Higher Percentage Of Black Residents Research Articles

County-level disparities in care for patients with glioblastoma.

Racial and socioeconomic disparities in neuro-oncological care for patients with brain tumors remain underexplored. This study aimed to analyze county-level disparities in glioblastoma (GBM) care in the United States, focusing on access to surgery and the use of adjuvant temozolomide chemotherapy and radiation therapy. Using repeated cross-sectional data from the Surveillance, Epidemiology, and End Results 17 database; the Area Health Resources File; and the American Community Survey, from 2010 to 2019, the authors performed multivariate regression analyses to understand the associations between county-level racial and socioeconomic characteristics, as well as the rates of surgery performed, delays in surgery, and use of adjuvant chemotherapy and radiation therapy for newly diagnosed GBM. In total, 29,609 GBM patients from 602 different US counties over a decade were included in this study. Counties with lower rates of surgery for GBM were associated with a higher percentage of Black residents (coefficient [CE] -0.001, 95% CI -0.002 to 0; p < 0.05) and being located in the Midwest (CE -0.132, 95% CI -0.195 to -0.069; p < 0.001) or West (CE -0.127, 95% CI -0.189 to -0.065; p < 0.001) relative to the Northeast. Counties with delayed surgical treatment were more likely to lack neurosurgeons (adjusted OR [aOR] 2.52, 95% CI 1.77-3.60; p < 0.001), have a higher percentage of Black residents (aOR 1.011, 95% CI 1.00-1.02; p < 0.05), and be located in the Midwest (aOR 3.042, 95% CI 1.12-8.24; p < 0.05) or West (aOR 3.175, 95% CI 1.12-8.97 p < 0.05). Counties with high rates of adjuvant radiation therapy were less likely to have higher percentages of Black residents (aOR 0.987, 95% CI 0.980-0.995; p < 0.01) and uninsured individuals (aOR 0.962, 95% CI 0.937-0.987; p < 0.01). Counties without neurosurgeons and those with a higher percentage of Black patients have delays in surgical care and demonstrate lower overall rates of surgery and adjuvant therapy for GBM. This study underscores the need for targeted interventions and policies that address structural barriers in healthcare access, improve equitable distribution of the neurosurgery workforce, and ensure timely and comprehensive GBM care to all populations.

Temporal trends in sociodemographic composition and land development within U.S. fenceline communities surrounding hazardous industrial facilities: 2001–2019

Unintended releases from industrial facilities can expose fenceline communities to hazardous substances, and distance between facilities and nearby residential development can play a role in preventing exposures. Here, we assess trends in fenceline community sociodemographic characteristics, land development, and the association between the two using sociodemographic data for census tracts (n = 34 068) surrounding 2457 petroleum refining and chemical manufacturing facilities between 2001 and 2019. We find a higher median growth in percentage of Latinx populations among fenceline communities compared to neighboring communities with no industrial facilities. The increase in the median percentage of Latinx populations within fenceline communities was six times higher than for White populations overall (+6 and +1 percentage points, respectively). Though the percentage of the Black populations did not change within fenceline communities over this period, we find a minor sustained higher percentage of Black residents within fenceline communities relative to neighboring communities (20% versus 19%, respectively). Employing a spatial autoregressive model with autoregressive disturbances, we find that an increase in community percentage Latinx population is associated with a decrease in the rate of land development. Comparing fenceline and neighboring communities, we conclude that Black and Latinx populations are disproportionately located near industrial facilities, potentially contributing to inequitable exposure to unintended chemical releases. Our work lends support to the value of considering of sociodemographic composition of fenceline communities when evaluating industrial facility hazards.

Social Determinants of Cardiovascular Health: A Longitudinal Analysis of Cardiovascular Disease Mortality in US Counties From 2009 to 2018.

