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Introduction: Adolescent sexual health interventions are increasingly incorporating content that is inclusive of LGBTQIA+ youth (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, and other marginalized sexualities and genders). Evaluations of such programs must also be inclusive to enhance the validity of evaluation results and avoid further marginalization. We present strategies for increasing LGBTQIA+-inclusivity based on our evaluation of SafeSpace, a sexual health curriculum. Methods: To design an LGBTQIA+-inclusive program evaluation, we leveraged LGBTQIA+ research staff's insights, pursued a parental consent waiver, developed an inclusive recruitment plan, and crafted demographic and sexual behavior survey measures with input from youth and equity experts. We conducted a pilot study with 42 youth ages 14-17 to assess the feasibility and efficacy of our strategies. Results: We obtained a parental consent waiver and recruited a majority LGBTQIA+ pilot study sample (62%). Using themes from cognitive interviews with youth and experts regarding inclusive framing and use of plain language, we refined demographic measures and expanded sexual behavior measures. Conclusion: Findings suggest that the strategies used to enhance LGBTQIA+-inclusivity in our evaluation of SafeSpace were effective in respectfully and more accurately capturing a fuller range of experiences and identities of LGBTQIA+ and cis-straight youth. The strategies and survey measures developed for this study can be applied to increase LGBTQIA+-inclusivity in other adolescent sexual health program evaluations. [ABSTRACT FROM AUTHOR]

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Objectives. To evaluate the impacts of an enhanced version of the Family Life and Sexuality Module of the HealthTeacher middle school curriculum. Methods. We conducted a cluster randomized trial of Chicago, Illinois, middle schools. We randomly assigned schools to a treatment group that received the intervention during the 2010-2011 school year or a control group that did not. The primary analysis sample included 595 students (7 schools) in the treatment group and 594 students (7 schools) in the control group. Results. Students in the treatment schools reported greater exposure to information on reproductive health topics such as sexually transmitted infections (STIs; 78% vs 60%; P< .01), abstinence (64% vs 37%; P< .01), and birth control (45% vs 29%; P< .01). They also reported higher average scores on an index of knowledge of contraceptive methods and STI transmission (0.5 vs 0.3; P= .02). We found no statistically significant differences in rates of sexual intercourse (12%vs12%;P= .99),oral sex (12%vs9%;P= .18), or other intermediateoutcomes. Results. Students in the treatment schools reported greater exposure to information on reproductive health topics such as sexually transmitted infections (STIs; 78% vs 60%; P< .01), abstinence (64% vs 37%; P< .01), and birth control (45% vs 29%; P< .01). They also reported higher average scores on an index of knowledge of contraceptive methods and STI transmission (0.5 vs 0.3; P= .02). We found no statistically significant differences in rates of sexual intercourse (12%vs12%;P= .99),oral sex (12%vs9%;P= .18), or other intermediateoutcomes. [ABSTRACT FROM AUTHOR]

Objective: To describe the prevalence and correlates of unobservable medication exposure time, and to recommend approaches for minimizing bias, in studies using Medicare Part D data. Sample: 179,065 Medicare patients hospitalized for an AMI in 2007 or 2008. Methods: We compared two methods for creating medication exposure observation periods using acute care discharge vs. post-acute care discharge dates. We examined options for increasing cohort sizes by requiring different thresholds for observable days, or by using as a covariate, in the observation period. We calculated the extent and health status correlates of unobserved Medicare Part D exposure time and examined its association with receipt of beta-blockers. Results: 39% of patients had unobservable time during the 30 day exposure assessment period following acute care; they were significantly older, had more comorbidity and longer acute care stays, had worse 1-year survival, and were significantly less likely to be classified as beta-blocker users. Using the alternative exposure assessment window, only 29% of the sample had unobservable time, and differences between groups were less pronounced. Significant gains in sample size can be obtained by restricting or controlling for the number of observable days required in the exposure assessment period. Conclusions: Unobservable exposure time is common among Medicare Part D beneficiaries, and they are often in worse health. To retain patients with unobservable exposure time, we recommend stratifying patients on receipt of post-acute facility-based care, calculating and using observable days as a covariate and, when appropriate, using the discharge date from contiguous post-acute facility care for beginning the exposure assessment period. [ABSTRACT FROM AUTHOR]

