Racial, ethnic, and rural disparities in distance to physicians among decedents with Alzheimer's disease and related dementias in Washington State.

INTRODUCTION: Distance to physicians may explain some of the disparities in Alzheimer's disease and related dementia (AD/ADRD) outcomes. METHODS: We generated round trip distance between residences of decedents with AD/ADRD and the nearest neurologist and primary care physician in Washington State. RESULTS: The overall mean distance to the nearest neurologist and primary care physician was 17 and 4 miles, respectively. Non-Hispanic American Indian and/or Alaska Native and Hispanic decedents would have had to travel 1.12 and 1.07 times farther, respectively, to reach the nearest neurologist compared to non-Hispanic White people. Decedents in micropolitan, small town, and rural areas would have had to travel 2.12 to 4.01 times farther to reach the nearest neurologist and 1.14 to 3.32 times farther to reach the nearest primary care physician than those in metropolitan areas. DISCUSSION: These results underscore the critical need to identify strategies to improve access to specialists and primary care physicians to improve AD/ADRD outcomes. HIGHLIGHTS: Distance to neurologists and primary care physicians among decedents with AD/ADRD American Indian and/or Alaska Native decedents lived further away from neurologists Hispanic decedents lived further away from neurologists Non-metropolitan decedents lived further away from neurologists and primary care Decrease distance to physicians to improve dementia outcomes.

Trends in Alzheimer Disease Mortality Among American Indian and Alaska Native People Between 2011 and 2019.

PURPOSE: The number of American Indian and Alaska Native (AI/AN) people living with dementia is expected to increase 5-fold by 2060. Social determinants of health may explain disparities in the incidence of Alzheimer disease (AD) but remain largely overlooked. METHODS: We examined the time trend of AD mortality rates and associations of the percentage of AI/ANs, density of primary care physicians and neurologists, area deprivation index, rurality, and Indian Health Service region with AD mortality in 646 purchased/referred care delivery area counties. RESULTS: AD mortality rates significantly increased over time. Counties with higher concentrations of AI/AN people had lower AD mortality. More deprived counties had 34% higher AD mortality compared with less deprived counties. AD mortality was 20% lower in nonmetro counties than in metro counties. CONCLUSIONS: Findings have implications for prioritizing areas where more resources for AD care, education, or outreach are needed.

Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids.

Background: An exemption to existing U.S. regulation of methadone maintenance therapy after the onset of the COVID-19 pandemic permitted increased take-home doses beginning March 2020.Objectives: We assessed the impact of this exemption on opioid use.Methods: A pre/post study of 187 clients recruited from an OTP who completed a survey and consented to share their urine drug testing (UDT) data. Use of fentanyl, morphine, hydromorphone, codeine, and heroin was assessed via UDT. Receipt of take-home methadone doses was assessed from clinic records for 142 working days pre- and post-COVID exemption. Analysis was conducted using a linear regression model to assess the association between increased take-home doses and use of illicit opioids.Results: In the pre- vs. post-COVID-19 SAMHSA exemption periods, 26.2% vs. 36.3% of UDTs were positive for 6-acetylmorphine respectively, 32.6% vs. 40.6% positive for codeine, 34.2% vs 44.2% positive for hydromorphone, 39.5% vs. 48.1% positive for morphine, 8.0% vs. 14.4% positive for fentanyl (p-value < .001). However, in the unadjusted descriptive data, when grouped by change in substance use, those clients who experienced a decrease in the use of morphine, codeine, and heroin post-COVID-19 were given significantly more take-home doses than the groups that had no change or an increase in the use of these substances. In the adjusted model, there was no significant relationship between change in opioid use and increased receipt of take-home methadone doses.Conclusions: Although take-home doses post-COVID-19 nearly doubled, this increase was not associated with a significant change in use of illicit opioids.

Yakima County Incidence Rates of Sexually Transmitted Infections From 2013 to 2018 in Urban-Rural and Area-Deprivation Continua.

