Stephen Downs | Indiana University Indianapolis (original) (raw)

Papers by Stephen Downs

Chronic Illness, 2010

In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease ... more In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease Management Program (ICDMP), a programme intended to improve the health and healthcare utilization of 15,000 Aged, Blind and Disabled Medicaid members living with diabetes and/or congestive heart failure in Indiana. Within ICDMP, programme components derived from the Chronic Care Model and education based on an integrated theoretical framework were utilized to create a telephonic care management intervention that was delivered by trained, nonclinical Care Managers (CMs) working under the supervision of a Registered Nurse. CMs utilized computerassisted health education scripts to address clinically important topics, including medication adherence, diet, exercise and prevention of disease-specific complications. Employing reflective listening techniques, barriers to optimal self-management were assessed and members were encouraged to engage in health-improving actions. ICDMP evaluation results suggest that this low-intensity telephonic intervention shifted utilization and lowered costs. We discuss this patient-centred method for motivating behaviour change, the theoretical constructs underlying the scripts and the branched-logic format that makes them suitable to use as a computer-based application. Our aim is to share these public-domain materials with other programmes.

Proceedings / AMIA ... Annual Symposium. AMIA Symposium, 2002

Computer-based prompting and reminder systems have been shown to be highly effective in increasin... more Computer-based prompting and reminder systems have been shown to be highly effective in increasing rates of preventive services delivery. However, there are many more recommended preventive services than can be practically included in a typical clinic visit. Therefore prioritization of preventive services prompts is necessary. We describe two approaches to prioritizing preventive services prompts based on expected value decision making. One method involves a static, global prioritization across all preventive services and has been used in a production system for almost 7 years. The second method uses influence diagrams to prioritize prompts dynamically, based on individual patient data. The latter approach is still under development. Both methods are labor intensive and require a combination of epidemiologic data and expert judgment. Compromises in strictly normative process were necessary to achieve user satisfaction.

Obstetrical & Gynecological Survey, 2002

To determine whether the vaginal delivery rate is increased in nulliparous women who have positiv... more To determine whether the vaginal delivery rate is increased in nulliparous women who have positive fetal fibronectin (fFN) testing before elective induction of labour, we performed a decision analysis that tested three options: (1) spontaneous labour; (2) testing nulliparous candidates for elective induction of labour at 39 weeks gestation with fFN and inducing labour if fFN positive (women who are fFN negative are managed expectantly); (3) elective induction of labour for women who are at least 39 weeks. We found that spontaneous labour had a vaginal delivery rate of 90, elective induction 79 and fFN screening 83. At baseline, a mother must be willing to take an additional 7 risk of caesarean delivery to warrant fFN testing or an additional 11 risk of caesarean delivery to warrant elective induction. We conclude that spontaneous labour has the highest vaginal delivery rates. An fFN test in a nulliparous woman may help to raise her likelihood of a vaginal delivery in an elective induction.

Artificial intelligence in medicine, 2015

Pediatric guidelines based care is often overlooked because of the constraints of a typical offic... more Pediatric guidelines based care is often overlooked because of the constraints of a typical office visit and the sheer number of guidelines that may exist for a patient's visit. In response to this problem, in 2004 we developed a pediatric computer based clinical decision support system using Arden Syntax medical logic modules (MLM). The Child Health Improvement through Computer Automation system (CHICA) screens patient families in the waiting room and alerts the physician in the exam room. Here we describe adaptation of Arden Syntax to support production and consumption of patient specific tailored documents for every clinical encounter in CHICA and describe the experiments that demonstrate the effectiveness of this system. As of this writing CHICA has served over 44,000 patients at 7 pediatric clinics in our healthcare system in the last decade and its MLMs have been fired 6182,700 times in "produce" and 5334,021 times in "consume" mode. It has run continuo...

