Small Metropolitan Areas Research Articles

30-day readmission after TAVR (Transcatheter Aortic Valve Replacement (TAVR) in patients with malignancy.

e18620 Background: Hospital readmissions after cardiac procedures are increasingly the major focus of quality improvement efforts. Although some reflect appropriate care, others are potentially preventable readmissions (PPRs). We aim to describe the burden, timing, and factors associated with readmissions after transcatheter aortic valve replacement (TAVR) in patients with malignancy. Methods: We performed a retrospective study of the 2017 National Readmission Database (NRD) of adult patients readmitted within 30 days after an index admission for TAVR with a concomitant diagnosis of malignancy. We aimed to identify 30-day readmission rate, mortality, healthcare related utilization of resources and other independent predictors of readmission. Results: A total of 2,213 patients with malignancy underwent TAVR. The 30-days readmission rate was 16% (n=355). Main causes of readmissions were found to be heart failure, sepsis, acute hypercapnic respiratory failure, coronary artery disease with angina, and AKI with ATN. Readmitted patients were more likely to come from small metropolitan areas (43.1% vs 33.6, p≤0.01), micropolitan areas (1.4% vs 0.35%, p≤0.01), rural hospital (20.3% vs 8.8%, p≤0.01), non-teaching hospital (23.5% vs 9.1%, p≤0.01), and small sized hospitals (11.5% vs 4%, p≤0.01). Patients re-admitted were more likely to have malnutrition (8% vs 3.2%, p≤0.01), new VTEs (3.8% vs 0.6, p≤0.01), AKI (26% vs 13.6%, p≤0.01) and deaths (4.6% vs 1.7%, p≤0.01). The total health care in-hospital economic burden of readmission was $5.9 million in total charges and $25 million in total costs. Independent predictors of readmission were disposition to short-term skilled nursing facilities, home-health care, and sepsis. Conclusions: We concluded that readmissions after TAVR in patients with malignancy are associated with higher in-hospital mortality rate and pose a higher health care burden. We also identified risk factors that can be targeted to decrease readmissions after TAVR, health care burden, and patient mortality.[Table: see text]

HIRO-NET: Heterogeneous Intelligent Robotic Network for Internet Sharing in Disaster Scenarios

This article describes HIRO-NET, an Heterogeneous Intelligent Robotic Network. HIRO-NET is an emergency infrastructure-less network that aims to address the problem of providing connectivity in the immediate aftermath of a natural disaster, where no cellular or wide area network is operational and no Internet access is available. HIRO-NET establishes a two-tier wireless mesh network where the Lower Tier connects nearby survivors in a self-organized mesh via Bluetooth Low Energy (BLE) and the Upper Tier creates long-range VHF links between autonomous robots exploring the disaster-stricken area. HIRO-NET's main goal is to enable users in the disaster area to exchange text messages to share critical information and request help from first responders. The mesh network discovery problem is analyzed and a network protocol specifically designed to facilitate the exploration process is presented. We show how HIRO-NET robots successfully discover, bridge and interconnect local mesh networks. Results show that the Lower Tier always reaches network convergence and the Upper Tier can virtually extend HIRO-NET functionalities to the range of a small metropolitan area. In the event of an Internet connection still being available to some user, HIRO-NET is able to opportunistically share and provide access to low data-rate services (e.g., Twitter, Gmail) to the whole network. Results suggest that a temporary emergency network to cover a metropolitan area can be created in tens of minutes.

