The association of travel burden with prenatal care utilization, what happens after provider-selection.

BACKGROUND: Birthing people in the United States face numerous challenges when accessing adequate prenatal care (PNC), with transportation being a significant obstacle. Nevertheless, previous studies that relied solely on the distance to the nearest provider cannot differentiate the effects of travel burden on provider selection and care utilization. These may exaggerate the degree of inequality in access and fail to capture perceived travel burden. This study investigated whether travel distances to the initially visited provider, to the predominant PNC provider, and perceived travel burden (measured by the travel disadvantage index (TDI)) are associated with PNC utilization. METHODS: A retrospective cohort of people with live births were identified from South Carolina Medicaid claims files in 2015-2018. Travel distances were calculated using Google Maps. The estimated TDI was derived from local pilot survey data. PNC utilization was measured by PNC initiation and frequency. Repeated measure logistic regression test was utilized for categorical variables and one-way repeated measures ANOVA for continuous variables. Unadjusted and adjusted ordinal logistic regressions with repeated measure were utilized to examine the association of travel burdens with PNC usage. RESULTS: For 25,801 pregnancies among those continuously enrolled in Medicaid, birthing people traveled an average of 24.9 and 24.2 miles to their initial and predominant provider, respectively, with an average TDI of -11.4 (SD, 8.5). Of these pregnancies, 60% initiated PNC in the first trimester, with an average of 8 total visits. Compared to the specialties of initial providers, predominant providers were more likely to be OBGYN-related specialists (81.6% vs. 87.9%, p < .001) and midwives (3.5% vs. 4.3%, p < .001). Multiple regression analysis revealed that every doubling of travel distance was associated with less likelihood to initiate timely PNC (OR: 0.95, p < .001) and a lower visit frequency (OR: 0.85, p < .001), and every doubling of TDI was associated with less likelihood to initiate timely PNC (OR: 0.94, p = .04). CONCLUSIONS: Findings suggest that the association between travel burden and PNC utilization was statistically significant but of limited practical significance.

Who is your prenatal care provider? An algorithm to identify the predominant prenatal care provider with claims data.

BACKGROUND: Using claims data to identify a predominant prenatal care (PNC) provider is not always straightforward, but it is essential for assessing access, cost, and outcomes. Previous algorithms applied plurality (providing the most visits) and majority (providing majority of visits) to identify the predominant provider in primary care setting, but they lacked visit sequence information. This study proposes an algorithm that includes both PNC frequency and sequence information to identify the predominant provider and estimates the percentage of identified predominant providers. Additionally, differences in travel distances to the predominant and nearest provider are compared. METHODS: The dataset used for this study consisted of 108,441 live births and 2,155,076 associated South Carolina Medicaid claims from 2015-2018. Analysis focused on patients who were continuously enrolled throughout their pregnancy and had any PNC visit, resulting in 32,609 pregnancies. PNC visits were identified with diagnosis and procedure codes and specialty within the estimated gestational age. To classify PNC providers, seven subgroups were created based on PNC frequency and sequence information. The algorithm was developed by considering both the frequency and sequence information. Percentage of identified predominant providers was reported. Chi-square tests were conducted to assess whether the probability of being identified as a predominant provider for a specific subgroup differed from that of the reference group (who provided majority of all PNC). Paired t-tests were used to examine differences in travel distance. RESULTS: Pregnancies in the sample had an average of 7.86 PNC visits. Fewer than 30% of the sample had an exclusive provider. By applying PNC frequency information, a predominant provider can be identified for 81% of pregnancies. After adding sequential information, a predominant provider can be identified for 92% of pregnancies. Distance was significantly longer for pregnant individuals traveling to the identified predominant provider (an average of 5 miles) than to the nearest provider. CONCLUSIONS: Inclusion of PNC sequential information in the algorithm has increased the proportion of identifiable predominant providers by 11%. Applying this algorithm reveals a longer distance for pregnant individuals travelling to their predominant provider than to the nearest provider.

Examining the influence of positive childhood experiences on childhood overweight and obesity using a national sample.

