Pooled Cross-sectional Analysis Research Articles

EE315 Trends in Medical Expenditure and Resource Utilization Among Opioid, Benzodiazepine, Skeletal Muscle Relaxant, and Gabapentin Users: A Pooled Cross Sectional Analysis from 2009 - 2019

To evaluate health expenditure and emergency department use associated with non-opioid analgesic, opioid-only, opioid+benzodiazepine (OP/BZD), opioid+benzodiazepine+skeletal muscle relaxant (OP/BZD/SMR), and opioid+gabapentin (OP/GABA) users in the US from 2009-2019.

Sociodemographic, lifestyle and insurance factors associated with household expenditure on sugary foods: A pooled cross-sectional analysis

Sociodemographic, lifestyle and insurance factors associated with household expenditure on sugary foods: A pooled cross-sectional analysis

Inequalities in Consumption Expenditure on Pharmaceuticals: Evidence from Malaysia.

Pharmaceuticals play an important role in health improvements. This study is the first of its kind to examine the influences of household heads' sociodemographic characteristics and household profiles on pharmaceuticals expenditure among households of different income levels. The country of interest is a fast-growing developing country. Data from the Malaysian Household Expenditure Surveys 2014 and 2016 were used in the pooled cross-sectional analyses. Double-hurdle models were used to analyze consumption and amount decisions of pharmaceuticals. Analyses stratified by income were conducted. Results showed that households headed by younger adults (<60 years), males, less educated individuals, Bumiputera, and divorced/widowed adults were less likely to consume and spent less on pharmaceuticals compared with households headed by older adults (≥60 years), females, more educated individuals, non-Bumiputera, and single adults. These differentials varied across income groups. In conclusion, household heads' age, gender, educational levels, ethnicity, marital status, and household profiles are important determining factors of expenditure on pharmaceuticals among low-, middle- and high-income households.

Examining Associations Between Resilience and PrEP Use Among HIV-negative GBM in Toronto, Montreal and Vancouver.

This study evaluated the association between resilience and PrEP use among a population-based sample of Canadian gay, bisexual, and other men who have sex with men (GBM). Sexually active GBM aged ≥ 16 years old were recruited via respondent-driven sampling (RDS) in Toronto, Montreal, and Vancouver from 02/2017 to 07/2019. We conducted a pooled cross-sectional analysis of HIV-negative/unknown GBM who met clinical eligibility for PrEP. We performed multivariable RDS-II-weighted logistic regression to assess the association between scores on the Connor-Davidson Resilience-2 Scale and PrEP. Mediation analyses with weighted logistic and linear regression were used to assess whether the relationship between minority stressors and PrEP use was mediated by resilience. Of 1167 PrEP-eligible GBM, 317 (27%) indicated they took PrEP in the past six months. Our multivariable model found higher resilience scores were associated with greater odds of PrEP use in the past six months (aOR = 1.13, 95%CI = 1.00, 1.28). We found that resilience reduced the effect of the association between heterosexist discrimination and PrEP use. Resilience also mediated the relationship between internalized homonegativity and PrEP use and mediated the effect of the association between LGBI acceptance concern and PrEP use. Overall,PrEP-eligible GBM with higher resilience scores had a greater odds of PrEP use in the past six months. We also found mixed results for the mediating role of resilience between minority stress and PrEP use. These findings underline the continued importance of strength-based factors in HIV prevention.

Social determinants of health and emergency department utilization in Alabama Children's Health Insurance Program.

