US States Research Articles

Political Connections and the Effectiveness of US State Government Resource Allocation

Political Connections and the Effectiveness of US State Government Resource Allocation

Justice-Involved Status and In-Hospital Mortality Among Nonelderly Adults During the COVID-19 Pandemic, 2021

ObjectiveThe purpose of this research is to examine the role of justice-involved status on in-hospital mortality among nonelderly adults during the second year of the COVID-19 pandemic. MethodsThis retrospective cohort study used data from the 2021 State Inpatient Databases for 20 US states, which included discharges from general acute care hospitals among adults aged 18-64 years hospitalized for at least 24 hours. The main outcome was all-cause in-hospital mortality and the primary comparison was justice-involved status. We used logistic regression to estimate the odds ratios and 95% confidence intervals (CIs), with adjustment for sociodemographic factors, Elixhauser comorbidities, COVID-19 diagnosis, admission acuity, other clinical features, metropolitan area, and seasonality. We randomly split the data into a 50% training and 50% validation set. With the latter, we evaluated the performance of our final model. ResultsThe study population included 4,712,441 discharges (1.1% justice-involved; mean [SD] age 47.5 [12.8] years; 47.0% women; 63.6% White, 21.8% Black, 11.8% Hispanic, 1.8% Asian/Pacific Islander, and 1.0% American Indian/Alaska Native). Among these, 102,735 in-hospital deaths (2.2%) occurred. In the multivariate analysis, in-hospital mortality was about 40% less likely among justice-involved patients (odds ratios 0.6, 95% CI 0.5-0.7, P value <0.01). The final validated model showed excellent discrimination (area under the curve for the receiver operator characteristic 0.953, 95% CI 0.952-0.954) and good calibration (Brier score 0.014, calibration belt P value .186). ConclusionsIn this cohort study, justice-involved status was independently associated with lower in-hospital mortality. Future studies should examine preadmission and postdischarge outcomes.

Virtual Pooled Registry-Cancer Linkage System: an improved method for ascertaining cancer diagnoses.

The National Cancer Institute funds many large cohort studies that rely on self-reported cancer data requiring medical record validation. This is labor intensive, costly, and prone to underreporting or misreporting of cancer and disparity-related differential response. US population-based central cancer registries identify incident cancer within their catchment area, yielding all malignant neoplasms and benign brain and central nervous system tumors with standardized data fields. This manuscript describes the development, implementation, and features of a system to facilitate linkage between cohort studies and cancer registries and the release of cancer registry data for matched cohort participants. The Virtual Pooled Registry-Cancer Linkage System (VPR-CLS) provides an online system to link cohorts with multiple state cancer registries by 1) securely transmitting a study file to registries, 2) providing an optimized linkage algorithm to generate preliminary match counts, and 3) providing a streamlined process and templated forms for submitting and tracking data requests for cohort participants who matched with registries. In 2022, the VPR-CLS launched with 45 registries, covering 95% of the US state populations and Puerto Rico. Registries have linked with 15 studies having 14 273-10.9 million participants. Except in 1 study, linkage sensitivity ranged from 87.0% to 99.9%. Numerous registries have adopted the VPR-CLS templated institutional review board-registry application (n = 39), templated data use agreement (n = 25), and central institutional review board (n = 16). The VPR-CLS markedly improves ascertainment of cancer outcomes and is the preferred approach for determination of outcomes from cohort studies, postmarketing surveillance, and clinical trials.

Abortion Stigma as a Barrier to Mifepristone Use among Obstetrician-Gynecologists in Alabama for Early Pregnancy Loss.

