improvement in early childhood education and care in Australia

International recognition of the early years as a crucial foundational period has led to the design and implementation of quality rating and improvement systems (QRIS) that define, communicate, and monitor the components of quality in early childhood education and care (ECEC). The aim of these policies is to achieve effective quality assurance and improvement through a system-oriented approach to assessment and evaluation. Informed by ecological systems theory, this paper outlines a three-phase, mixed-methods design for researching a national sample of child care centres that showed overall improvement on the Australian National Quality Standard (NQS) assessment and rating (A&R) criteria. The study samples are drawn from a national dataset of centre-based child care services with two or more A&R rounds and an initial rating of Working Towards NQS (N = 1,935). The results of this study will provide insights into the macro-, exo-, meso- and micro-systems level factors and strategies that support quality in ECEC services.

Management and outcomes of myocardial infarction in people with impaired kidney function in England

BackgroundAcute myocardial infarction (AMI) causes significant mortality and morbidity in people with impaired kidney function. Previous observational research has demonstrated reduced use of invasive management strategies and inferior outcomes in this population. Studies from the USA have suggested that disparities in care have reduced over time. It is unclear whether these findings extend to Europe and the UK.MethodsLinked data from four national healthcare datasets were used to investigate management and outcomes of AMI by estimated glomerular filtration rate (eGFR) category in England. Multivariable logistic and Cox regression models compared management strategies and outcomes by eGFR category among people with kidney impairment hospitalised for AMI between 2015–2017.ResultsIn a cohort of 5 835 people, we found reduced odds of invasive management in people with eGFR < 60mls/min/1.73m2 compared with people with eGFR ≥ 60 when hospitalised for non-ST segment elevation MI (NSTEMI). The association between eGFR and odds of invasive management for ST-elevation MI (STEMI) varied depending on the availability of percutaneous coronary intervention. A graded association between mortality and eGFR category was demonstrated both in-hospital and after discharge for all people.ConclusionsIn England, patients with reduced eGFR are less likely to receive invasive management compared to those with preserved eGFR. Disparities in care may however be decreasing over time, with the least difference seen in patients with STEMI managed via the primary percutaneous coronary intervention pathway. Reduced eGFR continues to be associated with worse outcomes after AMI.

Antimicrobial resistance of Escherichia coli in the UK: comparison of single vs. pooled samples from healthy pigs.

This study compared the antimicrobial resistance (AMR) of Escherichia coli detected from single samples vs. pooled samples at herd level. The national monitoring dataset included isolates from one sample per pig holding, whereas the research study included isolates from pooled samples of 10 pigs per holding. In both datasets, caecal samples were collected from healthy pigs randomly selected at slaughterhouses and plated on non-selective and antibiotic selective media. Resistance against a panel of nine antibiotics was compared between datasets by generalized linear mixed effects models (GLMMs) and by bootstrapped generalized linear model (GLM) to account for pooling. The highest proportion of resistant E. coli was observed against tetracycline and ampicillin in both datasets. In non-selective media, single and pooled samples showed similar results, but the bootstrapped GLM detected significantly lower resistance to ciprofloxacin and nalidixic acid in the national dataset. In selective media, a significantly greater proportion of resistant isolates was observed in the research dataset for ceftazidime (OR: 0.05, 95%CI=0.01-0.42) and nalidixic acid (OR: 0.15, 95%CI=0.05-0.51). The results suggest that one sample per holding provides similar information on AMR at herd level as pooled samples for most of the tested antibiotics, although less resistance to ciprofloxacin, ceftazidime, and nalidixic acid was detected.

Health Equity Ratings of U.S. Burn Centers-Does For-Profit Status Matter?

