Risk Factors for Pediatric Facial Trauma in an Appalachian Region: An Epidemiological Review at a Single Institution.

BACKGROUND: Rural and low-income pediatric populations are at higher risk for trauma. Craniomaxillofacial (CMF) trauma in this population has not been studied. PURPOSE: This study's purpose was to determine if rural populations or low-income populations are at higher risk for pediatric CMF trauma than urban or high-income populations, respectively, and to determine differences in mechanism of injury (MOI). STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of CMF trauma patients younger than 17 years-old, living in the region served by one institution in Tennessee, and requiring oral and maxillofacial surgery consultation between January 2011 and December 2022 was performed. Exclusion criteria were incomplete medical records. PREDICTOR VARIABLE: The primary predictor variable was geographic residence of the patient grouped into two categories: rural or urban defined by the state of Tennessee. Secondary variables were postal code (PC) average median household income (MHI) and PC population density. MAIN OUTCOME VARIABLE(S): The main outcome variable was pediatric CMF injury rate per 100,000 people. MOI is a secondary outcome variable. COVARIATE(S): Covariates included sex, age, and race. ANALYSES: Frequencies and percentages, Fisher's exact test, and Poisson regression models were utilized. Statistical significance was assumed at P-value <.05. RESULTS: Rural or urban county designation was not associated with differing trauma rates (incident risk ratio (IRR) = 0.91; 95% confidence interval (CI) 0.78 to 1.05; P = .18) by itself. One standard deviation increase in MHI decreased CMF trauma rates in rural designation counties by 24% (IRR: 0.76, 95% CI: 0.66, 0.88) and 6% in urban designation counties (IRR: 0.94, 95% CI: 0.87, 1.02). Lower rates of CMF trauma were associated with residence in higher income PCs (IRR = 0.91; 95% (CI) 0.86 to 0.97; P = .004), and higher population density (IRR = 0.87; 95% CI 0.79 to 0.94; P < .001). Dog bites and falls were more common in infancy and early childhood. Interpersonal violence was more common in older patients. CONCLUSIONS AND RELEVANCE: Patients in PCs with lower population density or incomes were at highest risk for CMF injuries. MOI differences by age were similar to findings in other studies. Tennessee's urban/rural county designation has complex interactions with MHI and pediatric CMF trauma rates.

Impact of the Affordable Care Act on Providing Equitable Healthcare Access for IBD in the Kentucky Appalachian Region.