Positive childhood experiences (PCEs) promote healthy social development, improve overall wellness, and help to moderate and prevent exposure to adverse childhood experiences. There has been limited research examining the association between positive childhood experiences and overweight or obesity status in children. The purpose of this study was to examine whether experiencing positive childhood experiences are associated with lower rates of overweight or obesity status in children between 10 and 17 years of age, using cross-sectional data from the 2018-2019 National Survey of Children's Health (n = 28,771), a nationally representative mail and online survey. Frequencies, proportions, and unadjusted associations for each variable were calculated using descriptive statistics and bivariate analyses. To examine the association between overweight or obesity and PCEs, multivariable regression models were used. Compared to children who were underweight or had a healthy weight, children who were overweight or obese were less likely to: participate after school activities (78.1%, p < 0.0001), volunteer in their community, school, or church (45.6%, p < 0.0001), have a mentor they feel comfortable going to for guidance (87.0%, p = 0.02), live in a safe neighborhood (61.3%, p < 0.0001), live in a supportive neighborhood (50.4%, p < 0.0001), and to live with a resilient family (78.3%; p = 0.0099). In adjusted analysis, among children exposed to two or more ACEs, children residing in a supportive neighborhood were less likely to be overweight or obese (aOR 0.87; 0.77-0.98). Our findings suggest that certain PCEs may mitigate overweight and obesity when children have experienced at least some childhood trauma.

Positive Childhood Experiences Promote School Success.

OBJECTIVES: Educational attainment has been demonstrated as a protective factor for the physical and mental health of children into adulthood, yet there has been limited research on the association between positive childhood experiences (PCEs) and school success. The purpose of this study is to examine the associations between PCEs and challenges to school success. METHODS: This cross-sectional study used data of 33,450 children from the 2017-2018 National Survey of Children's Health to examine PCEs and two challenges to school success (school absenteeism and repeated grades), using multivariable logistic regression analysis. RESULTS: The most prevalent types of PCEs were mentor for advice or guidance (89.8%), family resilience (81.1%), and after-school activity participation (79.8%). Children who participated in after-school activities had lower odds of reported school absenteeism (aOR 0.59; 95% CI 0.46-0.76) and repeating a grade (aOR 0.75; 95% CI 0.59-0.97) than their counterparts. Children who shared ideas with their caregiver had lower odds of repeating a grade (aOR 0.78; 95% CI 0.63-0.97) than children who did not share ideas with their caregiver. Children who lived in a supportive neighborhood were less likely to have reported school absenteeism than children who did not live in a supportive neighborhood (aOR 0.77; 95% CI 0.60-0.98). CONCLUSIONS FOR PRACTICE: Participation in after-school activities had optimal associations with both school absenteeism and repeated grade, suggesting its potential protective effect for school success. Promoting PCEs at the school, family, and community levels may help address school absenteeism and grade retention.

Summary of Selected Healthcare Encounters among a Selection of Patients with Myotonic Muscular Dystrophy.

OBJECTIVE: Research has not examined the use of health care by patients with myotonic muscular dystrophy (MMD), but it would provide insights into this population, which is prone to comorbidities and high service needs. This study is an analysis of this understudied subgroup, using a unique linked dataset to examine the characteristics and healthcare utilization patterns for people with MMD. METHODS: This analysis used 3 South Carolina datasets (2009-2014). The subjects included individuals with at least 1 encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification code of 359.21. The variables included sex, race, visit type, payer, and diagnoses. The analyses examined characteristics and number of encounters. RESULTS: The subjects were predominately female, white, and 45 to 64 years old. A total of 44.6% of the study population had at least 1 inpatient visit, whereas 64.2% had at least 1 emergency department visit. A majority of the subjects had at least 1 office visit (55.0%), and most (85.3%) did not have a home health encounter. CONCLUSIONS: Investigation of the reasons for these inpatient and emergency department encounters may be helpful in identifying ways to deliver high-quality care.

Disparities in home health service providers among Medicare beneficiaries with stroke.

This study examined the intensity of home health services, as defined by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiaries with stroke. A cross-sectional secondary data analysis was conducted using 2009 home health claims data obtained from the Centers for Medicare and Medicaid Services' Research Data Assistance Center. There were no significant rural-urban differences in the number of home health visits. Rural beneficiaries were significantly less likely than urban beneficiaries to receive services from rehabilitation specialists. Current home health payment reform recommendations may have unintended consequences for rural home health beneficiaries who need therapy services.

Exploring low back and pelvic pain challenges: Administrative insights into prevalence during pregnancy among 2016-2021 South Carolina Medicaid beneficiaries.

