Geographic Variation In Rates Research Articles

Bayesian spatial mapping of rates of substance use among high-school students in Florida

ABSTRACT Objective In adolescent substance use research, more work has been done in identifying risk factors at individual level while little work was done at community level. The objective of this study is to examine the possible risk factors associated with substance use by high-school students at county level. Methods Data on the percentages of county-level substance use by adolescents and county-level risk factors were obtained from the Florida Department of Health, Division of Public Health Statistics & Performance Management (DPHSM). Spatial beta models were used to examine the associations between risk factors and rates of substance use. Results Geographic variation in rates of substance use by adolescents was observed in Florida, ranging from 6.5% to 28.6% for drug use, and from 14.8% to 36.3% for alcohol. It was found that percentages of black population and individual below poverty level were inversely associated with rates of drug use by adolescents. There were no significant associations between percentages of drug use by adolescents and median income, adult drug use, school suspension, and student emotional/behavioral disability per county. Conclusion Interventions for reducing rates of adolescent substance use may focus on involving parents to monitor financial resources for their children.

US County–Level Variation in Preterm Birth Rates, 2007-2019

Preterm birth is a leading cause of preventable neonatal morbidity and mortality. Preterm birth rates at the national level may mask important geographic variation in rates and trends at the county level. To estimate age-standardized preterm birth rates by US county from 2007 to 2019. This serial cross-sectional study used data from the National Center for Health Statistics composed of all live births in the US between 2007 and 2019. Data analyses were performed between March 22, 2022, and September 29, 2022. Age-standardized preterm birth (<37 weeks' gestation) and secondarily early preterm birth (<34 weeks' gestation) rates by county and year calculated with a validated small area estimation model (hierarchical bayesian spatiotemporal model) and percent change in preterm birth rates using log-linear regression models. Between 2007 and 2019, there were 51 044 482 live births in 2383 counties. In 2007, the national age-standardized preterm birth rate was 12.6 (95% CI, 12.6-12.7) per 100 live births. Preterm birth rates varied significantly among counties, with an absolute difference between the 90th and 10th percentile counties of 6.4 (95% CI, 6.2-6.7). The gap between the highest and lowest counties for preterm births was 20.7 per 100 live births in 2007. Several counties in the Southeast consistently had the highest preterm birth rates compared with counties in California and New England, which had the lowest preterm birth rates. Although there was no statistically significant change in preterm birth rates between 2007 and 2019 at the national level (percent change, -5.0%; 95% CI, -10.7% to 0.9%), increases occurred in 15.4% (95% CI, 14.1%-16.9%) of counties. The absolute and relative geographic inequalities were similar across all maternal age groups. Higher quartile of the Social Vulnerability Index was associated with higher preterm birth rates (quartile 4 vs quartile 1 risk ratio, 1.34; 95% CI, 1.31-1.36), which persisted across the study period. Similar patterns were observed for early preterm birth rates. In this serial cross-sectional study of county-level preterm and early preterm birth rates, substantial geographic disparities were observed, which were associated with place-based social disadvantage. Stability in aggregated rates of preterm birth at the national level masked increases in nearly 1 in 6 counties between 2007 and 2019.

Abstract IA009: Curios case of cancer among American Indians and Alaska Natives

Abstract Cancer incidence data published in 2008, and cancer mortality data published in 2014, both paint a picture of profound geographic variation in these rates among American Indians/Alaska Natives. Non-Hispanic whites (NHWs) living across six large geographic regions upon which both datasets were analyzed rarely exhibited geographic variation greater than 25%, with an upper limit approaching 30%. This is in distinct contrast to the AIAN population living in the same regions, who routinely exhibited geographic variation in cancer incidence rates ranging over 100% and from some cancer types in excess of 500%. These data will be shown, and subsequent consequences future priorities discussed. By the conclusion of this presentation, attendees will Gain more valuable insight about the federal Indian Health Service Be delighted to see that they can understand raw cancer data including multiple lessons regarding the profound geographic variation in AIAN cancer incidence rates Identify how they may get involved with those of us who are focused on these AIAN cancer disparities. Citation Format: Jeffrey A. Henderson. Curios case of cancer among American Indians and Alaska Natives [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr IA009.

