Geographic and socioeconomic variation in treatment of elderly prostate cancer patients in Norway - a national register-based study.

PURPOSE: The aim of this study was to examine geographic and socioeconomic variation in curative treatment and choice of treatment modality among elderly prostate cancer (PCa) patients. METHODS: This register-based cohort study included all Norwegian men ≥ 70 years when diagnosed with non-metastatic, high-risk PCa in 2011-2020 (n = 10 807). Individual data were obtained from the Cancer Registry of Norway, the Norwegian Prostate Cancer Registry, and Statistics Norway. Multilevel logistic regression analysis was used to model variation across hospital referral areas (HRAs), incorporating clinical, demographic and socioeconomic factors. RESULTS: Overall, 5186 (48%) patients received curative treatment (radical prostatectomy (RP) (n = 1560) or radiotherapy (n = 3626)). Geographic variation was found for both curative treatment (odds ratio 0.39-2.19) and choice of treatment modality (odds ratio 0.10-2.45). Odds of curative treatment increased with increasing income and education, and decreased for patients living alone, and with increasing age and frailty. Patients with higher income had higher odds of receiving RP compared to radiotherapy. CONCLUSIONS: This study showed geographic and socioeconomic variation in treatment of elderly patients with non-metastatic, high-risk PCa, both in relation to overall curative treatment and choice of treatment modality. Further research is needed to explore clinical practices, the shared decision process and how socioeconomic factors influence the treatment of elderly patients with high-risk PCa.

County-Level Variation in Triple Guideline-Directed Medical Therapy in Heart Failure With Reduced Ejection Fraction.

Background: Current guidelines recommend simultaneous initiation of multidrug guideline-directed medical therapy classes for heart failure with reduced ejection fraction. Objectives: The purpose of this study was to evaluate county-level variation in use of triple guideline-directed medical therapy, defined as simultaneous prescription fills for beta-blockers, renin-angiotensin system inhibitors or angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists, in heart failure with reduced ejection fraction. Methods: We conducted a cohort study using Medicare Fee-for-Service claims data (parts A, B, and D between 2013 and 2019). Features of counties including area-level indicators of poverty, employment, and educational attainment and aggregated patient-level sociodemographic and medical history variables were compared by quintiles of triple therapy use. A multilevel logistic regression model was constructed to estimate the contextual effect of clustering by counties, which was expressed as a median OR. Results: 304,857 patients from 2,600 counties (83% of all U.S. counties) were included. The median for triple therapy use was 14.3% (IQR: 10.3%-18.8%) across included counties with a wide variation (range: 0%-54.5%). Compared to counties in the highest use quintile, counties in lowest triple therapy use quintile had worse area-level indicators of socioeconomic status (% unemployment 6.8% vs 6.2%). Counties in lowest quintile had higher proportion of Black patients (13.3% vs 5.7% in highest quintile) and patients with low-income subsidy (29.3% vs 25.8% in highest quintile). The median OR was 1.30 (95% CI: 1.28-1.33). Conclusions: We observed variation in triple therapy use across counties in the United States with suboptimal local use patterns correlating with indicators of socioeconomic disadvantage.

Spotted Hyena skull size variation across geography favors the energetic equivalence rule over Bergmann's Rule.

Much historic work has focused on establishing geographical and ecological rules that broadly explain patterns in size variation. We examined geographic variation in Spotted Hyena skull size using geometric morphometrics and spatial statistics. We quantified size variation and sexual size dimorphism of the skull, and evaluated the influence of temperature, precipitation, land cover type, and population density on skull size. We found that female spotted hyenas are slightly larger on average than males. Our analysis of regional differences did not indicate geographic variation in sexual size dimorphism. Skull size of Spotted Hyenas varies with geography but does not adhere to Bergmann's Rule. The smallest individuals of both sexes occur between -5.00° and 10.00° latitude and east of 28.50° longitude, with larger individuals being found elsewhere. Although Spotted Hyena skull size co-varies in some views with such variables as habitat type and climate indicators, skull size in this species most strongly co-varies with population density. The highest population densities are associated with the smallest skull size, possibly reflecting a relationship between high population density and access to resources. These results suggest that geographic variation in Spotted Hyena skull size is better explained by the energetic equivalence rule than Bergmann's Rule.

Phenotypic plasticity in the sailfin molly III: Geographic variation in reaction norms of growth and maturation to temperature and salinity.

