Type 2 diabetes and health-related quality of life among older Medicare beneficiaries: The mediating role of sleep.

OBJECTIVE: To examine mediating effects of sleep quality and duration on the association between T2D and QoL among Medicare beneficiaries 65+. METHODS: Data from the Medicare Health Outcome Survey (2015-2020) were used. The outcome was QoL (physical and mental health component-summary scores [PCS and MCS]) measured by the Veterans-Rand-12. The main predictor was diagnosed T2D. Mediators were sleep duration and sleep quality. The effect modifier was race/ethnicity. Structural Equation Modeling was used to estimate moderated-mediating effects of sleep quality and duration across race/ethnicity. RESULTS: Of the 746,400 Medicare beneficiaries, 26.7% had T2D, and mean age was 76 years (SD ± 6.9). Mean PCS score was 40 (SD ± 12.2), and mean MCS score was 54.0 (SD ± 10.2). Associations of T2D with PCS and MCS were negative and significant. For all racial/ethnic groups, those with T2D reported lower PCS. For White, Black, Asian, and Hispanic beneficiaries only, those with T2D reported lower MCS. The negative impact of T2D on PCS and MCS was mediated through sleep quality, especially very bad sleep quality. CONCLUSION: Improving sleep may lead to improvement in QoL in elderly adults with T2D.

Healthy food delivery for type 2 diabetes management in rural clinics' patients: A comparative effectiveness randomized controlled trial protocol.

BACKGROUND: Rural populations experience a higher prevalence of both food insecurity and type 2 diabetes mellitus (T2DM) than metropolitan populations and face many challenges in accessing resources essential to optimal T2DM self-management. This study aims to address these challenges by delivering a T2DM-appropriate food box and recipes directly to rural participants' homes. METHODS: This is a comparative effectiveness randomized controlled trial including 400 English- or Spanish-speaking rural adult participants with T2DM (HbA1c ≥6.5%) experiencing food insecurity. Participants are randomly assigned to a 3-month Healthy Food Delivery Intervention (HFDI) plus one 60-min virtual consultation with a diabetes educator or consultation only. The HFDI includes a weekly food box delivery with recipes. Data are collected at pre-intervention, 3-months (post-intervention), 9-months, and 15-months. The primary outcome is change in HbA1c, with secondary measures including diet quality (Healthy Eating Index-2015, calculated from one 24-h dietary recall at each data collection time point), cardio-metabolic risk factors (i.e., blood pressure, lipids, body mass index, glucose), and patient-centered outcomes (e.g., T2DM self-efficacy, T2DM-related distress). Process evaluation data (e.g., successful food box deliveries, diabetes educator consultation attendance, intervention satisfaction) are collected during and post-intervention (3-months). A cost-effectiveness analysis based on traditional cost per quality-adjusted life year gain thresholds will be conducted to estimate the incremental cost-effectiveness between HFDI plus consultation and consultation alone. CONCLUSION: Findings from this study will provide evidence regarding the effectiveness of an intervention that promotes participant adherence and improves access to healthy food. CLINICAL TRIAL REGISTRATION: NCT04876053.

Assessment of diabetes self-care behaviors and knowledge among Marshallese adults with type 2 diabetes in the Republic of the Marshall Islands.

AIMS: The aim of this study is to assess and document engagement in type 2 diabetes mellitus (T2DM) self-care behaviors and self-reported diabetes knowledge among Marshallese adults living in the Republic of the Marshall Islands (RMI). METHODS: The study uses data from a T2DM health screening study completed in the RMI; survey and biometric data were captured as part of the health screenings. Study objectives were examined using descriptive statistics to describe the characteristics of the participants, their diabetes self-care behaviors, and their levels of self-reported diabetes knowledge. RESULTS: Results indicate many Marshallese diagnosed with T2DM did not engage in adequate self-care behaviors, including blood sugar checks and foot examinations. Participants reported having forgone needed medical care and medication due to issues with cost and/or access, and participants reported low levels of diabetes knowledge. CONCLUSIONS: The results demonstrate the need for further work in improving engagement in diabetes self-care by Marshallese living in the RMI. Increased engagement in self-care and diabetes education programs may help Marshallese with T2DM to improve control of their glucose and avoid long-term health complications, as well as reduce costs to the healthcare system.

