Intersection of Living in a Rural Versus Urban Area and Race/Ethnicity in Explaining Access to Health Care in the United States

Alzheimer's Centers in US Hospitals: Enough to Adequately Address Dementia Care Nationwide?

Objectives: To investigate the availability of Alzheimer's Centers (ACs) in US hospitals. Methods: Utilizing the American Hospital Association Annual Survey, Area Health Resource File, and US Census (n = 3251), we employed multivariable logistic regression to examine hospital, county, and regional predictors of AC availability. Results: Large hospitals (>399 beds) had approximately 14 times higher odds of having an AC than small hospitals (<50 beds; OR = 14.0; 95% CI = 6.44 - 30.46). Counties with a higher proportion of Latino residents, relative to non-Latino Whites, had lower odds of having an AC (OR = .05; 95% CI = .01 - .41). Northeastern (OR = 1.92; 95% CI = 1.15 - 3.22) and Midwestern (OR = 2.12; 95% CI = 1.34 - 3.37) hospitals had higher odds of having an AC than Southern hospitals. Discussion: To address dementia needs and disparities, investment in a national infrastructure is critical.

Health care Utilization and Expenditures in Health Professional Shortage Areas

Healthcare provider shortages are associated with adverse health outcomes, presumably stemming from the lack of access to primary care. This study examines the impact of Health Professional Shortage Areas (HPSAs) on healthcare utilization and spending across different types of care. Using the Medical Expenditure Panel Survey from 2002 to 2019, this study estimates the difference in healthcare utilization in HPSAs compared with non-HPSAs using a generalized random forest, which allows for more complex modeling of the outcome and a principled examination of heterogenous treatment effects. The results indicate HPSAs are associated with a 5% reduction in medical office visits, but no reduction in hospital-based care. These effects are concentrated in older persons living in urban areas, Black persons, and Medicaid beneficiaries. No statistically significant effects on annual spending were observed. These results offer insight into potential areas for further policy efforts aimed at reducing provider shortages.

"We're Not Valued, We're Not Heard": Voices of Seasoned Nurses in a Rural State Following the Onset of COVID-19

The COVID-19 crisis shone a spotlight on long-standing issues in the nursing profession. Currently, nurses feel overworked, unsupported, and undervalued. This interpretive phenomenological study shares the perspectives of 10 seasoned nurses. The overarching theme is "My job doesn't love me back," supported by "Enough pizza already," "Band-Aid on a hemorrhage," "We were heroes and now no one remembers us," "We used to be so trusted," and "Nursing is psychological warfare." It is imperative that systems and leaders listen to the concerns of nurses and provide avenues for nurses to take action to collaborate and convene organizational culture change.

The plantation system and the roots of the southern rural mortality penalty in the northern Blackland Prairies of Texas

In recent decades, public health researchers have observed that the health of rural people has declined relative to the health of urban people in the United States. This disparity in health and life expectancy across the rural/urban divide has been described as the Rural Mortality Penalty. However, public health researchers have also noted that health and life expectancies are not uniform across the rural United States, but vary according to race, sex, gender, and other factors. Rural health disparities also vary geospatially and are especially pronounced in the American South, leading to recent calls for greater attention to the structural factors that shape the health of rural Southerners. In this study, we take an anthropological and historically explicit approach to study the impacts of systemic violence on rural health. Specifically, we focus on farm labor within the plantation system as a context where geospatial, racial, and sexual differences in mortality, often studied in isolation, find a common historical source. Here we analyze vital records data from the post-emancipation period in the Blackland Prairies ecoregion of Texas, a period when emerging forms of plantation labor such as tenant farming, convict leasing, and migrant labor were being developed to maintain the plantation economy after the abolishment of chattel slavery. We find that the plantation system remains a strong predictor of differential mortalities in rural Texas, accounting for nearly all the variation that exists across the rural/urban divide and elucidating the complex interactions of race, sex, labor, and health in the rural South.

Differences in Rural Versus Urban Patients With Prostate Cancer in Diagnosis and Treatment: An Analysis of a Population-Based Cohort

PURPOSE

Patients living in rural communities have greater barriers to cancer care and poorer outcomes. We hypothesized that rural patients with prostate cancer have less access and receive different treatments compared with urban patients.

METHODS

We used a population-based prospective cohort, the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study, to compare differences in prostate cancer diagnosis, access to care, and treatment in patients by geographic residence. The 2013 rural-urban continuum code (RUCC) was used to determine urban (RUCC 1-3) versus rural (RUCC 4-9) location of residence.

RESULTS

Patients with rural residence comprised 25% of the cohort (364 of 1,444); they were less likely to be White race and had lower income and educational attainment. Rural patients were more likely to have <12 cores on biopsy (47.1% v 35.7%; P < .001) and less likely (40.8% v 47.6%; P = .04) to receive multidisciplinary consultation. We observed significant differences in treatment between urban and rural patients, including rural patients receiving less active surveillance or observation (22.6% v 28.7%), especially in low-risk cancer (33.2% v 40.7%). On multivariable analysis that adjusted for patient and diagnostic factors, rural residence was associated with less use of active surveillance or observation over radical treatment (ie, surgery or radiation therapy; odds ratio, 0.49 v urban; P < .001) in patients with low-risk cancer.

CONCLUSION

Patients with prostate cancer who live in rural versus urban areas experience several differences in care that are likely clinically meaningful, including fewer cores in the diagnostic biopsy, less utilization of multidisciplinary consultation, less use of active surveillance, or observation for low-risk disease. Future studies are needed to assess the efficacy of interventions in mitigating these disparities.

Disparities in Acute and Chronic Complications of Diabetes Along the U.S. Rural-Urban Continuum

OBJECTIVE

To determine the relative hazards of acute and chronic diabetes complications among people with diabetes across the U.S. rural-urban continuum.

RESEARCH DESIGN AND METHODS

This retrospective cohort study used the OptumLabs Data Warehouse, a deidentified data set of U.S. commercial and Medicare Advantage beneficiaries, to follow 2,901,563 adults (age ≥18 years) with diabetes between 1 January 2012 and 31 December 2021. We compared adjusted hazard ratios (HRs) of diabetes complications in remote areas (population <2,500), small towns (population 2,500-50,000), and cities (population >50,000).

RESULTS

Compared with residents of cities, residents of remote areas had greater hazards of myocardial infarction (HR 1.06 [95% CI 1.02-1.10]) and revascularization (HR 1.04 [1.02-1.06]) but lower hazards of hyperglycemia (HR 0.90 [0.83-0.98]) and stroke (HR 0.91 [0.88-0.95]). Compared with cities, residents of small towns had greater hazards of hyperglycemia (HR 1.06 [1.02-1.10]), hypoglycemia (HR 1.15 [1.12-1.18]), end-stage kidney disease (HR 1.04 [1.03-1.06]), myocardial infarction (HR 1.10 [1.08-1.12]), heart failure (HR 1.05 [1.03-1.06]), amputation (HR 1.05 [1.02-1.09]), other lower-extremity complications (HR 1.02 [1.01-1.03]), and revascularization (HR 1.05 [1.04-1.06]) but a smaller hazard of stroke (HR 0.95 [0.94-0.97]). Compared with small towns, residents of remote areas had lower hazards of hyperglycemia (HR 0.85 [0.78-0.93]), hypoglycemia (HR 0.92 [0.87-0.97]), and heart failure (HR 0.94 [0.91-0.97]). Hazards of retinopathy and atrial fibrillation/flutter did not vary geographically.

CONCLUSIONS

Adults in small towns are disproportionately impacted by complications of diabetes. Future studies should probe for the reasons underlying these disparities.

Maternity Care Deserts in Louisiana and Breastfeeding Initiation

BACKGROUND

Breastfeeding provides physical, psychological, and immunological benefits to both the mother and infant, but breastfeeding rates are suboptimal. The purpose of this study was to examine whether residing in a maternity care desert (a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with lower breastfeeding rates among birthing people in Louisiana from 2019 to 2020.

METHODS

Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all live births provided by the Louisiana Office of Vital Records (n = 112,151), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory geospatial analysis to examine the association between place of residence and breastfeeding initiation and racial disparities in initiation. We conducted a secondary within-group analysis by fitting the fully adjusted model stratified by race/ethnicity for non-Hispanic white and non-Hispanic Black birthing people.

