By-degree Health and Economic Impacts of Lyme Disease, Eastern and Midwestern United States.

Lyme disease (LD) is the most common vector-borne disease in the United States (U.S.). This paper assesses how climate change may influence LD incidence in the eastern and upper Midwestern U.S. and the associated economic burden. We estimated future Ixodes scapularis habitat suitability and LD incidence with a by-degree approach using variables from an ensemble of multiple climate models. We then applied estimates for present-day and projected habitat suitability for I. scapularis, present-day presence of Borrelia burgdorferi, and projected climatological variables to model reported LD incidence at the county level among adults, children, and the total population. Finally, we applied an estimate of healthcare expenses to project economic impacts. We show an overall increase in LD cases with regional variation. We estimate an increase in incidence in New England and the upper Midwestern U.S. and a concurrent decrease in incidence in Virginia and North Carolina. At 3°C of national warming from the 1986-2015 baseline climate, we project approximately 55,000 LD cases, a 38-percent increase from present-day estimates. At 6°C of warming, our most extreme scenario, we project approximately 92,000 LD cases in the region, an increase of 145 percent relative to current levels. Annual LD-related healthcare expenses at 3°C of warming are estimated to be $236 million (2021 dollars), approximately 38 percent greater than present-day. These results may inform decision-makers tasked with addressing climate risks, the public, and healthcare professionals preparing for treatment and prevention of LD.

The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes.

AIMS: While several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease. METHODS: We used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables. RESULTS: Our calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes. CONCLUSIONS: There is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.

The impact of COVID-19 on patient safety attendant use.

ABSTRACT: Patient safety attendants (PSAs) provide constant direct observation to patients who have cognitive impairments or thoughts. Some estimates report that an acute care hospital in the United States may spend more than $1 million annually on PSAs, an expenditure often not reimbursed. With no national defined standards to regulate or monitor PSA use, this study sought to determine the impact of COVID-19 on a PSA reduction program in a large Midwestern healthcare system.

Race, Ethnicity, Neighborhood Characteristics, and In-Hospital Coronavirus Disease-2019 Mortality.

BACKGROUND: Despite many studies reporting disparities in coronavirus disease-2019 (COVID-19) incidence and outcomes in Black and Hispanic/Latino populations, mechanisms are not fully understood to inform mitigation strategies. OBJECTIVE: The aim was to test whether neighborhood factors beyond individual patient-level factors are associated with in-hospital mortality from COVID-19. We hypothesized that the Area Deprivation Index (ADI), a neighborhood census-block-level composite measure, was associated with COVID-19 mortality independently of race, ethnicity, and other patient factors. RESEARCH DESIGN: Multicenter retrospective cohort study examining COVID-19 in-hospital mortality. SUBJECTS: Inclusion required hospitalization with positive SARS-CoV-2 test or COVID-19 diagnosis at three large Midwestern academic centers. MEASURES: The primary study outcome was COVID-19 in-hospital mortality. Patient-level predictors included age, sex, race, insurance, body mass index, comorbidities, and ventilation. Neighborhoods were examined through the national ADI neighborhood deprivation rank comparing in-hospital mortality across ADI quintiles. Analyses used multivariable logistic regression with fixed site effects. RESULTS: Among 5999 COVID-19 patients median age was 61 (interquartile range: 44-73), 48% were male, 30% Black, and 10.8% died. Among patients who died, 32% lived in the most disadvantaged quintile while 11% lived in the least disadvantaged quintile; 52% of Black, 24% of Hispanic/Latino, and 8.5% of White patients lived in the most disadvantaged neighborhoods.Living in the most disadvantaged neighborhood quintile predicted higher mortality (adjusted odds ratio: 1.74; 95% confidence interval: 1.13-2.67) independent of race. Age, male sex, Medicare coverage, and ventilation also predicted mortality. CONCLUSIONS: Neighborhood disadvantage independently predicted in-hospital COVID-19 mortality. Findings support calls to consider neighborhood measures for vaccine distribution and policies to mitigate disparities.

What Industrial Categories Are Workers at Excess Risk of Filing a COVID-19 Workers' Compensation Claim? A Study Conducted in 11 Midwestern US States.

