Exercise, Sleep Quality, and Physical Health during the COVID-19 Pandemic.

OBJECTIVES: Sufficient exercise and high-quality sleep are important for good health, and they may be particularly crucial during the coronavirus pandemic. Sleeping difficulties and insufficient exercise are prevalent in the United States, however, and data indicate little to no change-or even worsening-of these health behaviors before the pandemic. This study explores how exercise quantity coincides with sleep quality in the United States during the pandemic and how both ultimately relate to physical health. METHODS: We used logistic regression and multinomial logistic regression to analyze data from the 2021 Crime, Health, and Politics Survey sampled from the National Opinion Research Center's AmeriSpeak panel. Survey responses were collected between May and June 2021. RESULTS: Results show that more typical weekly exercise and more exercise during the pandemic are significantly associated with higher odds of better current sleep quality and sleep quality during the pandemic, controlling for a variety of sociodemographic factors. Both exercise activity and sleep quality are also significantly associated with higher odds of good physical health. CONCLUSIONS: These findings support the literature that increases in exercise frequency and improved sleep quality are linked and are also associated with better physical health outcomes, even during a global crisis.

Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis.

BACKGROUND: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION: Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

Interstates of Infection: Preliminary Investigations of Human Mobility Patterns in the COVID-19 Pandemic.

PURPOSE: The COVID-19 pandemic has illuminated various heterogeneities between urban and rural environments in public health. The SARS-CoV-2 virus initially spread into the United States from international ports of entry and into urban population centers, like New York City. Over the course of the pandemic, cases emerged in more rural areas, implicating issues of transportation and mobility. Additionally, many rural areas developed into national hotspots of prevalence and transmission. Our aim was to investigate the preliminary impacts of road travel on the spread of COVID-19. This investigation has implications for future public health mitigation efforts and travel restrictions in the United States. METHODS: County-level COVID-19 data were analyzed for spatiotemporal patterns in time-to-event distributions using animated choropleth maps. Data were obtained from The New York Times and the Bureau of the Census. The arrival event was estimated by examining the number of days between the first reported national case (January 21, 2020) and the date that each county attained a given prevalence rate. Of the 3108 coterminous US counties, 2887 were included in the analyses. Data reflect cases accumulated between January 21, 2020, and May 17, 2020. FINDINGS: Animations revealed that COVID-19 was transmitted along the path of interstates. Quantitative results indicated rural-urban differences in the estimated arrival time of COVID-19. Counties that are intersected by interstates had an earlier arrival than non-intersected counties. The arrival time difference was the greatest in the most rural counties and implicates road travel as a factor of transmission into rural communities. CONCLUSION: Human mobility via road travel introduced COVID-19 into more rural communities. Interstate travel restrictions and road travel restrictions would have supported stronger mitigation efforts during the earlier stages of the COVID-19 pandemic and reduced transmission via network contact.

Characteristics of persistently unhealthy counties: A comparison of white and black mortality over time.

This research examines differences in white and black persistence of mortality in the United States over a period of nearly 50 years. Using data from the National Center for Health Statistics Compressed Mortality File, we calculated race-specific, all-cause age-adjusted mortality rates for ten time periods from 1968 to 2015. Counties ranking in the top 20% of mortality in at least half of the time periods are classified as persistently unhealthy. Race-specific mortality persistence is mapped illustrating geographic disparities in the clustering of unhealthy places. Persistence of white mortality is clustered in several distinct Southern regions, while black persistent mortality is evenly distributed geographically. Socioeconomic characteristics of white and black persistently unhealthy places are also examined, with a focus on rural-urban differences.

Physical Health, Mental Health, and Fear of Crime Among College Students: A Consideration of Sex Differences.

This article examines how physical health and mental health affect college students' fear of crime. Few studies have examined the influence of fear of crime on both objective and subjective measures of physical and mental health and-to our knowledge-none has examined how health measures vary by sex in the United States. In addition, most of the existing research targets older individuals, rather than college students. Using the ACHA-NCHA data set (American College Health Association-National College Health Assessment), we expand the fear of crime literature by examining both subjective and objective physical and mental health measures among college-aged men and women.

Assessing Trustworthiness in Research: A Pilot Study on CV Verification.