Injuries are the leading cause of death among children and youth in the United States, representing a major concern to society and to the public and private health plans covering pediatric patients. Data from ALL Kids, Alabama's Children's Health Insurance Program, were used to evaluate the relationship between community-level social determinants of health (SDOH) and pediatric emergency department (ED) use and differences in these associations by age and race. This was a retrospective, pooled cross-sectional analysis. We used ALL Kids data to identify ED visits (injury and all-cause) among children who were enrolled at any time from 2015 to 2017. Exploratory factor analysis was used to categorize SDOH from 18 selected Census tract-level variables. Multilevel Poisson regression models were used to evaluate the effects of community and individual factors and their interactions. Census tract-level SDOH were grouped as low socioeconomic status (SES), urbanicity, and immigrant-density factors. Low SES and urbanicity factors were associated with ED visits (injury and all-cause). The low SES and urbanicity factors also moderated the association between race and ED visits (injury and all-cause). The environment in which children live influences their ED use; however, the impact varies by age, race, and Census tract factors. Further studies should focus on specific community factors to better understand the relationship among SDOH, individual characteristics, and ED utilization.

Illnesses and hardship financing in India: an evaluation of inpatient and outpatient cases, 2014-18

BackgroundProgress towards universal health coverage requires strengthening the country's health system. In developing countries, the increasing disease burden puts a lot of stress on scarce household finances. However, this burden is not the same for everyone. The economic burden varies across the disease groups and care levels. Government intervention is vital in formulating policies in addressing financial distress at the household level. In India, even when outpatient care forms a significant proportion of out-of-pocket expenditure, government schemes focus on reducing household expenditure on inpatient care alone. Thus, people resort to hardship financing practices like informal borrowing or selling of assets in the event of health shocks. In this context, the present study aims to identify the disease(s) that correlates with maximum hardship financing for outpatients and inpatients and to understand the change in hardship financing over time.MethodsWe used two waves of National Sample Survey Organisation’s data on social consumption on health- the 71st and the 75th rounds. Descriptive statistics are reported, and logistic regression is carried out to explain the adjusted impact of illness on hardship financing. Pooled logistic regression of the two rounds is estimated for inpatients and outpatients. Marginal effects are reported to study the changes in hardship financing over time.ResultsThe results suggest that cancer had the maximum likelihood of causing hardship financing in India for both inpatients (Odds ratio 2.41; 95% Confidence Interval (CI): 2.03 - 2.86 (71st round), 2.54; 95% CI: 2.21 - 2.93 (75th round)) and outpatients (Odds ratio 6.11; 95% CI: 2.95 - 12.64 (71st round), 3.07; 95% CI: 2.14 - 4.40 (75th round)). In 2018, for outpatients, the hardship financing for health care needs was higher at public health facilities, compared to private health facilities (Odds ratio 0.72; 95% CI: 0.62 - 0.83 (75th round). The marginal effects model of pooled cross-section analysis reveals that from 2014 to 2018, the hardship financing had decreased for inpatients (Odds ratio 0.747; 95% CI:0.80 - -0.70), whereas it had increased for outpatients (Odds ratio 0.0126; 95% CI: 0.01 - 0.02). Our results also show that the likelihood of resorting to hardship financing for illness among women was lesser than that of men.ConclusionGovernment intervention is quintessential to decrease the hardship financing caused by cancer. The intra-household inequalities play an important role in explaining their hardship financing strategies. We suggest the need for more financial risk protection for outpatient care to address hardship financing.

Does the use of prediction equations to correct self-reported height and weight improve obesity prevalence estimates? A pooled cross-sectional analysis of Health Survey for England data

ObjectiveAdults typically overestimate height and underestimate weight compared with directly measured values, and such misreporting varies by sociodemographic and health-related factors. Using self-reported and interviewer-measured height and weight, collected from...

