Nonmetro Areas Research Articles

Abstract B037: Reach of digital interventions to address disparities in repeat lung cancer screening in Washington State

Abstract Lung cancer is the leading cause of cancer morbidity and mortality in the United States. Annual screening with low-dose computed tomography (LDCT) reduces lung cancer mortality. However, annual adherence to screening is suboptimal. To improve annual adherence to lung cancer screening (LCS), additional patient education beyond shared-decision making is needed to normalize the screening process. Interventions which leverage digital modes of delivery might have broad reach, but only if patients actively engage with messages from clinical providers. Furthermore, there may be disparities in access to digital communication by patient demographics which will need to be addressed to advance health equity through digital technology. The objective of this study was to understand factors associated with engagement with patient portal messaging. This study was nested within a pragmatic clinical trial to test the “Patient Voices Video” relative to usual care to determine if participants opened video intervention communication delivered through the patient portal. The video-based intervention (Patient Voices Video) incorporated patient testimonials to acknowledge LCS receipt, reminds patients they are due in 12 months for next scan, and reassurance to reduce fear of LCS and role of loved ones to support health choices. Study participants were Kaiser Permanente Washington members aged 50-78 years with recent normal LCS scan and were randomized to either Patient Voices Video or usual care. Study analyses were restricted to those assigned to video arm. Participants randomized to the video arm received a web link via a patient portal message 3 weeks after normal scan. We generated descriptive statistics to summarize differences in proportions in pre-specified demographic factors associated with opening the video message in the patient portal among those in the video arm and registered in patient portal (n=614). Overall, 85% of participants opened their patient portal message. Patient factors associated with not opening patient portal message included: current tobacco use (currently smoking 56% in group that did not open portal message vs 42% in group that opened portal message) and race/ethnicity (18% non-White in group that did not open portal message vs 10% in group that opened portal message). A higher proportion (8%) of those in non-metro areas opened portal message compared to 3% not opening message. There were no differences in likelihood of opening the portal message by age, sex, prior LCS experience, or area deprivation. Patient portal messages can be a successful delivery mode for LCS interventions with high utilization, but disparities in reach are still prevalent by race and ethnicity and tobacco status. Citation Format: Anjali Vasavada, Lorella Palazzo, Matthew Triplette, Hongyuan Gao, Melissa Anderson, Casey Luce, Yu-Ru Su, James Ralston, Kristine Rogers, Nadia Bezman, Beverly B Green, Lisa Carter-Bawa, Karen J Wernli. Reach of digital interventions to address disparities in repeat lung cancer screening in Washington State [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B037.

Abstract P314: A Community Outreach Program Focused on Hypertension Awareness Reaches 600+ People in Rural Georgia and Works to Build the Next Generation of Biomedical Scientists

The U.S. national average for the prevalence of hypertension in women aged 35-44 is 10.8%. In southeastern states including Georgia, Mississippi, and South Carolina, the prevalence of hypertension in women of this same age group is 13.5%, 17.8%, and 15.5%, respectively. The increase is mostly observed in Black women from non-metro areas. Thus, a need exists to improve awareness of cardiovascular risk in these communities and to support scientific research to improve the understanding of how sex contributes to differences in cardiovascular risk factors like hypertension. Rural Obese At Risk (ROAR) establishes a Specialized Center of Research Excellence on Sex Differences (SCORE) homed at Augusta University, spanning three Southeast universities. The overall goal is to establish ROAR as a national resource and recognized leader in cardiovascular disease in females, and to change perceptions and awareness surrounding cardiovascular risk in women across the Southeast, particularly in high-risk groups. One objective of ROAR Augusta is to establish a community outreach pipeline of trained scientists to increase awareness of sex as a biological variable (SABV), promote optimal cardiovascular healthcare for men and women, and empower the community to self-monitor and identify barriers to improving access to healthcare through the Community Engagement Core (CEC). The CEC aims to develop meaningful relationships among the research, medical, and lay communities promoting the increase of awareness of the importance of blood pressure control in women through community outreach, a Qualitative Needs Assessment, design and dissemination of unique illustrative educational materials related to cardiovascular disease in women, and the launch of a Blood Pressure Checks for Women campaign. In six months (December 2023 – May 2024), ROAR participated in 10 community events providing blood pressure checks and educational materials and reaching more than 600 people in 6 counties; awarded one pre-doctoral career enhancement mini-sabbatical; awarded three early career SABV pilot grants; hosted a SABV symposium reaching 120 biomedical scientists; and hosted a SABV seminar and workshop reaching 142 biomedical scientists. In conclusion, the ROAR CEC is well on its way to positively impacting hypertension perceptions and awareness in women across the Southeast.

