Telomere Length and Preterm Birth in Pregnant Mexican-Origin Women.

OBJECTIVES: Despite the obstacles of limited education and employment opportunities-and the stress associated with immigration and pregnancy-Mexican immigrant women have low rates of preterm birth (PTB) compared to the US national average for all races and ethnicities. Stressors during pregnancy, and stressors associated with acculturation, may accelerate cellular aging manifested by shortened telomere length (TL) in pregnant women. Our objectives were to: (1) determine whether women with PTBs had shorter telomere lengths compared to women who had full term births; (2) assess the association of acculturation with TL and PTB. METHODS: This prospective pilot study collected data from 100 self-identified Mexican-origin pregnant women. Survey data included self-administered sociodemographic and acculturation measures and was collected from participants via paper and pen, while biologic data was collected via a single blood draw during a regularly scheduled prenatal visit between 26 and 36 weeks gestation. PTB data was collected from the participant's medical record after delivery. RESULTS: TL was significantly associated with PTB; the median TL of the women with PTB was less than the median TL for the full sample (p = 0.02). Based on regression analysis for PTB vs acculturation, we found no significant associations between acculturation and PTB or TL. CONCLUSIONS FOR PRACTICE: This study provides important evidence of the association between shortened maternal TL and adverse birth outcomes. By linking social, clinical and biologic data, we can enhance our understanding of social determinants that may affect racial and ethnic disparities in preterm birth.

Texting-While-Driving Bans and Motor Vehicle Crash-Related Emergency Department Visits in 16 US States: 2007-2014.

OBJECTIVES: To examine the impact of state texting bans on motor vehicle crash (MVC)-related emergency department (ED) visits. METHODS: We used ED data from 16 US states between 2007 and 2014. We employed a difference-in-difference approach and conditional Poisson regressions to estimate changes in counts of MVC-related ED visits in states with and without texting bans. We also constructed age cohorts to explore whether texting bans have differential impacts by age group. RESULTS: On average, states with a texting ban saw a 4% reduction in MVC-related ED visits (incidence rate ratio = 0.96; 95% confidence interval = 0.96, 0.97). This equates to an average of 1632 traffic-related ED visits prevented per year in states with a ban. Both primary and secondary bans were associated with significant reductions in MVC-related visits to the ED regardless of whether they were on all drivers or young drivers only. Individuals aged 64 years and younger in states with a texting ban saw significantly fewer MVC-related ED visits following its implementation. CONCLUSIONS: Our findings suggest that states' efforts to curb distracted driving through texting bans and decrease its negative consequences are associated with significant decreases in the incidence of ED visits that follow an MVC.

Cervical Cancer Screening Barriers and Risk Factor Knowledge Among Uninsured Women.

A steady decline in cervical cancer incidence and mortality in the United States has been attributed to increased uptake of cervical cancer screening tests such as Papanicolau (Pap) tests. However, disparities in Pap test compliance exist, and may be due in part to perceived barriers or lack of knowledge about risk factors for cervical cancer. This study aimed to assess correlates of cervical cancer risk factor knowledge and examine socio-demographic predictors of self-reported barriers to screening among a group of low-income uninsured women. Survey and procedure data from 433 women, who received grant-funded cervical cancer screenings over a span of 33 months, were examined for this project. Data included demographics, knowledge of risk factors, and agreement on potential barriers to screening. Descriptive analysis showed significant correlation between educational attainment and knowledge of risk factors (r = 0.1381, P < 0.01). Multivariate analyses revealed that compared to Whites, Hispanics had increased odds of identifying fear of finding cancer (OR 1.56, 95% CI 1.00-2.43), language barriers (OR 4.72, 95% CI 2.62-8.50), and male physicians (OR 2.16, 95% CI 1.32-3.55) as barriers. Hispanics (OR 1.99, 95% CI 1.16-3.44) and Blacks (OR 2.06, 95% CI 1.15-3.68) had a two-fold increase in odds of agreeing that lack of knowledge was a barrier. Identified barriers varied with age, marital status and previous screening. Programs aimed at conducting free or subsidized screenings for medically underserved women should include culturally relevant education and patient care in order to reduce barriers and improve screening compliance for safety-net populations.