Achieving health equity is forefront in national discussions on healthcare structuring. Burn injuries transcend racial and socioeconomic boundaries. Burn center funding ranges from safety-net to for-profit without an understanding of how funding mechanisms translate into equity outcomes. We hypothesized that health equity would be highest at safety-net facilities and lowest at for-profit centers. All verified and non-verified American Burn Association burn centers were collated in 2022. Safety-net status, for-profit status, and health equity rating were extracted from national datasets. Equity ratings were compared across national burn centers and significance was determined with comparative statistics and ordinal logistic regression. On an equity grade of A-D (A is the best), 27.6% of centers were rated A, 27.6% rated B, 41.5% rated C, and 3.3% rated D. About 17.1% of all burn centers were designated as for-profit compared to 21.1% of centers that were safety-net. About 73.1% of safety-net centers scored an A rating, and 14.3% of for-profit centers scored an A rating. Safety-net centers were 21.8 times more likely (P < .001) to have the highest equity score compared to nonsafety-net centers. There was an 80% decrease in the odds of having a rating of A for for-profit centers compared to nonprofit centers (P = .04). Safety-net centers had the highest equity ratings while for-profit burn centers scored the lowest. For-profit funding mechanisms may lead to the delivery of less equitable burn care. Burn centers should focus on health equity in the triage and management of their patients.

The impact of multimodal analgesia in coronary artery bypass graft surgery—a population-based analysis

ObjectiveMultimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS), and opioid consumption among patients undergoing coronary artery bypass graft surgery. MethodsThis retrospective cohort study included 349,940 adult patients undergoing elective coronary artery bypass graft surgery (January 2006 to December 2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of nonopioid analgesic modalities. These included, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids only and multimodal analgesia with the addition of 1, 2 or ≥3 nonopioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in milligram oral morphine equivalents. ResultsMultimodal analgesia was associated with a beneficial dose response pattern. With increasing nonopioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed, eg, with the addition of 1, 2, or ≥3 nonopioid modalities the odds for any complication decreased by 8% (odds ratio [OR], 0.92; confidence interval [CI], 0.90-0.94), 17% (OR, 0.83; CI, 0.81-0.86), and 22% (OR, 0.78; CI 0.69-0.79), respectively. This stepwise pattern was consistent in respiratory, cardiac, and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities. ConclusionsThese nationally representative data indicate that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.

26 The Importance of Executive Functioning for Academic Achievement Among a National Sample of Children with Epilepsy

Objective:Children with epilepsy are at greater risk of lower academic achievement than their typically developing peers (Reilly and Neville, 2015). Demographic, social, and neuropsychological factors, such as executive functioning (EF), mediate this relation. While research emphasizes the importance of EF skills for academic achievement among typically developing children (e.g., Best et al., 2011; Spiegel et al., 2021) less is known among children with epilepsy (Ng et al., 2020). The purpose of this study is to examine the influence of EF skills on academic achievement in a nationwide sample of children with epilepsy.Participants and Methods:Participants included 427 children with epilepsy (52% male; MAge= 10.71), enrolled in the Pediatric Epilepsy Research Consortium (PERC) Epilepsy Surgery Database who had been referred for surgery and underwent neuropsychological testing. Academic achievement was assessed by performance measures (word reading, reading comprehension, spelling, and calculation and word-based mathematics) and parent-rating measures (Adaptive Behavior Assessment System (ABAS) Functional Academics and Child Behavior Checklist (CBCL) School Performance). EF was assessed by verbal fluency measures, sequencing, and planning measures from the Delis Kaplan Executive Function System (DKEFS), NEPSY, and Tower of London test. Rating-based measures of EF included the 'Attention Problems’ subscale from the CBCL and 'Cognitive Regulation’ index from the Behavior Rating Inventory of Executive Function (BRIEF-2). Partial correlations assessed associations between EF predictors and academic achievement, controlling for fullscale IQ (FSIQ; A composite across intelligence tests). Significant predictors of each academic skill or rating were entered into a two-step regression that included FSIQ, demographics, and seizure variables (age of onset, current medications) in the first step with EF predictors in the second step.Results:Although zero-order correlations were significant between EF predictors and academic achievement (.29 &lt; r’s &lt; .63 for performance; -.63 &lt; r’s &lt; -.50 for rating measures), partial correlations controlling for FSIQ showed fewer significant relations. For performance-based EF, only letter fluency (DKEFS Letter Fluency) and cognitive flexibility (DKEFS Trails Condition 4) demonstrated significant associations with performance-based academic achievement (r’s &gt; .29). Regression models for performance-based academic achievement indicated that letter fluency (ß = .22, p = .017) and CBCL attention problems (ß = -.21, p =.002) were significant predictors of sight-word reading. Only letter fluency (ß = .23, p =.006) was significant for math calculation. CBCL Attention Problems were a significant predictor of spelling performance (ß = -.21, p = .009) and reading comprehension (ß = -.18, p =.039). CBCL Attention Problems (ß = -.38, p &lt;.001 for ABAS; ß = -.34, p =.002 for CBCL School) and BRIEF-2 Cognitive Regulation difficulties (ß = -.46, p &lt; .001 for ABAS; ß = -.46, p =.013 for CBCL School) were significant predictors of parent-rated ABAS Functional Academics and CBCL School Performance.Conclusions:Among a national pediatric epilepsy dataset, performance-based and ratings-based measures of EF predicted performance academic achievement, whereas only ratings-based EF predicted parent-rated academic achievement, due at least in part to shared method variance. These findings suggest that interventions that increase cognitive regulation, reduce symptoms of attention dysfunction, and promote self-generative, flexible thinking, may promote academic achievement among children with epilepsy.