Epidemiology of drug arrests in the United States: Evidence from the national survey on drug use and health, 2015–2019

ObjectiveFollowing changes to drug criminalization policies, we re-examine the epidemiology of drug arrests among people who use drugs (PWUD) in the U.S. MethodsSerial cross-sectional data from the National Survey on Drug Use and Health (2015–2019) were utilized. Past-year illicit drug use (excluding cannabis) and drug arrests were described by year, area of residence, drug use characteristics and participant demographics. Adjusted associations between race and drug arrest were estimated using multivariable logistic regression. ResultsPast-year illicit drug use remained consistent over time and was highest among non-Hispanic (NH) white respondents. Of those reporting past-year illicit drug use (n = 25,429), prevalence of drug arrests remained stable over time overall and in metro areas while increasing in non-metro areas. Arrests were elevated among NH Black participants and those with lower income, unemployment, housing transience, non-metro area residence, polysubstance use, history of drug injection, substance use dependence and past-year drug selling. Adjusted odds of drug arrest remained significantly higher among NH Black individuals [aOR 1.92, 95% CI 1.30, 2.84]. ConclusionDespite recent shifts away from punitive drug policies, we detected no reduction in drug arrests nationally and increasing prevalence in non-metro areas. Despite reporting the lowest level of illicit substance use and drug selling, NH Black individuals had significantly increased odds of arrest across years. Findings highlight the need for further examination of policy implementation and policing practices in different settings, with more research focused non-metro areas, to address enduring structural racism in drug enforcement and its consequences for health.

Trends and Variations in Pancreatic Cancer Mortality Among US Metro and Nonmetro Adults, 1999-2020.

Pancreatic cancer is the third leading cause of cancer deaths in the United States. Despite decreasing cancer mortality rates as a whole, pancreatic cancer death rates in the United States remain steady and demonstrate racial/ethnic disparities. Divergent cancer mortality trends have also been observed between metro and nonmetro populations. We therefore aimed to compare metro and nonmetro trends in pancreatic cancer mortality rates in the United States from 1999 to 2020 and investigate potential sex and racial/ethnic differences. We analyzed National Center for Health Statistics data for all pancreatic cancer deaths among individuals aged 25 years or older in the United States. We estimated the average annual percent change (AAPC) in age-standardized pancreatic cancer mortality rates in metro versus nonmetro areas by sex and race/ethnicity. Of the total 810,425 pancreatic cancer-related deaths identified from 1999 to 2020, 668,547 occurred in metro areas and 141,878 in nonmetro areas. Non-Hispanic Black individuals had the highest rates of pancreatic cancer mortality regardless of metropolitan status. In both metro and nonmetro areas, pancreatic cancer mortality rates among non-Hispanic White individuals increased over the study period (AAPC: metro, males, 0.32%; females, 0.27%; nonmetro, males, 0.77%; females, 0.62%). Non-Hispanic Black individuals in metro areas had a decrease in pancreatic cancer mortality (AAPC: males, -0.25%; females, -0.29%), but rates among non-Hispanic Black women in nonmetro areas increased (AAPC, 0.49%). There are variations not only in pancreatic cancer mortality by metro and nonmetro status but also by sex and race/ethnicity within these areas. Individuals who live in nonmetro areas have higher pancreatic cancer mortality rates and increasing death rates compared with their metro counterparts. These findings highlight the need for targeted cancer prevention strategies that are specific to metro or nonmetro populations.