Challenges to intersectional analyses and building capacity for skin cancer research in minority populations

To the Editor: We thank Joshi and Lipoff for their commentary on our research letter assessing skin cancer prevalence and risk factors among foreign-born individuals in the United States, 1 Supapannachart K.J. Gangal A. Chen S.C. Yeung H. Skin cancer prevalence and risk among foreign-born people living in the United States: a pooled cross-sectional analysis. J Am Acad Dermatol. 2022; https://doi.org/10.1016/j.jaad.2022.08.056 Abstract Full Text Full Text PDF Scopus (0) Google Scholar recognizing heterogeneity within racial/ethnic minority subgroups in epidemiologic research. 2 Joshi T.P. Lipoff J.B. Skin cancer in foreign-born Americans: the importance of recognizing diversity within ethnic groups. J Am Acad Dermatol. 2022; https://doi.org/10.1016/j.jaad.2022.11.056 Abstract Full Text PDF Google Scholar In echoing these important sentiments, we highlight methodological limitations of existing datasets that preclude intersectional analyses of racial/ethnic minority subgroups by foreign-born status and call for efforts to collect relevant skin health data from under-sampled racial/ethnic subgroups. Skin cancer in foreign-born Americans: The importance of recognizing diversity within ethnic groupsJournal of the American Academy of DermatologyPreviewTo the Editor: We read with interest the research letter by Supapannachart et al1 and applaud them for analyzing the risk factors for, and the prevalence of, skin cancer in foreign-born individuals residing in the United States. The authors show skin cancer prevalence and risk factors to be lower among foreign-born versus US-born individuals. We recognized some limitations of the analysis by Supapannachart et al1 and identified an important gap that remains in the literature on the epidemiology of dermatologic disease in foreign-born Americans. Full-Text PDF

Skin Cancer Behavioral Risk Factors and Screening Among U.S. Adults in Same-Sex Relationships: A Population-Based Study from 2000 to 2015.

Purpose: Skin cancer is prevalent in sexual minority men but little is known about risk factors and screening specifically among couples in same-sex relationships (SSR). We aimed to compare sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) between people in SSR with those in opposite-sex relationships (OSR). Methods: We conducted a pooled cross-sectional analysis of 2000-2015 data from the National Health Interview Survey, a nationally representative survey of the United States civilian population. Results: Of 102,365 adults with a spouse or married partner, 448 (0.4%) were men in SSR, 48,312 (48.1%) men in OSR, 497 (0.5%) women in SSR, and 53,108 women in OSR (51.9%). Men in SSR were more likely than men in OSR to seek shade (adjusted odds ratio [aOR] = 1.41; 95% confidence interval [CI] = 1.07-1.85), tan indoors (aOR = 3.71; 95% CI = 2.38-5.78), and receive any TBSE (aOR = 2.45; 95% CI = 1.69-3.54) after adjusting for sociodemographic factors, health insurance status, and health behaviors. Men in SSR were less likely than men in OSR to wear long pants (aOR = 0.63; 95% CI = 0.46-0.85) and caps or visors (aOR = 0.50; 95% CI = 0.36-0.69). No differences in sunburns, sun-protective behaviors, indoor tanning, and TBSE between women in SSR and OSR were observed after multivariable adjustment. Conclusion: Patterns of sun-protective behaviors and indoor tanning among men in SSR, compared with men in OSR, demonstrate modifiable behaviors that may mitigate skin cancer risk. Dyadic counseling and public health interventions geared toward men in SSR may promote sun-protective behaviors and reduce indoor tanning.

HPR91 Disease-Specific Hardship Financing in India: A Pooled Cross-Section Analysis of Inpatient and Outpatient Cases

Universal Health Coverage (UHC) aims to provide quality health services to all without causing financial distress. In developing countries, people resort to ex-post distress financing when faced with a health shock. In India, intending to overcome this, the government has introduced a vast network of financial protection schemes for the poor and vulnerable, majorly at the inpatient level. However, studies suggest that free outpatient care is also critical in reaching the goal of UHC. Our study, based in India, uses hardship financing, which is ex-post informal borrowings, contributions from friends/ relatives, or sale of assets, as the indicator to measure financial constraints faced by individuals to meet the unforeseen health expenditures. The paper has two primary goals. The first is to identify the disease(s) causing the maximum financial hardship in the country. Secondly, it looks at the change in hardship financing over time.