Phenotypic plasticity, the ability of a single genotype to produce different phenotypes under different environmental conditions, plays a profound role in several areas of evolutionary biology. One important role is as an adaptation to a variable environment. While plasticity is extremely well documented in response to many environmental factors, there is controversy over how much of that plasticity is adaptive. Evidence is also mixed over how often conspecific populations display qualitative differences in the nature of plasticity. We present data on the reaction norms of growth and maturation to variation in temperature and salinity in male and female sailfin mollies (Poecilia latipinna) from three locally adjacent populations from South Carolina (SC). We compare these reaction norms to those previously reported in locally adjacent populations from north Florida (NF). In general, patterns of plasticity in fish from SC were similar to those in fish from NF. The magnitude of plasticity differed; fish from SC displayed less plasticity than fish from NF. This was because SC fish grew faster and matured earlier at the lower temperatures and salinities compared to NF fish. This is a countergradient pattern of variation, in which SC fish grew faster and matured earlier in conditions that would otherwise slow growth and delay maturity. Among fish from both regions, males were much less plastic than females, especially for length at maturity. While there was no detectable heterogeneity among populations from NF, males from one of the SC populations, which is furthest from the other two, displayed a qualitatively different response in age at maturity to temperature variation than did males from the other two SC populations. The pattern of population variation in plasticity within and among regions suggests that gene flow, which diminishes with distance in sailfin mollies, plays a critical role in constraining divergence in norms of reaction.

Geographical disparities in access to surgical treatment and mortality rates from abdominal aortic aneurysms in Brazil: A retrospective longitudinal study.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a growing public health problem, and not all patients have access to surgery when needed. This study aimed to analyze spatiotemporal variations in AAA mortality and surgical procedures in Brazilian intermediate geographic regions and explore the impact of different surgical techniques on operative mortality. METHODS: A retrospective longitudinal study was conducted to evaluate AAA mortality from 2008 to 2020 using space-time cube (STC) analysis and the emerging hot spot analysis tool through the Getis-Ord Gi* method. RESULTS: There were 34,255 deaths due to AAA, 13,075 surgeries to repair AAA, and a surgical mortality of 14.92%. STC analysis revealed an increase in AAA mortality rates (trend statistic = +1.7693, p = 0.0769) and a significant reduction in AAA surgery rates (trend statistic = -3.8436, p = 0.0001). Analysis of emerging hotspots revealed high AAA mortality rates in the South, Southeast, and Central-West, with a reduction in procedures in São Paulo and Minas Gerais States (Southeast). In the Northeast, there were extensive areas of increasing mortality rates and decreasing procedure rates (cold spots). CONCLUSION: AAA mortality increased in several regions of the country while surgery rates decreased, demonstrating the need for implementing public health policies to increase the availability of surgical procedures, particularly in less developed regions with limited access to services.

High parasite prevalence in an ecosystem engineer correlated with both local- and landscape-level factors.

Spatial variation in parasitic infection may have many physical and biological drivers. Uncovering these drivers may be especially important for parasites of ecosystem engineers because the engineers are foundational to their communities. Oysters are an important coastal ecosystem engineer that have declined drastically worldwide, in part due to enhanced cases of lethal oyster diseases, such as Dermo and MSX, caused by the protozoan parasites Perkinsus marinus and Haplosporidium nelsoni, respectively. Besides water quality and hydrodynamics, there is little information on how other variables influence the prevalence and intensity of these pathogens in oysters across a regional scale. To examine drivers of spatial variation in these oyster parasites-including host size, local reef properties, and landscape properties-we sampled 24 reefs systematically spread along the coast of Georgia, USA. Across sites, we found universally high prevalence of oysters with at least one of these parasites (91.02% ± 8.89, mean ± SD). Not only are high levels of parasite prevalence potentially problematic for a pivotal ecosystem engineer, but also low spatial variability may limit the explanatory power of variables across a regional scale. Our statistical models explained between 18 and 42% of the variation in spatial patterns of prevalence and intensity of these microparasites. Interestingly, landscape context was a positive predictor of P. marinus, but a negative predictor of H. nelsoni. Overall, our findings suggest that factors driving parasite prevalence and intensity operate across multiple spatial scales, and the same factor can both facilitate and hinder different parasites within the same host species.

Geographical variation in patient characteristics and outcomes in heart failure with mildly reduced and preserved ejection fraction.