BACKGROUND: Musculoskeletal changes occur during pregnancy; one-half of pregnant women experienced low back pain and/or pelvic pain during pregnancy. Prescription opioid use for Medicaid enrolled pregnant women has increased dramatically due to severe low back pain/pelvic pain. OBJECTIVES: This study aimed to explore the prevalence of low back pain/pelvic pain and related risk factors among a broader population. DESIGN: This is a retrospective cohort study. METHODS: This study utilized de-identified Medicaid claims data provided by the South Carolina Revenue and Fiscal Affairs Office, including individuals who gave birth between 2016 and 2021 during pregnancy. Low back pain/pelvic pain and a group of musculoskeletal risk factors were identified with International Classification of Diseases v10. Comparisons were made for the prevalence of low back pain and pelvic pain between those with pregnancy-related musculoskeletal risk and those without. RESULTS: Among 167,396 pregnancies, 65.6% were affected by musculoskeletal risk factors. The overall prevalence of low back pain was 15.6%, and of pregnancy-related pelvic pain was 25.2%. The overall prevalence for either low back pain or pelvic pain was 33.3% (increased from 29.5% in 2016 to 35.3% in 2021), with 24.6% being pregnancy-induced. Pregnancies with musculoskeletal risk factors were more likely to be diagnosed with low back pain (20.7% versus 5.7%, p < 0.001) or pelvic pain (35.3% versus 6.0%, p < 0.001) than those without. CONCLUSION: This study found a very high prevalence of musculoskeletal risk and a high prevalence of low back pain or pelvic pain, with an increasing trend, among South Carolina pregnancies enrolled in Medicaid during the period 2016-2021. Most of the diagnosed low back pain or pelvic pain were pregnancy induced. Musculoskeletal risk factors were associated with low back pain or pelvic pain.

How rural is All of Us? Comparing characteristics of rural participants in the National Institute of Health's All of Us Research Program to other national data sources.

PURPOSE: The National Institute of Health's All of Us Research Program represents a national effort to develop a database to advance health research, especially among individuals historically underrepresented in research, including rural populations. The purpose of this study was to describe the rural populations identified in the All of Us Research Program using the only proxy measure currently available in the dataset. METHODS: Currently, the All of Us Research Program provides a proxy measure of rurality that identifies participants who self-reported delaying care due to far travel distances associated with living in rural areas. Using the All of Us Controlled Tier Dataset v6, we compared sociodemographic and health characteristics of All of Us rural participants identified via this proxy to rural US residents from nationally representative data sources using chi-squared tests. RESULTS: 3.1% of 160,880 All of Us participants were rural, compared to 15%-20% of US residents based on commonly accepted rural definitions. Proportionally more rural All of Us participants reported fair or poor health status, history of cancer, and history of heart disease (P<.01). CONCLUSIONS: The All of Us measure may capture a subset of underserved participants who live in rural areas and experience health care access barriers due to distance. Researchers who use this proxy measure to characterize rurality should interpret their findings with caution due to differences in population and health characteristics using this proxy measure rural compared to other commonly used rural definitions.

Mobile health clinics for distribution of vaccinations to underserved communities during health emergencies: A COVID-19 case study.

Objectives: Mobile health clinics (MHCs) effectively provide healthcare to underserved communities. However, their application during health emergencies is understudied. We described the implementation of an MHC program delivering vaccinations during the COVID-19 pandemic, examined the program's reach to medically underserved communities, and investigated characteristics of vaccination uptake in order to inform the utility of MHCs during health emergencies. Study design: The study observed COVID-19 MHC vaccination rates and factors associated with uptake between February 20th, 2021, and February 17th, 2022. Methods: Prisma Health deployed six MHCs to underserved communities. We described the characteristics of individuals who utilized the MHCs and evaluated census tract-level community factors associated with use of the MHCs through generalized linear mixed effects models. Results: The MHCs conducted 260 visits at 149 unique sites in South Carolina, providing 12,102 vaccine doses to 8545 individuals: 2890 received a partial dose, 4355 received a primary series, and 1300 received a booster dose. Among individuals utilizing the MHC, the median age was 42 years (IQR: 22-58), 44.0 % were Black, 49.2 % were male, and 44.2 % were uninsured. Black, Hispanic, and uninsured individuals were significantly more likely to utilize MHC services for COVID-19 vaccination. During periods when vaccines were limited, MHC utilization was significantly greater in communities facing access barriers to healthcare. Conclusions: The high COVID-19 vaccination uptake at MHCs demonstrated that the MHC framework is an effective and acceptable intervention among medically underserved populations during health emergencies, especially when resources are scarce. The identified factors associated with vaccination uptake demonstrated that the MHCs had the greatest impact in higher-risk communities and can be used to inform allocation of such field-level interventions in future health emergencies.

