California Residents Research Articles

Assembly of the LongSHOT cohort: public record linkage on a grand scale

BackgroundVirtually all existing evidence linking access to firearms to elevated risks of mortality and morbidity comes from ecological and case–control studies. To improve understanding of the health risks and benefits...

California Launches Nation’s First Earthquake Early Warning System

The country’s first publicly available, statewide warning system could give California residents seconds to duck and cover before a quake.

Behavioral Response to State Income Taxation of High Earners: Evidence from California

In November 2012, California voters passed increases to state marginal income tax rates of 1 to 3 percentage points for upper-income households. Drawing on the universe of California income tax filings, we present new findings about the effects of personal income taxation on household location choice and pre-tax income. First, over and above baseline rates of taxpayer departure from California, an additional 0.8% of the California residential tax filing base whose 2012 income would have been in the new 12.3% top tax bracket were no longer full year residents of California in 2013. Second, to identify the impact of the California tax policy shift on the pre-tax earnings of high-income California residents, we use as a control group high-earning out-of-state taxpayers who persistently file as California non-residents. Using a differences-in-differences strategy paired with propensity score matching, we estimate a substantial intensive margin response which begins in 2012 amongst California top-bracket taxpayers. Our estimates imply an intensive margin elasticity of income with respect to the marginal net-of-tax rate of 2.5 to 3.2. Among top-bracket California taxpayers, outward migration and behavioral responses by stayers together eroded 45.2% of the windfall tax revenues from the reform within the first year and 60.9% within two years, with the extensive margin accounting for 9.5% of this total response.

California Takes the Lead on Data Privacy Law.

In the early 1970s, Congress considered enacting comprehensive privacy legislation, but it was unable to do so. In 1974, it passed the Privacy Act, applicable only to information in the possession of the federal government. In the intervening years, other information privacy laws enacted by Congress, such as the Health Insurance Portability and Accountability Act, have been weak and sector specific. With the explosion of information technology and the growing concerns about an absence of effective federal privacy laws, the legal focus has shifted to the states. Signaling a new direction in state data privacy and consumer protection law, the California Consumer Privacy Act establishes important rights and protections for California residents with regard to the collection, use, disclosure, and sale of their personal information. The CCPA is certain to spur similar legislation and to affect national and international businesses that collect data from California's residents. Understanding the new law is important for all data-driven industries, including health care.

Defining Value for Pancreatic Surgery in Early-Stage Pancreatic Cancer

Value-based care is increasingly important, with rising health care costs and advances in cancer treatment leading to greater survival for patients with cancer. Regionalization of surgical care for pancreatic cancer has been extensively studied as a strategy to improve perioperative outcomes, but investigation of long-term outcomes relative to health care costs (ie, value) is lacking. To identify patient and hospital characteristics associated with improved overall survival, decreased costs, and greater value among patients with pancreatic cancer undergoing curative resection. This retrospective cohort study identified 2786 patients with stages I to II pancreatic cancer who underwent pancreatic resection at 157 hospitals from January 1, 2004, through December 31, 2012. The study used the California Cancer Registry, which collects data from all California residents newly diagnosed with cancer, linked to the Office of Statewide Health Planning and Development database, which collects administrative data from all California licensed hospitals. Data were analyzed from November 11, 2017, through September 4, 2018. Pancreatic resection at high-volume and/or National Cancer Institute (NCI)-designated cancer centers. The primary outcomes were overall survival, surgical hospitalization costs, and value. High value was defined as the fourth quintile or higher for survival and the second quintile or less for costs. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation and inflation. Multivariable regression models were used to determine factors associated with overall survival, costs, and high value. Among the 2786 patients included (1394 [50.0%] male; mean [SD] age, 67.0 [10.7] years), postoperative chemotherapy (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.64-0.79; P < .001) and high-volume centers (aHR, 0.78; 95% CI, 0.61-0.99; P = .04) were associated with greater overall survival. Higher Elixhauser comorbidity index scores (estimate, 0.006; 95% CI, 0.003-0.008), complications (estimate, 0.22; 95% CI, 0.17-0.27), readmissions (estimate, 0.34; 95% CI, 0.29-0.39), and longer lengths of stay (estimate, 0.03; 95% CI, 0.03-0.04) were associated with higher costs (P < .001), whereas postoperative chemotherapy was associated with lower costs (estimate, -0.06; 95% CI, -0.11 to -0.02; P = .006). National Cancer Institute-designated and high-volume centers were not associated with costs. Although grades III and IV tumors (odds ratio [OR], 0.65; 95% CI, 0.39-0.91; P = .001), T3 category disease (OR, 0.71; 95% CI, 0.46-0.95; P = .005), complications (OR, 0.68; 95% CI, 0.49-0.86; P < .001), readmissions (OR, 0.64; 95% CI, 0.44-0.84; P < .001), and length of stay (OR, 0.82; 95% CI, 0.78-0.85; P < .001) were inversely associated with high-value care, NCI designation (OR, 1.07; 95% CI, 0.66-1.49; P = .74) and high-volume centers (OR, 1.08; 95% CI, 0.54-1.61; P = .07) were not. In this study, high-value care was associated with important patient characteristics and postoperative outcomes. However, NCI-designated and high-volume centers were not associated with greater value. These data suggest that targeted measures to enhance value may be needed in these centers.