RESULTS

We found that residing in a parish with limited (odds ratio [OR] = 0.87; 95% confidence interval [CI] [0.77, 0.99]) to no access (OR = 0.88; 95% CI [0.80, 0.97]) was significantly associated with lower breastfeeding initiation rates. The within-group analysis determined that both non-Hispanic Black and non-Hispanic white birthing people residing in a parish with limited or no maternity care access had lower breastfeeding initiation rates.

CONCLUSION

Reducing rural and racial inequities in breastfeeding may require structural changes and investments in infrastructure to deliver pregnancy care.

Racial and Ethnic Disparities in Geographic Availability of Buprenorphine

OBJECTIVES

Overdose mortality has risen most rapidly among racial and ethnic minority groups while buprenorphine prescribing has increased disproportionately in predominantly non-Hispanic White urban areas. To identify whether buprenorphine availability equitably meets the needs of diverse populations, we examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups.

METHODS

Using IQVIA longitudinal prescription data, IQVIA OneKey data, and Microsoft Bing Maps, we calculated 2 outcome measures across the continental United States: the number of buprenorphine prescribers per 1000 residents within a 30-minute drive of a ZIP code, and the number of buprenorphine prescriptions dispensed per capita at retail pharmacies among nearby buprenorphine prescribers. We then estimated differences in these outcomes by ZIP codes' racial and ethnic minority composition and rurality with t tests.

RESULTS

Buprenorphine prescribers per 1000 residents within a 30-minute drive decreased by 3.8 prescribers per 1000 residents in urban ZIP codes (95% confidence interval = -4.9 to -2.7) and 2.6 in rural ZIP codes (95% confidence interval = -3.0 to -2.2) whose populations consisted of ≥5% racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude.

CONCLUSIONS

Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.

Implementing an APRN-Led Integrated Behavioral Health Clinic in a Rural Community

OBJECTIVE

A rural primary care clinic implemented an advance practice providers, including nurse practitioner (APRN)-led integrated behavioral health program to facilitate holistic health care delivery.

METHODS

Implementation was facilitated by Health Resources and Services Administration Grant funding to a state University College of Nursing. The College formed an academic-practice partnership with a Federally Qualified Health Center (FQHC) to implement integrated care in a rural satellite clinic administered by the FQHC. An interdisciplinary team (two family APRNs, a psychiatric APRN, a licensed behavioral health provider, and the Grant Project Director who is a Psychiatric APRN and a licensed Psychologist) provided the integrated care based on the University of Washington's Collaborative Care Model.

RESULTS

This brief report describes the implementation of integrated care during the clinic's first year, services provided, lessons learned, community response, and improvement in anxiety and depressive symptoms for patients who were treated for behavioral health problems. An exemplar illustrates how collaborative care addressed one patient's behavioral health and primary care needs.

CONCLUSIONS

APRN-led collaborative care can expand access to holistic, affordable care in rural areas to improve mental health. Adaptation and flexibility in traditional roles may be necessary and determining post-grant access to funding for services will be necessary for sustainability.

Assessing interstate racial and socioeconomic disparities in newborn screening policies in the United States

Introduction

This paper explores racial and socioeconomic disparities in newborn screening (NBS) policies across the United States. While inter-state inequality in healthcare policies is often considered a meaningful source of systemic inequity in healthcare outcomes, to the best of our knowledge, no research has explored racial and socioeconomic disparities in newborn screening policies based on state of residence.

Methods

We investigate these disparities by calculating weighted average exposure to specific NBS tests by racial and socioeconomic group. We additionally estimate count models of the number (and type) of NBS conditions screened for by state racial and socioeconomic composition.

Results

Adding to the knowledge base that social determinants of health and health disparities are linked, our analysis surprisingly reveals little evidence of substantial inter-state inequity in newborn screenings along racial and socioeconomic lines.

Discussion

While there is substantial nationwide racial and socioeconomic inequity in terms of infant health, the distribution of state-level policies does not appear to be structured in a manner to be a driver of these disparities. Our findings suggest that efforts to reduce inequities in outcomes related to NBS should shift focus toward the delivery of screening results and follow-up care as discussion builds on expanding NBS to include more conditions and genomic testing.

Racial differences in triage assessment at rural vs urban Maine emergency departments

Data continue to accumulate demonstrating that those belonging to racialized groups face implicit bias in the emergency care delivery system across many indices, including triage assessment. The Emergency Severity Index (ESI) was developed and widely implemented across the US to improve the objectivity of triage assessment and prioritization of care delivery; however, research continues to support the presence of subjective bias in triage assessment. We sought to assess the relationship between perceived race and/or need for translator and assigned ESI score and whether this was impacted by hospital geography. We performed retrospective EMR-based review of patients presenting to urban and rural emergency departments of a health system in Maine with one of the top ten most common chief complaints (CC) across a 5-year period, excluding psychiatric CCs. We used multivariable regression to analyze the relationships between perceived race, need for translator, and gender with ESI score, wait time, and hallway bed assignments. We found that patients perceived as non-white were more likely to receive lower acuity ESI scores and have longer wait times as compared to patients perceived as white. Patients perceived as female were more likely to receive lower acuity scores and wait longer to be seen than patients perceived as male. The need for an interpreter was associated with increased wait times but not significantly associated with ESI score. After stratification by hospital geography, evidence of subjective bias was limited to urban emergency departments and was not evident in rural emergency departments. Further investigation of subjective bias in emergency departments in Maine, particularly in urban settings, is warranted.

Building Healthy Families: Outcomes of an Adapted Family Healthy Weight Program Among Children in a Rural Mid-Western Community

Background: This study aimed to evaluate the effectiveness of implementing an adapted, evidence-based 12-week Family Healthy Weight Program (FHWP), Building Healthy Families, on reducing BMI metrics and clinical health indicators in a real-world community setting. Methods: Ninety child participants with a BMI percentile greater or equal to the 95th percentile for gender and age and their parents/guardians (n = 137) enrolled in the program. Families attended 12 weekly group-based sessions of nutrition education, family lifestyle physical activity, and behavior modification. A pre-post study design with a 6-month follow-up was used. Results: Nine cohorts of families between 2009 and 2016 completed the program with 82.1% retention at 12 weeks and 53.6% at 6 months. Participants had statistically significant improvements at 12 weeks in BMI z-score, %BMIp95, body mass, body fat, fat mass, fat-free mass, and systolic blood pressure with greater improvement at 6 months in body mass, BMI metrics, body fat, fat mass, fat-free mass, and systolic blood pressure. Parents/guardians of the participants had similar statistically significant body composition and blood pressure improvements (p < 0.05). In addition, children had significant improvements in high-density lipoprotein (HDL) cholesterol and aspartate aminotransferase (AST) liver enzymes at 6 months. Conclusions: Overall, this study demonstrated that an evidence-based FHWP can result in statistically meaningful declines in BMI z-score and accompanied clinically meaningful changes in health risk. Participants lost ∼4% of their body mass in 12 weeks, while their parents/guardians lost closer to 7% of their body mass, which supports previous literature suggesting body mass changes influence health.

A Systematic Review of the Effectiveness of Health Education Programs for Cervical Cancer Prevention in Rural Communities: Implications for Promoting Health Equity

Rural women face an increased risk of cervical cancer diagnosis in comparison to women living in metropolitan areas. This review synthesized and critically evaluated cervical cancer screening interventions that target women living in rural communities in the USA. EBSCO, JSTOR, Medline, PsychINFO, Psychology and Behavioral Sciences Collection, PubMed, and Cochrane Library were searched using keywords related to cervical cancer screening, rural communities, and prevention interventions. Study eligibility included randomized controlled trials or quasi-experimental designs, a psychosocial or educational intervention targeting cervical cancer prevention, and implementation in a rural setting. Eleven articles met criteria for the systematic review and 6 of those included information sufficient for meta-analysis. Cochrane guidelines, CONSORT-Equity 2017, and PROGRESS-Plus were used to assess included studies. The systematic review encompassed 9720 participants who were involved in a variety of intervention types: social media campaigns, faith-based, and patient navigation with lay health advisors. None of the studies met all criteria for the health equity assessment. The meta-analysis found that women in the intervention groups were more likely to participate in cervical cancer screening than women in control groups (OR: 2.43, 95% CI: 1.49 to 3.97). The type of intervention mattered in increasing cervical cancer screening participation for women living in rural communities. Educational interventions in combination with patient navigation saw the most success in promoting cervical cancer screening. Further, health inequities focus is lacking robust consideration. Our results highlight a continued need to develop multicomponent interventions with a health equity focus to address barriers to screening and prevention.