Chronic Hepatitis B Virus Infection and Risk of Stroke Types: A Prospective Cohort Study of 500 000 Chinese Adults.

Stroke is a leading cause of mortality and permanent disability in China, with large and unexplained geographic variations in rates of different stroke types. Chronic hepatitis B virus infection is prevalent among Chinese adults and may play a role in stroke cause. The prospective China Kadoorie Biobank included >500 000 adults aged 30 to 79 years who were recruited from 10 (5 urban and 5 rural) geographically diverse areas of China from 2004 to 2008, with determination of hepatitis B surface antigen (HBsAg) positivity at baseline. During 11 years of follow-up, a total of 59 117 incident stroke cases occurred, including 11 318 intracerebral hemorrhage (ICH), 49 971 ischemic stroke, 995 subarachnoid hemorrhage, and 3036 other/unspecified stroke. Cox regression models were used to estimate adjusted hazard ratios (HRs) for risk of stroke types associated with HBsAg positivity. In a subset of 17 833 participants, liver enzymes and lipids levels were measured and compared by HBsAg status. Overall, 3.0% of participants were positive for HBsAg. HBsAg positivity was associated with an increased risk of ICH (adjusted HR, 1.29 [95% CI, 1.16-1.44]), similarly for fatal (n=5982; adjusted HR, 1.36 [95% CI, 1.16-1.59]) and nonfatal (n=5336; adjusted HR, 1.23 [95% CI, 1.06-1.44]) ICH. There were no significant associations of HBsAg positivity with risks of ischemic stroke (adjusted HR, 0.97 [95% CI, 0.92-1.03]), subarachnoid hemorrhage (adjusted HR, 0.87 [95% CI, 0.57-1.33]), or other/unspecified stroke (adjusted HR, 1.12 [95% CI, 0.89-1.42]). Compared with HBsAg-negative counterparts, HBsAg-positive individuals had lower lipid and albumin levels and higher liver enzyme levels. After adjustment for liver enzymes and albumin, the association with ICH from HBsAg positivity attenuated to 1.15 (0.90-1.48), suggesting possible mediation by abnormal liver function. Among Chinese adults, chronic hepatitis B virus infection is associated with an increased risk of ICH but not other stroke types, which may be mediated through liver dysfunction and altered lipid metabolism.

Assessing Geographic Variation in Rates of Cervical Cancer and Recurrent or Metastatic Cervical Cancer Among Medicaid Enrollees.

The objective of this study was to evaluate trends in prevalence of cervical cancer (CC) and rates of recurrent or metastatic cervical cancer (r/mCC) treatment initiation at the state and metropolitan statistical area (MSA) levels among Medicaid enrolled females from 2016 to 2019. Retrospective analyses of nationwide Medicaid claims data were used to identify adult CC and r/mCC patients from 2016 to 2019. CC prevalence was estimated as the proportion of females diagnosed with CC out of all adult female Medicaid beneficiaries, and r/mCC by the proportion of CC patients who initiated a systemic treatment not associated with surgery or radiation to the number of enrollees with CC diagnosis in each state or MSA. Overall and annual rates were calculated for each state and MSA from 2016 to 2019. The analytic cohort included 70,865 adult female Medicaid beneficiaries with CC from 2016 to 2019, among whom 3375 were identified as r/mCC patients. Nationwide annual prevalence of CC remained relatively stable from 2016 to 2019, while r/mCC decreased slightly over the study period. Several MSAs experienced increasing rates of r/mCC from 2016 to 2019, including Mayaguez, PR, Aguadeilla-Isabela, PR, and Green Bay, WI. Claims data demonstrate areas in the United States with disproportionately high or increasing CC or r/mCC burden, indicating a potential gap in preventative care for females and an unmet need for education and health care resource allocation. Future research should evaluate associations between community-level factors and r/mCC burden.

