Statewide Policy Research Articles

Key influences on residential photovoltaic solar panel adoption in the United States

ABSTRACT The prevalence of low-density residential development to host solar PV, the ubiquity of solar irradiation, and incentivizing policies have created substantial opportunities for homeowners in the United States. Federal, state, and municipal governments implement regulatory policies and financial incentives to promote photovoltaic solar systems in residential buildings with limited resources. Thus, understanding the main factors and their spatial variations is vital for expanding the accessibility of renewable energy benefits to specific socio-economic groups and submarkets. Our research includes linear regression, principal component regression, and spatial error models to provide empirical evidence for the relationship between the adoption rates and socio-economic, geographical, and technical factors while identifying characteristics of adopter groups. The results suggest that the relative advantage factors – electricity prices and solar irradiation – play the most significant role across all regions and market segmentations. Statewide policy indicators are the second most significant factor, followed by socio-economic variables on employment status, remote working, car ownership, and property value. Our results indicate that homeowners do not only differ in their circumstances but also in their motivations. This highlights a need for policy-makers and the solar industry to place greater emphasis on distinct characteristics of consumers motivated by ideology and consumers motivated by economic benefits.

Addressing Challenges to Ensuring Justice and Sustainability in Policy and Infrastructure for Texas Water Resources in the 21st Century

Environmental justice and sustainability have both become major concerns for water resource management, particularly with recent federal emphasis on environmental justice under the Biden administration in the United States. Texas, like many U.S. states, lags behind the federal government in this emphasis. While many localities have made progress in some respects—for example, some major Texas municipalities have included equity and sustainability metrics in their recent climate action plans—others have not. This has left a patchwork of persistent water management and availability issues that are exacerbated by extreme weather and worsening impacts of climate change. We provide a review of many of Texas’s water equity and sustainability challenges, both now and in a more extreme climate future. These include water access, affordability, contamination, flooding, drought, and aging infrastructure. For example, many Texas counties rank highest in the nation for flood risk, including coastal counties with high populations of disadvantaged communities and counties containing populations that live in persistent poverty in the Lower Rio Grande Valley. Additionally, approximately 44,000 Texans, or about 0.4% of the state population, lack access to complete plumbing facilities in their homes. The costs of water infrastructure leaks (estimated at about 51 gallons of water per day statewide) are shared across customers of all income levels, though they place a disproportionate burden on low-income customers. We then assess existing statewide and local policy and planning efforts and gaps in addressing these concerns in Texas. We focus particularly on the role of efforts to incorporate community voice—the ideas, concerns, needs, and expertise of impacted community members, dismantle causes of injustice, and improve equity in spending. If communities are not intentional with future development, new water infrastructure could continue to perpetuate existing harms. Thus, we provide a research agenda and recommendations for addressing some of the policy and planning gaps and persistent environmental justice issues. We aim to help water managers and policy makers identify and dismantle sources of inequity, particularly through including community voice.

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

ObjectivesTo assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). DesignObservational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and ParticipantsNHs (n = 678) and ALCs (n = 542) that reported staffing by shift in Ohio. MethodsResident-to-staff ratios in Ohio were calculated from staffing data. The proportion of daily nursing staff assigned to each shift was based on staffing data from the Biennial Survey for NHs and ALCs. Outcomes were calculated for aides and licensed nursing staff. ResultsOhio's NHs and ALCs had lower resident-to-staff ratios on the day shift. Lower resident-to-staff ratios mean there were more staff per resident (ie, better staffed). For both types of staff and all shifts, overall resident-to-staff ratios were lower in NHs than ALCs. However, resident-to-staff ratios for ALC MCUs were on par with NH MCUs. This was consistent with ALC and NH MCUs staffing in a more similar manner. Across all settings, the day shift had the most staff members present, while a number of ALCs had no licensed nurses on duty during the overnight shift. Conclusions and ImplicationsNHs and ALCs have different staffing patterns due to differences in resident needs. However, as ALCs provide for more residents that need NH level of care, ALCs may require additional staffing, especially on the overnight shift where some ALCs have no licensed nurses on duty. The evidence here can be used for decision making about future staffing policies, whether facility-wide policies that encompass MCUs or state-wide policies, so that care delivery aligns with care needs.