When scholars express concern about trust in science, they often focus on whether the public trusts research findings. This study explores a different dimension of trust and examines whether and how frequently researchers misrepresent their research accomplishments when applying for a faculty position. We collected all of the vitae submitted for faculty positions at a large research university for 1 year and reviewed a 10% sample for accuracy. Of the 180 applicants whose vitae we analyzed, 141 (78%) claimed to have at least one publication, and 79 of these 141 (56%) listed at least one publication that was unverifiable or inaccurate in a self-promoting way. We discuss the nature and implications of our findings, and suggest best practices for both applicants and search committees in presenting and reviewing vitae.

Long-Term Trends in Black and White Mortality in the Rural United States: Evidence of a Race-Specific Rural Mortality Penalty.

PURPOSE: The rural mortality penalty-growing disparities in rural-urban macro-level mortality rates-has persisted in the United States since the mid 1980s. Substantial intrarural differences exist: rural places of modest population size, close to urban areas, experience a greater mortality burden than the most rural locales. This research builds on recent findings by examining whether a race-specific rural mortality penalty exists; that is, are some rural areas more detrimental to black and/or white mortality than others? METHODS: Using data from the Compressed Mortality File from 1968 to 2012, we calculate annual age-adjusted, race-specific mortality rates for all rural-urban regions designated by the Rural-Urban Continuum Codes. Indicators for population, socioeconomic status, and health infrastructure, as a proxy for access to care, are used as predictors of race-specific mortality in multivariable regression models. FINDINGS: Three important results emerge from this analysis: (1) there is a substantial mortality disadvantage for both black and white rural Americans, (2) the most advantageous regions of mortality for blacks exhibit higher mortality than the most disadvantageous regions for whites, and (3) access to health care is a much stronger predictor of white mortality than black mortality. CONCLUSIONS: The rural mortality penalty is evident in race-specific mortality trends over time, with an added disadvantage in black mortality. The rate of mortality improvement for rural blacks and whites lags behind their same-race, urban counterparts, creating a diverging gap in race-specific mortality trends in rural America.

The differential effects of rural health care access on race-specific mortality.

We examined the relationship between race-specific rural mortality and the health infrastructure of rural counties in light of America's recent emergence of a rural mortality penalty. Using the Compressed Mortality File from National Center for Health Statistics (2008-2012) and county-level demographic, socioeconomic, and health care indicators from the Area Health Resource File and the US Census, we created a rural public health infrastructure index which encompasses four types of health care access (public health employees, critical access hospital/rural referral centers, rural health clinics, and emergency departments) within counties. We found that each unit increase in the index is associated with a decline in rural Black mortality, but is associated with an increase in rural White mortality. Policymakers could benefit from focusing on the declining rate of mortality improvement in many rural regions, specifically by trying to better understand how decisions concerning public health spending may influence mortality differently for Black and White residents.

Career expectancy of physicians active in patient care: evidence from Mississippi.

INTRODUCTION: Physician shortages in the USA, an issue that has been particularly challenging in Mississippi, have been a concern among health scholars and policy makers for several decades. Physician shortages hinder residents from easily obtaining routine care, potentially magnifying health disparities. This study examines physician career life expectancy, or how long physicians typically practice, in Mississippi. METHODS: Data on Mississippi's physician population actively involved between 2007 and 2011 were obtained from the Mississippi State Board of Medical Licensure. Abridged career life tables were constructed for all Mississippi physicians and population subgroups based on practice specialty, gender, race, urban-rural practice, and health professional shortage area status. RESULTS: Upon entry into practice in Mississippi, physicians practiced for about 14.4 years. Rural physicians, primary care physicians, minority physicians, physicians practicing in health professional shortage areas, and men had the longest career expectancies. Physicians who are women or who practice in urban counties were substantially more likely to exit practice compared to all other subgroups examined. The odds of remaining in practice were significantly different based on gender, race, urban-rural practice county, and health professional shortage area status. CONCLUSIONS: The first 5 years of practice are the most critical regarding retention for all physicians, regardless of practice specialty, gender, race, urban-rural status, or health professional shortage area status.

Race and gender disparities in nutrient intake are not related to metabolic syndrome in 20- to 59-year-old US adults.