Geografisk variasjon i vaksnes bruk av avtalespesialistar og DPS i psykisk helsevern

Background: Equitable mental healthcare regardless of area of residence is a political aim in Norway. The purpose of this study is to evaluate geographical variation in private practitioner coverage, and explore differences between private practitioners with public reimbursement and local community mental health centers (CMHCs) in terms of diagnoses and scope of outpatient treatment, with a focus on mood and neurotic disorders. Method: Cross-sectional registry-based study of adults in outpatient mental healthcare at private practitioners or CMHCs in Norway in 2014–2018. We calculated distribution of diagnoses, geographical variation in rates of private practitioners, and analyzed scope of treatment for patients with mood and neurotic disorders (ICD-10 disorders F3, F4). We estimate cost per treated patient and report geographic variation for hospital catchment areas. Results: Patients with F3, F4 disorders accounted for 64.7 % at private practitioners, and 31.5 % at CMHCs, and received more treatment at private practitioners, five more consultations in a 42 day longer period. There is considerable geographical variation in private practitioner coverage, highest in South-East Norway and lowest in North Norway. Implications: As long as management and priority setting are differently organized for CMHCs and private practitioners in mental health care, we must expect geographical variation in access and use. It appears as an equity paradox that a group of patients, rejected by or not referred to CMHC, receive more treatment by private practitioners. Keywords: mental healthcare, outpatient consultations, private practitioners, CMHC, geographical variation, equal access, equity, priority setting

Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction

IntroductionVariation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. Materials and methodsA retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. ResultsTwo thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1–9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1–0.5). The volume of operations performed within a state did not influence readmission. ConclusionsSurgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.

Incidence of circumcision among insured adults in the United States.

PurposeAlthough circumcision is the most commonly performed surgery in males, less is known about the incidence and indications of adult circumcision. In this study, we aim to present the incidence of adult circumcision across the United States.MethodsUsing IBM MarketScan® Commercial Database from 2015 to 2018, we obtained claims for circumcision in men between 18 and 64 years of age. We calculated the incidence of adult circumcision over the study period and across the United States. We also collected data on indications for surgery using International Classification of Diseases codes.ResultsWe identified a total of 12,298 claims for adult circumcisions. The mean age was 39 (±12.9) years. The average incidence rates remained relatively constant from 98.1 per 100,000 person-years in 2015 to 98.2 per 100,000 person-years in 2018 (Δ+0.1%). The age-standardized incidence rates varied significantly across the United States (from 0 to 194.8 per 100,000 person-years) with South Dakota having the highest rate. The most common indications for adult circumcision were phimosis (52.5%), routine/ritual circumcision (28.7%), phimosis + balanitis/balanoposthitis (6.8%), balanitis (3.8%) and balanoposthitis (2.6%), and significantly varied by age groups.ConclusionThis study suggested a wide geographic variation in rates of adult circumcision between states with highest incidences in the Northeast United States. Future studies can identify the underlying causes for the observed variations.

Determinants of accident and emergency attendances and emergency admissions in infants: birth cohort study

BackgroundThere is limited understanding of the drivers of increasing infant accident and emergency (A&E) attendances and emergency hospital admissions across England. We examine variations in use of emergency hospital services among infants by local areas in England and investigate the extent to which infant and socio-economic factors explain these variations.MethodsBirth cohort study using linked administrative Hospital Episode Statistics data in England. Singleton live births between 1-April-2012 and 31-March-2019 were followed up for 1 year; from 1-April-2013 (from the discharge date of their birth admission) until their first birthday, death or 31-March-2019.Mixed effects negative binomial models were used to calculate incidence rate ratios for A&E attendances and emergency admissions and mixed effects logistic regression models estimated odds ratio of conversion (the proportion of infants subsequently admitted after attending A&E). Models were adjusted for individual-level factors and included a random effect for local authority (LA).ResultsThe cohort comprised 3,665,414 births in 150 English LAs. Rates of A&E attendances and emergency admissions were highest amongst: infants born < 32 weeks gestation; with presence of congenital anomaly; and to mothers < 20-years-old. Area-level deprivation was positively associated with A&E attendance rates, but not associated with conversion probability. A&E attendance rates were highest in the North East (916 per 1000 child-years, 95%CI: 911 to 921) and London (876 per 1000, 95%CI: 874 to 879), yet London had the lowest emergency admission rates (232 per 1000, 95%CI: 231 to 234) and conversion probability (25% vs 39% in South West). Adjusting for individual-level factors did not significantly affect variability in A&E attendance and emergency admission rates by local authority.ConclusionsDrivers of A&E attendances and emergency admissions include individual-level factors such being born premature, with congenital anomaly and from socio-economically disadvantaged young parent families. Support for such vulnerable infants and families should be provided alongside preventative health care in primary and community care settings. The impact of these services requires further investigation. Substantial geographical variations in rates were not explained by individual-level factors. This suggests more detailed understanding of local and underlying service-level factors would provide targets for further research on mechanisms and policy priority.