BACKGROUND: This study aimed to examine variations in the incidence rates of sexually transmitted infections (STIs; i.e., chlamydia, gonorrhea, and syphilis) across the urban-rural and area-deprivation continua from January of 2013 to December of 2018 in Yakima County, Washington. The rates of STIs has been increasing in the United States in the past decade. Historically, Yakima County has higher rates of STIs than state and national rates. In addition, Yakima County contains rural areas and areas with greater deprivation that face gaps in access to care. METHODS: The Washington State Department of Health Database Surveillance System was used to conduct the study. The data set included diagnosed cases of chlamydia, gonorrhea, and syphilis with positive laboratory test results for the duration of the study period. Incidence rates of STIs were calculated and statistically analyzed across the urban-rural and area-deprivation continua using rural-urban commuting area codes and the area deprivation index. RESULTS: The incidence rates of STIs increased from January of 2013 to December of 2018. Rates of STI did not differ in micropolitan, small town, and rural block groups compared with the metropolitan block groups. Most-deprived block groups had significantly higher STI rates compared with less deprived block groups. CONCLUSIONS: There is a need for increased STI intervention in higher deprivation areas including STI education. Public health officials and health care providers should be aware of these risk factors and tailor interventions to the neighborhood they serve.

Disparities in Access to Radiation Therapy by Race and Ethnicity in the United States With Focus on American Indian/Alaska Native People.

OBJECTIVES: Striking disparities in access to radiation therapy (RT) exist, especially among racial and ethnic-minority patients. We analyzed census block group data to evaluate differences in travel distance to RT as a function of race and ethnicity, socioeconomic status, and rurality. METHODS: The Directory of Radiotherapy Centers provided the addresses of facilities containing linear accelerators for RT. We classified block groups as majority (≥ 50%) American Indian/Alaska Native (AI/AN), black, white, Asian, no single racial majority, or Hispanic regardless of race. We used the Area Deprivation Index to classify deprivation and Rural-Urban Commuting Area codes to classify rurality. Generalized linear mixed models tested associations between these factors and distance to nearest RT facility. RESULTS: Median distance to nearest RT facility was 72 miles in AI/AN-majority block groups, but 4 to 7 miles in block groups with non-AI/AN majorities. Multivariable models estimated that travel distances in AI/AN-majority block groups were 39 to 41 miles longer than in areas with non-AI/AN majorities. Travel distance was 1.3 miles longer in the more deprived areas versus less deprived areas and 16 to 32 miles longer in micropolitan, small town, and rural areas versus metropolitan areas. CONCLUSIONS: Cancer patients in block groups with AI/AN-majority populations, nonmetropolitan location, and low socioeconomic status experience substantial travel disparities in access to RT. Future research with more granular community- and individual-level data should explore the many other known barriers to access to cancer care and their relationship to the barriers posed by distance to RT care.

Promoting risk reduction among young adults with asthma during wildfire smoke: A feasibility study.

OBJECTIVE(S): This study explored the feasibility, acceptability, preliminary impact, and functionality of two risk reduction mobile application (app) interventions on asthma outcomes as compared to a control arm during wildfire season. DESIGN: Three-arm, 8-week randomized clinical trial. SAMPLE: Sixty-seven young adults with asthma were enrolled. MEASUREMENTS: The Asthma Control Test, forced expiratory volume in one second (FEV1 ) and the System Usability Scale were measured at baseline, 4, and 8 weeks. The Research Attitude Scale was administered at 8 weeks. Twenty participants from the two intervention arms completed an optional survey and six were interviewed after completing the study. INTERVENTION: Both intervention arms could access Smoke Sense Urbanova, an app that supports reducing risks from breathing wildfire smoke. The Smoke Sense Urbanova Plus arm also monitored their daily FEV1 , received air quality notifications, and accessed preventive tips and a message board. RESULTS: Most participants agreed the app and spirometer were usable and their privacy and confidentiality were maintained. No adverse events were reported. CONCLUSIONS: Participant-identified recommendations will support intervention refinement and testing. This research supports asthma self-management tools that public health nurses and community health workers can recommend for at-risk populations.

Geographic Disparities in Access to Specialty Care Programs for Early Psychosis in Washington State.

