State-specific Rates Research Articles

Persistent and extreme outliers in causes of death by state, 1999-2013.

In the United States, state-specific mortality rates that are high relative to national rates can result from legitimate reasons or from variability in coding practices. This paper identifies instances of state-specific mortality rates that were at least twice the national rate in each of three consecutive five-year periods (termed persistent outliers), along with rates that were at least five times the national rate in at least one five-year period (termed extreme outliers). The resulting set of 71 outliers, 12 of which appear on both lists, illuminates mortality variations within the country, including some that are amenable to improvement either because they represent preventable causes of death or highlight weaknesses in coding techniques. Because the approach used here is based on relative rather than absolute mortality, it is not dominated by the most common causes of death such as heart disease and cancer.

Neighbouring populations, opposite dynamics: influence of body size and environmental variation on the demography of stream-resident brown trout (Salmo trutta).

In organisms such as fish, where body size is considered an important state variable for the study of their population dynamics, size-specific growth and survival rates can be influenced by local variation in both biotic and abiotic factors, but few studies have evaluated the complex relationships between environmental variability and size-dependent processes. We analysed a 6-year capture-recapture dataset of brown trout (Salmo trutta) collected at 3 neighbouring but heterogeneous mountain streams in northern Spain with the aim of investigating the factors shaping the dynamics of local populations. The influence of body size and water temperature on survival and individual growth was assessed under a multi-state modelling framework, an extension of classical capture-recapture models that considers the state (i.e. body size) of the individual in each capture occasion and allows us to obtain state-specific demographic rates and link them to continuous environmental variables. Individual survival and growth patterns varied over space and time, and evidence of size-dependent survival was found in all but the smallest stream. At this stream, the probability of reaching larger sizes was lower compared to the other wider and deeper streams. Water temperature variables performed better in the modelling of the highest-altitude population, explaining over a 99 % of the variability in maturation transitions and survival of large fish. The relationships between body size, temperature and fitness components found in this study highlight the utility of multi-state approaches to investigate small-scale demographic processes in heterogeneous environments, and to provide reliable ecological knowledge for management purposes.

Economic impact of psychiatric relapse and recidivism among adults with schizophrenia recently released from incarceration: a Markov model analysis

Objectives:To develop an economic model that estimates the cost burden of psychiatric relapse and recidivism among patients with schizophrenia recently released from incarceration from a US state government perspective.Methods:A Markov state-transition model was developed to estimate the numbers of schizophrenia patients recently-released from incarceration who would experience psychiatric relapse and/or arrest and re-incarceration over a period of 3 years, along with corresponding costs. The model includes three health states: (1) in community, on therapy, (2) in community, off therapy, and (3) incarcerated. It is assumed that a patient’s probability of psychiatric hospitalization increases with treatment discontinuation, and the probability of arrest increases with the occurrence of a prior psychiatric hospitalization. Data from the US Census and Bureau of Justice Statistics were used to estimate the model population. Published literature was used to estimate the risks of psychiatric relapse, arrest, and all cost inputs. State-specific incarceration rates and sentence length data (from the state of Florida) were applied. The impact on outcomes and costs was evaluated by varying the rates of anti-psychotic treatment following release from incarceration and the annual risk of medication discontinuation.Results:Among 34,500 persons released from incarceration in the state of Florida annually, 5307 were estimated to have schizophrenia. The cumulative 3-year costs to the state government were $21,146,000 and $25,616,000 for criminal justice and psychiatric hospitalization costs, respectively ($3984 per patient criminal justice; $4827 per patient hospitalization costs). A relative 20% increase in the proportion of patients receiving antipsychotic treatment following release from incarceration decreased total cumulative costs over 3 years by $1,871,100 ($353 per patient).Conclusions:The economic impact of psychiatric relapse and recidivism among patients with schizophrenia is substantial from the state government perspective. This general model can be made state-specific by utilizing local criminal justice data sources.

Adaptation on the ground and beneath: does the local population maximize its λ1?