Increasing climatic decoupling of bird abundances and distributions.

Species abundances and distributions are changing in response to changing climate and other anthropogenic drivers but how this translates into how well species can match their optimal climate conditions as they change is not well understood. Using a continental-scale 30-year time series, we quantified temporal trends in climate matching of North American bird species and tested whether geographical variation in rates of climate and land use change and/or species traits could underlie variation in trends among species. Overall, we found that species abundances and distributions are becoming more decoupled from climate as it changes through time. Species differences in climate matching trends were related to their ecological traits, particularly habitat specialization, but not to average rates of climate and land use change within the species' ranges. Climatic decoupling through time was particularly prominent for birds that were declining in abundance and occupancy, including threatened species. While we could not discern whether climate decoupling causes or is caused by the negative population trends, higher climatic decoupling in declining species could lead to a feedback as birds experience increasing exposure to suboptimal climatic conditions.

Initial presentation for acute low back pain: is early physical therapy associated with healthcare utilization and spending? A retrospective review of a National Database

BackgroundEarly initiation of physical therapy (PT) has been associated with lower healthcare costs and utilization; however, these studies have been limited to single institutions or healthcare systems. Our goal was to assess healthcare utilization and spending among patients who present for the first time with low back pain (LBP), according to whether they received early physical therapy (PT), using a large, nationwide sample; and geographic variation in rates of early PT and 30-day LBP-related spending.MethodsUsing the Truven MarketScan database, we identified nearly 980,000 US adults ages 18–64 years who initially presented with acute LBP from 2010 through 2014 and did not have nonmusculoskeletal causes of LBP. Approximately 110,000 patients (11%) received early PT (≤2 weeks after presentation). We compared healthcare utilization and spending at 30 days and 1 year after presentation between patients who received early PT and those who did not. Alpha = 0.05.ResultsAt 30 days, early PT was associated with lower odds of chiropractor visits (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.40–0.42), pain specialist visits (OR = 0.49, 95% CI = 0.47–0.51), emergency department visits (OR = 0.51, 95% CI = 0.49–0.54), advanced imaging (OR = 0.57, 95% CI = 0.56–0.58), orthopaedist visits (OR = 0.67, 95% CI = 0.66–0.69), and epidural steroid injections (OR = 0.68, 95% CI = 0.65–0.70). At 1 year, early PT was associated with less healthcare utilization. At 30 days, patients with early PT had lower mean LBP-related spending ($1180 ± $1500) compared with those without early PT ($1250 ± $2560) (P < 0.001). At 1 year, LBP-related spending was significantly less among patients who did not receive early PT ($2510 ± $3826) versus those who did ($2588 ± $3704). Early PT rates (range, 4–25%; P < 0.001) and 30-day LBP-related spending differed by state (range, $421 to −$410; P < 0.001).ConclusionEarly PT for acute LBP was associated with less 30-day and 1-year healthcare utilization and less 30-day LBP-related spending. Early PT rates and 30-day spending differed by US state.Level of evidenceIV

Socioeconomic variations in rates of hospitalisation and mortality from COVID-19 in England