Journal of the American Medical Informatics Association : JAMIA, Jan 13, 2015

Clinicians at our institution typically respond to about half of the prompts they are given by th... more Clinicians at our institution typically respond to about half of the prompts they are given by the clinic's computer decision support system (CDSS). We sought to examine factors associated with clinician response to CDSS prompts as part of a larger, ongoing quality improvement effort to optimize CDSS use. We examined patient, prompt, and clinician characteristics associated with clinician response to decision support prompts from the Child Health Improvement through Computer Automation (CHICA) system. We asked pediatricians who were nonusers of CHICA to rate decision support topics as "easy" or "not easy" to discuss with patients and their guardians. We analyzed these ratings and data, from July 1, 2009 to January 29, 2013, utilizing a hierarchical regression model, to determine whether factors such as comfort with the prompt topic and the length of the user's experience with CHICA contribute to user response rates. We examined 414 653 prompts from 22 260...

Applied Clinical Informatics

ABSTRACT

Archives of Pediatrics and Adolescent Medicine

To analyze the value of studying or implementing office-based clinical preventive services for ad... more To analyze the value of studying or implementing office-based clinical preventive services for adolescents. Most adolescent mortality and morbidity is attributable to risky behaviors, yet clinical preventive services to reduce risky behaviors are often challenged because their efficacy has not been demonstrated. A cost-effectiveness model of adolescents' risky behaviors that compares standard practice with a program of screening visits for all adolescents and counseling visits for youth identified as high risk. We considered two risky behaviors, alcohol abuse and unsafe sexual activity, and five outcomes. Baseline cost-effectiveness of the program, minimum efficacy at which the program would be cost-effective, and sample sizes required for a trial of the program. Assuming that the program is 5% effective at preventing risky behaviors, it would cost 3035topreventanyoneadverseoutcomeand3035 to prevent any one adverse outcome and 3035topreventanyoneadverseoutcomeand471,000 to prevent a death from an automobile crash or from human immunodeficiency virus infection. Assuming society were willing to pay $600,000 to prevent a death (a generally accepted figure), the program would be cost-effective only if it were 5.6% effective at changing behavior. At this efficacy, the program would have a cost per year of life saved comparable to or better than many other accepted medical interventions. However, to demonstrate changes in outcomes at this efficacy would require a clinical trial with between 4000 and 95 million adolescents in each treatment group, depending on the outcome measured. Studying the ability of clinical preventive services to prevent outcomes of adolescents' risky behaviors would be impractical. The decision to implement these programs should be made based on current knowledge and beliefs; their efficacy can probably be studied only as part of widespread implementation.

Annals of internal medicine

Journal of Pediatrics

Because febrile infants with no obvious source of bacterial infection may have bacteremia, and be... more Because febrile infants with no obvious source of bacterial infection may have bacteremia, and because bacteremia is difficult to diagnose on clinical grounds, we used decision analysis to evaluate whether such infants should be treated with antibiotics, tested further, or sent home. Using a simple decision tree, we found that the decision to give empiric antibiotic treatment is the decision of choice. The difference in quality-adjusted life expectancy between the "best" and "worst" decisions was only 11 days. However, this difference translated to prevention of death or permanent disability in 60 cases per 100,000 febrile children. Further, empiric treatment remained the best management alternative unless the probability of bacteremia was less than 1.4% (less than any published prevalence), or the efficacy of treatment was less than 21%. Our analysis demonstrated that a test with far greater sensitivity than leukocyte count or other tests currently in use is needed to justify testing rather than treating empirically. Further, an enormous patient population would be needed to find a difference of both clinical and statistical significance between treated and untreated patients in a controlled trial. In the absence of such trials, we recommend blood culture and empiric antibiotic treatment of all infants at risk for occult bacteremia.