Background Disparities in cardiovascular disease (CVD) outcomes persist across the United States. Social determinants of health play an important role in driving these disparities. The current study aims to identify the most important social determinants associated with CVD mortality over time in US counties. Methods and Results The authors used the Agency for Healthcare Research and Quality's database on social determinants of health and linked it with CVD mortality data at the county level from 2009 to 2018. The age-standardized CVD mortality rate was measured as the number of deaths per 100 000 people. Penalized generalized estimating equations were used to select social determinants associated with county-level CVD mortality. The analytic sample included 3142 counties. The penalized generalized estimating equation identified 17 key social determinants of health including rural-urban status, county's racial composition, income, food, and housing status. Over the 10-year period, CVD mortality declined at an annual rate of 1.08 (95% CI, 0.74-1.42) deaths per 100 000 people. Rural counties and counties with a higher percentage of Black residents had a consistently higher CVD mortality rate than urban counties and counties with a lower percentage of Black residents. The rural-urban CVD mortality gap did not change significantly over the past decade, whereas the association between the percentage of Black residents and CVD mortality showed a significant diminishing trend over time. Conclusions County-level CVD mortality declined from 2009 through 2018. However, rural counties and counties with a higher percentage of Black residents continued to experience higher CVD mortality. Median income, food, and housing status consistently predicted higher CVD mortality.

Does Job Accessibility Matter in the Suburbs? Black Suburbia, Job Accessibility, and Employment Outcomes

The spatial mismatch hypothesis of John Kain proposes that geographic separation between residential locations and jobs creates a spatial barrier in accessing job opportunities, which has a negative impact on labor market outcomes. A key hypothesis is that Black populations have limited accessibility to suburban job opportunities due to residential segregation in the city, resulting in lower employment and earnings. However, the spatial structure of the U.S. metropolitan area has changed since then, with increased polycentric employment growth and Black suburbanization. This challenges Kain’s original hypothesis that residential segregation in the city creates a spatial barrier in accessing jobs. The spatial pattern of mismatch has changed and demonstrates a mismatch between Black suburbs and suburban jobs. Then, what role does job accessibility play in the change in the spatial pattern of mismatch? Does job accessibility continue to matter in the suburbs? Or, are there other more important neighborhood characteristics affecting labor market outcomes? The findings demonstrate that job accessibility remains closely associated with Black labor market outcomes. In Chicago, job accessibility has higher marginal effects on Black employment, especially in predominantly Black neighborhoods. However, in Atlanta, where a majority of the Black population lives in the suburbs, having a higher percentage of Black residents in the neighborhood negates the effects of job accessibility. Instead, the share of Black residents becomes a more significant factor in employment. The findings demonstrate that the effect of job accessibility varies by the spatial pattern of mismatch. Job accessibility becomes less important in highly segregated suburbs, but the share of Black residents matters more in labor market outcomes. In metropolitan areas with the traditional mismatch pattern, job accessibility is significantly associated with employment and earnings, especially in neighborhoods where the majority of the Black population remains segregated in the city.

Eviction from public housing in the United States

Neither academic researchers nor the U.S. Department of Housing and Urban Development have studied evictions from public housing in national perspective. Combining federal registers of public housing authorities (PHAs) with individual-level records from >25 million eviction filings issued between 2006 and 2016, this is the first national-level study to estimate the prevalence and dynamics of eviction in public housing units. We find that the average PHA files roughly 40 evictions each year or 7.6 cases for every 100 public housing households. Public housing complexes were responsible for approximately 5.8 out of every 100 eviction filings in our sample, while only 3.5 in 100 renting households resided in public housing. Controlling for socioeconomic factors, we show that PHAs with a higher percentage of Black residents have significantly higher eviction filing rates. Eviction filing rates in PHAs are associated with those in the surrounding private rental market, indicating that PHAs do not function independently from the social contexts in which they are embedded. These findings reveal significant variation in eviction filing rates across local PHAs and highlight the need for clear policies on lease terminations and improved documentation of eviction actions in public housing at the federal and local levels.

Identifying bright spot communities: Socioecological, workforce, and healthcare delivery factors influencing opioid mortality.

