Associations Between Historically Redlined Districts and Racial Disparities in Current Obstetric Outcomes.

Importance: Despite much higher health care expenditure than comparable countries, striking racial and ethnic disparities exist in obstetric outcomes in the United States. A multifaceted exploration of the factors influencing these disparities, including the legacy of structural racism, is important to improve health outcomes for all. Objective: To characterize the association of the historic racially discriminatory home loan practice of redlining with disparities in modern obstetric outcomes. Design, Setting, and Participants: In this retrospective cohort study of a 9-county birth certificate database in the Finger Lakes region of New York state from 2005 to 2018, modern obstetric outcomes were matched with regions classified by the federal government for mortgage loan servicing based on racially discriminatory criteria from the 1940 Home Owners' Loan Corporation map (HOLC; also known as the redline map). Patients with a live birth recorded in the data system with a recorded home zip code within the historic HOLC categories were included. Data were analyzed from July to December 2019. Exposure: Regions previously categorized by historic, racially discriminatory criteria. Main Outcomes and Measures: Each HOLC area was analyzed for the primary outcome of preterm birth and secondary outcomes of obstetric and medical complications, with logistic regression to address regional and patient-level covariates. Results: From 2005 until 2018, there were 64 804 live births within the 15 zip codes overlaying historic HOLC regions. Prevalence of preterm birth increased with decreasing HOLC categories, from the lowest overall preterm birth rate of 217 of 2873 births (7.55%) in the zip code historically defined as "Best" or "Still Desirable" and the highest overall preterm birth rate of 427 of 3449 births (12.38%) in the zip code historically defined as "Hazardous." These associations with preterm birth remained significant in logistic regression controlling for poverty levels and educational attainment (adjusted odds ratio, 1.46; 95% CI, 1.08-1.97) and parental race (adjusted odds ratio, 1.38; 95% CI, 1.25-1.53). Conclusions and Relevance: In this cohort study, the linkage of historic and modern community data sets with an obstetric data set offered the opportunity to characterize modern obstetric disparities associated with a system of historic inequity. The persistence of these findings after correcting for contemporary community socioeconomic characteristics suggest potential influences of a system of profound structural inequity that ripple forward in time, with impacts that extend beyond measurable socioeconomic inequity.

Social Determinants of Health and Geographic Variation in Medicare per Beneficiary Spending.

Importance: Despite substantial geographic variation in Medicare per beneficiary spending in the US, little is known about the extent to which social determinants of health (SDoH) are associated with this variation. Objective: To determine the associations between SDoH and county-level price-adjusted Medicare per beneficiary spending. Design, Setting, and Participants: This cross-sectional study used county-level data on 2017 Medicare fee-for-service (FFS) spending, patient demographic characteristics (eg, age and gender) and clinical risk score, supply of health care resources (eg, number of hospital beds), and SDoH measures (eg, median income and unemployment rate) from multiple sources. Multivariable regressions were used to estimate the association of the variation in spending across quintiles with SDoH. Main Outcomes and Measures: 2017 county-level price-adjusted Medicare Parts A and B spending per beneficiary. SDoH measures included socioeconomic position, race/ethnicity, social relationships, and residential and community context. Results: Among 3038 counties with 33 495 776 Medicare FFS beneficiaries (18 352 336 [54.8%] women; mean [SD] age, 72 [1.5] years), mean Medicare price-adjusted per beneficiary spending for counties in the highest spending quintile was $3785 (95% CI, $3706-$3862) higher, or 49% higher, than spending for bottom-quintile counties (mean [SD] spending per beneficiary, $11 464 [735] vs $7679 [522]; P < .001). The total contribution (including through both direct and indirect pathways) of SDoH was 37.7% ($1428 of $3785) of this variation, compared with 59.8% ($2265 of $3785) by patient clinical risk, 14.5% ($549 of $3785) by supply of health care resources, and 19.8% ($751 of $3785) by patient demographic characteristics. When all factors were included within the same model, the direct contribution of SDoH was associated with 5.8% of the variation, compared with 4.6% by supply, 4.7% by patient demographic characteristics, and 62.0% by patient clinical risk. Conclusions and Relevance: These findings suggest social determinants of health are associated with considerable proportions of geographic variation in Medicare spending. Policies addressing SDoH for disadvantaged patients in certain regions have the potential to contain health care spending and improve the value of health care; patient SDoH may need to be accounted for in publicly reported physician performance, and in value-based purchasing incentive programs for health care professionals.

Evolving population distribution in China's border regions: Spatial differences, driving forces and policy implications.

