Rural-urban Continuum Research Articles

Shifting of opioid prescription rate reporting impacts both rural and urban counties.

CDC annual reporting of opioid prescriptions per capita are key data used by systems for tracking opioid utilization and deaths. These data go back to 2006 and are measured at county-level resolution. Researchers and policy makers regularly use these data as inputs to models for tracking opioid trends geographically. Recent changes in reporting of these data from the dispenser to provider cause a longitudinal break in the ability for data users to evaluate data points pre and post-change. This report examines the geographical impact of the data change in the context of both rural and urban counties. Data were segmented by county and tied to corresponding USDA rural-urban continuum codes for comparison. Opioid prescription data provides a distinct view into the opioid epidemic that allows all states and counties to view the trends of opioid utilization within their areas compared to themselves longitudinally as well as others. The reporting format change causes a break in the ability for communities to connect data before and after the change, especially in rural counties. Researchers and policy makers need to be aware of the changes in opioid reporting metrics to avoid drawing false conclusions. In most cases, data before 2019 cannot be compared to later data points. The policy change in reporting significantly alters the ability to longitudinally analyze and connect information when examining county-level data. State-level trends are not impacted by this reporting change.

Rural disparities in oncology patient portal enrollment and use.

6557 Background: Patient portals support patient access, engagement, and care coordination, yet could also widen the digital divide and exacerbate disparities among vulnerable populations. There is emerging evidence that racial/ethnic minority patients are less likely to use portals, yet prior research has not examined potential rural differences. We identified sociodemographic factors associated with portal enrollment and use among a racially and geographically diverse population of cancer patients. Methods: We retrospectively examined portal enrollment and use at an NCI-designated comprehensive cancer center from January 2015 until February 2022 among patients 18+ years old with a neoplastic disease diagnosis (ICD-10-CM C00-D49). Potential predictors included gender, race/ethnicity, marital status, age, rural (Rural-Urban Continuum Codes [RUCC] 4-9) vs nonrural (RUCC 1-3) residence, residential distance from the cancer center, and time since diagnosis. We used multivariable logistic regression to generate odds ratios (ORs) for portal enrollment and having ever sent a portal message, and Poisson regression to determine incidence rate ratios (IRRs) for number of logins and number of healthcare team interactions (portal messages or appointment requests), controlling for ICD-10 diagnosis (SAS 9.4). Results: We identified 11,333 patients (average age 67 years, 59% female, 24% rural, 10% Non-Hispanic Black, 1% Hispanic, 20% non-melanoma skin cancer, 14% breast cancer, 9% lung cancer). 36% of patients had enrolled in the portal, and of these, 80% had sent at least one message. Patients logged in a median of 203.5 times and had a median of 19 portal interactions. Rural residents were less likely to enroll in the portal than urban patients (28% vs 38%, p < 0.0001). Non-Hispanic Black patients and Hispanic/Latinx patients were less likely to enroll in the portal compared with non-Hispanic White patients (22% and 27%, respectively, vs 38.5%, p < 0.0001). Women, younger patients, more recently diagnosed cancer patients, and patients who were married/ partnered were significantly more likely to enroll. In multivariable analysis controlling for cancer type, rural patients were half as likely to enroll in the portal (OR: 0.48 [0.43-0.54]). Among those enrolled, rural residents were 25% less likely to have ever sent a portal message (OR: 0.75 [(0.62-0.92]), and had nearly half the login and interaction rates (IRR: 0.66 [0.66-0.67]; IRR: 0.58 [0.58-0.59], respectively). Patients who were Non-Hispanic Black, Hispanic, or unmarried were also significantly less likely to enroll or engage in the portal. Conclusions: Patient portals remain underutilized among cancer patients, despite an increased reliance on virtual communications in the COVID era. Interventions to support portal engagement among rural residents and racial/ethnic minority patients are needed to avoid potentially exacerbating health disparities.

Urban-rural disparities in childhood obesogenic environments in the United States: Application of differing rural definitions.