There were 50,000 U.S. opioid overdose deaths in 2019. Millions suffer from opioid addiction. Identifying protective factors for low community opioid mortality may have important implications for addressing the opioid epidemic. This study was funded through the Virginia (VA) Department of Medical Assistance Services (DMAS) through a SUPPORT Act Grant. To identify "Bright Spot" communities in Virginia with protective factors associated with reduced opioid mortality and morbidity. Ecologic study. Virginia All Payer Claims Database (APCD), Virginia Department of Health (VDH) statewide medical examiner registry, and American Community Survey (ACS). 2016-2019; 2019 data cited here. APCD includes VA residents with medical claims through commercial, Medicaid, and Medicare coverage. VDH data includes fatal drug overdoses. ACS surveys all VA residents. Primary outcome: fatal opioid overdoses. Secondary outcomes: emergency room visits for overdoses and opioid-related diagnoses, outpatient diagnoses for opioid-related disorder, prescription rate for opioids, and prescription rate for buprenorphine. Opioid mortality was associated with higher rates of community poverty (r=.38, p<.0001) and disability (r=.52, r<.0001). Opioid mortality was associated with inequality, with higher Gini index associated with higher opioid mortality (r=.23, p<.0001). A higher percentage of black residents was associated with increased fatal opioid overdoses (r=.37, p<.0001) and ED visits for overdoses (r=.30, p<.0001). A higher percentage of white residents correlated with increased outpatient visits for opioid use disorder (r=.24, p<.0001) and higher rates of buprenorphine (r=.34, p<.0001) and opioid prescriptions (r=.31, p <.0001). These findings suggest significant racial disparities in opioid outcomes. Communities with a higher percentage of black residents are more likely to have higher opioid mortality and a lower rate of outpatient treatment. This association may be affected by the time period used in the analysis (2015-2019), as nationally there has been an increasing rate of synthetic opioid deaths in Black communities. These measures have been incorporated into a multivariate analysis to identify Bright Spot communities, which will be discussed during the presentation.

Refugee experiences in Cincinnati, Ohio: A local case study in the context of global crisis

AbstractWe examined refugees’ perceptions of their experiences living in greater Cincinnati, Ohio, USA and linked these findings to colonial context, coloniality theory, and decolonial psychology. We describe the process of developing a community based participatory research process with members of local refugee communities, and then discuss the findings of a survey completed by 280 local refugees that was collaboratively designed and administered. Noting historic and continuing disenfranchisement of the Black community in Cincinnati, in our survey analyses we compared the experiences of African refugees (Burundian, Congolese, and Somali) to the experiences of Bhutanese, Latinx, and Middle Eastern refugees residing in greater Cincinnati on several aspects of civic life. Analyses indicate that refugees from African countries reported more negative outcomes than other refugees residing in this area. Further, refugees residing in neighborhoods with a higher percentage of Black residents reported less satisfaction, likely due to neighborhood disinvestment. We discuss the costs and benefits of these findings and interpretation in the context of decolonial theory. Specifically, we connect racist colonial history to differences in treatment of refugees based on their physical appearance (i.e., Blackness) to the continued disenfranchisement of African Americans.

Neighborhood Inequities in Tobacco Retailer Density and the Presence of Tobacco-Selling Pharmacies and Tobacco Shops

Studies document inequitable tobacco retailer density by neighborhood sociodemographics, but these findings may not be robust to different density measures. Policies to reduce density may be less equitable depending on how the presence of store types differs by neighborhood characteristics. We built a 2018 list of probable tobacco retailers in the United States and calculated four measures of density for all census tracts (N = 71,495), including total count, and number of retailers per 1,000 people, square mile, and kilometers of roadway. We fit multivariable regression models testing associations between each density measure and tract-level sociodemographics. We fit logistic regression models testing associations between sociodemographics and the presence of a tobacco-selling pharmacy or tobacco shop. Across all measures, tracts with a greater percentage of residents living below 150% of the federal poverty level (FPL) had higher density. A higher percentage of Black residents, Hispanic or Latino residents, and vacant housing was inconsistently associated with density across measures. Neighborhoods with a greater percentage of Black residents had a lower odds of having a pharmacy (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI; 0.95, 0.97]) and tobacco shop (aOR = 0.87, CI [0.86, 0.89]), while those with a greater percentage of residents living below 150% FPL had greater odds of having a tobacco shop (aOR = 1.18, CI [1.16, 1.20]). Researchers and policymakers should consider how various measures of retailer density may capture different aspects of the environment. Furthermore, there may be an inequitable impact of retailer-specific policies on tobacco availability.

