Enhancing availability of services to control hypertension through a team-based care approach that includes pharmacists.

BACKGROUND: Primary care physician (PCP) shortages are expected to increase. The Michigan Medicine Hypertension Pharmacists' Program uses a team-based care (TBC) approach to redistribute some patient care responsibilities from PCPs to pharmacists for patients with diagnosed hypertension. OBJECTIVE: This evaluation analyzed whether the Michigan Medicine Hypertension Pharmacists' Program increased the availability of hypertension management services and described facilitators that addressed barriers to program sustainability and replicability. METHODS: We conducted a retrospective observational study that used a mixed methods approach. We examined the availability of hypertension management services using the number of pharmacists' referrals of patients to other services and the number of PCP appointments. We analyzed qualitative interviews with program staff and site-level quantitative data to examine the program's impact on the availability of services, the impact of TBC that engaged pharmacists, and program barriers and facilitators. RESULTS: Patients who visited a pharmacist had fewer PCP visits over 3- and 6-month periods compared to a matched comparison group that did not see a pharmacist and were 1.35 times more likely to receive a referral to a specialist within a 3-month period. Support from leaders and physicians, shared electronic health record access, and financial backing emerged as leading factors for program sustainability and replicability. CONCLUSION: Adding pharmacists to the care team reduced the number of PCP appointments per patient while increasing the availability of hypertension management services; this may in turn improve PCPs' availability. Similar models may be sustainable and replicable by relying on organizational buy-in, accessible infrastructure, and financing.

Health Impact Assessment of Transportation Projects and Policies: Living Up to Aims of Advancing Population Health and Health Equity?

Health impact assessment (HIA) is a forward-looking, evidence-based tool used to inform stakeholders and policy makers about the potential health effects of proposed projects and policies and to identify options for maximizing potential health benefits and minimizing potential harm. This review examines how health equity, a core principle of health impact assessment (HIA), has been operationalized in HIAs conducted in the United States in one sector, transportation. Two perspectives on promoting health equity appear in the broader public health research literature; one aims at reducing disparities in health determinants and outcomes in affected populations, whereas the other focuses on facilitating community participation and self-determination. Variations in how these perspectives are applied in HIA informed our typology of five ways of addressing health equity in HIA. Transportation HIAs commonly included two of these-selecting vulnerable populations for the focus of the HIA and stakeholder engagement, seen in more than 70% of the 96 HIAs reviewed. Fewer than half of the HIAs assessed current health disparities or changes in their distribution. Only 15% of HIAs addressed equity by focusing on capabilities development or empowerment. Routinely assessing and reporting how an HIA aims to address health equity might better manage expectations and could make HIA practitioners and users more conscious of how an HIA can realistically be used to advance health equity.

Developing an index of dose of exposure to early childhood obesity community interventions.

The recognition of the role of the environment in contributing to the obesity epidemic has led to increasing efforts to address obesity through environmental or place-based approaches in the past decade. This has challenged the use of the quasi-experimental design for evaluating community interventions. The objective of this study is to describe the development of an index of dose of exposure to community interventions that impact early childhood obesity. The goal is to provide an alternative means for evaluating the impact of multiple intervention strategies that target the same community at the same time. Two workgroups developed domains, constructs and protocols for estimating a "community intervention dose index" (CIDI). Information used to develop the protocol came from multiple sources including databases and reports of major funding organizations on obesity-related interventions implemented in Los Angeles County from 2005 to 2015, key informant interviews, and published literature. The workgroups identified five domains relevant to the consideration of dose of exposure to interventions: physical resources, social resources, context, capacity development, and programs and policies; developed a system for classifying programs and policies into macro- and micro-level intervention strategies; and sought ratings of strategy effectiveness from a panel of 13 experts using the Delphi technique, to develop an algorithm for calculating CIDI that considers intervention strength, reach and fidelity. This CIDI can be estimated for each community and used to evaluate the impact of multiple programs that use a myriad of intervention strategies for addressing a defined health outcome.

Influence of school environments on childhood obesity in California.