AIMS: Compared to heart failure (HF) with reduced ejection fraction, HF with preserved ejection fraction (HFpEF), and HF with mildly reduced ejection fraction (HFmrEF) are increasing in prevalence, yet little is known about the geographic variation in patient characteristics, treatments and outcomes among these two HF phenotypes. The aim of this study was to investigate geographic differences in HFpEF and HFmrEF. METHODS AND RESULTS: We conducted an individual patient analysis of five clinical trials enrolling patients with HFpEF or HFmrEF from North America (NA), Latin America (LA), Western Europe (WE), Central/Eastern Europe and Russia (CEER), and Asia-Pacific (AP). We compared regions using descriptive statistics and multivariable regression models. Among the 19 959 patients included, 4066 (23.1%) had HFmrEF and 15 353 (76.9%) HFpEF. Regardless of HF phenotype, patients from WE were oldest, and those in CEER youngest. LA had the largest portion of females and NA most black patients. Obesity and diabetes were most prevalent in NA and hypertension and coronary heart disease most common in CEER. Self-reported health status varied strikingly and was the worst in NA and best in AP. Among patients with HFmrEF, rates of the primary composite endpoint (cardiovascular death or HF hospitalization) were: NA 12.56 per 100 patient-years (/100py), AP 11.67/100py, CEER 10.12/100py, LA 8.90/100py, and WE 8.43/100py, driven by differences in the rate of HF hospitalization. The corresponding values in HFpEF were 11.47/100py, 7.80/100py, 5.47/100py, 5.92/100py, and 7.80/100py, respectively. CONCLUSIONS: There is substantial geographic variation in patient characteristics, treatment and outcomes among patients with HFpEF and HFmrEF. These findings have implications for interpretation and generalizability of trial results, design and conduct of future trials, and optimization of care for these patients.

"Point by point" source: The Chinese pine plantations in North China by evidence from mtDNA.

The geographical variation and domestication of tree species are an important part of the theory of forest introduction, and the tracing of the germplasm is the theoretical basis for the establishment of high-quality plantations. Chinese pine (Pinus tabuliformis Carr.) is an important native timber tree species widely distributed in northern China, but it is unclear exactly where germplasm of the main Chinese pine plantation populations originated. Here, using two mtDNA markers, we analyzed 796 individuals representing 35 populations (matR marker), and 873 individuals representing 38 populations (nad5-1 marker) of the major natural and artificial populations in northern China, respectively (Shanxi, Hebei and Liaoning provinces). The results confirmed that the core position of natural SX* populations ("*" means natural population) in the Chinese pine populations of northern China, the genetic diversity of HB and LN plantations was higher than that of natural SX* populations, and there was a large difference in genetic background within the groups of SX* and LN, HB showed the opposite. More importantly, we completed the "point by point" tracing of the HB and LN plantings. The results indicated that almost all HB populations originated from SX* (GDS*, ZTS*, GCS*, and THS*), which resulted in homogeneity of the genetic background of HB populations. Most of germplasm of the LN plantations originated from LN* (ZJS* and WF*), and the other part originated from GDS* (SX*), resulting in the large differences in the genetic background within the LN group. Our results provided a reliable theoretical basis for the scientific allocation, management, and utilization of Chinese pine populations in northern China, and for promoting the high-quality establishment of Chinese pine plantations.

Tropical and montane Apis cerana show distinct dance-distance calibration curves.

Social bees have evolved sophisticated communication systems to recruit nestmates to newly found food sources. As foraging ranges can vary from a few hundred meters to several kilometers depending on the environment or season, populations of social bee species living in different climate zones likely show specific adaptations in their recruitment communication. Accordingly, studies in the western honey bee, Apis mellifera, demonstrated that temperate populations exhibit shallower dance-calibration curves compared with tropical populations. Here, we report the first comparison of calibration curves for three Indian Apis cerana lineages: the tropical Apis indica, and the two montane Himalayan populations Apis cerana cerana (Himachal Pradesh) and Apis cerana kashmirensis (Jammu and Kashmir). We found that the colonies of the two montane A. cerana populations show dance-distance calibration curves with significantly shallower slopes than those of the tropical A. indica. Next, we transferred A. c. cerana colonies to Bangalore (∼ 2600 km away) to obtain calibration curves in the same location as A. indica. The common garden experiment confirmed this difference in slopes, implying that the lineages exhibit genetically fixed differences in dance-distance coding. However, the slopes of the calibration curves of the transferred A. c. cerana colonies were also significantly higher than those of the colonies tested in their original habitat, indicating an important effect of the environment. The differences in dance-distance coding between temperate and tropical A. cerana lineages resemble those described for Apis mellifera, suggesting that populations of both species independently evolved similar adaptations.