Research is needed that identifies environmental resourcedisparities and applies multiple rural definitions. Therefore, this study aims to examine urban-rural differences in food and physical activity(PA) environment resource availability by applying several commonly used rural definitions. We also examine differences in resourceavailability within urban-rural categories that are typically aggregated. Six food environment variables (access to grocery/superstores, farmers' markets, fast food, full-service restaurants, convenience stores, and breastfeeding-friendly facilities) and 4 PA environment variables (access to exercise opportunities and schools, walkability, and violent crimes) were included in the childhood obesogenic environment index (COEI). Total COEI, PA environment, and food environment index scores were generated by calculating the average percentile for related variables. US Department of Agriculture Urban Influence Codes, Office of Management and Budget codes, Rural-Urban Continuum Codes, Census Bureau Population Estimates for percent rural, and Rural Urban Commuting Area Codes were used. One-way ANOVA was used to detect urban-rural differences. The greatest urban-rural disparities in COEI (F=310.2, P<.0001) and PA environment (F=562.5, P<.0001) were seen using RUCC codes. For food environments, the greatest urban-rural disparities were seen using Census Bureau percent rural categories (food: F=24.9, P<.0001). Comparing remote rural categories, differences were seen for food environments (F=3.1, P=.0270) and PA environments (F=10.2, P<.0001). Comparing metro-adjacent rural categories, differences were seen for PA environment (F=4.7, P=.0090). Findings inform future research on urban and rural environments by outlining major differences between urban-rural classifications in identifying disparities in access to health-promotingresources.

Analysis of Rural Disparities in Ultrasound Access.

PurposeThis work aims to conduct a geospatial analysis of recent ultrasound access and usage within the United States, with a particular focus on disparities between rural and urban areas.Methods/MaterialsMultiple public datasets were merged on a county level, including US Department of Agriculture economic metrics and Centers for Medicare Services data using the most recent years available (2015-2019). From these databases, 39 total variables encompassing the socioeconomic, health, and ultrasound characteristics of each county were obtained. Current Procedural Terminology (CPT) codes incorporated included ultrasound-guided procedures and diagnostic exams. Three thousand eleven counties were included. The combined dataset was then exported to GeoDa for network-based analysis and to produce map visualizations. To identify statistically significant (p < 0.05) hotspots and coldspots in point-of-care ultrasound (POCUS) prevalence, Moran’s I was used. Choropleth maps were created for visualization. ANOVA was run across the four Moran’s I groups for each of 39 variables of interest.ResultsA total of 30,135,085 ultrasound-related CPT codes were billed to Medicare over 2015-2019, with 26.55% of codes being ultrasound-guided procedures and 73.45% being diagnostic exams. 38.84% of rural counties had access to POC ultrasound compared to 88.56% of metropolitan counties and 74.19% of counties overall. Hotspots of POCUS were in Southern California and the Eastern US (average of 1,441 per 10,000 Medicare members per year). Coldspot areas were seen in the Great Plains and Midwest (average of 7.43 per 10k Medicare members per year). Hotspot clusters, when compared to coldspot clusters, were significantly (p < 0.001) more dense (703.6 to 14.9 people per square mile), more urbanized (3.5 to 7.1 Rural-Urban Continuum (RUC)), more college-educated (25.1% to 20.0%), more likely to have an Emergency Department (ED) visit (725.8 to 616.9 visits per 1,000 Medicare members), more likely to be obese (19.0% to 12.9%), less likely to be uninsured (10.1% to 13.0%), had more Black representation (8.5% to 3.4%), and less Hispanic representation (2.6% to 5.5%).ConclusionsUltrasound access and usage demonstrate significant geospatial trends across the United States. Hotspot and coldspot counties differ on several key sociodemographic and economic variables.

Health trade-offs in pursuit of livelihood security: exploring the intersection of climate, migration and health from the perspective of Mekong Delta migrants in Ho Chi Minh City, Vietnam

ABSTRACT As climate change increasingly interacts with socioeconomic development factors to contribute to migration, understanding how climate and migration can coalesce to exacerbate health risks is urgent. Our study examines how migration influences the health of Mekong Delta migrants in Ho Chi Minh City and explores the role of weather and climate variability in the migration experience and health status of migrants before and after migration. Using a qualitative approach, we conducted 43 in-depth semi-structured interviews. We found migration is a strategy to cope with livelihood insecurity in the Mekong Delta. Livelihood trade-offs in Ho Chi Minh City produce precarious living and working conditions contributing to changes in the self-reported health status of migrants after migration, while climate variability is a threat multiplier for migrants’ health and livelihoods in both the Mekong Delta region and Ho Chi Minh City. Our findings illustrate the intersections of climate, migration and health where migrants make strategic health trade-offs to pursue better livelihoods, whilst weather and climate variability exacerbate the health risks and livelihood insecurity of migrants. This study supports the need to implement policies that reduce trade-offs, strengthen migrants’ adaptive capacity, and address underlying socioeconomic and political factors shaping vulnerability across the rural-urban continuum.

