Reducing tobacco use in substance use treatment: The California tobacco free initiative.

BACKGROUND: People in substance use disorder (SUD) treatment have a smoking prevalence that is five times higher than the national average. California funded the Tobacco Free for Recovery Initiative, designed to support programs in implementing tobacco-free grounds and increasing smoking cessation services. In the first cohort of the initiative (2018-2020) client smoking prevalence decreased from 54.2% to 26.6%. The current study examined whether similar findings would be replicated with a later cohort of programs (2020-2022). METHOD: Cross-sectional survey data were collected from clients in 11 residential SUD treatment programs at baseline (n = 185) and at post intervention (n = 227). Multivariate logistic regression assessed change over time in smoking prevalence, tobacco use behaviors, and receipt of cessation services across the two timepoints. RESULTS: Client smoking prevalence decreased from 60.3 % to 40.5 % (Adjusted Odds Ratio [AOR] = 0.46, 95 % CI = 0.27, 0.78; p = 0.004). Current smokers and those who quit while in treatment reported an increase in nicotine replacement therapy (NRT)/pharmacotherapy from baseline to post intervention (31.9 % vs 45.6 %; AOR = 2.22, 95 % CI = 1.08, 4.58; p = 0.031). CONCLUSIONS: Like the first cohort, the Tobacco Free for Recovery initiative was associated with decreased client smoking prevalence and an increase in NRT/pharmacotherapy. These findings strengthen the evidence that similar initiatives may be effective in reducing smoking prevalence among people in SUD treatment.

Impact of being underweight before pregnancy on preterm birth by race/ethnicity and insurance status in California: an analysis of birth records.

BACKGROUND: The US still has a high burden of preterm birth (PTB), with important disparities by race/ethnicity and poverty status. There is a large body of literature looking at the impact of pre-pregnancy obesity on PTB, but fewer studies have explored the association between underweight status on PTB, especially with a lens toward health disparities. Furthermore, little is known about how weight, specifically pre-pregnancy underweight status, and socio-economic-demographic factors such as race/ethnicity and insurance status, interact with each other to contribute to risks of PTB. OBJECTIVES: The objective of this study was to measure the association between pre-pregnancy underweight and PTB and small for gestational age (SGA) among a large sample of births in the US. Our secondary objective was to see if underweight status and two markers of health disparities - race/ethnicity and insurance status (public vs. other) - on PTB. STUDY DESIGN: We used data from all births in California from 2011 to 2017, which resulted in 3,070,241 singleton births with linked hospital discharge records. We ran regression models to estimate the relative risk of PTB by underweight status, by race/ethnicity, and by poverty (Medi-cal status). We then looked at the interaction between underweight status and race/ethnicity and underweight and poverty on PTB. RESULTS: Black and Asian women were more likely to be underweight (aRR = 1.0, 95% CI: 1.01, 1.1 and aRR = 1.4, 95% CI: 1.4, 1.5, respectively), and Latina women were less likely to be underweight (aRR = 0.7, 95% CI: 0.7, 0.7). Being underweight was associated with increased odds of PTB (aRR = 1.3, 95% CI 1.3-1.3) and, after controlling for underweight, all nonwhite race/ethnic groups had increased odds of PTB compared to white women. In interaction models, the combined effect of being both underweight and Black, Indigenous and People of Color (BIPOC) statistically significantly reduced the relative risk of PTB (aRR = 0.9, 95% CI: 0.8, 0.9) and SGA (aRR = 1.0, 95% CI: 0.9, 1.0). The combined effect of being both underweight and on public insurance increased the relative risk of PTB (aRR = 1.1, 95% CI: 1.1, 1.2) but there was no additional effect of being both underweight and on public insurance on SGA (aRR = 1.0, 95% CI: 1.0, 1.0). CONCLUSIONS: We confirm and build upon previous findings that being underweight preconception is associated with increased risk of PTB and SGA - a fact often overlooked in the focus on overweight and adverse birth outcomes. Additionally, our findings suggest that the effect of being underweight on PTB and SGA differs by race/ethnicity and by insurance status, emphasizing that other factors related to inequities in access to health care and poverty are contributing to disparities in PTB.

