As part of Northwestern University’s Master’s in Public Health program, students need to complete both a field and culminating experience. The field experience takes the form of a 200-hour internship while the culminating experience is a rigorous analysis of a public health topic most often taking the form of a research project. Below are the abstracts for the 2016 MPH students.
Arianne Cordon (MD/MPH Student)
The Intersection between Medical Care and Behavioral Health at a Small Community Health Center: Possible Effects of Behavioral Health Visits on Glycemic Control
Diabetes remains one of the most prevalent chronic diseases in the United States. Patients with diabetes are two and a half times more likely to have a co-existing depression (1). Moreover, depression increases the risk of developing diabetes-related complications. Prior evidence has shown improvement in glycosylated hemoglobin levels, known as hemoglobin A1C, in groups of patients with diabetes and depression undergoing an integrated intervention for depression. The first part of the analysis aimed at studying possible improvements in A1C levels in patients with diabetes and depression seeing behavioral health for more than one visit compared to patients not seeing behavioral health at a small community health clinic in the past five years. The second part of the analysis aimed at studying possible improvements in A1C levels in the same patients at least three months after starting behavioral health compared to before starting behavioral health. Although the differences were not statistically significant, patients seeing behavioral health had a lower average A1C level than patients not seeing behavioral health. In addition, the average A1C level was lower in the same patient group after starting behavioral health than before. Results suggest the potential of improving glycemic control by means of integrating behavioral health into the treatment of patients with coexisting diabetes and depression.
Jae Elkind (MD/MPH Student)
Pain Disparities in Neuraxial Labor Analgesia
Background: Prolonged unmanaged labor pain places women at risk for chronic persistent pain, which has been associated with postpartum depression. Neuraxial analgesia (NA) is a safe and effective method for alleviating extreme pain during childbirth, yet many women choose to not utilize this option during delivery. The reasons for this decision are complex and multifactorial and, therefore, opportunities to improve pre-delivery communication and decisionmaking about labor analgesia remain to be explored. The study identifies factors associated with anticipating using neuraxial analgesia. Because virtually all women requesting NA receive it, we then model factors associated with converting to NA during labor among women not initially planning to use. Finally, we look at postpartum pain scores and narcotic medication use by type of labor analgesia.
Methods: Data analyzed were electronic health records from the NMH-FSM Enterprise Data Warehouse (EDW). We analyze singleton deliveries for all English and non-English-speaking, nulliparous women from January 1, 2007 until December 3, 2015. We use Poisson regression to first model women’s pre-delivery preferred/anticipated labor analgesic method, controlling patients’ socioeconomic and clinical characteristics. We then model conversion to NA during delivery among the subgroup of women who did not initially anticipate using it. We also compare 24-hour postpartum maximum pain scores and 48-hour analgesic use among patients who anticipated, converted, or did not receive NA.
Results: The sample included 33,266 women over this 9-year period. Seventy-three percent of these women anticipated using neuraxial analgesia. Of the 27% of women who did not anticipate using neuraxial analgesia, 68% converted to using it. Younger age (IRR 0.94; 95% CI 0.89-0.99), minority race and ethnicity (IRR 0.82; 95% CI 0.79-0.84 for Hispanic), public insurance status (IRR 0.92; 95% CI 0.90-0.95), non-English language (IRR 0.83; 95% CI 0.77-0.89), use of a midwife as delivery provider (IRR 1.85; 95% CI 1.76-1.94 for obstetrician provider), and being unmarried (IRR 1.03; 95% CI 1.01-1.05) were all associated with a lower likelihood of anticipating using neuraxial analgesia. Among women who converted to neuraxial analgesia, the most significant factors were being African-American versus White (IRR 1.05; 95% CI 1.01-1.10), labor induction (IRR 1.28; 95% CI 1.25-1.31), and delivery by obstetrician versus midwife (IRR 1.47; 95% CI 1.41-1.54). Women who used the most analgesia 48-hours postpartum (33% with morphine equivalents of >46) were women who initially intended to use NA and received NA, followed by women who did not want but converted to NA (26%) and lastly women who did not plan for and did not receive NA (19%). Maximum pain scores (those >7 on a 0-10 scale within 24-hours postpartum) for these groups were 35%, 35%, and 38%, respectively.