Social Disadvantage, Politics, and Severe Acute Respiratory Syndrome Coronavirus 2 Trends: A County-level Analysis of United States Data.

BackgroundUnderstanding the epidemiology of SARS-CoV-2 is essential for public health control efforts. Social, demographic, and political characteristics at the US county level might be associated with changes in SARS-CoV-2 case incidence.MethodsWe conducted a retrospective analysis of the relationship between the change in reported SARS-CoV-2 case counts at the US county level during June 1, 2020 – June 30,2020 and social, demographic, and political characteristics of the county.Results1023/3142 US counties were included in the analysis. 678 (66·3%) had increasing, and 345 (33·7%) had non-increasing SARS-CoV-2 case counts between June 1 – June 30, 2020. In bivariate analysis, counties with increasing case counts had significantly higher Social Deprivation Index (median 48, IQR 24 – 72) than counties with non-increasing case counts (median 40, IQR 19 – 66; p=0·009). Counties with increasing case counts were significantly more likely to be metropolitan areas of 250,000 – 1 million population (p&0·001), to have a higher percentage of Black residents (9% vs. 6%, p=0·013), and to have voted for the Republican presidential candidate in 2016 by a 10-point or greater margin (p=0·044). In the multivariable model, metropolitan areas of 250,000 – 1 million population, higher percentage of Black residents and a 10-point or greater Republican victory were independently associated with increasing case counts.ConclusionsIncreasing case counts of SARS-CoV-2 in the US during June 2020 were associated with a combination of sociodemographic and political factors. Addressing social disadvantage and differential belief systems that may correspond with political alignment will play a critical role in pandemic control.

Community Racial Composition and Hospitalization Among Patients Receiving In-Center Hemodialysis

Community racial composition has been shown to be associated with mortality in patients receiving maintenenance dialysis. It is unclear whether living in communities with predominantly Black residents is also associated with risk for hospitalization among patients receiving hemodialysis. Retrospective analysis of prospectively collected data from a cohort of patients receiving hemodialysis. 4,567 patients treated in 154 dialysis facilities located in 127 unique zip codes and enrolled in US Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4 to 5 (2010-2015). Tertile of percentage of Black residents within zip code of patients' dialysis facility, defined through a link to the American Community Survey. Rate of hospitalizations during the study period. Associations of patient-, facility-, and community-level variables with community's percentage of Black residents were assessed using analysis of variance, Kruskal-Wallis, or χ2/Fisher exact tests. Negative binomial regression was used to estimate the incidence rate ratio for hospitalizations between these communities, with and without adjustment for potential confounding variables. Mean age of study patients was 62.7 years. 53% were White, 27% were Black, and 45% were women. Median and threshold percentages of Black residents in zip codes in which dialysis facilities were located were 34.2% and≥14.4% for tertile 3 and 1.0% and≤1.8% for tertile 1, respectively. Compared with those in tertile 1 facilities, patients in tertile 3 facilities were more likely to be younger, be Black, live in urban communities with lower socioeconomic status, have a catheter as vascular access, and have fewer comorbid conditions. Patients dialyzing in communities with the highest tertile of Black residents experienced a higher adjusted rate of hospitalization (adjusted incidence rate ratio, 1.32; 95% CI, 1.12-1.56) compared with those treated in communities within the lowest tertile. Potential residual confounding. The risk for hospitalization for patients receiving maintenance dialysis is higher among those treated in communities with a higher percentage of Black residents after adjustment for dialysis care, patient demographics, and comorbid conditions. Understanding the cause of this association should be a priority of future investigation.

Enforcement trends in the city of St. Louis from 2007 to 2017: Exploring variability in arrests and criminal summonses over time and across communities.