Applied Clinical Informatics, 2015

ABSTRACT

AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium

Clinical guideline authors, health information technology (HIT) standards development organizatio... more Clinical guideline authors, health information technology (HIT) standards development organizations, and information system implementers all work to improve the processes of healthcare, but have long functioned independently towards realizing these goals. This has led to clinical standards of care that often poorly align with the functional and technical HIT standards developed to realize them. We describe the shortcomings and inefficiencies inherent in this current process and introduce two national initiatives that attempt to unite these communities. The mission of these two initiatives is to create examples of unambiguous, decidable, and executable clinical guidelines which both utilize and inform HIT terminology and logical expression standards. All of the products of this work aim to facilitate enterprise-wide guideline implementation and create a rising tide which lifts all ships.

National surveillance clearly illustrates that U.S. children are becoming increasingly overweight... more National surveillance clearly illustrates that U.S. children are becoming increasingly overweight. However, the timing of the onset of childhood overweight has not been well-described.

International Journal of Pediatrics and Adolescent Medicine, 2015

Background and objectives: The goal is to inform proactive initiatives to expand the knowledge ba... more Background and objectives: The goal is to inform proactive initiatives to expand the knowledge base of clinical decision support systems. Design and setting: We describe an initiative in which research informationists and health services researchers employ visualization tools to map logic models for clinical decision support within an electronic health record. Materials and methods: We mapped relationships using software for social network analysis: NodeXL and CMAP. We defined relationships by shared observations, such as two Arden rules within medical logic modules that consider the same clinical observation, or by the presence of common keywords that were used to label rules according to standardized vocabularies. Results: We studied the Child Health Improvement through Computer Automation (CHICA) system, an electronic medical record that contains 170 unique variables representing discrete clinical observations. These variables were used in 300 medical logic modules (MLM's) that prompted health care providers to deliver preventive counseling or otherwise served as clinical decision support. Using data visualization tools, we generated maps that illustrate connections, or lack thereof, between clinical topics within CHICA's MLMs.

Applied clinical informatics, 2014

With the growing use of electronic health record systems, there is a demand for an electronic ver... more With the growing use of electronic health record systems, there is a demand for an electronic version of the leading American pediatric preventive care guideline, Bright Futures. As computer implementation requires actionable recommendations, it is important to assess to what degree Bright Futures meets criteria for actionability. We aimed to 1) determine the number of actionable recommendations in the current edition of Bright Futures and 2) to recommend a specific format for representing an important class of guidelines in a way that better facilitates computer implementation. We consolidated all action statements in Bright Futures into recommendations. We then used two dimensions (decidability and executability) in the Guideline Implementability Appraisal v 2.0 (GLIA) to determine the actionability of the recommendations. Decidability means the recommendation states precisely under what conditions to perform those actions. Executability means actions are stated specifically, unam...

Pediatrics, 2006

Inborn errors of metabolism are a significant cause of morbidity and death among children. Incons... more Inborn errors of metabolism are a significant cause of morbidity and death among children. Inconsistencies in how individual states arrive at screening strategies, however, lead to marked variations in testing between states. To determine the cost-effectiveness of each component test of a multitest newborn screening program, including screening for phenylketonuria, congenital adrenal hyperplasia, congenital hypothyroidism, biotinidase deficiency, maple syrup urine disease, galactosemia, homocystinuria, and medium-chain acyl-CoA dehydrogenase deficiency. A decision model was used, with cohort studies, government reports, secondary analyses, and other sources. Discounted costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were measured. All except 2 screening tests dominated the "no-test" strategy. The 2 exceptions were screening for congenital adrenal hyperplasia, which cost slightly more than $20,000 per QALY gained, and screening for gala...

Proceedings / AMIA ... Annual Symposium. AMIA Symposium, 2002

In this study, we use spatial analysis techniques to explore environmental and social predictors ... more In this study, we use spatial analysis techniques to explore environmental and social predictors of obesity in children. We constructed a merged database, incorporating clinical data from an electronic medical record system, the Regenstrief Medical Record System (RMRS) and societal & environmental data from a geographical information system, the Social Assets and Vulnerabilities Indicators (SAVI) Project. We used the RMRS to identify cohorts of children that were normal weight, overweight, or obese. The RMRS records were geocoded and merged into the SAVI database. Using the merged databases, we analyzed the relationships between markers of socioeconomic status and obesity outcomes in children. Our preliminary analyses show that markers of low socioeconomic status at the census tract level correlate with both overweight and obese outcomes in our study population. Utilization of geographic information systems (GIS) for the study of health epidemiology is discussed.