Cannabis use, use frequency, and use disorder in large metropolitan, small metropolitan, and nonmetropolitan areas

BackgroundDespite significant geographical heterogeneity of sociodemographic and clinical characteristics, little is known about potential differences in cannabis use behaviors in U.S. geographic areas. In this study, we examined cannabis use behaviors in large metropolitan, small metropolitan, and nonmetropolitan areas. We focused on interactions between geographic areas and health insurance status and medical cannabis laws (MCL). MethodsData came from the 2015–2018 National Survey on Drug Use and Health (NSDUH; N = 171,766 adults; N = 36,175 cannabis users). Weighted chi-squares tests of independence and multivariable Poisson regression models were used to examine study questions. ResultsPast-year use was highest in large metropolitan areas (16.08 %). Frequent use was highest among nonmetropolitan area users (48.67 %). Uninsured adults had a higher likelihood of past-year use (RRR = 1.21, 95 % CI = 1.14, 1.29) and frequent use (RRR = 1.27, 95 % CI = 1.14, 1.41), but a lower likelihood of cannabis use disorder (RRR = 0.77, 95 % CI = 0.66, 0.89). Uninsured adults in nonmetropolitan areas had a higher likelihood (RRR = 1.62, 95 % CI = 1.39, 1.88) of past-year use than insured nonmetropolitan area adults. MCL state residency was associated with a higher likelihood of frequent use among nonmetropolitan (RRR = 1.39, 95 % CI = 1.11, 1.74) and small metropolitan users (RRR = 1.30, 95 % CI = 1.15, 1.47). Cannabis use disorder likelihood did not vary by geographic area. ConclusionsLack of health insurance and MCL state residency are significant variables affecting cannabis use behaviors in small metropolitan and/or nonmetropolitan areas.

Disparities in colorectal cancer screening among breast and prostate cancer survivors.

ABSTRACTBackgroundColorectal cancer (CRC) screening is recommended as an integral part of cancer survivorship care. We compared the rates of CRC screening among breast and prostate cancer survivors by primary cancer type, patient, and geographic characteristics in a community‐based health‐care system with a mix of large and small metro urban areas.Materials and MethodsData for this retrospective study were abstracted from medical records of a multi‐specialty practice serving about 250,000 individuals in southern Maryland. Breast (N = 1056) and prostate (N = 891) cancer patients diagnosed prior to 2015 were followed up till June 2018. Screening colonoscopy within the last 10 years was considered to be guideline concordant. Multivariate logistic regression was used to determine the prevalence odds ratios of being concordant on CRC screening by age, gender, race, metro area type, obesity, diabetes, and hypertension.ResultsOverall 51% of survivors had undergone a screening colonoscopy. However, there was a difference in CRC screening rate between prostate (54%) and breast (44%) cancer survivors. Older age (≥65 years), being a breast cancer survivor compared to prostate cancer, and living in a large compared to small metropolitan area were associated with a lower probability of receiving CRC screening. Having hypertension was associated with higher likelihood of being current on colonoscopy screening guidelines among survivors; but diabetes and obesity were not associated with CRC screening.ConclusionsLow levels of CRC screening utilization were found among breast and prostate cancer survivors in a single center in Southern Maryland. Gender, comorbidities, and residential factors were associated with receipt of CRC screening.

Outcomes, resource utilization and predictors of thirty day readmission in patients with heart failure with preserved ejection fraction (HFpEF): insights from the Nationwide Readmissions Database 2017