Seeking care across the US-Mexico border: The experiences of Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress

BACKGROUND

Many Latinx and Indigenous Mexican populations in the United States Southwest live in unincorporated communities in the US-Mexico borderlands called colonias. These environmental justice communities often lack basic infrastructure, including healthcare services, prompting many to seek services across the border. However, due to geopolitical factors more vulnerable caregivers are limited to utilize healthcare services in the US. This paper reports the experiences and healthcare decision-making of caregivers living in colonias in the US-Mexico border region who care for children with respiratory health conditions.

METHODS

This study was carried out from September to December 2020. Focus groups and interviews were conducted with Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress. Qualitative interviews elicited caregivers' perspectives on the environmental factors affecting children's chronic health conditions and use of healthcare services. The analysis employed the concept of structure vulnerability to theorize geography as a structural determinant of health for caregivers faced with making healthcare decisions for their suffering from respiratory health conditions. A survey was administered to collect basic sociodemographic information.

RESULTS

A total of 36 caregivers participated in the study. Structural factors including unincorporated community status and government inaction intersected with social determinants of health to prompt caregivers to cross the US-Mexico border to access healthcare services in Mexico for their children. Yet, more vulnerable caregivers (i.e., those without documentation status in the US) and their children, accessing healthcare services in the US was not an option limiting caregivers' ability to meet their children's healthcare needs. In such cases, geography acts as a structural determinant of health.

CONCLUSION

This study shows the importance of geography in health. Rural unincorporated colonias located in the borderlands are precariously located and lack basic critical infrastructure including healthcare access. Within such places, historically and socially marginalized populations become invisible, are subject to the health effects of environmental hazards, and are limited depending on their positionality and thus vulnerability to healthcare services.

Adaptations of an Effective Evidence-Based Pediatric Weight Management Intervention

Current childhood obesity treatment programs do not address medically underserved populations or settings where all members of an interdisciplinary team may not exist-either within one organization or within the community. In this paper, we describe the use of a community-academic partnership to iteratively adapt Epstein's Traffic Light Diet (TLD), into Building Healthy Families (BHF), a community-placed evidence-based pediatric weight management intervention (PWMI) and evaluate its effectiveness in reducing BMI z scores. Nine cohorts of families completed BHF. Participants included children aged 6-12 years with obesity (M = 9.46, SD = 1.74). The Framework for Reporting Adaptations and Modifications-Expanded guided our classification of modifications across BHF cohorts. Using the FRAME reporting structure, the changes that were documented were (1) planned and occurred pre-implementation, (2) based on decisions from local stakeholders (e.g., school administrator, members of the implementation team), and (3) specific to changes in content and context-with a focus on implementation and potential for local scale-up. The nature of the adaptations included adding elements (whole of family approach), removing elements (calorie counting), and substituting elements (steps for minutes of physical activity). Across 9 cohorts, 84 families initiated the BHF program, 69 families successfully completed the 12-week program, and 45 families returned for 6-month follow-up assessments. Results indicated that the BMI z score in children was reduced by 0.31 ± 0.17 at 6 months across all cohorts. Reduction in BMI z score ranged from 0.41 in cohort 4 to 0.13 in cohort 5. Iterative adaptations to BHF were completed to improve the fit of BHF to the setting and participants and have contributed to a sustained community PWMI that adheres to the underlying principles and core elements of other evidence-based PWMIs. Monitoring adaptations and related changes to outcomes can play a role in long-term sustainability and effectiveness.

Green and blue space exposure and non-communicable disease related hospitalizations: A systematic review

The global increase in non-communicable diseases (NCDs) presents a critical public health concern. Emerging evidence suggests that exposure to natural environments may reduce the risk of developing NCDs through multiple pathways. The present systematic review aims to synthesize and evaluate the observational evidence regarding associations between exposure to green and blue spaces and hospital admissions related to NCDs. A comprehensive literature search strategy was conducted in Embase (Ovid), PubMed, and Web of Science. The risk of bias and quality of the evidence were assessed using The Navigation Guide methodology, an approach specifically designed for environmental health research. Of 3060 search results, 17 articles were included. Notably, the majority of the studies (n = 14; 82.4%) were published from 2020 onwards. Most studies were conducted in the United States (n = 6; 35.3%) and China (n = 4; 23.5%). Exposure to green spaces was assessed through all studies, while only three included blue spaces. In terms of study design, cohort design was employed in nearly half of the studies (n = 8; 47.1%), followed by case-crossover design (n = 3, 17.6%). Over 75% of the included studies (n = 13) had a high or probably high rating in the risk of bias assessment. The studies encompassed diverse NCD outcome domains; cardiovascular diseases (CVDs) (n = 10), respiratory diseases (RSDs) (n = 2), heat-related diseases (n = 1), metabolic diseases (n = 2), cancer (n = 1), neurodegenerative diseases (NDDs) (n = 2), and mental health disorders (n = 2). The present review suggests that a clear link between blue space exposure and NCD hospital admissions is not evident. However, exposure to green spaces appears to predominantly have a protective effect, although the direction of the association varies across different outcome domains. The heterogeneity among the outcome domains together with the limited number of studies, emphasizes the need for more robust evidence.

Impact of the Essential Public Health Service program on financial protection and health outcomes among hypertensive patients: A quasi-experimental study in China

BACKGROUND

The Chinese government launched the Essential Public Health Service (EPHS) program nationwide in 2009. However, prior studies have not provided clear and integrated evidence on whether the EPHS program improves health outcomes and prevents financial risks among individuals. Because hypertension is the chronic disease with the highest prevalence, this study evaluated the impact of the EPHS program among hypertensive patients to provide evidence for the progress of the program.

METHODS

A cohort of hypertensive patients was identified from the 2011-2018 China Health and Retirement Longitudinal Study (CHARLS). The outcomes assessed included hospitalization expenditure, outpatient expenditure and cardiovascular disease (heart attack and stroke). The key independent variable was whether an individual received EPHS-covered blood pressure measurements in 2013-2015. Based on the International Health Partnership+ (IHP+) common monitoring and evaluation (M&E) framework, a difference-in-differences (DID) method with propensity score matching (PSM) was used to examine the impact of the EPHS program on hypertensive patients.

RESULTS

The results showed that among hypertensive patients covered by the EPHS program, outpatient total costs/OOP costs were reduced by 29.8% and 30.8%, respectively, and hospitalization total costs/OOP costs were reduced by 34.9% and 35.6%, respectively. The EPHS program reduced the probability of heart attack and stroke among hypertensive patients by 3.5% and 2.7%, respectively. Mechanistic tests showed that the EPHS program improved health outcomes by reducing alcohol consumption and increasing physical activity, thereby further reducing health expenditure among hypertensive patients. The impacts of the EPHS program on hypertensive patients varied by age, educational attainment, residential region, and alcohol consumption status.

CONCLUSION

The EPHS program in China significantly improved health outcomes and prevented financial risks for hypertensive patients. This evidence provides a valuable reference for low- and middle-income countries with their essential public health service programs.

Evaluating the Connection Between Rural Travel Time and Health: A Cross-Sectional Analysis of Older Adults Living in the Northeast United States

INTRODUCTION

To characterize the impact of rural patients' travel time to obtain healthcare on their reported utilization of preventive healthcare services and personal health outcomes.

METHODS

Online survey data from rural adults ages 50+ years living in the Northeastern United States were collected from February to August 2021. Study measures included self-reported travel time to obtain healthcare, use of preventive healthcare, and health outcomes. The associations between travel time with use of preventive care and health outcomes were assessed using linear, Poisson, and logistic regression analyses controlling for demographic variables.

RESULTS

Our study population included 1052 rural adults, with a mean travel time of 18.5 min (range: 0-60). Travel time was greater for racial/ethnic minority participants and for higher-income participants (both P < .05), but it was not associated with use of preventive healthcare. Greater travel time was associated with poorer mental health and more comorbidities, including cancer and diabetes (all P < .05).