The objective of our study was to identify and characterize barriers to mifepristone use among obstetrician-gynecologists (OB-GYNs) for early pregnancy loss in a southern US state. In this qualitative study, we conducted semistructured interviews with 19 OB-GYNs in Alabama who manage early pregnancy loss. The interviews explored participants' knowledge of and experience with mifepristone use for miscarriage management and abortion, along with barriers to and facilitators of clinical mifepristone use. The interviews were coded by multiple study staff using inductive and deductive thematic coding. Nearly all of the interviewees identified abortion-related stigma as a barrier to mifepristone use. Interviewees often attributed stigma to a lack of knowledge about the clinical use of mifepristone for early pregnancy loss. The stigmatization of mifepristone due to its association with abortion was related to religious and political objections. Many interviewees also described stigma associated with misoprostol use. Although providers believed that mifepristone use for abortion would not be accepted in their practice, most believed that mifepristone could be used successfully for miscarriage management after practice-wide education on its use. Mifepristone is strongly associated with abortion stigma among OB-GYNs in Alabama, which is a barrier to its use for miscarriage management. Interventions to decrease abortion stigma and associated stigma surrounding mifepristone are needed to optimize early pregnancy loss care.

Examining the Impact of Minimum Handgun Purchase Age and Background Check Legislation on Young Adult Suicide in the United States, 1991-2020.

Objectives. To examine the independent and joint effects of state legislation on minimum age for purchasing handguns and background checks on the suicide of young adults aged 18 to 20 years. Methods. We used negative binomial regressions with fixed effects for year and generalized estimating equations for state to estimate the effects of state legislation on annual counts of firearm, nonfirearm, and total young adult suicides in all 50 US states from 1991 to 2020. Results. Minimum age laws decreased the incidence rate of firearm suicide among young adults, an effect that was amplified in states with permit to purchase laws; there was no effect on the nonfirearm or total suicide rate. Permit to purchase laws significantly decreased the young adult firearm suicide incidence rate by 39% (incidence rate ratio [IRR] = 0.61; 95% confidence interval [CI] = 0.51, 0.74) and the overall suicide incidence rate by 14% (IRR = 0.86; 95% CI = 0.75, 0.99), with no effect on the nonfirearm suicide rate. Conclusions. Permit to purchase laws are a more promising avenue for reducing young adult suicides than are age-based restrictions. (Am J Public Health. 2024;114(8):805-813. https://doi.org/10.2105/AJPH.2024.307689).

Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001–2015 in 14 states

ABSTRACT Prostate cancer (PCa) incidence is reportedly lower in men with HIV compared to men without HIV for unknown reasons. We describe PCa incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare. Men (N = 15,167,636) aged 18–64 with ≥7 months of continuous enrollment during 2001–2015 in 14 US states were retained for analysis. Diagnoses of HIV and PCa were identified using non-drug claims. We estimated cause-specific (csHR) comparing incidence of PCa by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions, and stratified by age and race-ethnicity. Hazard of PCa was lower in men with HIV than men without HIV (csHR = 0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR = 0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR = 0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR = 1.17; 95% CI: 0.91, 1.50). Findings were similar in models restricted to men aged 50–64 and 40–49, but not in men aged 18–39. Reported deficits in PCa incidence by HIV status may be restricted to specific groups defined by age and race ethnicity.

Political culture and the resource curse: public sector corruption across the United States

Purpose This study aims to examine the connection between political culture and public sector corruption, using the typology of Daniel Elazar, whose model traces the types of political cultures to their origins in various regions of England. Similarly, the “resource curse” concept, generally treated as a national-level phenomenon, is examined to assess how it might vary among jurisdictions within a country. Design/methodology/approach Regression analysis was applied to data from the 50 states of the US. Public sector corruption in each state was operationalized as the number of convictions by the Public Integrity Section of the US Department of Justice in relation to the number of public sector employees in that state. Findings Among the 50 states of the US, support was found for the association between political culture and public sector corruption. On the other hand, whether a state’s economy was dominated by natural resource extraction was not related to public sector corruption. This latter finding suggests the “resource curse” phenomenon does not cause corruption to be worse in states with resource-dependent economies. Research limitations/implications Although it is appropriate to apply regression analysis to a data set of the 50 US states, the small size of the data set limited the number of predictor variables that could be examined. Alternative research approaches are discussed, and it is conceivable that another analytical technique might have revealed other predictors that affect the occurrence of corruption. Originality/value While numerous studies have examined the impact of political culture and resource orientation on corruption at the national level, the current study examines how these variables affect corruption at the level of subnational jurisdictions within a major developed country, the United States.