BACKGROUND: Medicaid expansion improved insurance coverage for patients with chronic conditions and low income. The effect of Medicaid expansion on patients with IBD from high-poverty communities is unknown. OBJECTIVE: This study aimed to evaluate the impact of Medicaid expansion in Kentucky on care for patients with IBD from the Eastern Kentucky Appalachian community, a historically impoverished area. DESIGN: This study was a retrospective, descriptive, and ecological study. SETTINGS: This study was conducted in Kentucky using the Hospital Inpatient Discharge and Outpatient Services Database. PATIENTS: All encounters for IBD care for 2009-2020 for patients from the Eastern Kentucky Appalachian region were included. MAIN OUTCOME MEASURES: The primary outcomes measured were proportions of inpatient and emergency encounters, total hospital charge, and hospital length of stay. RESULTS: Eight hundred twenty-five preexpansion and 5726 postexpansion encounters were identified. Postexpansion demonstrated decreases in the uninsured (9.2%-1.0%; p < 0.001), inpatient encounters (42.7%-8.1%; p < 0.001), emergency admissions (36.7%-12.3%; p < 0.001), admissions from the emergency department (8.0%-0.2%; p < 0.001), median total hospital charge ($7080-$3260; p < 0.001), and median total hospital length of stay (4-3 days; p < 0.001). Similarly, postexpansion demonstrated increases in Medicaid coverage (18.8%-27.7%; p < 0.001), outpatient encounters (57.3%-91.9%; p < 0.001), elective admissions (46.9%-76.2%; p < 0.001), admissions from the clinic (78.4%-90.2%; p < 0.001), and discharges to home (43.8%-88.2%; p < 0.001). LIMITATIONS: This study is subject to the limitations inherent in being retrospective and using a partially de-identified database. CONCLUSION: This study is the first to demonstrate the changes in trends in care after Medicaid expansion for patients with IBD in the Commonwealth of Kentucky, especially Appalachian Kentucky, showing significantly increased outpatient care utilization, reduced emergency department encounters, and decreased length of stays. IMPACTO DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO EN LA PROVISIN DE ACCESO EQUITATIVO A LA ATENCIN MDICA PARA LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LA REGIN DE LOS APALACHES DE KENTUCKY: ANTECEDENTES: La expansión de Medicaid mejoró la cobertura de seguro para pacientes con enfermedades crónicas y bajos ingresos. Se desconoce el efecto de la expansión de Medicaid en pacientes con enfermedad inflamatoria intestinal de comunidades de alta pobreza.OBJETIVO: Este estudio tuvo como objetivo evaluar el impacto de la expansión de Medicaid en Kentucky en la atención de pacientes con enfermedad inflamatoria intestinal de la comunidad de los Apalaches del este de Kentucky, un área históricamente empobrecida.DISEÑO: Este estudio fue un estudio retrospectivo, descriptivo, ecológico.ESCENARIO: Este estudio se realizó en Kentucky utilizando la base de datos de servicios ambulatorios y de alta hospitalaria en pacientes hospitalizados.PACIENTES: Se incluyeron todos los encuentros para la atención de la enfermedad inflamatoria intestinal de 2009-2020 para pacientes de la región de los Apalaches del este de Kentucky.MEDIDAS DE RESULTADO PRINCIPALES: Los resultados primarios medidos fueron proporciones de encuentros de pacientes hospitalizados y de emergencia, cargo hospitalario total y duración de la estancia hospitalaria.RESULTADOS: Se identificaron 825 encuentros previos a la expansión y 5726 posteriores a la expansión. La posexpansión demostró disminuciones en los no asegurados (9.2% a 1.0%, p < 0.001), encuentros de pacientes hospitalizados (42.7% a 8.1%, p < 0.001), admisiones de emergencia (36.7% a 12.3%, p < 0,001), admisiones desde el servicio de urgencias (8.0% a 0.2%, p < 0.001), la mediana de los gastos hospitalarios totales ($7080 a $3260, p < 0.001) y la mediana de la estancia hospitalaria total (4 a 3 días, p < 0.001). De manera similar, la cobertura de Medicaid (18.8% a 27.7%, p < 0.001), consultas ambulatorias (57.3% a 91.9%, p < 0.001), admisiones electivas (46.9% a 76.2%, p < 0.001), admisiones desde la clínica (78.4% al 90.2%, p < 0.001), y las altas domiciliarias (43.8% al 88.2%, p < 0.001) aumentaron después de la expansión.LIMITACIONES: Este estudio está sujeto a las limitaciones inherentes de ser retrospectivo y utilizar una base de datos parcialmente desidentificada.CONCLUSIONES: Este estudio es el primero en demostrar los cambios en las tendencias en la atención después de la expansión de Medicaid para pacientes con enfermedad inflamatoria intestinal en el Estado de Kentucky, especialmente en los Apalaches de Kentucky, mostrando un aumento significativo en la utilización de la atención ambulatoria, visitas reducidas al departamento de emergencias y menor duración de la estancia hospitalaria. (Traducción-Dr. Jorge Silva Velazco ).

Examining Smoking Prevalence Disparities in Virginia Counties by Rurality, Appalachian Status, and Social Vulnerability, 2011-2019.