The Impact of Immigration Policy Changes on Preterm Birth Rates in Texas: An Examination of Border and Nonborder Regions.

BACKGROUND: Our study examined the acute and sustained impact of immigration policy changes announced in January 2017 on preterm birth (PTB) rates among Hispanic and non-Hispanic white women in Texas's border and nonborder regions. METHODS: Using Texas birth certificate data for years 2008 through 2020, we used a multiple group interrupted time series approach to explore changes in PTB rates. RESULTS: In the nonborder region, the PTB rate among Hispanic women of any race was 8.64% in 2008 and was stable each year before 2017 but increased by .29% (95% CI [.12, .46]) annually between 2017 and 2020. This effect remained statistically significant even when compared with that of non-Hispanic white women (p = .014). In the border areas, the PTB rate among Hispanic women of any race was 11.67% in 2008 and remained stable each year before and after 2017. No significant changes were observed when compared with that of non-Hispanic white women (p = .897). In Texas as a whole, the PTB rate among Hispanic women of any race was 10.16% in 2008 and declined by .07% (95% CI [-.16, -.03]) per year before 2017, but increased by .16% (95% CI [.05, .27]) annually between 2017 and 2020. The observed increase was not statistically significant when compared with that of non-Hispanic white women (p = .326). CONCLUSIONS: The January 2017 immigration policies were associated with a sustained increase in PTB among Hispanic women in Texas's nonborder region, suggesting that geography plays an important role in perceptions of immigration enforcement. Future research should examine the impact of immigration policies on maternal and child health, considering geography and sociodemographic factors.

Travel for medical or dental care by race/ethnicity and rurality in the U.S.: Findings from the 2001, 2009 and 2017 National Household Travel Surveys.

The travel burden for medical or dental care is a well-documented barrier to healthcare access, particularly in rural areas. There is limited research providing national estimates of the travel trends for medical/dental care, particularly among racial/ethnic groups, and among rural and urban populations. We analyzed data from the 2001, 2009, and 2017 National Household Travel Surveys. Main outcomes were the average travel distance (in miles), average travel time (in minutes), and travel burden, characterized as the percentage of trips lasting ≥ 30 miles or minutes for medical/dental care. We used ordinary least squares and multivariable logistic regressions to examine trends in the travel time/distance and travel burden, controlling for socio-demographic and travel dynamics. Among rural residents, the average travel distance for medical/dental care increased by 17.8% between 2001 and 2017, while no increase was observed among urban residents. Thirty-six percent of trips among rural residents lasted ≥ 30 minutes in 2001 but increased to 47.4% in 2017. Logistic regression estimates show that though Blacks experienced higher odds of a travel time burden compared to Whites, the burden lessened over time. In 2017, urban Blacks (OR = 0.41, 95% C.I. = 0.26,0.66), and rural Blacks (OR = 0.16, 95% C.I. = 0.05,0.55) were less likely to spend ≥ 30 minutes traveling for medical/dental care compared to Whites, using the year 2001 as the baseline. The travel distance and time for medical/dental care have increased in rural areas. However, the travel burden among rural and urban Black residents has decreased. Continuing to alleviate excess burdens of transportation may be beneficial.

Dental hygienists' scope of practice regulations and preventable non-traumatic dental emergency department visits: A cross-sectional study of 10 U.S. states.