Rural Employment Disparities by Race, Ethnicity, and Region

This FEDS Note explores racial and regional differences in metro-nonmetro employment disparities by looking at employment rates by age, sex, race and ethnicity, and region. It finds substantial differences in the metro-nonmetro employment gap across racial and ethnic groups, with Black or African American and American Indian and Alaska Native men and women having much lower employment rates in nonmetro areas relative to their metro peers.

Strengths and opportunities to clinical trial enrollment among BIPOC, rural dwelling patients in the northwest United States: a retrospective study.

Introduction: Clinical trials investigating the safety and efficacy of experimental drugs and devices are the cornerstone of medicinal advancement. Enrolling sufficient participants in these trials is vital to ensure adequate statistical power and generalizability. Clinical trial participation is particularly low among certain populations, including medically underserved communities (i.e., rural areas) and Black, Indigenous, and People of Color (BIPOC). Methods: A retrospective study design was used to understand patient outcomes and access/barriers to clinical trial participation in the rural northwest United States. A quantitatively focused retrospective chart review was conducted for adult participants enrolled in at least one clinical trial in a single northwest health system between 1999 and 2022. Descriptive and inferential statistical analyses were performed to assess trial outcomes at a significance level 0.05. Results: The retrospective chart review yielded 833 clinical trial records with 753 individual enrolled participants. The all-cause relative frequency of death at last known follow-up amongst clinical trial participants was 8.90% (n = 67). Based on logistic regression, the death was significantly associated with the participants' age at initial trial screening (β = 0.09, p-value <0.001), those that resided in non-metro areas (β = -0.86, p-value = 0.045), and those that lived in Northeastern Montana (β = 1.27, p-value = 0.025). Additionally, death at last known follow-up was significantly associated with enrollment in 2021-2022 (β = -1.52, p-value <0.001), enrolled in more than one study (β = 0.84, p-value = 0.023), in internationally sponsored trials (β = -2.08, p-value <0.001), in Phase I (β = 5.34, p-value <0.001), in Phase II trials (β = 1.37, p-value = 0.013), diabetes as a primary trial target (β = -2.04, p-value = 0.003). Conclusion: As decentralized trial design and remote or virtual elements of traditional trials become normative, representation of rural and frontier populations is imperative to support the generalizability of trial data encouraged by the FDA.

Schizophrenia spectrum disorders in India: A population-based study.

Schizophrenia spectrum disorders represent a significant global health concern, contributing significantly to the global burden of disease. The National Mental Health Survey (NMHS) of India, conducted between 2015 and 2016, investigated the prevalence and epidemiological correlates of schizophrenia spectrum disorders in India. The NMHS conducted a population-based cross-sectional study in 12 Indian states from 2015 to 2016, encompassing 34,802 adults. The overall study design of the NMHS was a multistage, stratified, random cluster sampling technique, incorporating random selection based on probability proportion to size at each stage. The Mini-International Neuropsychiatric Interview 6.0 was used for psychiatric diagnoses, disability was assessed using Sheehan's disability scale, and the illness-related socioeconomic impact was assessed using a questionnaire based on the World Health Organization Disability Assessment Schedule 2.0. Firth penalized logistic regression was employed to understand the correlates of current schizophrenia spectrum disorder. The study found a lifetime prevalence of schizophrenia spectrum disorders at 1.41%, with a current prevalence of 0.42%. A substantial treatment gap of 72% existed for current cases, rising to 83.3% in urban non-metro areas. The penalized logistic regression revealed that the age group category of 30-49 years, unemployed status, and lower education level had higher odds of association with schizophrenia spectrum disorders. The primary finding of this study is a lifetime prevalence of 1.41%, a current prevalence of 0.42%, and a substantial treatment gap of 72%. Addressing this treatment gap and holistic intervention is crucial for reducing the socioeconomic impact of this disorder. Strengthening the National Mental Health Program and implementing community-based rehabilitation are essential first steps in this direction.

Metro-Nonmetro Differences in Adverse Events in Residential Care Communities: Results From the National Post-Acute and Long-Term Care Study.