Objectives. To estimate county-level cigarette smoking prevalence in Virginia and examine cigarette use disparities by rurality, Appalachian status, and county-level social vulnerability. Methods. We used 2011-2019 Virginia Behavioral Risk Factor Surveillance System proprietary data with geographical information to estimate county-level cigarette smoking prevalence using small area estimation. We used the Centers for Disease Control and Prevention's social vulnerability index to quantify social vulnerability. We used the 2-sample statistical t test to determine the differences in cigarette smoking prevalence and social vulnerability between counties by rurality and Appalachian status. Results. The absolute difference in smoking prevalence was 6.16 percentage points higher in rural versus urban counties and 7.52 percentage points higher in Appalachian versus non-Appalachian counties in Virginia (P < .001). Adjusting for county characteristics, a higher social vulnerability index is associated with increased cigarette use. Rural Appalachian counties had 7.41% higher cigarette use rates than did urban non-Appalachian areas. Tobacco agriculture and a shortage of health care providers were significantly associated with higher cigarette use prevalence. Conclusions. Rural Appalachia and socially vulnerable counties in Virginia have alarmingly high rates of cigarette use. Implementation of targeted intervention strategies could reduce cigarette use, ultimately reducing tobacco-related health disparities. (Am J Public Health. 2023;113(7):811-814. https://doi.org/10.2105/AJPH.2023.307298).

Developing a Public Health Improvement Consortium in Appalachian Kentucky: Harnessing the Power of the Local Collective.

Many Appalachian counties in Kentucky are known for poor health and limited resources, however, by harnessing the power of relationships in the eight counties of the Kentucky River Area Development District, a team developed a public health improvement consortium to maximize power of the local collective.

Policy Implications of the COVID-19 Pandemic on Food Insecurity in Rural America: Evidence from Appalachia.

Rural communities are disproportionally affected by food insecurity, making them vulnerable to the consequences of supply disruptions caused by the COVID-19 pandemic. While access to food was initially diminished due to food supply disruptions, little is known about the mechanisms through which federal emergency assistance programs impacted food access in rural populations. Through a series of five focus groups in spring 2021, we examined the impact of the COVID-19 pandemic on food access in a rural Appalachian community in Kentucky. Data were analyzed using a Grounded Theory Approach. Findings revealed the following four primary themes: food scarcity in grocery stores; expanded federal food assistance; expanded community food resources; and expanded home gardening. Participants provided details regarding the way increased federal assistance, especially expanded benefits within the Supplemental Nutrition Assistance Program, allowed them to purchase greater quantities of nutritious food. This study unveils the specific impacts of the COVID-19 pandemic on one rural population, including the influence of some social determinants of health on food insecurity. Policymakers and stakeholders should recognize the layered protection of multiple federal emergency assistance programs against food insecurity and the potential for long-term population health promotion in rural areas.

Caregiver Feeding Practices as Predictors for Child Dietary Intake in Low-Income, Appalachian Communities.

The Appalachian region of the U.S. is disproportionately impacted by poverty, obesity, and nutrition-related chronic diseases. Evidence suggests that caregiver feeding practices may promote healthful eating behaviors among children; however, this has not been examined in low-income, rural, Appalachian populations. This study examines caregiver feeding practices as predictors for child diet in low-income Appalachian families, using a cross-sectional analysis of 178 caregivers of young children (ages 2-10 years old), that were recruited from low-income, rural communities in East Tennessee, from November 2017 to June 2018. Caregivers self-reported measures of demographics, feeding practices, and child dietary intake. Multiple linear regression analyses were run, and found that higher use of caregiver modeling positively predicted child vegetable consumption (Beta = 1.02; p = 0.04). Higher caregiver intake of fruits and vegetables positively predicted child fruit consumption (Beta = 0.29; p = 0.02) and vegetable consumption (Beta = 1.56; p < 0.001), respectively. Higher home availability of healthier foods positively predicted child fruit consumption (Beta = 0.06; p = 0.002) and vegetable consumption (Beta = 0.09; p = 0.05). Higher home availability of less healthy foods positively predicted child consumption of high-sugar/high-fat snack foods (Beta = 0.59; p = 0.003). The findings of this study indicate that caregiver modeling, healthy caregiver dietary intake, and healthful home food availability are associated with healthier child dietary intake among young children in low-income, rural, Appalachian areas. Promoting these practices among caregivers may be an important strategy to enhancing dietary intake of children in this hard-to-reach, underserved population.