Local populations of plant species, such as perennial grasses, are considered to adapt to their environments by means of polyvariant ontogeny, i.e., diverse pathways that an individual plant may follow through a variety of states in its life cycle expressed as the ontogenetic stages and chronological ages (in years). The corresponding projection matrix (L) in a matrix population model turns out to have a more complex pattern than the classical Leslie or Lefkovitch ones. The dominant eigenvalue (λ1) of L, in spite of the asymptotic role it plays in model dynamics, does measure the adaptation that the local population possessed in the place where, and at the time when, the population data were collected to calibrate the matrix L. The value of λ1 thus serves as the basis for site- and time-specific comparative studies, where the problem reduces to reliable matrix calibration on the specific data. The kind of data we deal with in a case study of vegetatively propagating woodreed (Calamagrostis epigeios) is called ‘identified individuals with unknown parents’ (Logofet, 2008, 2013c): we determined reliably the age-stage-specific status of each individual plant from the morphology of its above-ground part, but the parent–progeny rhizome links remained reliably hidden in the ground. Therefore, this kind of data enabled direct calculation of the transition part T in matrix L=T+F, but leaved the fertility part F uncertain, yet subject to certain linear constraints. The uncertainty gets eliminated if the maximal possible λ1 is hypothesized. Given the data and constraints, the calibration then reduces to a nonlinear constraint maximization problem, which has a unique solution. In order to test the maximization hypothesis, we have now designed a field experiment where a few sample plots with C. epigeios are dug out to disentangle the parent–progeny relations, hence to calculate the state-specific fertility rates (matrix F) in the direct way. We report on the outcome of the first-year experiment, which has confirmed the maximization hypothesis and revealed unexpected complexity in the popular methodology of λ1 as a measuring tool of comparative demography.

Relative Prices and Substitution Across Wage, Welfare, and Disability Income

In this paper I exploit the fact that the social and economic reforms over the past two decades differentially affected the opportunity costs of non-participation in work, welfare, and disability programs for single mothers across different birth-year and education cohorts. This cohort variation in after-tax wages and transfer benefits is used to identify own- and cross-price elasticities of demand for and substitution across wage, welfare, and disability income over 1979 to 2001 in the Current Population Survey. To estimate these key parameters I model household preferences with a conditional Almost Ideal Demand System that admits corner solutions, nonseparability, endogenous wages and incomes, and latent heterogeneity via cohort and state fixed effects. I match individual and family-level data in the CPS both with family-specific federal, state, and payroll tax rates, and with state-specific and time-varying benefit levels and effective tax rates in the AFDC and SSI programs. Using a two-limit Tobit instrumental variables estimator I find strong evidence of sizable own and cross-programmatic substitution effects. For example, the estimated elasticities imply that between 1979 and 1999 the increase in the generosity of SSI relative to AFDC accounts for about 40 percent of the average growth in SSI, while the increase in real wages accounts for about one-half of the average decline in AFDC shares over the past two decades. Simulations suggest that changes in relative after-tax wages and transfer-program benefits over the past two decades lead to a substantial pull out of cash welfare and into expanded reliance on employment and disability as a means of financial support among single mothers.

Epidemiology of hepatocellular carcinoma in the United States: where are we? Where do we go?

Epidemiology of hepatocellular carcinoma in the United States: where are we? Where do we go?

Child passenger deaths involving alcohol-impaired drivers.

Approximately 1 in 5 child passenger deaths in the United States involves an alcohol-impaired driver, most commonly the child's own driver. The objective of this study was to document recent trends and state-specific rates of these deaths. A descriptive analysis of 2001-2010 Fatality Analysis Reporting System data for child passengers aged <15 years killed in alcohol-impaired driving crashes. Driver impairment was defined as a blood alcohol concentration of ≥0.08 g/dL. During 2001-2010, 2344 children <15 years were killed in crashes involving at least 1 alcohol-impaired driver. Of these children, 1515 (65%) were riding with an impaired driver. Annual deaths among children riding with an alcohol-impaired driver decreased by 41% over the decade. Among the 37 states included in the state-level analysis, Texas (272) and California (135) had the most children killed while riding with an impaired driver and South Dakota (0.98) and New Mexico (0.86) had the highest annualized child passenger death rates (per 100 000 children). Most (61%) child passengers of impaired drivers were unrestrained at the time of the crash. One-third of the impaired drivers did not have a valid driver's license. Alcohol-impaired driving remains a substantial threat to the safety of child passengers in the United States, and typically involves children being driven by impaired drivers. This risk varies meaningfully among states. To make further progress, states and communities could consider increased use of effective interventions and efforts aimed specifically at protecting child passengers from impaired drivers.