OBJECTIVE: To conduct a state-wide examination of public schools and the school neighborhood as potential targets for environmental public health tracking to address childhood obesity. METHODS: We examined the relationship of social and physical environmental attributes of the school environment (within school and neighborhood) and childhood obesity in California with machine learning (Random Forest) and multilevel methods. We used data compiled from the California Department of Education, the U.S. Geological Survey, ESRI's Business Analyst, the U.S. Census, and other public sources for ecologic level variables for various years and assessed their relative importance to obesity as determined from the statewide Physical Fitness Test 2003 through 2007 for grades 5, 7, and 9 (n = 5,265,265). RESULTS: In addition to individual-level race and gender, the following within and school neighborhood variables ranked as the most important model contributors based on the Random Forest analysis and were included in multilevel regressions clustered on the county. Violent crime, English learners, socioeconomic disadvantage, fewer physical education (PE) and fully credentialed teachers, and diversity index were positively associated with obesity while academic performance index, PE participation, mean educational attainment and per capita income were negatively associated with obesity. The most highly ranked built or physical environment variables were distance to the nearest highway and greenness, which were 10th and 11th most important, respectively. CONCLUSIONS: Many states in the U.S. do not have school-based surveillance programs that collect body mass index data. System-level determinants of obesity can be important for tracking and intervention. The results of these analyses suggest that the school social environment factors may be especially important. Disadvantaged and low academic performing schools have a higher risk for obesity. Supporting such schools in a targeted way may be an efficient way to intervene and could impact both health and academic outcomes. Some of the more important variables, such as having credentialed teachers and participating in PE, are modifiable risk factors.

Safe Routes to Play? Pedestrian and Bicyclist Crashes Near Parks in Los Angeles.

BACKGROUND: Areas near parks may present active travelers with higher risks than in other areas due to the confluence of more pedestrians and bicyclists, younger travelers, and the potential for increased traffic volumes. These risks may be amplified in low-income and minority neighborhoods due to generally higher rates of active travel or lack of safety infrastructure. This paper examines active travel crashes near parks and builds on existing research around disparities in park access and extends research from the Safe Routes to School and Safe Routes to Transit movements to parks. METHODS: We utilized the Green Visions Parks coverage, encompassing Los Angeles County and several other cities in the LA Metropolitan area. We used negative bionomial regression modeling techniques and ten years of geolocated pedestrian and bicyclist crash data to assess the number of active travel injuries within a quarter mile (~400m) buffer around parks. We controlled for differential exposures to active travel using travel survey data and Bayesian smoothing models. RESULTS: Of 1,311,736 parties involved in 608,530 crashes, there were 896,359 injuries and 7317 fatalities. The number of active travel crash injuries is higher within a quarter-mile of a park, with a ratio of 1.52 per 100,000 residents, compared to areas outside that buffer. This higher rate near parks is amplified in neighborhoods with high proportions of minority and low-income residents. Higher traffic levels are highly predictive of active travel crash injuries. CONCLUSIONS: Planners should consider the higher risks of active travel near parks and the socioeconomic modification of these risks. Additional traffic calming and safety infrastructure may be needed to provide safe routes to parks.

The Interaction Between an Individual's Acculturation and Community Factors on Physical Inactivity and Obesity: A Multilevel Analysis.

OBJECTIVES: We examined whether the interactions between primarily speaking English at home and community-level measures (median household income and immigrant composition) are associated with physical inactivity and obesity. METHODS: We pooled the 2005 and 2007 Los Angeles County Health Survey data to construct a multilevel data set, with community-level median household income and immigrant density as predictors at the community level. After controlling for individual-level demographic variables, we included the respondent's perceived community safety as a covariate to test the hypothesis that perceived public safety mediates the association between acculturation and health outcomes. RESULTS: The interaction between community median household income and primarily speaking English at home was associated with lower likelihoods of physical inactivity (odds ratio [OR] = 0.644; 95% confidence interval [CI] = 0.502, 0.825) and obesity (OR = 0.674; 95% CI = 0.514, 0.882). These odds remained significant after we controlled for perceived community safety. CONCLUSIONS: Resources in higher-income areas may be beneficial only to residents fully integrated into the community. Future research could focus on understanding how linguistic isolation affects community-level social learning and access to resources and whether this differs by family-level acculturation.

Social Determinants of Health-Related Z Codes and Health Care Among Patients With Hypertension.