Description of a Lung Cancer Hotspot: Disparities in Lung Cancer Histology, Incidence, and Survival in Kentucky and Appalachian Kentucky.

INTRODUCTION: Kentucky is recognized as the state with the highest lung cancer burden for more than 2 decades, but how lung cancer differs in Kentucky relative to other US populations is not fully understood. PATIENTS AND METHODS: We examined lung cancer reported to the Surveillance, Epidemiology, and End Results (SEER) Program by Kentucky and the other SEER regions for patients diagnosed between 2012 and 2016. Our analyses included histologic types, incidence rates, stage at diagnosis, and survival in Kentucky and Appalachian Kentucky relative to other SEER regions. RESULTS: We found that both squamous cell carcinomas and small-cell lung cancers represent larger proportions of lung cancer diagnoses in Kentucky and Appalachian Kentucky than they do in the SEER registries. Furthermore, age-adjusted cancer incidence rates were higher in Kentucky for every subtype of lung cancer examined. Most notably, for Appalachian women the rate of small-cell carcinomas was 3.5-fold higher, and for Appalachian men the rate of squamous cell carcinoma was 3.1-fold higher, than the SEER rates. In Kentucky, lung cancers were diagnosed at later stages and lung cancer survival was lower for adenocarcinoma and neuroendocrine carcinomas than in SEER registries. Squamous cell carcinomas and small-cell carcinomas were most lethal in Appalachian Kentucky. CONCLUSION: Together, these data highlight the considerable disparities among lung cancer cases in the United States and demonstrate the continuing high burden and poor survival of lung cancer in Kentucky and Appalachian Kentucky. Strategies to identify and rectify causes of these disparities are discussed.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia.

OBJECTIVE: Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings. DATA SOURCE: We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia. STUDY INCLUSION AND EXCLUSION CRITERIA: Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings. DATA EXTRACTION: Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest. DATA SYNTHESIS: Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework. RESULTS: A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels. CONCLUSIONS: Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

Persistent disparities in smoking among rural Appalachians: evidence from the Mountain Air Project.

BACKGROUND: Adult smoking prevalence in Central Appalachia is the highest in the United States, yet few epidemiologic studies describe the smoking behaviors of this population. Using a community-based approach, the Mountain Air Project (MAP) recruited the largest adult cohort from Central Appalachia, allowing us to examine prevalence and patterns of smoking behavior. METHODS: A cross-sectional epidemiologic study of 972 participants aged 21 years and older was undertaken 2015-2017, with a response rate of 82%. Prevalence ratios and 95% confidence intervals for current smoking (compared to nonsmokers) were computed for the entire cohort then stratified by multiple characteristics, including respiratory health. Adjusted prevalence ratios for current smoking versus not smoking were also computed. RESULTS: MAP participants reported current smoking prevalence (33%) more than double the national adult smoking prevalence. Current smoking among participants with a reported diagnosis of chronic obstructive pulmonary disease and emphysema was 51.5 and 53.3%, respectively. Compared to participants age 65 years and older, those age 45 years or younger reported double the prevalence of smoking (PR: 2.04, 95% CI: 1.51-2.74). Adjusted analyses identified younger age, lower education, unmet financial need, and depression to be significantly associated with current smoking. CONCLUSIONS: Despite declining rates of smoking across the United States, smoking remains a persistent challenge in Central Appalachia, which continues to face marked disparities in education funding and tobacco control policies that have benefitted much of the rest of the nation. Compared with national data, our cohort demonstrated higher rates of smoking among younger populations and reported a greater intensity of cigarette use.

Assessment of pneumoconiosis in surface coal miners after implementation of a national radiographic surveillance program, United States, 2014-2019.

