Metropolitan Statistical Area Status Research Articles

Rural-Urban Disparities in the Uptake of New Diabetes Medications

OBJECTIVE This study assessed rural-urban differences in the uptake and use of glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors, and sodium–glucose cotransporter 2 (SGLT2) inhibitors among U.S. adults with diabetes. RESEARCH DESIGN AND METHODS We calculated person-level annual total and out-of-pocket (OOP) expenditures for new, other, and all diabetes medications in the Medical Expenditure Panel Survey. We defined newer diabetes medications as GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors. The primary outcome was whether a person received a new diabetes medication during the year, and secondary outcomes were medication expenditures. The key independent variable was metropolitan statistical area (MSA) status. Logistic regression was used to estimate use rates of new diabetes medications by MSA status, and a two-part model was used to estimate individual-level annual total and OOP expenditures on new, other, and all diabetes medications. RESULTS We observed no significant difference (adjusted odds ratio 0.943, P = 0.37) in newer diabetes medication use. Individuals with diabetes in non-MSA areas were more likely to have spending (probit coefficient 0.058, P = 0.06) and to spend more on other diabetes medications (combined marginal effect $103.13, P = 0.09), although this result was not statistically significant. This imbalance increased from $81.33 (P = 0.09) in 2003–2006 to $136.66 (P = 0.08) in 2017–2020. CONCLUSIONS Rural-urban diabetes outcome disparities are not likely to be the result of differences in the uptake of GLP-1 receptor agonist, DPP-4 inhibitor, and SGLT2 inhibitor medications.

Out-of-school Activities and Adherence to 24-hour Movement Guidelines

IntroductionThe purpose of this study was to explore associations between participation in out-of-school/weekend organized activities and adherence to the 24-hour movement guidelines among US adolescents. MethodsData from the 2022 National Survey of Children's Health (NSCH) (N=16,403, age=15.1±1.4 years, 48.1% female) was used for analyses in 2024. A parent/guardian completed surveys regarding adolescents’ 24-hour movement behaviors (physical activity [PA], sleep [SL], and screentime [ST]), as well as participation in out-of-school and weekend activities (sports, clubs, other organized activities, and volunteering). Weighted logistic regression models were used to examine associations between participation in out-of-school and weekend organized activities and 24-hour movement guideline adherence, adjusted for sex, age, race/ethnicity, federal poverty level status, metropolitan statistical area status, and overweight/obesity status. ResultsOnly 4.8% of adolescents met all three guidelines concurrently. Adolescents who participated in sports teams/lessons had higher odds of meeting PA (OR=2.11,95%CI:1.67-2.66), ST (OR=1.31,95%CI:1.12-1.53), PA+ST (OR=2.24,95%CI:1.63-3.07), PA+SL (OR=2.00,95%CI:1.53-2.63), SL+ST (OR=1.40,95%CI;1.19-1.66), and all three guidelines (OR=2.33,95%CI:1.61-3.39). Participation in other organized activities/lessons was associated with higher odds of meeting ST (OR=1.32,95%CI:1.13-1.56), and SL+ST guidelines (OR=1.39, 95%CI:1.16-1.66). Adolescents who volunteered had higher odds of meeting ST (OR=1.68,95%CI: 1.42-1.98), PA+ST (OR=1.75,95%CI:1.25-2.45), SL+ST (OR=1.64,95%CI:1.38-1.95), and all three guidelines (OR=1.80,95%CI:1.20-2.72). ConclusionsParticipating in sports teams/lessons and community service/volunteer work is beneficially associated with concurrently meeting all three 24-hour movement guidelines and participating in other organized activities or lessons is associated with adherence to individual components of the 24-hour movement guidelines among US adolescents.

End-Of-Life Care Planning and Bereavement Practices Among Adult Day Services Centers, 2018.

