York City Health Research Articles

Using Medicaid Claims Data to Identify Service Gaps for High-Need Clients: The NYC Mental Health Care Monitoring Initiative

Public mental health authorities have access to large administrative databases. Advances in information technology now make it possible to use secondary analyses of these data to inform policy and clinical interventions. New York City and State mental health authorities developed an initiative using Medicaid claims and other administrative data to identify individuals with serious mental illness living in New York City (NYC) who are at risk of lapses in care. The NYC Mental Health Care Monitoring Initiative represents one of the first efforts to create "evidence-based policy." The authors describe the initiative's background, development, and key collaborations.

CDC's Thomas Frieden—protecting health and reducing costs

CDC's Thomas Frieden—protecting health and reducing costs

Consumer Awareness of Fast-Food Calorie Information in New York City After Implementation of a Menu Labeling Regulation

We assessed consumer awareness of menu calorie information at fast-food chains after the introduction of New York City's health code regulation requiring these chains to display food-item calories on menus and menu boards. At 45 restaurants representing the 15 largest fast-food chains in the city, we conducted cross-sectional surveys 3 months before and 3 months after enforcement began. At both time points, customers were asked if they had seen calorie information and, if so, whether it had affected their purchase. Data were weighted to the number of city locations for each chain. We collected 1188 surveys pre-enforcement and 1229 surveys postenforcement. Before enforcement, 25% of customers reported seeing calorie information; postenforcement, this figure rose to 64% (P < .001; 38% and 72%, weighted). Among customers who saw calorie information postenforcement, 27% said they used the information, which represents a 2-fold increase in the percentage of customers making calorie-informed choices (10% vs 20%, weighted; P < .001). Posting calorie information on menu boards increases the number of people who see and use this information. Since enforcement of New York's calorie labeling regulation began, approximately 1 million New York adults have seen calorie information each day.

New York University School of Medicine

New York University School of Medicine

Formative Activities in Support of an Evaluation of the New York City Health Bucks Program

Formative Activities in Support of an Evaluation of the New York City Health Bucks Program

Mercury and polychlorinated biphenyls in Asian market fish: A response to results from mercury biomonitoring in New York City

In 2004, the New York City (NYC) Health and Nutrition Examination Survey measured the highest blood mercury levels in Asian and foreign-born Chinese demographic groups. Fish consumption was the strongest predictor of exposure. The survey did not inquire about consumption of individual species, and subsequent visits to fish markets serving the Asian community suggested that many popular species lack contaminant data. Our objective was to supplement existing information on contaminants in commercial fish by collecting data on species present in markets serving the Asian community. We measured total mercury and the sum of 101 polychlorinated biphenyl (PCB) congeners in 282 individual specimens of 19 species or products from retail fish markets in Chinese neighborhoods in NYC. Species were selected based on their volume in the market, and an absence or insufficiency of national data on mercury levels. PCBs were measured because they are also contaminants of concern. All measurements were made on a wet weight basis on whole fillets (with skin) or products (drained of liquid). Mean mercury levels ranged from below the limit of detection (0.004 μg/g) in tilapia to 0.229 μg/g in tilefish. The highest mercury level (1.150 μg/g) was measured in a tilefish specimen, and mercury levels in tilefish increased with the specimen size. Mean PCB levels ranged from 1 ng/g in red snapper to 98 ng/g in buffalo carp. The highest PCB levels were measured in a buffalo carp (469 ng/g) and a yellow croaker (495 ng/g). Species-specific differences in PCB levels accounted for only 6.3% of total variability, in contrast with 39.2% for mercury. Although we did not measure high mean mercury levels in the species we sampled, frequent consumption of fish with low to moderate levels can also elevate blood mercury. The data we collected can be used to guide fish consumption in Asian communities. However, risk-benefit trade-offs also need to be considered.