OBJECTIVES: As emergency department (ED) visits for non-traumatic dental complaints continue to rise in the United States (U.S.), some states are implementing initiatives to expand access to the oral health workforce. This study examines the associations between the 2014 Dental Hygiene Professional Practice Index (DHPPI) and preventable dental ED visits. METHODS: In 2020, we used ED data from 10 U.S. states and ordinary least squares models to examine the relationship between the states' DHPPI scores and preventable dental ED use. We stratified regressions by age to examine this relationship across different age cohorts and introduced interaction terms to assess the same relationship among rural and urban residents. RESULTS: On average, 23.8% of all non-traumatic dental ED visits were identified as preventable. Controlling for other factors, a one-point increase in DHPPI scores was associated with a decrease of 0.01 (95% CI -0.03, -0.02) preventable dental ED visits per 1000 county population in each year-quarter. In the age-stratified models, the strength of the association between DHPPI scores and preventable dental ED visits was higher in the 20 to 34 (-0.03, 95% CI -0.04, -0.02), and the 35 to 50 age cohorts (-0.17, 95% CI -0.00, -0.00). U.S. states with DHPPI scores below 60 saw significantly higher preventable dental ED visits among rural residents. CONCLUSIONS: This study demonstrates that stringent state policies regarding the dental hygienist workforce are associated with higher preventable dental ED visits in the U.S. Policy makers and stake holders must address the scope of practice policies to alleviate the burden of access to oral healthcare.

Factors associated with hospitalizations for co-occurring HIV and opioid-related diagnoses: Evidence from the national inpatient sample, 2009-2017.

There has been evidence of rising HIV incidence attributable to opioid misuse within some areas of the U.S. The purpose of our study was to explore national trends in co-occurring HIV and opioid-related hospitalizations and to identify their risk factors. We used the 2009-2017 National Inpatient Sample to indicate hospitalizations with co-occurring HIV and opioid misuse diagnoses. We estimated the frequency of such hospitalizations per year. We fitted a linear regression to the annual HIV-opioid co-occurrences with year as a predictor. The resulting regression did not reveal any significant temporal changes. We used multivariable logistic regression to determine the adjusted odds (AOR) of hospitalization for co-occurring HIV and opioid-related diagnoses. The odds of hospitalization were lower for rural residents (AOR = 0.28; CI = 0.24-0.32) than urban. Females (AOR = 0.95, CI = 0.89-0.99) had lower odds of hospitalization than males. Patients identifying as White (AOR = 1.23, CI = 1.00-1.50) and Black (AOR = 1.27, CI = 1.02-1.57) had higher odds of hospitalization than other races. When compared to co-occuring hospitalizations in the Midwest, the odds were higher in the Northeast. (AOR = 2.56, CI = 2.07-3.17) Future research should explore the extent to which similar findings occur in the context of mortality and targeted interventions should intesify for subpopulations at highest risk of co-occuring HIV and opioid misuse diagnoses.

Rural-urban, age, and gender disparities and trends in suicide and homicide: Multistate evidence across 12 years.

PURPOSE: Few studies have simultaneously assessed age and gender trends in homicide and suicide across the rural-urban continuum. Herein, we examine geographic and demographic trends in suicide and homicide death rates by: (1) determining overall macro and disaggregated trends; (2) examining differences in trends based on rural-urban county classification; and (3) identifying differences in stratified trends among age and gender classifications. METHODS: A retrospective study design used suicide and homicide data (n = 199,456) from years 2005to 2017 across 16 US states. Suicide and homicide deaths were grouped by age, gender, and rural-urban classification for descriptive analyses, and trends were analyzed using Joinpoint trend analysis software. FINDINGS: Violence resulted in 142,470 suicide and 56,986 homicide deaths between 2005 and 2017. Among both males and females, overall macro trends of suicide and homicide rates generally increased with greater rurality, and trends in rural rates differed from those in nonrural areas. Joinpoint trend analysis revealed significant increases in male suicide rates in large metropolitan (1.66%), micropolitan (1.78%), and rural areas (1.77%); female suicide rates in large metropolitan (2.17%), small metropolitan (3.25%), and micropolitan areas (3.26%); male homicide rates in large metropolitan areas (10.19%); and female homicide rates in rural areas (8.29%). Finally, when stratified by age, several significant trends were found, including increases in suicide rates among females aged 64 and older in rural areas (11.71%). CONCLUSIONS: Heterogeneous trends were found in suicide and homicide rates within specific rural-urban, age, and gender subgroups. Prevention efforts should proactively target those subgroups identified herein as most at-risk of violence.