Factors associated with breast cancer screening services use among women in the United States: An application of the Andersen's Behavioral Model of Health Services Use.

This study applied Andersen's Behavioral Model of Health Services Use to examine predisposing, enabling, and need factors associated with adherence to the United States Preventive Services Task Force (USPSTF) guidelines for breast cancer screening (BCS). Multivariable logistic regression was used to determine factors of BCS services utilization among 5484 women aged 50-74 from the 2019 National Health Interview Survey. Predisposing factors significantly associated with use of BCS services were: being a Black (odds-ratios [OR]:1.49; 95% confidence interval [CI]:1.14-1.95) or a Hispanic woman (OR:2.25; CI:1.62-3.12); being married/partnered (OR:1.32, CI:1.12-1.55); having more than a bachelor's degree (OR: 1.62; CI:1.14-2.30); and living in rural areas (OR:0.72; CI:0.59-0.92). Enabling factors were: poverty level [≤138% federal poverty level (FPL) (OR:0.74; CI:0.56-0.97), >138-250% FPL (OR:0.77; CI:0.61-0.97), and > 250-400% FPL (OR:0.77; CI:0.63-0.94)]; being uninsured (OR:0.29; CI:0.21-0.40); having a usual source of care at a physician office (OR:7.27; CI:4.99-10.57) or other healthcare facilities (OR:4.12; CI:2.68-6.33); and previous breast examination by a healthcare professional (OR:2.10; CI:1.68-2.64). Need factors were: having fair/poor health (OR:0.76; CI:0.59-0.97) and being underweight (OR:0.46; CI:0.30-0.71). Disparities in BCS services utilization by Black and Hispanic women have been reduced. Disparities still exist for uninsured and financially restrained women living in rural areas. Addressing disparities in BCS uptake and improving adherence to USPSTF guidelines may require revamping policies that address disparities in enabling resources, such as health insurance, income, and health care access.

Assessment of Colorectal Cancer Screening Disparities in U.S. Men and Women Using a Demographically Representative Sample.

Timely receipt of colorectal cancer (CRC) screening can reduce morbidity and mortality. This is the first known study to adopt Andersen's model of health services use to identify factors associated with CRC screening among US adults. The data from National Health Interview Survey from 2019 was utilized to conduct the analyses. Multivariable logistic regression was used to separately analyze data from 7,503 age-eligible women and 6,486 age-eligible men. We found similar CRC screening levels among men (57.7%) and women (57.6%). Factors associated with higher screening odds in women were older age, married/cohabitating with a partner, Black race, >bachelor's degree, having a usual source of care, and personal cancer history. Factors associated with lower odds for women were American Indian/Alaska Native race, living in the US for ≤10 years, ≤138% federal poverty level (FPL), uninsured or having Medicare, and in fair/poor health. For men, factors associated with higher screening odds were older age, homosexuality, married/cohabitating with a partner, Black race, >high school/general educational development education, having military insurance, having a usual source of care, and personal cancer history. Factors associated with lower odds for men were being a foreign-born US resident, living in the South or Midwest, ≤138% FPL, and being uninsured or having other insurance. Despite lower screening rates in the past, Black adults show a significantly higher likelihood of CRC screening than White adults; yet, screening disparities remain in certain other groups. CRC screening efforts should continue to target groups with lower screening rates to eliminate screening disparities.

Association of psychological distress and current cigarette smoking among Native Hawaiian and Pacific Islander adults and compared to adults from other racial/ethnic groups: Data from the National Health Interview Survey, 2014.