Background: 5.8 M living Americans have experienced a stroke at some time in their lives, 780K had either their first or a recurrent stroke this year, and 150K died from strokes this year. Stroke costs about $66B annually in the US, and also results in serious, long-term disability. Therefore, it is prudent to identify all possible risk factors and their effects so that appropriate intervention points may be targeted. Methods: Baseline (1993-1994) interview data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to 1993-2005 Medicare claims. Participants were 5,511 self-respondents ≥ 70 years old. Two ICD9-CM case-identification approaches were used. Two approaches to stroke case-identification based on ICD9-CM codes were used, one emphasized sensitivity and the other emphasized specificity. Participants were censored at death or enrollment into managed Medicare. Baseline risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting post-baseline nonstroke hospitalizations was included to reflect health shocks, and sensitivity analyses were conducted to identify its peak effect. Competing risk, proportional hazards regression was used. Results: Post-baseline strokes occurred for 545 (9.9%; high sensitivity approach) and 374 (6.8%; high specificity approach) participants. The greatest static risks involved increased age, being widowed or never married, living in multi-story buildings, reporting a baseline history of diabetes, hypertension, or stroke, and reporting difficulty picking up a dime, refusing to answer the delayed word recall test, or having poor cognition. Risks were similar for both case-identification approaches and for recurrent and first-ever vs. only first-ever strokes. The time-dependent health shock (recent hospitalization) marker did not alter the static model effect estimates, but increased stroke risk by 200% or more. Conclusion: The effect of our health shock marker (a time-dependent recent hospitalization indicator) was large and did not mediate the effects of the traditional risk factors. This suggests an especially vulnerable post-hospital transition period from adverse effects associated with both their underlying health shock (the reasons for the recent hospital admission) and the consequences of their treatments. [ABSTRACT FROM AUTHOR]

Background. We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them. Methods. A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used. Results. The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns. Conclusions. Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults. [ABSTRACT FROM AUTHOR]

Presents a study that investigated the relationships between levee damage and woody corridor along 353-mile segment of the Missouri River in Missouri during the flood of 1993. Methodology; Results of the study; Conclusion.

This article determines the manner in which Roman Catholicism affects abortion attitudes in the United States. Abortion will also be an important issue in state elections, for it is at the state level that abortion restrictions will be enacted. As states move to regulate access to abortion, the abortion issue will enter the realm of state electoral and legislative politics. Already the abortion issue has influenced votes for governor in several states and for other offices as well. If the abortion issue is, in effect, "repoliticized" by a series of statewide legislative battles over abortion restrictions, religious bodies interested in the issue may increase their efforts. Perhaps foremost among such religious groups is the Roman Catholic Church. While the Catholic Church is not the only "pro-life" religious group in the United States, it is perhaps the most visible. Moreover, the Catholic Church has impressive organizational resources with which to influence the political process and is an unusually effective teaching institution as well.

Examines individual differences in children's emotional understanding and behavioral adjustment. Dependent measures of emotional understanding and experience; Results indicating that children rated higher in behavior problems showed deficits in emotional understanding; Negative association of intellectual functioning and behavior problems.

Examines the distinctiveness of state attitudes and their impact on attitudes toward legal abortions in the United States. State differences in levels of support for abortion legality and restrictions; State political cultures and state public opinion's relevance to the politics of abortion.

Data from a 1989 CBS News/New York Times survey are used to examine the effect that the framing of questions on abortion has on estimates of what proportions of the population support various legal positions. The nationwide data and results from six state polls show that general questions with only two or three options overestimate the proportions of respondents who either favor a ban on all abortion or who would allow abortion under all circumstances. Questions that pose specific circumstances result in movement of respondents out of extreme categories and into more moderate ones. Even respondents who indicate they would favor abortion in all specific circumstances and those who favor abortion in none are likely to moderate their views when asked if they support restrictions that have been proposed in a number of states. [ABSTRACT FROM AUTHOR]

Analyzes the role the abortion issues in Senate voting in 1990. Identification of Senate elections in which abortion issues played an important role; Description of state distribution of opinions regarding abortion; Examination of the influence of abortion in vote choice using statistical methods.

Although scholars who focus on generational change generally portray the youngest cohorts as most liberal, this need not be so. Evidence is provided that among whites but not blacks, those who reached adulthood after the 1960s are less supportive of legal abortion than those who came of age during that decade. The decline in support for legal abortion is statistically significant after multivariate controls for demographic variables, religious and moral attitudes, attitudes toward gender roles, and general ideology and partisanship. Explanations for this result are tested. [ABSTRACT FROM AUTHOR]

Compares employed women, housewives and women who entered the labor force between 1972 and 1976 in order to examine the competing hypothesis of self-selection and political socialization. Application of a quasi-experimental design to the 1972-1976 Michigan National Election Study panel data; Background on research related to political socialization; Differences between housewives and working women.