Conclusion: Older, married, privately insured, White women delivering with obstetricians versus midwives request and anticipate NA significantly more than women of lower socioeconomic status. Most (68%) women who did not plan on using NA convert to neuraxial analgesia during labor, particularly those delivered by obstetrician and of African-American race. Women who anticipate NA use the most pain meds. Of those who did not anticipate NA, the women that convert use more pain meds postpartum. It was surprising to see little differences between pain scores in the different NA groups analyzed. We suspect nurse documentation of these scores to have significant subjectivity. More comprehensive and higher quality shared decision-making and communication between providers and patients regarding the labor analgesic plan is needed to improve pain control during labor and empower women to choose NA earlier before the pain is severe
Jeffrey Estrella, M.D. (MPH Student)
The Skokie Community Health Plan: A Community Health Needs Assessment
Preceptor: Dr. Catherine Counard, M.D., M.P.H.
Site: Skokie Health Department / 5127 Oakton St. / Skokie, IL 60077
Background: The Skokie Community Health Survey is a community health needs assessment conducted every 5 years. Results of the assessment are used to direct the goals and projects for the Skokie Health Department (SHD).
Methods: A qualitative survey assessing the most urgent healthcare needs and concerns in Skokie. Surveys were distributed electronically and through paper copies using a snowball method over a 6-week period. Respondents were eligible for the survey if they were at least 18 years old and lived, worked, or went to school in Skokie.
Results: 1,827 surveys were collected. The top concerns were Support for Growing Old, Being Overweight/Obese, and Opportunities for Exercise/Physical Fitness. The top concerns regarding access to services were Dental Care and Mental Health Services.
Conclusion: Moving forward, the SHD should promote physical health and provide new ways for citizens to exercise. Additionally, the SHD should reach out to its aging population to thoroughly investigate their health concerns.
Rachna Goswami (MD/MPH Student)
Using 2008-2013 Illinois Medicaid Data to Analyze Trends in Prescription Contraception Use and Subsequent Births for Illinois Teenagers
Background/Objective. Increasing the use of long-acting reversible contraception (LARC) by teenagers is an effective strategy for reducing teenage pregnancy. This report describes annual trends in prescription contraception claims from 2008 to 2013 and compares the frequency of births within a subsequent 12-month period for teenagers continuously enrolled in Illinois Medicaid.
Methods. De-identified files for five annual cohorts of female Medicaid enrollees ages 13-19 were obtained from the Illinois Department of Healthcare and Family Services with Medicaid outpatient prescription contraception and birth control procedure claims, as well as Medicaid childbirth deliveries from 2008 to 2014. For each year, we compared the demographic characteristics and childbirth status of continuously enrolled teenagers by their final annual prescription contraception type.
Results. Of the Illinois teenagers who received prescription contraception, 5.4% (n=1842, 2008) to 6.8% (n=2684, 2012) received a prescription for a LARC as their final annual contraceptive prescription. The lowest proportion of births within a year subsequent to the last contraceptive prescription was to teenagers prescribed LARC at 0.6% (n=8, 2009) to 2.3% (n=14, 2013) of all subsequent births.
Conclusion. Teenage Medicaid clients in Illinois have a low rate of LARC use despite its effectiveness in preventing births. This data can be used to tailor policy-based interventions to increase LARC use and decrease teenage pregnancy.
Ami Hughes (PhD/MPH Student)
Relationships between Virulence of Pseudomonas aeruginosa Clinical Isolates and Patient Outcomes
Every year thousands of patients experience potentially life-threatening complications during hospitalization from hospital-acquired infections (HAIs). The CDC categorized the Gram-negative bacterium Pseudomonas aeruginosa as a public safety threat level of “Serious” because it is a common causative agent of HAIs and P. aeruginosa infections are often resistant to antibiotics. Although scientific efforts focus on understanding mechanisms of P. aeruginosa pathogenesis, there is a lack of understanding as to how the scientific knowledge will affect public health efforts to address the burden of HAIs. In the current study, multivariate regression analysis was conducted to examine correlations between bacterial virulence in laboratory studies to clinical outcomes of patients who developed P. aeruginosa bacteremia during hospitalization. Although hospital-acquired P. aeruginosa bacteremia was associated with longer hospitalization and patient mortality, virulence of the strain in a mouse model of disease did not correlate with severity of disease or risk of mortality for patients. Upon further analysis, we were able to identify a novel genetic region, vAGE14, that was correlative with increased disease severity. Another separate genetic region, vAGE3, was also associated with antibiotic resistance. Our results suggest that strains may possess novel genetic regions that have greater influence on patient outcomes than virulence of the bacteria. Future studies will include a larger analysis of novel bacterial genetic regions to find correlations with patient outcomes without the use of an animal model of disease. Studies such as this have the potential to bolster public health efforts to reduce the threat of hospital-acquired P. aeruginosa infection by identifying bacterial factors that are most relevant to human disease as targets for development of novel therapeutic and prevention strategies.