Cigarette smoking is the leading cause of preventable deaths worldwide. Research has documented an association between psychological distress and smoking among certain racial/ethnic groups but has not examined this association among Native Hawaiian and Pacific Islander (NHPI) adults. Data from the 2014 general and the NHPI-specific National Health Interview Surveys were analyzed at the University of Arkansas for Medical Sciences Regional Campus (Fayetteville, AR) in April 2021 to determine the association between current cigarette smoking and levels of psychological distress among NHPI adults and to assess the difference in the magnitude of that association among NHPI adults compared to adults of other racial/ethnic groups in the United States. The final analytic sample (n = 34,782) included 1,916 NHPI, 20,430 White, 4,725 Black, 2,001 Asian, and 5,710 Hispanic adults. A significant association between current cigarette smoking and psychological distress levels was found among NHPI adults as well as among adults from other racial/ethnic groups. There was no significant difference in the magnitude of the detected association among NHPI adults compared to the magnitude of the same association detected among adults of other racial/ethnic groups. However, this finding indicates race/ethnicity does not moderate the association between psychological distress and current cigarette smoking. Future studies should explore factors that may further explain the variation in current cigarette smoking within and across all racial/ethnic groups.

Factors Associated with First-Time Telehealth Utilization for Marshallese Living in the United States.

Background: Mitigation efforts to prevent the spread of COVID-19 included the robust utilization of telehealth. However, racial/ethnic minority populations have demonstrated low telehealth utilization in the past. The aim of this study was to examine the first-time use of telehealth by Marshallese adults during the COVID-19 pandemic, using online survey data collected from 109 Marshallese respondents between July and November of 2020. Methods: To evaluate the relationships between sociodemographic characteristics, health care access, physical/mental health, and COVID-19-specific measures and the decision to use telehealth, we use bivariate analyses, including t-tests and chi-square analysis. Results: Eighteen respondents (16.5%) indicated they utilized telehealth for the first time during the pandemic. The number of chronic conditions reported was positively associated with the first-time use of telehealth (p = 0.013). Although not statistically significant, a higher proportion of Marshallese first-time telehealth users reported limited English proficiency, changes in health status, and changes in health insurance. Discussion: Although telehealth has been shown to reduce the absolute gaps in health disparities for minority populations, there is limited utilization by Marshallese communities. Conclusions: Significant research remains on the utilization of telehealth by Marshallese during the COVID-19 pandemic and to increase utilization in the future.

Use of Community-Based Participatory Research Partnerships to Reduce COVID-19 Disparities Among Marshallese Pacific Islander and Latino Communities - Benton and Washington Counties, Arkansas, April-December 2020.

Marshallese and Latino communities in Benton and Washington counties, Arkansas, were disproportionately affected by COVID-19. We evaluated the effectiveness of a comprehensive community-based intervention to reduce COVID-19 disparities in these communities. We examined all laboratory-confirmed COVID-19 cases in the 2 counties reported from April 6, 2020, through December 28, 2020. A 2-sample serial t test for rate change was used to evaluate changes in case rates before and after implementation of the intervention. After implementation, the proportions of cases among Marshallese and Latino residents declined substantially and began to align more closely with the proportions of these 2 populations in the 2 counties. Infection rates remained lower throughout the evaluation period, and weekly incidence also approximated Marshallese and Latino population proportions. Leveraging community partnerships and tailoring activities to specific communities can successfully reduce disparities in incidence among populations at high-risk for COVID-19 .

Investigating the Association between English Proficiency and General Health among Marshallese Adults in the United States.

Prior studies have not examined the association between English proficiency and health among Marshallese adults. Cross-sectional data from 378 Marshallese adults enrolled in a Diabetes Prevention Program study in Arkansas and Oklahoma were used to document English proficiency, assess the relationship between sociodemographic health-related characteristics and English proficiency, and examine the association between English proficiency and general health. Approximately one-fifth of participants reported limited English proficiency (LEP). One-fifth of participants reported being in fair or poor health. General health, age group, education, household food insufficiency, inability to afford necessities, and comorbidities were significantly associated with LEP. Participants with LEP were 78% less likely to report better general health compared with those who reported speaking English very well. Limited English proficiency was high among this sample of Marshallese adults. Findings highlight the need for additional Marshallese clinical interpretation and translation services.

