Public Attitudes, Inequities, and Polarization in the Launch of the 988 Lifeline.

CONTEXT: To address the considerable burden of mental health need in the United States, Congress passed the National Suicide Hotline Designation Act in 2020. The Act rebranded the national suicide prevention lifeline as 988 - a 3-digit number akin to 911 for individuals to call in the case of a mental health emergency. Surprisingly little is known about American attitudes towards this new lifeline. METHODS: We rely on a demographically representative sample of 5,482 US adults conducted from June 24-28, 2022. We examine the influence of mental health status, partisan identification, and demographic characteristics on public awareness, public support, and intended use of the new 988 lifeline. FINDINGS: We find that while only a quarter of Americans are aware of the lifeline, support for the 988 lifeline is widespread, with over 75% of Americans indicating they would be likely to use the new number if needed. We identify key disparities in awareness, support, and intended use, with Republicans, individuals with low socio-economic status, and Blacks less supportive and in some cases less likely to use the 988 lifeline. CONCLUSIONS: Our results point to the need for additional interventions that increase public awareness of 988 and reduce disparities in program knowledge, support, and intended use.

Communicating With Patients About Software for Enhancing Privacy in Secondary Database Research Involving Record Linkage: Delphi Study.

BACKGROUND: There is substantial prior research on the perspectives of patients on the use of health information for research. Numerous communication barriers challenge transparency between researchers and data participants in secondary database research (eg, waiver of informed consent and knowledge gaps). Individual concerns and misconceptions challenge the trust in researchers among patients despite efforts to protect data. Technical software used to protect research data can further complicate the public's understanding of research. For example, MiNDFIRL (Minimum Necessary Disclosure For Interactive Record Linkage) is a prototype software that can be used to enhance the confidentiality of data sets by restricting disclosures of identifying information during the record linkage process. However, software, such as MiNDFIRL, which is used to protect data, must overcome the aforementioned communication barriers. One proposed solution is the creation of an interactive web-based frequently asked question (FAQ) template that can be adapted and used to communicate research issues to data subjects. OBJECTIVE: This study aims to improve communication with patients and transparency about how complex software, such as MiNDFIRL, is used to enhance privacy in secondary database studies to maintain the public's trust in researchers. METHODS: A Delphi technique with 3 rounds of the survey was used to develop the FAQ document to communicate privacy issues related to a generic secondary database study using the MiNDFIRL software. The Delphi panel consisted of 38 patients with chronic health conditions. We revised the FAQ between Delphi rounds and provided participants with a summary of the feedback. We adopted a conservative consensus threshold of less than 10% negative feedback per FAQ section. RESULTS: We developed a consensus language for 21 of the 24 FAQ sections. Participant feedback demonstrated preference differences (eg, brevity vs comprehensiveness). We adapted the final FAQ into an interactive web-based format that 94% (31/33) of the participants found helpful or very helpful. The template FAQ and MiNDFIRL source code are available on GitHub. The results indicate the following patient communication considerations: patients have diverse and varied preferences; the tone is important but challenging; and patients want information on security, identifiers, and final disposition of information. CONCLUSIONS: The findings of this study provide insights into what research-related information is useful to patients and how researchers can communicate such information. These findings align with the current understanding of health literacy and its challenges. Communication is essential to transparency and ethical data use, yet it is exceedingly challenging. Developing FAQ template language to accompany a complex software may enable researchers to provide greater transparency when informed consent is not possible.

Texting-While-Driving Bans and Motor Vehicle Crash-Related Emergency Department Visits in 16 US States: 2007-2014.