Racial and Ethnic Differences in Rural-Urban Trends in 5-Year Survival of Patients With Lung, Prostate, Breast, and Colorectal Cancers: 1975-2011 Surveillance, Epidemiology, and End Results (SEER)

Considering reported rural-urban cancer incidence and mortality trends, rural-urban cancer survival trends are important for providing a comprehensive description of cancer burden. Furthermore, little is known about rural-urban differences in survival trends by racial and ethnic groups. To examine national rural-urban trends in 5-year cancer-specific survival probabilities for lung, prostate, breast, and colorectal cancers in a diverse sample of racial and ethnic groups. This cross-sectional study used an epidemiologic assessment with 1975 to 2016 Surveillance, Epidemiology, and End Results (SEER) data to analyze patients diagnosed no later than 2011. Patients were classified as living in rural and urban counties based on the 2013 Rural-Urban Continuum Codes. The 5-year cancer-specific survival probability of urban and rural patients for each cancer type was estimated by fitting Cox proportional hazard regression models accounting for race, ethnicity, tumor characteristics, and other sociodemographic characteristics. A generalized linear regression model was used to estimate the mean estimated probability of survival for each stratum. Joinpoint regression analysis estimated periods of significant change in survival. In this study, data from 3 659 417 patients with cancer (median [IQR] age, 67 [58-76]; 1 918 609 [52.4%] male; 237 815 [6.5%] Hispanic patients; 396 790 [10.8%] Black patients; 2 825 037 [77.2%] White patients) were analyzed, including 888 338 patients with lung cancer (24.3%), 750 704 patients with colorectal cancer (20.5%), 987 826 patients with breast cancer (27.0%) breast, and 1 023 549 patients with prostate cancer (28.0%). There were 430 353 rural patients (11.8%). Overall, there was an equal representation of rural and urban men. Rural patients were likely to be non-Hispanic White individuals, have more cases of distant tumors, and be older. Rural and non-Hispanic Black patients for all cancer types often had shorter survival. From 1975 to 2016, the 5-year lung cancer survival rate was shorter for non-Hispanic Black rural patients in 1975 at 48%, while increasing to 57% for both non-Hispanic Black urban and rural patients in 2011, but still the shortest among all cancer types. In 1975, the longest survival rate was observed in urban Asian and Pacific Islander patients with breast cancer at 86%, and in 2011, the longest survival rate was observed in urban non-Hispanic White patients with XX cancer at 92%. Even after accounting for sociodemographic and tumor characteristics, these findings suggest that non-Hispanic Black patients with cancer are particularly vulnerable to cancer burden, and resources are urgently needed to reverse decades-old survival trends.

Palliative Radiotherapy Deserts: Impact of Race, Poverty, the Rural-Urban Continuum, and Radiotherapy Resource Density on Late-Stage Prostate Cancer (RP518)

Palliative Radiotherapy Deserts: Impact of Race, Poverty, the Rural-Urban Continuum, and Radiotherapy Resource Density on Late-Stage Prostate Cancer (RP518)

Rural disparities in head and neck cancer from 2017 to 2021: a single institution analysis

Abstract Introduction: This study aims to look at the trends in our head and neck cancer patient population over the past 5 years with an emphasis on the past 2 years to evaluate how the coronavirus disease 2019 (COVID-19) pandemic has impacted our disparities and availability of care for patients, especially those living in rural areas. An additional aim is to identify existing disparities at our institution in the treatment of head and neck patients and determine solutions to improve patient care. Materials and Methods: A retrospective chart review was performed to identify patients who were consulted and subsequently treated with at least one fraction of radiation therapy at our institution with palliative or curative intent. Patient demographic information was collected including hometown, distance from the cancer centre based on zip-codes and insurance information and type of appointment (in-person or telehealth). Rural–urban continuum codes were used to determine rurality. Results: A total of 490 head and neck cancer patients (n = 490) were treated from 2017 to 2021. When broken down by year, there were no significant trends in patient population regarding travel distance or rurality. Roughly 20–30% of our patients live in rural areas and about 30% have a commute &gt; 50 miles for radiation treatment. A majority of our patients rely on public insurance (68%) with a small percentage of those uninsured (4%). Telehealth visits were rare prior to 2019 and rose to 5 and 2 visits in 2020 and 2021, respectively. Conclusions: Head and neck cancer patients, despite rurality or distance from a cancer centre, may present with alarmingly enough symptoms despite limitations and difficulties with seeking medical attention even during the COVID-19 pandemic in 2020. However, providers must be aware of these potential disparities that exist in the rural population and seek to address these.

