Income variability and incident cardiovascular disease in diabetes: a population-based cohort study.

BACKGROUND AND AIMS: Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D). METHODS: Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders. RESULTS: High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results. CONCLUSIONS: Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Geographic and Racial/Ethnic Differences in Access to Methamphetamine Detoxification Services, United States, 2021.

INTRODUCTION: Methamphetamine detoxification before entering formal and longer term treatment may have a positive impact on treatment retention and success. Understanding geographic distribution of methamphetamine specialty detox services and differential access by race/ethnicity is critical for establishing policies that ensure equitable access across populations. METHODS: We used the Mental health and Addiction Treatment Tracking Repository to identify treatment facilities that offered any substance use detoxification in 2021 (N=2346) as well as the census block group in which they were located. We sourced data from the US Census Bureau to identify the percentage of a census block group that was White, Black, and Hispanic. We used logistic regression to model the availability of methamphetamine-specific detox, predicted by the percentage of a block group that was Black and Hispanic. We adjusted for relevant covariates and defined state as a random effect. We calculated model-based predicted probabilities. RESULTS: Over half (60%) of detox facilities offered additional detox services specifically for methamphetamine. Sixteen states had <10 methamphetamine-specific detox facilities. The predicted probability of methamphetamine-specific detox availability was 60% in census block groups with 0%-9% Black residents versus only 46% in census block groups with 90%-100% Black residents, and was 61% in census block groups with 0%-9% Hispanic residents versus 30% in census block groups with 90%-100% Hispanic residents. CONCLUSIONS: During an unprecedented national methamphetamine crisis, access to a critical health care service was disproportionately lower in communities that were predominately Black and Hispanic. We orient our findings around a discussion of health disparities, residential segregation, and the upstream causes of the systematic exclusion of minoritized communities from health care.

Predicting pediatric severe asthma exacerbations: an administrative claims-based predictive model.

OBJECTIVE: Previous machine learning approaches fail to consider race and ethnicity and social determinants of health (SDOH) to predict childhood asthma exacerbations. A predictive model for asthma exacerbations in children is developed to explore the importance of race and ethnicity, rural-urban commuting area (RUCA) codes, the Child Opportunity Index (COI), and other ICD-10 SDOH in predicting asthma outcomes. METHODS: Insurance and coverage claims data from the Arkansas All-Payer Claims Database were used to capture risk factors. We identified a cohort of 22,631 children with asthma aged 5-18 years with 2 years of continuous Medicaid enrollment and at least one asthma diagnosis in 2018. The goal was to predict asthma-related hospitalizations and asthma-related emergency department (ED) visits in 2019. The analytic sample was 59% age 5-11 years, 39% White, 33% Black, and 6% Hispanic. Conditional random forest models were used to train the model. RESULTS: The model yielded an area under the curve (AUC) of 72%, sensitivity of 55% and specificity of 78% in the OOB samples and AUC of 73%, sensitivity of 58% and specificity of 77% in the training samples. Consistent with previous literature, asthma-related hospitalization or ED visits in the previous year (2018) were the two most important variables in predicting hospital or ED use in the following year (2019), followed by the total number of reliever and controller medications. CONCLUSIONS: Predictive models for asthma-related exacerbation achieved moderate accuracy, but race and ethnicity, ICD-10 SDOH, RUCA codes, and COI measures were not important in improving model accuracy.

Breastfeeding Intentions among Pregnant Women Enrolled in a Healthy Start Program in Arkansas.

INTRODUCTION: Exclusive breastfeeding is recognized as the optimal source of nutrition for infants. Although exclusive breastfeeding rates have increased overall in the United States, substantial inequities exist in breastfeeding among individuals of different socioeconomic statuses, races, and ethnicities. The purpose of this study was to examine characteristics associated with exclusive breastfeeding intentions among pregnant women in Arkansas enrolled in a Healthy Start program. METHODS: The current study included a cross-sectional design, with a sample of 242 pregnant women in Arkansas enrolled in a Healthy Start program. RESULTS: The majority of the participants (56.6%) indicated their infant feeding intentions included a combination of breastfeeding and formula feeding. There were substantial differences in breastfeeding intentions among women of different races/ethnicities, with 18.5% of Marshallese women indicating they planned to exclusively breastfeed, compared to 42.1% of White women, 47.6% of Black women, and 31.8% of Hispanic women (p < 0.001). Women over the age of 18 and with higher educational attainment were more likely to intend on exclusively breastfeeding. DISCUSSION: This is the first study to examine characteristics associated with exclusive breastfeeding intentions among pregnant women in Arkansas enrolled in a Healthy Start program. The study found that race/ethnicity and age were most strongly associated with breastfeeding intentions. These findings are critical to identifying populations for resource allocation and to developing culturally-tailored interventions to help women in Arkansas achieve their desired infant feeding methods.