Diversity-aware Population Models: Quantifying Associations between Socio-Spatial Factors and Cognitive Development in the ABCD Cohort.

Population-level analyses are inherently complex due to a myriad of latent confounding effects that underlie the interdisciplinary topics of research interest. Despite the mounting demand for generative population models, the limited generalizability to underrepresented groups hinders their widespread adoption in downstream applications. Interpretability and reliability are essential for clinicians and policymakers, while accuracy and precision are prioritized from an engineering standpoint. Thus, in domains such as population neuroscience, the challenge lies in determining a suitable approach to model population data effectively. Notably, the traditional strata-agnostic nature of existing methods in this field reveals a pertinent gap in quantitative techniques that directly capture major sources of population stratification. The emergence of population-scale cohorts, like the Adolescent Brain Cognitive DevelopmentSM (ABCD) Study, provides unparalleled opportunities to explore and characterize neurobehavioral and sociodemographic relationships comprehensively. We propose diversity-aware population modeling, a framework poised to standardize systematic incorporation of diverse attributes, structured with respect to intrinsic population stratification to obtain holistic insights. Here, we leverage Bayesian multilevel regression and poststratification, to elucidate inter-individual differences in the relationships between socioeconomic status (SES) and cognitive development. We constructed 14 varying-intercepts and varying-slopes models to investigate 3 cognitive phenotypes and 5 sociodemographic variables (SDV), across 17 US states and 5 race subgroups. SDVs exhibited systemic socio-spatial effects that served as fundamental drivers of variation in cognitive outcomes. Low SES was disproportionately associated with cognitive development among Black and Hispanic children, while high SES was a robust predictor of cognitive development only among White and Asian children, consistent with the minorities' diminished returns (MDRs) theory. Notably, adversity-susceptible subgroups demonstrated an expressive association with fluid cognition compared to crystallized cognition. Poststratification proved effective in correcting group attribution biases, particularly in Pennsylvania, highlighting sampling discrepancies in US states with the highest percentage of marginalized participants in the ABCD Study©. Our collective analyses underscore the inextricable link between race and geographic location within the US. We emphasize the importance of diversity-aware population models that consider the intersectional composition of society to derive precise and interpretable insights across applicable domains.

Retention in care and antiretroviral therapy adherence among Medicaid beneficiaries with HIV, 2001–2015

ABSTRACT Disparities in HIV care by socioeconomic status, place of residence, and race/ethnicity prevent progress toward epidemic control. No study has comprehensively characterized the HIV care cascade among people with HIV enrolled in Medicaid – an insurance source for low-income individuals in the US. We analyzed data from 246,127 people with HIV enrolled in Medicaid 2001–2015, aged 18–64, living in 14 US states. We estimated the monthly prevalence of four steps of the care cascade: retained in care/adherent to ART; retained/not adherent; not retained/adherent; not retained/not adherent. Beneficiaries were retained in care if they had an outpatient care encounter every six months. Adherence was based on medication possession ratio. We estimated prevalence using a non-parametric multi-state approach, accounting for death as a competing event and for Medicaid disenrollment using inverse probability of censoring weights. Across 2001–2015, the proportion of beneficiaries with HIV who were retained/ART adherent increased, overall and in all subgroups. By 2015, approximately half of beneficiaries were retained in care, and 42% of beneficiaries were ART adherent. We saw meaningful differences by race/ethnicity and region. Our work highlights an important disparity in the HIV care cascade by insurance status during this time period.

Gun Violence Exposure and Quality of Life in Nine US States.