Rural-urban, age, and gender disparities and trends in suicide and homicide: Multistate evidence across 12 years.

Few studies have simultaneously assessed age and gender trends in homicide and suicide across the rural-urban continuum. Herein, we examine geographic and demographic trends in suicide and homicide death rates by: (1) determining overall macro and disaggregated trends; (2) examining differences in trends based on rural-urban county classification; and (3) identifying differences in stratified trends among age and gender classifications. A retrospective study design used suicide and homicide data (n = 199,456) from years 2005to 2017 across 16 US states. Suicide and homicide deaths were grouped by age, gender, and rural-urban classification for descriptive analyses, and trends were analyzed using Joinpoint trend analysis software. Violence resulted in 142,470 suicide and 56,986 homicide deaths between 2005 and 2017. Among both males and females, overall macro trends of suicide and homicide rates generally increased with greater rurality, and trends in rural rates differed from those in nonrural areas. Joinpoint trend analysis revealed significant increases in male suicide rates in large metropolitan (1.66%), micropolitan (1.78%), and rural areas (1.77%); female suicide rates in large metropolitan (2.17%), small metropolitan (3.25%), and micropolitan areas (3.26%); male homicide rates in large metropolitan areas (10.19%); and female homicide rates in rural areas (8.29%). Finally, when stratified by age, several significant trends were found, including increases in suicide rates among females aged 64 and older in rural areas (11.71%). Heterogeneous trends were found in suicide and homicide rates within specific rural-urban, age, and gender subgroups. Prevention efforts should proactively target those subgroups identified herein as most at-risk of violence.

ShinyOPTIK, a User-Friendly R Shiny Application for Visualizing Cancer Risk Factors and Mortality Across the University of Kansas Cancer Center Catchment Area.

The University of Kansas Cancer Center (KU Cancer Center) recently developed a data warehouse to Organize and Prioritize Trends to Inform KU Cancer Center (OPTIK). The OPTIK database aggregates and standardizes data collected across the bistate catchment area served by the KU Cancer Center. To improve the usability of the OPTIK database, we developed shinyOPTIK, a user-friendly, interactive web application for visualizing cancer risk factor and mortality rate data across the KU Cancer Center Catchment area. Data in the OPTIK database were first consolidated at the county level across the KU Cancer Center catchment area. Next, the shinyOPTIK development team met with the KU Cancer Center leadership to discuss the needs and priorities of the shinyOPTIK web application. shinyOPTIK was developed under the R Shiny framework and consists of a user interface (ui.R) and a web server (server.R). At present, shinyOPTIK can be used to generate county-level geographical heatmaps; bar plots of demographic, screening, and risk factors; and line plots to visualize temporal trends at different Rural-Urban Continuum Codes (RUCCs), rural-urban status, metropolitan, or county levels across the KU Cancer Center catchment area. Two examples, adult obesity prevalence and lung cancer mortality, are presented to illustrate how researchers can use shinyOPTIK. Each example is accompanied by post hoc visualizations to help explain key observations in terms of rural-urban disparities. Although shinyOPTIK was developed to improve understanding of spatial and temporal trends across the population served by the KU Cancer Center, our hope is that the description of the steps involved in the creation of this tool along with open-source code for our application provided herein will serve as a guide for other research centers in the development of similar tools.

Road network evolution in the urban and rural United States since 1900

Road networks represent a key component of human settlements, such as cities, towns, and villages, that mediate pollution and congestion, as well as economic development. However, little is known about the long-term development trajectories of road networks in rural and urban settings. We leverage novel spatial data sources to reconstruct and analyze road networks in more than 850 US cities and over 2500 US counties since 1900. Our analysis reveals significant variations in the structure of roads both within cities and across the conterminous US. Despite differences in the evolution of these networks, there are commonalities and strong geographic patterns. These results persist across the rural-urban continuum and are therefore not just a product of accelerated urban growth. These findings refine and extend existing knowledge and illuminate the need for policies for urban and rural planning including the critical assessment of new development trends.