Perspectives of the Property Tax Forty Years after Proposition 13

We use results from the December 2016 CalSpeaks Survey to assess citizen understanding about how the property tax functions and the distributional impact of the tax. Key issues include (1) do California citizens today understand the provisions of Proposition 13 and the implications for how the property tax operates in California, and (2) given that knowledge, what is the perspective of California residents about the income incidence (progressivity) of the property tax. The survey results reveal weak current understanding of the tax rate limitations of Proposition 13 and a resulting overestimate of actual property tax payments. Only about one third of residents believe that the property tax is progressive (i.e. a greater percentage of income for a typical high-income person), with robust evidence that greater knowledge of the basic elements of Proposition 13 (fixed rate and method of assessment) increases the likelihood of belief that the property is progressive.

Variations in Costs of a Collaborative Care Model for Dementia.

Care coordination programs can improve patient outcomes and decrease healthcare expenditures; however, implementation costs are poorly understood. We evaluate the direct costs of implementing a collaborative dementia care program. We applied a micro-costing analysis to calculate operational costs per-participant-month between March 2015 and May 2017. The University of California, San Francisco (UCSF) and the University of Nebraska Medical Center (UNMC). Participants diagnosed with dementia, enrolled in Medicare or Medicaid, 45 years of age or older, residents of California, Nebraska or Iowa, and having a caregiver. The sample was 272 (UCSF) and 192 (UNMC) participants. A collaborative dementia care program provided by care team navigators (CTNs), advanced practice nurses, a social worker, and a pharmacist, focusing on caregiver support and education, medications, advance care planning, and behavior symptom management. We measured costs (personnel, supplies, equipment, and training costs) during three program periods, Start-up, Early Operations, and Continuing Operations, and estimated the effects of caseload variation on costs. Start-up and Early Operations costs were, respectively, $581 and $328 (California), and $501 and $219 (Nebraska) per-participant-month. Average costs decreased across phases to $241 (California) and $142 (Nebraska) per-participant-month during Continuing Operations. We estimated that costs would range between $75 (UNMC) and $92 (UCSF) per-participant-month with the highest projected caseloads (90). We found that CTN caseload is an important driver of service cost. We provide strategies for maximizing caseload without sacrificing quality of care. We also discuss current barriers to broad implementation that can inform new reimbursement policies. J Am Geriatr Soc 67:2628-2633, 2019.

Foodborne Botulism Outbreak Associated With Commercial Nacho Cheese Sauce From a Gas Station Market.