BACKGROUND: Pneumoconiosis can occur in surface coal miners. The Coal Workers' Health Surveillance Program (CWHSP) has only included surface coal miners as part of its regular disease surveillance since 2014. This analysis identifies the prevalence of pneumoconiosis among working surface coal miners participating in the CWHSP since their initial inclusion, through 2019. METHODS: Working surface coal miners who had chest radiographs through the CWHSP from January 1, 2014 through December 31, 2019 were included in this analysis. Demographic information, mining tenure and occupation, and radiographic classifications according to the International Labour Office system were included from each miner's most recent encounter with the CWHSP. Prevalence ratios were calculated comparing the prevalence of the disease by region and occupation by log-binomial regression. RESULTS: Pneumoconiosis was present in 109 (1.6%) surface coal miners, including 12 miners with progressive massive fibrosis, the most severe form of the disease. After taking surface mining tenure into account, surface miners in Central Appalachia (prevalence ratio [PR], 3.2; 95% confidence interval [CI], 2.2-4.7) and surface miners who worked as a driller or blaster (PR, 2.1; 95% CI, 1.3-3.5) were at increased risk of pneumoconiosis. CONCLUSION: The occurrence of pneumoconiosis in surface coal miners supports including them within a systematic respiratory health surveillance program. The current surveillance findings are consistent with past findings of pneumoconiosis, particularly silicosis, in surface mining occupations such as drilling and blasting.

Exploring Associations between Susceptibility to the Use of Electronic Nicotine Delivery Systems and E-Cigarette Use among School-Going Adolescents in Rural Appalachia.

Electronic nicotine delivery systems (ENDS) use, including e-cigarettes, has surpassed the use of conventional tobacco products. Emerging research suggests that susceptibility to e-cigarette use is associated with actual use among adolescents. However, few studies exist involving adolescents in high-risk, rural, socioeconomically distressed environments. This study examines susceptibility to and subsequent usage in school-going adolescents in a rural distressed county in Appalachian Tennessee using data from an online survey (N = 399). Relying on bivariate analyses and logistic regression, this study finds that while 30.6% of adolescents are ever e-cigarette users, 15.5% are current users. Approximately one in three adolescents are susceptible to e-cigarettes use, and susceptibility is associated with lower odds of being a current e-cigarette user (OR = 0.03; CI: 0.01-0.12; p < 0.00). The age of tobacco use initiation was significantly associated with decreased current use of e-cigarettes (OR = 0.89; CI: 0.83-0.0.97; p < 0.01). Overall, the results of this exploratory study suggest the need for larger studies to identify unique and generalizable factors that predispose adolescents in this high-risk rural, socioeconomically disadvantaged region to ENDS use. Nevertheless, this study offers insight into e-cigarette usage among U.S adolescents in rural, socioeconomically disadvantaged environments and provides a foundation for a closer examination of this vulnerable population.

The association of chronic diseases and mammography among Medicare beneficiaries living in Appalachia.

OBJECTIVE: This study assessed the relationship between presence and number of chronic disease and reception of mammogram in women 65 years and older, and how this relationship is influenced by primary care provider visits. METHODS: A total of 3306 women diagnosed with breast cancer from 2006 to 2008 from cancer registries in four Appalachian states were analyzed. RESULTS: Having a mammogram within the past 2 years was associated with having at least one chronic disease. The presence of a chronic disease was associated with an increased likelihood of breast cancer screening adherence but was not a strong predictor when demographic variables were added. CONCLUSION: This study supports the findings that women with more primary care provider visits were more likely to adhere to breast cancer screening guidelines but having several chronic diseases presents a barrier to achieving guideline-concordant mammography screening, highlighting the importance of preventive screening for patients managing chronic diseases.

Alzheimer's Disease and Related Disorders Prevalence Differs by Appalachian Residence in Ohio.