Abstract Background and aims Nearly half of all heart failure patients have heart failure with preserved ejection fraction (HFpEF). Due to differences in pathophysiology of heart failure with preserved and reduced ejection fraction, as well as a paucity of studies, the treatment of hHFpEF remains a challenge. We aimed to determine the rate of hospital readmission within 30 days of acute or acute on chronic HFpEF and its impact on mortality and health care utilization in the United States. We also focused on patient demographics as well as independent variables affecting readmission. Methods We performed a retrospective study using the Agency for Health-care Research and Quality's Health-care Cost and Utilization Project (HCUP), Nationwide Readmission Database (NRD) for the year of 2017 (data on approximately 18 million hospital stays at 2,454 hospitals in the United States). We collected data on hospital readmissions of 60,514 adults who were hospitalized for acute or acute on chronic diastolic heart failure and discharged. The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, and resource use (length of stay, total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis. Results The 30-day rate of readmission was 21%. Only 1,175 (9.17%) of readmissions were associated with an admitting diagnosis of acute on chronic diastolic heart failure. The most common readmission diagnosis was hypertensive chronic kidney disease with heart failure (1,245; 9.7%). Readmission cases were associated with increased in-hospital mortality compared to index admission (7.9% vs 2.9%, p=0.000). Readmission was associated with a total of 81,997 hospital days. Total health care in-hospital economic burden was $206 million (in costs) and $779 million (in charges). Significant predictors of increased thirty-day readmission were Medicaid insurance (1.15, 1.05–1.27, p=0.004), higher Charlson co-morbidity score (1.08, 1.06–1.09, p=0.000), patient admitted to teaching hospital (1.09, 1.04–1.15, p=0.001) and longer stays in the hospital (1.01, 1.01–1.02, p=0.000). Residence in a small metropolitan (0.91, 0.86–0.97, p=0.003) or micropolitan area (0.83, 0.77–0.90, p=0.000), older age (0.99, 0.993–0.997, p=0.000), female sex (0.91, 0.86–0.95, p=0.000), private (0.85, 0.77–0.93, p=0.000) or no insurance (0.70, 0.53–0.93, p=0.015) were associated with lower odds of readmission. Interestingly discharges to rehabilitation had no effect on re-admission (0.67, 0.28–1.6, p=0.381). Conclusions In conclusion patients hospitalized for acute or acute on chronic HFpEF, we found that 21% of patients were readmitted to the hospital within 30 days of discharge. Readmissions were associated with higher mortality and resource utilization. Most readmissions were due to cardiorenal syndrome. Funding Acknowledgement Type of funding source: None

The Geography of Employment Outcomes for Radiation Oncology Graduates in 2019

The geographic distribution of practicing radiation oncologists is of concern for multiple stakeholders within the field. Employment outcomes of graduating residents can affect that distribution, and they are of major concern to current residents. Data investigating employment outcomes of recent graduates are sparse. We aimed to analyze the employment outcomes of the radiation oncology residency class of2019. Using publicly available information, we identified the employment of 179 of 183 graduating residents in the class of 2019. For each, the place of employment, residency program, and medical school were geocoded using Google Maps. We used the rural-urban continuum code (RUCC) published by the United States Department of Agriculture to determine the rurality of each location and compared employment outcomes by RUCC and program size. Two thirds of graduates (66%) took a position in a county within a metropolitan area with a population greater than 1,000,000 people; only 3.4% took a position in a county outside of a metropolitan area. Graduates of smaller programs (≤6 residents) and those in smaller metropolitan areas were more likely to take positions in smaller metropolitan areas or nonmetropolitan areas. The geographic distance between location of employment and residency program did not significantly vary by program size or size of metropolitan area where a residency program was located. Among the class of 2019, a small proportion took positions in nonmetropolitan areas. Smaller programs and those in smaller metropolitan areas may be more likely to produce graduates that practice in similar settings, but those graduates might not do so locally. We advocate for a centralized, prospective data collection of employment outcomes for graduating residents to refine these analyses and to reduce employment prospect information asymmetry for trainees.

IMPACT OF HAVING PULMONARY HYPERTENSION IN PATIENTS ADMITTED WITH ACUTE EXACERBATION OF COPD IN THEIR HEALTHCARE UTILIZATION AND READMISSION: A US POPULATION COHORT STUDY

