Unveiling spatial inequalities: Exploring county-level disaster damages and social vulnerability on public disaster assistance in contiguous US.

Understanding the dynamics between public disaster assistance, disaster damages, and social vulnerability at county-level is crucial for designing effective disaster mitigation strategies. This study utilized the Local Bivariate Moran Index (LBMI) and geographically weighted regression (GWR) models to examine spatial patterns and relationships between disaster damages, social vulnerability, and public disaster assistance in contiguous US counties from 2001 to 2021. LBMI results reveal that public disaster assistance has predominantly been directed towards post-disaster recovery efforts, with a particular focus on coastal communities affected by major declared disasters. However, the distributions of public assistance and individual housing assistance, which are the two primary sources of public disaster assistance, do not adequately cover physically and socially vulnerable communities. The distribution of pre-disaster risk mitigation also falls short of sufficiently covering vulnerable communities. Results further indicate the complex interactions between different categories of natural disasters and public assistances. The GWR model results demonstrate spatial variations in predicting each category of public disaster assistance. These findings indicate the need to address disparities in accessing public disaster assistance in the US, and advocate for more equitable disaster mitigation strategies.

Prevalence of dental visits in older Japanese adults receiving public assistance.

OBJECTIVES: Exemption from paying dental care costs among recipients of public assistance contributes to universal health care coverage. Although this system might reduce the financial barriers to dental care among patients, there are still several other barriers for public assistance recipients. Therefore, this study examined whether receiving public assistance was associated with a higher prevalence of dental visits for any reason, treatment and prevention. METHODS: Data were obtained from 16 366 respondents from the 2019 wave of a nationwide cohort study on older adults in Japan. Poisson regression analyses with robust error variance were used to examine the associations between receiving public assistance and dental visits, adjusting for number of teeth, dental pain, periodontal conditions, age, sex, number of family members, education, equivalent household income, working status, instrumental activities of daily living, medical conditions, depressive symptoms, instrumental support and geographical variations. RESULTS: More than half of the non-recipients of public assistance visited a dentist for some reason in the past 6 months. Meanwhile, only 37% of the recipients visited a dentist. In addition, almost half of the non-recipients had treatment visits, while only 34% of the recipients visited. Furthermore, 46% of the non-recipients had dental visits for prevention, while 32% of the recipients had preventive visits. In the fully adjusted models, compared to non-recipients, public assistance recipients were 24% (Prevalence Ratio [PR]: 0.76, 95% Confidence Intervals [CI]: 0.64, 0.90), 23% (PR: 0.77, 95% CI: 0.65, 0.92) and 21% (PR: 0.79, 95% CI: 0.65, 0.95) less likely to have dental visits for any reason, treatment, and prevention, respectively. CONCLUSIONS: Although recipients were exempted from dental treatment fees, receiving public assistance was associated with a lower prevalence of dental visits for any reason, treatment and prevention. Future studies should identify the barriers to accessing dental care among public assistance recipients to improve dental visits.

Public Benefit Programs and Differential Associations With Child Maltreatment by Race and Ethnicity.

Importance: Public benefit programs, including state spending on local, state, and federal-state partnership programs, have consistently been associated with overall reductions in child protective services (CPS) involvement. Inequities in eligibility and access to benefit programs may contribute to varying associations by race and ethnicity. Objective: To determine whether associations between state spending on benefit programs and rates of CPS investigations differ by race and ethnicity. Design, Setting, and Participants: This cross-sectional ecological study used repeated state-level measures of child maltreatment from the National Child Abuse and Neglect Data System and population estimates from the US Census Bureau for all Black, Hispanic, and White children. All 50 US states from October 1, 2009, through September 30, 2019 (fiscal years 2010-2019), were included. Data were collected and analyzed from May 13, 2022, to March 2, 2023. Exposures: Annual state spending on benefit programs per person living below the federal poverty limit, total and by the following subcategories: (1) cash, housing, and in-kind; (2) housing infrastructure; (3) child care assistance; (4) refundable earned income tax credit; and (5) medical assistance programs. Main Outcomes and Measures: Race- and ethnicity-specific rates of CPS investigations. Generalized estimating equations, with repeated measures of states, an interaction between race and spending, and estimated incidence rate ratios (IRRs) and 95% CIs for incremental changes in spending of US $1000 per person living below the federal poverty limit were calculated after adjustment for federal spending, race- and ethnicity-specific child poverty rate, and year. Results: A total of 493 state-year observations were included in the analysis. The association between total spending and CPS investigations differed significantly by race and ethnicity: there was an inverse association between total state spending and CPS investigations for White children (IRR, 0.94 [95% CI, 0.91-0.98]) but not for Black children (IRR, 0.98 [95% CI, 0.94-1.02]) or Hispanic children (IRR, 0.99 [95% CI, 0.95-1.03]) (P = .02 for interaction). Likewise, inverse associations were present for only White children with respect to all subcategories of state spending and differed significantly from Black and Hispanic children for all subcategories except the refundable earned income tax credit (eg, IRR for medical assistance programs for White children, 0.89 [95% CI, 0.82-0.96]; P = .005 for race and spending interaction term). Conclusions and Relevance: These results raise concerns that benefit programs may add relative advantages for White children compared with Black and Hispanic children and contribute to racial and ethnic disparities in CPS investigations. States' eligibility criteria and distribution practices should be examined to promote equitable effects on adverse child outcomes.

Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers.

BACKGROUND: Public assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan. METHODS: This retrospective cohort study included public assistance recipients from two municipalities. We obtained participants' sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants' unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants' age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined. RESULTS: We identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00-2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00-3.59) and with children (IR 2.35, 95% CI 1.11-4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41-1.35) and those living with children (IR 0.50, 95% CI 0.20-1.23). A higher frequency in asthma visits was observed among working recipients living with family. CONCLUSIONS: Working adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations.

State Public Assistance Spending and Survival Among Adults With Cancer.

Importance: Social determinants of health contribute to disparities in cancer outcomes. State public assistance spending, including Medicaid and cash assistance programs for socioeconomically disadvantaged individuals, may improve access to care; address barriers, such as food and housing insecurity; and lead to improved cancer outcomes for marginalized populations. Objective: To determine whether state-level public assistance spending is associated with overall survival (OS) among individuals with cancer, overall and by race and ethnicity. Design, Setting, and Participants: This cohort study included US adults aged at least 18 years with a new cancer diagnosis from 2007 to 2013, with follow-up through 2019. Data were obtained from the Surveillance, Epidemiology, and End Results program. Data were analyzed from November 18, 2021, to July 6, 2023. Exposure: Differential state-level public assistance spending. Main Outcome and Measure: The main outcome was 6-year OS. Analyses were adjusted for age, race, ethnicity, sex, metropolitan residence, county-level income, state fixed effects, state-level percentages of residents living in poverty and aged 65 years or older, cancer type, and cancer stage. Results: A total 2 035 977 individuals with cancer were identified and included in analysis, with 1 005 702 individuals (49.4%) aged 65 years or older and 1 026 309 (50.4%) male. By tertile of public assistance spending, 6-year OS was 55.9% for the lowest tertile, 55.9% for the middle tertile, and 56.6% for the highest tertile. In adjusted analyses, public assistance spending at the state-level was significantly associated with higher 6-year OS (0.09% [95% CI, 0.04%-0.13%] per $100 per capita; P < .001), particularly for non-Hispanic Black individuals (0.29% [95% CI, 0.07%-0.52%] per $100 per capita; P = .01) and non-Hispanic White individuals (0.12% [95% CI, 0.08%-0.16%] per $100 per capita; P < .001). In sensitivity analyses examining the roles of Medicaid spending and Medicaid expansion including additional years of data, non-Medicaid spending was associated with higher 3-year OS among non-Hispanic Black individuals (0.49% [95% CI, 0.26%-0.72%] per $100 per capita when accounting for Medicaid spending; 0.17% [95% CI, 0.02%-0.31%] per $100 per capita Medicaid expansion effects). Conclusions and Relevance: This cohort study found that state public assistance expenditures, including cash assistance programs and Medicaid, were associated with improved survival for individuals with cancer. State investment in public assistance programs may represent an important avenue to improve cancer outcomes through addressing social determinants of health and should be a topic of further investigation.

Identifying meaningful subpopulation segments among older public assistance recipients: a mixed methods study to develop tailor-made health and welfare interventions.