Comprehensive and Integrated Services in Specialty Mental Health Treatment Facilities in the US: Differences by the Racial/Ethnic Composition of the Facility's Clientele, 2020.

The integration of multiple ancillary services into mental health treatment settings may improve outcomes, but there are no national studies addressing whether comprehensive services are distributed equitably. We investigated whether the availability of a wide range of service types differs based on the facility's racial/ethnic composition. We used the 2020 National Mental Health Services Survey to identify twelve services offered in outpatient mental health treatment facilities (N = 1,074 facilities). We used logistic regression to model each of the twelve services, predicted by the percentage of a facility's clientele that was White, Black, and Hispanic, adjusted for covariates. Facilities with the highest proportions of Black and Hispanic clientele demonstrated the lowest predicted probabilities of offering comprehensive and integrated services. Our findings offer context around upstream factors that may, in part, drive treatment disparities. We orient our findings around frameworks of structural racism and inequities in mental healthcare.

Association of the COVID-19 Pandemic With Women, Infants, and Children (WIC) Receipt Among Pregnant Individuals: United States, 2016-2022.

Objectives. To evaluate the effect of COVID-19 on Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receipt among pregnant individuals overall and by race/ethnicity. Methods. We measured changes in WIC receipt among Medicaid-covered births (n = 10 484 697) from the US National Center for Health Statistics Natality Files (2016-2022). Our interrupted time series logistic model included a continuous monthly variable, a binary post-COVID variable, and a continuous slope shift variable. We additionally fit separate models for each race/ethnicity relative to White individuals, using interaction terms between the time series variables and race/ethnicity. Results. We found decreases in WIC receipt (adjusted odds ratio [AOR] = 0.899; P < .001) from before COVID (66.6%) to after COVID (57.9%). There were larger post-COVID decreases for American Indian/Alaska Native (AOR = 0.850; P < .001), Native Hawaiian/Other Pacific Islander (AOR = 0.877; P = .003), Black (AOR = 0.974; P < .001), and Hispanic (AOR = 0.972, P < .001) individuals relative to White individuals. Conclusions. The greater reductions in WIC receipt among minoritized individuals highlights a pathway through which the pandemic may have widened gaps in already disparate maternal and infant health. Public Health Implications. Continued efforts to increase WIC utilization are needed overall and among minoritized populations. (Am J Public Health. 2023;113(S3):S240-S247. https://doi.org/10.2105/AJPH.2023.307525).

Evaluation of lung ultrasound to detect volume overload in children undergoing dialysis.

BACKGROUND: Lung ultrasound is a well-established technique to assess extravascular lung water, a proxy for volume status, in the adult population. Despite its utility, the data are limited supporting the use of ultrasound to evaluate fluid volume status among pediatric patients. Our study uses a simplified ultrasound protocol to evaluate changes in extravascular lung water, represented by b-lines, among pediatric patients undergoing hemodialysis. METHODS: This prospective single-center study included children from birth to 18 years of age. The number of b-lines per ml/kg of fluid removed was compared prior to, at the midpoint, and following termination of dialysis. An 8-zone protocol was utilized, and b-lines were correlated to hemoconcentration measured by the CRIT-LINE® hematocrit. RESULTS: Six patients with a total of 26 hemodialysis sessions were included in this study. The b-line measurements post-dialysis were 2.27 (p < 0.001; 94%CI -3.31, -1.22) lower relative to pre-dialysis. The number of b-lines was reduced by 1.69 (p < 0.001; -2.58, -0.80) between pre-dialysis and at the midpoint of dialysis and by 0.58 (p = 0.001; -0.90, -0.24) between the midpoint of dialysis and post-dialysis. A 1 mL/kg fluid loss correlated to a decrease in the original b-lines by 0.079. An inverse relationship (r = -0.54; 95% CI: -0.72, -0.34; p < 0.001) was noted between the b-lines and the patients' hematocrit levels. CONCLUSIONS: A simplified 8-zone ultrasound protocol can assess fluid volume change in real time and correlates with hematocrit levels obtained throughout dialysis. This provides a valuable method for monitoring fluid status in volume overloaded patient populations. A higher resolution version of the Graphical abstract is available as Supplementary information.