OBJECTIVES: To examine the impact of state texting bans on motor vehicle crash (MVC)-related emergency department (ED) visits. METHODS: We used ED data from 16 US states between 2007 and 2014. We employed a difference-in-difference approach and conditional Poisson regressions to estimate changes in counts of MVC-related ED visits in states with and without texting bans. We also constructed age cohorts to explore whether texting bans have differential impacts by age group. RESULTS: On average, states with a texting ban saw a 4% reduction in MVC-related ED visits (incidence rate ratio = 0.96; 95% confidence interval = 0.96, 0.97). This equates to an average of 1632 traffic-related ED visits prevented per year in states with a ban. Both primary and secondary bans were associated with significant reductions in MVC-related visits to the ED regardless of whether they were on all drivers or young drivers only. Individuals aged 64 years and younger in states with a texting ban saw significantly fewer MVC-related ED visits following its implementation. CONCLUSIONS: Our findings suggest that states' efforts to curb distracted driving through texting bans and decrease its negative consequences are associated with significant decreases in the incidence of ED visits that follow an MVC.

Local Public Health Department Characteristics Associated With Likelihood to Participate in National Accreditation.

OBJECTIVES: We examined factors associated with completing, initiating, or intending to pursue voluntary national accreditation among local health departments (LHDs). METHODS: We examined National Association of County and City Health Officials 2010 and 2013 profile data in a pooled cross-sectional design with bivariate and multivariable regression analyses. We conducted individual multivariable models with interest in accreditation and likely to accredit as outcome variables, comparing changes between 2010 and 2013. RESULTS: LHDs with formal quality improvement programs are significantly more likely to have initiated or completed the accreditation process (odds ratio [OR] = 7.99; confidence interval [CI] = 1.79, 35.60), to be likely to accredit (OR = 2.41; CI = 1.65, 3.50), or to report an interest in accreditation (OR = 2.32; CI = 1.67, 3.20). Interest was lower among LHDs in 2013 than in 2010 (OR = 0.56; CI = 0.41, 0.77); however, there was no difference regarding being likely to accredit. LHDs with a high number of full-time equivalent employees were more likely to indicate being likely to accredit or interest in accreditation. CONCLUSIONS: Quality improvement may facilitate the accreditation process or be a proxy measure for an unmeasurable LHD attribute that predicts accreditation.

The impact of texting bans on motor vehicle crash-related hospitalizations.

We used a panel design and the Nationwide Inpatient Sample from 19 states between 2003 and 2010 to examine the impact of texting bans on crash-related hospitalizations. We conducted conditional negative binomial regressions with state, year, and month fixed effects to examine changes in crash-related hospitalizations in states after the enactment of a texting ban relative to those in states without such bans. Results indicate that texting bans were associated with a 7% reduction in crash-related hospitalizations among all age groups. Texting bans were significantly associated with reductions in hospitalizations among those aged 22 to 64 years and those aged 65 years or older. Marginal reductions were seen among adolescents. States that have not passed strict texting bans should consider doing so.

Associations between driving performance and engaging in secondary tasks: a systematic review.

We conducted a systematic review and meta-analysis of the literature examining the relationship between driving performance and engaging in secondary tasks. We extracted data from abstracts of 206 empirical articles published between 1968 and 2012 and developed a logistic regression model to identify correlates of a detrimental relationship between secondary tasks and driving performance. Of 350 analyses, 80% reported finding a detrimental relationship. Studies using experimental designs were 37% less likely to report a detrimental relationship (P = .014). Studies examining mobile phone use while driving were 16% more likely to find such a relationship (P = .009). Quasi-experiments can better determine the effects of secondary tasks on driving performance and consequently serve to inform policymakers interested in reducing distracted driving and increasing roadway safety.

Impact of texting laws on motor vehicular fatalities in the United States.

Using a panel study design, we examined the effects of different types of texting bans on motor vehicular fatalities. We used the Fatality Analysis Reporting System and a difference-in-differences approach to examine the incidence of fatal crashes in 2000 through 2010 in 48 US states with and without texting bans. Age cohorts were constructed to examine the impact of these bans on age-specific traffic fatalities. Primarily enforced laws banning all drivers from texting were significantly associated with a 3% reduction in traffic fatalities in all age groups, and those banning only young drivers from texting had the greatest impact on reducing deaths among those aged 15 to 21 years. Secondarily enforced restrictions were not associated with traffic fatality reductions in any of our analyses.