Examining the association between rurality and positive childhood experiences among a national sample.

PURPOSE: The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states. METHODS: Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses. FINDINGS: Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18-1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45-2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54-2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01-1.20) than urban children. CONCLUSIONS: The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

Missing the handoff: post-hospitalization follow-up care among rural Medicare beneficiaries with diabetes.

INTRODUCTION: Diabetes is a condition that requires adequate care to ensure ideal outcomes. One need is for proper post-discharge follow-up care to reduce unnecessary hospital re-admissions. This care is more difficult in US rural areas due to lower physician and resource availability. The purpose of this analysis was to examine US urban-rural differences in 30 day post-discharge physician follow-up care. METHODS: This analysis utilized data from 2005 Medicare claims files, merged with county-level information from the area resource file. Beneficiaries with diabetes and with a hospitalization served as the study population. Differences in hospitalization rates and 30 day physician follow-up care were estimated across levels of rurality. Multi-level multivariate models estimated the factors that significantly contributed to obtaining such care. RESULTS: Approximately 90% of the study population had a follow-up physician visit within 30 days; this rate was lower among rural beneficiaries. Adjusted estimates indicated that beneficiaries in rural areas were not less likely to obtain a follow-up visit. Factors associated with obtaining a follow up included having addition comorbidities, being female or White, and living in the US Northeast. CONCLUSIONS: This analysis found evidence that rural Medicare beneficiaries were less likely to obtain post-discharge physician follow-up visits within 30 days. The adjusted result indicate that other factors such as personal demographic and illness characteristics are more predictive of this behavior than the rural location itself. More research is needed to identify why these specific factors are associated with visit behavior, and how to design interventions to improve these rates.

A national examination of poverty and interactive caregiving practices among parents of young children.

Interactive caregiving practices can be protective for the development of the brain in early childhood, particularly for children experiencing poverty. There has been limited research examining the prevalence of interactive caregiving practices in early childhood at the population level across the U.S. The purpose of this study was to describe the prevalence of three interactive caregiver activities: (1) reading, (2) telling stories/singing songs, and (3) eating a meal together, using the 2017-2018 National Survey of Children's Health, among a sample of children age five and younger, and to examine the relationship between these interactive caregiving practices across income levels and by selected potentially confounding household characteristics. Children living in families with incomes below the federal poverty level had lower odds of being read to every day compared to children living in families with incomes at 400% or more above the federal poverty level (aOR 0.70; 95% CI 0.53-0.92). Children living in families within incomes at 100-199% of the federal poverty level had lower odds of being sung to and told stories to every day than children living in families with incomes at 400% or above the federal poverty level (aOR 0.62; 95% CI 0.50-0.78).These findings have long-term implications for children, as interactive caregiving practices are known to improve cognitive activities such as language development, which is associated with educational attainment into adulthood. Finding ways to increase the adoption of interactive caregiving practices may be one way to mitigate disparities in education, especially among families experiencing poverty.

Obesity and related health behaviors among urban and rural children in the United States: data from the National Health And Nutrition Examination Survey 2003-2004 and 2005-2006.

OBJECTIVE: To assess rates of overweight/obesity and related health behaviors among rural and urban children using data from the National Health and Nutrition Examination Survey (NHANES). METHODS: Data were drawn from the 2003-2004 and 2005-2006 NHANES surveys regarding demographic characteristics, weight status, dietary behaviors and physical activity behaviors. RESULTS: Significantly more rural children were found to be obese than urban children. Health behavior differences to explain this differential obesity rate were primarily not significant, but multivariate analyses indicate that for rural children meeting physical activity recommendations is protective and engaging in more than 2 hr/day of electronic entertainment promotes obesity. CONCLUSIONS: There are modifiable health behavior differences between rural and urban children which may account for the significantly higher obesity rates among rural children.

Rural-Urban Differences in Positive Childhood Experiences Across a National Sample.