International Journal of Dermatology, 1996

Background. Genital warts is a common sexually transmitted disease treated by a variety of medica... more Background. Genital warts is a common sexually transmitted disease treated by a variety of medical specialists. Standard therapies offer symptomatic relief but cannot ensure lasting remission. Using tbe clinical literature, claims databases, and a panel of experienced practitioners, tbe relative efficacy, cost, and cost effectiveness of five common treatments for genital warts were assessed in this study.

Value in Health, 2012

Standard gamble (SG) and time trade-off (TTO) are two methods used for obtaining health utility v... more Standard gamble (SG) and time trade-off (TTO) are two methods used for obtaining health utility values (utilities). Whether the order in which the methods are applied alters the relative utilities obtained by each method is unknown. We sought to determine whether the order in which SG and TTO utilities were obtained affects the relative values of the utilities obtained by each technique. Utilities were assessed for 29 health states from 4016 parents by using SG and TTO. The assessment order was randomized by respondent. For analysis by health state, we calculated (SG - TTO) for each assessment and tested whether the SG - TTO difference was significantly different between the two groups (SG first and TTO first). For analysis by individual, we calculated a risk-posture coefficient, γ, defined by the utility curve, SG = TTO(γ). We predicted γ through regression analysis with the covariates: child age, child sex, birth order, respondent age, respondent education level, and assessment method order. In 19 of 29 health states, the SG - TTO difference was significantly greater (more risk averse) when TTO was assessed first. In the regression analysis, "child age" and "assessment method order" were significant predictors of risk attitude. The risk posture coefficient γ was higher (more risk-seeking) with increasing child age and in the SG-first respondents. The order in which the SG versus TTO method is used strongly influences the relative values of the utilities obtained.

Chronic Illness, 2010

In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease ... more In 2003, the Indiana Office of Medicaid Policy and Planning launched the Indiana Chronic Disease Management Program (ICDMP), a programme intended to improve the health and healthcare utilization of 15,000 Aged, Blind and Disabled Medicaid members living with diabetes and/or congestive heart failure in Indiana. Within ICDMP, programme components derived from the Chronic Care Model and education based on an integrated theoretical framework were utilized to create a telephonic care management intervention that was delivered by trained, nonclinical Care Managers (CMs) working under the supervision of a Registered Nurse. CMs utilized computerassisted health education scripts to address clinically important topics, including medication adherence, diet, exercise and prevention of disease-specific complications. Employing reflective listening techniques, barriers to optimal self-management were assessed and members were encouraged to engage in health-improving actions. ICDMP evaluation results suggest that this low-intensity telephonic intervention shifted utilization and lowered costs. We discuss this patient-centred method for motivating behaviour change, the theoretical constructs underlying the scripts and the branched-logic format that makes them suitable to use as a computer-based application. Our aim is to share these public-domain materials with other programmes.

Proceedings / AMIA ... Annual Symposium. AMIA Symposium, 2002

Computer-based prompting and reminder systems have been shown to be highly effective in increasin... more Computer-based prompting and reminder systems have been shown to be highly effective in increasing rates of preventive services delivery. However, there are many more recommended preventive services than can be practically included in a typical clinic visit. Therefore prioritization of preventive services prompts is necessary. We describe two approaches to prioritizing preventive services prompts based on expected value decision making. One method involves a static, global prioritization across all preventive services and has been used in a production system for almost 7 years. The second method uses influence diagrams to prioritize prompts dynamically, based on individual patient data. The latter approach is still under development. Both methods are labor intensive and require a combination of epidemiologic data and expert judgment. Compromises in strictly normative process were necessary to achieve user satisfaction.