Juleigh Nowinski Konchak, MD (MPH Student)
An analysis of birth rates and interpregnancy intervals among teenage mothers in the Illinois Medicaid program: 2008-2013.
Background: Teen pregnancy prevention is recognized as a public health priority nationally and locally due to its potentially significant health, social, and economic effects on a woman and her family. Teenage mothers have high rates of repeat pregnancies with short interpregnancy intervals (IPI), which is associated with poor birth outcomes. Use of long-acting reversible contraception has been associated with decreased repeat pregnancy among adolescents.
Study aims: Use Illinois Medicaid data to 1) examine trends in teen birth rates and 2) examine interpregnancy intervals for teen pregnancies, and potential correlates of short IPI.
Methods: This cross-section study used de-identified Illinois Medicaid claims data for continuously and intermittently enrolled teenage women ages 13-19 from 2008-2013. Pearson’s chi square test and multivariate logistic regression were utilized to assess for trends in birth rates, patterns of short IPIs, and potential associations with short IPI.
Aim 1: While Medicaid enrollment increased from 2008-2013 for teenage women ages 13-19, the birth rate for this population steadily decreased from 55.9 to 29.9 births per 1,000 women (p<0.001). Birth rates significantly declined for each study subgroup (by age, race/ethnicity, and geographic region) over the study period.
Aim 2: Overall, of the 32,729 repeat births to 12,320 teens during the study period, 13,628 (42%) were births after an IPI of less than 18 months, and 4,083 (12%) were births after an IPI of less than 6 months.
The following subgroups had significantly increased odds of having at least one short IPI of less than 18 months:
Women who were ages 16-19 years at the time of the first study birth (OR 1.22, reference value: ages 13-15 years);
Non-Hispanic Black and Hispanic women (OR 1.37 and 1.23, respectively; reference value: non-Hispanic White women);
Women from downstate counties (OR 1.18; reference value: Cook County);
Women who had their first study birth in 2010-2012 had a significantly decreased odds of having at least one short IPI (OR 0.85-0.86, reference value: first birth in 2008). These same patterns were maintained for odds of having at least one very short IPI of less than 6 months.
Conclusion: Trends in Illinois Medicaid teenage birth follow most national trends, including racial/ethnic and geographic disparities, except our study found lower birth rates among Hispanic teens among the continuously enrolled population likely due to eligibility restrictions for immigrants. Future research is needed to explore if the decreased odds of short IPI in later years of our study is due to increased use of long-acting reversible contraception.
Onyeka Otugo (MD/MPH Student)
Trends in Illinois Infectious Disease-Emergency Department Visits and Hospital Admissions for Patients Ages 18-64 by Insurance Status, 2010-2015
Infectious disease continues to be a major public health issue in the United States. One study estimated that the hospital related cost of infectious disease is approximately 96 billion dollars per year. In 2011, ID-related ED visits ranked in the top five reasons for hospital admission. Crowded emergency departments represent an obstacle in rapidly identifying and controlling the spread of transmissible disease creating implications to public health. Past studies have implicated overcrowded EDs in delayed diagnosis and treatment of pneumonia. The Institute of Medicine report implicates overcrowding as a barrier to quality of care and clinical outcomes in the emergency department. According to the Public Health Impact of ED Crowding and Boarding of Inpatients, due to overcrowding and strain on resources in emergency departments, infection control poses a continuous challenge. Part of the challenge includes preventing the spread of transmissible infections during outbreaks.
Aksharananda Rambachan (MD/MPH Student)
Physicians, The War on Drugs, and the Mass Incarceration of African-Americans
Mass incarceration is a public health crisis facing the African-American community, borne of decades of an increasingly punitive “War on Drugs” that systematically targets African-Americans. Despite comparable drug use by other ethnic groups, African-Americans face rates of incarceration many times greater than their White counterparts. Among the consequences of this disparity facing African-Americans include much higher rates of disease while imprisoned, multiple barriers to successful community re-entry and their communities’ health suffer from the downstream epidemiological effects of increasing disease, poverty, and crime. Physicians have played a seminal role in establishing destructive stereotypes about African-Americans and in supporting the creation of the criminal justice and narcotics regime. However today, there are multiple areas in which the medical community can lead efforts to help reduce the harms of mass incarceration and racial inequity in American society. Areas for potential intervention include quality healthcare within correctional facilities, community engagement, advocacy-based medical education and policy initiatives within physician organizations and legislative bodies. A harms reduction public health approach to substance abuse, along with an honest and transparent national discussion about the role of race in the criminal justice and healthcare systems, is critical to effectuating lasting measures to correct this long-standing injustice.