Incarceration as a key variable in racial disparities of asthma prevalence

BackgroundDespite the disproportionate incarceration of minorities in the United States, little data exist investigating how being incarcerated contributes to persistent racial/ethnic disparities in chronic conditions. We hypothesized that incarceration augments disparities in chronic disease.MethodsUsing data from the New York City Health and Nutrition Examination Study, a community-based survey of 1999 adults, we first estimated the association between having a history of incarceration and the prevalence of asthma, diabetes, hypertension using propensity score matching methods. Propensity scores predictive of incarceration were generated using participant demographics, socioeconomic status, smoking, excessive alcohol and illicit drug use, and intimate partner violence. Among those conditions associated with incarceration, we then performed mediation analysis to explore whether incarceration mediates racial/ethnic disparities within the disease.ResultsIndividuals with a history of incarceration were more likely to have asthma compared to those without (13% vs. 6%, p < 0.05) and not more likely to have diabetes or hypertension, after matching on propensity scores. Statistical mediation analysis revealed that increased rates of incarceration among Blacks partially contribute to the racial disparity in asthma prevalence.ConclusionHaving been incarcerated may augment racial disparities in asthma among NYC residents. Eliminating health disparities should include a better understanding of the role of incarceration and criminal justice policies in contributing to these disparities.

Business Process Improvement

The limitation of medical intern and resident work hours, known as the Bell 405 regulations, was initiated in New York State in 1989 with a modification to the state hospital code. The Bell 405 regulations were strengthened in 2000, and facilities would now be fined for noncompliance. Monitoring systems in place at that time were insufficient to provide an adequate level of review for the New York City Health and Hospitals Corporation (HHC) with more than 7,000 medical residents whose training is based at or who rotate through these public hospitals. A "simple to use," yet comprehensive, method of monitoring compliance needed to be developed to ensure that residents and interns complied with laws regulating working hours. The subsequent development of national accreditation standards increased the stakes for reliable scrutiny. HHC developed and implemented a Web-based Structured Query Language (SQL) application that facilitated easy access to work hour surveys captured through electronic time sheets. The time sheet data automatically entered a database that provided instant analysis of conformance to state law. The development of an electronic on-line application accessible from anywhere allowed HHC to efficiently identify nonconformance and pinpoint corrective action. Since the inception of the application and its expansion allowing access through the intranet, 26,000 individual time sheets have been submitted for evaluation. With the national movement regulating work hours, other hospitals still at the pencil and manual computation stage would greatly benefit by developing a similar application.

Testing GISS-MM5 physics configurations for use in regional impacts studies

The Mesoscale Modeling System Version 5 (MM5) was one-way nested to the Goddard Institute for Space Studies global climate model (GISS GCM), which provided the boundary conditions for present (1990s) and future (IPCC SRES A2 scenario, 2050s) five-summer “time-slice” simulations over the continental and eastern United States. Five configurations for planetary boundary layer, cumulus parameterization, and radiation scheme were tested, and one set was selected for use in the New York City Climate and Health Project—a multi-disciplinary study investigating the effects of climate change and land-use change on human health in the New York metropolitan region. Although hourly and daily data were used in the health project, in this paper we focus on long-term current and projected mean climate change. The GISS-MM5 was very sensitive to the choice of cumulus parameterization and planetary boundary layer scheme, leading to significantly different temperature and precipitation outcomes for the 1990s. These differences can be linked to precipitation type (convective vs. non-convective), to their effect on solar radiation received at the ground, and ultimately to surface temperature. The projected changes in climate (2050s minus 1990s) were not as sensitive to choice of model physics combination. The range of the projected surface temperature changes at a given grid point among the model versions was much less than the mean change for all five model configurations, indicating relative consensus for simulating surface temperature changes among the different model projections. The MM5 versions, however, offer less consensus regarding 1990s to 2050s changes in precipitation amounts. All of the projected 2050s temperature changes were found to be significant at the 95th percent confidence interval, while the majority of the precipitation changes were not.

Temporal trends in spatial access to pharmacies that sell over-the-counter syringes in New York City health districts: relationship to local racial/ethnic composition and need.