Obstetrical & Gynecological Survey, 2002

To determine whether the vaginal delivery rate is increased in nulliparous women who have positiv... more To determine whether the vaginal delivery rate is increased in nulliparous women who have positive fetal fibronectin (fFN) testing before elective induction of labour, we performed a decision analysis that tested three options: (1) spontaneous labour; (2) testing nulliparous candidates for elective induction of labour at 39 weeks gestation with fFN and inducing labour if fFN positive (women who are fFN negative are managed expectantly); (3) elective induction of labour for women who are at least 39 weeks. We found that spontaneous labour had a vaginal delivery rate of 90, elective induction 79 and fFN screening 83. At baseline, a mother must be willing to take an additional 7 risk of caesarean delivery to warrant fFN testing or an additional 11 risk of caesarean delivery to warrant elective induction. We conclude that spontaneous labour has the highest vaginal delivery rates. An fFN test in a nulliparous woman may help to raise her likelihood of a vaginal delivery in an elective induction.

Artificial intelligence in medicine, 2015

Pediatric guidelines based care is often overlooked because of the constraints of a typical offic... more Pediatric guidelines based care is often overlooked because of the constraints of a typical office visit and the sheer number of guidelines that may exist for a patient's visit. In response to this problem, in 2004 we developed a pediatric computer based clinical decision support system using Arden Syntax medical logic modules (MLM). The Child Health Improvement through Computer Automation system (CHICA) screens patient families in the waiting room and alerts the physician in the exam room. Here we describe adaptation of Arden Syntax to support production and consumption of patient specific tailored documents for every clinical encounter in CHICA and describe the experiments that demonstrate the effectiveness of this system. As of this writing CHICA has served over 44,000 patients at 7 pediatric clinics in our healthcare system in the last decade and its MLMs have been fired 6182,700 times in "produce" and 5334,021 times in "consume" mode. It has run continuo...

Journal of the American Medical Informatics Association : JAMIA, Jan 13, 2015

Clinicians at our institution typically respond to about half of the prompts they are given by th... more Clinicians at our institution typically respond to about half of the prompts they are given by the clinic's computer decision support system (CDSS). We sought to examine factors associated with clinician response to CDSS prompts as part of a larger, ongoing quality improvement effort to optimize CDSS use. We examined patient, prompt, and clinician characteristics associated with clinician response to decision support prompts from the Child Health Improvement through Computer Automation (CHICA) system. We asked pediatricians who were nonusers of CHICA to rate decision support topics as "easy" or "not easy" to discuss with patients and their guardians. We analyzed these ratings and data, from July 1, 2009 to January 29, 2013, utilizing a hierarchical regression model, to determine whether factors such as comfort with the prompt topic and the length of the user's experience with CHICA contribute to user response rates. We examined 414 653 prompts from 22 260...

Applied Clinical Informatics

ABSTRACT

Archives of Pediatrics and Adolescent Medicine

To analyze the value of studying or implementing office-based clinical preventive services for ad... more To analyze the value of studying or implementing office-based clinical preventive services for adolescents. Most adolescent mortality and morbidity is attributable to risky behaviors, yet clinical preventive services to reduce risky behaviors are often challenged because their efficacy has not been demonstrated. A cost-effectiveness model of adolescents' risky behaviors that compares standard practice with a program of screening visits for all adolescents and counseling visits for youth identified as high risk. We considered two risky behaviors, alcohol abuse and unsafe sexual activity, and five outcomes. Baseline cost-effectiveness of the program, minimum efficacy at which the program would be cost-effective, and sample sizes required for a trial of the program. Assuming that the program is 5% effective at preventing risky behaviors, it would cost 3035topreventanyoneadverseoutcomeand3035 to prevent any one adverse outcome and 3035topreventanyoneadverseoutcomeand471,000 to prevent a death from an automobile crash or from human immunodeficiency virus infection. Assuming society were willing to pay $600,000 to prevent a death (a generally accepted figure), the program would be cost-effective only if it were 5.6% effective at changing behavior. At this efficacy, the program would have a cost per year of life saved comparable to or better than many other accepted medical interventions. However, to demonstrate changes in outcomes at this efficacy would require a clinical trial with between 4000 and 95 million adolescents in each treatment group, depending on the outcome measured. Studying the ability of clinical preventive services to prevent outcomes of adolescents' risky behaviors would be impractical. The decision to implement these programs should be made based on current knowledge and beliefs; their efficacy can probably be studied only as part of widespread implementation.