Regionalized estimates of enteric methane emissions from cattle raised in Italian territory

Within the framework of the Extended Partnership "Economic-Financial Sustainability of Systems and Territories" (GRINS Project Spoke 1, WP3), this work proposes a regional estimate of the amount of enteric methane produced by cattle raised in the Italian territory. These data will be used to create national and regional datasets that will be an integral part of the AMELIA platform and will be freely available for use by both public and private managers for environmental impact assessments in the livestock sector. To this purpose, the IPCC (level 2) provides statistical models capable of evaluating this parameter, considering population, daily weight gain, animal weight, type of breeding, and dietary intake for each considered breed. In particular, in the calculation of enteric emissions, 37 pure breeds with different attitudes (milk, meat, and dual-purpose) have been considered, whose population is significant (>1%) at the national and/or regional level. For each individual breed, six classes have been considered, considering age and gender of the cattle. In addition, 22 crossbred breeds have been added, 21 specifics to each region and one at the national level. Regional emissions have been estimated by considering the average population of each breed in the period 2019-2022, normalizing the contributions of the individual species in a delimited territory and/or geographic area. In this way, six contributions have been calculated for each Italian region, representing a statistical assessment of the emissions that will subsequently be confirmed in the field through direct measurements using innovative instrumental technologies. Overall, this analysis offers a comprehensive view of how regional factors, and the composition of cattle breeds can impact greenhouse gas emissions. These findings provide valuable guidance for advancing sustainability initiatives within the agricultural sector.

National Trends for Temporary Mechanical Circulatory Support Utilization in Patients With Cardiogenic Shock From Decompensated Chronic Heart Failure: Incidence, Predictors, Outcomes, and Cost