Community benefits provided by religious, other nonprofit, and for-profit hospitals: a longitudinal analysis 2000-2009.

BACKGROUND: Nonprofit hospitals (NFPs) are expected to provide community benefits to justify the tax benefits they receive, but recent budgetary constraints have called into question the degree to which the tax benefits are justified. The empirical literature comparing community benefits provided by NFPs and their for-profit counterparts is mixed. However, NFPs are not a homogenous group and can include religious hospitals, community-owned hospitals, or academic medical centers. PURPOSE: This longitudinal study examines how religious hospitals compare with other NFPs and for-profit hospitals with respect to providing community benefits and how the provision of community benefits by hospitals has changed over time. METHODOLOGY: Using a pooled cross-sectional design, we examine two summated scores based on questions from the American Hospital Association annual survey that focus on community orientation among hospitals. We analyze two regressions with year, facility, and market controls to determine how religious hospitals compare with the other groups over time. FINDINGS: Overall, 11% of U.S. hospitals are religious. Religious hospitals were more likely to engage in each individual community benefit activity examined. In addition, the mean values of community benefits provided by religious hospitals, as measured on two summated scores, were significantly higher than those provided by other hospital types in bivariate and regression analyses. Overall, community benefits provided by all hospitals increased over time and then leveled off during the start of the recent economic downturn. PRACTICE IMPLICATIONS: As the debate continues regarding federal tax exemption status, policymakers should consider religious hospitals separately from NFPs. Managers at religious hospitals should consider how their increased levels of community benefits are related to their missions and set benchmarks that recognize and communicate those achievements.

Data Sharing in a Decentralized Public Health System: Lessons From COVID-19 Syndromic Surveillance.

The COVID-19 pandemic revealed that data sharing challenges persist across public health information systems. We examine the specific challenges in sharing syndromic surveillance data between state, local, and federal partners. These challenges are complicated by US federalism, which decentralizes public health response and creates friction between different government units. The current policies restrict federal access to state and local syndromic surveillance data without each jurisdiction's consent. These policies frustrate legitimate federal governmental interests and are contrary to ethical guidelines for public health data sharing. Nevertheless, state and local public health agencies must continue to play a central role as there are important risks in interpreting syndromic surveillance data without understanding local contexts. Policies establishing a collaborative framework will be needed to support data sharing between federal, state, and local partners. A collaborative framework would be enhanced by a governance group with robust state and local involvement and policy guardrails to ensure the use of data is appropriate. These policy and relational challenges must be addressed to actualize a truly national public health information system.

Case study on communicating with research ethics committees about minimizing risk through software: an application for record linkage in secondary data analysis.