Annals of internal medicine

Journal of Pediatrics

Because febrile infants with no obvious source of bacterial infection may have bacteremia, and be... more Because febrile infants with no obvious source of bacterial infection may have bacteremia, and because bacteremia is difficult to diagnose on clinical grounds, we used decision analysis to evaluate whether such infants should be treated with antibiotics, tested further, or sent home. Using a simple decision tree, we found that the decision to give empiric antibiotic treatment is the decision of choice. The difference in quality-adjusted life expectancy between the "best" and "worst" decisions was only 11 days. However, this difference translated to prevention of death or permanent disability in 60 cases per 100,000 febrile children. Further, empiric treatment remained the best management alternative unless the probability of bacteremia was less than 1.4% (less than any published prevalence), or the efficacy of treatment was less than 21%. Our analysis demonstrated that a test with far greater sensitivity than leukocyte count or other tests currently in use is needed to justify testing rather than treating empirically. Further, an enormous patient population would be needed to find a difference of both clinical and statistical significance between treated and untreated patients in a controlled trial. In the absence of such trials, we recommend blood culture and empiric antibiotic treatment of all infants at risk for occult bacteremia.

Applied Clinical Informatics, 2015

ABSTRACT

AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium

Clinical guideline authors, health information technology (HIT) standards development organizatio... more Clinical guideline authors, health information technology (HIT) standards development organizations, and information system implementers all work to improve the processes of healthcare, but have long functioned independently towards realizing these goals. This has led to clinical standards of care that often poorly align with the functional and technical HIT standards developed to realize them. We describe the shortcomings and inefficiencies inherent in this current process and introduce two national initiatives that attempt to unite these communities. The mission of these two initiatives is to create examples of unambiguous, decidable, and executable clinical guidelines which both utilize and inform HIT terminology and logical expression standards. All of the products of this work aim to facilitate enterprise-wide guideline implementation and create a rising tide which lifts all ships.

National surveillance clearly illustrates that U.S. children are becoming increasingly overweight... more National surveillance clearly illustrates that U.S. children are becoming increasingly overweight. However, the timing of the onset of childhood overweight has not been well-described.

International Journal of Pediatrics and Adolescent Medicine, 2015

Background and objectives: The goal is to inform proactive initiatives to expand the knowledge ba... more Background and objectives: The goal is to inform proactive initiatives to expand the knowledge base of clinical decision support systems. Design and setting: We describe an initiative in which research informationists and health services researchers employ visualization tools to map logic models for clinical decision support within an electronic health record. Materials and methods: We mapped relationships using software for social network analysis: NodeXL and CMAP. We defined relationships by shared observations, such as two Arden rules within medical logic modules that consider the same clinical observation, or by the presence of common keywords that were used to label rules according to standardized vocabularies. Results: We studied the Child Health Improvement through Computer Automation (CHICA) system, an electronic medical record that contains 170 unique variables representing discrete clinical observations. These variables were used in 300 medical logic modules (MLM's) that prompted health care providers to deliver preventive counseling or otherwise served as clinical decision support. Using data visualization tools, we generated maps that illustrate connections, or lack thereof, between clinical topics within CHICA's MLMs.