Community-acquired Staphylococcus aureus skin and soft tissue infection risk assessment using hotspot analysis and risk maps: the case of California emergency departments.

BACKGROUND: Community-acquired Staphylococcus aureus (CA-Sa) skin and soft tissue infections (SSTIs) are historically associated with densely populated urban areas experiencing high poverty rates, intravenous drug use, and homelessness. However, the epidemiology of CA-Sa SSTIs in the United States has been poorly understood since the plateau of the Community-acquired Methicillin-resistant Staphylococcus aureus epidemic in 2010. This study examines the spatial variation of CA-Sa SSTIs in a large, geographically heterogeneous population and identifies neighborhood characteristics associated with increased infection risk. METHODS: Using a unique neighborhood boundary, California Medical Service Study Areas, a hotspot analysis, and estimates of neighborhood infection risk ratios were conducted for all CA-Sa SSTIs presented in non-Federal California emergency departments between 2016 and 2019. A Bayesian Poisson regression model evaluated the association between neighborhood-level infection risk and population structure, neighborhood poverty rates, and being a healthcare shortage area. RESULTS: Emergency departments in more rural and mountainous parts of California experienced a higher burden of CA-Sa SSTIs between 2016 and 2019. Neighborhoods with high infection rates were more likely to have a high percentage of adults living below the federal poverty level and be a designated healthcare shortage area. Measures of population structure were not associated with infection risk in California neighborhoods. CONCLUSIONS: Our results highlight a potential change in the epidemiology of CA-Sa SSTIs in California emergency departments. Future studies should investigate the CA-Sa burden in other geographies to identify whether this shift in epidemiology holds across other states and populations. Further, a more thorough evaluation of potential mechanisms for the clustering of infections seen across California neighborhoods is needed.

Sexual and Gender Identity Disparities in Nicotine and Tobacco Use Susceptibility and Prevalence: Disaggregating Emerging Identities Among Adolescents From California, USA.

INTRODUCTION: Prior studies report nicotine/tobacco use disparities for sexual and gender minority (SGM) youth but have insufficiently characterized SGM identity diversity. AIMS AND METHODS: Adolescents (mean age = 15.2) from 11 high schools in Southern California completed surveys in Fall 2021. Ever use of combustible (cigarettes, cigars, hookah) and noncombustible (e-cigarettes, e-hookah, heated tobacco, smokeless/snus, oral nicotine) nicotine/tobacco (among overall sample, n = 3795) and susceptibility to future initiation of cigarettes, e-cigarettes, and flavored non-tobacco oral nicotine (among n = 3331 tobacco-naïve youth) were compared across four gender (male/masculine, female/feminine, transgender male/female, non-binary) and seven sexual (heterosexual, bisexual, pansexual, queer, questioning, gay/lesbian, asexual) identities. RESULTS: Non-binary (vs. cisgender male) youth had greater prevalence of ever combustible (prevalence ratio [PR] = 2.86, 95% confidence intervals (CI): 1.76 to 4.66) and non-combustible (PR = 1.94, 95% CI: 1.31 to 2.86) nicotine/tobacco use, and susceptibility to future nicotine/tobacco initiation (PR range = 2.32-2.68). Transgender (vs. cisgender male) youth had greater susceptibility to nicotine/tobacco use (PR range = 1.73-1.95), but not greater tobacco use prevalence. There was greater prevalence of non-combustible nicotine/tobacco use (PR range = 1.78-1.97) and susceptibility to nicotine/tobacco initiation (PR range = 1.36-2.18) for all sexual minority (vs. heterosexual) identities, except for asexual. Bisexual (PR = 2.03, 95% CI: 1.30 to 3.16) and queer (PR = 2.87, 95% CI: 1.31 to 6.27) youth had higher ever combustible tobacco use than heterosexual youth. Questioning (vs. heterosexual) youth were more susceptible to future tobacco initiation (PR range = 1.36-2.05) but did not differ in ever use. CONCLUSIONS: Disparities in nicotine/tobacco use and susceptibility were present with similar effect sizes across most, but not all, SGM identities. Inclusive measurement of SGM identities in research and surveillance may inform more precise tobacco control efforts to reduce disparities. IMPLICATIONS: Among high school students from Southern California with substantial diversity in sexual and gender identities, there was greater prevalence of tobacco use and susceptibility to future tobacco initiation for most, but not all, sexual and gender minority youth, including those with emerging sexual and gender identities such as non-binary, queer and pansexual. Additionally, findings indicate that tobacco control initiatives targeting youth who are questioning their sexual identities may be particularly important for preventing tobacco use initiation. This study reinforces the importance of measuring diversity within the LGBTQ + community for tobacco use research, and highlights how inclusive measurement can inform more precise tobacco control interventions.