OBJECTIVE: Determine the industries with the highest proportion of accepted COVID-19 related workers' compensation (WC) claims. METHODS: Study included 21,336 WC claims (1898 COVID-19 and 19,438 other claims) that were filed between January 1, 2020 and August 31, 2020 from 11 states in the Midwest United States. RESULT: The overwhelming proportion of all COVID-19 related WC claims submitted and accepted were from healthcare workers (83.77%). Healthcare was the only industrial classification that was at significantly higher COVID-19 WC claim submission risk (odds ratio [OR]: 4.00; 95% confidence intervals [CI]: 2.77 to 5.79) controlling for type of employment, sex, age, and presumption of COVID-19 work-relatedness. Within healthcare employment, WC claims submitted by workers in medical laboratories had the highest risk (crude rate ratio of 8.78). CONCLUSION: Healthcare employment is associated with an increased risk of developing COVID-19 infections and submitting a workers' compensation claim.

Neighborhood Deprivation and Racial/Ethnic Disparities in Human Immunodeficiency Virus Viral Suppression: A Single-center, Cross-sectional Study in the United States Midwest.

Combating disparities is a crucial goal of ongoing efforts to end the human immunodeficiency virus (HIV) epidemic. In a multivariable analysis of a cohort in the Midwestern United States, racial/ethnic disparities in HIV viral suppression were no longer robust after accounting for other sociodemographic factors. Neighborhood deprivation and low income were independently inversely associated with viral suppression.

High Blood Pressure Medication Adherence Among Urban, African Americans in the Midwest United States.

Hypertension is a chronic condition that disproportionately affects African Americans. Managing high blood pressure (HBP) requires adherence to daily medication. However, many patients with hypertension take their HBP medication inconsistently, putting them at heightened risk of heart disease. Researchers have shown that these health risks are greater for African Americans than for Caucasians. In this article, we examine barriers and facilitators of medication adherence among urban African Americans with hypertension. We interviewed 24 African Americans with hypertension (58.5% women, average age 59.5 years) and conducted a comprehensive thematic analysis. Twenty-two barriers and 32 facilitators to medication adherence emerged. Barriers included side effects and forgetting while facilitators included reminders, routines, and social support. Using this data, we developed a diagram of theme connectedness of factors that affect medication adherence. This diagram can guide multi-level HBP intervention research that targets African Americans to promote medication adherence, prevent heart disease, and reduce ethnic and racial health disparities.

Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System.

AIMS: Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system. METHODS: We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy. RESULTS: Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy. CONCLUSION: Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.

Human Papillomavirus Vaccination Estimates Among Adolescents in the Mississippi Delta Region: National Immunization Survey­Teen, 2015-2017.

INTRODUCTION: The Delta Regional Authority (DRA) consists of 252 counties and parishes in 8 states in the US Mississippi Delta region. DRA areas have high rates of disease, including cancers related to the human papillomavirus (HPV). HPV vaccination coverage in the DRA region has not been documented. METHODS: We analyzed data for 63,299 adolescents aged 13 to 17 years in the National Immunization Survey-Teen, 2015-2017. We compared HPV vaccination initiation coverage estimates (≥1 dose) in the DRA region with coverage estimates in areas in the 8 Delta states outside the DRA region and non-Delta states. We examined correlates of HPV vaccination coverage initiation and reasons parents did not intend to vaccinate adolescents. RESULTS: Vaccination rates in the DRA region (n = 2,317; 54.3%) and in Delta areas outside the DRA region (n = 6,028; 56.2%) were similar, but these rates were significantly lower than rates in non-Delta states (n = 54,954; 61.4%). Inside the DRA region, reasons for parents' vaccine hesitancy or refusal were similar to those expressed by parents in the Delta areas outside the DRA region. Some parents believed that the vaccine was not necessary or had concerns about vaccine safety. CONCLUSION: HPV vaccination coverage in the DRA region is similar to coverage in other Delta counties and parishes, but it is significantly lower than in non-Delta states. Activities to address parental concerns and improve provider recommendations for the vaccine in the DRA region are needed to increase HPV vaccination rates.

Distinct subgroups of emergency department frequent users: A latent class analysis.