Direct and indirect gun violence exposure (GVE) is associated with a broad range of detrimental health effects. However, much of this research has examined the effects of a single type of GVE (e.g., being shot) on discrete outcomes (e.g., daily pain, PTSD). Since people may experience numerous types of GVE (e.g., being threatened with a gun and hearing gunshots in their neighborhood) with broad effects on their well-being, we study the association between four types of direct and indirect GVE and five aspects of quality of life (overall, physical, psychological, social, and environmental). Using a representative sample of adults from nine states (N = 7455), we find that witnessing/hearing about a shooting in one's neighborhood was the most commonly experienced GVE associated with significant decreases in all five types of quality of life. Cumulative GVE was also associated with significant decreases in overall physical, psychological, social, and environmental quality of life. For example, individuals with four GVEs had an adjusted average physical quality of life that was 11.14 points lower and environmental quality of life that was 7.18 points lower than individuals with no GVE. Decreasing gun violence is a critical component of improving community health and well-being.

Impact of State Telehealth Parity Laws for Private Payers on Hypertension Medication Adherence Before and During the COVID-19 Pandemic.

Telehealth has emerged as an effective tool for managing common chronic conditions such as hypertension, especially during the COVID-19 pandemic. However, the impact of state telehealth payment and coverage parity laws on hypertension medication adherence remains uncertain. Data from the 2016 to 2021 Merative MarketScan Commercial Claims and Encounters Database were used to construct the study cohort, which included nonpregnant individuals aged 25 to 64 years with hypertension. We coded telehealth parity laws related to hypertension management in all 50 US states and the District of Columbia, distinguishing between payment and coverage parity laws. The primary outcomes were measures of antihypertension medication adherence: the average medication possession ratio; medication adherence (medication possession ratio ≥80%); and average number of days of drug supply. We used a generalized difference-in-differences design to examine the impact of these laws. Among 353 220 individuals (mean [SD] age, 49.5 (7.1) years; female, 45.55%), states with payment parity laws were significantly linked to increased average medication possession ratio by 0.43 percentage point (95% CI, 0.07-0.79), and an increase of 0.46 percentage point (95% CI, 0.06-0.92) in the probability of medication adherence. Payment parity laws also led to an average increase of 2.14 days (95% CI, 0.11-4.17) in prescription supply, after controlling for state-fixed effects, year-fixed effects, individual sociodemographic characteristics and state time-varying covariates including unemployment rates, gross domestic product per capita, and poverty rates. In contrast, coverage parity laws were associated with a 2.13-day increase (95% CI, 0.19-4.07) in days of prescription supply but did not significantly increase the average medication possession ratio or probability of medication adherence. State telehealth payment parity laws were significantly associated with greater medication adherence, whereas coverage parity laws were not. With the increasing adoption of telehealth parity laws across states, these findings may support policymakers in understanding potential implications on management of hypertension.

COVID companions: Exploring pets as social support.

This paper investigates the social support provided by domestic animals to humans during the COVID-19 pandemic. The study comprises interviews with 39 British and American pet owners during March 2021, the point at which the UK had recently emerged from the third national lockdown and US states were under various restrictions. A thematic network approach to data analysis revealed four global themes, illustrating how pets provided buffers to the stress of the pandemic, facilitated ontological security by maintaining a sense of routine and purpose, offered myriad types of emotional support and enhanced and enabled wider social support. Taken together, these results reinforce and extend knowledge pertaining to the importance of companion animals for social support.

US State and Territorial Indigenous Consultation Laws: A Potential Strategy to Improve the Social Determinants of Health.