Comparison of record linkage software for deduplicating patient identities in California's Prescription Drug Monitoring Program.

BACKGROUND: To help prevent overdose deaths involving prescription drugs, accurate linkage of prescription drug monitoring program (PDMP) records for individual patients is essential. OBJECTIVES: To compare the accuracy of the linkage program used by California's PDMP against various record linkage programs with respect to accuracy in deduplicating patient identities in the PDMP, with implications for identifying high-risk opioid use and outlier behaviors. RESEARCH DESIGN: We evaluated California's program, Link Plus, LinkSolv, and The Link King on 557 861 PDMP identity records with addresses in two 3-digit zip code areas for patients who filled a controlled substance prescription in 2013. Manual review was performed on a stratified sample of 720 paired records identified as matches by at least one program. MEASURES: We estimated sensitivity and positive predictive value, and computed PDMP patient alerts for the patient entities identified by each program. RESULTS: Sensitivity was 95% for LinkSolv and The Link King, 84% for Link Plus, and 73% for California's program; positive predictive value was ≥93% for all programs. The number of patient entities prompting a PDMP alert was similar among the programs for all alerts except multiple provider episodes (obtaining prescriptions from ≥6 prescribers or ≥6 pharmacies in the last 6 months), which were 10.9%, 26.6%, and 16.9% greater using The Link King, Link Plus, and LinkSolv, respectively, compared to California's program. CONCLUSIONS: PDMPs should assess the accuracy of record linkage algorithms and the impacts of these algorithms on patient safety alerts and develop national best practices for PDMP record linkage.

Racial and Economic Segregation Over the Life Course and Incident Hypertensive Disorders of Pregnancy Among Black Women in California.

Black women in the United States have the highest incidence of hypertensive disorders of pregnancy (HDP) and are disproportionately burdened by its adverse sequalae, compared with women of all racial and ethnic groups. Segregation, a key driver of structural racism for Black families, can provide information critical to understanding these disparities. We examined the association between racial and economic segregation at 2 points and incident HDP using intergenerationally linked birth records of 45,204 Black California-born primiparous mothers (born 1982-1997) and their infants (born 1997-2011), with HDP ascertained from hospital discharge records. Women's early childhood and adulthood neighborhoods were categorized as deprived, mixed, or privileged based on the Index of Concentration at the Extremes (a measure of concentrated racial and economic segregation), yielding 9 life-course trajectories. Women living in deprived neighborhoods at both time points experienced the highest odds of HDP (from mixed effect logistic regression, unadjusted odds ratio = 1.26, 95% confidence interval: 1.13, 1.40) compared with women living in privileged neighborhoods at both time points. All trajectories involving residence in a deprived neighborhood in early childhood or adulthood were associated with increased odds of HDP, whereas mixed-privileged and privileged-mixed trajectories were not. Future studies should assess the causal nature of these associations.

A cross-sectional study on social determinants of mental health during COVID-19 among adults in California.