Botulism is a rare and potentially fatal paralytic disease caused by botulinum neurotoxin (BoNT). In April 2017, 4 California residents from 2 adjacent counties were hospitalized with suspected foodborne botulism, precipitating an investigation by state and local public health departments in California. We interviewed suspected botulism patients and their families, inspected the suspect establishment, and collected suspect food. We tested patient sera, stool, and gastric aspirates using mouse bioassay for BoNT and/or culture for Clostridium botulinum. We tested suspect food and environmental samples for BoNT and confirmed presumptive positives using direct mouse bioassay and culture. We performed whole-genome sequencing on food and clinical isolates. From April 2017 through May 2017, 10 patients in the Sacramento area were hospitalized with laboratory-confirmed botulism; 7 required mechanical ventilation, and 1 died. Of 9 patients with information, all had visited Gas Station X before illness onset, where 8 reported consuming a commercial cheese sauce. BoNT/A and/or BoNT/A-producing C. botulinum were detected from each patient and from leftover cheese sauce. Clostridium botulinum isolates from 4 patients were closely related to cheese sauce isolates by whole-genome high-quality single-nucleotide polymorphism analysis. No other botulism cases associated with this cheese sauce were reported elsewhere in the United States. This large foodborne botulism outbreak in California was caused by consumption of commercial cheese sauce dispensed at a gas station market. The epidemiologic and laboratory evidence confirmed the cheese sauce as the outbreak source. The cheese sauce was likely locally contaminated, although the mechanism is unclear.

Using the CA Opioid Overdose Surveillance Dashboard to track opioid overdose deaths

Using the CA Opioid Overdose Surveillance Dashboard to track opioid overdose deaths

Characterizing sources and emissions of volatile organic compounds in a northern California residence using space- and time-resolved measurements.

We investigate source characteristics and emission dynamics of volatile organic compounds (VOCs) in a single-family house in California utilizing time- and space-resolved measurements. About 200 VOC signals, corresponding to more than 200 species, were measured during 8weeks in summer and five in winter. Spatially resolved measurements, along with tracer data, reveal that VOCs in the living space were mainly emitted directly into that space, with minor contributions from the crawlspace, attic, or outdoors. Time-resolved measurements in the living space exhibited baseline levels far above outdoor levels for most VOCs; many compounds also displayed patterns of intermittent short-term enhancements (spikes) well above the indoor baseline. Compounds were categorized as "high-baseline" or "spike-dominated" based on indoor-to-outdoor concentration ratio and indoor mean-to-median ratio. Short-term spikes were associated with occupants and their activities, especially cooking. High-baseline compounds indicate continuous indoor emissions from building materials and furnishings. Indoor emission rates for high-baseline species, quantified with 2-hour resolution, exhibited strong temperature dependence and were affected by air-change rates. Decomposition of wooden building materials is suggested as a major source for acetic acid, formic acid, and methanol, which together accounted for ~75% of the total continuous indoor emissions of high-baseline species.

Relaxing the No Liars Assumption in List Experiment Analyses

The analysis of list experiments depends on two assumptions, known as “no design effect” and “no liars”. The no liars assumption is strong and may fail in many list experiments. I relax the no liars assumption in this paper, and develop a method to provide bounds for the prevalence of sensitive behaviors or attitudes under a weaker behavioral assumption about respondents’ truthfulness toward the sensitive item. I apply the method to a list experiment on the anti-immigration attitudes of California residents and on a broad set of existing list experiment datasets. The prevalence of different items and the correlation structure among items on the list jointly determine the width of the bound estimates. In particular, the bounds tend to be narrower when the list consists of items of the same category, such as multiple groups or organizations, different corporate activities, and various considerations for politician decision-making. My paper illustrates when the full power of the no liars assumption is most needed to pin down the prevalence of the sensitive behavior or attitude, and facilitates estimation of the prevalence robust to violations of the no liars assumption for many list experiment applications.