BACKGROUND: Public assistance recipients have diverse and complex needs for health and social support in addition to financial support. Segmentation, which means dividing the population into subgroups (segments) with similar sociodemographic characteristics, is a useful approach for allocating support resources to the targeted segments. Clustering is a commonly used statistical method of segmentation in a data-driven marketing approach. This explanatory sequential mixed methods study applied a clustering technique, aiming to identify segments among older public assistance recipients quantitatively, and assess the meaningfulness of the identified segments in consultation and support activities for older recipients qualitatively. METHODS: We identified the segments of older recipients in two municipalities using probabilistic latent semantic analysis, a machine learning-based soft clustering method. Semi-structured interviews were subsequently conducted with caseworkers to ask whether the identified segments could be meaningful for them in practice and to provide a reason if they could not think of any older recipients from the segment. RESULTS: A total of 3,165 older people on public assistance were included in the analysis. Five distinct segments of older recipients were identified for each sex from 1,483 men and 1,682 women. The qualitative findings suggested most of identified segments reflected older recipients in practice, especially two of them: female Cluster 1 (facility residents aged over 85 years with disability/psychiatric disorder), and female Cluster 2 (workers). Some caseworkers, however, did not recall older recipients in practice when working with certain segments. CONCLUSIONS: A clustering technique can be useful to identify the meaningful segments among older recipients and can potentially discover previously unrecognized segments that may not emerge through regular consultation practices followed by caseworkers. Future research should investigate whether tailored support interventions for these identified segments are effective.

The Impact of Temporary Assistance for Needy Families Benefit Requirements and Sanctions on Maternal Material Hardship, Mental Health, and Parental Aggravation.

INTRODUCTION: Temporary Assistance for Needy Families requirements can be stress-inducing, difficult for families to complete, and may be detrimental during early life. We assessed the impact of TANF requirements on primary caregiving mothers' experiences of material hardship, anxiety, depression, and parental aggravation in the first year of a child's life. METHODS: Survey responses were selected from mothers in the Future of Families and Childhood Wellbeing Study, who received TANF in the first year of their child's life (N = 1085). RESULTS: Survey-weighted regression models showed associations between: presence of any requirements and increased material hardship, work requirements and increased material hardship, requirement to name the father of their child and increased depression, benefit cuts and increased parental aggravation, and benefit cuts and increased material hardship. DISCUSSION: Federal and state policies should revise requirement programs to increase program accessibility and support the mental health and financial stability of mothers applying for TANF to facilitate sustainable movement into employment.

Assessment of Medical and Public Assistance Expenditures and Employment Among US Adults With Cancer Diagnoses.

Importance: Prior research suggests significant social value associated with increased longevity due to preventing and treating cancer. Other social costs associated with cancer, such as unemployment, public medical spending, and public assistance, may also be sizable. Objective: To examine whether a cancer history is associated with receipt of disability insurance, income, employment, and medical spending. Design, Setting, and Participants: This cross-sectional study used data from the Medical Expenditure Panel Study (MEPS) (2010-2016) for a nationally representative sample of US adults aged 50 to 79 years. Data were analyzed from December 2021 to March 2023. Exposure: Cancer history. Main Outcomes and Measures: The main outcomes were employment, public assistance receipt, disability, and medical expenditures. Variables for race, ethnicity, and age were used as controls. A series of multivariate regression models were used to assess the immediate and 2-year association of a cancer history with disability, income, employment, and medical spending. Results: Of 39 439 unique MEPS respondents included in the study, 52% were female, and the mean (SD) age was 61.44 (8.32) years; 12% of respondents had a history of cancer. Individuals with a cancer history who were aged 50 to 64 years were 9.80 (95% CI, 7.35-12.25) percentage points more likely to have a work-limiting disability and were 9.08 (95% CI, 6.22-11.94) percentage points less likely to be employed compared with individuals in the same age group without a history of cancer. Nationally, cancer accounted for 505 768 fewer employed individuals in the population aged 50 to 64 years. A cancer history was also associated with an increase of $2722 (95% CI, $2131-$3313) in medical spending, $6460 (95% CI, $5254-$7667) in public medical spending, and $515 (95% CI, $337-$692) in other public assistance spending. Conclusions and Relevance: In this cross-sectional study, a history of cancer was associated with increased likelihood of disability, higher medical spending, and decreased likelihood of employment. These findings suggest there may be gains beyond increased longevity if cancer can be detected and treated earlier.

Forming the Perception of WIC Infant Feeding Recommendations: A Qualitative Study.