AIM: To explore the impact of structural and intermediary social determinants of health (SDoH) on Californian adults' mental health during the early phase of the COVID-19 pandemic. DESIGN: This cross-sectional study used data from the 2020 cycle of the California Health Interview Survey, the largest US state-level population health survey. METHODS: Descriptive statistics and logistic regression were used to analyse the data. Using a general social determinant of health framework, we operationalized different survey questions to measure structural and intermediary determinants of mental health. RESULTS: Mental health during the early phase of COVID-19 among adults in California was associated with age, gender, health conditions, delayed care, employment status (loss of job or reduced income) and discrimination. People in higher social strata were more likely to have better mental health for many of these factors. CONCLUSION: This study supports the assertion that material circumstances (such as employment status) and discrimination are associated with experiencing mental health issues among adults in California during COVID-19. Racism is a public health issue, and as nurses, addressing racism is critical. In addition, much work is needed to address SDoH to improve health outcomes, especially among marginalized populations. IMPACT: This study addressed the knowledge gap concerning the social determinants of mental health among Californian adults during the early phase of the COVID-19 pandemic. Those who had reduced income and those who lost their jobs during the COVID-19 pandemic were 46% and 56%, respectively, more likely to report mental health problems. Those who experienced discrimination in healthcare were 304% more likely to report mental health issues. This research will increase the understanding of the social determinants of health, particularly for those with chronic illnesses and mental health issues during the COVID-19 pandemic. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as we used an existing US state dataset. However, California Health Interview Survey is the largest state health survey in the United States and interviews more than 20,000 households each year representing the health care needs of Californians.

An Observational Study Quantifying the Disproportionate Impact of COVID-19 Among Immigrant Adults, 2021 California Health Interview Survey.

OBJECTIVE: Substantial data on COVID-19-related morbidity and mortality among medically underserved populations are available, yet data on the social impact of the COVID-19 pandemic among immigrants in the United States are limited. We identified COVID-19-related health and social disparities among US immigrants. METHODS: We analyzed predictors of COVID-19-related health and social outcomes (including ever had or thought had COVID-19, vaccine uptake, risk-reduction behaviors, job loss, childcare difficulties, and difficulty paying rent) during the pandemic by citizenship status, using data from the 2021 California Health Interview Survey. The overall sample size included 24 453 US-born citizens, naturalized citizens, and noncitizens aged ≥18 years. We examined relationships between sociodemographic variables, including immigration-related factors, and COVID-19-related health and social outcomes using descriptive, bivariate, and multivariate logistic regression analysis. RESULTS: When accounting for sociodemographic characteristics, noncitizens had higher odds than naturalized and US-born citizens of experiencing challenges during the COVID-19 pandemic, including difficulty paying rent (adjusted odds ratio [aOR] = 1.54; 95% CI, 1.47-2.42) and job loss (aOR = 1.43; 95%, CI, 1.14-1.79). At the bivariate level, noncitizens had the highest rate of ever had or thought had COVID-19 (24.7%) compared with US-born citizens (20.8%) and naturalized citizens (16.8%; all P < .001). Noncitizens also had a significantly higher likelihood of risk-reduction behaviors (eg, always wearing a face covering, getting vaccinated if available) than US-born citizens (P < .001). CONCLUSION: These findings reveal the disproportionate impact of the COVID-19 pandemic among noncitizens and reflect limited socioeconomic resources, limited access to health care, and precarious employment among noncitizens in California during the pandemic. Citizenship status should be considered a critical immigration-related factor when examining disparities among immigrant populations.

Prevalence and Severity of Glaucoma in the California Medicare Population.