Prevalence and Correlates of Simultaneous and Separate 30-Day Use of Tobacco and Cannabis: Results from the California Adult Tobacco Survey

Background: There is limited information on separate use and simultaneous use of tobacco and cannabis products, particularly for new electronic nicotine delivery systems (ENDS). This study presents detailed information about the prevalence and correlates of individual use, separate use, and simultaneous use of tobacco and cannabis in California, the first state to allow medical marijuana in the US. It specifically distinguishes between simultaneous use (both substances used in the same occasion) and separate use (both products used, but not simultaneously). Objectives: Participants in the 2016 California Adult Tobacco Survey (N = 3,058; age range 18–64 years) completed online surveys between February and March 2016 that assessed tobacco and cannabis use in the past 30 days. Results: Participants’ use of tobacco (15% cigarettes) was higher than use of ENDS (6%) or cannabis (10%); the overall rate of separate use was 6% and the overall rate of simultaneous use was 3%. Correlates of tobacco use included lower levels of education and income. Correlates of simultaneous tobacco and cannabis use included being unemployed or having a disability. Conclusions/Importance: This survey of California residents suggests how use patterns change in states that legalize medical marijuana prior to recreational cannabis, although it may underestimate prevalence due to reliance on self-reported use. Persons who were unemployed and persons with disabilities were at higher risk for simultaneous use of tobacco and cannabis. These findings suggest that prevention and cessation interventions intended to target simultaneous use should address these populations, as well as adolescents and young adults.

Towards sustainable water management: Preferences and willingness to pay for smart landscape irrigation technologies

Urbanization trends, leading to growing irrigated residential landscapes continue to escalate concerns on surface, ground, and drinking water quantity and quality among environmental groups and regulatory agencies. While automated lawn irrigation systems established in urban areas are critical factors affecting water quantity and quality, homeowners’ water use may vary with their preferences for lawn irrigation systems. The choice of an irrigation system is not determined only by local restrictions or policies but also by homeowners’ preferences. Further, individuals’ preferences can be influenced by the availability of product-specific attributes such as evapotranspiration or soil-moisture based controllers (known as smart irrigation controllers). With a focus on single-family home residents in California, Florida, and Texas, the present study uses the discrete choice analysis framework to link smart irrigation attributes (e.g., sensor types, wireless operation, remote control, alert notification) and monetary incentives (e.g., annual water bill savings, rebates) to preferences and willingness-to-pay. Results indicate that homeowners prefer smart irrigation controllers to conventional automated systems, and that savings on annual water bills could be one of the most important features determining adoption of smart irrigation controllers. Controller features such as the type of operation (i.e., wireless/on-site weather station) and system malfunction alert/notification also impacted homeowners’ preferences. The findings provide practical insights into the promotion of smart irrigation controllers that can be integrated with educational campaigns, or advertisements highlighting benefits of smart irrigation technologies. Clearer understanding about homeowners’ preferences could serve as a feedback loop for policy makers and improve water policies at state and local levels.

Perceived Importance of Climate Change Adaptation and Mitigation According to Social and Medical Factors Among Residents of Impacted Communities in the United States.

Purpose: To determine whether perceived importance of local climate change adaptation and mitigation efforts differs according to social or medical factors among residents of impacted communities.Methods: An online survey was conducted among residents of California (Los Angeles/Orange), Florida (Miami-Dade/Broward), and Arizona (Maricopa) counties in July 2018 (n=605). Multivariable ordered logistic regression measured associations between the perceived importance of adaptation/mitigation approaches and income, race/ethnicity, and health conditions, controlling for age, political party, and county.Results: Lower income was associated with higher perceived importance of improved emergency alerts, government-subsidized costs of household air conditioners and energy-efficient appliances, strengthening buildings against extreme weather, regulation of greenhouse gas emissions, urban planning using “cooling” technologies, and expanding community gardens/local agriculture. Black respondents perceived evacuation services for those with financial barriers during extreme weather, government-subsidized costs of energy-efficient appliances, and communication from government agencies about local climate impacts and mitigation as significantly more important compared to non-Black, non-Hispanic respondents. Hispanic respondents perceived significantly greater importance of improved emergency alerts and health care access during extreme weather, evacuation services for residents without transportation, government-subsidized costs of energy-efficient appliances, regulation of greenhouse gas emissions, communication from government agencies about local climate impacts and mitigation efforts, and intergovernmental cooperation on mitigation compared to non-Hispanic respondents.Conclusions: Perceptions of the importance of specific local climate actions differ according to race/ethnicity and income. Community engagement is recommended to help local decisions reflect priorities of the most affected residents.