Unexcused Absences and Failures: Dissecting the Variability in Course Credit Policies and Freshman Course Failure

This policy analysis examines the implementation of A.C.A. 6-18-222, a statewide policy in Arkansas that addresses unexcused absences and the subsequent consequences for course credit among students. Utilizing anonymized student-level data from the 2020-21 and 2021-22 school years, which includes a total of 65,651 freshmen, the study investigates the variability in policy implementation across districts. It also examines the differing language used to dictate the consequences of exceeding unexcused absence thresholds. Our multivariate logistic regression models demonstrate that students eligible for Free and Reduced Lunch (FRL) are notably more likely to fail a course after surpassing their district's absence threshold. Moreover, the data reveal that upon reaching this threshold, students are significantly more likely to fail core courses as opposed to non-core courses. These findings illuminate the variations in local policy implementation and their impact on student academic outcomes, emphasizing the importance of uniform policy enforcement to ensure equitable educational opportunities.

Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon.

A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies. To examine the effect of the policy on prescribing, health outcomes, and health service utilization. Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models. Adult Medicaid patients with back pain enrolled between 2014 and 2018. The Oregon Medicaid back pain policy. Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization. The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4days [95% CI - 0.53, - 0.26] slope), receipt of more than 7days of short-acting opioids (- 2.36pp [95% CI - 2.76, - 1.95] level, - 0.91pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm. A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Living in an Intimate Partner Violence Shelter During a Pandemic: Perspectives from Advocates and Survivors

ABSTRACT Purpose With state-wide quarantine policies during the COVID-19 pandemic like those implemented in the state of Texas, intimate partner violence (IPV) shelter staff were forced to incorporate new safety measures to keep survivors and advocates safe. To understand the impact of these adaptations fully, authors interviewed shelter staff and residents to capture both of their experiences living and working in the same shelter during the height of the coronavirus pandemic (summer 2020) to understand how changes in policy and procedure in shelters impacted survivors and advocates. Materials and Methods A qualitative phenomenological design was utilized to collect and analyze data from 10 staff and 10 survivors to develop both a textual and a structural description of participant experiences living in an IPV shelter. Results The current study captured the survivors’ and advocates’ perspectives related to the 1) vacillating views of shelter social distancing and quarantine policies, 2) shelter occupancy and staffing unpredictability, 3) the broader challenges related to environmental stressors and 4) mobility challenges. Discussion Results of this study highlight factors related to interpersonal relationships within the shelter and structural factors of shelter which contributed to stress for participants. Conclusion The coronavirus is continuing to present challenges for shelters. Implications can be drawn from provider and client experiences that can inform policies and procedures for future health crises, including the need to mitigate environmental stress and transportation challenges, as well as considerations for maintaining social support should social distancing be necessary in future epidemics.

EAST MEETS WEST: INTERVENTIONS, PRACTICE MODELS, AND POLICIES TO SUPPORT FAMILY CAREGIVERS IN DIVERSE CULTURES

Abstract This East Meets West symposium consists of six studies that examined innovative interventions, practice models and policies designed to support family caregivers of older adults in the U.S., Taiwan, and mainland China. The first two papers both used case management interventions to assist family caregivers with a focus on caregiver depression. The paper from the U.S. found that more difficulties of performing caregiving tasks and less caregiver preparation contributed to higher levels of depression, and the paper from Taiwan found that caregivers who received the case management service reduced depression at four-month and six-month follow-up assessments. The third paper discussed a “time travel” paradigm developed to guide service design and delivery for persons with dementia at different stages. The fourth paper used the state of Michigan as a case to examine service gaps in the current aging service network, and identifies an urgent need for statewide policy renovations to support family caregivers. The fifth and sixth papers both used large secondary data analyses to examine the effects of piloted policy and practice efforts on family caregiver outcomes. One study found that the long-term care insurance programs have resulted in positive caregiver outcomes including reduced caregiving financial cost, time, and physical and psychological burden. The other study found the use of home-based care services reduced adult children caregiver burden and did not affect the relationship between older adults and adult children caregivers. After individual presentations are done, two discussants will summarize shared themes in these papers and provide critical feedback.