The security and socioeconomic development of China's border areas are of great significance to the nation and the wider world. Using census, statistical, digital elevation model (DEM) and network data, this paper employs visual analysis to capture population distribution patterns in China's 131 border counties from 1982 to 2010. Multiple stepwise regression is carried out to identify the influencing factors of population dynamics in border regions. The main findings include: China's most heavily populated border areas are primarily in the northeast, northwest, and the Guangxi-Yunnan region, while rapid growth of population is found in western Inner Mongolia, southwest Xinjiang, northwest Tibet, and southern Yunnan. Given the increasingly market-oriented migration mechanism, the national reclamation policy has been no longer effective in population attraction in the new century. Education has significantly lowered and will continuously lower the fertility rate in remote border areas. The factors influencing population growth show a remarkable regional heterogeneity along China's long border.

Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models.

Importance: Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation. Objective: To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices. Design, Setting, and Participants: A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019. Exposures: Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors. Main Outcomes and Measures: Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts. Results: A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation. Conclusions and Relevance: Greater APM participation appears to be supported by integration and system ownership.

Does the agglomeration effect occur in the hospital sector? The impact of agglomeration economies on the financial performance of hospitals-An evidence from Poland.

The main aim of the article is to analyze the occurrence of agglomeration effect in the hospital sector on the basis of financial performance. The considerations are made on the example of hospitals in Poland-the country that survived the latest economic crisis relatively well, usually generating positive values of GDP, but where still there is an ongoing discussion on the final shape of healthcare financing model. The article is based on the assumption that there occur significant differences in financial performance between hospitals according to their location. The research hypothesis is as follows: Hospitals operating in big cities are featured by better financial condition than their counterparts operating in smaller towns. To verify the hypothesis, the methods of financial analysis and statistical hypothesis testing are used. As it is emphasized in the article, the assumption is true and the hypothesis can be verified positively.

Assessing the operational costs of routine immunization activities at the sub-center level in Myanmar: What matters for increasing national immunization coverage?

BACKGROUND: Myanmar's national immunization program was launched in 1978. Routine immunization is mainly provided at sub-center level with midwives assigned as main vaccinators. The vaccinators at the sub-centers have to obtain vaccines from their designated township health department's cold room for immunization services. This study aimed to calculate the operational costs of routine immunization at sub-centers in Myanmar. METHODS: A cross-sectional study was conducted among 160 sub-centers throughout the country. Face-to-face interviews were conducted with the main vaccinator at each sub-center using a pre-tested questionnaire. The study analyzed the operational costs per facility and the associations between sub-center characteristics and operational costs. RESULTS: In Myanmar, the average operational costs of routine immunization per sub-center ranged from 434,700-990,125 MMK for rural areas and 235,875-674,250 MMK for urban areas. The operational costs increased by 8,749.50 MMK (95% CI: 6,805.79-10,693.21; p < 0.001) per mile and 5,752.50 MMK (95% CI: 914.22-10,590.79; p < 0.05) per working day. CONCLUSION: This study indicated that the operational costs at sub-centers were high and varied significantly among the different geographical areas. The operational costs could be reduced by additional support for the resources, for example, installing cold chain facilities at sub-centers and opening new sub-centers throughout the country.

Nomadic ecology shaped the highland geography of Asia's Silk Roads.

There are many unanswered questions about the evolution of the ancient 'Silk Roads' across Asia. This is especially the case in their mountainous stretches, where harsh terrain is seen as an impediment to travel. Considering the ecology and mobility of inner Asian mountain pastoralists, we use 'flow accumulation' modelling to calculate the annual routes of nomadic societies (from 750 m to 4,000 m elevation). Aggregating 500 iterations of the model reveals a high-resolution flow network that simulates how centuries of seasonal nomadic herding could shape discrete routes of connectivity across the mountains of Asia. We then compare the locations of known high-elevation Silk Road sites with the geography of these optimized herding flows, and find a significant correspondence in mountainous regions. Thus, we argue that highland Silk Road networks (from 750 m to 4,000 m) emerged slowly in relation to long-established mobility patterns of nomadic herders in the mountains of inner Asia.

Geographic disparities in Healthy Eating Index scores (HEI-2005 and 2010) by residential property values: Findings from Seattle Obesity Study (SOS).