Associations between provider communication and personal recovery outcomes

BackgroundThis study examined whether two types of provider communication considered important to quality of care (i.e., shows respect and explains understandably) are associated with mental health outcomes related to personal recovery (i.e., connectedness, hope, internalized stigma, life satisfaction, and empowerment). This study also tested whether these associations varied by the type of provider seen (i.e., mental health professional versus general medical doctor).MethodsThis sample included participants from the 2014 California Well-Being Survey, a representative survey of California residents with probable mental illness, who had recently obtained mental health services (N = 429). Multiple regression was used to test associations between provider communication and personal recovery outcomes and whether these associations were modified by provider type.ResultsProviders showing respect was associated with better outcomes across all five of the personal recovery domains, connectedness (β = 1.12; p < .001), hope (β = 0.72; p < .0001), empowerment (β = 0.38; p < .05), life satisfaction (β = 1.10; p < .001) and internalized stigma (β = − 0.49; p < .05). Associations between provider showing respect and recovery outcomes were stronger among those who had seen a mental health professional only versus a general medical doctor only.ConclusionsRespectful communication may result in greater personal recovery from mental health problems. Respecting consumer perspectives is a hallmark feature of both recovery-oriented services and quality care, yet these fields have operated independently of one another. Greater integration between these two areas could significantly improve recovery-oriented mental health outcomes and quality of care.

Abstract WMP97: Racial/Ethnic Disparities in the Risk of Intracerebral Hemorrhage Recurrence

Background: Race/ethnicity is associated with risk of first-ever spontaneous intracerebral hemorrhage (ICH), but the influence of race/ethnicity on risk of ICH recurrence has not been well studied in a large, diverse population. Methods: We used claims data on all discharges from community hospital inpatient stays in California between January 1, 2005 and December 31, 2011 to identify patients who were hospitalized for ICH. California residents who survived to discharge were included. We used validated diagnosis codes to identify a primary outcome of recurrent ICH. We then used survival curves and log-rank tests for unadjusted analyses of survival across race/ethnic groups and multivariable Cox proportional-hazards regression to determine factors associated with risk of ICH recurrence after adjusting for potential confounders. Results: Between 2005-2011, we identified 31,554 first-ever ICH patients who survived to discharge, of which 15,828 (50%) were white, 6,254 (20%) Hispanic, 4,268 (14%) Asian, and 2,820 (9%) black. There were 1339 recurrences (4.2%) over a median follow-up time of 2.9 years (IQR 3.8). The 1-year recurrence rate was 3.0% (95% CI 2.8%-3.2%). In univariable and multivariable analysis, blacks (HR 1.22, 95% CI 1.01-1.48; p=0.035) and Asians (HR 1.29, 95% CI 1.10-1.50; p=0.001) had a higher risk of ICH recurrence than whites (reference categories). Private insurance was associated with a significant reduction in the risk of ICH recurrence compared to subjects with Medicare (HR 0.60, 95% CI 0.50-0.73, p&lt;0.001), with consistent estimates across race/ethnic groups. Conclusions: Black and Asian subjects had a higher risk of ICH recurrence than white or Hispanic subjects. Further research is needed to determine drivers of these disparities.

Distributing the Green (Cards): Permanent residency and personal income taxes after the Immigration Reform and Control Act of 1986

We explore how permanent residency affects personal income tax participation and net personal income tax payments using variation from the Immigration Reform and Control Act of 1986 (IRCA), which authorized the largest U.S. amnesty to date. We exploit the timing and geographic unevenness of IRCA's legalization programs alongside newly digitized data on personal income taxes in California, home to the majority of applicants. Green Cards induced the previously unauthorized to file state income tax returns at rates comparable to other California residents. While the new returns generated little additional revenue through the end of the 1990s, they did raise the incomes of families with children through new claims of the federal Earned Income Tax Credit.

