Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area.

Introduction: We examined the geographic distribution and sociodemographic and economic characteristics of chronic disease prevalence in the US. Understanding disease prevalence and its impact on communities is crucial for effective public health interventions. Methods: Data came from the American Community Survey, the American Hospital Association Survey, and the Centers for Disease Control and Prevention's PLACES. We used quartile thresholds for 10 chronic diseases to assess chronic disease prevalence by Zip Code Tabulation Areas (ZCTAs). ZCTAs were scored from 0 to 20 based on their chronic disease prevalence quartile. Three prevalence categories were established: least prevalent (score ≤6), moderately prevalent (score 7-13), and highest prevalence (score ≥14). Community characteristics were compared across categories and spatial analyses to identify clusters of ZCTAs with high disease prevalence. Results: Our study showed a high prevalence of chronic disease in the southeastern region of the US. Populations in ZCTAs with the highest prevalence showed significantly greater socioeconomic disadvantages (ie, lower household income, lower home value, lower educational attainment, and higher uninsured rates) and barriers to health care access (lower percentage of car ownership and longer travel distances to hospital-based intensive care units, emergency departments, federally qualified health centers, and pharmacies) compared with ZCTAs with the lowest prevalence. Conclusion: Socioeconomic disparities and health care access should be addressed in communities with high chronic disease prevalence. Carefully directed resource allocation and interventions are necessary to reduce the effects of chronic disease on these communities. Policy makers and clinicians should prioritize efforts to reduce chronic disease prevalence and improve the overall health and well-being of affected communities throughout the US.

Co-occurrence of mental illness and substance use among US pregnant individuals, 2012-2021.

AIM: Substance use disorders are increasingly prevalent among pregnant individuals, with evident risks of adverse perinatal outcomes. This study examines substance use (tobacco, alcohol and marijuana) among pregnant individuals with mental illness. METHODS: A national representative sample of pregnant individuals were derived from 2012 to 2021 National Survey of Drug Use and Health data. Associations of past-year mental illness with past-month polysubstance use and each substance use were analyzed by logistic regression models, with complex sampling weights and survey year. RESULTS: Among 6801 pregnant individuals, 16.4% reported having any mental illness (AMI) in 2012 and 2013, increasing to 23.8% in 2020-2021; and SMI increased from 3.3% to 9.4%. Polysubstance use increased disproportionately among those with severe mental illness (SMI), from 14.0% to 18.6%. Pregnant individuals with greater severity of mental illness had higher odds of polysubstance use (Adjusted Odds Ratio, 95% CI: AMI but no SMI vs. without AMI: 1.59 [1.04, 2.44]; SMI vs. without AMI: 5.48 [2.77, 10.82]). CONCLUSIONS: Pregnant individuals with greater severity of mental illness were more likely to engage in substance use. Evidence-based educational, screening and treatment services, and public policy changes are warranted to mitigate the harmful health outcomes of substance use among US pregnant individuals with mental illness.

Availability and quality of dialysis care in rural versus urban U.S. counties.

INTRODUCTION: Rural areas face significant disparities in dialysis care compared to urban areas due to limited access to dialysis facilities, longer travel distances, and a shortage of healthcare professionals. The objective of this study is to conduct a national examination of rural-urban differences in quality of dialysis care offered across counties in the U.S. METHODS: Data was gathered from Medicare-certified dialysis facilities in 2020 from the Centers for Medicare & Medicaid Services website. To identify high-need counties, county-level estimated crude prevalence of diabetes in adults were obtained from the 2022 CDC PLACES data portal. Our analysis reviewed 3,141 counties in the U.S. The primary outcome measured was whether the county had a dialysis facility. Among those counties that had a dialysis facility, additional outcomes were the average star rating, whether peritoneal dialysis was offered, and whether home dialysis was offered. RESULTS: Type of services offered by dialysis facilities varied significantly, with peritoneal dialysis the most commonly offered services (50.8%), followed by home hemodialysis (28.5%), and late shift services (16.0%). These service availabilities are more prevalent in urban facilities than in rural facilities. The Centers for Medicare & Medicaid Services Five Star Quality ratings were quite different between urban and rural facilities, with 40.4% of rural facilities having a ranking of five, compared to 27.1% in urban. CONCLUSION: The majority of rural counites lack a single dialysis facility. Counties with high rates of chronic kidney disease, diabetes, and blood pressure, deemed high need, were less likely to have a highly rated dialysis facility. The findings can be used to further inform targeted efforts to increase diabetes educational programming and design appropriate interventions to those residing in rural communities and high need counties who may need it the most.