The goal of this study is twofold: (a) to describe trends in enforcement activity in the city of St. Louis from 2007 through 2017 and (b) to document community variation in these trends. Five types of enforcement actions are examined: felony, misdemeanor, municipal, and bench warrant arrests and criminal summonses-in-lieu of arrest. Results indicate that enforcement activity decreased over the study period, particularly for nonfelony arrests among Blacks. City-wide trends obscure some variability in neighborhood enforcement. Neighborhood trends in enforcement varied by type of action, but in all cases, trends were conditioned by racial composition. For example, misdemeanor and bench warrant arrests exhibited steeper declines in neighborhoods with a higher percentage of Black residents, resulting in a narrowing of the race gap. In contrast, differences in criminal summonses across neighborhoods of varying racial compositions increased. The effects persisted net of measures of economic disadvantage, community location, residential mobility, household composition, calls for service, and population size. The findings highlight the importance of disaggregating enforcement trends by race and place and documenting changes in less serious, but more prevalent, types of law enforcement activity.

Density of outdoor advertising of consumable products in NYC by neighborhood poverty level

BackgroundTo determine if outdoor advertising density for non-alcoholic drinks, food, tobacco products, and alcohol, is associated with neighborhood poverty or other Census-level characteristics in New York City (NYC).MethodsFrom June – July of 2015, photographs were taken of all street-level, stationary outdoor advertising (posters, stickers, decals, etc.) for consumable products in a sample of 953 NYC retail-dense street segments. Density of product images was analyzed by neighborhood poverty level and other characteristics using multivariate negative-binomial regression.ResultsA total of 16,305 discrete advertisements displaying 50,673 product images were photographed. Total product image prevalence relative to retail density was not significantly higher in high- vs. low-poverty neighborhoods, as hypothesized (OR: 1.31; 95% CI: 0.98, 1.77). However, total product image prevalence was higher in neighborhoods with a higher percentage of Black residents (OR: 1.08; 95% CI: 1.04, 1.12), and for sugary drinks in areas with a higher percentage of adults with <HS diploma (OR: 1.32; 95% CI: 1.11, 1.58).ConclusionsProduct images were abundant throughout NYC’s retail-dense areas, with marginally greater prevalence by some Census-level demographics, irrespective of the content displayed.

The association of neighborhood racial mix and ED visit count in a cohort of patients on hemodialysis

BackgroundNeighborhood racial mix is associated with dialysis facility performance metrics and mortality outcomes in patients on hemodialysis. We explored the association of neighborhood racial mix with emergency department (ED) visits in patients receiving hemodialysis.MethodsUsing Looking Glass (Montefiore’s clinical database) we identified a cohort of patients on hemodialysis with an index ED visit at any of 4 Montefiore Hospital locations, between January 2013 and December 2017 and followed it for number of ED visits through December of 2017 or dropout due to death. The racial mix data for the Bronx block group of each subject’s residence was derived from the Census Bureau. We then used negative binomial regression to test the association of quintile of percent of Black residents per residential block group with ED visits in unadjusted and adjusted models. To adjust further for quality offered by local dialysis facilities, with the facility zip code as the locus, we used data from the “Dialysis Compare” website.ResultsThree thousand nine-hundred and eighteen subjects were identified and the median number of ED visits was 3 (interquartile range (IQR) 1–7) during the study period. Subjects living in the highest quintile of percent Black residents were older, more commonly female and had lower poverty rates and higher rates of high school diplomas. Unadjusted models showed a significant association between the highest quintiles of Black neighborhood residence and count of ED visits. Fully adjusted, stratified models revealed that among males, and Hispanic and White subjects, living in neighborhoods with the highest quintiles of Black residents was associated with significantly more ED visits (p-trend =0.001, 0.02, 0.01 respectively). No association was found between dialysis facility locations’ quintile of Black residents and quality metrics.ConclusionsLiving in a neighborhood with a higher percentage of Black residents is associated with a higher number of ED visits in males and non-Black patients on hemodialysis.