BACKGROUND: Emergency department (ED) frequent users have high resource utilization and associated costs. Many interventions have been designed to reduce utilization, but few have proved effective. This may be because this group is more heterogeneous than initially assumed, limiting the effectiveness of targeted interventions. The purpose of this study was to identify and describe distinct subgroups of ED frequent users and to estimate costs to provide hospital-based care to each group. METHODS: Latent class analysis was used to identify homogeneous subgroups of ED frequent users. ED frequent users (n = 5731) from a single urban tertiary hospital-based ED and level 1 trauma center in 2014 were included. Descriptive statistics (counts and percentages) are described to characterize subgroups. A cost analysis was performed to examine differences in direct medical costs between subgroups from the healthcare provider perspective. RESULTS: Four subgroups were identified and characterized: Short-term ED Frequent Users, Heart-related ED Frequent Users, Long-term ED Frequent Users, and Minor Care ED Frequent Users. The Heart-related group had the largest per person costs and the Long-term group had the largest total group costs. CONCLUSION: Distinct subgroups of ED frequent users were identified and described using a statistically objective method. This taxonomy of ED frequent users allows healthcare organizations to tailor interventions to specific subgroups of ED frequent users who can be targeted with tailored interventions. Cost data suggest intervention for long-term ED frequent users offers the greatest cost-avoidance benefit from a hospital perspective.

Effect of the Affordable Care Act on a Safety-Net Burn Center.

We hypothesized that the Patient Protection and Affordable Care Act (ACA) would have beneficial financial effects on our burn center at a safety-net hospital. We performed a retrospective chart review of all burn patients admitted to our center from 2008-2016. These were further divided into three time periods: 2008-2010 (pre-ACA), 2011-2013 (transitional), and 2014-2016 (post-ACA). Cost and reimbursement dollars were adjusted to health personal consumption expenditures price index. Total charges increased from the pre-ACA group ($69,400) to the transitional group ($85,600) and increased again in the post-ACA group ($100,100) (p<.001). When looking at reimbursements relative to charges, actual reimbursement by percentage dropped over each time period. Despite an increase in insured patients, our burn center actually saw a decrease in reimbursements relative to billing.

Life Course Patterns of Concurrent Trajectories of BMI and Affective Symptoms of Rural Mothers: Socioeconomic Antecedents and Disease Outcomes in Later Life.

OBJECTIVES: The current study, using prospective data over 25 years (1991-2015), concurrently investigates patterns of body mass index (BMI) and affective symptom trajectories in middle-aged mothers and the socioeconomic antecedents and disease outcomes of these patterns. METHOD: Growth mixture modeling was used to identify latent classes of conjoint health risk trajectories (BMI, depressive symptoms, and anxiety symptoms) from 1991 to 2001. For each latent class, we identified mean trajectories of each health risk. Then, analyses were conducted identifying how these conjoint health risk classes were associated with respondents' socioeconomic background profiles in 1991 and subsequent chronic health problems in 2015. RESULTS: Socioeconomic background profiles were significantly associated with initially high-risk trajectories. There was a statistically significant association between membership in certain classes of conjoint trajectories and physical health outcomes in later years. Consistent patterns of association with changes in different health outcomes including onset of diseases were observed when classes of conjoint risk trajectories are examined. DISCUSSION: The identification of members of various conjoint risk trajectory groups provides a potentially useful prognostic tool for early preventive intervention efforts, treatment, and policy formation. Such interventions should promote and develop resiliency factors, thereby aiding in the redirection of middle-aged women's adverse risk trajectories.

Availability of Bedside and Laboratory Testing for Carbon Monoxide Poisoning in the Upper Midwestern United States.

INTRODUCTION: The objective of this study was to assess the ability to test patients for carbon monoxide (CO) exposure in all hospitals in three United States (U.S.) Midwestern states. METHODS: We surveyed hospitals in three states. Telephone queries assessed processes for measuring carboxyhemoglobin, including capacity for real-time vs send-out testing. Facilities were separated based on their location's population size for further analysis. Descriptive statistics are reported. RESULTS: Of the 250 hospitals queried, we ultimately excluded 25. Nearly all (220, 97.8%) reported a process in place to test for CO exposure. Over 40% (n=92) lacked real-time testing. Testing ability was positively associated with increasing population size quartile (range 32.6% - 100%). Hospitals in the lowest-quartile population centers were more likely to report that they were unable to test in real time than those in the largest-quartile population centers (67.4% vs 0%). CONCLUSION: In a large geographic region encompassing three states, hospital-based and real-time capacity to test for CO exposure is not universal. Hospitals in smaller population areas are more likely to lack real-time testing or any testing at all. This may have significant public health, triage, and referral implications for patients.