CONCLUSIONS

Travel time varied by patient demographic factors, and it was associated with mental health and comorbidities. There was no association between travel time and preventive care use, suggesting that other barriers likely contribute to suboptimal use of these services within rural communities. Further research is needed to elucidate the causal pathways linking travel time to mental health and comorbidities within rural communities, as increased travel may exacerbate intrarural health disparities.

Structural barriers to health care as risk factors for preterm and small-for-gestational-age birth among US-born Black and White mothers

We develop county-level measures of structural and institutional barriers to care, and test associations between these barriers and birth outcomes for US-born Black and White mothers using national birth records for 2014-2017. Results indicate elevated odds of greater preterm birth severity for Black mothers in counties with higher uninsurance rates among Black adults, fewer Black physicians per Black residents, and fewer publicly-funded contraceptive services. Most structural barriers were not associated with small-for-gestational-age birth, and barriers defined for Black residents were not associated with birth outcomes for White mothers, with the exception of Black uninsurance rate. Structural determinants of care may influence preterm birth risk for Black Americans.

Contextual Pathways Linking Cumulative Experiences of Racial Discrimination to Black American Men's COVID Vaccine Hesitancy

The COVID-19 pandemic has revealed and widened racialized health disparities, underscoring the impact of structural inequities and racial discrimination on COVID-19 vaccination uptake. A sizable proportion of Black American men report that they either do not plan to or are unsure about becoming vaccinated against COVID-19. The present study investigated hypotheses regarding the mechanisms by which experiences of racial discrimination are associated with Black American men's COVID-19 vaccine hesitancy. Hypotheses were tested using structural equation modeling with 4 waves of data from 242 Black American men (aged ~ 27) living in resource-poor communities in the rural South. Study findings revealed that racial discrimination was indirectly associated with COVID-19 vaccine hesitancy via increased endorsement of COVID-19 conspiratorial beliefs. Findings also demonstrated that increased levels of ethnic identity strengthen the association between experiences of racial discrimination and COVID-19 conspiratorial beliefs. In contrast, increased levels of social support weakened the association between cumulative experiences of racial discrimination and COVID conspiratorial beliefs. Taken together, these results suggest that racial discrimination may promote conspiratorial beliefs which undermine Black American men's willingness to be vaccinated. Future interventions aimed towards promoting vaccine uptake among Black American men may benefit from the inclusion of targeted efforts to rebuild cultural trust and increase social support.

Association of Race/Ethnicity, Persistent Poverty, and Opioid Access Among Patients with Gastrointestinal Cancer Near the End of Life

BACKGROUND

Social determinants of health (SDoH) can impact access to healthcare. We sought to assess the association between persistent poverty (PP), race/ethnicity, and opioid access among patients with gastrointestinal cancer near the end-of-life (EOL).

METHODS

SEER-Medicare patients with gastric, liver, pancreatic, biliary, colon, and rectal cancer were identified between 2008 and 2016 near EOL, defined as 30 days before death or hospice enrolment. Data were linked with county-level poverty from the American Community Survey and the US Department of Agriculture (2000-2015). Counties were categorized as never high-poverty (NHP), intermittent high-poverty (IHP) and persistent poverty (PP). Trends in opioid prescription fills and daily dosages (morphine milligram equivalents per day) were examined.

RESULTS

Among 48,631 Medicare beneficiaries (liver: n = 6551, 13.5%; pancreas: n = 13,559, 27.9%; gastric: n = 5486, 1.3%; colorectal: n = 23,035, 47.4%), there was a steady decrease in opioid prescriptions near EOL. Black, Asian, Hispanic, and other racial groups had markedly decreased odds of filling an opioid prescription near EOL (Black: OR 0.84, 95% CI 0.79-0.90; Asian: OR 0.86, 95% CI 0.79-0.94; Hispanic: OR 0.90, 95% CI 0.84-0.95; Other: OR 0.83, 95% CI 0.74-0.93; all p < 0.05). Even after filling an opioid prescription, this subset of patients received lower daily doses versus White patients (Black: -16.5 percentage points, 95% CI -21.2 to -11.6; Asian: -11.9 percentage points, 95% CI -18.5 to -4.9; Hispanic: -19.1 percentage points, 95%CI -23.5 to -14.6; all p < 0.05). The disparity in opioid access and average daily doses among was attenuated in IHP/PP areas for Asian, Hispanic, and other racial groups, yet exacerbated among Black patients.

CONCLUSIONS

Race/ethnicity-based disparities in EOL pain management persist with SDoH-based variations in EOL opioid use. In particular, PP impacted EOL opioid access and utilization.

Rural-Urban Health Care Cost Differences Among Latinx Adults With and Without Dementia in the United States

OBJECTIVES

To compare rural-urban health care costs among Latinx adults ages 51+ and examine variations by dementia status.

METHODS

Data are from the Health and Retirement Study (2006-2018 waves; n = 15,567). We inflation-adjusted all health care costs using the 2021 consumer price index. Geographic context and dementia status were the main exposure variables. We applied multivariate two-part generalized linear models and adjusted for sociodemographic and health characteristics.

RESULTS

Rural residents had higher total health care costs, regardless of dementia status. Total health care costs were $850 higher in rural ($2,640) compared to urban ($1,789) areas (p < .001). Out-of-pocket costs were $870 higher in rural ($2,677) compared to urban ($1,806) areas (p < .001). Dementia status was not an effect modifier.

DISCUSSION

Health care costs are disproportionately higher among Latinx rural, relative to urban, residents. Addressing health care costs among Latinx rural residents is a public health priority.

Associations between urbanicity and spinal cord astrocytoma management and outcomes

BACKGROUND

The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown.

METHODS

The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018).

RESULTS

1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002).

CONCLUSIONS

Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities.

Reducing Rural and Urban Disparities in Potentially Preventable Hospitalizations: Evidence of Hospital-Based Health Information Technology and Enabling Services

Background: Telehealth and enabling services are promising approaches to address the intersecting challenges of chronic disease burden, a growing aging population, and poor access to care disproportionately affecting rural areas. Using potentially preventable hospitalizations (PPHs) as an indicator for health system efficiency and quality, this study examined the relationship between health information technology and hospital-provided enabling services on PPHs across rural, micropolitan, and metropolitan areas. Methods: We constructed a patient-, hospital-, community-, and state-level data set using the Medicare fee-for-service claims file and the Medicare Master Beneficiary Summary File, and the American Hospital Association Annual Survey. Logistic regressions were applied to examine associations between PPH and telehealth post-discharge, telehealth treatment, and telehealth post-discharge and enabling services. Results: Approximately 50% of rural and micropolitan residents (vs. 36% of urban residents) were treated in hospitals providing neither telehealth post-discharge services nor enabling services, and 7% (vs. 11% of urban residents) were treated in hospitals with both services. Telehealth post-discharge services were associated with significantly lower odds ratio (OR) of having any PPH due to acute (OR = 0.91, p < 0.001) and chronic conditions (OR = 0.94, p < 0.001). The ORs of having any PPH due to acute and chronic conditions were the least among beneficiaries who were treated in hospitals with both telehealth post-discharge and enabling services (OR = 0.56, p < 0.001, for acute conditions, and OR = 0.73, p < 0.001, for chronic conditions). Conclusions: Hospital use of post-discharge telehealth alongside enabling services may help provide timely access to care, improve care coordination, and reduce PPHs for older rural residents.

Health Equity and Antibiotic Prescribing in the United States: A Systematic Scoping Review

We performed a scoping review of articles published from 1 January 2000 to 4 January 2022 to characterize inequities in antibiotic prescribing and use across healthcare settings in the United States to inform antibiotic stewardship interventions and research. We included 34 observational studies, 21 cross-sectional survey studies, 4 intervention studies, and 2 systematic reviews. Most studies (55 of 61 [90%]) described the outpatient setting, 3 articles were from dentistry, 2 were from long-term care, and 1 was from acute care. Differences in antibiotic prescribing were found by patient's race and ethnicity, sex, age, socioeconomic factors, geography, clinician's age and specialty, and healthcare setting, with an emphasis on outpatient settings. Few studies assessed stewardship interventions. Clinicians, antibiotic stewardship experts, and health systems should be aware that prescribing behavior varies according to both clinician- and patient-level markers. Prescribing differences likely represent structural inequities; however, no studies reported underlying drivers of inequities in antibiotic prescribing.

Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018

Policy Points Policymakers should invest in programs to support rural health systems, with a more targeted focus on spatial accessibility and racial and ethnic equity, not only total supply or nearest facility measures. Health plan network adequacy standards should address spatial access to nearest and second nearest hospital care and incorporate equity standards for Black and Latinx rural communities. Black and Latinx rural residents contend with inequities in spatial access to hospital care, which arise from fundamental structural inequities in spatial allocation of economic opportunity in rural communities of color. Long-term policy solutions including reparations are needed to address these underlying processes.

CONTEXT

The growing rate of rural hospital closures elicits concerns about declining access to hospital-based care. Our research objectives were as follows: 1) characterize the change in rural hospital supply in the US South between 2007 and 2018, accounting for health system closures, mergers, and conversions; 2) quantify spatial accessibility (in 2018) for populations most at risk for adverse outcomes following hospital closure-Black and Latinx rural communities; and 3) use multilevel modeling to examine relationships between structural factors and disparities in spatial access to care.

METHODS

To calculate spatial access, we estimated the network travel distance and time between the census tract-level population-weighted centroids to the nearest and second nearest operating hospital in the years 2007 and 2018. Thereafter, to describe the demographic and health system characteristics of places in relation to spatial accessibility to hospital-based care in 2018, we estimated three-level (tract, county, state-level) generalized linear models.

FINDINGS

We found that 72 (10%) rural counties in the South had ≥1 hospital closure between 2007 and 2018, and nearly half of closure counties (33) lost their last remaining hospital to closure. Net of closures, mergers, and conversions meant hospital supply declined from 783 to 653. Overall, 49.1% of rural tracts experienced worsened spatial access to their nearest hospital, whereas smaller proportions experienced improved (32.4%) or unchanged (18.5%) access between 2007 and 2018. Tracts located within closure counties had longer travel times to the nearest acute care hospital compared with tracts in nonclosure counties. Moreover, rural tracts within Southern states with more concentrated commercial health insurance markets had shorter travel times to access the second nearest hospital.

CONCLUSIONS

Rural places affected by rural hospital closures have greater travel burdens for acute care. Across the rural South, racial/ethnic inequities in spatial access to acute care are most pronounced when travel times to the second nearest open acute care hospital are accounted for.

Community Socioeconomic and Urban-Rural Disparities in Prehospital Notification of Stroke by Emergency Medical Services in North Carolina

OBJECTIVES

Notification by emergency medical services (EMS) to the destination hospital of an incoming suspected stroke patient is associated with timelier in-hospital evaluation and treatment. Current data on adherence to this evidence-based best practice are limited, however. We examined the frequency of EMS stroke prenotification in North Carolina by community socioeconomic status (SES) and rurality.

METHODS

Using a statewide database of EMS patient care reports, we selected 9-1-1 responses in 2019 with an EMS provider impression of stroke or documented stroke care protocol use. Eligible patients were 18 years old and older with a completed prehospital stroke screen. Incident street addresses were geocoded to North Carolina census tracts and linked to American Community Survey socioeconomic data and urban-rural commuting area codes. High, medium, and low SES tracts were defined by SES index tertiles. Tracts were classified as urban, suburban, and rural. We used multivariable logistic regression to estimate independent associations between tract-level SES and rurality with EMS prenotification, adjusting for patient age, sex, and race/ethnicity; duration of symptoms; incident day of week and time of day; 9-1-1 dispatch complaint; EMS provider primary impression; and prehospital stroke screen interpretation.

RESULTS

The cohort of 9527 eligible incidents was mostly at least 65 years old (65%), female (55%), and non-Hispanic White (71%). EMS prenotification occurred in 2783 (29%) patients. Prenotification in low SES tracts (27%) occurred less often than in medium (30%) and high (32%) SES tracts. Rural tracts had the lowest frequency (21%) compared with suburban (28%) and urban (31%) tracts. In adjusted analyses, EMS prenotification was less likely in low SES (vs high SES; odds ratio 0.76, 95% confidence interval 0.67-0.88) and rural (vs urban; odds ratio 0.64, 95% confidence interval 0.52-0.77) tracts.

CONCLUSIONS

Across a large, diverse population, EMS prenotification occurred in only one-third of suspected stroke patients. Furthermore, low SES and rural tracts were independently associated with a lower likelihood of prehospital notification. These findings suggest the need for education and quality improvement initiatives to increase EMS stroke prenotification, particularly in underserved communities.

Assessing trauma center accessibility in the Southeastern region of the U.S. to improve healthcare efficacy using an anti-covering approach

Accessibility to trauma centers is vital for the patients of severe motor vehicle crashes. Many vehicle crash fatalities failed to reach the proper emergency medical services since the accident location was far away from trauma centers. The spatial discordance between the service coverage area of trauma centers and actual locations of motor vehicle accidents delays the definitive medical care and results in death or disability. Many fatalities would have been prevented if the patients had a chance to get proper treatment in time at Southeastern region of the U.S. Also, the accessibility to trauma centers from the actual locations of motor vehicle accidents is different in the Southeastern region. This research aimed to facilitate the accessibility to trauma centers for severe motor vehicle crash patients in the Southeastern region. The analyses are conducted to assess current trauma center accessibility and suggest the optimal locations of future trauma centers using the Anti-covering location model for trauma centers (TraCt model). This study found that existing trauma centers failed to serve many demands, and the actual coverages of the current locations of trauma centers over potential demands are highly different in each Southeastern state. TraCt model is applied to each Southeastern state, and its solutions provide better coverage for demand locations. However, the TraCt model for each state tends to choose too many facilities, with excessively supplied facilities across the Southeastern region. The excessive service supply issue is addressed by applying the TraCt Model to a broader spatial extent. TraCt model applied to the entire Southeastern region and most of the demand, over 98% covered by the service coverage of optimal facility locations with 15 additional facilities. This research proves that the GIS and TraCt model applied to the broader spatial extent works well with increasing trauma medical service beneficiaries while providing a minimum number of additional facilities.

Regional variations of cardiovascular risk in gout patients: a nationwide cohort study in Korea

Objective

The extent of regional variations in cardiovascular risk and associated risk factors in patients with gout in South Korea remains unclear. Therefore, we aimed to investigate the risk of major cardiovascular events in gout patients in different regions.

Methods

This was a nationwide cohort study based on the claims database of the Korean National Health Insurance and the National Health Screening Program. Patients aged 20 to 90 years newly diagnosed with gout after January 2012 were included. After cardiovascular risk profiles before gout diagnosis were adjusted, the relative risks of incident cardiovascular events (myocardial infarction, cerebral infarction, and cerebral hemorrhage) in gout patients in different regions were assessed.

Results

In total, 231,668 patients with gout were studied. Regional differences in cardiovascular risk profiles before the diagnosis were observed. Multivariable analysis showed that patients with gout in Jeolla/Gwangju had a significantly high risk of myocardial infarction (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.02~1.56; p=0.03). In addition, patients with gout in Gangwon (aHR, 1.38; 95% CI, 1.09~1.74; p<0.01), Jeolla/Gwangju (aHR, 1.41; 95% CI, 1.19~1.67; p<0.01), and Gyeongsang/Busan/Daegu/Ulsan (aHR, 1.37; 95% CI, 1.19~1.59; p<0.01) had a significantly high risk of cerebral infarction.

Conclusion

We found there were regional differences in cardiovascular risk and associated risk factors in gout patients. Physicians should screen gout patients for cardiovascular risk profiles in order to facilitate prompt diagnosis and treatment.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Serving Individuals With Autism Spectrum Disorder in the Age of COVID-19: Special Considerations for Rural Families

This position paper explores the needs of rural families of children, adolescents, and adults with autism spectrum disorder (ASD) during the COVID-19 pandemic. Prior to COVID-19, literature portrays elevated stress in families of individuals with ASD and health and socioeconomic disparities for rural and underserved populations. These disparities were exacerbated due to COVID-19 and subsequent lockdowns and economic turmoil. Academic and adaptive skills training were particularly impacted due to school closures, with parents tasked with taking some responsibility for training these skills. Our goals for this article focus on special considerations for rural families regarding (a) neurobiological and developmental impacts of stressful experiences like COVID-19, (b) delineation of the impacts on individuals with ASD and other comorbid and related conditions, and (c) education and intervention needs during these times. Finally, we offer suggestions for future care during pandemic events, including recommendations for improving service delivery under such conditions.