Massachusetts' opioid limit law associated with a reduction in postoperative opioid duration among orthopedic patients.

Postoperative orthopedic patients are a high-risk group for receiving long-duration, large-dosage opioid prescriptions. Rigorous evaluation of state opioid duration limit laws, enacted throughout the country in response to the opioid overdose epidemic, is lacking among this high-risk group. We took advantage of Massachusetts' early implementation of a 2016 7-day-limit law that occurred before other statewide or plan-wide policies took effect and used commercial insurance claims from 2014-2017 to study its association with postoperative opioid prescriptions greater than 7 days' duration among Massachusetts orthopedic patients relative to a New Hampshire control group. Our sample included 14 097 commercially insured, opioid-naive adults aged 18 years and older undergoing elective orthopedic procedures. We found that the Massachusetts 7-day limit was associated with an immediate 4.23 percentage point absolute reduction (95% CI, 8.12 to 0.33 percentage points) and a 33.27% relative reduction (95% CI, 55.36% to 11.19%) in the percentage of initial fills greater than 7 days in the Massachusetts relative to the control group. Seven-day-limit laws may be an important state-level tool to mitigate longer duration prescribing to high-risk postoperative populations.

Governing Through Gridlock: Bill Composition under Divided Government

AbstractWhat is the effect of divided government on issue attention in state legislatures? Much of the research on divided government examines how it affects the enactment of significant legislation but does not consider other effects on legislative behavior. In this article, I propose a new theory of the relationship between divided government and legislative activity. Regardless of partisan control, reelection-minded legislators face pressure to deliver benefits to voters, yet divided government can make substantive policy change difficult. As a result of these competing pressures, under divided government legislators increasingly turn their focus to bills that benefit their local constituents, which are seen as easier to enact and allow them to engage in advertising, credit claiming, and position taking. Consistent with this theory, I find that under divided government, legislators introduce bills at the same rate, but the type of legislation introduced shifts away from statewide policy changes and towards district-specific legislation.

Genomic epidemiology reveals the dominance of Hennepin County in the transmission of SARS-CoV-2 in Minnesota from 2020 to 2022.

We analyzed over 22,000 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes of patient samples tested at Mayo Clinic Laboratories during a 2-year period in the COVID-19 pandemic, which included Alpha, Delta, and Omicron variants of concern to examine the roles and relationships of Minnesota virus transmission. We found that Hennepin County, the most populous county, drove the transmission of SARS-CoV-2 viruses in the state after including the formation of earlier clades including 20A, 20C, and 20G, as well as variants of concern Alpha and Delta. We also found that Hennepin County was the source for most of the county-to-county introductions after an initial predicted introduction with the virus in early 2020 from an international source, while other counties acted as transmission "sinks." In addition, major policies, such as the end of the lockdown period in 2020 or the end of all restrictions in 2021, did not appear to have an impact on virus diversity across individual counties.

Key Issues in the First Year of Transition for a Large Medicaid-Funded Children's Service.

Behavioral Health Rehabilitation Service (BHRS) is a comprehensive service for Pennsylvania's Medicaid-enrolled youth and their families. In 2021, BHRS transitioned to Intensive Behavioral Health Service (IBHS) through state-wide policy change. To assess impact, the largest behavioral health managed care organization in the state compared service utilization in BHRS in 2019 versus IBHS in 2021. Results show that significantly more youth received non-Applied Behavior Analysis (non-ABA) services in BHRS (n = 13,795) than IBHS (n = 10,083) and more youth were discharged during the measurement period for BHRS versus IBHS (47% vs. 44%). Significantly more youth received ABA through IBHS versus BHRS (n = 4,385 vs. n = 2,690). The number of youth served in therapeutic service in IBHS did not indicate improved access during this first year of transition; however, more youth received evidence based treatments through IBHS indicating higher quality care for some youth and families.