Applied clinical informatics, 2014

With the growing use of electronic health record systems, there is a demand for an electronic ver... more With the growing use of electronic health record systems, there is a demand for an electronic version of the leading American pediatric preventive care guideline, Bright Futures. As computer implementation requires actionable recommendations, it is important to assess to what degree Bright Futures meets criteria for actionability. We aimed to 1) determine the number of actionable recommendations in the current edition of Bright Futures and 2) to recommend a specific format for representing an important class of guidelines in a way that better facilitates computer implementation. We consolidated all action statements in Bright Futures into recommendations. We then used two dimensions (decidability and executability) in the Guideline Implementability Appraisal v 2.0 (GLIA) to determine the actionability of the recommendations. Decidability means the recommendation states precisely under what conditions to perform those actions. Executability means actions are stated specifically, unam...

Pediatrics, 2006

Inborn errors of metabolism are a significant cause of morbidity and death among children. Incons... more Inborn errors of metabolism are a significant cause of morbidity and death among children. Inconsistencies in how individual states arrive at screening strategies, however, lead to marked variations in testing between states. To determine the cost-effectiveness of each component test of a multitest newborn screening program, including screening for phenylketonuria, congenital adrenal hyperplasia, congenital hypothyroidism, biotinidase deficiency, maple syrup urine disease, galactosemia, homocystinuria, and medium-chain acyl-CoA dehydrogenase deficiency. A decision model was used, with cohort studies, government reports, secondary analyses, and other sources. Discounted costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios were measured. All except 2 screening tests dominated the "no-test" strategy. The 2 exceptions were screening for congenital adrenal hyperplasia, which cost slightly more than $20,000 per QALY gained, and screening for gala...

Proceedings / AMIA ... Annual Symposium. AMIA Symposium, 2002

In this study, we use spatial analysis techniques to explore environmental and social predictors ... more In this study, we use spatial analysis techniques to explore environmental and social predictors of obesity in children. We constructed a merged database, incorporating clinical data from an electronic medical record system, the Regenstrief Medical Record System (RMRS) and societal & environmental data from a geographical information system, the Social Assets and Vulnerabilities Indicators (SAVI) Project. We used the RMRS to identify cohorts of children that were normal weight, overweight, or obese. The RMRS records were geocoded and merged into the SAVI database. Using the merged databases, we analyzed the relationships between markers of socioeconomic status and obesity outcomes in children. Our preliminary analyses show that markers of low socioeconomic status at the census tract level correlate with both overweight and obese outcomes in our study population. Utilization of geographic information systems (GIS) for the study of health epidemiology is discussed.

International Journal of Dermatology, 1996

Background. Genital warts is a common sexually transmitted disease treated by a variety of medica... more Background. Genital warts is a common sexually transmitted disease treated by a variety of medical specialists. Standard therapies offer symptomatic relief but cannot ensure lasting remission. Using tbe clinical literature, claims databases, and a panel of experienced practitioners, tbe relative efficacy, cost, and cost effectiveness of five common treatments for genital warts were assessed in this study.

Value in Health, 2012

Standard gamble (SG) and time trade-off (TTO) are two methods used for obtaining health utility v... more Standard gamble (SG) and time trade-off (TTO) are two methods used for obtaining health utility values (utilities). Whether the order in which the methods are applied alters the relative utilities obtained by each method is unknown. We sought to determine whether the order in which SG and TTO utilities were obtained affects the relative values of the utilities obtained by each technique. Utilities were assessed for 29 health states from 4016 parents by using SG and TTO. The assessment order was randomized by respondent. For analysis by health state, we calculated (SG - TTO) for each assessment and tested whether the SG - TTO difference was significantly different between the two groups (SG first and TTO first). For analysis by individual, we calculated a risk-posture coefficient, γ, defined by the utility curve, SG = TTO(γ). We predicted γ through regression analysis with the covariates: child age, child sex, birth order, respondent age, respondent education level, and assessment method order. In 19 of 29 health states, the SG - TTO difference was significantly greater (more risk averse) when TTO was assessed first. In the regression analysis, "child age" and "assessment method order" were significant predictors of risk attitude. The risk posture coefficient γ was higher (more risk-seeking) with increasing child age and in the SG-first respondents. The order in which the SG versus TTO method is used strongly influences the relative values of the utilities obtained.