A systems-level model of direct and indirect links between environmental health, socioeconomic factors, and human mortality

Major efforts are being made to better understand how human health and ecosystem health are influenced by climate and other environmental factors. However, studies that simultaneously address human and ecosystem health within a systems-level framework that accounts for both direct and indirect effects are rare. Using path analysis and a large database of environmental and socioeconomic variables, we create a systems-level model of direct and indirect effects on human and ecosystem health in counties throughout the conterminous United States. As indicators of human and ecosystem health, we use age-adjusted mortality rate and an index of biological integrity in streams and rivers, respectively. We show that: (i) geology and climate set boundary conditions for all other variables in the model; (ii) hydrology and land cover have predictable but distinct effects on human and ecosystem health; and (iii) forest cover is a key link between the environment and the socioeconomic variables that directly influence human health.

Racial and Ethnic Disparities in Opioid Access and Urine Drug Screening Among Older Patients With Poor-Prognosis Cancer Near the End of Life

PURPOSE

To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms.

METHODS

Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends in opioid prescription fills and potency (morphine milligram equivalents [MMEs] per day [MMEDs]) near the end of life (EOL), defined as 30 days before death or hospice enrollment. We estimated the effects of race and ethnicity on opioid access, controlling for demographic and clinical factors. Models were further adjusted for socioeconomic factors including dual-eligibility status, community-level deprivation, and rurality. We similarly explored disparities in UDS.

RESULTS

Between 2007 and 2019, White, Black, and Hispanic decedents experienced steady declines in EOL opioid access and rapid expansion of UDS. Compared with White patients, Black and Hispanic patients were less likely to receive any opioid (Black, -4.3 percentage points, 95% CI, -4.8 to -3.6; Hispanic, -3.6 percentage points, 95% CI, -4.4 to -2.9) and long-acting opioids (Black, -3.1 percentage points, 95% CI, -3.6 to -2.8; Hispanic, -2.2 percentage points, 95% CI, -2.7 to -1.7). They also received lower daily doses (Black, -10.5 MMED, 95% CI, -12.8 to -8.2; Hispanic, -9.1 MMED, 95% CI, -12.1 to -6.1) and lower total doses (Black, -210 MMEs, 95% CI, -293 to -207; Hispanic, -179 MMEs, 95% CI, -217 to -142); Black patients were also more likely to undergo UDS (0.5 percentage points; 95% CI, 0.3 to 0.8). Disparities in EOL opioid access and UDS disproportionately affected Black men. Adjustment for socioeconomic factors did not attenuate the EOL opioid access disparities.

CONCLUSION

There are substantial and persistent racial and ethnic inequities in opioid access among older patients dying of cancer, which are not mediated by socioeconomic variables.

Defining rurality: an evaluation of rural definitions and the impact on survival estimates

BACKGROUND

Patients with cancer living in rural areas have inferior cancer outcomes; however, studies examining this association use varying definitions of "rural," complicating comparisons and limiting the utility of the results for policy makers and future researchers.

METHODS

Surveillance, Epidemiology, and End Results data (2000-2016) were used to assess risk of cancer mortality and mortality from any cause across 4 definitions of rurality: Urban Influence codes (UIC), National Center for Health Statistics (NCHS), Rural-Urban continuum codes (RUCC), and Index of Relative Rurality. Binary (urban vs rural) and ternary (urban, micropolitan, rural) definitions were evaluated. Multivariable parametric survival models estimated hazards of mortality overall and among 3 cancer groupings: screening related, obesity related, and tobacco related. Definition agreement was also assessed.

RESULTS

Overall, 3 788 273 patients with an incident cancer representing 605 counties were identified. There was little discordance between binary definitions of rural vs urban and moderate agreement at the 3 levels. Adjusted models using binary definitions revealed 15% to 17% greater hazard of cancer mortality in rural compared with urban. At the 3 levels when comparing rural with metropolitan, RUCC and NCHS saw similarly increased hazard ratios; however, Index of Relative Rurality did not. Screening-related cancers saw the highest hazards of mortality and the largest divergence between definitions. Obesity-related and tobacco-related cancers saw similarly increased hazards of mortality at the binary and ternary levels.

CONCLUSIONS

Hazard of death is similar across binary definitions; however, this differed when categorized as ternary or continuous, especially among screening-related cancers. Results suggest that study purpose should direct choice of definitions and categorization.

American Indians travel great distances for obstetrical care: Examining rural and racial disparities

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

A Geodemographic Analysis of Travel Time to Uveitis Specialists in the United States

PURPOSE

Travel time to a patient's medical provider represents a significant component of access to care. We examined travel time to the nearest uveitis specialist for the American population and characterize its impact on access to uveitis care.

DESIGN

Observational studies using the American Community Survey and American Census Bureau population estimates.

METHODS

Addresses of fellowship-trained uveitis specialists were collected from the American Uveitis Society (AUS) and the Ocular Immunology and Uveitis Foundation (OIUF) websites and geocoded using ArcGIS Pro 2.9. Service areas were defined as all locations within a 60-min drive time from each specialist's location. Demographic and population data for total population, racial groups, household poverty levels, population in dependent groups (younger than 18, older than 65), and health insurance status were overlaid. Data were aggregated for census tracts within and outside service areas and compared using chi-square analysis. Main Outcome Measures: Differences in population demographics for people within and outside service area coverage.

RESULTS

223 uveitis specialist addresses were geocoded into ArcGIS. Of specialist locations, 94% were found in urban areas. Of the total United States population, 63.3% were found to be within service areas. Of these, 55.9% were White and 14.7% were African American, whereas 70% of the people outside service areas were White and 10.1% were African American (p < 0.0001) (Table 1). Only 8.3% of the people within service area coverage had no health insurance compared with 9.5% outside service areas (p < 0.0001). Within coverage areas, 12.7% of the households had a total income below the federal poverty level versus 15.1% of the households outside service area coverage (p < 0.0001). Within service area coverage, 37.4% of the people were in a dependent age group compared with 40.4.% outside service area coverage (p < 0.0001).

CONCLUSIONS

Our analysis shows a significant travel burden to the nearest uveitis specialist for a large proportion of Americans. More providers are needed in rural areas, as patients there are more likely to live under the poverty line, be uninsured, or belong to a dependent age group.

The Workforce Needed to Address Population Health

Policy Points Although a single definition of the population health workforce does not yet exist, this workforce needs to have the skills and competencies to address the social determinants of health, to understand intersectionality, and to coordinate and work in concert with an array of skilled providers in social and health care to address multiple health drivers. On-the-job training programs and employer support are needed for the current health workforce to gain skills and competencies to address population health. Funding and leadership combined are critical for developing the population health workforce with the goal of supporting a broad set of workers beyond health and social care to include, for example, those in urban planning, law enforcement, or transportation professions to address population health.

Ensuring privacy in telemedicine: Ethical and clinical challenges

Data privacy in telemedicine has been extensively considered and reviewed in the literature, such as explorations of consent, who can access information, and the security of electronic systems. However, privacy breaches are also a potential concern in the physical setting and surroundings of the patient. Here we review clinical situations in which there is unanticipated loss of privacy, as well as potential physical and psychological safety concerns for the patient and others when privacy is limited. We identify ethical concerns and explore the challenges of supporting full true autonomous decision-making in this situation. We close with preliminary recommendations at the patient, clinician, and systems levels to help ensure privacy is maintained.

Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South

As persistent inequities in health gained increased attention nationally due to COVID-19 and racial justice protests in 2020, it has become increasingly important to evaluate both the process and outcomes associated with coalition-based efforts to address health inequities. The Two Georgias Initiative supports coalitions in 11 rural counties to (1) achieve greater health equity, (2) improve health and health care, (3) build healthier rural communities and improve social conditions that impact the health of rural populations, and (4) build community, organizational, and individual leadership capacity for health equity. Rural communities suffer significant health disparities relative to urban areas, and also experience internal inequities by race and poverty level. The evaluation framework for The Two Georgias Initiative provides a comprehensive mixed methods approach to evaluating both processes and outcomes. Early results related to community readiness and capacity to address health inequities, measured through a coalition member survey (n = 236) conducted at the end of the planning phase, suggest coalitions were in the preparation stage, with higher levels of readiness among coalition members and organizations/groups similar to the coalition members' own, lower levels among public officials and other leaders, and the lowest levels among county residents. In addition, coalition members reported more experience with downstream drivers (e.g., access to care) of health than upstream drivers (e.g., affordable housing, environmental or racial justice). By providing a logic model, evaluation questions and associated indicators, as well as a range of data collection methods, this evaluation approach may prove practical to others aiming to evaluate their efforts to address health equity.