Crowded Nests: Parent-Adult Child Coresidence Transitions and Parental Mental Health Following the Great Recession.

Although many studies have examined contemporary increases in parent-adult child coresidence, questions about what this demographic shift means for the well-being of parents remain. This article draws on insights from the life course perspective to investigate the relationship between parent-adult child coresidence and parental mental health among U.S. adults ages 50+, distinguishing between parents stably living with and without adult children and those who transitioned into or out of coresidence with an adult child. Based on analyses of the 2008 to 2012 waves of the Health and Retirement Study (N = 11,277), parents with a newly coresidential adult child experienced an increase in depressive symptoms relative to their peers without coresidential adult children. Further analyses suggest that transitions to coresidence that occurred in the southern United States or involved out-of-work children were particularly depressing for parents. These findings highlight the significance of evolving intergenerational living arrangements for the well-being of older adults.

A Community-Based Participatory Assessment of the Health Status and Obesity Risks in Children From Rural Farmworker Families in the Midwest.

Obesity prevalence is higher among Hispanic children (22.4%) compared with general U.S. children (17%). Children of migrant and seasonal farmworking families are at heightened risk for obesity and related conditions. Limited research, including needs assessments and health promotion programs, has been conducted in Latino migrant farm working communities. Our objective was to identify needs, opportunities, and barriers for designing health promotion programs for children attending a community agency in a small Midwestern town. As part of a community-based participatory research project, a needs assessment was undertaken with 38 children aged 5 to 12 years (74% Latino). Measures included demographics, dietary patterns, physical activity (PA), and anthropometrics. The study was approved by the university's institutional review board and written parental consent, and child assent, was obtained. More than half of the sample had overweight (29%) or obesity (26%); 31% had elevated blood pressure levels. Participants did not meet the U.S. Department of Agriculture recommendations for most food groups and nutrients; 13% fell into the "poor" and 87% into the "needs improvement" category based on Healthy Eating Index scores. PA levels were low; only 34% of respondents engaged in sufficient exercise. Findings indicate the need for programs promoting improvements in dietary intake and increased PA.

Demographic differences in response rates for PHQ9 in a university student population.

OBJECTIVE: To examine differences in complete response rates for depression screening questions based on demographic characteristics. METHODS: Cross-sectional study examining associations between demographic characteristics and completely responding depression-screening questions. PARTICIPANTS: "Healthy Minds Study" data, collected in a public University in February 2016, where 7,326 students participated. RESULTS: women (AOR: 0.69; 95% CI =0.57-0.83) and gay/lesbian students (AOR: 0.24; 95% CI =0.10-0.60) had better complete response rates. Non-US (AOR: 1.46; 95% CI =1.03-2.07), black (AOR: 3.32; 95% CI =1.92-5.77), and Middle-Eastern students (AOR: 3.73; 95% CI =1.73-8.02) had lower complete response rates. CONCLUSIONS: Our study shows sex, gender, citizenship, and race categories have significant differences in complete response rates for the outcome. Our findings have several implications; including recognizing interventions for depression based on responders may not target those that tend to be "partial-responders". Efforts in survey design, recruiting and completion of surveys should be maximized.

What's Race Got to Do With It? Racial Socialization's Contribution to Black Adolescent Coping.

While youth generally experience stressors from developmental milestones, Black youth also face racialized stressors. Racial socialization has been found to help Black youth cope with racialized stressors, but research has yet to show its contribution to coping beyond general socialization practices. This study examines how racial socialization contributes beyond that of general coping socialization to coping behaviors. Fifty-eight third-eighth-grade (Mage  = 11.3, SD = 1.54) youth reported general coping socialization and racial socialization practices and coping behaviors. Results indicate that for engagement coping, racial socialization messages contributed significantly to parent-provided engaged socialization strategies. Implications are considered for the ways in which Black youth experience stress and require culturally specific practices for successful coping with frequently encountered stressors.