SESSION TITLE: New Insights into COPD and Its Complications SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: This study aimed to Quantify the Impact of Pulmonary Hypertension (PH) mortality, 30-day readmission, Morbidity, and Resource utilization among patients with Acute exacerbation of chronic obstructive pulmonary disorder (AECOPD). METHODS: This is a retrospective analysis by using the 2016 and 2017 National Readmission Database (NRD). Inclusion criteria were admissions with a diagnosis of AECOPD, as a primary diagnosis and pulmonary Hypertension (PH) as a secondary diagnosis using ICD 10-CM codes. Exclusion criteria were age under 18 years, non-elective admission, and discharge in December. The primary outcome was in-hospital Mortality during the index admission. Secondary outcomes were 30-Day Readmission rates, Resource utilization, and Morbidity Including Intubation rates (IR), Prolong Invasive Mechanical Ventilation >96hr (PIMV), Tracheostomy Rate (TR), Chest tube Placement rate (CR) and Bronchoscopy rate (BR) during the Index admission. We used multivariate linear/logistic models to adjust for confounders. RESULTS: 821,468 patients with AECOPD were included in the study, and 68,429 (8.33 %) patients had a diagnosis of PH. PH was more common among females (61.1%) with a mean age of 70, Medicare recipients (79.5%), with higher Charlson Comorbidity burden, lower economic status, and treated in a large urban teaching hospital. PH is associated with greater in-hospital mortality (adjusted odds ratio (aOR): 1.89, Confidence Interval (CI):1.73- 2.07 , P<0.01), higher 30 day readmission aOR-1.24,(CI)-1.21-1.28,p<0.001 compared to patient without PHT. In addition, PHT was associated with higher morbidity including IR (aOR: 199, CI: 1.85 -2.14,p<0.01), PIMV (aOR: 2.12, CI:1.89-2.38, p<0.001), TR (aOR-2.15,CI-1.53-2.9,p<0.001), BR(aOR-1.46,CI-1.11-1.94,p<0.007) and CR(aOR-1.39,CI-1.11-1.74,p<0.004). PH was also associated with higher resource utilization with total hospitalization cost (aMD: $2785, CI: 2602-2967, p<0.01) and LOS (aMD-1.09,CI-1.02-1.15,p<0.001). Independent predictors of higher 30-day readmissions were age group of 30-50 years, Index LOS> 3days, Medicare Insurance recipients, Higher Charlson Comorbidity burden, higher Hospital volume quintile for AECOPD, Opioid and cocaine-dependent, discharge other than routine during the index hospitalization. In contrast, independent predictors of lower 30-day readmissions were female gender, private insurance recipients, and Uninsured, higher Household income, and people who reside in the small metropolitan area during the index admission. CONCLUSIONS: PH is related to higher in-hospital Mortality, morbidity, IR, BR, TR, PIMV, CR, and Resource utilization, including total Hospitalization Cost and LOS. We also found predictors for readmission. CLINICAL IMPLICATIONS: Early diagnosis and appropriate treatment of PH, Close Follow up and Early referral to lung transplant will be beneficial to such patients who found to have PH in Management of AECOPD. DISCLOSURES: No relevant relationships by Rucha Jiyani, source=Web Response No relevant relationships by Si Li, source=Web Response No relevant relationships by Palakkumar Patel, source=Web Response No relevant relationships by Pranavi Patel, source=Web Response No relevant relationships by Yichen Wang, source=Web Response

The Emerging Intersection Between Injection Drug Use and Early Syphilis in Nonurban Areas of Missouri, 2012-2018.

The national rate of syphilis has increased among persons who inject drugs (PWID). Missouri is no exception, with increases in early syphilis (ES), congenital syphilis, and PWID, especially in nonurban counties. Disease intervention specialist records for ES cases in Missouri (2012-2018) were examined. Drug use was classified as injection drug use (IDU) (opioid or methamphetamine) or non-IDU (opioid, methamphetamine, or cocaine). Rates were compared based on residence, sex of sex partner, and drug use. Rates of ES in Missouri increased 365%, particularly in small metropolitan and rural areas (1170%). Nonurban areas reported a higher percentage of persons with ES who used injection drugs (12%-15%) compared with urban regions (2%-5%). From 2012 to 2018, women comprised an increasing number of ES cases (8.3%-21%); 93% of women were of childbearing age. Increasingly more women in rural areas with ES also reported IDU during this time (8.4%-21.1%). As syphilis increases in small metropolitan and rural regions, access to high-quality and outreach-based sexual health services is imperative. Healthcare policy to equip health departments with harm reduction services and drug treatment resources offers an opportunity to impact both syphilis increases as well as health outcomes associated with IDU.