Geographical patterns and environmental influencing factors of variations in Asterothamnus centraliasiaticus seed traits on Qinghai-Tibetan plateau.

Introduction: Seed traits related to recruitment directly affect plant fitness and persistence. Understanding the key patterns and influencing factors of seed trait variations is conducive to assessing plant colonization and habitat selection. However, the variation patterns of the critical seed traits of shrub species are usually underrepresented and disregarded despite their vital role in alpine desert ecosystems. Methods: This study gathered seeds from 21 Asterothamnus centraliasiaticus populations across the Qinghai-Tibetan Plateau, analyzing geographical patterns of seed traits to identify external environmental influences. Additionally, it explored how seed morphology and nutrients affect germination stress tolerance, elucidating direct and indirect factors shaping seed trait variations. Results: The results present substantial intraspecific variations in the seed traits of A. centraliasiaticus. Seed traits except seed length-to-width ratio (LWR) all vary significantly with geographic gradients. In addition, the direct and indirect effects of climatic variables and soil nutrients on seed traits were verified in this study. Climate mainly influences seed nutrients, and soil nutrients significantly affect seed morphology and seed nutrients. Furthermore, climate directly impacts seed germination drought tolerance index (GDTI) and germination saline-alkali tolerance index (GSTI). Seed germination cold tolerance index (GCTI) is influenced by climate and soil nutrients (mostly SOC). GDTI and GSTI are prominently influenced by seed morphology (largely the seed thousand-grain weight (TGW)), and GCTI is evidently affected by seed nutrients (mainly the content of soluble protein (CSP)). Discussion: The findings of this study amply explain seed trait variation patterns of shrubs in alpine desert ecosystems, possessing significant importance for understanding the mechanism of shrub adaptation to alpine desert ecosystems, predicting the outcomes of environmental change, and informing conservation efforts. This study can be a valuable reference for managing alpine desert ecosystems on the Qinghai-Tibetan Plateau.

Geographic variation in sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide-1 receptor agonist use in people with type 2 diabetes in New South Wales, Australia.

AIM: Sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) improve glycaemic control and cardio-renal outcomes for people with type 2 diabetes (T2D). However, geographic and socio-economic variation in use is not well understood. METHODS: We identified 367 829 New South Wales residents aged ≥40 years who dispensed metformin in 2020 as a proxy for T2D. We estimated the prevalence of use of other glucose-lowering medicines among people with T2D and the prevalence of SGLT2i and GLP-1RA use among people using concomitant T2D therapy (i.e. metformin + another glucose-lowering medicine). We measured the prevalence by small-level geography, stratified by age group, and characterized by remoteness and socio-economic status. RESULTS: The prevalence of SGLT2i (29.7%) and GLP-1RA (8.3%) use in people with T2D aged 40-64 increased with geographic remoteness and in areas of greater socio-economic disadvantage, similar to other glucose-lowering medicines. The prevalence of SGLT2i (55.4%) and GLP-1RA (15.4%) among people using concomitant T2D therapy varied across geographic areas, with lower SGLT2i use in more disadvantaged areas and localized areas of high GLP-1RA use (2.5 times the median). Compared with people aged 40-64 years, the prevalence of SGLT2i and GLP-1RA use was lower in older age groups, but with similar patterns of variation across geographic areas. CONCLUSIONS: The prevalence of SGLT2i and GLP-1RA use varied by geography, probably reflecting a combination of system- and prescriber-level factors. Socio-economic variation in GLP-1RA use was overshadowed by localized patterns of prescribing. Continued monitoring of variation can help shape interventions to optimize use among people who would benefit the most.

Variation in colorectal cancer treatment and outcomes in Scotland: real world evidence from national linked administrative health data.