BackgroundTrends in temporary mechanical circulatory support (tMCS) use with associated outcomes and cost in cardiogenic shock secondary to decompensated chronic heart failure (HF-CS) remains poorly understood. We describe trends in tMCS use, associated outcomes, and cost in HF-CS. MethodsWe included adults enrolled in a national insurance claims dataset with HF-CS who received intra-aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) without acute coronary syndrome, or postcardiotomy shock. We identified predictors of device use, associated outcomes, and inflation-adjusted costs. ResultsWe studied 2722 HF-CS patients receiving tMCS: 1799 (66%) male, 1771 (65%) White, and 1836 (67%) with ischemic cardiomyopathy. Rate of tMCS use increased from 2010-2019. Impella use showed the largest increase (Δ+344%), followed by ECMO (Δ+112%). Patients receiving ECMO had a higher comorbidity burden, and patients receiving IABP were more likely to have valvular heart disease. Compared with IABP, 30-day mortality rate was no different for Impella (adjusted odds ratio, 1.24; 95% CI, 0.93-1.66) but was higher with ECMO (adjusted odds ratio, 3.08; 95% CI, 2.22-4.27). Adjusted hospitalization cost was highest for ECMO (median, $191,079 [IQR, $165,760-$239,373]), followed by Impella (median, $142,518 [IQR, $126,845-$179,938]), and IABP (median, $132,060 [IQR, $113,794-$160,244]). We observed a linear association between price standardized cost-quartile and complications, but not for 30-day mortality. ConclusionsThe use of Impella and ECMO is increasing with an associated cost increase. The use of ECMO coincided with higher 30-day mortality compared with IABP in HF-CS. These findings likely reflect increasing disease severity and evolving practice patterns rather than causation.

Development of a framework for action to advocate for a coherent prevention policy for tobacco, alcohol, and foods high in fats, salt, or sugar: a mixed-methods approach

BackgroundTobacco, alcohol, and foods high in fats, salt, or sugar (HFSS) are health harming products. Limited progress in prevention is partly due to health-harming industry lobbying. Action on Smoking and Health (ASH), Alcohol Health Alliance, and Obesity Health Alliance collaborated with the aim of developing a framework for action to address the saturation of these products in our environment. MethodsWe used a mixed-methods approach. Focus groups with academic experts, local government, and national government, recruited through snowball sampling were held in Nov 3, 2022 (14 participants); April 25, 2023 (20 participants); and June 15, 2023 (20 participants). Iteratively, data analysis was presented, and key themes tested. Commissioned economic analysis of national survey datasets quantified consumer spend on tobacco, alcohol, and food products above government recommendations (all tobacco use, >14 units of alcohol, and national dietary guidelines) and industry percentage of revenues (net of tax). Public opinion data from the ASH YouGov Smokefree Survey 2022 on a nationally representative sample of 13 088 adults were descriptively analysed for specific policy options. FindingsThe framework for action to achieve a coherent prevention approach across products included three key enablers (secure funding for prevention, a comprehensive strategy, and protecting health policy from industry interference). Five key actions were: regulate advertising to limit harm, regulate product use and environments they can be used in, promote healthy messaging, raise the price of health-harming products, and fund treatment services. Economic analysis identified 100% of tobacco usage, 43·4% of alcohol purchased, and 28·8% of food purchased by households was above government recommendations. Post-tax industry revenue was £7·3 billion for tobacco, £11·2 billion for alcohol, and £34·2 billion for HFSS foods. Strong public support for levies (5%, n=8495) and protecting health policy from industry influence (69%, n=9006) was apparent. InterpretationA coherent approach to prevention across health-harming products is effective and has public support. Strengths include the iterative process to develop the framework for action among focus groups and use of nationally representative datasets. Limitations include the snowball sampling. The findings were built into a strategy intended to inform future collaborative work in the area. FundingCancer Research UK (grant PICADV-Feb22\\100004).

Health Care Stereotype Threat and Sexual and Gender Minority Well-Being.

Sexual and gender minorities (SGMs) have experienced progressive change over the last 50 years. However, this group still reports worse health and health care experiences. An innovative survey instrument that applies stereotype threat to the health care setting, health care stereotype threat (HCST), offers a new avenue to examine these disparities. We harmonized two national probability data sets of SGMs-Generations and TransPop-capturing 503 gay men, 297 lesbians, 467 bisexuals, and 221 trans people. Using these data, we, first, explored how HCST's association with self-rated health and psychological distress changed while considering more established constructs: discrimination and stigma. Second, we examined how HCST's association varied across SGM groups. Results suggest that HCST is a unique predictor net of the associations with discrimination and stigma. Furthermore, results highlight the more consequential associations for trans people on well-being compared to gay men. We discuss implications of these findings for future research and potential interventions.