Introduction: This study describes the end-of-life (EOL) care planning and bereavement practices among adult day services centers (ADSC) when an ADSC participant is dying or has died. Methods: Data are from the 2018 National Study of Long-term Care Providers' biennial survey of ADSCs. Respondents were asked about the following 4 practices: 1) honoring the deceased in some public way in this center; 2) offering bereavement services to staff and participants; 3) documenting in the care plan what is important to the individual at the end of life (EOL), such as the presence of family or religious or cultural practices; and 4) discussing spiritual needs at care planning conferences. ADSC characteristics included US Census region, metropolitan statistical area status, Medicaid authorization, electronic health records (EHR) use, for-profit status, employment of aides, services provision, and model type. Results: About 50% to 30% of ADSCs offered the EOL care planning or bereavement services. Honoring the deceased was the most common practice (53%), followed by bereavement services (37%), discussing spiritual needs (29%), and documenting what is important at EOL (28%). Fewer ADSCs in the West had EOL practices relative to the other regions. The EOL planning and bereavement practices were offered more often in ADSCs that used EHRs, accepted Medicaid, employed an aide, provided nursing, hospice, and palliative care services, and were categorized as medical models, compared with ADSCs without these characteristics. Conclusion: These results highlight the importance of understanding how ADSCs provide EOL and bereavement care to participants who are near EOL.

Youth Sport Participation By Metropolitan Status: 2018-2019 National Survey Of Children’s Health (NSCH)

Youth sport participation in rural populations is understudied, including minimal information being available on how participation rates vary by urbanicity. This information is crucial for identifying demographic groups within different levels of urbanicity that may need additional support to increase sport participation. PURPOSE: To examine the association between metropolitan statistical area (MSA) status and sport participation among American youth ages 6-17. METHODS: This cross-sectional study used data from the 2018-2019 National Survey of Children’s Health. Weighted prevalence statistics were computed for sport participation by MSA status (living in an MSA, yes/no), overall and by child sex and age. Modified Poisson regression was used to estimate incidence rate ratios (IRR) for non-MSA versus MSA youth, before and after adjusting for special health care needs, race/ethnicity, income, and parent education. RESULTS: The final sample included 30,029 children [11.6 years (SD = 0.4), 51.4% female, 49.0% White). About 56% participated in sport in the past year. Sport participation prevalence was lower outside of (versus within) MSAs [53.6% (95% CI: 51.1%-56.0%) versus 56.0% (95% CI: 54.7%-57.3%)]. Among youth ages 6-11, those in non-MSAs (versus MSAs) were less likely to participate in sport [IRR 0.92 (95% CI: 0.86-0.99)], which was non-significant after adjustment. In adjusted models, youth ages 12-17 in non-MSAs (versus in MSAs) were more likely to participate in sport [aIRR 1.07 (95% CI: 1.00-1.15)]. This association was stronger for older males [aIRR 1.12 (95% CI: 1.02-1.23)]. CONCLUSIONS: There was a negative association between living in a non-MSA and sport participation. However, in adjusted models, non-MSA youth were more likely to participate. The relationship between MSA status and sport participation may be largely driven by factors (e.g., household income) that affect children’s ability to participate in sport. Efforts promoting youth sport should focus on reducing cost-related barriers to increase participation regardless of household income.

Youth Sport Participation by Metropolitan Status: 2018–2019 National Survey of Children’s Health (NSCH)

ABSTRACTPurpose: This cross-sectional study used data from the 2018–2019 National Survey of Children’s Health to examine the association between metropolitan statistical area (MSA) status and sports participation among American youth ages 6–17. Methods: Weighted prevalence statistics were computed for sports participation by MSA status (non-MSA, MSA), overall and by child sex and age. Modified Poisson regression was used to estimate prevalence ratios (PR) for non-MSA versus MSA youth, before and after adjusting for special health-care needs, race/ethnicity, household income, parent education, and family structure. Results: The final sample included 30,029 youth [Mage = 11.6 years (SD = 0.4), 51.4% female, 49.0% White]. About 56% participated in sports in the past year. Sports participation was significantly higher among females versus males [59.1% (95% CI: 57.4%–60.7%) versus 52.1% (95% CI: 50.4%–53.8%), p < .001]. Among ages 6–11, those in non-MSAs (versus MSAs) were less likely to participate in sports [PR 0.92 (95% CI: 0.86–0.99), p = .033], which was non-significant after adjustment. In adjusted models, youth ages 12–17 in non-MSAs (versus in MSAs) were more likely to participate in sports overall [aPR 1.07 (95% CI: 1.00–1.15), p = .042] and among males [aPR 1.12 (95% CI: 1.01–1.23), p = .026]. Conclusion: The relationship between MSA status and sports participation may be largely driven by factors that affect youth’s ability to participate in sports. Sports participation was higher among females versus males overall. In the models adjusted for demographics, non-MSA youth ages 12–17 were more likely to participate, particularly males. Efforts promoting youth sports should consider differences in socio-demographic factors between MSA versus non-MSA areas to help increase participation.