PURPOSE: The purpose of this study was to examine the prevalence of positive childhood experience (PCE) and adverse childhood experience (ACE) exposures in 31 states plus the District of Columbia and to estimate exposure differences between rural and urban children. METHODS: A cross-sectional study was conducted with a sample of 19,251 respondents from the 2017-2018 National Survey of Children's Health (NSCH), a nationally representative sample of US children. Sociodemographic information, residence, and PCE and ACE responses were utilized. To calculate frequencies, proportions, and unadjusted associations for each variable, descriptive statistics and bivariate analyses were used. Multivariable regression models were used to examine the association between residence and PCEs that showed significance in bivariate analyses. FINDINGS: In adjusted analyses of PCEs, there was no significant difference between rural and urban children for after-school activities. However, rural children were more likely to volunteer in the community, school, or church than were urban children (aOR 1.32; 95% CI: 1.14-1.54). Rural children also had greater odds of having a mentor for advice or guidance, compared to urban children (aOR 1.8; 95% CI: 1.40-2.52). CONCLUSIONS: An examination of both PCEs and ACEs provides policy makers, program developers, and other stakeholders the opportunity to determine needs of rural children and where to target interventions. Furthering the understanding of PCEs and ACEs is important to bring individuals, families, and communities together to both address childhood adversity and utilize existing family and community-level assets.

Chemical Sulfide Tethering Improves Low-Temperature Li-S Battery Cycling.

Demands for energy storage and delivery continue to rise worldwide, making it imperative that reliable performance is achievable in diverse climates. Lithium-sulfur (Li-S) batteries offer a promising alternative to lithium-ion batteries owing to their substantially higher specific capacity and energy density. However, improvements to Li-S systems are still needed in low-temperature environments where polysulfide clustering and solubility limitations prohibit complete charge/discharge cycles. We address these issues by introducing thiophosphate-functionalized metal-organic frameworks (MOFs), capable of tethering polysulfides, into the cathode architecture. Compared to cells with the parent MOFs, cells containing the functionalized MOFs exhibit greater capacity delivery and decreased polarization for a range of temperatures down to -10 °C. We conduct thorough electrochemical analyses to ascertain the origins of performance differences and report an altered Li-S redox mechanism enabled by the thiophosphate moiety. This investigation is the first low-temperature Li-S study using MOF additives and represents a promising direction in enabling energy storage in extreme environments.

Examining the Relationship Between Adverse Childhood Experiences and ADHD Diagnosis and Severity.

OBJECTIVE: Although prior research has examined the prevalence of ACEs among children with attention deficit-hyperactivity disorder (ADHD), little is known about the household and family settings of children with ADHD. Our study utilizes a recent nationally representative dataset to examine the association between adverse childhood experiences (ACEs), child and household characteristics, and ADHD diagnosis and severity. METHODS: Using the 2017-2018 National Survey of Children's Health (NSCH), our sample consisted of children three years of age or older, as this is the youngest age at which the NSCH begins to ask caregivers if a child has been diagnosed with ADHD (n = 42,068). Multivariable logistic regression was used to examine the association between ACE type, score, and ADHD and ADHD severity, controlling for child and household characteristics. RESULTS: Children exposed to four or more ACEs had higher odds of ADHD (aOR 2.16; 95% CI 1.72-2.71) and moderate to severe ADHD (aOR 1.89; 95% CI 1.31-2.72) than children exposed to fewer than four ACEs. Other child characteristics positively associated with ADHD included age and public insurance; other Non-Hispanic races compared to Non-Hispanic White had lower odds of ADHD. Of children reported with ADHD, public insurance was also associated with caregiver-reported moderate to severe ADHD. CONCLUSIONS: Children with ADHD have a higher prevalence of ACEs, making this study important for understanding the relationship between ACEs and ADHD at the population level.

Diabetes care and outcomes: disparities across rural America.

We examined differences in receipt of diabetes care and selected outcomes between rural and urban persons living with diabetes, using nationally representative data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS). "Rural" was defined as living in a non-metropolitan county. Diabetes care variables were physician visit, HbA1c testing, foot examination, and dilated eye examination. Outcome variables were presence of foot sores and diabetic retinopathy. Analysis was limited to persons 18 and older self-reporting a diagnosis of diabetes (n = 29,501). A lower proportion of rural than urban persons with diabetes reported a dilated eye examination (69.1 vs. 72.4%; P = 0.005) or a foot examination in the past year (70.6 vs. 73.7%; P = 0.016). Conversely, a greater proportion of rural than urban persons reported diabetic retinopathy (25.8 vs. 22.0%; P = 0.007) and having a foot sore taking more than four weeks to heal (13.2 vs. 11.2%; P = 0.036). Rural residence was not associated with receipt of services after individual characteristics were taken into account in adjusted analysis, but remained associated with an increased risk for retinopathy (OR = 1.20, 95% CI = 1.02-1.42). Participation in Diabetes Self-Management Education (DSME) was positively associated with all measures of diabetes care included in the study. Availability of specialty services and travel considerations could explain some of these differences.