Uptake and Trends in the Use of Medicare Advance Care Planning Visits

Research ObjectiveRecognizing that advance care planning (ACP) supports alignment of end‐of‐life care with an individual’s preferences and is associated with improved patient outcomes, and Medicare initiated billing codes for ACP in 2016. Adoption of the ACP codes during the first year has been low. In order to inform Medicare on opportunities to promote the use of the program, we now examine Year 2 trends in uptake by patient and provider characteristics.Study DesignACP claims in 2016‐7 were identified by CPT codes. We examined (a) the total annual number of claims; (b) beneficiary ACP use (number and rate of Medicare beneficiaries having one or more ACP visits, annually and cumulative over 2 years); (c) provider ACP claim rate (ACP claims per 10,000 total claims); and (d) spread (increase in total number of unique billing providers by NPI).Population Studied348 190 ACP claims from a 20% random sample of fee‐for‐service (FFS) Medicare beneficiaries continuously enrolled from 2016 to 2017.Principal FindingsThe number of ACP claims increased from 137 079 in 2016 to 348,190 in 2017, an increase of 154%.ACP Use RatesThe cumulative beneficiary ACP use rate increased from 2.12% in 2016 to 3.28% in 2017. Persons over the age of 85 had the highest ACP cumulative use rate (6.15%) in 2017 and the highest percent annual increase in number of users (160%). Whites had the highest ACP cumulative use rate (3.92%); however, blacks had the highest percent annual increase in number of users (176%). Females had the highest ACP cumulative use rate (4.20%); however, males had a slightly higher percent annual increase in users (155%).Provider ACP Claim Rates per 10,000: Among specialties, hospice and palliative care providers had the highest ACP cumulative claim rate (93.16) in 2017, although acute care specialists had the largest percent increase (243%). By provider role, Clinical Nurse Specialists had the highest ACP claim rate (10.16), although Physician Assistants had the largest percent increase (188%.) The majority of claims (87.2%) were in urban areas, although small metropolitan areas saw the largest percent increase 161%.In terms of spread, the total number of unique billing providers increased from 14,207 in 2016 to 26,434 in 2017, an increase of 86%.ConclusionsThe use of ACP codes continues to increase; however, the increase in uptake and spread among providers is still quite low. Despite larger gains among Blacks and men, older female and white beneficiaries remain the group most frequently receiving an ACP visit claim. The use of the ACP billing codes has spread to new clinician specialties and provider roles and to small metropolitan areas.Implications for Policy or PracticeThere are many barriers to integrating ACP into practice, and the use of ACP billing codes is one method to incentivize the behavior. Despite the growing use of ACP codes, the slow uptake is notable. The use of ACP billing codes is underutilized, and increased promotion by CMS may be warranted, particularly targeting younger, male patients and more clinical specialties in rural areas.Primary Funding SourceNational Institutes of Health.

The Consequences of Medicare Pricing: An Explanation of Treatment Choice

Primary care physicians (PCPs) provide more specialty procedures in less-urban areas, where specialists are fewer. Using a structural random-coefficient model and the demographic and time variation in the data, this paper shows that changes in policy-set reimbursements lead to a reallocation of the suddenly-more-remunerative procedures away from specialists and toward PCPs, and this effect is stronger, the more rural an area is. A reimbursement-unit increase for a given procedure leads to outside-metro PCPs gaining 7-15% market share more than metro PCPs in that procedure, at the expense of specialists. Small metropolitan areas and very rural areas are the most affected.