PURPOSE: To examine the prevalence of glaucoma by type and severity in the 2019 California (CA) Medicare population, and to identify associated demographic and systemic factors. DESIGN: Retrospective cross-sectional design. METHODS: The study population included all 2019 CA Medicare beneficiaries ≥65 years of age with Part A and Part B coverage. Outcomes included prevalence of any glaucoma, primary open angle glaucoma (POAG), secondary open angle glaucoma (SOAG), and angle closure glaucoma (ACG). Covariates included age, sex, race and ethnicity, Charlson Comorbidity Index (CCI) score, pseudophakia, and age-related macular degeneration. Logistic regression modeling was used to examine multivariable predictors of each type of glaucoma. RESULTS: Of 5,856,491 beneficiaries in the 2019 California Medicare population, there were 220,662 (3.8%) with any glaucoma, 171,988 (2.9%) with POAG, 8,827 (0.2%) with SOAG, and 12,978 (0.2%) with ACG. The largest proportion of beneficiaries had moderate to severe glaucoma (68,553 of 220,662 [31.0%] for any glaucoma moderate stage, 3,168 of 12,978 [24.4%] for ACG severe stage). Multivariable predictors of any glaucoma included age ≥85 years vs 65 to 69 years (adjusted odds ratio [aOR] = 2.03, 95% CI = 2.00, 2.06), female vs male sex (aOR = 1.03, 95% CI = 1.02, 1.04), Black vs non-Hispanic White race and ethnicity (aOR = 1.70, 95% CI = 1.67, 1.73), and CCI ≥5 vs 0 (aOR = 5.59, 95% = 5.51, 5.67). CONCLUSIONS: In the 2019 CA Medicare population, multiple demographic and systemic factors were associated with increased likelihood of glaucoma, and beneficiaries with glaucoma had a high prevalence of moderate to severe disease. Strategies are needed to improve early screening and diagnosis for elderly individuals at risk for glaucoma in California.

Temporal Trends in Early Pediatric Cochlear Implantations in California from 2018 to 2020.

OBJECTIVE: To characterize the demographics of children receiving cochlear implantations, identify factors associated with delayed implantations, and trend these factors over time. DESIGN: Retrospective cross-sectional study. SETTING: Healthcare Cost and Utilization Project California State Ambulatory Surgery Database for calendar years 2018-2020. PATIENTS: Children 5 years or younger undergoing cochlear implantation. INTERVENTIONS: Cochlear implantation. MAIN OUTCOMES MEASURES: The population-controlled number of cochlear implantations was calculated and stratified by race and insurance. Early implantation was defined as implantation at age 2 years or younger. A mixed-effects logistic regression model was generated to identify factors associated with early implantation and how that association changed from 2018 to 2020. RESULTS: The final cohort included 467 children. The number of implantations increased from 141 to 175 implants from 2018 to 2020 (24.1% increase); 229 (49.0%) children were implanted at 2 years or younger. Medicaid insurance was associated with decreased odds of early implantation (odds ratio, 0.18 [95% confidence interval, 0.15-0.23], p < 0.001); this association with Medicaid insurance was significant when stratified across all racial groups. The percentage of children with Medicaid who were implanted at 2 years or younger increased from 20.9 to 62.0% from 2018 to 2020. CONCLUSIONS AND RELEVANCE: Among children in California, socioeconomic factors, in particular public insurance, are correlated with age of cochlear implantation. These disparities improved significantly from 2018 to 2020. Further investigation into changes and initiatives in California during this time frame may aid in directing national efforts to improve pediatric cochlear implantation access.

Survival outcomes for lung neuroendocrine tumors in California differ by sociodemographic factors.