Association of COVID-19 pandemic societal closures with gestational weight gain among women in South Carolina, 2018-2021.

PURPOSE: During the early COVID-19 pandemic, an increase in weight gain among the general population was observed; however, gestational weight gain (GWG) was not thoroughly evaluated. We evaluated changes in GWG during the pandemic closures in South Carolina. METHODS: We used live, singleton birth records to compare GWG outcomes among three pregnancy groups occurring before (January 2018-February 2020), during (March-May 2020), and after (June 2020-December 2021) pandemic closures. GWG categories were defined by the Institute of Medicine (IOM) recommendations. We used multinomial logistic regression models to calculate prevalence ratios (PRs) of GWG categories stratified by prepregnancy body mass index (BMI) category. RESULTS: We analyzed 177,571 birth records. Women with normal weight (n = 64,491, 36%) had a slightly lower prevalence of excessive GWG during and after the pandemic closures (PR 0.94; 95% CI: 0.91-0.98 and PR 0.95; 95% CI: 0.93-0.98, respectively). We observed no changes in GWG patterns for women with overweight and obesity. CONCLUSIONS: We found limited changes in GWG patterns for a subset of pregnant women during and after pandemic closures, compared with prepandemic period in South Carolina, countering findings of weight changes among the general population.

Rural-urban differences in access to care among children and adolescents in the United States.

PURPOSE: Rural children and adolescents face disproportionate challenges in access to health care services than their urban counterparts. Yet, recent evidence on disparities in access to health care between rural and urban children and adolescents has been limited. This study examines the associations of residence location with receipt of preventive care, foregone medical care, and continuity of insurance coverage among US children and adolescents. METHODS: This study used cross-sectional data from the 2019 to 2020 National Survey of Children's Health, with a final sample size of 44,679 children. Descriptive statistics, bivariate analyses, and multivariable logistic regression models were used to examine the differences in preventive care, foregone care, and continuity of insurance coverage between rural and urban children and adolescents. FINDINGS: Rural children had lower odds of receiving preventive care (aOR 0.64; 95% CI 0.56-0.74) and having continuous health insurance coverage (aOR 0.68; 95% CI 0.56-0.83) compared to urban children. The odds of foregone care were similar between rural and urban children. Children at every federal poverty level (FPL) less than 400% were less likely to receive preventive care, and more likely to forego care than children residing at 400% or above FPL. CONCLUSIONS: Rural disparities in child preventive care and insurance continuity warrant ongoing surveillance and local access to care initiatives, especially for children in low-income households. Without updated public health surveillance, policymakers and program developers may not be aware of current disparities. School-based health centers are 1 avenue for meeting the unmet health care needs of rural children.

Severe maternal morbidity by race and ethnicity before vs. during the COVID-19 pandemic.

PURPOSE: To examine the change in racial disparity in severe maternal morbidity (SMM) during the COVID-19 pandemic and the associations between SARS-CoV-2 infection and SMM. METHODS: This retrospective cohort study used linked databases of all livebirths delivered between 2018 and 2021 in South Carolina (n = 162,576). Exposures were 1) pre-pandemic and pandemic periods (before vs. March 2020 onwards); 2) SARS-CoV-2 infection, severity, and timing of first infection. Log-binomial regression models were used. RESULTS: SMM rate was higher among pandemic childbirths than pre-pandemic period (p = 0.06). The risk of SMM among Hispanics was doubled from pre-pandemic to pandemic periods (adjusted relative risk (aRR)= 2.50, 95% CI: 1.27, 4.94). During pre-pandemic, compared to White women, Black women (aRR=1.37, 95% CI: 1.14-1.64), while Hispanics had lower risk of SMM (aRR=0.42, 95% CI: 0.24-0.73). During the pandemic, the Black-White difference in the risk of SMM persisted (aRR=1.24, 95% CI: 1.00-1.54) and Hispanic-White difference in SMM risk became insignificant (aRR=0.85, 95% CI: 0.54-1.34). SARS-CoV-2 infection, its severity, and the late diagnosis were associated with 1.78-5.06 times higher risk of SMM. CONCLUSIONS: During pandemic, Black-White racial disparity in SMM persisted but the relative pre-pandemic advantage in SMM among Hispanic women over White women disappeared during the pandemic.