Identification of racial/ethnic disparities associated with severe maternal morbidity using the Arkansas All-Payer Claims Database (2013-2017).

OBJECTIVE: To evaluate the effect of maternal characteristics on the odds of severe maternal morbidity (SMM) through 42 days postpartum. STUDY DESIGN: We conducted a retrospective observational study of 77 172 births using birth certificate and insurance claims data from the Arkansas All Payers Claims Database, years 2013-2017, to identify racial disparities associated with SMM for births between April 1, 2014, and November 19, 2017. METHODS: Multiple logistic regression was used to examine the effect of sociodemographic factors and clinical comorbidities on the odds of SMM among non-Hispanic white ("white"), non-Hispanic Black ("Black"), and Hispanic women. RESULTS: The rate of SMM was 227.41 per 10 000 births, with Black women (330 per 10 000 births; 95% CI: 296.16-366.38), having a significantly higher rates than white women (197; 95% CI: 171.72-225.84) and Hispanic women (180; 95% CI: 155.86-207.54). After adjusting for maternal demographics, birth-related clinical variables, and comorbidities, SMM remained higher among Black women (aOR 1.37; 95% CI 1.11-1.70) relative to white women. CONCLUSIONS: Comorbidities, socioeconomic factors, and other factors did not fully explain the Black-white disparities in SMM. Persistent disparities in the rates of SMM throughout 42 days postpartum among Black women relative to white women points to the need for higher quality, more equitable care for women of color in the fist months postpartum.

Application Status Among Women Enrolled in a Healthy Start Program in Arkansas for the Special Nutrition Program for Women and Children.

This study aimed to examine the demographic characteristics of pregnant women in a Healthy Start program who are presumed eligible for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but who have not yet applied for WIC benefits. We used a cross sectional evaluation of data collected from pregnant women (n=203) participating in a Healthy Start program. Data came from surveys administered at enrollment in the Healthy Start program from July 15th, 2019 until January 14th, 2022. The primary outcome was WIC application status, which was determined by whether the woman had applied or was receiving benefits at the time of enrollment. Covariates included race/ethnicity, marital status, insurance, education, income, age, employment, and having previous children/pregnancies. Fisher exact tests and logistic regression were used to examine associations. Approximately 65% of women had not yet applied for WIC benefits. Marshallese women (80.9%) and other NHPI women (80.0%) had the highest need for assistance. In adjusted analyses, White women (p = 0.040) and Hispanic women (p = 0.005) had lower rates of needing assistance applying for WIC than Marshallese women. There were higher rates of needing assistance in applying for women with private insurance or with no insurance and for those with higher incomes. Nearly two out of every three pregnant women who were eligible for WIC had not yet applied for benefits. The findings highlight the need for outreach for all populations that may be eligible, particularly among racial/ethnic minorities and those with higher incomes.

Characteristics of nursing homes with high percentages of falls and falls with injuries among residents with obesity.

BACKGROUND: Obesity among United States nursing home (NH) residents is increasing. These residents have special care needs, which increases their risk for falls and falls with injuries. NH are responsible for ensuring the health of their residents, including minimizing falls. However, given the special care needs of residents with obesity, different factors may be important for developing programs to minimize falls among this group. AIM: We aimed to identify NH characteristics associated with falls and falls with injuries among residents with obesity. METHOD: We used resident assessment data and logistic regression analysis. RESULTS: We found that rates of falls and falls with injuries among residents with obesity varied significantly based on for-profit status, size, acuity index, obesity rate among residents, and registered nurse hours per patient day. CONCLUSION: Recommendations are made as to how NH may be able to lower risk for falls and falls with injuries among their residents with obesity.

Characteristics of Nursing Homes with High Rates of Urinary Tract Infections among Their Residents with Obesity.

Nursing home residents with obesity are at high risk for contracting urinary tract infections. In this research study, we found nursing homes in multi-facility chain organizations, for-profit status, nursing home size, obesity rate of resident population, and market competition were significantly associated with rates of urinary tract infections among residents with obesity.

Individual and Health Policy Factors Associated With Positive Heroin and Opioid Treatment Response: United States, 2018.

