County-level Characteristics Research Articles

Disparities in Access to Pediatric Neurooncological Surgery in the United States

The objective of this study was to investigate whether disparities in access to high-volume centers for neurooncological care existed in the United States in 1988-2005. A retrospective analysis of the Nationwide Inpatient Sample (1988-2005) was performed, with additional factors incorporated from the Area Resource File (2006). International Classification of Diseases, Ninth Revision, diagnosis/procedure coding was used to identify patients. High-volume centers were defined as those with > or =50 neurosurgical cases per year. Patients >18 years of age were excluded. Covariates included age, gender, race, Charlson Index score, insurance, and county-level characteristics (including median home value, proportion of foreign born residents, and county neurosurgeon density). Multivariate analysis was performed by using multiple logistic regression models. P values of <.05 were considered statistically significant. A total of 4421 patients were identified; 1651 (37.34%) were admitted to high-volume centers. Overall access to high-volume centers improved slightly over the 18-year period (odds ratio [OR]: 1.04). Factors associated with greater access to high-volume centers included greater county neurosurgeon density (OR: 1.72) and greater county home value (OR: 1.66). Factors associated with worse access included Hispanic ethnicity (OR: 0.68) and each 1% increase in foreign residents per county (OR: 0.59). All reported P values were <.05. This study demonstrates that racial and socioeconomic disparities in access to high-volume neurooncological care exist for the pediatric population. We also identify numerous prehospital factors that potentially contribute to persistent disparities and may be amenable to change through national health policy interventions.

Evaluating the Strength of School Tobacco Policies: The Development of a Practical Rating System

School tobacco control policies vary widely in their strength, extensiveness, and enforcement. Currently, no standardized method exists to assess the comprehensiveness of school tobacco policies. The purpose of this study was to develop a new practical rating system for school tobacco policies, assess its reliability, and present preliminary validation data. This study presents the systematic development of a rating system to assess the strength of school tobacco policies. Based on the empirical literature and the expertise of an advisory panel consisting of educational leaders and tobacco control advocates and practitioners, a "gold standard" school tobacco policy was developed and guided the content of the 40-point rating system. The 4 domains of the School Tobacco Policy Index were: Tobacco-free environment (14 points), Enforcement (12 points), Prevention and treatment services (6 points), and Policy organization (8 points). The Index was pilot-tested using 95 Missouri public school district tobacco policies and proved to be highly reliable among coders. The evaluated policies varied greatly between school districts, with the lowest total policy score of phi and the highest score of 21. School district policy scores were significantly related to a number of county-level tobacco policy characteristics, including support for a tobacco excise tax increase. The Index is a user-friendly, practical tool for tobacco control professionals and educators, providing them with the ability to easily evaluate their own school policies. Their evaluation efforts will be useful in strengthening existing policies and developing new comprehensive policies to protect the health of students, staff, administrators, and visitors.

Tribal Linkage and Race Data Quality for American Indians in a State Cancer Registry

Racial misclassification of American Indian and Alaska Native (AI/AN) individuals as non-AI/AN in cancer registries presents problems for cancer surveillance, research, and public health practice. The aim of this study was to investigate the efficiency of tribal linkages in enhancing the quality of racial information in state cancer registries. Registry Plus Link Plus 2.0 probabilistic record linkage software was used to link the Michigan state cancer registry data (1985-2004; 1,031,168 cancer cases) to the tribal membership roster (40,340 individuals) in July of 2007. A data set was created containing AI/AN cancer cases identified by the state registry, Indian Health Service (IHS) linkages, and tribal linkage. The differences between these three groups of individuals were compared by distribution of demographic, diagnostic, and county-level characteristics using multilevel analysis (conducted in 2007-2008). From 1995 to 2004, the tribal enrollment file showed linkages to 670 cancer cases (583 individuals) and the tribal linkage led to the identification of 190 AI/AN cancer cases (168 individuals) that were classified as non-AI/AN in the registry. More than 80% of tribal members were reported as non-AI/AN to the registry. Individuals identified by IHS or tribal linkages were different from those reported to be AI/AN in terms of stage at diagnosis, tumor confirmation, and characteristics of the county of diagnosis, including contract health services availability, tribal health services availability, and proportion of AI/AN residents. The data linkage between tribal and state cancer registry data sets improved racial classification validity of AI/AN Michigan cancer cases. Assessing tribal linkages is a simple, noninvasive way to improve the accuracy of state cancer data for AI/AN populations and to generate tribe-specific cancer information.