More than 1 in 5 older Americans live in rural areas (10.6 million of the 46.2 million aged 65 and older). Long-term care for aging rural populations is a growing challenge in the United States. Research on long-term care services in nonmetro areas has focused almost exclusively on nursing home care, despite growth of residential care alternatives. This paper uses unique facility-level data from the 2020 National Post-acute and Long-term Care Study (NPALS) to examine the relationship of residential care community (RCC) features in metro and nonmetro settings with adverse outcomes (emergency department visits, overnight hospital stays, and falls). Nationally, in 2020, about 13.5% of RCC residents made visits to the emergency department, 8.6% had overnight hospital stays, and 21.3% had falls. Controlling for facility characteristics, RCCs in metro areas had higher risks of overnight hospital stays (p < .001) but lower risks of falls (p = .06).

Closing the gap: Technology access and telehealth use among older adults in the U.S. Medicare beneficiaries

The use of digital technology offers numerous benefits for older individuals. However, failure to access technology could result in missed resources and opportunities, with some in this age group being hesitant to adopt new technology due to unfamiliarity or fear. Telehealth, as a form of digital technology, holds the potential to overcome geographic and temporal limitations, enabling socially isolated and physically homebound older adults to access a broader spectrum of healthcare options. Despite the potential advantages, the availability, acceptability, and accessibility of telehealth interventions for aging care remain unclear. This study aims to examine the impact of digital technologies on access to health and social care for older adults while identifying socioeconomic factors that may hinder access to services. We utilized the 2021 Medicare Current Beneficiary Survey COVID-19 Winter Supplement Public Use File dataset and the total sample size was 10,592 Medicare beneficiaries aged 65 years and above. Several statistical analyses, including multivariable logistic regression, were conducted. Our findings revealed that individuals from Black non-Hispanic and Hispanic racial and ethnic groups, as well as those with lower income and residing in non-metro areas, had lower odds of using technology devices and accessing the internet, This highlights the need for targeted interventions and policies to promote equitable access to digital resources and healthcare services for all seniors. Moreover, seniors who possess technology devices and have internet access are more inclined to engage with primary care providers (PCPs) who provide telehealth consultations. The study discussed future directions and limitations, providing valuable insights into the intersection of digital technology, healthcare access, and socioeconomic factors for older adults.

Association of Provider Zip Code Sociodemographic Characteristics with Radiation Therapy Modality Use in the Medicare Population

Variations in healthcare delivery by provider and patient-level characteristics have been well studied in the US health system as a whole, though these patterns are not as well defined in radiation oncology. We evaluated the association of provider zip-code level sociodemographic characteristics with variations in radiation therapy (RT) modality use. We used the Centers for Medicare & Medicaid Services (CMS) Physician and Other Supplier Public Use File, CMS Physician Compare, and National Neighborhood Data Archive databases to link non-facility based radiation oncologists and their submitted Medicare charges in 2020 with sociodemographic information of the provider's zip code. We selected radiation oncologists who submitted for any of the following RT treatments: proton RT (PRT), stereotactic body RT (SBRT), intensity modulated RT (IMRT), 3D conformal RT (3DCRT), and brachytherapy (BT). Sociodemographic covariates included predominant race/ethnicity of area (Black, White, or Hispanic), percentage of population earning above $75,000 annually, provider rurality (metropolitan vs non-metropolitan), and predominant education level attained of area (Bachelor's degree vs no Bachelor's degree). We measured the association of these covariates with the use of different RT modalities with multivariable logistic regression. We identified 1,126 radiation oncologists for analysis. PRT was more likely to be used by providers in areas with a predominantly Black population compared with providers in areas with a predominantly White or Hispanic population (Black as reference, White odds ratio (OR) 0.11; 95% CI 0.05-0.24; Hispanic OR 0.23; 95% CI 0.08-0.56). IMRT was more likely to be used by providers in areas with a predominantly White or Hispanic population compared with providers in areas with a predominantly Black population (White OR 3.40; 95% CI 1.63-6.78; Hispanic OR 2.46; 95% CI 1.04-5.97). SBRT was less likely to be used in non-metro areas compared with metro areas (OR 0.28, 95% CI 0.12-0.56). The annual income measure was not associated with any RT modality. Providers in areas with predominantly Bachelor's degree attained were more likely to use PRT (Bachelor's degree as reference, OR 0.34; 95% CI 0.17-0.64) and less likely to use SBRT (OR 1.53; 95% CI 1.04-2.26), IMRT (OR 2.04; 95% CI 1.20-3.48), and 3DCRT (OR 1.52; 95% CI 1.04-2.22). No covariates were associated with BT use. We identified notable variations in RT delivery with multiple sociodemographic factors. A predominantly Black population was associated with a higher likelihood of PRT use, and BT use was not associated with any sociodemographic covariate. These findings might reflect reduced barriers to care afforded by the universal healthcare setting of Medicare or ongoing improvements in RT delivery with respect to previously identified health disparities. Additional work is needed to further elucidate these patterns of RT use and determine if they represent effective care.