Trends in human papillomavirus (HPV) vaccination initiation among adolescents aged 13–17 by metropolitan statistical area (MSA) status, National Immunization Survey – Teen, 2013 – 2017

ABSTRACT Disparities in HPV vaccination coverage by metropolitan statistical area (MSA) status were observed in the 2016 and 2017 National Immunization Survey – Teen (NIS-Teen). In 2017, HPV vaccination initiation (≥1dose) coverage was 11 percentage points lower for adolescents living in non-MSAs (mostly rural areas) and 7 percentage points lower among those living in MSA, non-principal cities (suburban areas) compared to those living in MSA, principal cities (mostly urban areas). In order to understand how this disparity has changed over time, we examined trends in HPV vaccine initiation by MSA status from 2013 to 2017. Weighted linear regression by survey year was used to estimate annual percentage point changes in HPV vaccination initiation. The five-year average annual percentage point increases in HPV vaccination initiation coverage were 5.2 in mostly urban areas, 4.9 for suburban areas, and 5.2 for mostly rural areas. Despite increases in each MSA area, coverage in mostly rural areas was consistently and significantly lower than coverage in mostly urban areas. Coverage was significantly lower among teens living in mostly rural areas regardless of poverty status, sex, and race/ethnicity except among black, non-Hispanic adolescents. There was no significant change in the magnitude of the disparity between mostly urban areas and mostly rural areas over time (p = .98). A better understanding of the facilitators and barriers to HPV vaccination in mostly rural areas is needed to identify and implement targeted strategies to improve HPV vaccination coverage and reduce these disparities.

Factors associated with not receiving HPV vaccine among adolescents by metropolitan statistical area status, United States, National Immunization Survey–Teen, 2016–2017

ABSTRACT The 2016 and 2017 National Immunization Surveys-Teen (NIS-Teen) highlighted disparities in human papillomavirus (HPV) vaccination coverage by metropolitan statistical area (MSA) status. Coverage with ≥1 dose of HPV vaccine was significantly lower among teens in suburban and mostly rural areas than it was among those in mostly urban areas. Reasons underlying this disparity are poorly understood; this analysis sought to identify sociodemographic factors associated with not initiating the HPV vaccine series and to determine whether these factors differed by MSA status. Using NIS-Teen data for a sample of 41,424 adolescents from the 2016 and 2017 survey years, multivariate logistic regression was utilized to assess associations between various sociodemographic factors and non-initiation of the HPV vaccine series by MSA status. Adjusted prevalence ratios and 95% confidence intervals are reported. A secondary analysis assessed missed opportunities for HPV vaccination by MSA status and estimated what coverage could be if these missed opportunities had not occurred. Most factors associated with not receiving HPV vaccine were similar across all three MSAs, including living in the South, having a mother with some college education, not having an 11–12-year-old well-child visit, and not receiving a provider recommendation for vaccination. Others were associated with non-initiation of the HPV vaccine series in only specific MSAs. Teens in suburban areas (82.2%) were more likely to miss opportunities for HPV vaccination than those in mostly urban (79.3%) areas. Coverage with ≥1 dose of HPV vaccine in all three MSAs would be substantially higher if these missed opportunities had been eliminated.

Prevalence of children walking to school and related barriers—United States, 2017

Children and adolescents can engage in an active lifestyle by walking to school; however, several barriers may limit this behavior. This study estimates the prevalence of walking to school and related barriers as reported by U.S. parents. Data from the 2017 SummerStyles, a Web-based survey conducted on a nationwide sample of U.S. adults, were analyzed in 2017. Parents of children aged 5–18 years (n = 1137) were asked whether their youngest child walked to or from school during a usual school week and what barriers make this difficult. Frequencies are presented overall and by parent characteristics. About 1 in 6 parents (16.5%) reported their youngest child walks to or from school at least once during a usual week. Prevalence differed by parental race/ethnicity, marital status, region, and distance from school. The most common barrier was living too far away (51.3%), followed by traffic-related danger (46.2%), weather (16.6%), “other” barrier (14.7%), crime (11.3%), and school policy (4.7%). The frequency at which parents reported certain barriers varied by their child's walking status, distance to school, age of youngest child, race/ethnicity, education level, household income, and metropolitan statistical area status. However, the relative ranking of barriers did not differ by these characteristics. Prevalence of walking to school is low in the U.S., and living too far away and traffic-related danger are common barriers reported by parents. Implementing Safe Routes to School programs and other initiatives that utilize strategies to overcome locally-relevant barriers could help increase the prevalence of children walking to school.