Association between fire-safe cigarette legislation and residential fire deaths in the United States.

BackgroundCigarettes and other tobacco-related smoking products have traditionally been a major ignition source for residential fire deaths. In the United States, all 50 states and the District of Columbia have passed laws requiring that cigarettes self-extinguish if they are not being smoked (so-called fire-safe cigarette laws). The purpose of this study was to quantify the association between state-level implementation of fire-safe cigarette legislation and the rate of residential fire death.MethodsPoisson regression was used to analyze state-years data. Main intervention: Implementation dates for fire-safe cigarette legislation in each state. Outcome: Residential fire mortality rate.ResultsImplementation of fire-safe cigarette legislation was associated with a 19% reduction in overall residential fire mortality rates, adjusted for demographic differences between states (rate ratio = 0.81, 95% confidence interval: 0.79, 0.84). This is approximately similar to the estimated proportion of residential fire deaths in which smoking materials are an ignition source (23%). Legislation implementation was associated with a protective effect for every age, sex, race, and ethnicity strata that we examined. State-specific residential fire mortality death rates decreased (defined as a drop of at least 5%) in 32 states after fire-safe cigarette legislation was implemented. In 12 states there was either less than a 5% decrease or an increase, and seven states had insufficient deaths to evaluate state-level changes.ConclusionsImplementation of fire-safe cigarette is associated with reductions in residential fire mortality rates.

Abstract TMP43: Ischemic Stroke Hospitalization Rates by State and Age

Background: Medicare data show regional differences in stroke hospitalizations for older patients, but data on regional patterns for younger patients are limited. We assessed geographic patterns of ischemic stroke hospitalizations rates by state for younger and older U.S. adults. Methods: Ischemic stroke hospitalizations (ICD-9 433, 434, 436) were identified using the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (HCUP) for 2007-2008. Rates were expressed per 100,000 person-years (P-Y) with state-level age- and sex-specific Census data as a denominator. A hierarchical random effects Poisson model estimated state-specific risk-adjusted rates, adjusting for age-sex and applying HCUP sampling weights. Bootstrapping simulation was used to obtain interval estimates of rates for each state and age group (18-64 and 65+). Rates were categorized as being significantly higher, no different, or significantly lower than the national average based on their interval estimates. Results: More than half of strokes in older patients occurred in women (54.4%) compared to 43.5% in younger patients. The prevalence of many comorbidities (COPD, HF, HTN, and renal failure) was expectedly higher for older patients, but the prevalence of diabetes was higher in the younger group (36.2% vs. 30.5%, p&lt;0.001). The overall stroke hospitalization rate was 93 per 100,000 P-Y in the younger group and 1134 per 100,000 P-Y for those 65+ yrs. Ten states’ classifications differed between age groups indicating moderate state-level variance, with rates above the national average tending to cluster in the southeast (figure). Conclusion: Geographic patterns of hospitalization were moderately different for younger and older patients with ischemic stroke. Understanding factors contributing to regional heterogeneity may help target areas in need of improved stroke prevention interventions.

Teen pregnancy prevention

Teen pregnancy has been subject of public concern for many years. In the United States, despite nearly 2 decades of declining teen pregnancy and birth rates, the problem persists, with significant disparities present across racial groups and in state-specific rates. This review examines recent trends, pregnancy prevention initiatives and family planning policies that address the special needs of vulnerable youth. Unintended teen pregnancies impose potentially serious social and health burdens on teen parents and their children, as well as costs to society. Trends in teen pregnancy and birth rates show continued decline, but state and racial disparities have widened. Demographic factors and policy changes have contributed to these disparities. Research supports comprehensive pregnancy prevention initiatives that are multifaceted and promote consistent and correct use of effective methods of contraception for youth at risk of becoming pregnant. There is strong consensus that effective teen pregnancy prevention strategies should be multifaceted, focusing on delay of sexual activity especially in younger teens while promoting consistent and correct use of effective methods of contraception for those youth who are or plan to be sexually active. There is a need for further research to identify effective interventions for vulnerable populations.