Background/Aims As well as age and presence of comorbidities, research has suggested that socioeconomic factors, such as income and ethnicity, may affect an individual's risk of severe COVID-19. This study looked at the geographical variations in rates of hospitalisation and death from COVID-19, exploring whether socioeconomic factors were linked to these variations. Methods A cross-sectional retrospective quantitative study was conducted using data regarding the number of cases of COVID-19 cases during the first wave of the pandemic in England (March–July 2020). A total of 242 624 confirmed cases of COVID-19 from across England were analysed. The extent to which predisposing factors, such as population density, age and comorbities, affected morbidity and mortality rates in the different regions was calculated. The impact of socioeconomic factors, such as employment status and ethnicity, were also analysed. Results There was a significant association between long unemployment and likelihood of death from COVID-19. Areas with higher proportions of individuals from Black, Asian and ethnic minority backgrounds were also more likely to have higher rates of hospitalisations and deaths from COVID-19. Overall, London was the region with the highest standardised rates of hospitalisation (67.73%) and mortality (20%). Conclusions Socioeconomic factors have contributed to the geographical variations in COVID-19 mortality across different areas of England. This implies that these factors should be taken into account when planning healthcare and public health strategies.

Geographic Variation in Apical Support Procedures for Pelvic Organ Prolapse.

To measure geographic variation in rates of apical support procedures for the treatment of pelvic organ prolapse (POP) among female Medicare beneficiaries. We conducted a retrospective, cross-sectional study and used 100% Medicare fee-for-service claims to identify a cohort of women aged 65-99 years who had an apical support procedure, defined by Current Procedural Terminology codes, in 2016-2018. We included all vaginal and abdominal approaches (native tissue and mesh colpopexies) and obliterative procedures. We excluded vaginectomies with a diagnosis of gynecologic cancer that did not have a diagnosis for prolapse. We created rates of apical POP procedures by hospital referral region and computed coefficients of variation to measure the degree of geographic variation. An average of 26,005 apical POP procedures were performed annually from 2016 to 2018. The majority of patients were aged 65-74 years (64.3%), and 28.5% had concomitant hysterectomy. From 2016 to 2018, there was a mean of 1.79 apical POP procedures per 1,000 female beneficiaries performed across hospital referral regions (95% CI 1.74-1.84). Rate estimates ranged between 0.87 (95% CI 0.63-1.11) apical POP procedures per 1,000 female beneficiaries (Alexandria, Louisiana) and 3.33 (95% CI 2.91-3.74) per 1,000 beneficiaries (Akron, Ohio), a nearly fourfold difference in rates. Variation between hospital referral regions for abdominal apical prolapse procedures was the greatest (coefficient of variation 0.52). Vaginal and obliterative approaches demonstrated less variation between hospital referral regions (respectively, coefficient of variation 0.36 and 0.40). There is wide geographic variation among hospital referral regions for the treatment of POP. Women may be treated differently based on where they live and seek care, which raises questions about possible overuse in some regions and concerns about underuse and lack of access in other regions.

Unwarranted geographic variation in paediatric health care in the United States and Norway.

We present the four US and Norwegian paediatric and neonatal health atlases and discuss the concept and causes of unwarranted geographic variation in paediatric health care. The four atlases analyse data from both publicly owned health registers, registers of insurance claims and quality registers. Healthcare utilisation is counted per recipient in predefined hospital service areas, adjusted for relevant confounders and presented as extremal ratios between the highest and lowest rate. The atlases describe geographic variation in rates for primary health care, hospital admissions, outpatient visits, treatment procedures and diagnostic testing. A difference in extremal ratios from 2 to 4 between health service areas are common, and for some procedures extremal ratios is even higher. Variation in healthcare utilisation of the magnitude described in these four atlases cannot be explained by differences in population morbidity or patient preferences and are therefore characterised as unwarranted variation. Individual provider preferences or supply of resources such as hospital beds may explain the observed variation.

Population-based Trends in Obesity and Kidney Transplantation Among Patients With End-stage Kidney Disease.