Trends in patient perceptions of care toward rural and urban hospitals in the United States: 2014-2019.

PURPOSE: Understanding rural-urban disparities in patient satisfaction is critical to identify gaps for improvement in patient-centered care and tailor interventions to specific patient needs, especially those in the Frontier and Remote areas (FAR). This study aimed to examine disparities in patient perceptions of care between urban, rural non-FAR, and FAR hospitals between 2014 and 2019. METHODS: This is a retrospective longitudinal study using 2014-2019 Hospital Consumer Assessment of Healthcare Providers and Systems data linked to American Hospital Annual Survey data (3,524 hospitals in 2014 and 3,440 hospitals in 2019). Multivariable linear regression models were used to identify differential trends in patient perceptions of care by hospital rurality over 2014-2019, adjusting hospital- and county-level characteristics. FINDINGS: In 2014, patients at rural non-FAR and FAR hospitals had lower percentages of willingness to definitely recommend these hospitals than urban hospitals (average percentage difference, 95% CI: -4.0% [-4.5%, -3.5%]; -2.0% [-2.8%, -1.2%]); yet, over the study period, rural hospitals experienced steeper increases in patient willingness to recommend (0.2% [0.07%, 0.4%]; 0.4% [0.08%, 0.7%]). FAR hospitals also showed improvements in patient experience in a clean environment, communication with nurses, communication about medicines, and responsiveness of staff. Communication with doctors showed slight decreases across hospital locations. CONCLUSIONS: Patient perceptions of care were generally improved in all US hospitals from 2014 to 2019, except communications with doctors. These findings highlight the potential for enhancing patient satisfaction and experience in urban hospitals and suggest the need to improve patient willingness to recommend in rural FAR hospitals.

Rural-Urban Differences in Overweight and Obesity, Physical Activity, and Food Security Among Children and Adolescents.

INTRODUCTION: Childhood obesity has been associated with numerous poor health conditions, with geographic disparities demonstrated. Limited research has examined the association between rurality and food security, physical activity, and overweight or obesity among children. We examined rates of food security, physical inactivity, and overweight or obesity among rural and urban children and adolescents, and associations between rurality and these 3 outcomes. METHODS: We used cross-sectional data from a nationally representative sample of children and adolescents aged 10 to 17 years from the 2019-2020 National Survey of Children's Health (N = 23,199). We calculated frequencies, proportions, and unadjusted associations for each variable by using descriptive statistics and bivariate analyses. We used multivariable logistic regression models to examine the association between rurality and food security, physical activity, and overweight or obesity. RESULTS: After adjusting for sociodemographic factors, rural children and adolescents had higher odds than urban children and adolescents of being overweight or obese (adjusted odds ratio = 1.30; 95% CI, 1.11-1.52); associations between rurality and physical inactivity and food insecurity were not significant. CONCLUSION: The information from this study is timely for policy makers and community partners to make informed decisions on the allocation of healthy weight and obesity prevention programs for children and adolescents in rural settings. Our study provides information for public health programming and the designing of appropriate dietary and physical activity interventions needed to reduce disparities in obesity prevention among children and adolescents.

Successes and Barriers of Health Information Exchange Participation Across Hospitals in South Carolina From 2014 to 2020: Longitudinal Observational Study.

BACKGROUND: The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation. OBJECTIVE: This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals. METHODS: This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated. RESULTS: Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68%), difficulty in finding patient health information (27/40, 68%), adapting different vendor platforms (26/40, 65%), difficulty matching or identifying same patients between systems (23/40, 58%), and providers that do not typically exchange patient data (23/40, 58%). CONCLUSIONS: HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information.

Racial disparities in adequacy of prenatal care during the COVID-19 pandemic in South Carolina, 2018-2021.