Description of Variation in Age of Onset of Functional Limitations of Native Hawaiian and Pacific Islanders Compared to Other Racial and Ethnic Groups.

(1) Background: The purpose of this exploratory study was to describe variation in age of onset of functional limitations of Native Hawaiian and Pacific Islanders (NHPI) compared to other racial and ethnic groups. (2) Methods: Adults age 45 years and older who responded to the Functioning and Disability module within the 2014 National Health Interview Survey (NHIS) were included (n = 628 NHPI; 7122 non-Hispanic Whites; 1418 Blacks; 470 Asians; and 1216 Hispanic adults). The NHIS Functioning and Disability module included 13 items, which we organized into three domains of functional limitations using factor analysis: Mobility, Gross Motor Skills, and Fine Motor Skills. Responses were summed within each domain. (3) Results: After adjusting for age and sex, we found that racial/ethnic minority groups, with the exception of Asians, experience more functional limitations than Whites. Results further indicate that NHPI adults experienced an earlier surge in all three domains of functional limitations compared to other racial/ethnic groups. (4) Conclusions: These findings are novel and provide additional evidence to the existence of disparities in functional health outcomes across racial/ethnic groups. Future studies are needed to develop targeted and culturally tailored interventions for those most in need.

Effects of Race and Poverty on Sleep Duration: Analysis of Patterns in the 2014 Native Hawaiian and Pacific Islander National Health Interview Survey and General National Health Interview Survey Data.

BACKGROUND: There are health concerns associated with unhealthy sleep duration. A growing body of evidence indicates that there are disparities in sleep duration based upon race/ethnicity and socioeconomic status. Prior studies have suffered from inadequate measures of poverty and have not included Native Hawaiians and Pacific Islanders (NHPI). METHODS: Using the 2014 National Health Interview Survey (NHIS) and the 2014 NHPI-NHIS, the effect of race/ethnicity and poverty was examined for associations with sleep duration. RESULTS: Significant differences among race/ethnicity groups and sleep duration were found in adjusted associations. Compared with Whites, NHPIs and Blacks were twice as likely to experience very short sleep; NHPI, Hispanic, and Blacks were more likely to experience short sleep; Blacks were also more likely to experience long sleep. Asians were less likely to experience unhealthy sleep (very short, short, or long sleep). Persons living in poverty were significantly more likely to experience very short sleep compared with persons not living in poverty. CONCLUSION: This is the first population-based study that has examined the relationship between sleep duration and poverty with a large sample that included NHPI in relation to other races/ethnicities. The difference in sleep duration between NHPI and Asians provides a strong rationale for not aggregating Asian and NHPI data in population-based studies.

Race, Nativity, and Sex Disparities in Human Papillomavirus Vaccination Among Young Adults in the USA.

Research has demonstrated that the human papillomavirus (HPV) vaccine is a safe and effective way to decrease HPV-related cervical cancers; however, the vaccination rate in the USA is suboptimal. The current study examined racial and ethnic disparities in HPV vaccination among a nationally representative sample, including Native Hawaiian and Pacific Islanders (NHPI). This study also investigated the associations between nativity and vaccination, and sex differences between race/ethnicity and vaccination and nativity and vaccination. A cross-sectional study was conducted with a sample of adults aged 18-26 years drawn from the 2014 NHPI National Health Interview Survey (n = 2590) and the general 2014 National Health Interview Survey (n = 36,697). Log-binomial models were fitted to examine differences in vaccination. There was a statistically significant racial/ethnic difference in HPV vaccination (p = 0.003). More women than men were vaccinated (41.8% vs. 10.1%) (p < 0.001). There was a significant difference in HPV vaccination based on nativity: 27.4% of adults aged 18 to 26 years who were born in the USA and 27.7% born in a US territory received the HPV vaccine compared with 14.3% among those not born in the USA or a US territory (p < 0.001). The association of HPV vaccination with nativity and race/ethnicity differed by sex and showed several nuanced differences. Overall, the prevalence of HPV vaccination was low. The study's findings demonstrate the need for public health strategies to increase vaccination rates among all populations, with the critical need to identify strategies that are effective for men, racial/ethnic minorities, and immigrant women born outside the USA.