Trends in Costs of Depression in Adults with Diabetes in the United States: Medical Expenditure Panel Survey, 2004-2011.

To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one of four categories of comorbid depression: no depression, unrecognized depression, asymptomatic depression, or symptomatic depression. Data from the 2004-2011 Medical Expenditure Panel Survey (MEPS) was used to create nationally representative estimates. The dependent variable was total healthcare expenditures for the calendar year, including office-based, hospital outpatient, emergency room, inpatient hospital, prescription, dental, and home health care expenditures. The 2004-2011 direct medical costs were adjusted to a common 2014 dollar value. The primary independent variable was four mutually exclusive depression categories created from ICD-9-CM codes and the PHQ-2 depression screening tool. Healthcare expenditures were estimated using a two-part model and were adjusted for age, sex, race, marital status, education, health insurance, metropolitan statistical area status, region, income level, and comorbidities. Based on a national sample of adults with diabetes (unweighted sample of 15,548, weighted sample of 17,465,579), 10.2 % had unrecognized depression, 13.6 % had asymptomatic depression, and 8.9 % had symptomatic depression. In the pooled sample, after adjusting for covariates, the incremental cost of unrecognized depression was $2872 (95 % CI 1660-4084), asymptomatic depression increased by $3347 (95 % CI 2568-4386), and symptomatic depression increased by $5170 (CI 95 % 3610-6731) compared to patients with no depression. Adjusted analyses showed that expenditures were $2000-3000 higher for unrecognized and asymptomatic depression than no depression, and $5000 higher for symptomatic depression. Higher medical expenditures persisted over time, with only symptomatic depression showing a sustained decrease over time.

Presence of Medical Home and School Attendance: An Analysis of the 2005‐2006 National Survey of Children With Special Healthcare Needs

Children with special healthcare needs (CSHCN) tend to miss more school because of illness. Medical homes are a model of primary health care that coordinate services to better meet the needs of the child. The purpose of this study was to examine the association between presence of medical home and missed school days among CSHCN. A secondary analysis of cross-sectional data from the 2005 National Survey of Children With Special Healthcare Needs (NS-CSHCN) was conducted. Multivariate ordinal logistic regression was done to analyze the relationship between presence of a medical home and number of missed school days. The presence of a medical home among CSHCN was associated with being in the highest category of missed school days. The adjusted odds ratios for the number of missed school days, after adjustment for poverty, metropolitan statistical area status, education in the household, age, race and ethnicity, demonstrated that access to a medical home does not decrease school absences. Although the data did not support the hypothesis that CSHCN with a medical home would have fewer missed school days due to illness, this study does evoke future research questions, such as what is the relationship between parental perception of child health status with number of missed school days and how adequate is the communication between families and healthcare providers in the medical home.

Exogenous Predictors of National Performance Measures for Emergency Department Crowding

We explore the relationship between exogenous-level predictors and performance on 4 emergency department (ED) throughput measures approved by the National Quality Forum: median ED length of visit for admitted and discharged patients, median waiting time, and rate of left without being seen. We seek to find predictors for benchmarking and public reporting. This was a study of 424 US hospitals that reported data to the National Hospital Ambulatory Care Survey in 2008 to 2009. Wald F tests and generalized linear models were used to test the relationship between exogenous variables (case mix, age mix, ED volume, teaching status, and Metropolitan Statistical Area status) and performance on the measures. Median waiting time was 35 minutes (95% confidence interval [CI] 26 to 43 minutes), median length of visit for patients treated but not admitted was 131 minutes (95% CI 121 to 142 minutes), median length of visit for patients admitted was 244 minutes (95% CI 218 to 270 minutes), and rate of left without being seen was 1.3% (95% CI 0.9% to 1.8%). Most exogenous variables, including ED volume, Metropolitan Statistical Area, teaching hospital status, age mix, and case mix, demonstrated significant association with waiting times and lengths of visit. Older age and a higher proportion of respiratory complaints were associated with differences in rates of left without being seen. Several exogenous factors outside of a hospital's control are associated with National Quality Forum-approved ED performance measures, which will have important implications for future benchmarking and public reporting of these data.