BACKGROUND: Areas within the Appalachian region may have a greater burden of under diagnosed Alzheimer's disease and related disorders (ADRD). OBJECTIVE: To estimate the prevalence of ADRD in the Appalachian counties of Ohio, and to determine if differences exist by geographic location (Appalachian/non-Appalachian and rural/urban) and across time among Medicare beneficiaries. METHODS: Centers for Medicare and Medicaid Services Public Use Files from 2007-2017 were used to estimate county-level ADRD prevalence among all fee-for-service beneficiaries in Ohio. Negative binomial regression was used to estimate prevalence overall, by Appalachian Regional Commission's Appalachian/non-Appalachian designation, and by rural/urban (Rural-Urban Continuum Codes) classification. Models were repeated, adjusting for county-level demographics and comorbidities. RESULTS: The prevalence of ADRD varied by both Appalachian residence and rural status (p = 0.008). Before adjustment by county-level demographics and comorbidities, the prevalence of ADRD in urban Appalachian counties was 1-3% lower than in urban non-Appalachian counties, while rural Appalachian counties had 2-3% higher prevalence compared to rural non-Appalachian counties. After adjustment, the differences between prevalence ratios were accentuated; the prevalence ratio was consistently higher for rural Appalachian counties, yet varied across the study period for urban counties (1.03 in 2007 to 0.97 in 2017). CONCLUSION: The results suggest a disparate burden of ADRD in Ohio with higher prevalence in rural Appalachian counties. This potential difference by Appalachian region is important to consider for availability of services and subsequent delivery of care. In order to better understand the disparity, further epidemiologic studies are necessary to better estimate the burden of ADRD.

Rural cancer survivors' health information needs post-treatment.

OBJECTIVE: This study describes the most common cancer-related health information needs among rural cancer survivors and characteristics associated with reporting more information needs. METHODS: Rural breast, prostate, and colorectal cancer survivors, two to five years post-diagnosis, identified from an institutional cancer registry, completed a mailed/telephone-administered survey. Respondents were asked about 23 health information needs in eight domains (tests and treatment, side effects and symptoms, health promotion, fertility, interpersonal, occupational, emotional, and insurance). Poisson regression models were used to assess relationships between number of health information needs and demographic and cancer characteristics. RESULTS: Participants (n = 170) reported an average of four health information needs, with the most common domains being: side effects and symptoms (58 %), health promotion (54 %), and tests and treatment (41 %). Participants who were younger (compared to 5-year increase, rate ratio [RR] = 1.11, 95 % CI = 1.02-1.21), ethnic minority (RR = 1.89, 95 % CI = 1.17-3.06), less educated (RR = 1.49, 95 % CI = 1.00-2.23), and financially stressed (RR = 1.87, 95 % CI = 1.25-2.81) had a greater number of information needs. CONCLUSIONS: Younger, ethnic minority, less educated, and financially strained rural survivors have the greatest need for informational support. PRACTICE IMPLICATIONS: The provision of health information for rural cancer survivors should consider type of cancer, treatments received, and sociocultural differences to tailor information provided.

A Multi-level Model to Understand Cervical Cancer Disparities in Appalachia.

The Appalachian region experiences higher incidence and mortality due to cervical cancer compared with other regions of the United States. The goal of the Ohio State University Center for Population Health and Health Disparities (CPHHD), called the Community Awareness Resources and Education (CARE) project, was to understand reasons for this disparity. The first wave (2003-2008) of funding included three projects focusing on the known risk factors for cervical cancer, lack of screening, smoking, and infection with human papillomavirus (HPV). On the basis of the results of these projects, the second wave (2011-2017) included four projects, designed to address a multi-level model of factors contributing to cervical disparities in Appalachia. The results of these projects were then used to refine a multi-level model that explains cervical cancer disparities in Appalachia. Future funded projects will take these multi-level explanations for cervical disparities and focus on implementation science strategies to reduce the burden of cervical cancer morbidity and mortality in Appalachia.See all articles in this Special Collection Honoring Paul F. Engstrom, MD, Champion of Cancer Prevention.