Introduction: Tracking social needs can provide information on barriers to controlling hypertension and the need for wraparound services. No recent studies have examined ICD-10-CM social determinants of health-related Z codes (Z55-Z65) to indicate social needs with a focus on patients with hypertension. Methods: Three cohorts were identified with a diagnosis of hypertension during 2016-2017 and continuously enrolled in fee-for-service insurance through June 2021: (1) commercial, age 18-64 years (n=1,024,012); (2) private insurance to supplement Medicare (Medicare Supplement), age ≥65 years (n=296,340); and (3) Medicaid, age ≥18 years (n=146,484). Both the proportion of patients and healthcare encounters or visits with social determinants of health-related Z code were summarized annually. Patient and visit characteristics were summarized for 2019. Results: In 2020, the highest annual documentation of social determinants of health-related Z codes was among Medicaid beneficiaries (3.02%, 0.46% commercial, 0.42% Medicare Supplement); documentation was higher among inpatient than among outpatient visits for all insurance types. Z63 (related to primary support group) was more common among commercial and Medicare Supplement beneficiaries, and Z59 (housing and economic circumstances) was more common among Medicaid beneficiaries. The 2019 total unadjusted medical expenditures were 1.85, 1.78, and 1.61 times higher for those with social determinants of health-related Z code than for those without commercial, Medicare Supplement, and Medicaid, respectively. Patients with social determinants of health-related Z code also had higher proportions of diagnosed chronic conditions. Among Medicaid beneficiaries, differences in the presence of social determinants of health-related Z code by race or ethnicity were observed. Conclusions: Although currently underreported, social determinants of health-related Z codes provide an opportunity to integrate social and medical data and may help decision makers understand the need for additional services among individuals with hypertension.

A Literature Review of Productivity Loss Associated with Hypertension in the United States.

A literature review of peer-reviewed articles published 2000-2019 was conducted to determine the types and extent of hypertension-associated productivity loss among adults in the United States. All monetary outcomes were standardized to 2019 $ by using the Employment Cost Index. Twenty-seven articles met the inclusion criteria. Nearly half of the articles (12 articles) presented monetary outcomes of productivity loss. Absenteeism (14 articles) and presenteeism (8 articles) were most frequently assessed. Annual absenteeism was estimated to cost more than $11 billion, nationally controlling for sociodemographic characteristics. The annual additional costs per person were estimated at $63 for short-term disability, $72-$330 for absenteeism, and $53-$156 for presenteeism, controlling for participant characteristics; and may be as high as $2362 for absenteeism and presenteeism when considered in combination. The annual additional time loss per person was estimated as 1.3 days for absenteeism, controlling for common hypertension comorbidities, including stroke and diabetes; and 15.6 days for work and home productivity loss combined, controlling for sociodemographic characteristics. The loss from absenteeism alone might be more than 20% of the total medical expenditure of hypertension. Although the differences in estimation methods and study populations make it challenging to synthesize the costs across the studies, this review provides detailed information on the various types of productivity loss. In addition, the ways in which methods could be standardized for future research are discussed. Accounting for the costs from productivity loss can help public health officials, health insurers, employers, and researchers better understand the economic burden of hypertension.

Evaluation of a Pharmacists' Patient Care Process Approach for Hypertension.

INTRODUCTION: An estimated 116 million American adults (47.3%) have hypertension. Most adults with hypertension do not have it controlled-3 in 4 (92.1 million) U.S. adults with hypertension have a blood pressure ≥130/80 mmHg. The Pharmacists' Patient Care Process is a standardized patient-centered approach to the provision of pharmacist care that is done in collaboration with other healthcare providers. Through the Michigan Medicine Hypertension Pharmacists' Program, pharmacists use the Pharmacists' Patient Care Process to provide hypertension management services in collaboration with physicians in primary care and community pharmacy settings. In 2019, the impact of Michigan Medicine Hypertension Pharmacists' Program patient participation on blood pressure control was evaluated. METHODS: Propensity scoring was used to match patients in the intervention group with patients in the comparison group and regression analyses were then conducted to compare the 2 groups on key patient outcomes. Negative binomial regression was used to examine the number of days with blood pressure under control. The findings presented in this brief are part of a larger multimethod evaluation. RESULTS: More patients in the intervention group than in the comparison group achieved blood pressure control at 3 months (66.3% vs 42.4%) and 6 months (69.1% vs 56.5%). The intervention group experienced more days with blood pressure under control within a 3-month (18.6 vs 9.5 days) and 6-month period (57.0 vs 37.4 days) than the comparison group did. CONCLUSIONS: Findings support the effectiveness of the Michigan Medicine Hypertension Pharmacists' Program approach to implementing the Pharmacists' Patient Care Process to improve blood pressure control.