Evolving Trends in US Mortality from Opioid Overdose: Heroin and Beyond

ObjectiveOur objective was to explore evolving trends in US drug overdose mortality, overall and by age, sex, race, urbanization, and geography from 1999-2020. MethodsThis is a descriptive epidemiologic study. We used the US Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research and Multiple Cause of Death files from the National Center for Health Statistics. We used crude and age-adjusted cause of death and mortality rate ratios as measures of effects and 95% confidence limits to test for significance. ResultsFrom 1999-2020, drug overdoses caused 1,013,852 deaths and 4.3-fold increase in mortality rate ratios. Subgroup findings were sex (4.5 men, 4.0 women), race (4.6 White, 3.9 Black or African American, 4.0 Asian or Pacific Islanders, 5.1 Native Americans or Alaskan Natives), age (highest 5.6 in 25-34 years, lowest 1.1 in 75-84, and 0.77 in 85+), geography (highest 6.0 in Midwest, lowest 2.6 in West), and urbanization (highest 6.2 in non-metro, lowest 3.7 in metro). ConclusionsDrug overdoses in the United States from 1999-2020 increased 4.3-fold, with the highest increase in White and Native American or Alaskan Native populations, and Midwest and non-metro areas. The data create preventive and therapeutic challenges, including restrictions on pharmaceutical industries and enhanced efforts by health care providers in safer prescribing. Addiction care should be integrated into all clinical practices, regardless of specialty, and into undergraduate, graduate, and continuing medical education. Targeted interventions are needed to adequately assess patients and provide care. Analytic studies designed a priori are necessary to test hypotheses formulated from these data.

High-speed internet access and diffusion of new technologies in nonmetro areas

Using Federal Communications Commission internet data during the period 2014–2021, this paper studies high-speed internet access across metro and nonmetro areas by technology types. The paper develops the measures of the tract-level availability of a technology, based on the number of internet service providers of the technology in each census block. The analysis shows that all technologies had been less available and slower in nonmetro areas than metro areas even after controlling for relevant factors such as household incomes and labor market conditions. In addition, a new technology, namely Cable Modem-DOCSIS (Data Over Cable Service Interface Specifications) 3.1, had replaced an old one, namely Cable Modem-DOCSIS 3.0, in nonmetro areas at much slower rates than in metro areas. The paper then discusses policy implications of the high-speed internet gap.

Migration Across Metro‐Nonmetro Boundaries and Hourly Wages☆

AbstractPrevious scholars have demonstrated that nonmetro residents who move to metro areas earn higher wages. It remains an open question whether this metro wage advantage persists in the contemporary era, and how migrating influences young adults from metro areas. Migrants may earn higher wages due to higher education. Alternatively, they may earn lower wages because they lack social capital. They may experience different associations of migration and wages when growing up in nonmetro versus metro areas due to different family backgrounds, education, and community contexts. This article uses data from the National Longitudinal Study of Youth 97 and multilevel/mixed‐effects models to test these competing predictions. The findings show that young adults earned higher wages if they worked in metro rather than in nonmetro areas, regardless of migration, confirming a metro wage advantage. People who left nonmetro areas earned higher wages than if they stayed, consistent with a “rural brain drain.” In addition, people earned similar wages if they stayed in, returned, and moved from metro to nonmetro areas, even though migrants and returnees had higher average education. The non‐significant wage differences may be due to the less diverse wage structure in nonmetro labor markets and in‐migrants' lack of social capital.