An Emerging Model for Community Health Worker-Based Chronic Care Management for Patients With High Health Care Costs in Rural Appalachia.

Community health workers (CHWs) can improve patients' health by providing them with ongoing behavioral support during the health care experience, and they help decrease health care costs, especially among patients whose starting costs are high and among underserved and minority populations. We developed a CHW-based care model with the aim of improving outcomes and lowering costs for high-risk diabetes patients in rural Appalachia. Enrolled patients experienced a mean decrease in HbA1c of 2.4 percentage points, and 60% or more of patients with diabetes lowered their blood glucose between baseline and 6 to 12 months after enrollment. As health care providers and patients became familiar with this model of care management, enrollment in the program accelerated.

Appalachian disparities in tobacco cessation treatment utilization in Medicaid.

BACKGROUND: Kentucky Medicaid enrollees, particularly those in the rural Appalachian region, face disproportionate smoking rates and tobacco-related disease burden relative to the rest of the United States (US). The Affordable Care Act (ACA) mandated tobacco cessation treatment coverage by the US public health insurance program Medicaid. Medicaid coverage was also expanded in Kentucky, in 2013, with laxer income eligibility requirements. This short report describes tobacco use incidence and tobacco cessation treatment utilization, comparing by Appalachian status before and after ACA-mandated cessation treatment coverage. METHODS: The study design was a retrospective cross-sectional analysis from 2013 to 2015. Subjects were Medicaid enrollees with 1) diagnosis of any tobacco use (2013 n = 541,349; 2014 n = 864,183; 2015 n = 1,090,274); and/or (2) procedure claim for tobacco cessation counseling, and/or (3) pharmaceutical claim for varenicline or any nicotine replacement product. Primary measures included tobacco use incidence and proportion of users receiving cessation treatment. Analysis was via chi square testing of change by year. RESULTS: Overall, the proportion of tobacco users utilizing cessation treatment decreased (4.75% tobacco users in 2013; 3.15% in 2015). Tobacco users receiving counseling decreased from 2.06% pre-ACA (2013) to 1.06% post-ACA (2015, p < 0.001), as did the proportion receiving nicotine replacement products post-ACA (2.69% in 2013 to 1.55% by 2015; p < 0.001). More Appalachians received cessation treatment than non-Appalachians in 2013 (2.72% vs. 2.03%), but by 2015 non-Appalachians received more treatment overall (1.50% vs. 1.65%; p < 0.001). Appalachians received more counseling and NRT, but less varenicline, than non-Appalachians. CONCLUSIONS: Utilization of all forms of tobacco cessation treatment throughout Kentucky, and particularly in rural Appalachia, remained limited despite Medicaid enrollment as well as coverage expansions. These findings suggest that barriers persist in access to tobacco cessation treatment for individuals in Medicaid.

Uterine Corpus Malignancies in Appalachia Kentucky: Incidence, Survival, and Related Health Disparities.

OBJECTIVES: Uterine cancer is the nation's most common gynecologic malignancy, but it is understudied in the geographically and socioeconomically diverse state of Kentucky (KY). Our aim was to assess the frequency, distribution, and survival of uterine corpus malignancies in KY, and specifically the differences between Appalachia (AP) and non-Appalachia (NAP) KY. METHODS: This population-based cohort study used Surveillance, Epidemiology, and End Results data and the Kentucky Cancer Registry to study uterine corpus malignancy between January 1, 2000 and December 31, 2014. The analysis looked at the incidence between diagnoses in AP and NAP. The evaluation criteria included tumor histology (type I, type II, sarcoma, and mixed uterine malignancy), age, race, smoking status, stage at diagnosis, insurance status, and county of residence at diagnosis. RESULTS: The overall age-adjusted incidence rate and survival are similar for US and KY populations; however, histologic types and distribution differ. Compared with the United States, the incidence of corpus cancers in KY is higher for type I (P = 0.03), but lower for type II (P = 0.003), sarcoma (P = 0.006), and mixed (P < 0.001). AP KY has a higher incidence of type I (P < 0.0001) and mixed malignancy (P = 0.04), younger age at diagnosis (P < 0.0001), larger non-Hispanic white population (P < 0.0001), fewer smokers (P = 0.002), and more uninsured and Medicaid recipients (P < 0.0001) compared with NAP KY. The hazard ratio for death is similar in AP and NAP KY (0.896; 95% confidence interval 0.795-1.009). CONCLUSIONS: Type I and mixed uterine corpus cancers have a higher age-adjusted incidence and a younger age at diagnosis in AP compared with NAP KY.