The interaction among donor characteristics, severity of liver disease, and the cost of liver transplantation.

Accurate assessment of the impact of donor quality on liver transplant (LT) costs has been limited by the lack of a large, multicenter study of detailed clinical and economic data. A novel, retrospective database linking information from the University HealthSystem Consortium and the Organ Procurement and Transplantation Network registry was analyzed using multivariate regression to determine the relationship between donor quality (assessed through the Donor Risk Index [DRI]), recipient illness severity, and total inpatient costs (transplant and all readmissions) for 1 year following LT. Cost data were available for 9059 LT recipients. Increasing MELD score, higher DRI, simultaneous liver-kidney transplant, female sex, and prior liver transplant were associated with increasing cost of LT (P < 0.05). MELD and DRI interact to synergistically increase the cost of LT (P < 0.05). Donors in the highest DRI quartile added close to $12,000 to the cost of transplantation and nearly $22,000 to posttransplant costs in comparison to the lowest risk donors. Among the individual components of the DRI, donation after cardiac death (increased costs by $20,769 versus brain dead donors) had the greatest impact on transplant costs. Overall, 1-year costs were increased in older donors, minority donors, nationally shared organs, and those with cold ischemic times of 7-13 hours (P < 0.05 for all). In conclusion, donor quality, as measured by the DRI, is an independent predictor of LT costs in the perioperative and postoperative periods. Centers in highly competitive regions that perform transplantation on higher MELD patients with high DRI livers may be particularly affected by the synergistic impact of these factors.

The implementation cost of a safety-net hospital program addressing social needs in Atlanta.

OBJECTIVE: To describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers. DATA SOURCES/STUDY SETTING: Costs for a heart failure health care program based in a safety-net hospital were reported by program staff for the program year May 2018-April 2019. Additional data sources included hospital records, invoices, and staff survey. STUDY DESIGN: We conducted a retrospective, cross-sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities. DATA COLLECTION: Program cost data were collected using a activity-based, micro-costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation. PRINCIPAL FINDINGS: Program costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30-day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities. DISCUSSION: Historically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.

Impact of Medicaid Expansion on Insurance Coverage Rates Among Adult Populations with Low Income and by Obesity Status.

OBJECTIVE: This study examines insurance coverage rates among working-age adults with low income and with or without obesity before and after Medicaid expansion under the Affordable Care Act. METHODS: Individual-level data on noninstitutionalized and nonpregnant adult participants aged 18 to 64 years with household income below $15,000 from the Centers for Disease Control and Prevention 2006-2017 Behavioral Risk Factor Surveillance System were used. A difference-in-differences design with logistic regression was used to examine the likelihood of insurance coverage before and after Medicaid expansion. RESULTS: Working-age adults (analytic sample N = 316,151) who were white, female, less educated, unemployed, and living in a Medicaid-expansion state were more likely to have insurance coverage. The insurance coverage rate in Medicaid-expanded states in years after expansion increased for both subgroups with and without obesity. However, the increase was slightly lower for the subpopulation with obesity (5.59%, 95% CI: 2.35%-8.83%) compared with the subpopulation without obesity (7.35%, 95% CI: 5.35%-9.34%). CONCLUSIONS: Increased attention should be paid to reduce insurance coverage barriers for working-age adults with low income and obesity to address potential health disparities caused by lack of access to care. This is important, as access to care provides opportunities to increase prevention and treatment-oriented services to address obesity and associated health care costs.

To drive or not to drive? A study of travel behavior for a recent drinking occasion.

Despite decades of education and enforcement campaigns, alcohol-impaired driving persists as a social problem in the U.S. Are there other factors influencing decisions to drive after alcohol consumption that may be amenable to change? We conducted a roadside survey in California in 2012 to assess whether residential accessibility, travel attitudes (indicated by ratings of convenience and safety for travel options), and perceptions of arrest risk affect travel choices made subsequent to alcohol consumption. We conducted hybrid choice modeling for 580 participants. Mode-specific travel attitudes were valid constructs and predictive of travel behavior. Perceived level of service (speed) increased the utility for taxi and getting a ride. Perceiving high risk of arrest affected mode choice through travel attitudes. Not everyone assessed their mode options in the same way. For example, frequent binge drinkers appear to be more willing to consider taxis, men had stronger preferences towards active modes, and younger drivers were less pro-driving in this context. Past drinking and driving behavior affected one's attitude towards driving, while the number of drinks was related to mode choice. While our accessibility measure was not significantly related to attitudes or choice, decreasing urbanicity corresponded with stronger preferences for driving. This pilot study suggests that improving level of service (speed), convenience, and overall safety are considerations for public health in terms of promoting alternatives to drinking and driving. This line of research also has implications for emerging options, such as ride hailing, and how these might be optimized for specific segments of the population.