Early evidence of flavored tobacco product restrictions in Massachusetts and New York State.

With many US states and localities enacting policies that restrict flavored e-cigarette sales, evaluation of these restrictions is critical to inform future efforts. This study analyzed both survey and retail scanner data to assess early-stage impacts of flavored tobacco sales restrictions in Massachusetts and New York State on e-cigarettes sales and product use among young people. This study uses state-level e-cigarette retail sales data and survey data from youth and young adults (aged 13-24 years). Cross-sectional surveys were conducted at two time points in Massachusetts (both post policy implementation) and New York (pre and post policy implementation); retail sales data in both states were analyzed from 2019 through 2020 and compared to sales in control states. E-cigarette unit sales decreased significantly following the implementation of statewide restrictions on flavored e-cigarettes in both Massachusetts and New York State (p<0.001). Survey data showed a decrease in mint flavored e-cigarette use in Massachusetts and an increase in tobacco flavored e-cigarette use in New York State over time (p=0.001). In both states, a greater proportion of respondents reported using disposable e-cigarettes at Time 2 compared to Time 1 (p=0.001). Among those who reported using fruit-flavored e-cigarettes in New York State, a significantly greater proportion reported disposable device use at Time 2 compared to Time 1 (p=0.004). Findings from these case studies from two US states suggest that statewide policies reduce the availability of e-cigarettes and have the potential to reduce use of many youth-appealing flavors. The increase in use of disposable e-cigarettes likely reflects existing loopholes in federal policy, which may be attenuating the potential impact of strong state-level policies.

SCouT: Synthetic Counterfactuals via Spatiotemporal Transformers for Actionable Healthcare

The synthetic control method has pioneered a class of powerful data-driven techniques to estimate the counterfactual reality of a unit from donor units. At its core, the technique involves a linear model fitted on the pre-intervention period that combines donor outcomes to yield the counterfactual. However, linearly combining spatial information at each time instance using time-agnostic weights fails to capture important inter-unit and intra-unit temporal contexts and complex nonlinear dynamics of real data. We instead propose an approach to use local spatiotemporal information before the onset of the intervention as a promising way to estimate the counterfactual sequence. To this end, we suggest a Transformer model that leverages particular positional embeddings, a modified decoder attention mask, and a novel pre-training task to perform spatiotemporal sequence-to-sequence modeling. Our experiments on synthetic data demonstrate the efficacy of our method in the typical small donor pool setting and its robustness against noise. We also generate actionable healthcare insights at the population and patient levels by simulating a state-wide public health policy to evaluate its effectiveness, an in silico trial for asthma medications to support randomized controlled trials, and a medical intervention for patients with Friedreich’s ataxia to improve clinical decision making and promote personalized therapy (code is available at https://github.com/JHA-Lab/scout ).

Impact of state opioid laws on prescribing in trauma patients

BackgroundExcessive opioid prescribing has resulted in opioid diversion and misuse. In July 2018, Michigan’s Public Act 251 established a state-wide policy limiting opioid prescriptions for acute pain to a 7-day supply. Traumatic injury increases the risk for new persistent opioid use, yet the impact of prescribing policy in trauma patients remains unknown. To determine the relationship between policy enactment and prescribing in trauma patients, we compared oral morphine equivalents prescribed at discharge before and after implementation of Public Act 251. MethodsIn this cross-sectional study, adult patients who received any oral opioids at discharge from a Level 1 trauma center between January 1, 2016, and June 30, 2021, were identified. The exposure was patients admitted starting July 1, 2018. Inpatient oral morphine equivalents per day 48 hours before discharge and discharge prescription oral morphine equivalents per day were calculated. Student’s t test and an interrupted time series analysis were performed to compare mean oral morphine equivalents per day pre- and post-policy. Multivariable risk adjustment accounted for patient/injury factors and inpatient oral morphine equivalent use. ResultsA total of 3,748 patients were included in the study (pre-policy n = 1,685; post-policy n = 2,063). Implementation of the prescribing policy was associated with a significant decrease in mean discharge oral morphine equivalents per day (34.8 ± 49.5 vs 16.7 ± 32.3, P < .001). After risk adjustment, post-policy discharge prescriptions differed by −19.2 oral morphine equivalents per day (95% CI −21.7 to −16.8, P < .001). The proportion of patients obtaining a refill prescription 30 days post-discharge did not increase after implementation (0.38 ± 0.48 vs 0.37 ± 0.48, P = .7). ConclusionDischarge prescription amounts for opioids in trauma patients decreased by approximately one-half after the implementation of opioid prescribing policies, and there was no compensatory increase in subsequent refill prescriptions. Future work is needed to evaluate the effect of these policies on the adequacy of pain management and functional recovery after injury.