The Effect of Sentencing Reform on Racial and Ethnic Disparities in Involvement with the Criminal Justice System: The Case of California's Proposition 47

We analyze the disparate effects of a recent California sentencing reform on the arrest, booking, and incarceration rates experienced by California residents from different racial and ethnic groups. In November 2014 California voters passed state proposition 47 that redefined a series of felony and wobbler offenses (offenses that can be charged as either a felony or misdemeanor) as straight misdemeanors, causing an immediate 15 percent decline in total drug arrests, an approximate 20 percent decline in total property crime arrests, and shifts in the composition of arrests away from felonies towards misdemeanors.Using microdata on the universe of arrests in the state in conjunction with demographic data from the American Community Survey, we document a substantial narrowing in inter-racial differences in overall arrest rates and arrest rates by offense type, with very large declines in the inter-racial arrest rate gaps for felony drug offenses. Conditional on being arrested, we see declines in bookings rates for all groups, though we find a larger decrease for white arrestees.This relatively larger decline for white arrests is largely explained by difference in the distribution of arrests across recorded offenses. Despite the widening of racial gaps in the conditional booking rate, we observe substantial declines in overall booked arrests that are larger for African Americans and Hispanics relative to whites. For some offenses (felony drug offenses), inter-racial disparities in jail booking rates narrow by nearly half.Finally, we use data from the American Community Survey to analyze change in the proportion incarcerated on any given day and how these changes vary by race and ethnicity. For these results, we present trends for the time period spanning the larger set of policy reforms that have been implemented in the state since 2011. We observe sizable declines in the overall incarceration rate for African Americans, with the largest declines observed for African America males. The one-quarter decline in total correctional populations in the state coincided with sizable narrowing in inter-racial difference in incarceration rates.

Slowdown in the Decline of Tuberculosis Rates in California, 2000-2016.

To determine the impact of the 2007-2009 economic crisis on tuberculosis (TB) trends among California residents. We analyzed available data from 4 different population-representative data sets. We used time charts, trend lines, and change-point detection tests during 2000 to 2016 to describe TB trends in California. We found statistically significant changes in California TB trends with the time of the onset of the economic downturn based on age-adjusted TB case rates and TB mortality rates, crude rate of TB hospitalizations, and self-reported TB. Change on TB incidence was especially apparent among racial/ethnic minority groups. To our knowledge, changes in TB trends in the United States matching in time with the 2007-2009 economic crisis have not been previously reported. This study identified a slowdown in the decline of TB rates by 2007 to 2009 and provides new knowledge on TB trends that can be used to achieve California's goal of eliminating TB by 2040 and in the prevention and control of TB in the United States.

Rice Drain Management to Reduce Seepage Exports in the Sacramento-San Joaquin Delta, California.

Many deltas worldwide face subsidence issues due to increased anthropogenic activity. The Sacramento-San Joaquin delta similarly faces ongoing subsidence, more than 8 m in some areas, that increases levee failure risks and threatens the security of this water source for 25 million California residents and 1.2 million ha of agriculture. Rice ( L.) fields are an integral part of a proposed new strategy for managing subsidence because they have been shown to stop subsidence and provide an alternative crop for growers. Two important considerations for implementing rice fields are additional water requirement and the effect on water quality from mobilized dissolved organic carbon (DOC) and disinfection byproduct precursors. To understand constituent transport and potential management opportunities for rice farming, a plug flow reactor mass balance model was used to quantify surface and subsurface hydrologic pathways. Management of adjacent drainage ditch water levels under low and high scenarios were tested as a strategy to reduce seepage and water quality loads. Under high drains, groundwater met 10% of evapotranspiration (ET). Low drains resulted in a 100% increase in ET demand, which was met by surface water applied for irrigation. High drains reduced subsurface seepage by 95%. Subsurface DOC, trihalomethane, and total dissolved nitrogen loads were reduced 10-fold in high drains compared with low drains. Flow rate accounted for 74 to 90% of load variance and was the primary determinant of constituent loads. Thoughtful implementation of rice cultivation, with high water levels in adjacent drains, can be leveraged to reduce irrigation water demand and constituent load outputs.