Early physical maturation and subjective health complaints in adolescent girls: a pooled cross-sectional analysis

BackgroundAlthough adolescents are generally healthy, subjective health complaints (SHC) are common in this age group, especially in adolescent girls. We explored the association between early menarche and the frequency of...

Association of State-Level Firearm-Related Deaths With Firearm Laws in Neighboring States

Firearms are easily transported over state borders; hence permissive firearm laws in one state may have an interstate association with firearm-related deaths in nearby states. To examine whether certain firearm laws have an interstate association with firearm-related deaths in nearby states. This cross-sectional observational study used data on state firearm-related deaths in the 48 contiguous states of the US between January 1, 2000, and December 31, 2019. A spatial autoregressive model with fixed effects for state and year was used to evaluate within-state, interstate, and overall associations between firearm laws and firearm-related deaths. Analyses were performed during January 2022. The following 9 types of laws were evaluated: universal background checks for all firearms purchase, background checks for handgun sales at gun shows, license requirement to purchase all firearms, state dealer license requirement for handgun sales, requirement of retaining records of handgun sales, ban on purchasing a handgun on behalf of another, prohibition of firearm possession by persons who committed violent misdemeanors, required relinquishment of firearms for persons becoming prohibited from possessing them, and discretion in granting a concealed carry permit. State-level total firearm-related death rates, suicide rates, and homicide rates. In sum, the study period included 662 883 firearm-related deaths of all intents. License requirement for firearm purchase had a within-state association (effect size, -1.79 [95% CI, -2.73 to -0.84]), interstate association (effect size, -10.60 [95% CI, -17.63 to -3.56]), and overall association (effect size, -12.38 [95% CI, -19.93 to -4.83]) per 100 000 population decrease in total firearm-related deaths. This law also had within-state association (effect size, -1.26 [95% CI, -1.72 to -0.80]), interstate association (effect size, -9.01 [95% CI, -15.00 to -3.02]), and overall association (effect size, -10.27 [95% CI, -16.53 to -4.01]) per 100 000 population decrease in firearm-related homicide. The findings of this pooled cross-sectional analysis suggest that certain firearm laws in one state were associated with other states' firearm-related deaths. Synergic legislative action in adjacent states, federal firearm legislation, and measures that reduce migration of firearms across state borders should be part of the overarching strategy to prevent firearm-related deaths.

Changes in racial and ethnic disparities in glucose-lowering drug utilization and glycated haemoglobin A1c in US adults with diabetes: 2005-2018.

To examine changes in racial and ethnic disparities in glucose-lowering drugs (GLD) use and glycated haemoglobin A1c in US adults with diabetes from 2005 to 2018. We conducted pooled cross-sectional analysis using data from the 2005-2018 Medical Expenditure Panel Surveys, and the 2005-2018 National Health and Nutrition Examination Survey. Individuals ≥18 years with diabetes were included. Racial and ethnic disparities were measured in (a) newer non-insulin GLD use; (b) insulin analogue use; (c) non-insulin GLDs adherence; (d) insulin adherence; and (e) glucose management, along with (f) the proportion of the disparities explained by potential contributing factors. From 2005 to 2018, racial and ethnic disparities persisted in newer GLD use, non-insulin GLDs adherence, insulin analogue use and glucose management. In 2018, compared with non-Hispanic white adults, non-Hispanic black, Hispanic and other race/ethnicity groups had lower rates of using newer GLDs (adjusted risk ratio: 0.44, 0.52, 0.64, respectively; p < .05 for all) and insulin analogues (adjusted risk ratio: 0.93, 0.89, 0.95, respectively; p < .05 for all except other groups), lower non-insulin GLD adherence (proportion of days covered: -4.5%, -5.6%, -4.3%, respectively; p < .05 for all), higher glycated haemoglobin A1c (0.29%, 0.32%, 0.02%, respectively; p < .05 for all except other group), and similar insulin adherences. Socioeconomic and health status were the main contributors to these disparities. Our findings provide evidence of racial and ethnic disparities in newer GLD use and quality of care in glucose management. Our study results can inform decision-makers of the status of racial and ethnic disparities and identify ways to reduce these disparities.