Spatial Analysis of Rural Economic Development Using a Locally Weighted Regression Model

This study uses locally weighted regression to identify county-level characteristics that serve as drivers of creative employment throughout the southern United States. We found that higher per capita income, greater infrastructure investments, and the rural nature of a county tended to promote creative employment density, while higher scores on a natural amenity index had the opposite effect. We were also able to identify and map clusters of rural counties where the marginal effects of these variables on creative employment density were greatest. These findings should help rural communities to promote creative employment growth as a means of furthering rural economic development.

Colorectal Cancer Screening in the Elderly Population: Disparities by Dual Medicare–Medicaid Enrollment Status

To assess the disparities in colorectal cancer (CRC) screening between elderly dual Medicare-Medicaid enrollees (or duals), the most vulnerable subgroup of the Medicare population, and nonduals. The 1999 Medicare Denominator File, the Medicare Outpatient Standard Analytic Files, and Physician Supplier Part B files. In addition, the 1998 Area Resource File was used as a source for county-level attributes. CRC screening procedures for 1999-fecal occult blood test (FOBT), flexible sigmoidoscopy (FLEX), colonoscopy with FOBT and/or FLEX (COL-WFF), and colonoscopy only (COL-ONLY)-were extracted from claim records, using diagnostic and procedure codes. Duals (n = 2.5 million) and nonduals (n = 20.2 million) receiving their care through the fee-for-service system were identified from the Denominator file. Hierarchical logistic regression analysis was conducted to adjust for individual- and county-level characteristics. Compared with nonduals, duals were disproportionately represented by female, older-old, and minority individuals (respectively 74.4 versus 58.5 percent; 19.3 versus 10.8 percent; 35.7 versus 8.0 percent), and CRC screening was significantly lower in duals than in nonduals (5.1 versus 12.2 percent for FOBT adjusted odds ratio [AOR]: 0.48, 95 percent confidence interval [CI]: 0.45-0.51); 0.7 versus 1.9 percent for FLEX, (AOR: 0.55, 95 percent CI: 0.49-0.61); 0.4 versus 0.8 percent for COL-WFF (AOR: 0.60, 95 percent CI: 0.54-0.67); and 1.8 versus 2.5 percent for COL-ONLY (AOR: 0.85, 95 percent CI: 0.80-0.89); p < .001 for all comparisons. Duals are significantly less likely than nonduals to undergo CRC screening, even after adjusting for individual- and county-level covariates. Future studies should evaluate the contribution of comorbidity and low socioeconomic status to these disparities.

Predictors of Improved HbA1c Testing by Primary Care Physicians

Measurement of glycosylated hemoglobin (HbA1c) among patients with diabetes mellitus contributes to attaining control of blood glucose, which in turn is associated with fewer complications. Here, we seek to identify physician and county level characteristics that predict increased HbA1c testing among Medicare beneficiaries with diabetes who did not have testing in the baseline year. Physicians in counties with more people on Medicaid, or with fewer physicians per capita tended to have less improvement in HbA1c testing among Medicare beneficiaries over the three year study period.

Context and Healthcare Access

Although health is influenced by an individual's characteristics and choices, accumulating evidence suggests that contextual attributes may influence a variety of health outcomes. Whether these factors also represent "upstream" factors affecting one's ability to enter the healthcare system is less clear, however. The objective of this study was to assess associations between contextual characteristics and an individual's report of having a usual source of health care. Cross-sectional, survey-weighted data assessing demographics, insurance status, needs, and healthcare access were obtained through telephone survey in 1998 and were linked with county-level data from the 1998 Area Resource File and the 1990 US Census. A state-representative sample of 16,261 adult residents, living in urban, suburban, and rural settings throughout Ohio comprised this study. Operational measures for social, economic, and health system characteristics were used in multilevel logistic regression models to test associations with an individual's report of a usual source of care. The weighted proportion of individuals reporting no usual source of care was 18.0%. Although individuals' current health, insurance status, income, demographics, educational attainment, and social support were closely associated with this outcome, significant associations remained for county-level characteristics representing the level of poverty and degree of urbanization. Persisting health status disparities increase the need for programs that promote equitable access to health care. Policy interventions may be more effective if they look beyond individual characteristics to incorporate strategies that address economic factors in areas where healthcare access is inequitable.