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

Comparisons of Intimate Partner Violence Among Partners in Same-Sex and Opposite-Sex Relationships in the United States

Using 2005-2007 Behavioral Risk Factor Surveillance System data, we examined intimate partner violence (IPV) by same-sex and opposite-sex relationships and by Metropolitan Statistical Area status. Same-sex victims differed from opposite-sex victims in some forms of IPV prevalence, and urban same-sex victims had increased odds of poor self-perceived health status (adjusted odds ratio=2.41; 95% confidence interval=1.17, 4.94). Same-sex and opposite-sex victims experienced similar poor health outcomes, underscoring the need both of inclusive service provision and consideration of sexual orientation in population-based research.

Clinical Practice Characteristics of Osteopathic and Allopathic Primary Care Physicians at Academic Health Centers: Results From the National Ambulatory Medical Care Survey

To explore characteristics of patient visits to osteopathic physicians (DOs) and allopathic physicians (MDs) in the provision of ambulatory primary care services at academic health centers (AHCs) relative to non-AHC sites. Physicians report patient visits to the National Ambulatory Medical Care Survey (NAMCS). The authors used NAMCS data (2002-2006) to statistically estimate, characterize, and compare patient visits of four physician provider type- and AHC site-specific subgroups: DOs and MDs at non-AHC sites, and DOs and MDs at AHC sites. The 134,369 patient visits reported in the NAMCS database represented 4.57 billion physician office visits after the authors applied patient weights. These visits included 2.03 billion primary care patient visits (205.1 million DO visits and 1.77 billion MD visits at non-AHC sites; 5.8 million DO visits and 52.3 million MD visits at AHC sites). Practicing at an AHC site appeared to change the dynamic of the patient visit to an osteopathic physician. Most notably, these changes involved patient demographics (sex), patient visit context (practice metropolitan statistical area status, patient symptom chronicity, and injury as reason for the visit), and medical management (diagnostic testing, frequency and intensity of ordering drugs, and use of osteopathic manipulative treatment). Evidence suggests that osteopathic physicians in community, non-AHC settings offer a more distinctive osteopathic approach to primary care than osteopathic physicians at AHC sites, which both indicates a need for further research to explain this phenomenon and has potentially important implications for osteopathic medical education.

Dispensing Pattern of Generic and Brand-Name Drugs in Children

To describe the dispensing patterns of generic and brand-name drugs in children and to identify patient sociodemographic characteristics associated with generic drug use. We analyzed data from the 2002 Medical Expenditures Panel Survey. This survey is conducted by the Agency for Healthcare Research and Quality and consists of a nationally representative sample of civilian noninstitutionalized population of the United States. The 2002 survey included 14 828 families and 37 418 individuals, 11 099 of whom were children 0 to 17 years of age. Our unit of analysis was individual prescription drugs dispensed to children 0 to 17 years of age. The main dependent variable for the logistic model was the use of generic drugs. Independent variables included age, gender, race, insurance type, family income, Metropolitan Statistical Area status, and health status. Generic drugs were filled in 40.6% of the 24 465 prescriptions analyzed. Average expenditure for generic drugs was $20.92 (SD 24.53) per prescription versus $71.65 (SD $170.22) for brand-name drugs. Use of generic versus brand-name drugs varied by conditions and medication class. Uninsured patients were more likely than privately insured patients to have a generic drug dispensed than brand-name drugs (odds ratio [OR] 1.42; 95% confidence interval [CI], 1.10-1.84). Asian children were more likely than white children to receive generic drugs (OR, 1.66; 95% CI, 1.07-2.57). Girls were also more likely than boys to receive generic drugs over brand-name drugs (OR, 1.36; 95% CI, 1.08-1.73). Generic drugs were dispensed more often to uninsured children, Asian children, and girls.