Pharmacies that sell over-the-counter (OTC) syringes are a major source of sterile syringes for injection drug users in cities and states where such sales are legal. In these cities and states, however, black injectors are markedly less likely to acquire syringes from pharmacies than white injectors. The present analysis documents spatial and temporal trends in OTC pharmacy access in New York City health districts over time (2001-2006) and investigates whether these trends are related to district racial/ethnic composition and to local need for OTC pharmacies. For each year of the study period, we used kernel density estimation methods to characterize spatial access to OTC pharmacies within each health district. Higher values on this measure indicate better access to these pharmacies. "Need" was operationalized using two different measures: the number of newly diagnosed injection-related AIDS cases per 10,000 residents (averaged across 1999-2001), and the number of drug-related hospital discharges per 10,000 residents (averaged across 1999-2001). District sociodemographic characteristics were assessed using 2000 US decennial census data. We used hierarchical linear models (HLM) for descriptive and inferential analyses and investigated whether the relationship between need and temporal trajectories in the Expanded Syringe Access Demonstration Program access varied by district racial/ethnic composition, controlling for district poverty rates. HLM analyses indicate that the mean spatial access to OTC pharmacies across New York City health districts was 12.71 in 2001 and increased linearly by 1.32 units annually thereafter. Temporal trajectories in spatial access to OTC pharmacies depended on both need and racial/ethnic composition. Within high-need districts, OTC pharmacy access was twice as high in 2001 and increased three times faster annually, in districts with higher proportions of non-Hispanic white residents than in districts with low proportions of these residents. In low-need districts, "whiter" districts had substantially greater baseline access to OTC pharmacies than districts with low proportions of non-Hispanic white residents. Access remained stable thereafter in low-need districts, regardless of racial/ethnic composition. Conclusions were consistent across both measures of "need" and persisted after controlling for local poverty rates. In both high- and low-need districts, spatial access to OTC pharmacies was greater in "Whiter" districts in 2001; in high-need districts, access also increased more rapidly over time in "whiter" districts. Ensuring equitable spatial access to OTC pharmacies may reduce injection-related HIV transmission overall and reduce racial/ethnic disparities in HIV incidence among injectors.

Adherence to treatment of latent tuberculosis infection in a clinical population in New York City

Background Low adherence to treatment of latent tuberculosis infection (TLTBI) diminishes TB prevention efforts. This study examined the treatment completion rate among those who started TLTBI and factors associated with adherence to TLTBI. Methods Patients who started TLTBI in New York City (NYC) Health Department chest clinics during January 2002–August 2004 were studied. TLTBI completion rate were described and compared according to patient demographic and clinical characteristics by regimen using univariate analysis and log-binomial regression. Results A total of 15 035 patients started and 6788 (45.2%) completed TLTBI. Treatment completers were more likely than non-completers to be ≥35 years old (52.5%, adjusted relative risk (aRR) = 1.2, 95% confidence interval (CI) = 1.1, 1.2), contacts to pulmonary TB patients (57.4%, aRR = 1.5, 95% CI = 1.4, 1.7), treated by directly observed preventive therapy (DOPT) (71.4%, aRR = 1.3, 95% CI = 1.2, 1.3), and to have received the rifamycin-based regimen (60.0%, aRR = 1.2, 95% CI = 1.1, 1.3). The completion rate with an isoniazid regimen did not differ between HIV-infected and HIV-uninfected persons. Among those who failed to complete, 3748 (47.8%) failed to return for isoniazid and 59 (14.7%) for rifamycin after the first month of medication dispensing. Conclusions Shorter regimen and DOPT increased completion rates for LTBI. Though efforts to improve TLTBI completion need to address all groups, greater focus is needed for persons who are contacts and HIV-infected, as they have higher risk of developing TB.

Scourge of Tobacco and Trans Fats Chosen for CDC

New York City health commissioner Thomas Frieden has been appointed by President Barack Obama to direct the Centers for Disease Control and Prevention.