Bringing health into transportation and land use scenario planning: Creating a National Public Health Assessment Model (N-PHAM).

There is mounting evidence linking land development and transportation investments to physical activity with resulting implications for chronic disease prevention. Links between the physical environment and health have traditionally focused on harmful exposures such as air pollution, noise, and traffic injury. Given limited funds and competition for how and where investments are made, there is a need to prioritize and target resources to maximize health benefits that can include activity related chronic disease prevention. The ability to apply this evidence to decision making has been limited by the complexity and inconsistency of research methods, and lack of a direct connection with the planning contexts in which decisions are made. Scenario planning tools provide a method to apply evidence with spatial planning decisions at a range of geographic scales. The US Environmental Protection Agency commissioned the development of a National Public Health Assessment Model (N-PHAM). This project utilized built and natural environment data at the block-group level and large population surveys to model the relationships of the environment with several health outcomes for a range of age and income groups. N-PHAM is the first health assessment tool that can connect to multiple existing scenario planning platforms utilizing nationally available data and can be consistently applied nationally. Such tools can empower communities to choose investments that have the greatest potential to improve public health and quality of life, reduce health care costs, and address environmental justice related disparities.

Latent analysis of Complete Streets and traffic safety along an urban corridor.

BACKGROUND: To evaluate Complete Street implementations that covary, the present paper aims to: 1) explore the development of typologies of intersections; and 2) examine how these typologies relate to traffic safety. METHODS: The study site is a five-mile segment in Los Angeles County, California. Multiple indicators of environmental features were collected in 2012 and were included in a latent analysis. Latent classes were then analyzed as a predictor of the number of pedestrian injuries/fatalities and injuries/fatalities for all modes in separate models using negative binomial regression and controlling for exposures. Injuries/fatalities represent the most recent 3 years of crash data available surrounding the environmental data collection (2009-2014). We also examined the role of alcohol. RESULTS: For a relatively short segment of an urban corridor, we identified two distinct classes of intersections. One class was more complete with respect to pedestrian features but was also associated with indicators of increased potential conflict and was predictive of higher overall injuries/fatalities for all modes. This class also had higher pedestrian volumes but was not predictive of higher pedestrian injuries/fatalities in the final models. The alcohol involvement in crash injuries at these locations did not differ by intersection class but was positively associated with injuries/fatalities for all modes and with severe/fatal injuries for pedestrians in the final models. CONCLUSIONS: Identifying typologies can be used to understand the combination of features and prioritize locations for treatment. While Complete Streets may help counter pedestrian injury trends, the efforts captured in this data are insufficient for municipalities aiming for Vision Zero. Ideally, future research can examine these intersections after the implementation of additional improvements in order to isolate treatment effects. These findings suggest additional intersection countermeasures are needed, in addition to efforts to address social problems such as alcohol use and traffic safety.

Socioeconomic and food-related physical characteristics of the neighbourhood environment are associated with body mass index.

OBJECTIVE: To determine whether socioeconomic and food-related physical characteristics of the neighbourhood are associated with body mass index (BMI; kg/m(2)) independently of individual-level sociodemographic and behavioural characteristics. DESIGN AND METHODS: Observational study using (1) individual-level data previously gathered in five cross-sectional surveys conducted by the Stanford Heart Disease Prevention Program between 1979 and 1990 and (2) neighbourhood-level data from (a) the census to describe socioeconomic characteristics and (b) data obtained from government and commercial sources to describe exposure to different types of retail food stores as measured by store proximity, and count of stores per square mile. Data were analysed using multilevel modelling procedures. The setting was 82 neighbourhoods in agricultural regions of California. PARTICIPANTS: 7595 adults, aged 25-74 years. RESULTS: After adjusting for age, gender, ethnicity, individual-level socioeconomic status, smoking, physical activity and nutrition knowledge, it was found that (1) adults who lived in low socioeconomic neighbourhoods had a higher mean BMI than adults who lived in high socioeconomic neighbourhoods; (2) higher neighbourhood density of small grocery stores was associated with higher BMI among women; and (3) closer proximity to chain supermarkets was associated with higher BMI among women. CONCLUSION: Living in low socioeconomic neighbourhoods, and in environments where healthy food is not readily available, is found to be associated with increased obesity risk. Unlike other studies which examined populations in other parts of the US, a positive association between living close to supermarkets and reduced obesity risk was not found in this study. A better understanding of the mechanisms by which neighbourhood physical characteristics influence obesity risk is needed.