The Absence of State-Wide Policy on Providing Standard Dialysis Care for Undocumented Immigrants: Challenges and Opportunities.

The Absence of State-Wide Policy on Providing Standard Dialysis Care for Undocumented Immigrants: Challenges and Opportunities.

A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity

Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity. Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022. The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested. A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Reducing flood risk and improving system resiliency in Sacramento, California: overcoming obstacles and emerging solutions

Sacramento, the capital of California, has a population of over 2 million and is one of the most flood prone regions in the nation. Its problems exemplify those of many urban communities built near riverine and deltaic systems, that are subject to climate change. The city and its surrounding communities are protected by an elaborate system of levees and flood bypasses; but aging infrastructure, expected increases in extreme wet weather, and projected sea level rise are increasing the risk of levee failures. We explore how flood management approaches including social/institutional (non-structural), traditional structural, and ecological based approaches are being implemented in the Lower Sacramento/North Delta Region amid significant obstacles, to build resilient flood management systems. We review four case studies, one structural levee project and three multi-benefit projects that are only recently being implemented. We also examine the barriers, constraints, and challenges for implementing flood protection projects, and how project proponents are collectively working through these obstacles. We conclude that significant progress has been made in building flood resiliency since the 2008 Central Valley Flood Protection Act and the release of the 2012 Central Valley Flood Protection Plan. Informational tools and policies are being developed to educate the public and prepare for floods. Structural levee investments are substantial and are being implemented through partnerships. Statewide policies and investments are increasingly supporting multi-benefit projects that incorporate ecological restoration/enhancement while expanding flood volume capacity. Progress on implementing multi-benefit projects has been slow, due to land acquisition, easements, funding, regulatory and construction challenges; however, solutions to these impediments are emerging to facilitate more rapid progress. It is essential to continue and intensify the progress made in the last two decades, by learning from past projects, and improving on existing pathways to implement sustainable projects at a faster rate.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

ABSTRACT Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey’s (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model’s goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications. Objectives: To explore office-based addiction treatment providers’ experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers. Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes. Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations. Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Specialty cancer care and survival in AYA ALL: A U.S. multi-state analysis.