Area Deprivation Index and Rurality in Relation to Financial Toxicity among Breast Cancer Surgical Patients: Retrospective Cross-Sectional Study of Geospatial Differences in Risk Profiles.

Financial toxicity (FT) depicts the burden of cancer treatment costs and is associated with lower quality of life and survival in breast cancer patients. We examined the relationship between geospatial location, represented by rurality and Area Deprivation Index (ADI), and risk of FT. A single-institution, cross-sectional study was performed on adult female surgical breast cancer patients using survey data retrospectively collected between January 2018 and June 2019. Chart reviews were used to obtain patient information, and FT was identified using the COmprehensive Score for Financial Toxicity questionnaire, which is a validated instrument. Patients' home addresses were used to determine rurality using the Rural Urban Continuum Codes and linked to national ADI score. ADI was analyzed in tertiles for univariate statistical analyses, and as a continuous variable to develop multivariable logistic regression models to evaluate the independent associations of geospatial location with FT. A total of 568 surgical breast cancer patients were included. Univariate analyses found significant differences across ADI tertiles with respect to race/ethnicity, marital status, insurance type, education, and rurality. In multivariable analysis, advanced cancer stage (odds ratio [OR] 2.26, 95% CI 1.15 to 4.44) and higher ADI (OR 1.012, 95% CI 1.01 to 1.02) were associated with worsening odds of FT. Increasing age (continuous) (OR 0.976, 95% CI 0.96 to 0.99), married status (vs unmarried) (OR 0.46, 95% CI 0.30 to 0.70), and receipt of bilateral mastectomy (OR 0.56, 95% CI 0.32 to 0.96) were protective of FT. FT was significantly associated with areas of greater socioeconomic deprivation as measured by the ADI. However, in adjusted analyses, rurality was not significantly associated with FT. ADI can be useful for preoperative screening of at-risk populations and the targeted deployment of community-based interventions to alleviate FT.

Delivery of fluoride varnish during pediatric medical visits by rurality.

To examine variation in the delivery of fluoride varnish during pediatric medical visits by rurality. This observational study used private health insurance claims (2016-2018) for children aged 1-5 years from Connecticut, Maine, New Hampshire, and Rhode Island linked to the county-level Rural-Urban Continuum codes. County-level Rural-Urban Continuum codes were categorized into three groups: metropolitan, rural, and remote rural. Logistic regression models were used to estimate the odds of a well-child medical visit including fluoride varnish by county rurality, adjusting for other individual and county characteristics. Among 328,661 pediatric well-child visits paid by private insurance, fluoride varnish was included in 4.3% of visits in metropolitan counties, 6.2% of visits in rural counties, and 10.3% of visits in remote rural counties. There were significantly higher odds of a visit including fluoride varnish in rural remote counties (odds ratio [OR]=3.5, 95% confidence interval [CI]=2.3-5.3, p < 0.001) and in rural counties (OR=2.4, 95% CI=1.4-4.0, p < 0.001) compared to metropolitan counties. Rates of fluoride varnish during well-child visits increased since 2016 in metropolitan counties and remained stable in rural counties. All young children are recommended to receive fluoride varnish applications in medical settings, yet overall rates were low. For privately insured young children, pediatric well-child medical visits were more likely to include fluoride varnish in rural and rural remote counties than metropolitan counties.

Differences in food insecurity across the rural/urban spectrum—The role of trade flows

AbstractThere has been little work relating food flows with food insecurity, and how inter‐county trading can drive differences across the rural/urban divide. Using rural–urban continuum codes in combination with a new data set on food flows at the county level we examine the correlation between food insecurity and trade. Results indicate heterogeneous impacts of food trade flows and county types on food insecurity rates. From Oaxaca‐Blinder decompositions we find that differences between rural and metropolitan counties are largely due to explained factors, but differences between nonmetropolitan, nonrural counties and the other county types are unexplained factors.

Identifying Racial and Rural Disparities of Cognitive Functioning Among Older Adults: The Role of Social Isolation and Social Technology Use.