BACKGROUND: The goal of this study was to examine the relationship between macronutrient and micronutrient intake and metabolic syndrome within race and gender cohorts of young US adults. METHODS: The 2007-2010 National Health and Nutrition Examination Survey (NHANES) data for adults (n=2440) aged 20-59 were analyzed. Two 24-hr dietary recalls were used to measure intake of total calories, macronutrients, and 20 vitamins and minerals. Metabolic syndrome and its components were defined by the National Heart, Lung and Blood Institute criteria. Differences in statistical tests were noted when significant at P<0.05. RESULTS: Prevalence of metabolic syndrome among 20- to 59-year-old adults was 30.4% [95% confidence interval 27.6-33.2]. Among cohorts, metabolic syndrome was highest in black women and white men, and lowest in black men and white women. Regression analysis indicated that no macronutrients were associated with greater risk of metabolic syndrome. For relative macronutrient intake, men with metabolic syndrome consumed more polyunsaturated fats, whereas women with metabolic syndrome consumed more total, saturated and monounsaturated fats and less fiber and starch than women without metabolic syndrome. Among races, white men and women consumed greater absolute quantities of all macronutrients except carbohydrates and sugar. Micronutrient intake was greatest for white men and women; women without metabolic syndrome had greater micronutrient adequacy than women with metabolic syndrome. CONCLUSION: Nutrient intake varied between race/gender cohorts; however, there were few clinically significant differences in nutrient intake between those with and without metabolic syndrome. Diet may be marginally related to diagnosis of metabolic syndrome.

Access to primary care physicians differs by health insurance coverage in Mississippi.

OBJECTIVES: The objective of the study was to measure how access to primary health care in Mississippi varies by type of health insurance. METHODS: We called primary care physician (general practitioner, family practice, internal medicine, obstetrics/gynecology, and pediatric) offices in Mississippi three times, citing different types of health insurance coverage in each call, and asked for a new patient appointment with a physician. RESULTS: Of all of the offices contacted, 7% of offices were not currently accepting new patients who had private insurance, 15% of offices were not currently accepting new Medicare patients, 38% were not currently accepting new Medicaid patients, and 9% to 21% of office calls were unresolved in one telephone call to the office. CONCLUSIONS: Access to health insurance does not ensure access to primary health care; access varies by type of health insurance coverage.

The use of technology and perceptions of its effectiveness in training physicians.

BACKGROUND: Technology has been incorporated into the classrooms of future healthcare professionals for decades and vast research has investigated its effectiveness. Much less attention, however, has examined how medical schools are actually using technology and telemedicine to aid teaching. AIMS: It is unclear how medical schools use technology as pedagogical aids. This study investigates technology and telemedicine use in physician training in the United States. METHODS: We distributed an online survey on technology and telemedicine use through the American Association of Colleges of Osteopathic Medicine and the Association of American Medical Colleges. RESULTS: Both allopathic and osteopathic institutions train students with various forms of technology, but appear to be doing so differently. Few schools use telemedicine in the classroom and even fewer require it. CONCLUSION: Osteopathic institutions report more positive attitudes toward e-learning and technology, but allopathic schools on an average have more technology available and longer years of use.

The rise and fall of medicaid managed care in Mississippi: lessons for public health policy makers.

This article describes the development, implementation, and termination of a primary care case management program in the State of Mississippi. The study provides policy makers with critical information as to factors associated with successful implementation of current health care initiatives.

Does one medical school's admission policy help a rural state "grow their own" physicians?

CONTEXT: The University of Mississippi Medical Center (UMC) has been the only medical school in the state since its inception in 1955 (until the 2008 establishment of the William Carey College of Osteopathic Medicine, yet to graduate its first class). Recruiting out-of-state physicians is difficult in Mississippi, and stakeholders frequently talk of "growing our own" physicians, especially challenging with a single public medical school. PURPOSE: This study investigates: (1) the proportion of a recent (1990-1999) cohort of UMC graduates practicing in Mississippi, (2) the proportion of all practicing Mississippi physicians who are UMC grads, (3) whether UMC graduates are more likely to practice in rural, small towns, or geographically isolated areas than other physicians, and (4) whether UMC graduates are more likely to recommend Mississippi as a practice location to new medical school graduates. METHODS: Using Mississippi Board of Medical Licensure data (2009) and Mississippi Medical Doctors survey data (2007-2008), we employ GIS, logistic regression, and multinomial logistic regression models. We also use qualitative methods to examine interviews from purposefully sampled minority and/or female Mississippi physicians from the Mississippi Medical Doctors survey. FINDINGS: Approximately 56% of UMC 1990-1999 cohort grads are practicing in Mississippi. Moreover, UMC graduates--of any year--constitute about 58% of Mississippi's practicing physicians. UMC graduates are not more likely to practice in rural, small towns, or geographically isolated areas in Mississippi than physicians who graduated elsewhere. Controlling for other factors, UMC grads are not more likely to recommend practicing in Mississippi than physicians trained elsewhere. CONCLUSION: Health educators and policy makers should consider broadening UMC's enrollment policies, and greater emphasis should be placed on recruiting physicians.