Nearly half of newborns in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Promoting breastfeeding is a programmatic priority, although formula vouchers are provided for those who do not exclusively breastfeed. Previous literature suggests that participant perception of WIC's breastfeeding recommendations is a significant factor predicting breastfeeding initiation, duration, and exclusivity outcomes. However, little is known about how participants' perceptions of WIC's breastfeeding recommendations are formed. To address this knowledge gap, we conducted a qualitative pilot study in Nevada, interviewing 10 postpartum WIC mothers and 12 WIC staff who had interacted with participants regarding infant feeding. Results showed participants and staff reported various perceptions of what WIC recommends, the factors that contribute to these perceptions, and how these perceptions affect breastfeeding practices. Respondents also described that WIC has a negative legacy as the "free formula program," and that environmental factors, such as the recent formula recall, have had an impact on participants' infant feeding practices. More effective public campaigns and programmatic strategies are needed to target participants' prenatal self-efficacy and to communicate the availability of skilled lactation support in the early postpartum period to improve participants' perceptions of WIC's position on breastfeeding.

Copay assistance use and prescription abandonment across race, ethnicity, or household income levels for select rheumatoid arthritis and oral oncolytic medicines.

BACKGROUND: Disparities in prescription abandonment may exacerbate health inequities. Whether copay assistance is associated with changes in prescription abandonment across different patient groups is unknown. OBJECTIVE: To assess disparities in copay assistance use; prescription abandonment across race, ethnicity, or income; and association of copay use with prescription abandonment and whether it differs across race, ethnicity, or household income. METHODS: This pooled, cross-sectional study assessed claims-level prescription data linked to a consumer database containing information on race, ethnicity, and household income for commercially insured patients. The first prescription for rheumatoid arthritis (RA) or oral oncolytic medicines from 2016 to 2020 was included. Logistic regression models measured odds of copay assistance use (copay/discount cards or free-trial voucher) and prescription abandonment (prescription not filled within 30 days of health plan approval). Interaction terms for copay assistance use by race, ethnicity, and income were tested. RESULTS: The sample included 67,674 patients prescribed RA medications and 9,560 prescribed oral oncolytic medications. Copay assistance use across race, ethnicity, and income ranged from 28.2% to 31.1% (RA medicines) and 27.2% to 36.7% (oral oncolytic medicines). Among those prescribed RA medicines and not using copay assistance, Black/African American, Hispanic patients, and those with household incomes less than $50,000 were more likely to abandon prescriptions than White patients and patients with household incomes more than $200,000 (odds ratio [OR] [95% CI], P value: Black/African American: 1.17 [1.06-1.29], P < 0.01; Hispanic: 1.11 [1.01-1.22], P = 0.03; income <$50,000: 1.24 [1.11-1.37], P < 0.01). Among patients using oral oncolytic medicines and not using copay assistance, there was no racial or ethnic difference in prescription abandonment. Patients using oral oncolytics with household incomes less than $50,000 were more likely to use copay assistance (1.34 [1.12-1.61], P < 0.01), but also more likely to abandon their prescriptions if not using copay assistance (1.44 [1.12-1.85], P < 0.01). Copay assistance was associated with a 79% (RA) and 71% (oral oncolytics) lower odds of prescription abandonment (0.21 [0.19-0.24], P < 0.01; 0.29 [0.24-0.36], P < 0.01), which did not differ across race, ethnicity, or income levels (P > 0.05). CONCLUSIONS: Copay assistance has potential to narrow disparities in prescription abandonment for commercially insured Black/African American or Hispanic patients taking RA medicines and patients with household incomes less than $50,000; however, efforts to improve access to copay assistance are needed. Copay assistance, as a factor facilitating equal access to medicines, is an important consideration when evaluating policies that impact access to copay assistance programs. DISCLOSURES: Genentech, Inc., provided funding and support for this study. Dr Wong is an employee of Genentech, Inc., and shareholder of Roche, Inc. Ms Donahue, Mr Thiesen, and Mr Yeaw are employees of IQVIA.

Temporary Assistance For Needy Families: Sanctioning And Child Support Compliance Among Black Families In Illinois.

Temporary Assistance for Needy Families (TANF) is a federal cash welfare program for low-income, working families with children in the United States that requires participation with child support enforcement, if one parent is noncustodial, to receive the cash benefit. Cash assistance has been linked to improved child health and academic achievement, but sanctions to benefits can increase health risks. Our community-engaged, mixed-methods research project sought to identify barriers to TANF among families with young children in Illinois. In this study we analyzed TANF sanctions related to child support enforcement, using analysis of TANF administrative data and semistructured interviews with TANF customers. We conducted logistic regression and Fisher's test to explore demographic differences in sanctioning and sanction types. Black families were 111 percent more likely than White families to receive at least one sanction in 2018-19. Black families who were enrolled in TANF received more sanctions for child support noncompliance (2018: 42 percent; 2019: 50 percent) than White families (2018: 30 percent; 2019: 34 percent). Mothers who were survivors of intimate partner violence voiced particular challenges with child support compliance. Policy recommendations include shifting to alternative cash assistance models and removing pass-through funding so that families receive the full child support benefit.