Ovarian cancer treatment in the New York City municipal hospital system

5569 Background: OC patients (pts) from minority groups/lower socioeconomic strata are reported to have poorer outcomes. New York City (NYC) Health and Hospitals Corporation (HHC) has 11 municipal hospitals. We evaluated surgical management of OC pts in HHC hospitals. Methods: The New York State SPARCS database of admissions was queried for OC pts in the years 2001 to 2006. Pts from HHC were compared to pts from all other NYC hospitals (other cohort). Pt demographics, procedure performed, emergent vs. scheduled admission, length of stay, and hospital charges were compared utilizing chi-square. A comorbidity index was applied to both cohorts. Surgeons were stratified by subspecialty training and OC case volume. Results: 6,010 admissions for OC were identified. 3,624 were major surgical procedures: 187 from the HHC cohort and 3,436 from the other cohort. Demographics for HHC vs other cohort, respectively: Caucasian 37 (20%) vs 2,224 (65%); African-American (AA): 64 (34%) vs 460 (13%); Asian 20 (11%) vs 181 (5%); other: 66 (35%) vs 286 (8%); unknown 0 vs. 286 (8%) (p&lt; 0.001). Payors for the HHC vs other cohort, respectively: Medicaid 108/187 (57%) vs 279/3,437 (8%); Medicare 22/187 (12%) vs 872/3,437 (25%); private insurance 38/187 (20%) vs 2,244/3,437 (65%); self-pay 18/187 (10%) vs 40/3,437 (1%) (p &lt; 0.001). Urgent admissions were 96/187 (51%) of HHC cohort vs 902/3,436 (26%) of other cohort (p &lt; 0.001). There were no differences in comorbidity rating or procedures performed. Subspecialty surgeons were documented for 59/187 (32%) of HHC cohort vs 1,839/3,437 (53%) of other cohort (p &lt; 0.001). The majority of surgeons performed less than two OC cases over the six year period, however surgeons with cases at HHC hospitals were more likely to be represented in the top 15% of total case volume (25% vs 14%, p &lt; 0.01) due to affiliations with academic centers. Conclusions: Pts in HHC cohort were more likely to be AA, have an urgent admission and less likely to have insurance or have a gynecologic oncologist as a surgeon. However there is evidence of centralized care for some in the HHC cohort. Despite the limitations associated with using a large database, clear differences were seen in the patterns of care between municipal and all other NYC OC pts. Studies to document outcomes and further optimize care within the HHC hospital system are ongoing. No significant financial relationships to disclose.

Sociodemographic disparities in epilepsy care: Results from the Houston/New York City health care use and outcomes study

The purpose of this study was to identify sociodemographic disparities in health care use among epilepsy patients receiving care at different sites and the extent to which the disparities persisted after adjusting for patient characteristics and site of care. Three months of health care use data were obtained from baseline interviews of approximately 560 patients at four sites. One-half of the patients were from a Houston site and two NYC sites that serve predominantly low-income, minority, publicly insured, or uninsured patients. The other half were at the remaining site in Houston that serves a more balanced racial/ethnic and higher sociodemographic population. Differences in general and specialist visits, hospital emergency room (ER) care, and hospitalizations were associated with race/ethnicity, income, and coverage. Logistic regression was used to assess the extent to which the differences persisted when adjusting for individual patient characteristics and site of care. Compared to whites, blacks and Hispanics had higher rates of generalist visits [odds ratio (OR) = 5.3 and 4.9, p < 0.05), ER care (OR = 3.1 and 2.9, p < 0.05) and hospitalizations (OR = 5.4 and 6.2, p < 0.05), and lower rates of specialist visits (OR = 0.3 and 0.4, p < 0.05). A similar pattern was found related to patient income and coverage. The magnitude and significance of the disparities persisted when adjusting for individual characteristics but decreased substantially or were eliminated when site of care was added to the model. There are sociodemographic disparities in health care for people with epilepsy that are largely explained by differences in where patients receive care.

Integrating Consumer Health Care With Supportive Housing Services

Integrating Consumer Health Care With Supportive Housing Services

1: Baseline Demographic and Biochemical Characteristics of Dialysis Population in New York City's Health and Hospital Corporation (HHC) Hospitals – Compared With the USRDS Population

1: Baseline Demographic and Biochemical Characteristics of Dialysis Population in New York City's Health and Hospital Corporation (HHC) Hospitals – Compared With the USRDS Population

FDA TEAM NAMED

PRESIDENT BARACK OBAMA has nominated former New York City Health Commissioner Margaret (Peggy) A. Hamburg as head of FDA and Baltimore Health Commissioner Joshua M. Sharfstein as her deputy. In his weekly address to the nation on March 14, Obama also announced his plans to create a Food Safety Working Group to modernize and enforce food safety laws and coordinate measures across the federal government. “There are certain things only a government can do. And one of those things is ensuring that the foods we eat and the medicines we take are safe and don’t cause us harm,” Obama said during his address. The President renewed his pledge to include $1 billion in the 2010 federal budget to increase the number of food inspections and FDA staff needed to protect the food supply. Hamburg has a reputation of integrity and a record of making Americans more secure, Obama noted. While serving as health commissioner of ...

New York City's Fight Over Calorie Labeling

In 2006, New York City's Health Department amended the city Health Code to require the posting of calorie counts by chain restaurants on menus, menu boards, and item tags. This was one element of the city's response to rising obesity rates. Drafting the rule involved many decisions that affected its impact and its legal viability. The restaurant industry argued against the rule and twice sued to prevent its implementation. An initial version of the rule was found to be preempted by federal law, but a revised version was implemented in January 2008. The experience shows that state and local health departments can use their existing authority over restaurants to combat obesity and, indirectly, chronic diseases.