Objectives. To identify client- and state-level factors associated with positive treatment response among heroin and opioid treatment episodes in the United States. Methods. We used national data from 46 states using the Treatment Episode Dataset‒Discharges (2018) to identify heroin and opioid treatment episodes (n = 162 846). We defined positive treatment response as a decrease in use between admission and discharge. We used multivariable regression, stratified by race/ethnicity, to identify demographic, pain-related, and state-level factors associated with positive treatment response. Results. Lower community distress was the strongest predictor of better treatment outcomes across all racial/ethnic groups, particularly among White and American Indian/Alaska Native episodes. A primary opioid of heroin was associated with worse outcomes among White and Hispanic episodes. Legislation limiting opioid dispensing was associated with better outcomes among Hispanic episodes. Buprenorphine availability was strongly associated with better outcomes among Black episodes. Conclusions. State-level variables, particularly community distress, had greater associations with positive treatment outcomes than client-level variables. Public Health Implications. Changes in state-level policies and increased resources directed toward areas of high community distress have the potential to improve opioid use disorder treatment and reduce racial/ethnic disparities in treatment outcomes. (Am J Public Health. 2022;112(S1):S66-S76. https://doi.org/10.2105/AJPH.2021.306503).

SARS-CoV-2 Incidence in K-12 School Districts with Mask-Required Versus Mask-Optional Policies - Arkansas, August-October 2021.

Masks are effective at limiting transmission of SARS-CoV-2, the virus that causes COVID-19 (1), but the impact of policies requiring masks in school settings has not been widely evaluated (2-4). During fall 2021, some school districts in Arkansas implemented policies requiring masks for students in kindergarten through grade 12 (K-12). To identify any association between mask policies and COVID-19 incidence, weekly school-associated COVID-19 incidence in school districts with full or partial mask requirements was compared with incidence in districts without mask requirements during August 23-October 16, 2021. Three analyses were performed: 1) incidence rate ratios (IRRs) were calculated comparing districts with full mask requirements (universal mask requirement for all students and staff members) or partial mask requirements (e.g., masks required in certain settings, among certain populations, or if specific criteria could not be met) with school districts with no mask requirement; 2) ratios of observed-to-expected numbers of cases, by district were calculated; and 3) incidence in districts that switched from no mask requirement to any mask requirement were compared before and after implementation of the mask policy. Mean weekly district-level attack rates were 92-359 per 100,000 persons in the community* and 137-745 per 100,000 among students and staff members; mean student and staff member vaccination coverage ranged from 13.5% to 18.6%. Multivariable adjusted IRRs, which included adjustment for vaccination coverage, indicated that districts with full mask requirements had 23% lower COVID-19 incidence among students and staff members compared with school districts with no mask requirements. Observed-to-expected ratios for full and partial mask policies were lower than ratios for districts with no mask policy but were slightly higher for districts with partial policies than for those with full mask policies. Among districts that switched from no mask requirement to any mask requirement (full or partial), incidence among students and staff members decreased by 479.7 per 100,000 (p<0.01) upon implementation of the mask policy. In areas with high COVID-19 community levels, masks are an important part of a multicomponent prevention strategy in K-12 settings (5).

Nursing home directors of nursing experiences regarding safety among residents with obesity.

The prevalence of nursing home (NH) residents with obesity is rising. Perspectives of NH Directors of Nursing (DONs) who oversee care trajectories for residents with obesity is lacking. This study aimed to describe the experiences of NH DONs regarding care and safety for NH residents with obesity. An adapted version of Donabedian's structure-process-outcome model guided this qualitative descriptive study. Semi-structured interviews were conducted with 15 DONs. Data were analyzed using directed content analysis, and findings are presented under the model's constructs. We learned that admission decisions for NH referrals of patients with obesity are complex due to reimbursement issues, available space and resources, and resident characteristics. DONs described the need to coach and mentor Certified Nursing Assistants to provide safe quality care and that more staff education is needed. We identified novel findings regarding the challenges of short-term residents' experience transitioning out of care due to limited resources.

Cardiac Manifestation among Children with Hemolytic Uremic Syndrome.