BACKGROUND: During the COVID-19 pandemic, hospitals' decision of not admitting pregnant women's partner or support person, and pregnant women's fear of contracting COVID-19 in hospitals may disrupt prenatal care. We aimed to examine whether prenatal care utilization in South Carolina varied before and during the COVID-19 pandemic, and whether the variation was different by race. METHODS: We utilized 2018-2021 statewide birth certificate data using a pre-post design, including all women who delivered a live birth in South Carolina. The Kotelchuck Index - incorporating the timing of prenatal care initiation and the frequency of gestational age-adjusted visits - was employed to categorize prenatal care into inadequate versus adequate care. Self-reported race includes White, Black, and other race groups. Multiple logistic regression models were used to calculate adjusted odds ratio of inadequate prenatal care and prenatal care initiation after first trimester by maternal race before and during the pandemic. RESULTS: A total of 118,925 women became pregnant before the pandemic (before March 2020) and 29,237 women during the COVID-19 pandemic (March 2020 - June 2021). Regarding race, 65.2% were White women, 32.0% were Black women and 2.8% were of other races. Lack of adequate prenatal care was more prevalent during the pandemic compared to pre-pandemic (24.1% vs. 21.6%, p < 0.001), so was the percentage of initiating prenatal care after the first trimester (27.2% vs. 25.0%, p < 0.001). The interaction of race and pandemic period on prenatal care adequacy and initiation was significant. The odds of not receiving adequate prenatal care were higher during the pandemic compared to before for Black women (OR 1.26, 95% CI 1.20-1.33) and White women (OR 1.10, 95% CI 1.06-1.15). The odds of initiating prenatal care after the first trimester were higher during the pandemic for Black women (OR 1.18, 95% CI 1.13-1.24) and White women (OR 1.09, 95% CI 1.04-1.13). CONCLUSIONS: Compared to pre-pandemic, the odds of not receiving adequate prenatal care in South Carolina was increased by 10% for White women and 26% for Black women during the pandemic, highlighting the needs to develop individual tailored interventions to reverse this trend.

Dual Barriers: Examining Digital Access and Travel Burdens to Hospital Maternity Care Access in the United States, 2020.

Policy Points The White House Blueprint for Addressing the Maternal Health Crisis report released in June 2022 highlighted the need to enhance equitable access to maternity care. Nationwide hospital maternity unit closures have worsened the maternal health crisis in underserved communities, leaving many birthing people with few options and with long travel times to reach essential care. Ensuring equitable access to maternity care requires addressing travel burdens to care and inadequate digital access. Our findings reveal socioeconomically disadvantaged communities in the United States face dual barriers to maternity care access, as communities located farthest away from care facilities had the least digital access. CONTEXT: With the increases in nationwide hospital maternity unit closures, there is a greater need for telehealth services for the supervision, evaluation, and management of prenatal and postpartum care. However, challenges in digital access persist. We examined associations between driving time to hospital maternity units and digital access to understand whether augmenting digital access and telehealth services might help mitigate travel burdens to maternity care. METHODS: This cross-sectional study used 2020 American Hospital Association Annual Survey data for hospital maternity unit locations and 2020 American Community Survey five-year ZIP Code Tabulation Area (ZCTA)-level estimates of household digital access to telecommunication technology and broadband. We calculated driving times of the fastest route from population-weighted ZCTA centroids to the nearest hospital maternity unit. Rural-urban stratified generalized median regression models were conducted to examine differences in ZCTA-level proportions of household lacking digital access equipment (any digital device, smartphones, tablet), and lacking broadband subscriptions by spatial accessibility to maternity units. FINDINGS: In 2020, 2,905 (16.6%) urban and 3,394 (39.5%) rural ZCTAs in the United States were located >30 minutes from the nearest hospital maternity units. Regardless of rurality, these communities farther away from a maternity unit had disproportionally lower broadband and device accessibility. Although urban communities have greater digital access to technology and broadband subscriptions compared to rural communities, disparities in the percentage of households with access to digital devices were more pronounced within urban areas, particularly between those with and without close proximity to a hospital maternity unit. Communities where nearest hospital maternity units were >30 minutes away had higher poverty and uninsurance rates than those with <15-minute access. CONCLUSIONS: Socioeconomically disadvantaged communities face significant barriers to maternity care access, both with substantial travel burdens and inadequate digital access. To optimize maternity care access, ongoing efforts (e.g., Affordable Connectivity Program introduced in the 2021 Infrastructure Act), should bridge the gaps in digital access and target communities with substantial travel burdens to care and limited digital access.