Cervical Cancer Screening Outcomes Among a Sample of Low-Income Uninsured Women: A Program-Based Study.

Background: Most studies examining cervical cancer screening outcomes have focused on either an age-specific diagnosis and outcomes of abnormal smears or frequency of abnormal outcomes among a sample of insured women. Thus, it is unclear what the distribution outcomes would be when other sociodemographic characteristics are considered. This study examines the variation in cervical cancer screening outcomes and sociodemographic characteristics (patients' age, marital status, race/ethnicity, rurality, and Papanicolaou [Pap] test screening history) within a sample of low-income and uninsured women. Materials and Methods: Our grant-funded program provided 751 Pap tests, 577 human papillomavirus (HPV) tests, and 262 colposcopies to 841 women between 2013 and 2019. Observed outcomes for each procedure type were cross-tabulated by patients' sociodemographic characteristics. Chi-squared and Fisher's exact tests were used to test the independence of screening outcomes and sociodemographic characteristics. Results: The overall positivity rate was 7.2% for Pap tests (n = 54/751), 3.6% for HPV tests (n = 21/577), and 44.7% for colposcopies (n = 117/262). Significance tests suggested that the Pap test and colposcopy outcomes we observed were independent of sociodemographic characteristics in all but one instance-Pap test outcomes were not independent of patient age (p = 0.009). Moreover, the Pap test positivity rate increased with patient age. Conclusions: Our findings support recommendations to discontinue screening for women older than 65 years at low risk for cervical cancer. Our ability to identify an association between cervical screening outcomes and other sociodemographic characteristics may have been limited by our small sample size. This highlights an important barrier to studying health outcomes within low-income and uninsured populations, which are often missing in larger research data sets (e.g., claims).

The impact of childhood sexual abuse and adverse childhood experiences on adult health related quality of life.

BACKGROUND: Adverse childhood experiences (ACEs) have been shown to be associated with adult physical, psychological, and socioeconomic well-being, indicative of poor health-related quality of life (HRQoL). However, the association between child sexual abuse (CSA) and adult HRQoL, independent of other ACEs, has been less well examined. OBJECTIVES: To examine associations between self-reported CSA, including the nature of CSA, and adult HRQoL. PARTICIPANTS: Data are from 10,624 respondents to CSA and HRQoL questions on the 2015 Texas Behavioral Risk Factor Surveillance System survey. METHODS: Analyses included chi square and t-tests to compare sociodemographic and HRQoL differences among those with and without history of CSA. Multivariable logistic regressions were used to evaluate associations between nature of CSA and HRQoL, controlling for covariates. RESULTS: The prevalence of self-reported CSA in the sample was 10.3%. Compared to the non-exposed group, individuals exposed to CSA were more likely to report their general health as poor (AOR, 1.51; 95% CI, 1.09-2.09), report 14 or more physical unhealthy days (AOR, 1.46; 95% CI, 1.06-2.02), 14 or more mental unhealthy days (AOR, 1.86; 95% CI, 1.30-2.64), and 14 or more activity limitation days (AOR, 2.22; 95% CI, 1.58-3.10) in a month. HRQoL outcomes were worse for respondents who reported being forced to have sex as a child compared with those who reported being touched or forced to touch someone. CONCLUSIONS: Self-reported CSA is associated with lower HRQoL. The association varies by the nature of reported sexual abuse. Understanding the long-term impacts of CSA can inform adult treatment options and policies to prevent and treat CSA.

Mammography Screening Beliefs and Knowledge among a Multi-ethnic Sample of Low-income, Uninsured Women.

The purpose of this study was to examine screening mammography prevalence and its associated beliefs among a multi-ethnic sample of low-income, uninsured women. Data pertaining to the sample's demographic characteristics, mammography screening history and beliefs, and knowledge on recommended screening age were analyzed (n=533). Overall, 22.1% of the participants had never been screened. Black women were more likely than others to have never been screened, White women were more likely to be overdue, and Hispanic women were more likely to report recent screening. Fear of not knowing what will be done during mammography consistently predicted screening among the racial/ethnic groups. Concerns about "people doing mammograms being rude to women" had the highest negative correlation with mammography among Hispanic women. A majority of the sample believed that screening should begin at age 40. Interventions to increase screening mammography must incorporate information about the screening procedure and be sensitive to cultural differences in screening barriers.