Economic impacts of being close to subway networks: A case study of Korean metropolitan areas

Subway networks are often developed in densely populated metropolitan areas that have enough potential passengers to merit their operation. Once a network has been constructed, it provides mobility to passengers and improves local accessibility to various destinations, thereby having economic, social, and public health impacts. This study aims to examine the economic impacts of subway networks in metropolitan areas among the various, wide-ranging effects of provision of transit networks. The association between actual transaction prices of condominiums and accessibility to subway networks in four metropolitan areas in South Korea is examined. Condominiums make up the dominant housing type in South Korea, so they provide a valid proxy for housing prices. In the modeling process, factors known to have a close relationship with housing prices are integrated along with the accessibility of subway networks, and spatially lagged models are utilized to effectively deal with the spatial patterns. The results of this research show that the expected positive effects of transit accessibility exist in the majority of cases in metropolitan areas, though one metropolis was an exception. These findings enhance our understanding of the economic impacts of public transit systems in relatively small metropolitan areas with less complex subway systems.

Increased 30-day readmission rate after craniotomy for tumor resection at safety net hospitals in small metropolitan areas.

Unplanned readmission of post-operative brain tumor patients is often attributed to hospital and patient characteristics and is associated with higher mortality and cost. Previous studies demonstrate multiple patient outcome disparities in safety net hospitals (SNHs) when compared to non-SNHs. This study uses the Nationwide Readmissions Database (NRD) to determine if initial brain tumor resection at SNHs is associated with increased 30-day non-elective readmission rates. Patients with benign or malignant primary or metastatic brain tumor undergoing craniotomy for surgical resection were retrospectively identified in the NRD from 2010 to 2014. SNHs were defined as hospitals with Medicaid and uninsured patient burden in the top quartile. Descriptive and multivariate analyses employing survey-adjusted logistic regression evaluated patient and hospital level factors influencing 30-day readmissions. During the study period, 83,367 patients met inclusion criteria. 44.7% of patients had a benign tumor, and 55.3% had a malignant tumor. Secondary CNS neoplasm (5.99%), post-operative infection (5.96%), and septicemia (4.26%) caused most readmissions within 30days. Patients had increased unplanned readmission rates if they underwent craniotomy for tumor resection at a SNH in a small metropolitan area (OR 1.11, 95% CI 1.02-1.21, p = 0.01), but not at a SNH in a large metropolitan area (OR 0.99, 95% CI 0.93-1.05, p = 0.73). This finding may reflect differences in access to care and disparities in neurosurgical resources between small and large metropolitan areas. Inequities in expertise and capacity are relevant as surgical volume was also related to readmission rates. Further studies may be warranted to address such disparities.

Will autonomous vehicles change auto commuters’ value of travel time?

This paper examines the potential impact of autonomous vehicles on commuters’ value of travel time (VOTT). In particular, we focus on the effect on auto commuters in small and medium-sized metropolitan areas, concerning the spatial variability across urban areas, suburbs, and rural areas. We design a stated choice experiment to elicit potential changes in 1,881 auto commuters’ valuation of travel time in autonomous vehicles and apply a mixed logit model to quantify the changes in the value of travel time if taking autonomous vehicles. The results of this study suggest that the effect of autonomous vehicles on the VOTT is spatially differentiated. We find that riding in a private autonomous vehicle reduces the commuting VOTT of suburban, urban, and rural drivers by 32%, 24%, and 18%, respectively, compared to 14%, 13%, and 8% for riding in a shared autonomous vehicle. Finally, we discuss the implications of these lower values of time on transportation and land use planning.

Breast Cancer Presentation, Surgical Management and Mortality Across the Rural-Urban Continuum in the National Cancer Database.