Improving quality of life assessments for high-need adult Medicaid service users with mental health conditions.

PURPOSE: There is a lack of consensus on how to evaluate health and social service programs for people with mental health (MH) conditions. Having service users be the primary decision makers in selecting outcome measures can inform a meaningful evaluation strategy. We sought to identify the quality of life (QoL) survey preferences of high-need adult service users with MH conditions. METHODS: A systematic review identified generic, self-reported QoL surveys with evidence of validity in MH populations of interest. An advisory panel selected the most promising surveys to assess the success of programs like Medicaid for MH service users. Three groups of high-need, adult service users with MH conditions and one group of direct care staff ranked the surveys from the advisory panel, and generated and ranked characteristics that were desirable or undesirable in a QoL survey. RESULTS: Twenty-two surveys met the inclusion criteria. Of the six surveys selected by the advisory panel, groups of service users and direct care staff most preferred the Warwick-Edinburg Mental Well-being Scale (WEMWBS). The WEMWBS best embodied the features prioritized by the groups: to have a user-friendly format and positive focus, to be clearly worded and brief, and to avoid presumptive or unrealistic items. Service user groups appreciated survey topics most amenable to self-report, such as satisfaction with relationships. CONCLUSION: Using QoL surveys that service users prefer can reduce the chance that deteriorating QoL is going unchecked, and increase the chance that decisions based on survey findings are meaningful to service users.

Geographic Hotspots for Low Birthweight: An Analysis of Counties With Persistently High Rates.

This study evaluated persistency in county-level rates of low birthweight outcomes to identify "hotspot counties" and their associated area-level characteristics. Administrative data from the National Center for Health Statistics Birth Data Files, years 2011 to 2016 were used to calculate annual county-level rates of low birthweight. Counties ranking in the worst quintile (Q5) for ≥3 years with a neighboring county in the worst quintile were identified as hotspot counties. Multivariate logistic regression was used to associate county-level characteristics with hotspot designation. Adverse birth outcomes were persistent in poor performing counties, with 52% of counties in Q5 for low birthweight in 2011 remaining in Q5 in 2016. The rate of low birthweight among low birthweight hotspot counties (n = 495) was 1.6 times the rate of low birthweight among non-hotspot counties (9.3% vs 5.8%). The rate of very low birthweight among very low birthweight hotspot counties (n = 387) was twice as high compared to non-hotspot counties (1.8% vs 0.9%). A one standard deviation (6.5%) increase in the percentage of adults with at least a high school degree decreased the probability of low birthweight hotspot designation by 1.7 percentage points (P = .006). A one standard deviation (20%) increase in the percentage of the population that was of minority race/ethnicity increased hotspot designation for low birthweight by 5.7 percentage points (P < .001). Given the association between low birthweight and chronic conditions, hotspot counties should be a focus for policy makers in order to improve health equity across the life course.

County-level Variation in Low Birthweight and Preterm Birth: An Evaluation of State Medicaid Expansion Under the Affordable Care Act.