"If you're in a community together, then you're basically a family": Perceptions of community among a predominantly African-American/Black youth cohort in a semi-rural region in the Southeastern United States

Geographic racism gives rise to health inequities that impact communities in detrimental ways. Southern ethnic minority groups, particularly African American/Black semi-rural communities, are subject to especially unjust outcomes in health, education, and wealth. Asset-based community development (ABCD) is a way of engaging with communities in participatory and positive ways that center community voices as expert. Youth can participate in ABCD, are sensitive to the ways in which their communities are structured, and have insights as to how to improve the places they live. We undertook a qualitative interview study which included a cognitive mapping exercise with 28 youth to understand how African American/Black youth who had participated in an ABCD-informed summer program conceptualized community and preferences about where they lived. Using a phenomenological approach to qualitative analysis, our study revealed that many youth defined community as a combination of people and place, enjoyed engaging with unique resources in their communities as well as seeking peace and quiet, experienced hardships as "something everybody knows" when observing constraints on their communities, and were committed to their communities and interested in seeing-and participating in-their flourishing. Our study provides a nuanced and contemporary understanding of the ways in which African American/Black semi-rural youth experience community which can contribute to cyclical asset-based development strategy aimed at empowering young people and improving health outcomes in resilient communities.

Engagement and Utilization of a Complete Remote Digital Care Program for Musculoskeletal Pain Management in Urban and Rural Areas Across the United States: Longitudinal Cohort Study

BACKGROUND

Musculoskeletal (MSK) conditions are the number one cause of disability worldwide. Digital care programs (DCPs) for MSK pain management have arisen as alternative care delivery models to circumvent challenges in accessibility of conventional therapy. Despite the potential of DCPs to reduce inequities in accessing care, the outcomes of such interventions in rural and urban populations have yet to be studied.

OBJECTIVE

The aim of this study was to assess the impact of urban or rural residency on engagement and clinical outcomes after a multimodal DCP for MSK pain.

METHODS

This study consists of an ad hoc analysis of a decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were coded according to their zip codes to a specific rural-urban commuting area code and grouped into rural and urban cohorts. Changes in their engagement and clinical outcomes from baseline to program end were assessed. Latent growth curve analysis was performed to estimate change trajectories adjusting for the following covariates: age, gender, BMI, employment status, and pain acuity. Outcomes included engagement, self-reported pain, and the results of the Generalized Anxiety Disorder 7-item, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment scales. A minimum clinically important difference (MCID) of 30% was considered for pain.

RESULTS

Patients with urban and rural residency across the United States participated in the program (n=9992). A 73.8% (7378/9992) completion rate was observed. Both groups reported high satisfaction scores and similar engagement with exercise sessions, with rural residents showing higher engagement with educational content (P<.001) and higher program completion rates (P=.02). All groups showed a significant improvement in all clinical outcomes, including pain, mental health, and work productivity, without statistically significant intergroup differences. The percentage of patients meeting the MCID was similar in both groups (urban: 67.1%, rural: 68.3%; P=.30).

CONCLUSIONS

This study advocates for the utility of a DCP in improving access to MSK care in urban and rural areas alike, showcasing its potential to promote health equity. High engagement, satisfaction, and completion rates were noted in both groups, as well as significant improvements in clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

County-level jail incarceration, community economic distress, rurality, and preterm birth among women in the US South

Introduction

The USA has higher rates of preterm birth and incarceration than any other developed nation, with rates of both being highest in Southern states and among Black Americans, potentially due to rurality and socioeconomic factors. To test our hypothesis that prior-year county-level rates of jail admission, economic distress, and rurality were positively associated with premature birth rates in the county of delivery in 2019 and that the strength of these associations is greater for Black women than for White or Hispanic women, we merged five datasets to perform multivariable analysis of data from 766 counties across 12 Southern/rural states.

Methods

We used multivariable linear regression to model the percentage of babies born premature, stratified by Black (Model 1), Hispanic (Model 2), and White (Model 3) mothers. Each model included all three independent variables of interest measured using data from the Vera Institute, Distressed Communities Index, and Index of Relative Rurality.

Results

In fully fitted stratified models, economic distress was positively associated with premature births among Black (F = 33.81, p < 0.0001) and White (F = 26.50, p < 0.0001) mothers. Rurality was associated with premature births among White mothers (F = 20.02, p < 0.0001). Jail admission rate was not associated with premature births among any racial group, and none of the study variables were associated with premature births among Hispanic mothers.

Conclusions

Understanding the connections between preterm birth and enduring structural inequities is a necessary scientific endeavor to advance to later translational stages in health-disparities research.

Association of distance traveled on receipt of surgery in patients with locally advanced rectal cancer

PURPOSE

Studies have shown patients residing in rural settings have worse cancer-related outcomes than those in urban settings. Specifically, rural patients with colorectal cancer have lower rates of screening and longer time to treatment. However, physical distance traveled has not been as well studied. This study sought to determine disparities in receipt of surgery in patients by distance traveled for care.

METHODS

A retrospective cohort study of patients with AJCC stage II/III rectal adenocarcinoma was identified within the National Cancer Database (2004-2017). Primary outcome was correlation of distance traveled to receipt of surgery. Multi-variable logistic regression was used to adjust for confounding factors.

RESULTS

65,234 patients were included in the analysis. 94.6% resided in urban-metro areas while 2.2% resided in rural areas. Patients were predominantly non-Hispanic White (NHW) (75.2%) with an overall median age at diagnosis of 61 (IQR 52-71). Overall, 82.6% of patients received surgery. NHW patients were more likely to receive surgery than non-Hispanic Black patients (OR 0.67; 95% CI 0.61-0.73, p < 0.001), as were patients who were privately insured (OR 1.90, 95% CI 1.67-2.15, p < 0.001) or had Medicare (OR 1.68, 95% CI 1.47-1.92, p < 0.001) compared to uninsured patients. Patients traveling distances in the 4th quartile (median 47.9 miles) were more likely to receive surgery than those traveling the shortest distances (1st quartile: median 2.5 miles) (OR 1.37, 95% CI 1.24-1.50, p < 0.001).

CONCLUSION

Patients traveling farther distances were more likely to receive surgery than those traveling shorter distances. Shorter distance traveled does not appear to be associated with higher rates of surgical resection in patients with stage II/III rectal cancer.

Geographic disparities in COVID-19 testing and outcomes in Florida

BACKGROUND

Understanding geographic disparities in Coronavirus Disease 2019 (COVID-19) testing and outcomes at the local level during the early stages of the pandemic can guide policies, inform allocation of control and prevention resources, and provide valuable baseline data to evaluate the effectiveness of interventions for mitigating health, economic and social impacts. Therefore, the objective of this study was to identify geographic disparities in COVID-19 testing, incidence, hospitalizations, and deaths during the first five months of the pandemic in Florida.  METHODS: Florida county-level COVID-19 data for the time period March-July 2020 were used to compute various COVID-19 metrics including testing rates, positivity rates, incidence risks, percent of hospitalized cases, hospitalization risks, case-fatality rates, and mortality risks. High or low risk clusters were identified using either Kulldorff's circular spatial scan statistics or Tango's flexible spatial scan statistics and their locations were visually displayed using QGIS.

RESULTS

Visual examination of spatial patterns showed high estimates of all COVID-19 metrics for Southern Florida. Similar to the spatial patterns, high-risk clusters for testing and positivity rates and all COVID-19 outcomes (i.e. hospitalizations and deaths) were concentrated in Southern Florida. The distributions of these metrics in the other parts of Florida were more heterogeneous. For instance, testing rates for parts of Northwest Florida were well below the state median (11,697 tests/100,000 persons) but they were above the state median for North Central Florida. The incidence risks for Northwest Florida were equal to or above the state median incidence risk (878 cases/100,000 persons), but the converse was true for parts of North Central Florida. Consequently, a cluster of high testing rates was identified in North Central Florida, while a cluster of low testing rate and 1-3 clusters of high incidence risks, percent of hospitalized cases, hospitalization risks, and case fatality rates were identified in Northwest Florida. Central Florida had low-rate clusters of testing and positivity rates but it had a high-risk cluster of percent of hospitalized cases.