The United Nations (UN) has articulated the right to self-determination as a human right for Indigenous people; however, US states and territories have been slow to operationalize this aspect of the UN Declaration on the Rights of Indigenous Peoples. Indigenous consultation laws require all federal executive agencies to consult with tribal nations before implementing policies that have a "tribal implication," and these form the cornerstone of US efforts to implement the UN Declaration on the Rights of Indigenous Peoples. Despite these federal efforts, less is known about the degree to which state and territorial laws require consultation with Indigenous communities. We reviewed all Indigenous consultation laws identified through a search of 50 US states, the District of Columbia, and 5 territories to provide a holistic picture of how jurisdictions have regulated Indigenous consultation efforts. Of the 56 states, 49 (87.5%) had at least 1 Indigenous consultation law; the remaining 7 jurisdictions had none. States engaged in Indigenous consultation in various ways, generally falling into 1 of 3 categories: (1) centralized consultation facilitated through an agency or department, (2) indirect consultation through a designated commission, and (3) fragmented Indigenous consultation through discrete laws. Important gaps were identified, including the lack of a definition for Indigenous consultation, the absence of an appeal process, and the need to train state officials on existing policies. The results provide a baseline on the degree to which US states and territories consult with Indigenous communities and can be used to identify gaps in US compliance with UN human rights mandates.

Climate stress testing for mortgage default probability

Extreme natural disasters, such as tropical cyclones, have a low probability of materialising, but a high social and economic impact, including spillover to financial institutions. We propose a framework for performing a climate-stress testing exercise for the default probability of mortgage loans. We estimated a dynamic credit scoring model based on survival analysis with a relative damage index built using the wind speed of tropical cyclones. We considered scenarios involving tropical cyclone wind speeds with different return periods. We analyse a portfolio of approximately 190,000 mortgage loans granted in Louisiana, one of the US states most affected by tropical cyclones. Our findings suggest that coastline areas are most exposed to severe damage from tropical cyclones. If the geographical area is exposed to an event with a very large return period of 1-in-1,000 years, the probability of default increases by approximately nine percentage points compared to a baseline scenario in the absence of tropical cyclones. However, this finding was mitigated by the insurance coverage. This percentage increases to almost 20 percent in the absence of insurance coverage.

Concealed firearm carrying laws and defensive firearm use in public locations of US metropolitan areas, 1986–2004

ObjectivesThere has been extensive debate in the USA as to how laws regulating the carrying of concealed firearms affect crime and public safety. This study examines whether US state laws...

Measuring absence: Narrative obstacles to counting contemporary enforced disappearances in Latin America

Statistics hold the potential to lend political urgency to otherwise seemingly isolated human rights abuses. Yet, despite the persistence of the problem, statistics on enforced disappearances in contemporary non-civil war Latin American democracies are rare. This article examines the available statistics found in the annual human rights reports of Amnesty International, Human Rights Watch, and the US State Department and assesses the narratives that accompany them. The article argues that the reports’ narrative frames present three key obstacles to the statistical visibility of enforced disappearances in contemporary Latin America that pertain to the definition of problem, whose information is included (voice), and the narrative’s clarity and consistency. These obstacles affect case counts and, consequently, the political urgency attributed to the need for accountability and policy change.

High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies.

How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown. To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing. A county-level multiple-policy difference-in-difference event study framework. A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019. The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions. Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found. State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

Examining the relationship between proposed anti-LGBTQ+ legislation and LGBTQ+ college student mental health: findings from the Healthy Minds Study, 2021–2022

Objective: This study aimed to investigate the association between proposed anti-LGBTQ+ legislation and depressive symptoms among LGBTQ+ college students. Participants: Participants (N = 72,135) included LGBTQ+ college students (N = 21,466) from over 530 colleges and universities, including technical and community institutions, across the United States who took part in the Healthy Minds Study (HMS). Methods: Data on proposed anti-LGBTQ+ legislation introduced in 2021–2022 were collected from all 50 US states, categorized, and analyzed. Individual-level data for 2021–2022 were obtained from the HMS, and a multilevel analysis was conducted to assess the association between proposed anti-LGBTQ+ legislation and depressive symptoms while considering individual factors. Results: A significant positive association between proposed anti-LGBTQ+ legislation and increased depressive symptoms among LGBTQ+ college students was found. This association remained significant after controlling for individual-level stressors and identities, including a sense of belonging, campus environment perceptions, first-generation student status, and transgender or gender non-conforming identity (TGNC). Conclusions: The findings underscore the need for mental health support and inclusive policies for LGBTQ+ college students, particularly in regions where anti-LGBTQ+ legislation is proposed or enacted, to mitigate the potential negative impact of multiple factors on their mental well-being.