State-Specific ATV-Related Fatality Rates: An Update in the New Millennium

We compared state-specific all-terrain vehicle (ATV) fatality rates from 2000-2007 with 1990-1999 data, grouping states according to helmet, training, and licensure requirements. We used the CDC WONDER online database to identify ATV cases from 2000-2007 and calculate rates per 100,000 population by state, gender, and age. ATV deaths (n=7,231) occurred at a rate of 0.32 per 100,000 population. Males accounted for 86% of ATV-related deaths at a rate that was six times that for females (0.55 vs. 0.09 per 100,000 population, respectively); 60% of the male deaths occurred in the 15- to 44-year age group. With the exception of the two oldest age categories, rates were consistently higher in the no-helmet-law group. Both the number and rate of ATV-related deaths increased more than threefold between 1990-1999 and 2000-2007. West Virginia and Alaska continue to have the highest ATV fatality rates (1.63 and 2.67 ATV deaths per 100,000 population, respectively). Helmet-use requirements seem to slightly mitigate ATV-related death, but training requirements do not. For policy to be effective, it must be enforced.

Interstate variation in trends of psychotropic medication use among Medicaid-enrolled children in foster care

High rates of treating children in foster care with second-generation antipsychotics, both singly and in combination with other psychotropics, have focused public interest on the use of these medications, and motivated some states to implement programs to curtail usage. To estimate any antipsychotic use and psychotropic polypharmacy among children in foster care during the last decade and to characterize interstate variation in these trends. Centers for Medicare and Medicaid Services Medicaid Analytic Extract data files for 47 states and the District of Columbia for years 2002–2007. The study sample included an average of 686,080 children annually aged 3–18 years of age with foster care Medicaid eligibility. Repeated cross-sectional design conducted with multilevel logistic regression, clustered at the state level and controlling for patient demographics. Main outcome measures were rates of filled prescriptions for any antipsychotic medication and for psychotropic polypharmacy (defined as concurrent use of 3 or more psychotropic medication classes for at least 30 days during the year). State-level rate trajectories over time were classified as increased (≥ 5% relative increase over interval), decreased (≥ 5% relative decrease over the interval), or stable. The rate of any antipsychotic use increased from 8.9% in 2002 to 11.8% in 2007 (P < .001 for temporal trend). In contrast, the rate of psychotropic polypharmacy was 5.2% in 2002, peaked in 2004 at 5.9%, and fell to 5.3% in 2007 (P < .001 for trend). State-specific rates of any antipsychotic use were significantly increased in 45 states over the period, while rates of psychotropic polypharmacy increased in only 18 states and declined in 19. Although absolute rates of any antipsychotic use and psychotropic polypharmacy among children in foster care remained high, psychotropic polypharmacy began to abate during the last decade, as rates of antipsychotic use continued to rise. ► We describe national trends in psychotropic medication use in youth in foster care. ► We examine interstate variation in antipsychotic use and polypharmacy trends. ► In aggregate, rates of antipsychotic use increased, while polypharmacy declined. ► We found notable interstate variation in medication trends for foster care youth.

Paying for Prevention: Associations between Pay for Performance and Cessation Counseling in Primary Care Practices

To examine associations between pay for performance (P4P) and recommended cessation counseling among primary care practices (PCPs). Cross-sectional survey of 89 PCPs participating in a joint Robert Wood Johnson Foundation (RWJF)-Agency for Healthcare Research and Quality (AHRQ) health promotion initiative. 100% response rate from PCPs participating in the RWJF-AHRQ initiative. Survey data on cessation counseling, practice involvement with P4P, practice size, public reporting of performance, practice competition, linkages with community resources, integration of evidence-based guidelines, patient recommendations for cessation, and state-specific smoking rates. Logistic regression was used to examine associations between practice involvement with P4P and cessation counseling offered by PCPs. Practice characteristics, including size and availability of other cessation services, were included in the analysis. Practices that were involved with P4P had greater odds of offering recommended cessation counseling (odds ratio [OR] = 27.6, p < .01). Practices that linked patients to community resources, experienced greater competition, and were larger in size also provided more counseling (p < .05). Publicly reporting performance information and being located in states with higher smoking rates were associated with decreased odds of offering counseling support (p < .10). Findings suggest that P4P is associated with recommended counseling for smoking cessation. Study limitations include small sample size and unavailability of information on the magnitude of P4P incentives and program design. Further analysis considering these programmatic details is warranted.