Supported by the 10% set-aside funds in the Community Mental Health Block grant, distributed at the state level, coordinated specialty care (CSC) have been widely disseminated throughout the U.S. This study explores variations in the geographical accessibility of CSC programs by neighborhood level characteristics in Washington State. CSC locations were geocoded. Socioeconomic neighborhood deprivation (i.e., Area deprivation index) and rurality (i.e., Rural-Urban Commuting Area codes) were neighborhood level characteristics extracted from the 2018 American Community Survey. Geographic accessibility of CSC was assessed using a two-step floating catchment area technique and multilevel linear models were used to examine the association between specific neighborhood characteristics and geographic accessibility. The association between access and socioeconomically deprived neighborhoods varied differentially by neighborhood rurality (an interaction effect). Model estimates indicated that the least deprived, metropolitan neighborhoods had the best access (M = 0.38; CI: 0.34, 0.42) and rural neighborhoods in the second most deprived quartile had the worst access (M = 0.16; CI: 0.11, 0.21) to CSC. There was a clear decrease in accessibility for more rural neighborhoods, regardless of other neighborhood characteristics. In conclusions, findings provide important insight into how resource distribution contributes to geographic disparities in access to CSC. The use of spatial analytic techniques has the potential to identify specific neighborhoods and populations where there is a need to expand and increase availability of CSC to ensure access to rural and socioeconomically deprived neighborhoods.

Disparities in Access to Opioid Treatment Programs and Office-Based Buprenorphine Treatment Across the Rural-Urban and Area Deprivation Continua: A US Nationwide Small Area Analysis.

OBJECTIVES: To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States. METHODS: Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis. RESULTS: Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns. CONCLUSIONS: The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems.

Disparities in Technology and Broadband Internet Access Across Rurality: Implications for Health and Education.

Amidst the COVID-19 pandemic, interest in using telehealth to increase access to health and mental health care has grown, and school transitions to remote learning have heightened awareness of broadband inequities. The purpose of this study was to examine access and barriers to technology and broadband Internet service ("broadband") among rural and urban youth. Washington State public school districts were surveyed about youth's access to technology (ie, a device adequate for online learning) and broadband availability in spring 2020. Availability of and barriers to broadband (ie, geography, affordability, and smartphone-only connectivity) were assessed across rurality. Among responding districts, 64.2% (n = 172) were rural and 35.8% (n = 96) were urban. Rural districts reported significantly fewer students with access to an Internet-enabled device adequate for online learning (80.0% vs 90.1%, P < .01). Access to reliable broadband varied significantly across geography (P < .01). Compared with their urban peers, rural youth face more challenges in accessing the technology and connectivity needed for remote learning and telehealth. Given that inadequate broadband infrastructure is a critical barrier to the provision of telehealth services and remote learning in rural areas, efforts to improve policies and advance technology must consider geographical disparities to ensure health and education equity.

The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era.

BACKGROUND: Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. OBJECTIVE: To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. METHODS: A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. RESULTS: Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. CONCLUSIONS: Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.

The Association Between Obesity, Socio-Economic Status, and Neighborhood Environment: A Multi-Level Analysis of Spokane Public Schools.

Socio economic inequities in obesity have been attributed to individuals' psychosocial and behavioral characteristics. School environment, where children spend a large part of their day, may play an important role in shaping their health. This study aims to assess whether prevalence of overweight and obesity among elementary school students was associated with the school's social and built environments. Analyses were based on 28 public elementary schools serving a total of 10,327 children in the city of Spokane, Washington. Schools were classified by percentage of students eligible for free and reduced meals (FRM). Crime rates, density of arterial roads, healthy food access, and walkability were computed in a one-mile walking catchment around schools to characterize their surrounding neighborhood. In the unadjusted multilevel logistic regression analyses, age, sex, percentage of students eligible for FRM, crime, walkability, and arterial road exposure were individually associated with the odds of being overweight or obese. In the adjusted model, the odds of being overweight or obese were higher with age, being male, and percentage of students eligible for FRM. The results call for policies and programs to improve the school environment, students' health, and safety conditions near schools.

Rural-Urban Disparities in Access to Medicaid-Contracted Pharmacies in Washington State, 2017.