7008 Background: Unlike children with acute lymphoblastic leukemia (ALL) who receive cancer care almost exclusively from pediatric oncologists at specialized cancer centers (SCC; defined here as National Cancer Institute and/or Children’s Oncology Group designated cancer centers), adolescents and young adults (AYAs; 15-39 years) in the United States receive care in a variety of settings. Using state-wide population-based data, we sought to describe the health care delivery settings in which AYAs with ALL receive treatment and determine associations between front-line treatment at an SCC and leukemia-specific and overall survival (LSS/OS). Methods: We used data from the 2004-2018 California (CA), New York (NY), and Texas (TX) state cancer registries to identify front-line treatment setting of AYAs newly diagnosed with ALL. Multivariable logistic regression models evaluated characteristics associated with receiving treatment at an SCC. Cox proportional hazards regression models evaluated the associations with LSS/OS. All models were adjusted for gender, age, sex, race/ethnicity, socioeconomic status, insurance, and diagnosis year. Results: The cohort was comprised of 2283 (CA), 795 (NY), and 955 (TX) AYAs with ALL. Across all states, approximately 70% were ³18 years and 65% were male. Race/ethnicity varied by state: a majority in CA (63%) and TX (64%) were Hispanic, while most in NY were non-Hispanic White (NHW) (50%). Health insurance coverage also varied: most in CA were publicly insured (48%), while most in NY were privately insured (54%); TX had the highest rate of uninsured (18%). Treatment at an SCC occurred in 48.2% (CA), 44.4% (NY), and 19.5% (TX) of AYAs, increasing in CA and NY over time, but remaining unchanged in TX. Among all states, older age and uninsured status were significantly associated with lower odds of treatment at an SCC. In both CA (OR 0.58, 95% CI 0.45-0.74) and TX (OR 0.55, 95% CI 0.35-0.86), Hispanic patients had significantly lower odds of treatment at an SCC than NHW. In NY (OR 0.45, 95% CI 0.31-0.67) and TX (OR 0.49, 95% CI 0.3-0.8), publicly insured AYAs had significantly lower odds of receiving treatment at an SCC than those with private insurance. Front-line treatment at an SCC was significantly associated with both superior LSS (HR 0.73, 95% CI 0.63-0.85) and OS (HR 0.73, 95% CI 0.63-0.85) in CA and superior LSS (HR 0.70, 95% CI 0.51-0.94) and OS (HR 0.61, 95% CI 0.45-0.83) in TX; a non-significant association was seen in NY (LSS: HR 0.86, 95% CI 0.65-1.12; OS: HR 0.83, 95% CI .64-1.08). Conclusions: Only 20-50% of newly diagnosed AYA ALL patients receive front-line treatment at SCCs, with age, race/ethnicity, and insurance type independently influencing AYA ALL care setting. We show that the treatment of ALL at an SCC is associated with superior survival, highlighting the importance of statewide and national policy efforts to improve access and reduce inequities in AYA ALL.

Evaluation of Statewide Restrictions on E-Cigarette Nicotine Strength- United States, 2017-2022.

To evaluate statewide policies restricting e-cigarette nicotine strength. A difference-in-difference regression analysis was used to compare e-cigarette sales in states that restrict nicotine strength with states with no restrictions. Since flavor restrictions might affect sales and nicotine strength, states with flavor restrictions were also assessed. United States e-cigarette retail sales data during January 2017-March 2022 were licensed from Information Resources Incorporated. States with restrictions included Massachusetts (restricted maximum nicotine strength to 3.5% and non-tobacco flavored e-cigarette sales in December 2019); Utah (restricted nicotine strength to 3.6% in September 2021); and Rhode Island, New York, and Washington (restricted non-tobacco flavor sales in October 2019, May 2020, and October 2019-January 2020 respectively). These were compared with data from 34 states with no e-cigarette nicotine strength or flavor restrictions MEASUREMENTS: Weighted mean nicotine strength and total unit sales. Total unit sales per 1,000 state population were summed into 4-week periods by state. Models controlled for emergency responses, state demographics, tobacco control policies, time, and state fixed effects. Restricting both nicotine strength and flavors in Massachusetts was associated with a 2.04 percentage point (pp) reduction in mean nicotine strength and 86.76-unit reduction in monthly unit sales per 1,000 persons compared with states with no restrictions (all p<0.01). Restricting nicotine strength only in Utah was associated with a 1.77 pp (p<0.01) reduction in mean nicotine strength; however, there was no impact on unit sales. Restricting non-tobacco flavor sales only in Rhode Island, New York, and Washington slightly reduced mean nicotine strength (0.21, 0.62, and 0.19 pp, respectively) and sales (36.66, 34.51, and 16.37 units, respectively) (all p<0.01). US statewide policies restricting e-cigarette nicotine strength appear to be associated with reductions in average nicotine strength in sales within that state; however, there appears to be no impact on unit sales. When these policies are implemented along with flavor restrictions; reductions in average nicotine strength occur in addition to reduced unit sales.