Racial, Rural, and Regional Disparities in Diabetes-Related Lower-Extremity Amputation Rates, 2009-2017.

OBJECTIVE: To examine the racial/ethnic, rural-urban, and regional variations in the trends of diabetes-related lower-extremity amputations (LEAs) among hospitalized U.S. adults from 2009 to 2017. RESEARCH DESIGN AND METHODS: We used the National Inpatient Sample (NIS) (2009-2017) to identify trends in LEA rates among those primarily hospitalized for diabetes in the U.S. We conducted multivariable logistic regressions to identify individuals at risk for LEA based on race/ethnicity, census region location (North, Midwest, South, and West), and rurality of residence. RESULTS: From 2009 to 2017, the rates of minor LEAs increased across all racial/ethnic, rural/urban, and census region categories. The increase in minor LEAs was driven by Native Americans (annual percent change [APC] 7.1%, P < 0.001) and Asians/Pacific Islanders (APC 7.8%, P < 0.001). Residents of non-core (APC 5.4%, P < 0.001) and large central metropolitan areas (APC 5.5%, P < 0.001) experienced the highest increases over time in minor LEA rates. Among Whites and residents of the Midwest and non-core and small metropolitan areas there was a significant increase in major LEAs. Regression findings showed that Native Americans and Hispanics were more likely to have a minor or major LEA compared with Whites. The odds of a major LEA increased with rurality and was also higher among residents of the South than among those of the Northeast. A steep decline in major-to-minor amputation ratios was observed, especially among Native Americans. CONCLUSIONS: Despite increased risk of diabetes-related lower-limb amputations in underserved groups, our findings are promising when the major-to-minor amputation ratio is considered.

The association between rurality, sociodemographic characteristics, and mammogram screening outcomes among a sample of low-income uninsured women.

Studies have found a positive association between adherence to mammography screening guidelines and early detection of breast cancer lesions, yet the proportion of women who get screened for breast cancer remains below national targets. Previous studies have found that mammography screening rates vary by sociodemographic factors including race/ethnicity, income, education, and rurality. It is less known whether sociodemographic factors are also related to mammography screening outcomes in underserved populations. Thus, with a particular interest in rurality, we examined the association between the sociodemographic characteristics and mammography screening outcomes within our sample of 1,419 low-income, uninsured Texas women who received grant-funded mammograms between 2013 and 2019 (n = 1,419). Screening outcomes were recorded as either negative (Breast Imaging Reporting and Data System (BI-RADS) classification 1-3) or positive (BI-RADS classification 4-6). When we conducted independency tests between sociodemographic characteristics (age, race/ethnicity, rurality, county-level risk, family history, and screening compliance) and screening outcomes, we found that none of the factors were significantly associated with mammogram screening outcomes. Similarly, when we regressed screening outcomes on age, race/ethnicity, and rurality via logistic regression, we found that none were significant predictors of a positive screening outcome. Though we did not find evidence of a relationship between rurality and mammography screening outcomes, research suggests that among women who do screen positive for breast cancer, rural women are more likely to present with later stage breast cancer than urban women. Thus, it remains important to continue to increase breast cancer education and access to routine cancer screening for rural women.

Emergency department visits for nontraumatic dental conditions: a systematic literature review.