We utilized data from the US Renal Data System from 2008 to 2016 to identify a prevalent cohort of 1 079 410 patients with ESKD. Linear regression determined trends in the proportion of patients within each category of BMI. We also evaluated geographic variation in rates of obesity and transplantation across the United States. Among the 1 079 410 ESKD patients, the largest cohort of patients were those with obesity (n = 423 270; 39.2%). There were 309 707 (28.7%) patients with an overweight BMI and 274 683 (25.4%) with a normal BMI. The proportion of patients with obesity increased significantly from 36.8% in 2008 to 40.2% in 2016 (trend 0.28; 95% confidence interval, 0.05-0.51). There was significant geographic variation by state with rates of obesity ranging from 32.3% to 45.4% and state transplant rates among those obese patients ranging from 22.5% to 46.8%. There is a weak correlation between states with increased rates of obese ESKD patients and states with an increased obesity transplant rate as indicated with r = 0.40 (P = 0.003). Beneficiaries with obesity are now the largest and fastest growing demographic among patients with ESKD in the United States.

Regional differences in gene regulation may underlie patterns of sensitivity to novel insecticides in Leptinotarsa decemlineata.

Agricultural insect pests frequently exhibit geographic variation in levels of insecticide resistance, which are often presumed to be due to the intensity of insecticide use for pest management. However, regional differences in the evolution of resistance to novel insecticides suggests that other factors are influencing rates of adaptation. We examined median lethal concentration (LC50 ) bioassay data spanning 15 years and six insecticides (abamectin, imidacloprid, spinosad, cyantraniliprole, chlorantraniliprole, and metaflumizone) for evidence of regional differences in Leptinotarsa decemlineata baseline sensitivity to insecticides as they became commercially available. We consistently found that larvae from Colorado potato beetle populations from the northwestern USA had the highest baseline sensitivity to novel insecticides, while populations from the eastern USA had the lowest. Comparisons of gene expression between populations from these regions revealed constitutively elevated expression of an array of detoxification genes in the East, but no evidence of additional induction when exposed to imidacloprid. Our results suggest a mechanism for geographic variation in rates of adaptation to insecticides, whereby baseline levels of gene expression determine a population's response to novel insecticides. These findings have implications for the regional development of insecticide resistance management strategies and for the fundamental question of what determines the rate of adaptation to insecticides. © 2020 Society of Chemical Industry.

Geographic variation in preventable hospitalisations across Canada: a cross-sectional study

ObjectiveThe objective of this study is to examine the magnitude and pattern of small-area geographic variation in rates of preventable hospitalisations for ambulatory care-sensitive conditions (ACSC) across Canada (excluding Québec).Design...

Global Geographical Variation in Rates of Cardiac Recovery and Left Ventricular Assist Device Explantation in Chronic Heart Failure: Insights from the International Registry for Mechanically Assisted Circulatory Support

There is limited information on regional variation in rates of cardiac recovery and left ventricular assist device (LVAD) explantation at a global level. We aimed to compare the rates of cardiac recovery and LVAD explantation across several world regions. LVAD recipients registered in the International Registry for Mechanically Assisted Circulatory Support (IMACS) were analyzed. Cardiac recovery was defined as follow-up LVEF >40% and a pre-LVAD LVEF <30%. Cardiac recovery and LVAD explantation/deactivation due to recovery were evaluated in bridge-to-recovery (BTR) and non-BTR designation patients in the Americas, Asia-Pacific and Europe. A total of 16,029 patients met our inclusion criteria and were included in the analysis. Of these, 9,381 patients had at least one follow-up echocardiogram and a minimum of 3 months of LVAD support. Cardiac recovery was achieved in 13.3% (n=1,249) of patients, with a rate of 55.3% (n=21) in BTR compared with 13.1% (n=1,228) in non-BTR patients. Rates of cardiac recovery varied significantly by region: 12.7% (n=1,079) in the Americas, 15.9% (n=94) in Asia-Pacific and 29.5% (n=76) in Europe (p<0.001) (Figure 1A). Rates of LVAD explantation/deactivation were similar between the Americas (5.7%) and Asia-Pacific (4.6%) and lower in Europe (2.0%) (p<0.001) (Figure 1B). Global rates of both cardiac recovery and LVAD explantation are higher in patients implanted with a priori BTR strategy. Rates of cardiac recovery appear to be higher in Europe for reasons that warrant further investigation. The global rates of LVAD explantation are much lower compared to the corresponding cardiac recovery rates. This observation invites future investigations to identify the challenges in regards to LVAD weaning when recovery is identified, which could result in higher rates of LVAD explantation.