Travel distance to prenatal care and high blood pressure during pregnancy.

OBJECTIVE: To assess whether poor geographic accessibility to prenatal care, as indicated by long distance trips to prenatal care, produced high blood pressure (HPB) during pregnancy. METHODS: Using the 2007 Los Angeles Mommy and Baby Study for women without hypertension prior to pregnancy (n = 3405), we compared self-reported HBP by travel distance to prenatal care controlling for age, race/ethnicity, marital status, education, household income, weight status, and physical activity. RESULTS: Results of the multilevel logistic regression shows traveling more than 50 mi to prenatal care is associated with an increased odds for having HPB during pregnancy (odds ratio [OR] = 2.867, 95% confidence interval [CI] = 1.079,7.613), as compared with a travel distance shorter than 5 mi. Traveling 5-14 mi (OR = 0.917, 95% CI = 0.715-1.176), 15-29 mi (OR = 0.955, 95% CI = 0.634-1.438), or 30-50 mi (OR = 1.101, 95% CI = 0.485-2.499) were not significantly associated with more risk of HBP during pregnancy. CONCLUSION: To our knowledge, no previous studies have examined the association between poor geographic accessibility to care and the possible harms of travel burdens for pregnant women. Future research that replicates these findings can assist in developing recommendations for pregnant women and health-care accessibility.

Non-Emergency Medical Transportation Needs of Middle-Aged and Older Adults: A Rural-Urban Comparison in Delaware, USA.

Background: Older adults in rural areas have unique transportation barriers to accessing medical care, which include a lack of mass transit options and considerable distances to health-related services. This study contrasts non-emergency medical transportation (NEMT) service utilization patterns and associated costs for Medicaid middle-aged and older adults in rural versus urban areas. Methods: Data were analyzed from 39,194 NEMT users of LogistiCare-brokered services in Delaware residing in rural (68.3%) and urban (30.9%) areas. Multivariable logistic analyses compared trip characteristics by rurality designation. Results: Rural (37.2%) and urban (41.2%) participants used services more frequently for dialysis than for any other medical concern. Older age and personal accompaniment were more common and wheel chair use was less common for rural trips. The mean cost per trip was greater for rural users (difference of $2910 per trip), which was attributed to the greater distance per trip in rural areas. Conclusions: Among a sample who were eligible for subsidized NEMT and who utilized this service, rural trips tended to be longer and, therefore, higher in cost. Over 50% of trips were made for dialysis highlighting the need to address prevention and, potentially, health service improvements for rural dialysis patients.

Drinking and driving and perceptions of arrest risk among California drivers: Relationships with DUI arrests in their city of residence.

OBJECTIVE: Addressing drinking and driving remains a challenge in the United States. The present study aims to provide feedback on driving under the influence (DUI) in California by assessing whether drinking and driving behavior is associated with the DUI arrest rates in the city in which the driver lives; whether this is due to perceptions that one can get arrested for this behavior; and whether this differed by those drivers who would be most affected by deterrence efforts (those most likely to drink outside the home). METHODS: This study consisted of a 2012 roadside survey of 1,147 weekend nighttime drivers in California. City DUI arrest rates for 2009-2011 were used as an indicator of local enforcement efforts. Population average logistic modeling was conducted modeling the odds of perceived high arrest likelihood for DUI and drinking and driving behavior within the past year. RESULTS: As the DUI arrest rates for the city in which the driver lives increased, perceived high risk of DUI arrest increased. There was no significant relationship between either city DUI arrest rates or perceived high risk of DUI arrest with self-reported drinking and driving behavior in the full sample. Among a much smaller sample of those most likely to drink outside the home, self-reported drinking and driving behavior was negatively associated with DUI arrests rates in their city of residence but this was not mediated by perceptions. CONCLUSION: The results of the present study suggest that perceptions are correlated with one aspect of DUI efforts in one's community. Those who were more likely to drink outside the home could be behaviorally influenced by these efforts.