BACKGROUND: Higher socioeconomic status (SES) has been linked with higher-quality diets. New GIS methods allow for geographic mapping of diet quality at a very granular level. OBJECTIVE: To examine the geographic distribution of two measures of diet quality: Healthy Eating Index (HEI 2005 and HEI 2010) in relation to residential property values in Seattle-King County. METHODS: The Seattle Obesity Study (SOS) collected data from a population-based sample of King County adults in 2008-09. Socio-demographic data were obtained by 20-min telephone survey. Dietary data were obtained from food frequency questionnaires (FFQs). Home addresses were geocoded to the tax parcel and residential property values were obtained from the King County tax assessor. Multivariable regression analyses using 1116 adults tested associations between SES variables and diet quality measured (HEI scores). RESULTS: Residential property values, education, and incomes were associated with higher HEI scores in bivariate analyses. Property values were not collinear with either education or income. In adjusted multivariable models, education and residential property were better associated with HEI, compared to than income. Mapping of HEI-2005 and HEI-2010 at the census block level illustrated the geographic distribution of diet quality across Seattle-King County. CONCLUSION: The use of residential property values, an objective measure of SES, allowed for the first visual exploration of diet quality at high spatial resolution: the census block level.

On the Morphology of a Growing City: A Heuristic Experiment Merging Static Economics with Dynamic Geography.

In this paper, we aim at exploring how individual location decisions affect the shape of a growing city and, more precisely, how they may add up to a configuration that diverges from equilibrium configurations formulated ex-ante. To do so, we provide a two-sector city model merging a static equilibrium analysis with agent-based simulations. Results show that under strong agglomeration effects, urban development is monotonic and ends up with circular, monocentric long-term configurations. For low agglomeration effects however, elongated and multicentric urban configurations may emerge. The occurrence and underlying dynamics of these configurations are also discussed regarding commuting costs and the distance-decay of agglomeration economies between firms. To sum up, our paper warns urban planning policy makers against the difference that may stand between appropriate long-term perspectives, represented here by analytic equilibrium configurations, and short-term urban configurations, simulated here by a multi-agent system.

Geoengineering: re-making climate for profit or humanitarian intervention?

Climate engineering, or geoengineering, refers to large-scale climate interventions to lower the earth's temperature, either by blocking incoming sunlight or removing carbon dioxide from the biosphere. Regarded as 'technofixes' by critics, these strategies have evoked concern that they would extend the shelf life of fossil-fuel driven socio-ecological systems for far longer than they otherwise would, or should, endure. A critical reading views geoengineering as a class project that is designed to keep the climate system stable enough for existing production systems to continue operating. This article first examines these concerns, and then goes on to envision a regime driven by humanitarian agendas and concern for vulnerable populations, implemented through international development and aid institutions. The motivations of those who fund research and implement geoengineering techniques are important, as the rationale for developing geoengineering strategies will determine which techniques are pursued, and hence which ecologies are produced. The logic that shapes the geoengineering research process could potentially influence social ecologies centuries from now.

Geography and global health.

In the wake of the report of the World Health Organisation's Commission on the Social Determinants of Health, Closing the gap in a generation (Marmot 2008), this invited commentary considers the scope for geographical research on global health. We reflect on current work and note future possibilities, particularly those that take a critical perspective on the interplay of globalisation, security and health.

Balancing urban and peri-urban exchange: water geography of rural livelihoods in Mexico.

The peri-urban area is the region where there is a more dynamic interaction between the urban and rural. The peri-urban area supplies natural resources, such as land for urban expansion and agricultural products to feed the urban population. In arid and semi-arid lands, such as northern Mexico, these areas may also be the source of water for the city's domestic demand. In addition, scholars argue that peri-urban residents may have a more advantageous geographical position for selling their labour and agricultural products in cities and, by doing so, sustaining their livelihoods. A considerable number of studies have examined the peri-urban to urban natural resources transfer in terms of land annexation, housing construction, and infrastructure issues; however, the study of the effects of the reallocation of peri-urban water resources to serve urban needs is critical as well because the livelihoods of peri-urban residents, such as those based on agriculture and livestock, depend on water availability. In the case of Hermosillo there is a tremendous pressure on the water resources of peri-urban small farm communities or ejidos because of urban demand. Based on interviews and structured surveys with producers and water managers, this paper examines how peri-urban livelihoods have been reshaped by the reallocation of the city's natural resources in many cases caused some ejido members or ejidatarios to lose livelihoods.

Weather, geography, and vehicle-related hyperthermia in children.