Rural-Urban Disparities in Hospital Admissions and Mortality Among Patients with COVID-19: Evidence from South Carolina from 2021 to 2022.

Although rural communities have been hard-hit by the COVID-19 pandemic, there is limited evidence on COVID-19 outcomes in rural America using up-to-date data. This study aimed to estimate the associations between hospital admissions and mortality and rurality among COVID-19 positive patients who sought hospital care in South Carolina. We used all-payer hospital claims, COVID-19 testing, and vaccination history data from January 2021 to January 2022 in South Carolina. We included 75,545 hospital encounters within 14 days after positive and confirmatory COVID-19 testing. Associations between hospital admissions and mortality and rurality were estimated using multivariable logistic regressions. About 42% of all encounters resulted in an inpatient hospital admission, while hospital-level mortality was 6.3%. Rural residents accounted for 31.0% of all encounters for COVID-19. After controlling for patient-level, hospital, and regional characteristics, rural residents had higher odds of overall hospital mortality (Adjusted Odds Ratio - AOR = 1.19, 95% Confidence Intervals - CI = 1.04-1.37), both as inpatients (AOR = 1.18, 95% CI = 1.05-1.34) and as outpatients (AOR = 1.63, 95% CI = 1.03-2.59). Sensitivity analyses using encounters with COVID-like illness as the primary diagnosis only and encounters from September 2021 and beyond - a period when the Delta variant was dominant and booster vaccination was available - yielded similar estimates. No significant differences were observed in inpatient hospitalizations (AOR = 1.00, 95% CI = 0.75-1.33) between rural and urban residents. Policymakers should consider community-based public health approaches to mitigate geographic disparities in health outcomes among disadvantaged population subgroups.

Trends in the availability of community-based home visiting services for oldest-old in China, 2005-2018.

OBJECTIVES: This study aims to examine trends in neighbourhood availability of community-based home visiting services (CHVS) (ie, coverage by local primary healthcare providers) over time and disparities in service availability according to individual characteristics using nationwide data of oldest-old individuals (age >80) in China. DESIGN: Repeated, cross-sectional study. SETTING: This study derived nationally representative data from the 2005-2018 Chinese Longitudinal Health Longevity Survey. PARTICIPANTS: A final analytical sample of 38 032 oldest-old individuals. PRIMARY OUTCOME MEASURES: Availability of CHVS was defined as having home visiting services in one's neighbourhood. Cochran-Armitage tests were used to test linear trends in the proportions of oldest-old with service availability. Weighted logistic regression models were used to examine variations in service availability across individual characteristics. RESULTS: Of 38 032 oldest-old individuals, availability of CHVS decreased from 9.7% in 2005 to 7.8% in 2008/2009, followed by continual increases to 33.7% in 2017/2018. These changes were similar between rural and urban oldest-old. After accounting for individual characteristics, in 2017/2018, compared with their counterparts, urban residents who had white-collar jobs before retirement and those residing in Western and Northeast China were less likely to have service availability. Oldest-old with disabilities, those living alone and those with low incomes did not report having greater availability of CHVS in either 2005 or 2017/2018. CONCLUSIONS: Despite the increasing service availability over the past 13 years, persistent geographical disparities in the availability of CHVS remain. As of 2017/2018, only one in three oldest-old in China reported having service availability, which raises concerns regarding continuity of care across different settings of services for those most in need, especially those living alone or with disabilities. National policies and targeting efforts are necessary to improve the availability of CHVS and reduce inequity in service availability for optimal long-term care to the oldest-old population in China.

Association Between Positive Childhood Experiences and Childhood Flourishing Among US Children.