Exploring geospatial characteristics of hashtag activism in Ferguson, Missouri: An application of social disorganization theory

Following the shooting of Michael Brown in 2014, a series of social protests on the streets and social media were ignited. The current research draws upon social disorganization theory to explore the geospatial patterns of Twitter activity related to the Michael Brown case across the state of Missouri. Geotagged Twitter data and census tract level American Community Survey data were used to determine if neighborhoods with greater social disadvantage were more represented in political discourse regarding police brutality. Results indicated wealthier neighborhoods with a higher percentage of black residents were more likely to engage in Twitter activity related to the Michael Brown case. A higher volume of activity was found, however, in more disadvantaged neighborhoods with little effect as to the percentage of black residents. Within a social disorganization framework, findings support the potential for future research to examine the idea that marginalized neighborhoods use social media as an outlet for their concerns about criminal justice practices.

Using Zoning as a Public Health Tool to Reduce Oversaturation of Alcohol Outlets: an Examination of the Effects of the New "300 Foot Rule" on Packaged Goods Stores in a Mid-Atlantic City.

The oversaturation of alcohol outlets can have disastrous public health consequences. The goal of this study was to evaluate the potential impact of new zoning legislation, TransForm Baltimore on locations of alcohol outlets. More specifically, the study sought to determine the effect of the new zoning code on the potential redistribution of alcohol outlets and also provide empirical support for the need to actively monitor redistribution of outlets to avoid further inequitable oversaturation in disadvantaged neighborhoods. Data on off-premise alcohol outlets (e.g., packaged goods stores) were obtained from the Board of Liquor License Commissioners for Baltimore City. The alcohol outlets were geocoded and assigned to zoning parcels. Churches and schools were also geocoded. The alcohol outlets were also assigned to census tracts to calculate socioeconomic statuses. One hundred seventy-two of the 263 off-premise packaged goods stores (PGS) were in violation of the new zoning law. TransForm will reduce the land parcels available to alcohol outlets by 27.2%. Areas containing non-conforming PGS were more likely to have a higher percentage of Black residents, single parent-families, unemployment, household poverty, and vacancy compared to Baltimore City averages and areas without non-conforming PGS. Planning enforcement efforts need to accompany related laws to prevent/reduce overconcentration of PGS in disadvantaged neighborhoods.

Managing Racial Diversity: Matching Internal Strategies with Environmental Needs

AbstractAlthough demographic diversity has been of paramount concern to researchers and practitioners in public management, studies exploring managerial strategies to capitalize on and respond to the needs of diverse client populations are scarce. This article examines strategies for managing diversity as a way to buffer environmental challenges in service delivery and performance resulting from heterogeneous client demands. Findings suggest that administrators prioritize diversity efforts when faced with higher levels of regulatory violations (a performance measure). A higher percentage of black residents is associated with lower service quality. However, the effect of managerial strategies for diversity on performance is conditioned by the racial composition of the clients: as the percentage of black nursing home residents increases, diversity management efforts are associated with a lower number of regulatory violations. Similarly, at higher levels of racial heterogeneity, diversity management efforts are associated with fewer regulatory violations.

Using More Activities to Address Health Disparities

Local health departments (LHDs) are expected to address health disparities. Little is known, however, about what factors influence the activities used by an LHD in addressing health disparities. The objective of this study was to examine factors such as an LHD's leader, jurisdiction, and organizational characteristics that could be considered to influence the approaches used within LHDs to address health disparities. We used a cross-sectional, 2-level, mixed linear model with secondary LHD data nested within states. National data were used, depicting activities conducted by LHDs. The sample consisted of the 2332 LHDs that responded to the National Association of County and City Health Officials's 2008 National Profile of LHDs Survey. The activities used by LHDs in addressing health disparities were depicted as respondents indicating that they had employed 0 to 8 types of the activities listed in the Profile Survey in relation to addressing disparities. Local health departments significantly vary in the number of types of activities used in addressing health disparities. Significant associations exist between more types of health disparities activities used by LHDs and LHDs having a "top executive" with more education, clinical training, and/or less than 5 years of experience as the LHD's top executive. Local health departments with a jurisdiction that is urban, with a higher percentage of black residents, with a higher percentage of Hispanic residents, with higher per capita LHD expenditures, and/or that has conducted a community health assessment in last 3 years were also significantly associated with higher numbers of types of health disparities activities used. Local context and the characteristics of an LHD's top executive appear to be important factors related to the activities used to address health disparities across LHDs. A focus on the competencies and development of LHD leaders may be important in promoting LHD engagement in a wider range of approaches toward reducing disparities.