Prevalence of multiple long-term conditions (multimorbidity) in England: a whole population study of over 60 million people.

To determine the prevalence of multiple long-term conditions (MLTC) at whole English population level, stratifying by age, sex, socioeconomic status and ethnicity. A whole population study. Individuals registered with a general practice in England and alive on 31 March 2020. 60,004,883 individuals. MLTC prevalence, defined as two or more of 35 conditions derived from a number of national patient-level datasets. Multivariable logistic regression was used to assess the independent associations of age, sex, ethnicity and deprivation decile with odds of MLTC. The overall prevalence of MLTC was 14.8% (8,878,231), varying from 0.9% (125,159) in those aged 0-19 years to 68.2% (1,905,979) in those aged 80 years and over. In multivariable regression analyses, compared with the 50-59 reference group, the odds ratio was 0.04 (95% confidence interval (CI): 0.04-0.04; p < 0.001) for those aged 0-19 years and 10.21 (10.18-10.24; p < 0.001) for those aged 80 years and over. Odds were higher for men compared with women, 1.02 (1.02-1.02; p < 0.001), for the most deprived decile compared with the least deprived, 2.26 (2.25-2.27; p < 0.001), and for Asian ethnicity compared with those of white ethnicity, 1.05 (1.04-1.05; p < 0.001). Odds were lower for black, mixed and other ethnicities (0.94 (0.94-0.95) p < 0.001, 0.87 (0.87-0.88) p < 0.001 and 0.57 (0.56-0.57) p < 0.001, respectively). MLTC for persons aged 0-19 years were dominated by asthma, autism and epilepsy, for persons aged 20-49 years by depression and asthma, for persons aged 50-59 years by hypertension and depression and for those aged 60 years and older, by cardiometabolic factors and osteoarthritis. There were large numbers of combinations of conditions in each age group ranging from 5936 in those aged 0-19 years to 205,534 in those aged 80 years and over. While this study provides useful insight into the burden across the English population to assist health service delivery planning, the heterogeneity of MLTC presents challenges for delivery optimisation.

Proximity of alcohol outlets and presentation to hospital by young people after self-harm: A retrospective geospatial study using the integrated data infrastructure.

There is a well-established association between alcohol use, misuse, intoxication and self-harm, the latter of which is associated with suicide. This study aimed to better understand the association between proximity to alcohol outlets and the likelihood of young people presenting to hospital following self-harm. This was a nationwide retrospective geospatial study using data from the New Zealand Integrated Data Infrastructure using population-level data for 10-29-year-olds for the 2018 and 2017 calendar years. Presentations to hospital following self-harm were identified using the national minimum data set. Proximity to alcohol outlets was defined in road network distance (in kilometres) and ascertained using Integrated Data Infrastructure geospatial data. Alternative measures of proximity were employed in sensitivity analyses. Complete-case two-level random intercept logistic regression models were used to estimate the relationship between alcohol outlet proximity and hospital presentation for self-harm. Adjusted models included sex, age, ethnicity, area-level deprivation, urbanicity and distance to nearest medical facility. Analyses were also stratified by urbanicity. Of the 1,285,368 individuals (mean [standard deviation] age 20.0 [5.9] years), 7944 (0.6%) were admitted to hospital for self-harm. Overall, the odds of presenting to hospital for self-harm significantly decreased as the distance from the nearest alcohol outlet increased, including in adjusted models (adjusted odds ratio 0.980; 95% confidence interval = [0.969-0.992]); the association was robust to changes in the measure of alcohol proximity. The effect direction was consistent across all categorisations of urbanicity, but only statistically significant in large urban areas and rural areas. The findings of this study show a clear association between young people's access to alcohol outlets and presentation to hospital for self-harm and may provide a mandate for government policies and universal interventions to reduce young people's access to alcohol outlets. Further research regarding causative mechanisms is needed.