School and County Characteristics as Predictors of School Rates of Drug, Alcohol, and Tobacco Offenses

Despite evidence that school factors are associated with differences in various types of student behavior, little research has explored the predictive utility of school factors for school-level substance offense rates. Using data from the State of Florida Department of Education and the Census, we explore the associations between school climate and school substance offense rates, controlling for county level characteristics. Results from a multilevel analysis show that school culture, school organization, and social milieu predict variation in school substance incident rate. We interpret the findings as consistent with research utilizing the "school culture/school effectiveness" model.

County characteristics and racial and ethnic disparities in the use of preventive services

Background. Studies examining predictors of preventive service utilization generally focus on individual characteristics and ignore the role of contextual variables. To help address this gap in the literature, the present study investigates whether county-level characteristics, such as racial and ethnic composition, are associated with the use of preventive services. Methods. Data from the Medical Expenditure Panel Survey and the Area Resource Files (1996–1998) are used to identify the individual- and county-level predictors of five types of preventive services ( n = 49,063). Results. County racial or ethnic composition is associated with the utilization of certain preventive services, net of individual-level characteristics. Specifically, individuals in high percent Hispanic counties are more likely to report cholesterol screenings, while those in counties with more blacks are more likely to have regular mammograms. Moreover, county racial or ethnic composition modifies the relationship between individual race or ethnicity and preventive use. In particular, Hispanic individuals who reside in high percent black counties report higher levels of utilization for most preventive services compared to Hispanics living in other counties. Conclusions. Physical and social environments are key determinants of health behaviors and outcomes. Future studies should take into account the racial or ethnic composition of an area and how this interacts with individual race or ethnicity when investigating predictors of preventive care use.

Fundamentals, Panics and Bank Distress During the Depression

This paper provides the first comprehensive econometric analysis of the causes of bank distress during the Depression. We assemble bank-level data for Fed member banks, and combine those data with county-level, state-level, and national-level economic characteristics to capture cross-sectional and inter-temporal variation in the fundamental determinants of bank failure. We find that fundamentals explain most of the incidence of bank failure, and argue that or were a relatively unimportant influence on bank failure risk prior to 1933. At the national level, we find that the first two banking crises identified by Friedman and Schwartz in 1930 and 1931 are not associated with positive unexplained residual failure risk, or with changes in the importance of liquidity measures for forecasting bank failures. The third banking crisis they identify is a more ambiguous case, but even if one views it as a bona fide liquidity crisis, the size of the contagion effect could not have been very large. The last banking crisis they identify - at the beginning of 1933 - is associated with important, unexplained increases in bank failure risk. We also investigate the potential role of regional or local contagion and illiquidity for promoting bank failure and find some evidence in support of such effects, but these are of small importance in the aggregate.

Trickle Up Political Socialization: The Impact of Kids Voting USA on Voter Turnout in Kansas

AbstractCan a school curriculum influence the political socialization of students? And if so, can such socialization “trickle up” to influence the political socialization of these students' parents? We examine the effects of Kids Voting USA in Kansas to answer these questions. By the 1996 presidential election, Kids Voting was implemented in several Kansas counties. Consequently, we are able to compare turnout—and change in turnout across different elections—in such counties with those that did not adopt the program. After controlling for a variety of county-level characteristics that are likely to affect turnout, regression analyses indicate a positive and significant contribution of Kids Voting to county turnout, and change in turnout across elections. We address the practical implications of this study and emphasize its theoretical contribution to theories of political socialization.

ENVIRONMENTAL JUSTICE, SWINE PRODUCTION AND FARM LOSS IN NORTH CAROLINA

Since the early 1990s, North Carolina has been the fastest growing swine-producing state in the country and the leading innovator in vertically integrated, industrially structured hog farming. Although the growth and concentration of swine production has been associated with a host of negative social and environmental impacts on the states air, land, and waterways, environmental justice and farm loss concerns have played a particularly key role in the evolution of the controversy in North Carolina. Using multivariate analysis of statewide census and agricultural data, we identified the county-level sociodemographic characteristics associated with farm loss between 1982 and 1997. We found that recent patterns of farm loss were more pronounced in Black communities, regardless of income, and low-income communities, regardless of race. Furthermore, counties that had greater hog industry growth in the early 1980s and had large hog populations by 1992 have suffered greater farm loss since the early 1980s than counties where the hog industry growth did not intensify until more recently. The implications of these findings with reference to an expanded environmental justice framework regarding the discriminatory impacts of swine facilities on minority and low-income rural communities are discussed.