County-level Variation in Low Birthweight and Preterm Birth: An Evaluation of State Medicaid Expansion Under the Affordable Care Act.

Rates of low birthweight and prematurity vary 2-fold across states in the United States, with increased rates among states with higher concentrations of racial minorities. Medicaid expansion may serve as a mechanism to reduce geographic variation within states that expanded, by improving health and access to care for vulnerable populations. The objective of this study was to identify the association of Medicaid expansion with changes in county-level geographic variation in rates of low birthweight and preterm births, overall and stratified by race/ethnicity. We compared changes in the coefficient of variation and the ratio of the 80th-to-20th percentiles using bootstrap samples (n=1000) of counties drawn separately for all births and for white, black, and Hispanic births, separately. County-level rates of low birthweight and preterm birth. Before Medicaid expansion, counties in expansion states were concentrated among quintiles with lower rates of adverse birth outcomes and counties in nonexpansion states were concentrated among quintiles with higher rates. In expansion states, county-level variation, measured by the coefficient of variation, declined for both outcomes among all racial/ethnic categories. In nonexpansion states, geographic variation reduced for both outcomes among Hispanic births and for low birthweight among white births, but increased for both outcomes among black births. The decrease in county-level variation in adverse birth outcomes among expansion states suggests improved equity in these states. Further reduction in geographic variation will depend largely on policies or interventions that reduce racial disparities in states that did and did not expand Medicaid.

US Geographical Variation in Rates of Shoulder and Knee Arthroscopy and Association With Orthopedist Density

Although rates of arthroscopy have substantially increased, recent data question its comparative effectiveness. To assess time trends and geographical variations among several US states in arthroscopy rates and to assess the association of orthopedist density with arthroscopy rates. In this cross-sectional study, procedure rates were calculated for knee arthroscopy, shoulder arthroscopy, and arthroscopic rotator cuff repair using data from the State Ambulatory Surgery and Services Databases for 2006 to 2016 (as available) for the states of California, Colorado, Florida, Iowa, Kentucky, Maryland, Maine, Michigan, Minnesota, North Carolina, Nebraska, New Jersey, Nevada, New York, Oregon, Utah, Vermont, and Wisconsin. Data were analyzed from June 2017 to October 2019. Rates of knee arthroscopy, shoulder arthroscopy, and arthroscopic rotator cuff repair. The combined data sets included 4 856 385 records with 2 530 840 female patients (47%); mean (SD) patient age was 49.13 (16.34) years. Rates per 100 000 persons showed large geographical variations for knee arthroscopy (from 63.31 [95% CI, 5.92-198.95] to 721.72 [95% CI, 633.41-806.20]), shoulder arthroscopy (from 53.02 [95% CI, 2.80-164.36] to 438.25 [95% CI, 399.00-476.78]), and arthroscopic rotator cuff repair (from 11.94 [95% CI, 1.30-56.98] to 185.35 [95% CI, 143.84-226.20]) across US states and years. There were significant downward time trends in knee arthroscopy rates in California, Florida, Iowa, Maryland, Michigan, Nebraska, and New Jersey and upward trends for arthroscopic rotator cuff repair in Colorado, Florida, Kentucky, Maine, and North Carolina. Orthopedist density was not associated with knee arthroscopy rates (slope = 3.07; 95% CI, -9.88 to 16.03; P = .54), shoulder arthroscopy rates (slope = 2.74; 95% CI, -6.53 to 12.01; P = .47), or rates of arthroscopic rotator cuff repair (slope = 1.15; 95% CI, -2.77 to 5.05; P = .49). There is large geographical variation in arthroscopy rates despite the questionable comparative effectiveness of these procedures. The reasons for increasing rates of rotator cuff surgery should be further examined.