Correlating pharmaceutical data with a national health survey as a proxy for estimating rural population health.

BACKGROUND: Chronic disease accounts for nearly three-quarters of US deaths, yet prevalence rates are not consistently reported at the state level and are not available at the sub-state level. This makes it difficult to assess trends in prevalence and impossible to measure sub-state differences. Such county-level differences could inform and direct the delivery of health services to those with the greatest need. METHODS: We used a database of prescription drugs filled in the US as a proxy for nationwide, county-level prevalence of three top causes of death: heart disease, stroke, and diabetes. We tested whether prescription data are statistically valid proxy measures for prevalence, using the correlation between prescriptions filled at the state level and comparable Behavioral Risk Factor Surveillance System (BRFSS) data. We further tested for statistically significant national geographic patterns. RESULTS: Fourteen correlations were tested for years in which the BRFSS questions were asked (1999-2003), and all were statistically significant. The correlations at the state level ranged from a low of 0.41 (stroke, 1999) to a high of 0.73 (heart disease, 2003). We also mapped self-reported chronic illnesses along with prescription rates associated with those illnesses. CONCLUSIONS: County prescription drug rates were shown to be valid measures of sub-state estimates of diagnosed prevalence and could be used to target health resources to counties in need. This methodology could be particularly helpful to rural areas whose prevalence rates cannot be estimated using national surveys. While there are no spatial statistically significant patterns nationally, there are significant variations within states that suggest unmet health needs.

Policy, autonomy, and physician satisfaction.

It is important to understand how policy influences physician satisfaction, which in turn affects access to and quality of care. Two Mississippi policy crises in the past decade indirectly jeopardized its primary health care supply. During a volatile malpractice climate in 2002, physician groups claimed physicians would retire or relocate or quit medicine entirely. The second crisis in 2005 temporarily shut down Medicaid reimbursement. Both crises had the capacity to undermine physician satisfaction, a predictor of physician retention. We used data from two cross-sectional Mississippi physician surveys to test how malpractice experiences and Medicaid reimbursement influenced physician satisfaction. The Medicaid shutdown had no measurable effect on physician satisfaction, while the immediate effects of a litigious malpractice climate dampened physician satisfaction. However, the data indicate that the effects of malpractice experiences may be quite short-lived.

Does familiarity breed respect? Physician attitudes toward nurse practitioners in a medically underserved state.

PURPOSE: An evolving primary care environment underscores the importance of physician and nurse practitioner (NP) interactions. We analyze how physician characteristics and close working relationships (presence of NPs in practice) influence physicians' attitudes toward NPs. DATA SOURCES: Bivariate analyses of 2007-2008 Mississippi Physician Workforce Study survey data (response rate 23.3%) identified Mississippi physician characteristics associated with having NPs in practices and discrete NP-attitudinal items. Generalized physician attitudes toward NPs were modeled using multivariate regression. CONCLUSIONS: Generalists, physicians in public sector employment and physicians in larger practices are more likely to work in practices that also include NPs. Physicians working with NPs are somewhat younger than those who do not. Regression analysis indicates that male physicians had less-positive attitudes toward NPs, while physicians who practice alongside NPs and who have been in practice longer have the most positive generalized attitudes toward NPs. IMPLICATIONS FOR PRACTICE: Physicians who work in the same practice with NPs have more positive attitudes toward them. However, regardless of work arrangements, MS physicians are reluctant for NPs to practice independently. Physicians with early collaborative training with NPs may have more positive attitudes, but even such exposure will not necessarily lead physicians to support NPs' independent practice.