The incentive effects of malpractice liability rules on dental practice behavior.

The impact of malpractice liability rules on dental practice behavior was estimated using data from a 1992 nationwide survey of US general dentists. The study examined the premise that malpractice liability rules can affect quality of care and related resource allocation decisions by dentists, but that market features, such as relatively complete and "non-experience rated" malpractice insurance, are likely to weaken the incentive effects of malpractice liability. General practice dentists in the United States were selected randomly, and 3,048 dentists were studied by mail survey. Secondary data on county-level characteristics were used to measure market area factors. Quality-of-care measures were derived from the survey about self-reported practice policies and behavior and participation in continuing education. Legal measures were assembled from state statutes and appellate court decisions. Ordinary least squares was used to assess the relation between legal variables and dependent variables of quality of care, continuing education, and the rate of dental output. Hypotheses about the effects of malpractice law on practice quality and participation in continuing education were not supported. The relation between pro-dentist law and output was supported. A number of legal provisions related to differences in practice behavior, but often in ways opposite to the expected direction. The direct effects of specific malpractice liability rules on dentist practice behavior often failed to point in the direction predicted by theory and were economically insignificant. It is possible that relatively complete malpractice liability insurance, coupled with "noisy" liability rules, substantially dulls the deterrent effect of malpractice liability. Other forces, such as the dentist's past malpractice claims experience, were more significant in shaping dentist behavior.

Access to Public Mental Health Services

This study examined factors that affect access to Veterans Administration mental health services. Data from national Veterans Affairs databases and the 1990 Decennial Census were used to estimate rates of Veterans Affairs mental health service use in each US county (n = 3,156) among all US veterans and in three subpopulations defined by eligibility and clinical status. Independent variables examined in standard multivariate analyses and using hierarchical linear modeling techniques included county-level sociodemographic characteristics (age, race, and income); "unmanaged" service system characteristics (those not directly controlled by Veterans Affairs program managers, eg, distance from residence to Veterans Affairs and to non-Veterans Affairs services, local supply of non-Veterans Affairs services); and "managed" service system factors (those directly controlled by Veterans Affairs program managers, eg, per capita Veterans Affairs funding level and the efficiency of Veterans Affairs service delivery). Altogether, 2.0% of US veterans used Veterans Affairs mental health services. More than one third (36%) of the variance in utilization was explained by sociodemographic factors; 8% was explained by unmanaged service system factors and 7% was explained by managed service system factors, with variations among subgroups. Substitution effects were demonstrated between Veterans Affairs and non-Veterans Affairs systems and appeared to be diagnosis-specific. Both per capita funding levels and efficient service delivery were significantly associated with increased access to mental health services. Implications for health system performance assessment and management are discussed.

The Association Between Environmental Risk and Internal Migration Flows

Over the past several decades, the environmental awareness and concern of the American public has greatly increased. This concern is reflected, for example, in public opinion polls, participation in curbside recycling programs and community mobilization against the siting of environmentally-hazardous facilities. This study examines the possibility that such concern is also reflected by internal migration patterns. More specifically, this research considers the relationship between county-level environmental characteristics and in- and outmigration streams. The results suggest that counties with environmental hazards such as air and water pollution, hazardous waste and Superfund sites do not lose residents at greater rates than areas without such hazards. However, areas with such risks gain relatively fewer new residents.

Physicians Who Move and Why They Move

Physicians in the United States migrate across county lines more often than nonphysicians, but their migration parallels that of the population at large: from the northern "Frost Belt" to the southern "Sun Belt." The data presented herein show that mobile physicians ("movers") are more often younger and female than nonmobile physicians ("stayers"). Stayers are more likely to be primary care of self-employed physicians, and movers more often are in nonprimary care or in medical administration, research, teaching, or other medical employment modalities. County-level characteristics such as population income and size also help determine whether a physician will be a mover or stayer.

Physicians who move and why they move

Physicians in the United States migrate across county lines more often than nonphysicians, but their migration parallels that of the population at large: from the northern "Frost Belt" to the southern "Sun Belt." The data presented herein show that mobile physicians ("movers") are more often younger and female than nonmobile physicians ("stayers"). Stayers are more likely to be primary care or self-employed physicians, and movers more often are in nonprimary care or in medical administration, research, teaching, or other medical employment modalities. County-level characteristics such as population income and size also help determine whether a physician will be a mover or stayer. (<i>JAMA</i>1982;248:1490-1492)