Lung neuroendocrine tumors (NETs) have few known predictors of survival. We investigated associations of sociodemographic, clinicopathologic, and treatment factors with overall survival (OS) and lung cancer-specific survival (LCSS) for incident lung NET cases (typical or atypical histology) in the California Cancer Registry (CCR) from 1992 to 2019. OS was estimated with the Kaplan-Meier method and compared by sociodemographic and disease factors univariately with the log-rank test. We used sequential Cox proportional hazards regression for multivariable OS analysis. LCSS was estimated using Fine-Gray competing risks regression. There were 6038 lung NET diagnoses (5569 typical, 469 atypical carcinoid); most were women (70%) and non-Hispanic White (73%). In our multivariable model, sociodemographic factors were independently associated with OS, with better survival for women (hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.57-0.68, P < 0.001), married (HR 0.76, 95% CI 0.70-0.84, P < 0.001), and residents of high socioeconomic status (SES) neighborhoods (HRQ5vsQ1 0.73, 95% CI 0.62-0.85, P < 0.001). Compared to cases with private insurance, OS was worse for cases with Medicare (HR 1.24, 95% CI 1.10-1.40, P < 0.001) or Medicaid/other public insurance (HR 1.45, 95% CI 1.24-1.68, P < 0.001). In our univariate model, non-Hispanic Black Californians had worse OS than other racial/ethnic groups, but differences attenuated after adjusting for stage at diagnosis. In our LCSS models, we found similar associations between sex and marital status on survival, but no differences in outcomes by SES or insurance. By race/ethnicity, American Indian cases had worse LCSS. In summary, beyond disease-related and treatment variables, sociodemographic factors were independently associated with survival in lung NETs.

Disparities among Black and Hispanic colorectal cancer patients: Findings from the California Cancer Registry.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in California and second among Hispanic/Latinx (H/L) males. Data from the California Cancer Registry were utilized to investigate the differential impact on CRC outcomes from demographic and clinical characteristics among non-Hispanic white (NHW), non-Hispanic Black (NHB), U.S. born (USB), and non-U.S. born (NUSB) H/L patients diagnosed during 1995-2020. METHODS: We identified 248,238 NHW, 28,433 NHB, and 62,747 H/L cases (32,402 NUSB and 30,345 USB). Disparities across groups were evaluated through case frequencies, odds ratios (OR) from logistic regression, and hazard ratios (HR) from Cox regression models. All statistical tests were two-sided. RESULTS: NHB patients showed a higher proportion of colon tumors (75.8%) than NHW (71.5%), whereas both NUSB (65.9%) and USB (66.9%) H/L cases had less (p < 0.001). In multivariate models, NUSB H/L cases were 15% more likely than NHW to have rectal cancer. Compared to NHW, NHB cases had the greatest proportion of Stage IV diagnoses (26.0%) and were more likely to die of CRC (multivariate HR = 1.12; 95% CI = 1.10-1.15). Instead, NUSB H/L patients were less likely to die of CRC (multivariate HR = 0.87; 95% CI = 0.85-0.89) whereas USB H/L did not differ from NHW. CONCLUSIONS: NHB and H/L cases have more adverse characteristics at diagnosis compared to NHW cases, with NHB cases being more likely to die from CRC. However, NUSB H/Ls cases showed better survival than NHW and US born H/L patients. These findings highlight the importance of considering nativity among H/L populations to understand cancer disparities.

Estimating the effect of timing of earned income tax credit refunds on perinatal outcomes: a quasi-experimental study of California births.

BACKGROUND: The largest poverty alleviation program in the US is the earned income tax credit (EITC), providing $60 billion to over 25 million families annually. While research has shown positive impacts of EITC receipt in pregnancy, there is little evidence on whether the timing of receipt may lead to differences in pregnancy outcomes. We used a quasi-experimental difference-in-differences design, taking advantage of EITC tax disbursement each spring to examine whether trimester of receipt was associated with perinatal outcomes. METHODS: We conducted a difference-in-differences analysis of California linked birth certificate and hospital discharge records. The sample was drawn from the linked CA birth certificate and discharge records from 2007-2012 (N = 2,740,707). To predict eligibility, we created a probabilistic algorithm in the Panel Study of Income Dynamics and applied it to the CA data. Primary outcome measures included preterm birth, small-for-gestational age (SGA), gestational diabetes, and gestational hypertension/preeclampsia. RESULTS: Eligibility for EITC receipt during the third trimester was associated with a lower risk of preterm birth compared with preconception. Eligibility for receipt in the preconception period resulted in improved gestational hypertension and SGA. CONCLUSION: This analysis offers a novel method to impute EITC eligibility using a probabilistic algorithm in a data set with richer sociodemographic information relative to the clinical and administrative data sets from which outcomes are drawn. These results could be used to determine the optimal intervention time point for future income supplementation policies. Future work should examine frequent income supplementation such as the minimum wage or basic income programs.