OBJECTIVE: The primary objectives of the study were to describe the association between cardiac manifestations and in-hospital mortality among children with hemolytic uremic syndrome. STUDY DESIGN: Using the Pediatric Health Information System database, this retrospective, multicenter, cohort study identified the first hemolytic uremic syndrome-related inpatient visit among children ≤18 years (years 2004-2018). The frequency of selected cardiac manifestations and mortality rates were calculated. Multivariate analysis identified the association of specific cardiac manifestations and the risk of in-hospital mortality. RESULTS: Among 3915 patients in the analysis, 238 (6.1%) had cardiac manifestations. A majority of patients (82.8%; n = 197) had 1 cardiac condition and 17.2% (n = 41) had ≥2 cardiac conditions. The most common cardiac conditions was pericardial disease (n = 102), followed by congestive heart failure (n = 46) and cardiomyopathy/myocarditis (n = 34). The percent mortality for patients with 0, 1, or ≥2 cardiac conditions was 2.1%, 17.3%, and 19.5%, respectively. Patients with any cardiac condition had an increased odds of mortality (OR, 9.74; P = .0001). In additional models, the presence of ≥2 cardiac conditions (OR, 9.90; P < .001), cardiac arrest (OR, 38.25; P < .001), or extracorporeal membrane oxygenation deployment (OR, 11.61; P < .001) were associated with increased risk of in-hospital mortality. CONCLUSIONS: This study identified differences in in-hospital mortality based on the type of cardiac manifestations, with increased risk observed for patients with multiple cardiac involvement, cardiac arrest, and extracorporeal membrane oxygenation deployments.

Association of the COVID-19 pandemic and dying at home due to ischemic heart disease.

The coronavirus disease 2019 (COVID-19) pandemic has been associated with a declining volume of patients seen in the emergency department. Despite the need for seeking urgent care for conditions such as myocardial infarction, many people may not seek treatment. This study seeks to measure associations between the COVID-19 pandemic and location of death among individuals who died from ischemic heart disease (IHD). Data obtained from death certificates from the Arkansas Department of Health was used to conduct a difference-in-difference analysis to assess whether decedents of IHD were more likely to die at home during the pandemic (March 2020 through September 2020). The analysis compared location of death for decedents of IHD pre and during the pandemic to location of death for decedents from non-natural causes. Before the pandemic, 50.0% of decedents of IHD died at home compared to 57.9% dying at home during (through September 2020) the pandemic study period (p < .001). There was no difference in the proportion of decedents who died at home from non-natural causes before and during the pandemic study period (55.8% vs. 53.5%; p = .21). After controlling for confounders, there was a 48% increase in the odds of dying at home from IHD during the pandemic study period (p < .001) relative to the change in dying at home due to non-natural causes. During the study period, there was an increase in the proportion of decedents who died at home due to IHD. Despite the ongoing pandemic, practitioners should emphasize the need to seek urgent care during an emergency.

The State of Neonatal and Pediatric Interfacility Transport During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has altered the provision of health care, including interfacility transport of critically ill neonatal and pediatrics patients. Transport medicine faces unique challenges in the care of persons infected with the severe acute respiratory syndrome coronavirus 2. In particular, the multitude of providers, confined spaces for prolonged time periods, varying modes (ground, rotor wing, and fixed wing) of transport, and the need for frequent aerosol-generating procedures place transport personnel at high risk. This study describes the clinical practices, personal protective equipment, and potential exposure risks of a large cohort of neonatal and pediatric interfacility transport teams. METHODS: Data for this study came from a survey distributed to members of the American Academy of Pediatrics Section on Transport Medicine. RESULTS: Fifty-four teams responded, and 47 reported transporting COVID-19-positive patients. Among the 47 teams, 25% indicated having at least 1 team member convert to COVID-19 positive. A small percentage of teams (40% ground, 40% fixed wing, and 18% rotor wing) reported allowing parental accompaniment during transport. There was no difference in teams with a positive team member among those that do (26%) and do not (25%) allow parents. There was a higher percentage of teams with a positive team member among teams that intubate (32% vs. 0%) and place laryngeal mask airways (34% vs. 0%) during transport. CONCLUSION: Our study shows that exceptional care during interfacility transport, including a family-centered approach, can continue during the COVID-19 pandemic. Teams must take steps to protect themselves, as well as the patients and families they serve, in order to mitigate the transmission of the SARS-CoV-2 virus.

Association of Insurance Status With Treatment and Outcomes in Pediatric Patients With Severe Traumatic Brain Injury.

OBJECTIVE: To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank. DESIGN: Retrospective cohort study. SETTING: National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States. PATIENTS: Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007-2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001). CONCLUSIONS: Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.

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

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