Geographic Access to Hospice in the United States

Despite a 41% increase in the number of hospices since 2000, more than 60% of Americans die without hospice care. Given that hospice care is predominantly home based, proximity to a hospice is important in ensuring access to hospice services. We estimated the proportion of the population living in communities within 30 and 60 minutes driving time of a hospice. We conducted a cross-sectional study of geographic access to U.S. hospices using the 2008 Medicare Provider of Services data, U.S. Census data, and ArcGIS software. We used multivariate logistic regression to identify gaps in hospice availability by community characteristics. As of 2008, 88% of the population lived in communities within 30 minutes and 98% lived in communities within 60 minutes of a hospice. Mean time to the nearest hospice was 15 minutes and the range was 0 to 403 minutes. Community characteristics independently associated with greater geographic access to hospice included higher population density, higher median income, higher educational attainment, higher percentage of black residents, and the state not having a Certificate of Need policy. The percentage of each state's population living in communities more than 30 minutes from a hospice ranged from 0% to 48%. Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice.

Geography Matters: Relationships among Urban Residential Segregation, Dialysis Facilities, and Patient Outcomes

End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race-a prominent feature of many U.S. cities--on outcomes of patients receiving dialysis and on facility performance has not been evaluated. To examine the relationship among racial composition of ZIP codes in metropolitan areas, outcomes of patients receiving dialysis, and characteristics of dialysis facilities. Retrospective cohort study of patients receiving dialysis and cross-sectional study of dialysis facilities. U.S. metropolitan ZIP codes with differing percentages of black residents. Black and non-Hispanic white patients who initiated long-term dialysis between 1 January 1995 and 31 December 2002 (n = 399,424) and dialysis facilities in operation in December 2004 (n = 3244). Mortality and time to transplantation among patients receiving dialysis, and performance of dialysis facilities on the basis of quality indicators (anemia management, dialysis adequacy, and facility-level mortality rates). Most black patients (50.3%) but few white patients (5%) lived in the 3% (n = 769) of ZIP codes in which most residents were black. In analyses adjusted for patient and ZIP code characteristics, mortality rates were higher among white patients but not among black patients living in areas with a higher percentage of black residents (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 1.14 [95% CI, 1.07 to 1.21] for white patients and 1.02 [CI, 0.99 to 1.06] for black patients). Time to transplantation was longer among both black and white patients (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 0.84 [CI, 0.78 to 0.92] and 0.63 [CI, 0.57 to 0.71] for black patients and white patients, respectively). Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher-than-expected mortality rates and were less likely to meet performance targets. Patient-level analyses were restricted to black and non-Hispanic white patients. Patient-level and facility-level analyses focused only on the percentage of black residents in each ZIP code. The racial composition of urban residential areas is associated with time to transplantation and dialysis facility performance on standard quality measures. Closer scrutiny of care provided to patients receiving dialysis who live in predominantly black residential areas and to dialysis facilities operating in these areas may be warranted.

Understanding the Geospatial Relationship of Neighborhood Characteristics and Rates of Maltreatment for Black, Hispanic, and White Children

The disproportionate number of racial and ethnic minority children in the child welfare system concerns many child welfare professionals. Few studies have investigated how neighborhood processes may contribute to this disparity. This study examined how neighborhood characteristics are associated with rates of child maltreatment for black, Hispanic, and white children. Spatial regression procedures were used to analyze data from 940 census tracts in California. For black children, higher rates of poverty and higher densities of off-premise alcohol outlets were positively associated with maltreatment rates, but increases in population since 1990, a higher percentage of residents who had moved, and a higher percentage of black residents were associated with lower rates. Percentage of female-headed families, poverty, and unemployment were positively related to maltreatment rates among Hispanic children. For white children, the percentage of elderly people, percentage of poverty, ratio of children to adults, and percentage of Hispanic residents were positively associated with neighborhood rates. Reducing neighborhood poverty may reduce rates of child maltreatment for all children, but additional efforts to prevent maltreatment at the neighborhood level may need to be tailored to the specific demographic characteristics to be most effective.