Use of Caregiving Support Services Among Diverse Dementia Caregivers by Geographic Context.

Little is known about how race/ethnicity and geographic context relate to support service use among dementia caregivers. Our objectives were to investigate (a) whether the use of at least one formal caregiving service-support groups, respite care, and training-differed by race/ethnicity and across metro and nonmetro areas; and (b) whether predisposing, enabling, and need characteristics influenced support service use by race/ethnicity. Data were analyzed from a sample of primary caregivers of care recipients aged 65 years or older with probable dementia (n = 482) in the 2017 National Health and Aging Trends Study and National Study of Caregiving. We calculated weighted prevalence estimates and then used the Hosmer-Lemeshow goodness of fit statistic to find the best-fitting logistic regression models. Among minority dementia caregivers, support service use was higher in metro than nonmetro areas (35% and 15%); the trend was reversed for non-Hispanic White caregivers (47% nonmetro and 29% metro). The best-fitting regression models included predisposing, enabling, and need factors for both minority and non-Hispanic White caregivers. Younger age and more disagreement within the family were consistently associated with more service use in both groups. Among minority caregivers, better caregiver and care recipient health were associated with using support services. Among non-Hispanic White caregivers, nonmetro geographic context and caregiving interfering with valued activities were associated with using support services. Geographic context differently affected support service use and the influence of predisposing, enabling, and need factors varied by race/ethnicity.

Association of medical debt and cancer mortality in the US.

6505 Background: Medical debt is associated with non-medical and medical financial hardship, such as food and housing insecurity, as well as delaying or forgoing recommended health care. This study examines county level associations between medical debt and cancer mortality in the US. Methods: We conducted a county level ecological study, using 2018 medical debt data from the Urban Institute linked with 2015-2019 mortality data from the National Centers for Health Statistics. All US counties with non-missing information on medical debt and other covariates were included. Primary outcomes were age-adjusted mortality rates per 100,000 person-years for all malignant cancers and by cancer type. Multivariable linear mixed models were used to estimate the association of percent of population with medical debt with cancer mortality, adjusting for county level sociodemographic characteristics. Additional analyses examined the association between median amount of medical debt per person and cancer mortality for the subset of counties with these data. Models were weighted by county level population size, with standard errors clustered at the state level. Results: Among 2,943 counties, an average of 19.8% of the population had medical debt, ranging from 0% to 53.6% across counties. Higher percentages of the population with medical debt were observed in non-metro areas, counties with higher percentages of non-Hispanic Black people, adults without high school education, living below poverty level, uninsured, or unemployed. One percentage point increase in the population with medical debt was associated with a 1.12 (95% CI=1.02-1.22) increase in age-adjusted mortality rate (per 100,000 person-years) for all malignant cancers, a 0.47 (95% CI=0.43-0.52) increase for lung cancer, a 0.09 (95% CI=0.07-0.11) increase for colorectal cancer, and a 0.06 (95% CI=0.04-0.07) increase for female breast cancer. Among 1,949 counties with the amount of medical debt available, each $100 increase in median medical debt was associated with a 0.86 (95% CI=0.52-1.21) increase in age-adjusted mortality rate for all malignant cancers. Associations between increases in median medical debt and increased mortality rates were statistically significant for major cancer types. Conclusions: Medical debt is associated with significantly higher cancer mortality at the county level. Policies increasing access to affordable health care may improve cancer outcomes. [Table: see text]

Dementia Caregiving Experiences and Health Across Geographic Contexts by Race and Ethnicity.