Pregnancy-Related Mortality and Severe Maternal Morbidity in Rural Appalachia: Established Risks and the Need to Know More.

PURPOSE: The Centers for Disease Control and Prevention (CDC) and the American College of Obstetrics and Gynecology have called for researchers to further elucidate medical and social determinants of pregnancy-related death and severe maternal morbidity. This report begins to answer this call in the context of rural Appalachia. METHODS: This report identifies risk factors exposing women in rural Appalachia to pregnancy-related death and severe maternal morbidity. We also use CDC WONDER data to illustrate rural-urban differences in pregnancy-related death. FINDINGS: Rural women nationally die of pregnancy-related causes at a greater rate than urban women. It is unknown how rurality specifically influences pregnancy-related death, but rural women more often embody multiple risk factors associated with negative maternal outcomes. Established risk factors, including high rates of chronic illness and substance abuse, place rural women at risk for severe maternal morbidity and pregnancy-related mortality. These women may also lack the resources to mitigate these risks, including access to high-risk obstetric care. NEXT STEPS: To address these issues and the concerning lack of data, we propose 4 directions for future study: (1) a determination of the prevalence of pregnancy-related death and severe maternal morbidity in this population; (2) an examination of how rural women utilize existing pre- and perinatal resources; (3) better validation concerning surveillance methods of pregnancy-related death and severe maternal morbidity in rural areas; and (4) an exploratory qualitative study of rural women and health care providers.

Investigating confounders of the association between survival and adjuvant radiation therapy after breast conserving surgery in a sample of elderly breast Cancer patients in Appalachia.

BACKGROUND: To explain the association between adjuvant radiation therapy after breast conserving surgery (BCS RT) and overall survival (OS) by quantifying bias due to confounding in a sample of elderly breast cancer beneficiaries in a multi-state region of Appalachia. METHODS: We used Medicare claims linked registry data for fee-for-service beneficiaries with AJCC stage I-III, treated with BCS, and diagnosed from 2006 to 2008 in Appalachian counties of Kentucky, Ohio, North Carolina, and Pennsylvania. Confounders of BCS RT included age, rurality, regional SES, access to radiation facilities, marital status, Charlson comorbidity, Medicaid dual status, institutionalization, tumor characteristics, and surgical facility characteristics. Adjusted percent change in expected survival by BCS RT was examined using Accelerated Failure Time (AFT) models. Confounding bias was assessed by comparing effects between adjusted and partially adjusted associations using a fully specified structural model. RESULTS: The final sample had 2675 beneficiaries with mean age of 75, with 81% 5-year survival from diagnosis. Unadjusted percentage increase in expected survival was 2.75 times greater in the RT group vs. non-RT group, with 5-year survival of 85% vs 60%; fully adjusted percentage increase was 1.70 times greater, with 5-year rates of 83% vs 71%. Quantification of incremental confounding showed age accounted for 71% of the effect reduction, followed by tumor features (12%), comorbidity (10%), dual status(10%), and institutionalization (8%). Adjusting for age and tumor features only resulted in only 4% bias from fully adjusted percent change (70% change vs 66%). CONCLUSION: Quantification of confounding aids in determining covariates to adjust for and in interpreting raw associations. Substantial confounding was present (60% of total association), with age accounting for the largest share (71%); adjusting for age plus tumor features corrected for most of the confounding (4% bias). The direct effect of BCS RT on OS accounted for 40% of the total association.