Outcomes in solid organ transplant recipients receiving organs from a donor with Fusarium solani species complex meningitis.

Five organs (heart, right lung, liver, right, and left kidneys) from a deceased patient were transplanted into five recipients in four US states; the deceased patient was identified as part of a healthcare-associated fungal meningitis outbreak among patients who underwent epidural anesthesia in Matamoros, Mexico. After transplant surgeries occurred, Fusarium solani species complex, a fungal pathogen with a high case-mortality rate, was identified in cerebrospinal fluid from the organ donor by metagenomic next-generation sequencing (mNGS) and fungal-specific polymerase chain reaction and in plasma by mNGS. Four of five transplant recipients received recommended voriconazole prophylaxis; four were monitored weekly by serum (1-3)-β-d-glucan testing. All five were monitored for signs of infection for at least 3 months following transplantation. The liver recipient had graft failure, which was attributed to an etiology unrelated to fungal infection. No fungal DNA was identified in sections of the explanted liver, suggesting that F. solani species complex did not contribute to graft failure. The remaining recipients experienced no signs or symptoms suggestive of fusariosis. Antifungal prophylaxis may be useful in preventing donor-derived infections in recipients of organs from donors that are found to have Fusarium meningitis.

Defining Levels of US Hospitals’ Pediatric Capabilities

Classifying hospitals across a wide range of pediatric capabilities, including medical, surgical, and specialty services, would improve understanding of access and outcomes. To develop a classification system for hospitals' pediatric capabilities. This cross-sectional study included data from 2019 on all acute care hospitals with emergency departments in 10 US states that treated at least 1 child per day. Statistical analysis was performed from September 2023 to February 2024. Pediatric hospital capability level, defined using latent class analysis. The latent class model parameters were the presence or absence of 26 functional capabilities, which ranged from performing laceration repairs to performing organ transplants. A simplified approach to categorization was derived and externally validated by comparing each hospital's latent class model classification with its simplified classification using data from 3 additional states. Health care utilization and structural characteristics, including inpatient beds, pediatric intensive care unit (PICU) beds, and referral rates (proportion of patients transferred among patients unable to be discharged). Using data from 1061 hospitals (716 metropolitan [67.5%]) with a median of 2934 pediatric ED encounters per year (IQR, 1367-5996), the latent class model revealed 4 pediatric levels, with a median confidence of hospital assignment to level of 100% (IQR, 99%-100%). Of 26 functional capabilities, level 1 hospitals had a median of 24 capabilities (IQR, 21-25), level 2 hospitals had a median of 13 (IQR, 11-15), level 3 hospitals had a median of 8 (IQR, 6-9), and level 4 hospitals had a median of 3 (IQR, 2-3). Pediatric level 1 hospitals had a median of 66 inpatient beds (IQR, 42-86), level 2 hospitals had a median of 16 (IQR, 9-22), level 3 hospitals had a median of 0 (IQR, 0-6), and level 4 hospitals had a median of 0 (IQR, 0-0) (P < .001). Level 1 hospitals had a median of 19 PICU beds (IQR, 10-28), level 2 hospitals had a median of 0 (IQR, 0-5), level 3 hospitals had a median of 0 (IQR, 0-0), and level 4 hospitals had a median of 0 (IQR, 0-0) (P < .001). Level 1 hospitals had a median referral rate of 1% (IQR, 1%-3%), level 2 hospitals had a median of 25% (IQR, 9%-45%), level 3 hospitals had a median of 70% (IQR, 52%-84%), and level 4 hospitals had a median of 100% (IQR, 98%-100%) (P < .001). In this cross-sectional study of hospitals from 10 US states, a system to classify hospitals' pediatric capabilities in 4 levels was developed and was associated with structural and health care utilization characteristics. This system can be used to understand and track national pediatric acute care access and outcomes.