Between 1972 and 1984, the American National Election Studies included a feeling thermometer that measured affect toward the ‘women's liberation movement.’ In 1988 the survey substituted a new item that asked respondents to rate ‘feminists,’ and in 1990, the questionnaire changed the wording to ‘the women's movement.’ Using data from the 1985 Pilot Study, we compare responses to these two items for both men amid women. We conclude that the new measure is a ‘harder’ measure, eliciting more negative responses. Moreover, the correlates of the new measure differ from the original feeling thermometer. When the feeling thermometer is incorporated into a multi-item measure of feminist consciousness, however, the pattern of correlations is very similar, suggesting that a limited type of longitudinal analysis may still be possible. [ABSTRACT FROM AUTHOR]

The concept of group consciousness has proven useful in the analysis of political and social groups, and has clear utility in the study of feminism. Although sophisticated measures of feminist consciousness have been proposed to enable scholars to opera- tionalize the concept in the American National Election Studies, these measures have problems with continuity, or have conceptual problems. This paper proposes a measure that can be used in all American National Election Studies since the rise of the feminist movement, and provides data that suggest the measure has external validity. [ABSTRACT FROM AUTHOR]

Urban forests and herbaceous open space play a vital role in the environmental and aesthetic 'health' of cities, yet they are rarely identified in land-use inventories of urban areas. To provide informationon urban forests and other vegetative land cover in Illinois cities,Landsat Thematic Mapper (TM) data from June 27, 1988, were classified for the Chicago metropolitan region (9,717 km2). Ten land-cover classes were identified, including two types of forestland (occupying 5.8% of the total area), residential land with trees (14.6%)or without trees (7.8%), cropland (37.5%), two types of grassland (7.7%), urban with impervious surfaces (23.1%), water (1.6%), and miscellaneous vegetation (2.1%). Correlation analyses indicated that household income and household density are strongly related to land coversin the region, particularly those with tree cover and urbanized land. Population changes for 1980-1985 and 1985-2010 (projected) show a pattern of increasing density in the urbanized zone concurrent with continued urban sprawl, primarily into current cropland. [ABSTRACT FROM AUTHOR]

Background: Comparative effectiveness studies using Medicare claims data are vulnerable to treatment selection biases and supplemental data from a sample of patients has been recommended for examining the magnitude of this bias. Previous research using nationwide Medicare claims data has typically relied on the Medicare Current Beneficiary Survey (MCBS) for supplemental data. Because many important clinical variables for our specific research question are not available in the MCBS, we collected medical record data from a subsample of patients to assess the validity of assumptions and to aid in the interpretation of our estimates. This paper seeks to describe and document the process used to collect and validate this supplemental information., Methods: Medicare claims data files for all patients with fee-for-service Medicare benefits who had an acute myocardial infarction (AMI) in 2007 or 2008 were obtained. Medical records were obtained and abstracted for a stratified subsample of 1,601 of these patients, using strata defined by claims-based measures of physician prescribing practices and drug treatment combinations. The abstraction tool was developed collaboratively by study clinicians and researchers, leveraging important elements from previously validated tools., Results: Records for 2,707 AMI patients were requested from the admitting hospitals and 1,751 were received for an overall response rate of 65%; 1,601 cases were abstracted by trained personnel at a contracted firm. Data were collected with overall 96% inter-abstractor agreement across all variables. Some non-response bias was detected at the patient and facility level., Conclusion: Although Medicare claims data are a potentially powerful resource for conducting comparative effectiveness analyses, observational databases are vulnerable to treatment selection biases. This study demonstrates that it is feasible to abstract medical records for Medicare patients nationwide and collect high quality data, to design the sampling purposively to address specific research questions, and to more thoroughly evaluate the appropriateness of care delivered to AMI patients.

Background: Despite strong evidence to designate statin use for secondary prevention of cardiovascular disease (CVD) as "effective care," observational studies show that many patients with CVD do not receive statins. This suggests that statin prescribing decisions for complex CVD patients are preference sensitive., Objectives: The aim of this study was to evaluate local area variation in statin prescribing for subsets of complex patients after acute myocardial infarction (AMI) to assess whether current statin prescribing patterns fit profiles of either "effective care" or "preference-sensitive care.", Research Design and Subjects: This was a retrospective cohort study of 124,618 Medicare patients with fee-for-service parts A, B, and D benefits who were hospitalized with AMI in 2008 or 2009 with no evidence of AMI in the past 12 months., Measures: Patient complexity was defined by the presence of diabetes, heart failure, and chronic kidney disease in the year before AMI admission. Local area practice styles for "no statin," "lower-intensity statins," and "high-intensity statins" were measured using the driving area for clinical care method. Statin prescribing rates for complex patient subsets were contrasted across patients grouped by local areas practice styles., Results: Lower statin treatment rates were observed for patients with complex conditions, especially among those with heart failure. However, substantial local area variation in statin prescribing is observed across all complex patient groups., Conclusions: Despite guidelines promoting the use of statins for secondary prevention for CVD patients, substantial local area variation suggests that patient and provider beliefs and preferences weigh heavily in statin prescribing decisions.