Macroeconomic impact of foot-and-mouth disease vaccination strategies for an outbreak in the Midwestern United States: A computable general equilibrium.

The impacts of alternative responses to a hypothetical foot-and-mouth disease (FMD) outbreak occurring in the Midwestern United States are estimated using the Regional Economic Modelling Incorporated Policy Insight + (REMI) computable general equilibrium model, with particular attention paid to the employment impact estimates. The impact on employment and GDP is estimated using forecasts of a 10-year period with disease outbreak duration up to 2 years. Fifteen different vaccination protocols are compared to a disease control protocol that relies on animal depopulation with no vaccination. Results show that over the 10-year study period, the strictly depopulation strategy that made no use of vaccination results in approximately 677,000 jobs lost with $47 billion GDP loss. Based on the analysis conducted, losses can be reduced through protocols that utilize vaccination strategies. Through a vaccinate-to-live strategy with the highest vaccination capacity and largest vaccination zone, savings can be as many as 509,000 jobs in comparison to the strategy that relies strictly on slaughter with no use of vaccination. By including detailed job losses by occupation, this study highlights the downstream employment effects and shows that job losses resulting from an FMD outbreak can go far beyond the farm sector impacts that have been reported in earlier studies. Understanding the impacts on employment by sector provides more actionable information than producer and consumer surplus estimates frequently reported in economic impact studies.

Adverse Childhood Experiences and Young Adult Health Outcomes Among Youth Aging Out of Foster Care.

OBJECTIVE: Former youth in foster care (YFC) are at greater risk of chronic health conditions than their peers. Although research in general population samples has shown a dose-response relationship between adverse childhood experiences (ACEs) and adult health outcomes, few studies have conducted similar analyses in highly stress-exposed populations such as YFC. In this study we used person-centered latent class analysis methods to examine the relationship between different profiles of ACE exposures and divergent health trajectories among this high-risk population. METHODS: Data are from longitudinal research that followed transition-age YFC from age 17 to 26 (N = 732). Using 3 subgroups previously identified by their ACEs histories-complex, environmental, and lower adversity groups-we applied group mean statistics to test for differences between the groups for physical and sexual health outcomes in young adulthood. RESULTS: In contrast to previous research that showed that the environmental group was at the highest risk of criminalbehavior outcomes, for most of the physical and sexual health risk outcomes evaluated in this study, the complex adversity group had the highest risk. CONCLUSIONS: This study shows that there are subgroups of YFC, which each have a distinct profile of risk in young adulthood, with the complex group being at highest risk of the physical and sexual health risk outcomes evaluated. Findings strongly suggest the need for targeted strategies to promote screening for ACEs and chronic health conditions, linkage to adult health care, and continuity of care for adolescents and young adults in foster care to offset these trajectories.

Farmers' Market Manager's Level of Communication and Influence on Electronic Benefits Transfer (EBT) Adoption at Midwest Farmers' Markets.

OBJECTIVE: To understand market managers' level of communication and use of technology that might influence decision to adopt Electronic Benefits Transfer (EBT) at farmers' markets. DESIGN: Cross-sectional study using the Theory of Diffusion of Innovation. SETTING: Electronic survey administered in midwest states of Illinois, Michigan, and Wisconsin. PARTICIPANTS: Farmers' market managers in Illinois, Michigan, and Wisconsin. MAIN OUTCOME MEASURES: Information on EBT adoption, market managers' communication, and technology use. ANALYSIS: Binary logistic regression analysis with EBT adoption as the dependent variable and frequency of technology use, partnership with organizations, farmers' market association (FMA) membership, Facebook page and Web site for the market, and primary source of information as independent variables. Chi-square tests and ANOVA were used to compare states and adopter categories. RESULTS: Logistic regression results showed that the odds of adopting EBT was 7.5 times higher for markets that had partnership with other organizations. Compared with non-adopters, a significantly greater number of early adopters had partnership, FMA membership, and a Facebook page and Web site for market, and reported to a board of directors. CONCLUSIONS AND IMPLICATIONS: Markets that had partnership, FMA membership, a Facebook page and Web site, and mandatory reporting to a board of directors were important factors that influenced EBT adoption at midwest farmers' markets.