BACKGROUND: Rates of low birthweight and prematurity vary 2-fold across states in the United States, with increased rates among states with higher concentrations of racial minorities. Medicaid expansion may serve as a mechanism to reduce geographic variation within states that expanded, by improving health and access to care for vulnerable populations. OBJECTIVE: The objective of this study was to identify the association of Medicaid expansion with changes in county-level geographic variation in rates of low birthweight and preterm births, overall and stratified by race/ethnicity. RESEARCH DESIGN: We compared changes in the coefficient of variation and the ratio of the 80th-to-20th percentiles using bootstrap samples (n=1000) of counties drawn separately for all births and for white, black, and Hispanic births, separately. MEASURES: County-level rates of low birthweight and preterm birth. RESULTS: Before Medicaid expansion, counties in expansion states were concentrated among quintiles with lower rates of adverse birth outcomes and counties in nonexpansion states were concentrated among quintiles with higher rates. In expansion states, county-level variation, measured by the coefficient of variation, declined for both outcomes among all racial/ethnic categories. In nonexpansion states, geographic variation reduced for both outcomes among Hispanic births and for low birthweight among white births, but increased for both outcomes among black births. CONCLUSIONS: The decrease in county-level variation in adverse birth outcomes among expansion states suggests improved equity in these states. Further reduction in geographic variation will depend largely on policies or interventions that reduce racial disparities in states that did and did not expand Medicaid.

Effects of a family diabetes self-management education intervention on the patients' supporters.

INTRODUCTION: Diabetes self-management education (DSME) programs that engage the families of patients with diabetes have shown to be effective in improving diabetes-related outcomes of the patients. The health effects of these "family models" of DSME on participating family members are rarely studied. Opportunity exists for the participating family members to benefit from the healthy lifestyle recommendations offered through such programs. METHOD: Using data from a randomized controlled trial to assess the effect of family DSME compared to standard DSME among Marshallese adults with Type 2 diabetes, this study examined baseline to 12-month changes in A1c, body mass index (BMI), food consumption, and physical activity among participating family members, comparing outcomes of family members based on attended at least 1 (n = 98) versus attended no (n = 44) DSME sessions. RESULTS: Overall, family member attendance was low. There were no differences in the level of change from baseline to 12 months for A1c, BMI, food consumption, and physical activity between groups. After controlling for attendance and sociodemographic measures, lowering of BMI was the only significant predictor of not having an A1c level indicative of diabetes at 12 months. DISCUSSION: Future research on family DSME should consider ways to improve family member attendance; have them set their own health improvement goals; and integrate healthy lifestyle education, such as healthy eating and being physically active, along with the DSME core content to create an added benefit of diabetes prevention for participating family members. The limitations of this study and recommendations for future research are provided. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Are community health workers more effective in identifying persons in need of home and community-based long-term services than standard-passive approaches.

Consumers prefer home and community-based long-term care (LTC) services (HCBS) but lack information on those services. We examined the use of community health workers (CHWs) to find and help Medicaid beneficiaries with unmet LTC needs access HCBS compared to standard HCBS outreach approaches. We found that CHWs were very effective at finding persons with greater needs and were better able to help them access a greater range of HCBS services. We also found that five times fewer HCBS beneficiaries helped by CHWs had to use nursing home care services than those not helped by the CHWs despite the fact that their health status was poorer than those not helped by the CHWs. Our study provides evidence of the effectiveness of CHWs for HCBS service awareness and navigation.

Prevalence, Health and Resource Utilization, and Unmet Healthcare Needs of Native Hawaiian and Pacific Islander Children With Developmental Disabilities.

Little is known about health limitations and service utilization among the Native Hawaiian and Pacific Islander (NHPI) children with developmental disabilities (DDs) due to limited data. Our study examined the prevalence of DDs, health limitations, services used, and the unmet needs of NHPI children aged 3 to 17 years using cross-sectional data from the 2014 NHPI National Health Interview Survey. Results showed that prevalence of DDs among NHPI children was lower than American children of other races. DDs were negatively associated with health and functioning of NHPI children. There is a need to promote understanding of DDs among NHPI families and to inform public policy makers to identify appropriate intervention services for NHPI children.

Association of State Medicaid Expansion Status With Low Birth Weight and Preterm Birth.