Objective: In retrospective secondary data analysis studies, researchers often seek waiver of consent from institutional Review Boards (IRB) and minimize risk by utilizing complex software. Yet, little is known about the perspectives of IRB experts on these approaches. To facilitate effective communication about risk mitigation strategies using software, we conducted two studies with IRB experts to co-create appropriate language when describing a software to IRBs. Materials and Methods: We conducted structured focus groups with IRB experts to solicit ideas on questions regarding benefits, risks, and informational needs. Based on these results, we developed a template IRB application and template responses for a generic study using privacy-enhancing software. We then conducted a three-round Delphi study to refine the template IRB application and the template responses based on expert panel feedback. To facilitate participants' deliberation, we shared the revisions and a summary of participants' feedback during each Delphi round. Results: 11 experts in two focus groups generated 13 ideas on risks, benefits, and informational needs. 17 experts participated in the Delphi study with 13 completing all rounds. Most agreed that privacy-enhancing software will minimize risk, but regardless all secondary data studies have an inherent risk of unexpected disclosures. The majority (84.6%) noted that subjects in retrospective secondary data studies experience no greater risks than the risks experienced in ordinary life in the modern digital society. Hence, all retrospective data-only studies with no contact with subjects would be minimal risk studies. Conclusion: First, we found fundamental disagreements in how some IRB experts view risks in secondary data research. Such disagreements are consequential because they can affect determination outcomes and might suggest IRBs at different institutions might come to different conclusions regarding similar study protocols. Second, the highest ranked risks and benefits of privacy-enhancing software in our study were societal rather than individual. The highest ranked benefits were facilitating more research and promoting responsible data governance practices. The highest ranked risks were risk of invalid results from systematic user error or erroneous algorithms. These societal considerations are typically more characteristic of public health ethics as opposed to the bioethical approach of research ethics, possibly reflecting the difficulty applying a bioethical approach (eg, informed consent) in secondary data studies. Finally, the development of privacy-enhancing technology for secondary data research depends on effective communication and collaboration between the privacy experts and technology developers. Privacy is a complex issue that requires a holistic approach that is best addressed through privacy-by-design principles. Privacy expert participation is important yet often neglected in this design process. This study suggests best practice strategies for engaging the privacy community through co-developing companion documents for software through participatory design to facilitate transparency and communication. In this case study, the final template IRB application and responses we released with the open-source software can be easily adapted by researchers to better communicate with their IRB when using the software. This can help increase responsible data governance practices when many software developers are not research ethics experts.

The Impact of Immigration Policy Changes on Preterm Birth Rates in Texas: An Examination of Border and Nonborder Regions.

BACKGROUND: Our study examined the acute and sustained impact of immigration policy changes announced in January 2017 on preterm birth (PTB) rates among Hispanic and non-Hispanic white women in Texas's border and nonborder regions. METHODS: Using Texas birth certificate data for years 2008 through 2020, we used a multiple group interrupted time series approach to explore changes in PTB rates. RESULTS: In the nonborder region, the PTB rate among Hispanic women of any race was 8.64% in 2008 and was stable each year before 2017 but increased by .29% (95% CI [.12, .46]) annually between 2017 and 2020. This effect remained statistically significant even when compared with that of non-Hispanic white women (p = .014). In the border areas, the PTB rate among Hispanic women of any race was 11.67% in 2008 and remained stable each year before and after 2017. No significant changes were observed when compared with that of non-Hispanic white women (p = .897). In Texas as a whole, the PTB rate among Hispanic women of any race was 10.16% in 2008 and declined by .07% (95% CI [-.16, -.03]) per year before 2017, but increased by .16% (95% CI [.05, .27]) annually between 2017 and 2020. The observed increase was not statistically significant when compared with that of non-Hispanic white women (p = .326). CONCLUSIONS: The January 2017 immigration policies were associated with a sustained increase in PTB among Hispanic women in Texas's nonborder region, suggesting that geography plays an important role in perceptions of immigration enforcement. Future research should examine the impact of immigration policies on maternal and child health, considering geography and sociodemographic factors.

Travel for medical or dental care by race/ethnicity and rurality in the U.S.: Findings from the 2001, 2009 and 2017 National Household Travel Surveys.

The travel burden for medical or dental care is a well-documented barrier to healthcare access, particularly in rural areas. There is limited research providing national estimates of the travel trends for medical/dental care, particularly among racial/ethnic groups, and among rural and urban populations. We analyzed data from the 2001, 2009, and 2017 National Household Travel Surveys. Main outcomes were the average travel distance (in miles), average travel time (in minutes), and travel burden, characterized as the percentage of trips lasting ≥ 30 miles or minutes for medical/dental care. We used ordinary least squares and multivariable logistic regressions to examine trends in the travel time/distance and travel burden, controlling for socio-demographic and travel dynamics. Among rural residents, the average travel distance for medical/dental care increased by 17.8% between 2001 and 2017, while no increase was observed among urban residents. Thirty-six percent of trips among rural residents lasted ≥ 30 minutes in 2001 but increased to 47.4% in 2017. Logistic regression estimates show that though Blacks experienced higher odds of a travel time burden compared to Whites, the burden lessened over time. In 2017, urban Blacks (OR = 0.41, 95% C.I. = 0.26,0.66), and rural Blacks (OR = 0.16, 95% C.I. = 0.05,0.55) were less likely to spend ≥ 30 minutes traveling for medical/dental care compared to Whites, using the year 2001 as the baseline. The travel distance and time for medical/dental care have increased in rural areas. However, the travel burden among rural and urban Black residents has decreased. Continuing to alleviate excess burdens of transportation may be beneficial.