INTRODUCTION: Community retail pharmacies offer multiple public health services to meet the health care needs of medically underserved rural communities. Many rural residents are enrolled in Medicaid insurance, and it is important that pharmacies contract with Medicaid to meet the health care needs of these people. The objective of this study was to evaluate disparities in access to Medicaid-contracted pharmacies across the rural-urban continuum in Washington State. METHODS: We linked data on licensed community retail pharmacies in Washington State in 2017 to lists of state Medicaid-contracted pharmacies. We classified pharmacies as being located in small rural, large rural, suburban, and urban areas by using rural-urban commuting area (RUCA) codes. We evaluated the likelihood of zip code-level access to at least 1 pharmacy that was contracted with a Medicaid insurance plan across the rural-urban continuum by using descriptive statistics and modified Poisson regression models, adjusted for zip code-level community characteristics. RESULTS: Of 1,145 pharmacies in our study sample, 8.4% (n = 96) were not contracted with a Medicaid plan. Compared with urban core zip codes, small rural zip codes (adjusted relative risk [ARR] = 0.64; 95% CI, 0.46-0.91) and large rural zip codes (ARR = 0.68; 95% CI, 0.49-0.95) were significantly less likely to have access to a Medicaid-contracted pharmacy. Suburban zip codes did not differ significantly from urban core areas in their access to Medicaid-contracted pharmacies. CONCLUSION: In Washington State, the likelihood of access to a Medicaid-contracted pharmacy decreased significantly as rurality increased. Policy efforts should aim to improve access for Medicaid enrollees, especially those outside urban centers.

Spatial access to opioid treatment program and alcohol and cannabis outlets: analysis of missed doses of methadone during the first, second, and third 90 days of treatment.

Background: The burden of access to opioid treatment programs (OTPs) may change as clients become eligible for take-home privileges. Our previous study showed clients who lived more than 10-miles away from an OTP were more likely to miss methadone doses during the first 30 days of treatment. Proximity to alcohol and cannabis outlets may also negatively influence treatment adherence.Objective: To examine the association between access to this OTP, alcohol and cannabis outlets, and the number of missed methadone doses during the first, second, and third 90 days of treatment.Methods: The number of missed methadone doses was calculated for 752, 689, and 584 clients who remained in treatment, respectively, for at least 3, 6, and 9 months (50% female). Distance between client's home and the OTP, alcohol, and cannabis outlets was measured. Generalized linear models were employed.Results: Shorter distance from a client's residence to the OTP was associated with a decreased number of missed methadone doses during the first 90 days of treatment. Shorter distance to the closest cannabis retail outlet was associated with an increased number of missed methadone doses during the first and second 90 days of treatment. Shorter distance to the closest off-premise alcohol outlet was associated with an increased number of missed methadone doses during the third 90 days of treatment.Conclusions: Improving spatial accessibility of OTPs are essential to ensure treatment opportunities are available for individuals so affected. Exploring to what extent residing in areas that facilitate alcohol and cannabis availability can influence treatment adherence is warranted.

Urban green and blue spaces and general and mental health among older adults in Washington state: Analysis of BRFSS data between 2011-2019.

A growing body of evidence highlights the significant effect of built environment features on mental and general health. This study examined the association between distance to and percentage of green and blue space measures and serious psychological distress, general health, and frequent mental distress among older adults living in urban ZIP codes in Washington state. Percentage of green space, particularly tree canopy and forest space, was significantly associated with better self-rated general health and reduced odds of serious psychological distress. Closer distance to blue space was associated with better self-rated general health. Programs which incentivize exposure to green and blue spaces for urban-dwelling, older adults may improve health outcomes.

Disparities in access to opioid treatment programs and buprenorphine providers by race and ethnicity in the contiguous U.S.