The ultra-processed food content of school meals and packed lunches in the UK, 2008–17: a pooled cross-sectional study

BackgroundBritish children have the highest ultra-processed food (UPF) intake in Europe, concerning as UPF is linked to adverse health outcomes. Schools are a potential setting for intervention, yet the rate of UPFs consumed at schools is currently unknown. This study aimed to describe the UPF content of school food in the UK and to explore differences in UPF content by meal type (school meals and packed lunches [food from home]) and children's household income. MethodsWe performed a pooled cross-sectional analysis of 1895 primary school children (aged 4–11 years) and 1408 secondary school children (aged 11–18 years) using data from the UK's National Diet and Nutrition Survey (from Feb, 2008, to June, 2017). Student's meal type was recorded using food diaries. UPF intake was defined using the NOVA food classification system. Income was measured through interview. We used quantile regression models to assess the association between meal type and lunchtime UPF intake (by both the percentage of calories and weight). We stratified models by school phase (primary or secondary) and interacted meal type with income. FindingsThe majority of schoolchildren's lunch was defined as UPFs, with secondary school children having higher median intakes of UPFs than primary school children (78% kcal [IQR 58–95] vs 73% kcal [55–86). School meals were associated with a lower median UPF intake than packed lunches for primary school children (61% kcal [IQR 44–75] vs 81% kcal [71–91]) and for secondary school children (70% kcal [IQR 48–89] vs 84% kcal [65–99]). Results were similar when UPFs were analysed as a percentage of the total weight of lunch. Overall, income was inversely associated with UPF lunch content. However, in primary school children, there was no significant association between percentage of UPF content of school meals by weight. InterpretationIn the first nationally representative study, we showed that UK school children have a high intake of UPFs at lunch. UPF intake was increased in children who consumed packed lunches, secondary school children, and children of a lower income. School meal procurement policies must be re-evaluated to protect children from high UPF intake. FundingThis study was funded by the National Institute for Health Research School for Public Health Research.

Skin cancer prevalence and risk among foreign-born people living in the United States: A pooled cross-sectional analysis

Skin cancer prevalence and risk among foreign-born people living in the United States: A pooled cross-sectional analysis

Risk factors for child survival among tribal dominated states in India: a pooled cross sectional analysis

Risk factors for child survival among tribal dominated states in India: a pooled cross sectional analysis

Predictors of Pediatric Frequent Emergency Department Use Among 7.6 million Pediatric Patients in New York.

This study examines the characteristics and factors associated with frequent emergency department (ED) utilization among the pediatric population. We conducted a pooled cross-sectional secondary analysis using the Healthcare Cost and Utilization Project State Emergency and Inpatient Databases on ED visits to all hospitals in New York from 2011 to 2016 by patients aged 0 to 21. We used multivariable logistic and negative binomial regressions to investigate the predictors of multiple ED visits in the pediatric population. Overall, our study included 7.6 million pediatric patients who accounted for more than 12 million ED visits. Of those, 6.2% of patients were frequent ED users (≥4 visits/year), accounting for 20.8% of all ED visits (5.4 ED visits/year on average). The strongest predictors of frequent ED use were having at least one ED visit related to asthma (aOR=8.37 [95% CI: 6.34-11.04]), mental health disorders (aOR=9.67 [95% CI: 8.60-10.89]), or multiple comorbidities compared to none. Larger shares of ED visits for not-emergent conditions were also associated with frequent ED use (aOR=6.63 [95% CI=5.08-8.65]). Being covered by Medicaid compared to private (aOR=0.45 [95% CI: 0.42-0.47]) or no insurance (aOR=0.41 [95% CI: 0.38-0.44]) were further associated with frequent ED use. The results from the negative binomial regression yielded consistent findings. Pediatric patients who exhibit increased ED use are more medically complex and have increased healthcare needs that are inextricably tied to social determinants of health. Better integrated health systems should emphasize connecting vulnerable patients to appropriate social and primary care services outside of emergency settings.