Dental hygienists' scope of practice regulations and preventable non-traumatic dental emergency department visits: A cross-sectional study of 10 U.S. states.

OBJECTIVES: As emergency department (ED) visits for non-traumatic dental complaints continue to rise in the United States (U.S.), some states are implementing initiatives to expand access to the oral health workforce. This study examines the associations between the 2014 Dental Hygiene Professional Practice Index (DHPPI) and preventable dental ED visits. METHODS: In 2020, we used ED data from 10 U.S. states and ordinary least squares models to examine the relationship between the states' DHPPI scores and preventable dental ED use. We stratified regressions by age to examine this relationship across different age cohorts and introduced interaction terms to assess the same relationship among rural and urban residents. RESULTS: On average, 23.8% of all non-traumatic dental ED visits were identified as preventable. Controlling for other factors, a one-point increase in DHPPI scores was associated with a decrease of 0.01 (95% CI -0.03, -0.02) preventable dental ED visits per 1000 county population in each year-quarter. In the age-stratified models, the strength of the association between DHPPI scores and preventable dental ED visits was higher in the 20 to 34 (-0.03, 95% CI -0.04, -0.02), and the 35 to 50 age cohorts (-0.17, 95% CI -0.00, -0.00). U.S. states with DHPPI scores below 60 saw significantly higher preventable dental ED visits among rural residents. CONCLUSIONS: This study demonstrates that stringent state policies regarding the dental hygienist workforce are associated with higher preventable dental ED visits in the U.S. Policy makers and stake holders must address the scope of practice policies to alleviate the burden of access to oral healthcare.

Maternal exposure to SSRIs or SNRIs and the risk of congenital abnormalities in offspring: A systematic review and meta-analysis.

BACKGROUND: The association of maternal exposure to selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) with the risk of system-specific congenital malformations in offspring remains unclear. We conducted a meta-analysis to examine this association and the risk difference between these two types of inhibitors. METHODS: A literature search was performed from January 2000 to May 2023 using PubMed and Web of Science databases. Cohort and case-control studies that assess the association of maternal exposure to SSRIs or SNRIs with the risk of congenital abnormalities were eligible for the study. RESULTS: Twenty-one cohort studies and seven case-control studies were included in the meta-analysis. Compared to non-exposure, maternal exposure to SNRIs is associated with a higher risk of congenital cardiovascular abnormalities (pooled OR: 1.64 with 95% CI: 1.36, 1.97), anomalies of the kidney and urinary tract (pooled OR: 1.63 with 95% CI: 1.21, 2.20), malformations of nervous system (pooled OR: 2.28 with 95% CI: 1.50, 3.45), anomalies of digestive system (pooled OR: 2.05 with 95% CI: 1.60, 2.64) and abdominal birth defects (pooled OR: 2.91 with 95%CI: 1.98, 4.28), while maternal exposure to SSRIs is associated with a higher risk of congenital cardiovascular abnormalities (pooled OR: 1.25 with 95%CI: 1.20, 1.30), anomalies of the kidney and urinary tract (pooled OR: 1.14 with 95%CI: 1.02, 1.27), anomalies of digestive system (pooled OR: 1.11 with 95%CI: 1.01, 1.21), abdominal birth defects (pooled OR: 1.33 with 95%CI: 1.16, 1.53) and musculoskeletal malformations (pooled OR: 1.44 with 95%CI: 1.32, 1.56). CONCLUSIONS: SSRIs and SNRIs have various teratogenic risks. Clinicians must consider risk-benefit ratios and patient history when prescribing medicines.