Vehicle-related hyperthermia is an unfortunate tragedy that leads to the accidental deaths of children each year. This research utilizes the most extensive dataset of child vehicle-related hyperthermia deaths in the United States, including 414 deaths between 1998 and 2008. Deaths follow a seasonal pattern, with a peak in July and no deaths in December or January. Also, deaths occurred over a wide range of temperature and radiation levels and across virtually all regions, although most of them took place across the southern United States. In particular, the Phoenix, Houston, Dallas, and Las Vegas metropolitan areas had the greatest number of deaths. We utilize our vehicle hyperthermia index (vhi) to compare expected deaths versus actual deaths in a metropolitan area, based on the number of children in the area who are under the age of five and on the frequency of hot days in the area. The vhi indicates that the Memphis, West Palm Beach-Boca Raton, and Las Vegas metropolitan areas are the most dangerous places for vehicle-related hyperthermia. We conclude by discussing several recommendations with public health policy implications.

Hydrology and empire: the Nile, water imperialism and the partition of Africa.

Why did the British march up the Nile in the 1890s? The answers to this crucial question of imperial historiography have direct relevance for narratives and theories about imperialism, in general, and the partition of Africa in the nineteenth century, in particular. They will also influence our understanding of some of the main issues in the modern history of the whole region, including state developments and resource utilisation. This article presents an alternative to dominant interpretations of the partition of Africa and the role of British Nile policies in this context. It differs from mainstream diplomatic history, which dominates this research field, in its emphasis on how geographical factors and the hydrological characteristics of the Nile influenced and framed British thinking and actions in the region. Realising the importance of such factors and the specific character of the regional water system does not imply less attention to traditional diplomatic correspondence or to the role of individual imperial entrepreneurs. The strength of this analytical approach theoretically is that it makes it possible to locate the intentions and acts of historical subjects within specific geographical contexts. Empirically, it opens up a whole new set of source material, embedding the reconstruction of the British Nile discourse in a world of Nile plans, water works and hydrological discourses.

Short communication: Farm and socioeconomic characteristics of the top 100 dairy farm counties in the United States.

The objectives of this study are to describe dairy farm demographic and socioeconomic conditions in the top 100 counties in the United States for dairy sales in 2007, and to describe the association of dairy farm demographics with socioeconomic conditions. The top 100 counties were responsible for 56% of all US dairy sales in 2007 with a median growth rate of 78% compared with 1997. Counties varied widely for farm demographics with as few as 5 very large dairy farms that averaged $17,924,000 in dairy sales per farm to as many as 1,730 dairy farms with less than $250,000 in dairy sales per farm. Most of the top 100 dairy counties had higher illiteracy rates, a higher proportion of residents without a high school degree, and lower median incomes than state averages, but unemployment rates were similar to the state average. The socioeconomic measures were from public records and not collected specifically for this research. Nevertheless, the top dairy counties in the western states tended to have poorer socioeconomic conditions than the top dairy counties in other regions, and significant associations were observed between dairy farm demographics and socioeconomic conditions. Having many dairy farms was associated more favorably with county socioeconomic conditions than having high dairy sales.

Planning ideology and geographic thought in the early twentieth century: Charles Whitnall's progressive era park designs for socialist Milwaukee.

As Milwaukee's chief park planner in the early to mid-twentieth century, Charles Whitnall responded to the various underlying ideologies of the period within which he worked. His preference for parks was a political and physical response to and remedy for the industrialized and heavily congested city he called home. By examining the Progressive Era discourse associated with planning, this article situates Whitnall's work within the political, aesthetic, and environmental contexts of geographic thought that influenced his plans for Milwaukee. In promoting a physical awareness associated with the natural features of the region and responding to the sociopolitical framework of contemporaries such as Ebenezer Howard, Whitnall incorporated a sense of compassion within his planning. He responded to the preexisting beer gardens of Pabst and Schlitz, as well as Olmsted-designed park spaces, by advocating for decentralization as part of a broader socialist agenda that had swept through Milwaukee during the early 1900s.

Domestic violence, poverty, and social services: does location matter?

Objective. This study investigates whether or not domestic violence agencies are located in areas of need. Recent research indicates that community economic disadvantage is a risk factor for intimate partner violence, but related questions regarding the geographic location of social service agencies have not been investigated.Methods. Using Connecticut as a case study, we analyze the relationship of agency location and police-reported domestic violence incidents and assaults using OLS regression and correcting for spatial autocorrelation.Results. The presence of an agency within a town has no relationship with the rates of domestic violence. However, regional patterns are evident.Conclusion. Findings indicate that programs are not geographically mismatched with need, but neither are programs located in towns with higher rates of incidents or assaults. Future research and planning efforts should consider the geographic location of agencies.