OBJECTIVE: There has been limited research examining the fostering of positive childhood experiences (PCEs) that could promote flourishing among children. The purpose of this study is to examine the relationship between 7 selected PCEs and the outcome of flourishing, among a nationally based population-level survey sample of children aged 6 to 17 years. METHODS: Data were drawn from the 2018 to 2019 National Survey of Children's Health, with children aged 6 years and older included (n = 40,561). Children were designated as flourishing if they had responses of always or usually to all 3 flourishing items measured by the National Survey of Children's Health, which were (1) showing an interest and curiosity in learning new things, (2) working to finish the task they started, and (3) staying calm and in control when faced with a challenge. To examine the association between PCEs and flourishing, multivariable logistic regression models were used. RESULTS: Children who experienced each type of PCE had higher odds of flourishing: after-school activities (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.58-2.07), community volunteer (aOR, 1.63; 95% CI, 1.47-1.80), guiding mentor (aOR, 1.66; 95% CI, 1.39-2.00), resilient family (aOR, 2.35; 95% CI, 2.08-2.67), safe neighborhood (aOR, 1.43; 95% CI, 1.29-1.60), supportive neighborhood (aOR, 1.57; 95% CI, 1.42-1.74), and connected caregiver (aOR, 3.26; 95% CI, 2.93-3.64). CONCLUSION: Findings demonstrating a significant association between PCEs and flourishing have implications for population-wide approaches to improving the prevalence of flourishing among children and youth.

Trends in the availability of community-based psychological counselling services for oldest-old in China, 2005 to 2018.

BACKGROUND: Community-based psychological counselling services (CPCS) is crucial for the oldest-old who often faces challenges or are reluctant to seek care at the healthcare settings. This study aims to examine trends in availability of CPCS over time and rural-urban disparities in service availability among nationwide oldest-old in China. METHODS: Multiple cross-sectional data were derived from the 2005-2018 Chinese Longitudinal Health Longevity Survey. Service availability was reported by each oldest-old participant or their next-of-kins as having CPCS in one's neighborhood. We used Cochran-Armitage tests to estimate service availability trends and applied sample-weighted logistic regression models to examine its rural-urban disparities. RESULTS: Of 38,032 oldest-old, CPCS availability decreased from 6.7 % in 2005 to 4.8 % in 2008/2009, followed by continual increases to 13.6 % in 2017/2018. In 2017/2018, rural oldest-old's neighborhoods had no greater service availability. Oldest-old residing in the Central (6.7 %), Western (13.4 %) and Northeast China (8.1 %) were less likely to report having services locally than their Eastern counterparts (17.8 %). Oldest-old having any disability or living in the nursing homes reported having greater service availability than those without disability or living at home. LIMITATION: Service availability might have been disrupted during the COVID-19 pandemic. CONCLUSIONS: Despite the increasing service availability, as of 2017/2018, only 13.6 % oldest-old in China had reported CPCS availability. It raises concerns on the disproportionate access to and continuity of mental health care, especially for those living the Central, Western China and those living at home. Policy efforts are needed to incentivize service expansion and eliminate disparities in the service availability.

Risk for stillbirth among pregnant individuals with SARS-CoV-2 infection varied by gestational age.

BACKGROUND: Despite previous research findings on higher risks of stillbirth among pregnant individuals with SARS-CoV-2 infection, it is unclear whether the gestational timing of viral infection modulates this risk. OBJECTIVE: This study aimed to examine the association between timing of SARS-CoV-2 infection during pregnancy and risk of stillbirth. STUDY DESIGN: This retrospective cohort study used multilevel logistic regression analyses of nationwide electronic health records in the United States. Data were from 75 healthcare systems and institutes across 50 states. A total of 191,403 pregnancies of 190,738 individuals of reproductive age (15-49 years) who had childbirth between March 1, 2020 and May 31, 2021 were identified and included. The main outcome was stillbirth at ≥20 weeks of gestation. Exposures were the timing of SARS-CoV-2 infection: early pregnancy (<20 weeks), midpregnancy (21-27 weeks), the third trimester (28-43 weeks), any time before delivery, and never infected (reference). RESULTS: We identified 2342 (1.3%) pregnancies with COVID-19 in early pregnancy, 2075 (1.2%) in midpregnancy, and 12,697 (6.9%) in the third trimester. After adjusting for maternal and clinical characteristics, increased odds of stillbirth were observed among pregnant individuals with SARS-CoV-2 infection only in early pregnancy (odds ratio, 1.75, 95% confidence interval, 1.25-2.46) and midpregnancy (odds ratio, 2.09; 95% confidence interval, 1.49-2.93), as opposed to pregnant individuals who were never infected. Older age, Black race, hypertension, acute respiratory distress syndrome or acute respiratory failure, and placental abruption were found to be consistently associated with stillbirth across different trimesters. CONCLUSION: Increased risk of stillbirth was associated with COVID-19 only when pregnant individuals were infected during early and midpregnancy, and not at any time before the delivery or during the third trimester, suggesting the potential vulnerability of the fetus to SARS-CoV-2 infection in early pregnancy. Our findings underscore the importance of proactive COVID-19 prevention and timely medical intervention for individuals infected with SARS-CoV-2 during early and midpregnancy.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States.