CONCLUSIONS

Substantial disparities in the spatial distribution of COVID-19 outcomes and testing and positivity rates exist in Florida, with Southern Florida counties generally having higher testing and positivity rates and more severe outcomes (i.e. hospitalizations and deaths) compared to Northern Florida. These findings provide valuable baseline data that is useful for assessing the effectiveness of preventive interventions, such as vaccinations, in various geographic locations in the state. Future studies will need to assess changes in spatial patterns over time at lower geographical scales and determinants of any identified patterns.

Clinician Perspectives on Referring Medicaid Back Pain Patients to Integrative and Complementary Medicine: A Qualitative Study

Objective: To increase understanding of referral processes from primary care to integrative and complementary medicine (ICM) under an Oregon Medicaid policy that restricted opioids and expanded access to ICM for back pain patients. Methods: Four asynchronous online focus groups with 48 medical clinicians were conducted. Themes were constructed using thematic analysis. Results: Three themes were constructed related to the clinician's experience: (1) high patient receptivity to ICM, (2) difficulty finding ICM providers who accept Medicaid beneficiaries, and (3) uncertainty of the effectiveness of ICM among clinicians. Conclusions: Findings suggest that health systems expanding access to ICM for Medicaid beneficiaries may benefit from establishing and supporting linkages between clinicians and ICM providers, especially in rural areas.

Can virtual human clinicians help close the gap in colorectal cancer screening for rural adults in the United States? The influence of rural identity on perceptions of virtual human clinicians

Rural adults experience disparities in colorectal cancer screening, a trend even more distinct among rural Black adults. Healthcare disruptions caused by COVID-19 exacerbated inequities, heightening attention on virtual communication strategies to increase screening. Yet little is known about how rural adults perceive virtual human clinicians (VHCs). Given that identifying as rural influences perceived source credibility often through appearance judgments, the goal of this pilot was to explore how to develop VHCs that individuals highly identified with rurality find attractive. Between November 2018 and April 2019, we tested a culturally tailored, VHC-led telehealth intervention delivering evidence-based colorectal cancer prevention education with White and Black adults (N = 2079) in the United States recruited through an online panel who were non-adherent to screening guidelines and between 50 and 73 years of age. Participants were randomized on three factors (VHC race-matching, VHC gender-matching, Intervention type). Ordinal logistic regression models examined VHC appearance ratings. Participants with a high rural identity (AOR = 1.12, CI = [1.02, 1.23], p =.02) rated the VHCs more attractive. High rural belonging influenced VHC attractiveness for Black participants (AOR = 1.22, CI = [1.03, 1.44], p =.02). Also, Black participants interacting with a Black VHC and reporting high rural self-concept rated the VHC as more attractive (AOR = 2.22, CI = [1.27, 3.91], p =.01). Findings suggest adults for whom rural identity is important have more positive impressions of VHC attractiveness. For patients with strong rural identities, enhancing VHC appearance is critical to tailoring colorectal cancer prevention interventions.

The Scholarly Neglect of Black Autistic Adults in Autism Research

Black autistic individuals, regardless of age, have not been centered in autism research. Instead, they often exist on the margins-on the periphery of autism research. In fact, Black autistic adults are largely absent from the literature. Most participants in autism research are majority-white autistic individuals and families. In this conceptual article, we use intersectionality and Dis/ability Studies and Critical Race Theory theories to contextualize Black autistic adults' experiences. Second, we argue that systemic disparities and methodological concerns are two contributors to the scholarly neglect of Black autistic adults in autism research. Third, we provide guidelines to support researchers in moving from neglect to inclusive research with Black autistic adults.

Racial, ethnic, and language differences in screening measures for statin therapy following a major guideline change

Atherosclerotic cardiovascular disease (ASCVD) disproportionally affects racial and ethnic minority populations. Statin prescribing guidelines changed in 2013 to improve ASCVD prevention. It is unknown whether risk screening for statin eligibility differed across race and ethnicity over this guideline change. We examine racial/ethnic/language differences in screening measure prevalence for period-specific statin consideration using a retrospective cohort design and linked electronic health records from 635 community health centers in 24 U.S. states. Adults 50+ years, without known ASCVD, and ≥ 1 visit in 2009-2013 and/or 2014-2018 were included, grouped as: Asian, Latino, Black, or White further distinguished by language preference. Outcomes included screening measure prevalence for statin consideration, 2009-2013: low-density lipoprotein (LDL), 2014-2018: pooled cohort equation (PCE) components age, sex, race, systolic blood pressure, total cholesterol, high-density lipoprotein, smoking status. Among patients seen both periods, change in period-specific measure prevalence was assessed. Adjusting for sociodemographic and clinical factors, compared to English-preferring White patients, all other groups were more likely to have LDL documented (2009-2013, n = 195,061) and all PCE components documented (2014-2018, n = 344,504). Among patients seen in both periods (n = 128,621), all groups had lower odds of PCE components versus LDL documented in the measures' respective period; English-preferring Black adults experienced a greater decline compared to English-preferring White adults (OR 0.81; 95% CI: 0.72-0.91). Racial/ethnic/language disparities in documented screening measures that guide statin therapy for ASCVD prevention were unaffected by a major guideline change advising this practice. It is important to understand whether the newer guidelines have altered disparate prescribing and morbidity/mortality for this disease.

Trends in the Use of Opioids vs Nonpharmacologic Treatments in Adults With Pain, 2011-2019

IMPORTANCE

Chronic pain prevalence among US adults increased between 2010 and 2019. Yet little is known about trends in the use of prescription opioids and nonpharmacologic alternatives in treating pain.

OBJECTIVES

To compare annual trends in the use of prescription opioids, nonpharmacologic alternatives, both treatments, and neither treatment; compare estimates for the annual use of acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy; and estimate the association between calendar year and pain treatment based on the severity of pain interference.

DESIGN, SETTING, AND PARTICIPANTS

A serial cross-sectional analysis was conducted using the nationally representative Medical Expenditure Panel Survey to estimate the use of outpatient services by cancer-free adults with chronic or surgical pain between calendar years 2011 and 2019. Data analysis was performed from December 29, 2021, to August 5, 2022.

EXPOSURES

Calendar year (2011-2019) was the primary exposure.

MAIN OUTCOMES AND MEASURES

The association between calendar year and mutually exclusive pain treatments (opioid vs nonpharmacologic vs both vs neither treatment) was examined. A secondary outcome was the prevalence of nonpharmacologic treatments (acupuncture, chiropractic care, massage therapy, occupational therapy, and physical therapy). All analyses were stratified by pain type.

RESULTS

Among the unweighted 46 420 respondents, 9643 (20.4% weighted) received surgery and 36 777 (79.6% weighted) did not. Weighted percentages indicated that 41.7% of the respondents were aged 45 to 64 years and 55.0% were women. There were significant trends in the use of pain treatments after adjusting for demographic factors, socioeconomic status, health conditions, and pain severity. For example, exclusive use of nonpharmacologic treatments increased in 2019 for both cohorts (chronic pain: adjusted odds ratio [aOR], 2.72; 95% CI, 2.30-3.21; surgical pain: aOR, 1.53; 95% CI, 1.13-2.08) compared with 2011. The use of neither treatment decreased in 2019 for both cohorts (chronic pain: aOR, 0.43; 95% CI, 0.37-0.49; surgical pain: aOR, 0.59; 95% CI, 0.46-0.75) compared with 2011. Among nonpharmacologic treatments, chiropractors and physical therapists were the most common licensed healthcare professionals.

CONCLUSIONS AND RELEVANCE

Among cancer-free adults with pain, the annual prevalence of nonpharmacologic pain treatments increased and the prevalent use of neither opioids nor nonpharmacologic therapy decreased for both chronic and surgical pain cohorts. These findings suggest that, although access to outpatient nonpharmacologic treatments is increasing, more severe pain interference may inhibit this access.