BACKGROUND: The burden of drug overdose mortality varies by race and ethnicity, with American Indian/Alaska Native (AI/AN), Black, and White people experiencing the largest burden. We analyzed census block group data to evaluate differences in travel distance to opioid treatment programs (OTP) and buprenorphine providers by race and ethnicity. METHODS: The Substance Abuse and Mental Health Services Administration provided the addresses of OTPs and buprenorphine providers. The study classified block groups as majority (≥50 %) AI/AN, Black, Asian, White, no single racial majority, or Hispanic. We classified deprivation and rurality using the Area Deprivation Index and Rural-Urban Commuting Area codes. The study applied generalized linear mixed models. RESULTS: Among all block groups, the median road distance to the nearest OTPs and buprenorphine providers was 8 and 2 miles, respectively. AI/AN-majority block groups had the longest median distances to OTPs (88 miles versus 4-10 miles) and buprenorphine providers (17 miles versus 1-3 miles) compared to other racial or ethnic majority block groups. For OTPs and buprenorphine providers, travel distances were slightly greater in more deprived block groups compared to less deprived block groups. The median distance to the nearest OTPs and buprenorphine providers were larger in micropolitan and small town/rural block groups compared to metropolitan areas. CONCLUSIONS: Disparities exist in travel distance to OTPs and buprenorphine providers. People in block groups with AI/AN-majority, nonmetropolitan, or more deprived designation experience travel disparities accessing treatment. Future research should develop targeted interventions to reduce access to care disparities for individuals with opioid use disorder.

Machine learning-driven identification of air toxic combinations associated with asthma symptoms among elementary school children in Spokane, Washington, USA.

Air toxics are atmospheric pollutants with hazardous effects on health and the environment. Although methodological constraints have limited the number of air toxics assessed for associations with health and disease, advances in machine learning (ML) enable the assessment of a much larger set of environmental exposures. We used ML methods to conduct a retrospective study to identify combinations of 109 air toxics associated with asthma symptoms among 269 elementary school students in Spokane, Washington. Data on the frequency of asthma symptoms for these children were obtained from Spokane Public Schools. Their exposure to air toxics was estimated by using the Environmental Protection Agency's Air Toxics Screening Assessment and National Air Toxics Assessment. We defined three exposure periods: the most recent year (2019), the last three years (2017-2019), and the last five years (2014-2019). We analyzed the data using the ML-based Data-driven ExposurE Profile (DEEP) extraction method. DEEP identified 25 air toxic combinations associated with asthma symptoms in at least one exposure period. Three combinations (1,1,1-trichloroethane, 2-nitropropane, and 2,4,6-trichlorophenol) were significantly associated with asthma symptoms in all three exposure periods. Four air toxics (1,1,1-trichloroethane, 1,1,2,2-tetrachloroethane, BIS (2-ethylhexyl) phthalate (DEHP), and 2,4-dinitrophenol) were associated only in combination with other toxics, and would not have been identified by traditional statistical methods. The application of DEEP also identified a vulnerable subpopulation of children who were exposed to 13 of the 25 significant combinations in at least one exposure period. On average, these children experienced the largest number of asthma symptoms in our sample. By providing evidence on air toxic combinations associated with childhood asthma, our findings may contribute to the regulation of these toxics to improve children's respiratory health.

Patterns of mean age at drug use initiation by race and ethnicity, 2004-2019.

INTRODUCTION: Adolescent drug use can result in clinically significant psychiatric outcomes later in life mitigated by targeted prevention strategies. While mean age of drug initiation has increased over time, there is little research of mean age of drug initiation among adolescents by race/ethnicity. METHODS: The study used the National Survey on Drug Use and Health data (2004-2019). Sample included individuals aged 12 to 21 years. Year-by-year drug use initiation (i.e., first-time use within the past year) trends examined for each drug by race/ethnicity using jointpoint regression. RESULTS: Sample included 95,022 initiates for any of 18 drugs. Year-by-year mean initiation age significantly increased for alcohol (except Non-Hispanic [NH] White, 2004-2012), tobacco cigarettes (except NH American Indian/Alaska Native [AI/AN]), cigars, marijuana (except NH Asian or Pacific Islander, NH Multiracial), cocaine (except NH Black). Significant increase in mean initiation age found for heroin (Hispanic/Latinx only), hallucinogens (NH White, NH Black only), LSD (NH White only), methamphetamines (NH White only), smokeless tobacco (NH White, NH Black only), inhalants (only NH White, NH AI/AN; NH Multiracial, 2004-2011), sedatives (NH White, Hispanic/Latinx only), stimulants (NH White, Hispanic/Latinx only), and ecstasy (NH White, NH Black, Hispanic/Latinx only). Significant decrease in mean initiation age found for alcohol (only NH White, 2013-2019), smokeless tobacco (only Hispanic/Latinx, 2015-2019; NH AI/AN, 2012-2019), and inhalants (only NH Multiracial, 2012-2019). CONCLUSION: Mean initiation age differed widely by race/ethnicity. Mean initiation age in most racial/ethnic groups increased for several drugs including alcohol, marijuana, and tobacco products and decreased for some drugs such as inhalants. These findings could help inform groups to target for future prevention strategies.