Easing Cash Assistance Rules During COVID-19 Was Associated With Reduced Days Of Poor Physical And Mental Health.

Unemployment rates soared at the beginning of the COVID-19 pandemic in the US, increasing financial stress that can affect physical and mental health. Temporary Assistance for Needy Families (TANF) is the primary cash assistance program for low-income families in the US, with benefits conditional on work activities and subject to suspension. However, many states loosened requirements during the pandemic. Using TANF policy data and data from the Behavioral Risk Factor Surveillance System from the period January 2017-December 2020 with a triple-difference design, we found a general protective effect of supportive changes to TANF on poor physical and mental health days and binge drinking during the COVID-19 pandemic for likely TANF participants. For example, providing emergency cash benefits to those not already participating in TANF, waiving work requirements, waiving or pausing sanctions, and automatically recertifying benefits were associated with reductions in the number of mentally unhealthy days. This study provides support for increasing generosity and easing administrative burdens in safety-net programs to buffer against negative impacts of public health and economic crises.

Theorizing on neo public assistance: How do race and class impact resource uptake and behavior following disaster?

The consequences of environmental disasters and other ecologic and communal crises are frequently worst in racially/ethnically minoritized and low-income populations relative to other groups. This disproportionality may create or deepen patterns of governmental distrust and stoke health promotion disengagement in these groups. To date, there has been limited contextualization of how historically disenfranchised populations utilize government-administered or facilitated resources following such disasters. Focusing on the water crisis in Flint, Michigan, we examine and theorize on the usage of neo public assistance, free risk reduction resources that are provided to disaster survivors as a liminal means of redressing ills created and/or insufficiently mitigated by the state. We surveyed 331 Flint residents, evaluating their usage of four neo public assistance resources following the FWC, finding low to moderate uptake: 131 residents (39.6%) indicated that they obtained blood lead level (BLL) screenings, 216 (65.3%) had their tap water tested for lead (Pb) and other contaminants, 137 (41.4%) had their home water infrastructure replaced, and 293 (88.5%) had acquired bottled water at community distribution sites. Unemployment, receiving public benefits, and lacking reliable transportation and stable housing were associated with lower uptake of some resources. Compared to White and "Other" race individuals, Black residents were generally more likely to acquire/utilize these resources, suggesting heightened concerns and health promotion proclivities even in the face of observed macro and individual-level challenges. Potential reasons and implications are discussed.

The 2016 Presidential Election, the Public Charge Rule, and Food and Nutrition Assistance Among Immigrant Households.

Objectives. To investigate whether the 2016 US presidential election and the subsequent leak of a proposed change to the public charge rule reduced immigrant families' participation in food and nutrition assistance programs. Methods. We used nationally representative data on n = 57 808 households in the United States from the 2015-2018 Current Population Survey-Food Security Supplement. We implemented difference-in-difference-in-difference analyses to investigate whether the election and proposed rule change produced decreases in immigrant families' participation in food and nutrition assistance programs and whether such decreases varied according to state policy generosity toward immigrants. Results. Findings indicate significant and large decreases in Supplemental Nutrition Assistance Program, School Breakfast Program, and National School Lunch Program participation among immigrants in moderately generous states but no changes to receipt of food assistance from nongovernmental sources or to household food insecurity. Conclusions. Both anti-immigrant rhetoric and the perceived threat of policy enactment can be enough to produce chilling effects that have potentially serious implications for the health of immigrant households and thus the health of the nation. (Am J Public Health. 2022;112(12):1738-1746. https://doi.org/10.2105/AJPH.2022.307011).

Risk profiles of frequent outpatients among public assistance recipients in Japan: a retrospective cohort study using a classification and regression trees algorithm.