INTRODUCTION: The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based). METHODS: We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type. RESULTS: Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic. DISCUSSION: The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

Broadband access within Medically Underserved Areas and its implication for telehealth utilization.

PURPOSE: There is little information as to how America's broadband infrastructure might impact recent efforts to expand access to virtual care for underserved communities. OBJECTIVE: To examine potential and realized access to broadband internet services within Medically Underserved Areas (MUAs) that rely on community health care service providers for primary care. METHODS: This cross-sectional study included 214,946 US Census Block Group estimates from the 2017 and 2019 American Community Survey and the corresponding Federal Communications Commission database. Changes in household broadband subscription rates and Healthy People 2020 access thresholds within MUAs were assessed. FINDINGS: In 2019, 24,304 MUA households (31.9%) met Healthy People 2020 targets for broadband subscription rates, compared to 64.4% of non-MUA households (n = 89,285). On average, 74.7% of MUA households had a broadband internet subscription compared to 85.2% of non-MUA households, whereas 61.1% (n = 46,635) of MUA households had access to broadband speeds of at least 25.0 Mbps, compared to 75.6% (n = 104,696) of non-MUA households. Within urban households, there was a 0.8 to 1.3 to 1.6 annual percentage point convergence in MUA versus non-MUA broadband disparities between across quintiles (P < .05). Rural MUA households showed little improvement in broadband access between 2017 and 2019. CONCLUSIONS: There has been an overall convergence of broadband access disparities between MUA and non-MUA households over time, but less improvements in access among the most rural households. Reimbursement for audio-only telehealth visits by state Medicaid agencies would help drive down barriers to virtual health care options for populations residing in MUAs.

Association of rurality, type of primary caregiver and place of death with end-of-life medical expenditures among the oldest-old population in China.

BACKGROUND: Understanding whether the type of primary caregiver and end-of-life (EOL) care location are associated with EOL medical expenditures is crucial to inform global debates on policies for efficient and effective EOL care. This study aims to assess trends in the type of primary caregiver and place of death stratified by rural‒urban status among the oldest-old population from 1998-2018 in China. A secondary objective is to determine the associations between rurality, the type of primary caregiver, place of death and EOL medical expenditures.  METHODS: A total of 20,149 deaths of people aged 80 years or older were derived from the Chinese Longitudinal Health Longevity Survey (CLHLS). Cochran-Armitage tests and Cuzick's tests were used to test trends in the type of primary caregiver and place of death over time, respectively. Tobit models were used to estimate the marginal associations of rurality, type of primary caregiver, and place of death with EOL medical expenditures because CLHLS sets 100,000 Chinese yuan (approximately US$15,286) as the upper limit of the outcome variable.  RESULTS: Of the 20,149 oldest-old people, the median age at death was 97 years old, 12,490 (weighted, 58.6%, hereafter) were female, and 8,235 lived in urban areas. From 1998-2018, the prevalence of informal caregivers significantly increased from 94.3% to 96.2%, and home death significantly increased from 86.0% to 89.5%. The proportion of people receiving help from informal caregivers significantly increased in urban decedents (16.5%) but decreased in rural decedents (-4.0%), while home death rates significantly increased among both urban (15.3%) and rural (1.8%) decedents. In the adjusted models, rural decedents spent less than urban decedents did (marginal difference [95% CI]: $-229 [$-378, $-80]). Those who died in hospitals spent more than those who died at home ($798 [$518, $1077]). No difference in medical expenditures by type of primary caregiver was observed. CONCLUSIONS: Over the past two decades, the increases in informal caregiver utilization and home deaths were unequal, leading to substantially higher EOL medical expenditures among urban decedents and deceased individuals who died at hospitals than among their counterparts who lived in rural areas and died at home.