National trends and coding patterns in fall-related mortality among the elderly in the United States

Because good information on deaths caused by a fall would be important for prevention policies, we analyzed the influence of coding differences on variability in state-level fall death rates in the elderly. We examined state differences in the number of cause of death codes on death certificates, death certifiers, completeness of E-coding, and indicators of specificity of coding. We found that state-specific fall mortality rates ranged from 13.9 to 140.4 in people aged 65 years and above. States employing a coroner to investigate injury deaths had 14 per cent fewer recorded fall deaths than those where a medical examiner conducted the investigations. Each unit increase in the median number of cause of death codes was associated with a 10 per cent increase in the number of falls. For each 1 per cent increase in the use of unspecified codes for the underlying cause of death, the number of falls dropped by 2 per cent. Current fall mortality data do not appear to identify all instances of falls. Variability in unintentional fall-related death rates among states may be partly explained by death certification coding practices. Standardization of coding and training for documentation of fall events and death certificate reporting could help uncover the actual fall mortality burden in the elderly.

A multiquantum dataset for vibrational excitation and dissociation in high-temperature O2–O2 collisions

The Forced Harmonic Oscillator (FHO) model is applied to the production of a multiquantum dataset of V–T and V–D rates for O2–O2 collisions, for T=100–100000K. A simplified 1D O2–O2 intermolecular potential, accounting for long-range interactions, has been obtained through comparison of FHO and reference state-specific rates. A Morse potential with parameters α=4Å-1 and E=380K provides the best fit between those. This potential has then been applied to the production of the overall multiquantum V–T and V–D rates, considering 47 vibrational levels. The resulting thermal dissociation rates agree remarkably well with experimental dissociation rates.

Effects of demographic structure on key properties of stochastic density-independent population dynamics

The development of stochastic demography has largely been based on age structured populations, although other types of demographic structure, especially permanent and dynamic heterogeneity, are likely common in natural populations. The combination of stochasticity and demographic structure is a challenge for analyses of population dynamics and extinction risk, because the population structure will fluctuate around the stable structure and the population size shows transient fluctuations. However, by using a diffusion approximation for the total reproductive value, density-independent dynamics of structured populations can be described with only three population parameters: the expected population growth rate, the environmental variance and the demographic variance. These parameters depend on population structure via the state-specific vital rates and transition rates. Once they are found, the diffusion approximation represents a substantial reduction in model complexity.Here, we review and compare the key population parameters across a wide range of demographic structure, from the case of no structure to the most general case of dynamic heterogeneity, and for both discrete and continuous types. We focus on the demographic variance, but also show how environmental stochasticity can be included. This study brings together results from recent models, each considering a specific type of population structure, and places them in a general framework for structured populations. Comparison across different types of demographic structure reveals that the reproductive value is an essential concept for understanding how population structure affects stochastic dynamics and extinction risk.

Lung cancer mortality in a combined cohort of North Carolina and South Carolina asbestos textile workers

ObjectivesPrior studies of asbestos textile workers in two US cohorts (North Carolina (NC) and South Carolina (SC)) found increased risk of lung cancer mortality with exposure to chrysotile asbestos. The...

Development, validation, and results of a measure of 30‐day readmission following hospitalization for pneumonia