Social isolation is associated with poorer cognitive outcomes among older adults. The use of online social technology platforms may provide a means to reduce social isolation. However, research examining whether social technology can mitigate the negative effects of social isolation on cognitive functioning is limited. This study investigates the interaction between social isolation and social technology use on cognitive functioning among older adults and seeks to identify racial and rural-urban differences in this relationship. Data were obtained from the Health and Retirement Study 2014-2018 waves (N = 5,358). Participants (aged 50-102) completed self-report measures of social isolation, loneliness, and frequency of online social communication and completed the modified Telephone Interview for Cognitive Status, which assesses cognitive functioning. Examinations of race focused on differences between Black/African American and White/Caucasian groups; rurality was operationalized using Beale Rural-Urban Continuum Codes. Data were analyzed using structural equation models. Social technology use moderated the negative relationship between social isolation and cognitive functioning, controlling for age, education, gender, wealth, and general computer usage. Greater social technology use was associated with better cognitive functioning among socially isolated older adults. Results showed evidence of racial, but not rural-urban, differences in the relationship between social technology use and cognitive functioning. Regardless of the degree of social isolation, frequent social technology use was associated with improved cognitive functioning in Black/African American older adults but not White/Caucasians older adults. Social technology may represent a way to mitigate cognitive decline, particularly among Black/African American older adults.

Definition and categorization of rural and assessment of realized access to care.

To examine how three measures of realized access to care vary by definitions and categorizations of "rural". Health Information National Trends Survey (HINTS) data, a nationally representative survey assessing knowledge of health-related information, were used. Participants were categorized by county-based Urban Influence Codes (UICs), Rural-Urban Continuum Codes (RUCCs), and census tract-based Rural-Urban Commuting Area (RUCAs). Three approaches were used across categories of UICs, RUCCs, and RUCAs: (1) non-metropolitan/metropolitan, (2) three-group categorization based upon population size, and (3) three-group categorization based on adjacency to metropolitan areas. Wald Chi-square tests evaluated differences in sociodemographic variables and three measures of realized access across three of Penchansky's "A's of access" and approaches. The three outcome measures included: having a regular provider (realized availability), self-reported "excellent" quality of care (realized acceptability), and self-report of the provider "always" spending enough time with you (provider attentiveness-realized accommodation). The average marginal effects corresponding to each outcome were calculated. N/A PRINCIPAL FINDINGS: All approaches indicated comparable variation in sociodemographics. In all approaches, RUCA-based categorizations showed differences in having a regular provider (e.g., 68.9% of non-metropolitan and 64.4% of metropolitan participants had a regular provider). This association was attenuated in multivariable analyses. No rural-urban differences in quality of care were seen in unadjusted or adjusted analyses regardless of approach. After adjustment for covariates, rural respondents reported greater provider attentiveness in some categorizations of rural compared with urban (e.g., non-metropolitan respondents reported 6.03 percentage point increase in probability of having an attentive provider [CI=0.76-11.31%] compared with metropolitan). Our findings underscore the importance of considering multiple definitions of rural to understand access disparities and suggest that continued research is needed to examine the interplay between potential and realized access. These findings have implications for federal funding, resource allocation, and identifying health disparities.

Smoke-free Ordinances and Youth Tobacco Use in Kentucky.

Determine associations of strength of local smoke-free laws and urban/rural location with cigarette and smokeless tobacco use among high school students in grades 10 and 12. Secondary data analysis from the 2004-2018 biennial Kentucky Incentives for Prevention Survey. Public high schools in Kentucky. N = 353502 10th/12th graders. County-level smoke-free law status from the Kentucky Center for Smoke-free Policy; Rural Urban Continuum Codes; self-reported last 30-day alcohol, marijuana, cigarette, and smokeless tobacco use. Generalized estimating equations modeling assessed the association of law status and urban/rural location with tobacco use across cohorts, controlling for demographics and other substance use. Students in counties with a comprehensive smoke-free law were 23% less likely to smoke cigarettes and 16% less likely to use smokeless, compared to those in counties without a law. Students in counties with moderate/weak laws did not differ in likelihood of use for either product, compared to those in counties without a law. Students in urban counties were 14% less likely to smoke, but there was no difference in likelihood of smokeless use by urban/rural location. Comprehensive smoke-free laws are associated with a lower likelihood of youth cigarette and smokeless use. Rural youth may be at increased risk of cigarette smoking relative to youth in urban areas.