OBJECTIVE: To summarize the literature on factors associated with emergency department (ED) use for nontraumatic dental conditions (NTDCs). METHODS: Following a database search, empirical studies were included if they examined factors associated with ED visits for NTDCs. The factors identified in these studies were further categorized using the Andersen Behavioral Model. Where appropriate, odds ratios (ORs) predicting the likelihood of NTDC ED visits were extracted to obtain summary estimates using random effects models. RESULTS: Sixty-three articles were included. Nontraumatic dental ED visits made up about 2.2 percent of all ED visits. Having public health insurance coverage such as Medicaid [OR = 2.17, 95 percent confidence interval (CI) = 1.79-2.64], and being uninsured (OR = 2.80, 95 percent CI = 2.39-3.39) were predictive of ED visits for NTDCs. Adults were more likely to use the ED for NTDCs compared to children and older adults. Rural adults had increased odds of ED use for NTDCs compared to urban adults (OR = 1.31, 95 percent CI = 1.12-1.52). Among younger children, regular dental care without sealant placement was associated with increased ED use for NTDCs. In the United States, both expansion and restriction of Medicaid dental coverage for adults were associated with increased ED visits for NTDCs. CONCLUSIONS: Policy makers and health care providers should address modifiable factors such as accessible dental care for the uninsured, and comprehensive dental coverage for those with public dental benefits. Targeted interventions should focus on young adults, children with special needs, and subpopulations with low socioeconomic status and chronic health conditions.

Factors affecting the likelihood of a hospitalization following a diabetes-related emergency department visit: A regional and urban-rural analysis.

BACKGROUND: The objective of this study is to examine place-based and individual-level predictors of diabetes-related hospitalizations that stem from emergency department (ED) visits. METHODS: We conducted a pooled cross-sectional analysis of the National Inpatient Sample (NIS) for 2009 to 2014 to identify ED-initiated hospitalizations that were driven by the need for diabetes care. The odds of an ED-initiated diabetes-related hospitalization were assessed for the United States as a whole and separately for each census region. RESULTS: Nationally, residents of noncore areas (odds ratio [OR] 1.10; CI 1.08, 1.12), the South (OR 8.03; CI 6.84, 9.42), Blacks (OR 2.49; CI 2.47, 2.52), Hispanics (OR 2.32; CI 2.29, 2.35), Asians or Pacific Islanders (OR 1.20; CI 1.16, 1.23), Native Americans (OR 2.18; CI 2.10, 2.27), and the uninsured (OR 2.14; CI 2.11, 2.27) were significantly more likely to experience an ED-initiated hospitalization for diabetes care. Census region-stratified models showed that noncore residents of the South (OR 1.17; CI 1.14, 1.20) and Midwest (OR 1.06; CI 1.02, 1.11) had higher odds of a diabetes-related ED-initiated hospitalization. CONCLUSIONS: As continued efforts are made to reduce place-based disparities in diabetes care and management, targeted focus should be placed on residents of noncore areas in the South and Midwest, racial and ethnic minorities, as well as the uninsured population.

The Changing Landscape of Diabetes Mortality in the United States Across Region and Rurality, 1999-2016.

PURPOSE: This brief report examines place-based differences in diabetes mortality in order to understand whether disparities in diabetes mortality have changed across United States Census regions and levels of rurality over time. METHODS: We use data from the National Center for Health Statistics from 1999 to 2016 to analyze changes in diabetes mortality over time and across geographical regions of the United States. FINDINGS: We find evidence that diabetes mortality has declined in the United States over the past 2 decades, but that improvements in mortality vary considerably by place. Improvements are observed in urban America and in the Northeast and Midwest while diabetes mortality has remained largely unchanged in rural areas, particularly in the rural South. CONCLUSIONS: Diabetes is one of the leading causes of death in the United States, but important differences have emerged in the burden of this disease. Reductions in diabetes mortality are lagging in rural areas, and the rural South in particular, relative to other areas of the country. Continued innovations in care and targeted interventions in rural areas are warranted.

Diabetes-related hospital mortality in the U.S.: A pooled cross-sectional study of the National Inpatient Sample.