The Ultra-Processed Food Content of School Meals and Packed Lunches in the United Kingdom.

British children have the highest levels of ultra-processed food (UPF) consumption in Europe. Schools are posited as a positive setting for impacting dietary intake, but the level of UPFs consumed in schools is currently unknown. This study determined the UPF content of school food in the UK. We conducted a pooled cross-sectional analysis of primary (4–11 years, n = 1895) and secondary schoolchildren (11–18 years, n = 1408) from the UK’s National Diet and Nutrition Survey (2008–2017). Multivariable quantile regression models determined the association between meal-type (school meal or packed lunch) and lunchtime UPF intake (NOVA food classification system). We showed that on average, UPF intake was high in both primary (72.6% total lunch Kcal) and secondary schoolchildren (77.8% total lunch Kcal). Higher UPF intakes were observed in packed lunch consumers, secondary schoolchildren, and those in lower income households. This study highlights the need for a renewed focus on school food. Better guidance and policies that consider levels of industrial processing in food served in schools are needed to ensure the dual benefit of encouraging school meal uptake and equitably improving children’s diets.

Dietary quality of school meals and packed lunches: a national study of primary and secondary schoolchildren in the UK.

School lunches represent a key opportunity to improve diets and health of schoolchildren. No recent nationally representative studies have examined the nutritional differences between school meals and packed lunches in the UK. This study aimed to characterise and compare the nutritional quality of school meals and packed lunches among primary and secondary school-age children. A pooled cross-sectional analysis of the UK's National Diet and Nutrition Survey (2008-2017). United Kingdom. 3001 children (aged 4-16 years) who completed a 3/4-d food diary which recorded meal type (school meal/packed lunch). Multivariable logistic regression models assessed associations of meeting food and nutrient recommendations by meal type. Analyses were stratified by academic key stages (KS). KS-1 (4-7 years) and 2 (8-11 years) children consuming school meals were more likely to meet minimum recommendations for vegetables, protein-rich foods and fibre, and not exceed maximum recommendations for salt, savoury and sweet snacks compared with pupils consuming packed lunches. However, in KS-3 (12-14 years) and 4 (14-16 years), these effects were reduced. As children aged, the median weight of fruits, vegetables, protein-rich foods and dairy products consumed typically decreased for both school meals and packed lunches, and generally an increasing proportion of school meals contained sweet and savoury snacks. These findings suggest school meals are nutritionally superior to packed lunches but are not yet optimal. Quality declined at higher KS. Actions to improve lunches of primary and secondary schoolchildren across the UK are needed, with attention to KS-3 and 4 in secondary schools.

Do sanctuary policies increase crime? Contrary evidence from a county-level investigation in the United States

Immigration and Customs Enforcement (ICE) has rolled out a series of programs that leverage local and state resources to detain and deport undocumented immigrants. There is little understanding, however, about the public safety consequences of mobilizing local police to enforce immigration law. I use ICE administrative records, Uniform Crime Reports, and American Community Survey population estimates to investigate whether and under what circumstances local immigration enforcement is associated with property crime and violent crime. Results show that crime trends in sanctuary and non-sanctuary counties were not significantly different in the first decade of the 2000s. However, after the proliferation of sanctuary practices around 2014, both property crime and violent crime decreased more in sanctuary counties than non-sanctuary counties, net of other predictors of crime. Further, a pooled cross-sectional analysis of 2013–2016 data shows that sanctuary practices strengthen the inverse relationship between proportion foreign-born Latino and property crime, and reverse the positive relationship between proportion native-born Latino and property crime. I theorize that this occurs because sanctuary practices encourage immigrant political integration, have positive spillover effects to non-immigrant Latinx communities, and increase social harmony.