OBJECTIVES: Although several individual risk factors of frequent outpatient attendance (FOA) have previously been reported, identifying a specific risk profile is needed to provide effective intervention for impoverished citizens with complex biopsychosocial needs. We aimed to identify potential risk profiles of FOA among public assistance recipients in Japan by using classification and regression trees (CART) and discussed the possibilities of applying the CART to policypractice as compared with the results of conventional regression analyses. DESIGN: We conducted a retrospective cohort study. SETTING: We used secondary data from the public assistance databases of six municipalities in Japan. PARTICIPANTS: The study population included all adults on public assistance in April 2016, observed until March 2017. We obtained the data of 15 739 people on public assistance. During the observational period, 435 recipients (2.7%) experienced FOA. OUTCOME MEASURE: We dichotomised a cumulative incidence of FOA during the study period into a binary variable of exhibiting FOA or not. We adopted the definition of FOA by the Ministry of Health, Labour, and Welfare: visiting the same medical institution more than 15 days a month. RESULTS: The results of the CART showed that an employed subpopulation with mental disabilities exhibited the highest risk of FOA (incidence proportion: 16.7%). Meanwhile, multiple Poisson regression showed that the adjusted incidence ratio of being unemployed (vs employed) was 1.71 (95% CI 1.13 to 2.59). CONCLUSIONS: Using the CART model, we could identify specific risk profiles that could have been overlooked when considering only the risk factors obtained from regression analysis. Public health activities can be provided effectively by focusing on risk factors and the risk profiles.

The association of COVID-19 employment shocks with suicide and safety net use: An early-stage investigation.

This paper examines whether the COVID-19-induced employment shocks are associated with increases in suicides and safety net use in the second and third quarters of 2020. We exploit plausibly exogenous regional variation in the magnitude of the employment shocks in Japan and adopt a difference-in-differences research design to examine and control for possible confounders. Our preferred point estimates suggest that a one-percentage-point increase in the unemployment rate in the second quarter of 2020 is associated with, approximately, an additional 0.52 suicides, 28 unemployment benefit recipients, 88 recipients of a temporary loan program, and 10 recipients of public assistance per 100,000 population per month. A simple calculation based on these estimates suggests that if a region experienced a one-percentage-point increase in the unemployment rate caused by the COVID-19 crisis in the second quarter of 2020, which is roughly equivalent to the third-highest regional employment shock, this would be associated with 37.4%, 60.5%, and 26.5% increases in the total, female, and male suicide rates respectively in July 2020 compared with July 2019. These results are primarily correlational rather than causal due to the limitation of our data and research design, but our baseline findings are robust to several different model specifications.

Public assistance in patients with acute heart failure: a report from the KCHF registry.

AIMS: There is a scarcity of data on the post-discharge prognosis in acute heart failure (AHF) patients with a low-income but receiving public assistance. The study sought to evaluate the differences in the clinical characteristics and outcomes between AHF patients receiving public assistance and those not receiving public assistance. METHODS AND RESULTS: The Kyoto Congestive Heart Failure registry was a physician-initiated, prospective, observational, multicentre cohort study enrolling 4056 consecutive patients who were hospitalized due to AHF for the first time between October 2014 and March 2016. The present study population consisted of 3728 patients who were discharged alive from the index AHF hospitalization. We divided the patients into two groups, those receiving public assistance and those not receiving public assistance. After assessing the proportional hazard assumption of public assistance as a variable, we constructed multivariable Cox proportional hazard models to estimate the risk of the public assistance group relative to the no public assistance group. There were 218 patients (5.8%) receiving public assistance and 3510 (94%) not receiving public assistance. Patients in the public assistance group were younger, more frequently had chronic coronary artery disease, previous heart failure hospitalizations, current smoking, poor medical adherence, living alone, no occupation, and a lower left ventricular ejection fraction than those in the no public assistance group. During a median follow-up of 470 days, the cumulative 1 year incidences of all-cause death and heart failure hospitalizations after discharge did not differ between the public assistance group and no public assistance group (13.3% vs. 17.4%, P = 0.10, and 28.3% vs. 23.8%, P = 0.25, respectively). After adjusting for the confounders, the risk of the public assistance group relative to the no public assistance group remained insignificant for all-cause death [hazard ratio (HR), 0.97; 95% confidence interval (CI), 0.69-1.32; P = 0.84]. Even after taking into account the competing risk of all-cause death, the adjusted risk within 180 days in the public assistance group relative to the no public assistance group remained insignificant for heart failure hospitalizations (HR, 0.93; 95% CI, 0.64-1.34; P = 0.69), while the adjusted risk beyond 180 days was significant (HR, 1.56; 95% CI, 1.07-2.29; P = 0.02). CONCLUSIONS: The AHF patients receiving public assistance as compared with those not receiving public assistance had no significant excess risk for all-cause death at 1 year after discharge or a heart failure hospitalization within 180 days after discharge, while they did have a significant excess risk for heart failure hospitalizations beyond 180 days after discharge. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) and https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238).