The purpose of this study was to examine differences in presentation, surgical management, and mortality among breast cancer patients in the National Cancer Database (NCDB) based on area of residence. The NCDB was queried for women with a diagnosis of breast cancer from 1 January 2004-31 December 2015. The data were divided by metropolitan (large, medium, small) and non-metropolitan (urban, rural) status. Cancer stage increased with rurality (p < 0.0001). Residency in a large metropolitan area was associated with increased breast reconstruction rates (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.19-1.30) and reduced overall mortality (hazard ratio 0.92, 95% CI 0.89-0.95) compared with rural areas. There was no difference in mastectomy use among small metropolitan (OR 1.03, 95% CI 1.01-1.04), urban (OR 0.99, 95% CI 0.98-1), and rural areas (OR 1.05, 95% CI 1.01-1.07) compared with large metropolitan areas. Across the rural-urban continuum in the NCDB, stage of cancer presentation increased with rurality. Conversely, residency in a large metropolitan area was associated with higher reconstruction rates and a reduction in overall mortality. Future studies should evaluate factors contributing to advanced disease presentation and lower reconstruction rates among rural breast cancer patients.

Guidelines for a Polycentric Region to Reduce Vehicle Use and Increase Walking and Transit Use

Problem, research strategy, and findings: The monocentric development pattern in the Alonso–Mills–Muth model underpinned theoretical discussions of urban form in the 1960s and 1970s and truly dominated theory up to the point when Joel Garreau published Edge City: Life on the New Frontier in the early 1990s. Monocentric development patterns remain dominant to this day among smaller metropolitan areas in the United States. However, for larger metropolitan areas in the United States, regional transportation plans suggest a paradigm shift to a polycentric structure. We review 126 regional transportation plans in the United States and find that a hierarchy of centers connected by high-quality transit has become the dominant vision for most of them. The plan for Salt Lake City (UT), for example, strives for a multicentered region even though secondary centers are only beginning to emerge beyond a dominant downtown. Generally missing from regional transportation plans are quantitative criteria for designating and guiding centers: In no case are the quantitative criteria empirically based on proven transportation benefits. Here we investigate how the built environment characteristics of centers are associated with people’s travel mode choices and vehicle use. We employ visual and exploratory approaches through a generalized additive model (GAM) to identify nonlinear relationships between travel outcomes and “D” variables (density, diversity, design, destination accessibility, and distance to transit) within centers. The model and plots help us recommend the built environment characteristics of centers.Takeaway for practice: The built environment thresholds and relevant tools provided here can enable planners to make informed decisions about future growth patterns, set realistic—yet visionary—goals, and improve the overall health of its residents and communities. We provide strategies and tools that planning agencies, such as metropolitan planning organizations, transit agencies, and municipalities, can adopt to channel developments into centers.

Closing the Gap: Participatory Formative Evaluation to Reduce Cancer Screening Disparities among Patients with Limited English Proficiency.

Patients with limited English proficiency (LEP) have disproportionately lower rates of cancer screening than English-proficient patients. Given the multifactorial nature of screening disparities, strategies to improve screening rates must address barriers within and outside of the clinic setting. The objectives of this study were to understand local barriers from multiple stakeholder perspectives, to identify potential multilevel intervention approaches, and to mobilize community-engaged intervention decision making and planning. This participatory formative evaluation approach employed needs assessment and user engagement in order to enhance intervention usefulness and relevance. The study took place in several stages and involved clinic and community partners in a small metropolitan area of the Midwest USA. Interviews were conducted with LEP patients (n = 9) who had not completed three recommended screenings (breast, cervical, and colorectal), primary care providers (n = 5), medical interpreter (n = 5), and community members (n = 3). These highlighted multilevel barriers including limited patient understanding of preventive health, time and cost constraints, and variable roles of language interpreters. The literature was also reviewed to identify interventions used with similar populations. Findings from this review suggest that interventions are largely focused on single population groups or address single screening barriers. Finally, a community-academic summit (n = 48 participants) was held to review results and develop recommendations for community and clinic interventions. Findings from this study indicate that it is possible to engage a diverse group of stakeholders in strategies that are responsive to health care providers and patients, including LEP patients from heterogeneous backgrounds.