Budget Impact Tool for Implementing Contingency Management for Co-occurring Alcohol Use Disorders and Serious Mental Illness.

OBJECTIVE: Contingency management (CM) is a behavioral intervention in which tangible incentives are provided to patients when they achieve a desired behavior (e.g., reducing or abstaining from alcohol use). The authors sought to describe the resource requirements and associated costs of various CM versions (usual, high magnitude, and shaping) tailored to a high-risk population with co-occurring serious mental illness and severe alcohol use disorder. METHODS: A microcosting analysis was conducted to identify the resource requirements of the different CM versions. This approach included semistructured interviews with site investigators, who also staffed the intervention. The resource costing method-multiplying the number of units of each resource utilized by its respective unit cost-was used to value the resources from a provider's perspective. All cost estimates were calculated in 2021 U.S. dollars. RESULTS: The cost of setting up a CM program was $6,038 per site. Assuming full capacity and 56% of urine samples meeting the requirement for receipt of the CM incentive, the average cost of 16 weeks of usual and shaping CM treatments was $1,119-$1,136 and of high-magnitude CM was $1,848-$1,865 per participant. CONCLUSIONS: A customizable tool was created to estimate the costs associated with various levels of treatment success and CM design features. After the trial, the tool will be updated and used to finalize per-participant cost for incorporation into a comprehensive economic evaluation. This costing tool will help a growing number of treatment providers who are interested in implementing CM with budgeting for and sustaining CM in their practices.

Travel Burden to Cancer Screening and Treatment Facilities Among Washington Women: Data From an Integrated Healthcare Delivery System.

PURPOSE: To characterize distance traveled for breast cancer screening and to sites of service for breast cancer treatment, among rural and urban women served by a Washington State healthcare network. METHODS: Data for this study came from one of the largest not-for-profit integrated healthcare delivery systems in Washington State. Generalized linear mixed models with gamma log link function were used to examine the associations between travel distance and sociodemographic and contextual characteristics of patients. RESULTS: Median travel distance for breast cancer screening facilities, hematologist/oncologists, radiation oncologists, or surgeons was 11, 19, 23, or 11 miles, respectively. Travel distance to breast cancer screening or referral facilities was longer in non-core metropolitan ZIP codes compared to metropolitan ZIP codes. AI/AN and Hispanic women travelled longer distances to reach referral facilities compared to other racial and ethnic groups. CONCLUSION: Disparities exist in travel distance to breast cancer screening and treatment. Further research is needed to describe sociodemographic and system level characteristics that contribute to such disparities and to discover novel approaches to alleviate this burden.

Geographic Disparities in the Availability of Mental Health Services in U.S. Public Schools.

INTRODUCTION: The purpose of this study was to examine geographic variation in the availability of and barriers to school-based mental health services. METHODS: A weighted, nationally representative sample of U.S. public schools from the 2017-2018 School Survey on Crime and Safety was used. Schools reported the provision of diagnostic mental health assessments and/or treatment as well as factors that limited the provision of mental health services. Availability of mental health services and factors limiting service provision were examined across rurality, adjusting for school enrollment and grade level. The analysis was conducted in December 2021. RESULTS: Half (51.2%) of schools reported providing mental health assessments, and 38.3% reported providing treatment. After adjusting for enrollment and grade level, rural schools were 19% less likely, town schools were 21% less likely, and suburban schools were 11% less likely to report providing mental health assessments than city schools. Only suburban schools were less likely than city schools to provide mental health treatment (incidence rate ratio=0.85; 95% CI=0.72, 1.00). Factors limiting the provision of services included inadequate access to professionals (70.9%) and inadequate funding (77.0%), which were most common among rural schools. CONCLUSIONS: Significant inequities in school-based mental health services exist outside of urban areas.