Kindergarten Vaccination Status in California After Changes to Medical Exemption Policy.

This study evaluates changes in medical exemptions and geographic distribution of kindergarteners in California not up to date on vaccination after changes to state legislation.

Variation in rates of sexual assault crisis counsellor usage during forensic examination in California: an observational study.

OBJECTIVES: A critical asset to post-assault care of survivors is support from sexual assault crisis counsellors (SACCs). We sought to elucidate variation in implementation between California counties in SACC accompaniment during Sexual Assault Forensic Examination (SAFE). METHODS: SACC attendance data from 2019 was obtained from the California Governor's Office of Emergency Services (CalOES). To assess SACC attendance rates during SAFEs, we requested SAFE quantity data from sheriffs and public health departments, the State Forensic Bureau, and the California Department of Justice (DOJ), but all requests were unanswered or denied. We also sought SAFE data from District Attorneys (DAs) in each county, and received responses from Marin and Contra Costa Counties. To estimate numbers of SAFEs per county, we gathered crime statistics from the Federal Bureau of Investigation's (FBI's) Uniform Crime Reporting Program and OpenJustice, a transparency initiative by the California DOJ. For each data source, we compared SACC attendance to SAFE quantities and incidences of sexual assault statewide. RESULTS: At the state level, data on SACC attendance per CalOES and DOJ archival data on sexual assault were used to approximate relative rates of SACC accompaniment at SAFEs; 83% (30 of 36) of counties had values <50%. The joint sexual assault crisis centre for Contra Costa and Marin Counties reported that 140 SACCs were dispatched in 2019, while DAs in Contra Costa and Marin reported completion of 87 SAFEs in 2019, for a calculated SACC accompaniment rate of 161%. Proxy data sourced from FBI and DOJ crime statistics displayed significant inconsistencies, and DOJ data was internally inconsistent. CONCLUSIONS: SACC accompaniment at SAFEs appears to be low in most California counties, however, limited data accessibility and data discrepancies and inaccuracies (e.g., rates over 100%) prevented reliable determination of SACC accompaniment rates during SAFEs. Substantial improvements in data accuracy and transparency are needed to ensure survivors' adequate access to resources.

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach.

BACKGROUND: Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. METHODS: This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. RESULTS: Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. CONCLUSIONS: Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Neighborhood gentrification, displacement, and severe maternal morbidity in California.

Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.

Temporal assessment of disparities in California COVID-19 mortality by industry: a population-based retrospective cohort study.

PURPOSE: To assess changes in the COVID-19 mortality rate and disparities over variants or waves by industry. METHODS: We identified COVID-19 deaths that occurred between January 2020 and May 2022 among California workers aged 18-64 years using death certificates, and estimated Californians at risk using the Current Population Survey. The waves in deaths were wave 1: March-June 2020, wave 2: July-November 2020, wave 3/Epsilon and Alpha variants: December 2020-May 2021, wave 4/Delta variant: June 2021-January 2022, and wave 5/Omicron variant: February-May 2022. We used Poisson regression to generate wave-specific mortality rate ratios (MRR) and included an interaction term between industry and wave in different models to assess significance of the change in MRR. RESULTS: In all waves of the pandemic, healthcare, other services, manufacturing, transportation, and retail trade industries had higher mortality rates than the professional, scientific, and technical industry. The healthcare industry had the highest relative rate earlier in the pandemic, while other services, utilities, and accommodation and food services industries had substantial increases in MRR in later waves. CONCLUSIONS: Industries that consistently had disproportionate COVID-19 mortality may have benefitted from protections that consider workers' increased exposure and vulnerability to severe outcomes.