Few studies have examined how the intersectionality of geographic context and race/ethnicity influences dementia caregiving. Our objectives were to determine whether caregiver experiences and health (a) differed across metro and nonmetro areas and (b) differed by caregiver race/ethnicity and geography. We used data from the 2017 National Health and Aging Trends Study and National Study of Caregiving. The sample included caregivers (n = 808) of care recipients ages 65 and older with "probable" dementia (n = 482). The geographic context was defined as the care recipient's residence in metro or nonmetro counties. Outcomes included caregiving experiences (care situation, burden, and gains) and health (self-rated anxiety, depression symptoms, and chronic health conditions). Bivariate analyses indicated that nonmetro dementia caregivers were less racially/ethnically diverse (82.7% White, non-Hispanic) and more were spouses/partners (20.2%) than their metro counterparts (66.6% White, non-Hispanic; 13.3% spouses/partners). Among racial/ethnic minority dementia caregivers, nonmetro context was associated with more chronic conditions (p < .01), providing less care (p < .01), and not coresiding with care recipients (p < .001). Multivariate analyses demonstrated that nonmetro minority dementia caregivers had 3.11 times higher odds (95% confidence interval [CI] = 1.11-9.00) of reporting anxiety in comparison to metro minority dementia caregivers. Geographic context shapes dementia caregiving experiences and caregiver health differently across racial/ethnic groups. Findings are consistent with previous studies that have shown that feelings of uncertainty, helplessness, guilt, and distress are more prevalent among people providing caregiving from a distance. Despite higher rates of dementia and dementia-related mortality in nonmetro areas, findings suggest both positive and negative aspects of caregiving among White and racial/ethnic minority caregivers.

Unmet mental health need and subsequent substance use in individuals with a history of depression: Are there differences between metro and nonmetro areas?

More than nine million U.S. adults have a co-occurring mental health and substance use disorder. The self-medication hypothesis suggests that individuals with unmet need may alleviate the symptoms of their mental illness by using alcohol or drugs. We examine the relationship between unmet mental health need and subsequent substance use among individuals with a history of depression as well as differences in metro and nonmetro areas. We used repeated cross-sectional data from the National Survey on Drug Use and Health (NSDUH), 2015-2018 after identifying individuals with depression in the past year (n = 12,211). We used logistic regressions with interaction terms to examine the association between unmet need for mental health care and substance use by geographic location. Unmet mental health need was associated with increased use of marijuana (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.08-1.64), illicit drugs (OR = 1.75, 95% CI: 1.19-2.58), and prescription drugs (OR = 1.89, 95% CI: 1.19-3.00) among individuals with depression, which did not vary by geographic location. Unmet need was not associated with increased heavy alcohol drinking (OR = 0.87, 95% CI: 0.60-1.26). No differences in substance usage between metro and nonmetro populations were observed for those with an unmet need for mental health care. We found support for the self-medication hypothesis among individuals with depression with respect to alcohol. We examine whether individuals with depression and unmet care needs are more likely to self-medicate with substances including prescription drugs. Due to higher unmeet needs in nonmetro areas, we examine whether the likelihood of self-medication differs in metro and nonmetro areas.

Disparities in Medicare beneficiaries' receiving medication synchronization.

Medication synchronization (med-sync) aligns patients' monthly or quarterly chronic medications to a predetermined single pickup date at a community pharmacy. The study objective was to examine med-sync enrollment disparities based on Medicare beneficiaries' predisposing, enabling, and need characteristics. This was a retrospective cohort study using a Medicare dataset of beneficiaries receiving medications from pharmacies that self-identified as providing med-sync. Medicare beneficiaries who were continuously enrolled in fee-for-service medical and pharmacy benefits during the study period (2014-2016) were included. Study cohorts (med-sync and non-med-sync patients) were defined, and bivariate and multivariable logistic regression analyses were performed. Andersen's Health Services Utilization Model guided our inclusion of predisposing, enabling, and need characteristics to examine for association with med-sync enrollment. A total of 170,180 beneficiaries were included, of which 13,193 comprised the med-sync cohort and 156,987 comprised the non-med-sync cohort. Bivariate logistic regression analysis revealed statistically significant differences (P < 0.05) in cohorts based on age, geographic region, type of residence, number of unique chronic medications, comorbidities, outpatient visits, and inpatient hospitalizations. Beneficiaries had higher odds of being enrolled in med-sync with increasing age (adjusted odds ratio [AOR] 1.003 [95% CI 1.001-1.005]) and if they resided in the Northeast (AOR 1.094 [95% CI 1.018-1.175]), South (AOR 1.109 [95% CI 1.035-1.188]), and West (AOR 1.113 [95% CI 1.020-1.215]) than those in the Midwest. Beneficiaries residing in nonmetro areas had lower odds of enrollment (AOR 0.914 [95% CI 0.863-0.969]) than those in metro areas. Beneficiaries with previous fewer inpatient hospitalizations (AOR 0.945 [95% CI 0.914-0.977]) were more likely to be enrolled, and those with more outpatient visits (AOR 1.003 [95% CI 1.001-1.004]) were more likely to be enrolled. Those taking a higher number of oral chronic medications (AOR 1.005 [95% CI 1.002-1.008]) had greater odds of enrollment in med-sync. Med-sync program expansion opportunities exist to address potential enrollment disparities based on age, geographic region, metropolitan area, and prior health utilization. Further studies are needed to develop and examine strategies among pharmacies to improve med-sync enrollment outreach to these subgroups of patients.