Alcohol- and Drug-Related Mortality Among Adults Within and Outside the U.S.–Mexico Border Region

Although researchers and policy makers have often considered the U.S.-Mexico border region to be at high risk for substance use problems, epidemiological studies of this region have been hard to interpret because of their modest geographic coverage, reliance on self-report, and mixed results. The current study addresses limitations of existing studies and extends the knowledge base by comparing alcohol- and drug-related mortality in counties on versus off the border across all four U.S. border states. Data were from the 2008-2017 Centers for Disease Control and Prevention WONDER Multiple Causes of Death data set, American Community Survey, and Rural Urban Continuum Codes, including all four border states. Spatial lag models tested differences across on- and off-border counties in total alcohol- and drug-related mortality ("total mortality"), alcohol-related mortality, and drug-related mortality. In multivariate models, mortality rates were significantly higher in off- versus on-border counties for all three outcomes (ps < .05). Rates for total mortality, alcohol-related mortality, and drug-related mortality were 28%, 82%, and 30% higher, respectively, off versus on the border. Border effects were similar, excluding California; robust over time; and stronger for Latinx versus White decedents. Results suggest a revised understanding of the border, revealing that residents of interior counties of border states are at highest risk of severe substance use consequences. Results are consistent with other research finding that border counties were protected against drug overdose deaths, particularly for Latinx residents.

164 Racial Disparities in Surgical Recommendations for Primary Central Nervous System Tumors

INTRODUCTION: Racial disparities in treatment and outcomes disproportionately affect patients of color in many surgical fields. There is limited research on these disparities within the field of neurosurgery and most studies report solely on outcomes, not management, of populations at a single institution. METHODS: The National Cancer Institute Surveillance, Epidemiology, and End Results database (1971-2015) was used to collect demographic and clinical variables on patients with meningioma (n = 63674), glioblastoma (n = 35258), pituitary adenoma (n = 27506), vestibular schwannoma (n = 11525), astrocytoma (n = 5402), or oligodendroglioma (n = 3977). Univariate and multivariate logistic regression were performed to identify factors independently associated with recommendation against surgical resection. RESULTS: Independent of age at diagnosis, sex, tumor histology, grade, and size, Black patients with meningioma (OR 1.20, 95% CI 1.12-1.27, p &lt; 0.001), glioblastoma (OR 1.15, 95% CI 1.02-1.30, p = 0.023), pituitary adenoma (OR 1.19, 95% CI 1.11-1.28, p &lt; 0.001), and vestibular schwannoma (OR 1.56, 95% CI 1.26-1.93, p &lt; 0.001) were more likely to be recommended against surgical resection compared to White patients. Results were consistent after accounting for patient insurance status and rural-urban continuum code for the county of treatment. CONCLUSION: On review of the NCI SEER database, Black patients were more likely to be recommended against surgery compared to White patients for a number of primary CNS neoplasms, independent of clinical and demographic factors. Further research is needed to identify specific contributions to this inequity.

International medical graduate dermatologists in rural and medically underserved areas: a national cross-sectional analysis.

International medical graduates (IMGs) comprise a quarter of the United States (US) physician workforce but are a diminishing minority among dermatologists. Studies on IMGs in other specialties have demonstrated their importance in addressing provider shortage in rural and medically underserved areas (MUAs), but this trend has not been systematically explored within dermatology. This study aims to assess the state-by-state distribution of IMG dermatologists in the US as compared to US medical graduates (USMGs) with focus on provider density in rural settings and MUAs. A national cross-sectional study was performed on actively practicing dermatologists who submitted Medicare claims within 1year of July 2020; rural and MUA-serving status were determined based on federally designated rural-urban Continuum Codes and Census Bureau data. Nationally, the density of dermatologists has increased from 3.4 per 100,000 persons in 2016 to 3.66 per 100,000 persons in 2020. However, 70% of US states continue to have fewer than 4 dermatologists per 100,000 persons, the estimated minimum necessary to adequately care for a population. Among 12,009 dermatologists, only 576 (4.8%) are IMGs, with disparate distribution across the US: Kansas has the greatest percentage of IMGs with the latter comprising 8.3% of its state dermatology workforce, whereas 8 states have no IMGs. Notably, a significantly greater percentage of IMG dermatologists (43.9%) work in areas designated as MUAs compared to USMGs (37.4%) (P < 0.01). In contrast, a lower percentage of IMG dermatologists (2.8%) work in rural settings compared to USMGs (4.8%) (P = 0.03). Interestingly, no significant difference was observed when rural dermatologists were further stratified by MUA-serving status. These findings corroborate the importance of IMGs in providing greater access to dermatological care in areas with healthcare provider shortage. Further studies on the underlying causes of the decline of IMGs within dermatology are needed.