Readmission following hospital discharge has become an important target of quality improvement. To describe the development, validation, and results of a risk-standardized measure of hospital readmission rates among elderly patients with pneumonia employed in federal quality measurement and efficiency initiatives. A retrospective cohort study using hospital and outpatient Medicare claims from 2005 and 2006. A total of 4675 hospitals in the United States. Medicare beneficiaries aged >65 years with a principal discharge diagnosis of pneumonia. None. Hospital-specific, risk-standardized 30-day readmission rates calculated as the ratio of predicted-to-expected readmissions, multiplied by the national unadjusted rate. Comparison of the areas under the receiver operating curve (ROC) and measurement of correlation coefficient in development and validation samples. The development sample consisted of 226,545 hospitalizations at 4675 hospitals, with an overall unadjusted 30-day readmission rate of 17.4%. The median risk-standardized hospital readmission rate was 17.3%, and the odds of readmission for a hospital one standard deviation above average was 1.4 times that of a hospital one standard deviation below average. Performance of the medical record and administrative models was similar (areas under the ROC curve 0.59 and 0.63, respectively) and the correlation coefficient of estimated state-specific standardized readmission rates from the administrative and medical record models was 0.96. Rehospitalization within 30 days of treatment for pneumonia is common, and rates vary across hospitals. A risk-standardized measure of hospital readmission rates derived from administrative claims has similar performance characteristics to one based on medical record review.

Motor-vehicle crashes during pregnancy: a retrospective cohort study

Background: The purpose of this study was to assess the risk of motor-vehicle pregnant driver crashes in Pennsylvania using vital statistics linked to police and ambulance reports. This was supplemented with a review of national age and sex specific crash and fertility data to put this risk into perspective and rank the likelihood for pregnancy-related crashes in other states. Methods: Motor vehicle police crash reports from the Pennsylvania Department of Transportation were probabilistically linked to four years of birth and fetal death data and five years of infant death records and ambulance reports. State specific motor-vehicle traffic injury rates (fatal and non-fatal) were compared to birth rates, by age, for women ages 15 - 34. Results: 5929 (1.1%) of the women with a birth or fetal death linked to a police reported motor vehicle driver crash during pregnancy. One-third (32.5%) of these crashes resulted in minor maternal injuries and 7.5% resulted in moderate to fatal maternal injuries. Crashes were evenly distributed across gestational ages. Young drivers (20 - 24) were at highest risk. Police reported non-belt use was 10%. Conclusions: This study quantifies the risk of motor vehicle crashes during pregnancy in Pennsylvania and offers a perspective on potential variations in other states. Pregnancy related crashes occur at a higher rate than infant related crashes with a concomitant threat to the fetus and new-born not usually tracked within current crash data systems.

Adoption of Rollover Protective Structures (ROPS) on U.S. Farm Tractors by State: 1993-1995, 2001, and 2004

This research compares state-level rollover protective structure (ROPS) prevalence rates from the early and mid-1990s to those observed in the years 2001 and 2004. In addition, state-level ROPS prevalence rates are compared to state-level tractor overturn fatality rates. Tractor data for 1993-1995 and for 2001 and 2004 for all tractors and ROPS-equipped tractors in use on U.S. farms were derived from surveys conducted for NIOSH by the USDA-NASS. Changes in ROPS prevalence rates at the state level between the two time periods were assessed using a two-sample paired t-test with unequal sample sizes. Poisson regression was used to assess the association between ROPS prevalence rates and tractor overturn fatality rates at the state level. Overall, 49 of the 50 states had an observed increase in the percentage of farm tractors equipped with ROPS from 1993-1995 to 2001 and 2004. This increase was statistically significant for 34 states. Large shifts in ROPS prevalence were found within individual states and in clusters of states. These include a major increase in the southeastern U.S. and some western states. However, a core of states in the northeast (many of them in or near the Appalachian Mountains) through the upper midwest remain in the bottom quartile for ROPS prevalence. For the years 1992 through 2004, the highest fatality rates were observed in many of the same states that were identified previously as having persistently low ROPS prevalence rates. There is a clear relationship between low state-level ROPS prevalence rates and high state-specific tractor overturn fatality rates. While progress has been made in increasing the percentage of ROPS-equipped farm tractors, it is projected that ROPS prevalence rates will not reach a protective level nationally until after 2015. Regionally, the northeast and midwest will not reach protective levels of ROPS-equipped tractors until after 2020. Based on the adoption rates observed, tractor overturn rates will likely continue to be a more localized, but significant, public health issue for several states beyond the year 2020. The results of this study show the geographic areas of the U.S. where the greatest need exists, and where a greater emphasis should be placed on ROPS promotion activities. However, addressing this public health issue on a large scale will require resources and an organized commitment, which have historically been lacking.