Social Determinants, Cardiovascular Disease, and Health Care Cost: A Nationwide Study in the United States Using Machine Learning.

Background Existing studies on cardiovascular diseases (CVDs) often focus on individual-level behavioral risk factors, but research examining social determinants is limited. This study applies a novel machine learning approach to identify the key predictors of county-level care costs and prevalence of CVDs (including atrial fibrillation, acute myocardial infarction, congestive heart failure, and ischemic heart disease). Methods and Results We applied the extreme gradient boosting machine learning approach to a total of 3137 counties. Data are from the Interactive Atlas of Heart Disease and Stroke and a variety of national data sets. We found that although demographic composition (eg, percentages of Black people and older adults) and risk factors (eg, smoking and physical inactivity) are among the most important predictors for inpatient care costs and CVD prevalence, contextual factors such as social vulnerability and racial and ethnic segregation are particularly important for the total and outpatient care costs. Poverty and income inequality are the major contributors to the total care costs for counties that are in nonmetro areas or have high segregation or social vulnerability levels. Racial and ethnic segregation is particularly important in shaping the total care costs for counties with low poverty rates or social vulnerability level. Demographic composition, education, and social vulnerability are consistently important across different scenarios. Conclusions The findings highlight the differences in predictors for different types of CVD cost outcomes and the importance of social determinants. Interventions directed toward areas that have been economically and socially marginalized may aid in reducing the impact of CVDs.

RESOURCES AND EXPERIENCES AMONG DIVERSE DEMENTIA CAREGIVERS BY GEOGRAPHIC CONTEXT

Abstract Rural caregivers are often underserved by caregiving services, yet little is known about how the intersectionality of geographic context and race/ethnicity relates to caregiving resources among dementia caregivers. We examined whether 1) caregiving resources and experiences differ across metro and non-metro areas; and 2) the use of caregiving resources is associated with geographic context by race/ethnicity, controlling for age, gender, and education. We analyzed a sample of caregivers of care recipients aged 65 years or older with ‘probable’ dementia (n= 808) in the 2017 National Health and Aging Trends Study (NHATS) and the associated National Study of Caregiving (NSOC). We defined geographic context by the recipient’s residence in metro (urban) or non-metro (rural) counties and grouped formal (respite care, support groups, caregiving training) and informal (family or friend help) resources. Among minority caregivers, 47% of those living in metro and 36% in non-metro areas used a formal service, and 83% and 72%, respectively, used informal resources. Among White caregivers, estimates were 44%, 48%, 76%, and 66%, respectively. Multivariate regression analyses revealed that non-metro White dementia caregivers had 2.04 times higher odds (95% CI=1.10-3.78) of using formal resources than metro White dementia caregivers. This pattern was not observed among minority dementia caregivers. The use of informal resources did not differ across geographic contexts by race/ethnicity. Findings suggest the influence of geographic context on the use of formal caregiving resources varies by race/ethnicity. With higher rates of dementia in non-metro areas, formal caregiving resources among non-metro minority dementia caregivers need more attention.