Importance: Low birth weight and preterm birth are associated with adverse consequences including increased risk of infant mortality and chronic health conditions. Black infants are more likely than white infants to be born prematurely, which has been associated with disparities in infant mortality and other chronic conditions. Objective: To evaluate whether Medicaid expansion was associated with changes in rates of low birth weight and preterm birth outcomes, both overall and by race/ethnicity. Design, Setting, and Participants: Using US population-based data from the National Center for Health Statistics Birth Data Files (2011-2016), difference-in-differences (DID) and difference-in-difference-in-differences (DDD) models were estimated using multivariable linear probability regressions to compare birth outcomes among infants in Medicaid expansion states relative to non-Medicaid expansion states and changes in relative disparities among racial/ethnic minorities for singleton live births to women aged 19 years and older. Exposures: State Medicaid expansion status and racial/ethnic category. Main Outcomes and Measures: Preterm birth (<37 weeks' gestation), very preterm birth (<32 weeks' gestation), low birth weight (<2500 g), and very low birth weight (<1500 g). Results: The final sample of 15 631 174 births (white infants: 8 244 924, black infants: 2 201 658, and Hispanic infants: 3 944 665) came from the District of Columbia and 18 states that expanded Medicaid (n = 8 530 751) and 17 states that did not (n = 7 100 423). In the DID analyses, there were no significant changes in preterm birth in expansion relative to nonexpansion states (preexpansion to postexpansion period, 6.80% to 6.67% [difference: -0.12] vs 7.86% to 7.78% [difference: -0.08]; adjusted DID: 0.00 percentage points [95% CI, -0.14 to 0.15], P = .98), very preterm birth (0.87% to 0.83% [difference: -0.04] vs 1.02% to 1.03% [difference: 0.01]; adjusted DID: -0.02 percentage points [95% CI, -0.05 to 0.02], P = .37), low birth weight (5.41% to 5.36% [difference: -0.05] vs 6.06% to 6.18% [difference: 0.11]; adjusted DID: -0.08 percentage points [95% CI, -0.20 to 0.04], P = .20), or very low birth weight (0.76% to 0.72% [difference: -0.03] vs 0.88% to 0.90% [difference: 0.02]; adjusted DID: -0.03 percentage points [95% CI, -0.06 to 0.01], P = .14). Disparities for black infants relative to white infants in Medicaid expansion states compared with nonexpansion states declined for all 4 outcomes, indicated by a negative DDD coefficient for preterm birth (-0.43 percentage points [95% CI, -0.84 to -0.02], P = .05), very preterm birth (-0.14 percentage points [95% CI, -0.26 to -0.02], P = .03), low birth weight (-0.53 percentage points [95% CI, -0.96 to -0.10], P = .02), and very low birth weight (-0.13 percentage points [95% CI, -0.25 to -0.01], P = .04). There were no changes in relative disparities for Hispanic infants. Conclusions and Relevance: Based on data from 2011-2016, state Medicaid expansion was not significantly associated with differences in rates of low birth weight or preterm birth outcomes overall, although there were significant improvements in relative disparities for black infants compared with white infants in states that expanded Medicaid vs those that did not.

Impact of Economic Constraints on Public Health Delivery Systems Structures.

OBJECTIVES: We estimated the effect of economic constraints on public health delivery systems (PHDS) density and centrality during 3 time periods, 1998, 2006, and 2012. METHODS: We obtained data from the 1998, 2006, and 2012 National Longitudinal Study of Public Health Agencies; the 1993, 1997, 2005, and 2010 National Association for County and City Health Officials Profile Study; and the 1997, 2008, and 2011 Area Resource Files. We used multivariate regression models for panel data to estimate the impact of economic constraints on PHDS density and centrality. RESULTS: Findings indicate that economic constraints did not have a significant impact on PHDS density and centrality over time but population is a significant predictor of PHDS density, and the presence of a board of health (BOH) is a significant predictor of PHDS density and centrality. Specifically, a 1% increase in population results in a significant 1.71% increase in PHDS density. The presence of a BOH is associated with a 10.2% increase in PHDS centrality, after controlling for other factors. CONCLUSIONS: These findings suggest that other noneconomic factors influence PHDS density centrality.