AIMS: Despite advancements in the diagnosis and treatment of diabetes in the U.S., place-based disparities still exist. The purpose of this study is to determine place-based and other individual-level variations in diabetes-related hospital deaths. METHODS: A pooled cross-sectional study of the 2009-2015 National Inpatient Sample was conducted to examine the odds of a diabetes-related hospital death. The main predictors were rurality and census region. Individual-level socio-demographic factors were also examined. RESULTS: Approximately 1.5% (n = 147,069) of diabetes-related hospitalizations resulted in death. In multivariable analysis, the odds of diabetes-related hospital deaths increased across the urban-rural continuum, except for large fringe metropolitan areas, with the highest odds of such deaths occurring among residents of micropolitan (OR = 1.16, 95% C.I. = 1.14, 1.18) and noncore areas (OR = 1.21, 95% C.I. = 1.19, 1.24). Compared to residents of the Northeast, residents in the South, West and Midwest regions were significantly more likely to experience a diabetes-related hospital death. Asian or Pacific Islanders, Medicaid-covered patients and the uninsured were also more likely to die during a diabetes-related hospitalization. CONCLUSIONS: Place-based disparities in diabetes-related hospital deaths exist. Targeted focus should be placed on the control of diabetic complications in the South, West and Midwest census regions, and among rural residents.

Congestive heart failure-related hospital deaths across the urban-rural continuum in the United States.

Congestive heart failure (CHF) is a growing public health problem that affects nearly 6.5 million individuals nationwide. Access to quality outpatient care and disease management programs has been shown to improve disease treatment and prognosis. Rural populations face unique challenges in the availability and accessibility of quality cardiovascular care. In 2018, we conducted a pooled cross-sectional analysis of the Nationwide Inpatient Sample (NIS) for 2009-2014 to examine recent trends in CHF-related hospital deaths in the United States, highlighting urban-rural differences within each census region. We performed a multivariable logistic regression analysis to compare the odds of CHF-related hospital death, by levels of rurality and within each census region. Most CHF-related hospital deaths occurred in the South and Midwest census regions and in large central metropolitan areas. Findings from census region stratified models revealed that non-core residents living within the West (OR 1.47, CI 1.26, 1.71), Midwest (OR 1.30, CI 1.17, 1.44), and South (OR = 1.21, 95% C.I. = 1.12-1.32) had a higher relative risk (but not higher absolute numbers) of experiencing death during a CHF-related hospitalization, compared to patients in large central metropolitan areas. Within each census region, there were also differences in odds of a CHF-related hospital death depending on patient sex, comorbidities, insurance type, median annual income, and year. As efforts to reduce rural health disparities in CHF morbidity continue, more work is needed to understand and test interventions to reduce the risk of death from CHF in noncore areas of the West, Midwest, and South.

Economic evaluation of dental sealants: A systematic literature review.

OBJECTIVES: To systematically review the literature on economic evaluations of dental sealants and examine the costs and effectiveness of caries prevention using sealants. METHODS: Of 21 full-text articles examined, a total of 13 were included in this study. These studies are grouped by the type of intervention as follows: (i) sealants compared with no sealants; (ii) sealants compared with other forms of caries prevention; (iii) resin-based sealants compared with glass-ionomer sealants; (iv) different sealing strategies in primary teeth; (v) different sealing strategies in permanent teeth; and (vi) sealants based on school- or clinic-based setting of delivery. All currency is reported in constant 2010 US$. RESULTS: Cost-effectiveness analyses differed due to varying study designs, assumptions, sealant delivery settings, outcomes, caries risk assessment and study durations. Findings varied on the cost-effectiveness of sealants compared with other caries-preventive strategies. Under the assumption of equal caries risk, always sealing primary molars appeared to be the most effective strategy, whereas risk-based sealing was the optimal strategy with differing caries risk. Studies that assessed sealing strategies in permanent teeth reported that risk-based sealing was more cost-effective than not sealing, but they differed on the cost-effectiveness of risk-based seal compared with non-risk-based seal. Sealants delivered in school settings had mixed results on costs but were as equally effective as sealants delivered in private practices. CONCLUSIONS: The cost-effectiveness of sealants is dependent on the conditions of delivery. The list of cost-effectiveness ratios for each intervention can support policy makers to estimate expected returns on their investments in dental sealants.