Personal and contextual factors that contribute to a higher out-of-pocket to total income ratio.

INTRODUCTION: This analysis sought to define the out-of-pocket healthcare spending to total income ratio for rural residents, as well as to explore the impact of county-level factors that may contribute to urban-rural differences. METHODS: Three years of pooled data were utilized from the Medical Expenditure Panel Survey (2003-2005). The dependent variable was the ratio of total out-of-pocket healthcare spending to total income, at the household level. Unadjusted and adjusted analyses estimated the factors associated with this ratio, including rurality, socio-demographics, and county-level factors. RESULTS: The unadjusted analysis indicated that small adjacent and remote rural residents had higher out-of-pocket to total income ratios than urban residents. The adjusted multivariate analysis indicated that when other factors are held equal, rurality is no longer a significant factor. Other factors such as insurance type, healthcare utilization, and income, which differ significantly by rurality, are better predictors of the ratio. CONCLUSIONS: The identification of factors that contribute to a higher ratio among some rural residents is necessary in order to better target interventions that will reduce this financial burden.

Rural-Urban Differences in Adverse Childhood Experiences Across a National Sample of Children.

PURPOSE: The purpose of this study was to examine the prevalence of adverse childhood experiences (ACEs) exposure in 34 states and the District of Columbia, and whether exposure differs between rural and urban residents. METHODS: This cross-sectional study used data from the 2016 National Survey of Children's Health (NSCH), restricted to states in which rural versus urban residence was indicated in the public use data (n = 25,977 respondents). Bivariate analyses were used to estimate unadjusted associations. Multivariable regression models were run to examine the association between residence (rural or urban) and ACE counts of 4 or more. FINDINGS: Compared to urban children, rural children had higher rates of exposure to the majority of the ACEs examined: parental separation/divorce, parental death, household incarceration, household violence, household mental illness, household substance abuse, and economic hardship. In adjusted analysis, there was no significant difference for rural children compared to urban children. The odds of 4 or more ACEs decrease as poverty levels decline, with children residing 0%-99% below the federal poverty line more likely to have reported 4 or more ACEs, compared to children residing 400% or above the federal poverty line (aOR 4.02; CI: 2.65-6.11). CONCLUSIONS: Our findings suggest that poverty is a key policy lever that may mitigate the burden of ACE exposure. The findings of this study may be instructive for policymakers and program planners as they develop interventions to stop, reduce, or mitigate ACE exposure and the long-term impact of ACEs among children in rural America.

Point-of-Care Ultrasound in Family Medicine Residencies 5-Year Update: A CERA Study.

BACKGROUND AND OBJECTIVES: In 2014, family medicine residency programs began to integrate point-of-care ultrasound (POCUS) into training, although very few had an established POCUS curriculum. This study aimed to evaluate the resources, barriers, and scope of POCUS training in family medicine residencies 5 years after its inception. METHODS: Questions regarding current training and use of POCUS were included in the 2019 Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine residency program directors, and results compared to similar questions on the 2014 CERA survey. RESULTS: POCUS is becoming a core component of family medicine training programs, with 53% of program directors reporting establishing or an established core curriculum. Only 11% of program directors have no current plans to add POCUS training to their program, compared to 41% in 2014. Despite this increase in training, the reported clinical use of POCUS remains uncommon. Only 27% of programs use six of the eight surveyed POCUS modalities more than once per year. The top three barriers to including POCUS in residency training in 2019 have not changed since 2014, and are (1) a lack of trained faculty, (2) limited access to equipment, and (3) discomfort with interpreting images without radiologist review. CONCLUSIONS: Training in POCUS has increased in family medicine residencies over the last 5 years, although practical use of this technology in the clinical setting may be lagging behind. Further research should explore how POCUS can improve outcomes and reduce costs in the primary care setting to better inform training for this technology.