Objectives: Discuss the tradeoffs inherent in choosing a local area size when using a measure of local area practice style as an instrument in instrumental variable estimation when assessing treatment effectiveness., Study Design: Assess the effectiveness of angiotensin converting-enzyme inhibitors and angiotensin receptor blockers on survival after acute myocardial infarction for Medicare beneficiaries using practice style instruments based on different-sized local areas around patients. We contrasted treatment effect estimates using different local area sizes in terms of the strength of the relationship between local area practice styles and individual patient treatment choices; and indirect assessments of the assumption violations., Results: Using smaller local areas to measure practice styles exploits more treatment variation and results in smaller standard errors. However, if treatment effects are heterogeneous, the use of smaller local areas may increase the risk that local practice style measures are dominated by differences in average treatment effectiveness across areas and bias results toward greater effectiveness., Conclusion: Local area practice style measures can be useful instruments in instrumental variable analysis, but the use of smaller local area sizes to generate greater treatment variation may result in treatment effect estimates that are biased toward higher effectiveness. Assessment of whether ecological bias can be mitigated by changing local area size requires the use of outside data sources., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

Background: We identified hip fracture risks in a prospective national study., Methods: Baseline (1993-1994) interview data were linked to Medicare claims for 1993-2005. Participants were 5,511 self-respondents aged 70 years and older and not in managed Medicare. ICD9-CM 820.xx (International Classification of Diseases, 9th Edition, Clinical Modification) codes identified hip fracture. Participants were censored at death or enrollment into managed Medicare. Static risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting postbaseline hospitalizations was included., Results: A total of 495 (8.9%) participants suffered a postbaseline hip fracture. In the static proportional hazards model, the greatest risks involved age (adjusted hazard ratios [AHRs] of 2.01, 2.82, and 4.91 for 75-79, 80-84, and > or =85 year age groups vs those aged 70-74 years; p values <.001), sex (AHR = 0.45 for men vs women; p < .001), race (AHRs of 0.37 and 0.46 for African Americans and Hispanics vs whites; p values <.001 and <.01), body mass (AHRs of 0.40, 0.77, and 1.73 for obese, overweight, and underweight vs normal weight; p values <.001, <.05, and <.01), smoking status (AHRs = 1.49 and 1.52 for current and former smokers vs nonsmokers; p values <.05 and <.001), and diabetes (AHR = 1.99; p < .001). The time-dependent recent hospitalization marker did not alter the static model effect estimates, but it did substantially increase the risk of hip fracture (AHR = 2.51; p < .001)., Conclusions: Enhanced discharge planning and home care for non-hip fracture hospitalizations could reduce subsequent hip fracture rates.

Background: Health services use typically is examined using either self-reports or administrative data, but the concordance between the 2 is not well established., Objective: We evaluated the concordance of hospital and physician utilization data from self-reports and claims data, and identified factors associated with disagreement., Methods: We performed a secondary analysis on linked observational and administrative data. A national sample of 4310 respondents who were 70 years old or older at their baseline interviews was used. Self-reported and Medicare claims-based hospital episodes and physician visits for 12 months before baseline were examined. Kappa statistics were used to evaluate concordance, and multivariable multinomial logistic regression was used to identify factors associated with overreporting (self-reports > claims), underreporting (self-reports < claims), and concordant-reporting (self-reports approximately claims)., Results: The concordance of hospital episodes was high (kappa = 0.767 for the 2 x 2 comparison of none vs. some and kappa = 0.671 for the 6 x 6 comparison of none, 1, ..., 4, or 5 or more), but concordance for physician visits was low (kappa = 0.255 for the 2 x 2 comparison of none versus some and kappa = 0.351 for the 14 x 14 comparison of none, 1, ..., 12, and 13 or more). Multivariable multinomial logistic regression indicated that over-, under-, and concordant-reporting of hospital episodes was significantly associated with gender, alcohol consumption, arthritis, cancer, heart disease, psychologic problems, lower body functional limitations, self-rated health, and depressive symptoms. Over-, under-, and concordant-reporting of physician visits were significantly associated with age, gender, race, living alone, veteran status, private health insurance, arthritis, cancer, diabetes, hypertension, heart disease, lower body functional limitations, and poor memory., Conclusions: Concordance between self-reported and claims-based hospital episodes was high, but concordance for physician visits was low. Factors significantly associated with bidirectional (over- and underreporting) and unidirectional (over- or underreporting) error patterns were detected. Therefore, caution is advised when drawing conclusions based on just one physician visit data source.