Field Notes

Field Notes Erika Blacksher Private choice, public health. Fall 2006 was a perfect time for a scholar interested in the ethics of health promotion to arrive in New York City, which has been experimenting with some of the nation's more innovative and controversial policies to improve population health. Many of these policies alter the environment in ways that affect health—for example, by eliminating trans fats from fast foods and cigarette smoke from public places and by creating bike lanes and parks. If New York City Health Commissioner Thomas Frieden prevails, sodium levels in packaged foods will be next. This approach to health promotion aims to shift the behaviors of a community through policy and structural changes. In contrast, typical U.S. health policy educates people about some health-relevant risk factor, such as cholesterol. Both approaches attempt to alter people's behavior, but while the former remakes the environment to promote healthy habits, the latter relies on informed individuals to remake themselves. Herein lies one facet of the controversy stirred by some of the broad-based health initiatives in New York City and other progressive municipalities and states. Critics believe such measures are paternalistic, overreaching the state's authority and imposing a particular view of the good life. These measures may indeed convey a strong message about the putative value of "healthy living," but it is less clear that they are paternalistic in a morally problematic sense. Strong paternalism occurs when interventions aim to protect individuals from themselves against their own free and informed choices. To decide when a policy is paternalistic, then, we have to look at the voluntariness of choices and the reach of harmful consequences. Bike lanes and safe parks expand, rather than limit, people's transportation and recreation options. If smoking bans are justified by the harm of second-hand smoke and by nicotine's addictive power (raising questions about voluntariness), then they are not paternalistic in a strong sense. The ban on trans fats in restaurants looks more like strong paternalism, at least if we assume that people's food choices are informed and voluntary (a view some argue against) and that foods that contain trans fats harm only those who choose them (one could argue that parents choose fast, cheap meals not only for themselves but also for their young children, extending the harm to those not yet able to consent to the risk). But even with these assumptions in place, bans on trans fats differ from public health measures such as seat belt laws, which trump personal choice by penalty of law. The ban on trans fats neither polices nor penalizes the private culinary practices of committed trans fat consumers. It frustrates the pursuit of their preferences, but it also eliminates a health-harming ingredient from fast, cheap meals, which many fast food consumers may welcome. These bans, to use economist Richard Thaler's and legal scholar Cass Sunstein's phrase, "nudge" us in the direction of healthier choices. Just how far and by what criteria states should nudge their citizens toward healthy choices merits spirited debate. Epidemiology is an imperfect science, and health is not the only good we care about. For two years I took part in such a debate as a Robert Wood Johnson Foundation Health and Society Scholar at Columbia University. This past October I relocated to The Hastings Center and have brought that debate with me. Erika Blacksher Research Scholar Copyright © 2009 The Hastings Center

New York City Health and Nutrition Examination Survey

Thorpe et al. (1) are to be commended for undertaking a comprehensive evaluation of glycemic status in adults from New York City. Their article represents the efforts of a health and nutrition survey within a large metropolitan area, the New York City (NYC) Health and Nutrition Examination Survey (HANES), and provides very useful information concerning the prevalence of hyperglycemia and control of diabetes in an urban setting. Such efforts have been undertaken in the U.S. by way of national surveys of the populace in terms of lifestyle behaviors and risk factor levels over several decades (2–4), but a survey that used population-based methods in a single city is new, provides valuable information, and may well serve as a model for the future. The study by Thorpe et al. reports that diabetes affects 12.5% of adults living in New York City and that the frequency of pre-diabetes, which was previously called “impaired fasting glucose,” was almost double that (23.5%). Using the 1997 American Diabetes Association criteria for diabetes and data from the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994), the investigators reported that the prevalence of impaired fasting glucose was 6.9%, undiagnosed diabetes 2.8%, and diagnosed diabetes 5.1% (5). Previously, Harris et al. expressed concern that the prevalence of diabetes in American adults aged 40–74 years had increased from 8.9% in 1976–1980 to 12.3% in 1988–1994. The 1999–2003 NHANES estimates of diabetes are generally 6.6% at ages 40–59 years and ∼15.5% after age 60 years, which suggests that the national prevalence of diabetes after age 40 …