Health service inequalities during the COVID-19 pandemic among elderly people living in large urban and non-urban areas in Florida, USA.

Objective:Health inequalities were often exacerbated during the emerging epidemic. This study examined urban and non-urban inequalities in health services among COVID-19 patients aged 65 years or above in Florida, USA, from 2 March to 27 May 2020.Methods:A retrospective time series analysis was conducted using individual patient records. Multivariable Poisson’s and logistic models were used to calculate adjusted incidence of COVID-19 and the associated rates of emergency department visits, hospitalizations, and deaths.Results:As of 27 May 2020, there were 13,659 elderly COVID-19 patients (people aged 65 years or above) in Florida and 14.9% of them died. Elderly people living in small metropolitan areas might be less likely to be confirmed with COVID-19 infection than those living in large metropolitan areas. The emergency department visit and hospitalization rates decreased significantly across metropolitan statuses for both men and women. Those patients living in small metropolitan or rural areas were less likely to be hospitalized than those living in large metropolitan areas (35% and 34% vs 41%). Elderly women aged 75 years or above living in rural areas had 113% higher adjusted incidence of COVID-19 than those living in large metropolitan areas, and the rates of hospitalizations were lower compared with those counterparts living in large metropolitan areas (29% vs 46%; odds ratio: 0.37 (0.25–0.54), p < 0.001).Conclusion:For elderly people living in Florida, USA, those living in small metropolitan or rural areas were less likely to receive adequate health care than those living in large or medium metropolitan areas during the COVID-19 pandemic.

Problem on the Plains: College Earnings Premiums in Small Metropolitan Areas

I use the American Community Survey to examine how college earnings premiums differ across small metropolitan statistical areas (MSAs) in the U.S. I document that the West North Central Division (Plains Region) has especially low average college earnings premiums. Controlling for observable MSA characteristics via regression explains some of the difference between the Plains and other regions, but large and important differences remain. The low return to education for small MSAs in the Plains suggests that they will face special challenges building and retaining human capital in the near future. These areas may especially struggle to attract college-educated in-migrants.

Spatial‐temporal trends in complementary and alternative medicine (CAM) offices in Ontario, Canada

This paper assesses complementary and alternative medicine (CAM) from a spatial‐temporal perspective; it would be of particular interest to those who evaluate health care resource accessibility over space. The analysis compares CAM supply (number of offices, employment, and sales) in Ontario by provincial district, metropolitan influence classification, and health care and social assistance employment quintiles using summary statistics, Kruskal‐Wallis and median analyses, and local spatial autocorrelation evaluation. Metropolitan areas throughout Ontario, but especially in the southcentral part of the province, are well endowed with CAM supply and tend to be most important in terms of CAM change. CAM offices are increasing in size in the most populated parts of the province and shrinking in regions that are more peripheral. CAM supply per capita is highest in census subdivisions with moderate levels of health care and social assistance employment, a result that is not offset by significant temporal change. While CAM supply is restructuring in many of Ontario's most populated urban locations, the overall attraction of CAM resources to large and small metropolitan areas is clear. If current spatial‐temporal trends continue, CAM spatial disparities will be exacerbated as accessibility to CAM in Ontario's most peripheral locations worsen.

Impacts of High-Speed Rail Construction on Urban Agglomerations: Evidence from Kyushu in Japan

High-speed rail integrates regions and cities, and thus can possibly have significant impacts on the distribution of economic activities. Using the opening and extensions of a high-speed rail, Shinkansen, in Kyushu, Japan, we examine its effects on the distribution of economic activities across urban agglomerations. We focus on changes in land prices and estimate hedonic price equations to conduct a difference-in-differences analysis. We find that the large metropolitan areas gained from the high-speed rail by experiencing increases in land prices, whereas small metropolitan areas located between them lost by experiencing decreased land prices.