Rural healthy people 2030: New decade, new challenges.

Rural Healthy People is a companion piece to the federal Healthy People initiative released once a decade to identify the most important Healthy People priorities for rural America, as identified by rural stakeholders, for the current decade. This study reports on the findings of Rural Healthy People 2030. The study relied on a survey of rural health stakeholders collected from July 12, 2021, to February 14, 2022, and: 1) identified the 20 Healthy People priorities most frequently selected as priorities for rural America, 2) studied the priorities that were most frequently selected as a "top 3" priority within each Healthy People 2030 category, and 3) investigated Healthy People 2030 priorities in terms of ranked importance for rural Americans. The analysis finds that for the first time across 3 decades of Rural Healthy People, a greater proportion of respondents selected "Mental Health and Mental Disorders" and "Addiction" as Healthy People priorities for rural America, than did "Health Care Access and Quality". Even still, respondents ranked "Health Care Access and Quality" as the single-most important rural priority. "Economic Stability," a new priority within the Social Determinant of Health category, debuted within the 10 most frequently selected priorities for rural America for the coming decade. As public health practitioners, researchers, and policymakers work toward closing the urban-rural divide, the most important rural priorities to address in the coming decade are mental health and substance use disorders, access to high quality health care services, and social determinants of health, such as economic stability.

Factors associated with hospitalizations for co-occurring HIV and opioid-related diagnoses: Evidence from the national inpatient sample, 2009-2017.

There has been evidence of rising HIV incidence attributable to opioid misuse within some areas of the U.S. The purpose of our study was to explore national trends in co-occurring HIV and opioid-related hospitalizations and to identify their risk factors. We used the 2009-2017 National Inpatient Sample to indicate hospitalizations with co-occurring HIV and opioid misuse diagnoses. We estimated the frequency of such hospitalizations per year. We fitted a linear regression to the annual HIV-opioid co-occurrences with year as a predictor. The resulting regression did not reveal any significant temporal changes. We used multivariable logistic regression to determine the adjusted odds (AOR) of hospitalization for co-occurring HIV and opioid-related diagnoses. The odds of hospitalization were lower for rural residents (AOR = 0.28; CI = 0.24-0.32) than urban. Females (AOR = 0.95, CI = 0.89-0.99) had lower odds of hospitalization than males. Patients identifying as White (AOR = 1.23, CI = 1.00-1.50) and Black (AOR = 1.27, CI = 1.02-1.57) had higher odds of hospitalization than other races. When compared to co-occuring hospitalizations in the Midwest, the odds were higher in the Northeast. (AOR = 2.56, CI = 2.07-3.17) Future research should explore the extent to which similar findings occur in the context of mortality and targeted interventions should intesify for subpopulations at highest risk of co-occuring HIV and opioid misuse diagnoses.

The relationship between built environments and physical activity: a systematic review.

OBJECTIVES: We conducted a systematic review of the literature examining the relationship between built environments (e.g., parks, trails, sidewalks) and physical activity (PA) or obesity rates. METHODS: We performed a 2-step inclusion protocol to identify empirical articles examining any form of built environment and any form of PA (or obesity rate) as the outcome. We extracted data from included abstracts for analysis by using a standard code sheet developed for this study. RESULTS: Of 169 included articles, 89.2% reported beneficial relationships-but virtually all articles utilized simple observational study designs not suited for determining causality. Studies utilizing objective PA measures (e.g., pedometer) were 18% less likely to identify a beneficial relationship. Articles focusing on children in community settings (-14.2%), those examining direct measures of obesity (-6.2%), or those with an academic first author (-3.4%) were less likely to find a beneficial relationship. CONCLUSIONS: Policymakers at federal and local levels should encourage more rigorous scientific research to determine whether altered built environments will result in increased PA and decreased obesity rates.

Uncertainty, scarcity and transparency: Public health ethics and risk communication in a pandemic.

Communicating public health guidance is key to mitigating risk during disasters and outbreaks, and ethical guidance on communication emphasizes being fully transparent. Yet, communication during the pandemic has sometimes been fraught, due in part to practical and conceptual challenges around being transparent. A particular challenge has arisen when there was both evolving scientific knowledge on COVID-19 and reticence to acknowledge that resource scarcity concerns were influencing public health recommendations. This essay uses the example of communicating public health guidance on masking in the United States to illustrate ethical challenges of developing and conveying public health guidance under twin conditions of uncertainty and resource scarcity. Such situations require balancing two key principles in public health ethics: the precautionary principle and harm reduction. Transparency remains a bedrock value to guide risk communication, but optimizing transparency requires consideration of additional ethical values in developing and implementing risk communication strategies.

Rural and Urban Differences in COVID-19 Prevention Behaviors.

PURPOSE: To examine whether the adoption of COVID-19-related preventive health behaviors vary in rural versus urban communities of the United States while accounting for the influence of political ideology, demographic factors, and COVID-19 experiences. METHODS: We rely on a representative survey of 5009 American adults collected from May 28 to June 8, 2020. We analyze the influence of rural status, political ideology, demographic factors, and COVID-19 experiences on self-reported adoption of 8 COVID-19-related preventive health behaviors. FINDINGS: Rural residents are significantly less likely to have worn a mask in public, sanitized their home or workplace with disinfectant, avoided dining at restaurants or bars, or worked from home. These findings, with the exception of dining out, are robust to the inclusion of measures accounting for political ideology, demographic factors, and COVID-19 experiences. CONCLUSIONS: Rural residents are significantly less likely to participate in several COVID-19-related preventive health behaviors. This reality could exacerbate existing disparities in health access and outcomes for rural Americans. Health messaging targeted at improving COVID-19 preventive behavior adoption in rural America is warranted.

Racial, Rural, and Regional Disparities in Diabetes-Related Lower-Extremity Amputation Rates, 2009-2017.

OBJECTIVE: To examine the racial/ethnic, rural-urban, and regional variations in the trends of diabetes-related lower-extremity amputations (LEAs) among hospitalized U.S. adults from 2009 to 2017. RESEARCH DESIGN AND METHODS: We used the National Inpatient Sample (NIS) (2009-2017) to identify trends in LEA rates among those primarily hospitalized for diabetes in the U.S. We conducted multivariable logistic regressions to identify individuals at risk for LEA based on race/ethnicity, census region location (North, Midwest, South, and West), and rurality of residence. RESULTS: From 2009 to 2017, the rates of minor LEAs increased across all racial/ethnic, rural/urban, and census region categories. The increase in minor LEAs was driven by Native Americans (annual percent change [APC] 7.1%, P < 0.001) and Asians/Pacific Islanders (APC 7.8%, P < 0.001). Residents of non-core (APC 5.4%, P < 0.001) and large central metropolitan areas (APC 5.5%, P < 0.001) experienced the highest increases over time in minor LEA rates. Among Whites and residents of the Midwest and non-core and small metropolitan areas there was a significant increase in major LEAs. Regression findings showed that Native Americans and Hispanics were more likely to have a minor or major LEA compared with Whites. The odds of a major LEA increased with rurality and was also higher among residents of the South than among those of the Northeast. A steep decline in major-to-minor amputation ratios was observed, especially among Native Americans. CONCLUSIONS: Despite increased risk of diabetes-related lower-limb amputations in underserved groups, our findings are promising when the major-to-minor amputation ratio is considered.