Background: Colorectal cancer (CRC) is the fourth most common type of cancer in the United Kingdom and the second leading cause of cancer death. Despite improvements in CRC survival over time, Scotland lags behind its UK and European counterparts. In this study, we carry out an exploratory analysis which aims to provide contemporary, population level evidence on CRC treatment and survival in Scotland. Methods: We conducted a retrospective population-based analysis of adults with incident CRC registered on the Scottish Cancer Registry (Scottish Morbidity Record 06 (SMR06)) between January 2006 and December 2018. The CRC cohort was linked to hospital inpatient (SMR01) and National Records of Scotland (NRS) deaths records allowing a description of their demographic, diagnostic and treatment characteristics. Cox proportional hazards regression models were used to explore the demographic and clinical factors associated with all-cause mortality and CRC specific mortality after adjusting for patient and tumour characteristics among people identified as early-stage and treated with surgery. Results: Overall, 32,691 (73%) and 12,184 (27%) patients had a diagnosis of colon and rectal cancer respectively, of whom 55% and 53% were early-stage and treated with surgery. Five year overall survival (CRC specific survival) within this cohort was 72% (82%) and 76% (84%) for patients with colon and rectal cancer respectively. Cox proportional hazards models revealed significant variation in mortality by sex, area-based deprivation and geographic location. Conclusions: In a Scottish population of patients with early-stage CRC treated with surgery, there was significant variation in risk of death, even after accounting for clinical factors and patient characteristics.

Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data.

Introduction: In Japan, a country at the forefront of population ageing, significant geographic variation has been observed in inpatient medical expenditures for older adults aged 75 and above (IMEP75), both at the small- and large-area levels. However, our understanding of how different levels of administrative (geographic) units contribute to the overall geographic disparities remains incomplete. Thus, this study aimed to assess the degree to which geographic variation in IMEP75 can be attributed to municipality-, secondary medical area (SMA)-, and prefecture-level characteristics, and identify key factors associated with IMEP75. Methods: Using nationwide aggregate health insurance claims data of municipalities for the period of April 2018 to March 2019, we conducted a multilevel linear regression analysis with three levels: municipalities, SMA, and prefectures. The contribution of municipality-, SMA-, and prefecture-level correlates to the overall geographic variation in IMEP75 was evaluated using the proportional change in variance across six constructed models. The effects of individual factors on IMEP75 in the multilevel models were assessed by estimating beta coefficients with their 95% confidence intervals. Results: We analysed data of 1,888 municipalities, 344 SMAs, and 47 prefectures. The availability of healthcare resources at the SMA-level and broader regions to which prefectures belonged together explained 57.3% of the overall geographic variance in IMEP75, whereas the effects of factors influencing healthcare demands at the municipality-level were relatively minor, contributing an additional explanatory power of 2.5%. Factors related to long-term and end-of-life care needs and provision such as the proportion of older adults certified as needing long-term care, long-term care benefit expenditure per recipient, and the availability of hospital beds for psychiatric and chronic care and end-of-life care support at home were associated with IMEP75. Conclusion: To ameliorate the geographic variation in IMEP75 in Japan, the reallocation of healthcare resources across SMAs should be considered, and drivers of broader regional disparities need to be further explored. Moreover, healthcare systems for older adults must integrate an infrastructure of efficient long-term care and end-of-life care delivery outside hospitals to alleviate the burden on inpatient care.

The United States dermatology inpatient workforce between 2013 and 2019: a Medicare analysis reveals contraction of the workforce and vast access deserts-a cross-sectional analysis.

While time spent practicing inpatient dermatology has decreased since the 1990s, less is known about the current state of inpatient dermatology. We describe the distribution and frequency of inpatient dermatology encounters servicing the United States Medicare population between 2013 and 2019. Cross-sectional analysis of publicly available inpatient Medicare Part B claims data from 2013 to 2019 was conducted. Main outcomes and measures were characteristics and trends of dermatologists performing inpatient encounters. Categorical variables were compared using χ2 analysis. Trends were analyzed for linearity using Pearson correlation coefficient. 782 physicians met inclusion criteria for inclusion. Dermatologists were more often male (56.5%), possessing allopathic Medical Doctorate (MD) (86.3%), and in metropolitan settings (98.2%). However, proportion of female inpatient dermatologists increased significantly (37.9% to 46.2%). Across rural and metropolitan practices, number of inpatient physicians (2013: 356; 2019: 281) and number of medical centers in which dermatology encounters occurred (2013: 239; 2019: 157) decreased, more significantly in non-residency-associated institutions. Spatial analysis revealed wide regions lacking dermatologists meeting defined criteria. Limitations included the need for ten Medicare inpatient encounters for inclusion, counties without reported data. In conclusion, the number of dermatologists performing > 10 inpatient encounters per year is decreasing, and large variations exist in the number of U.S. inpatient dermatology visits.

Developmental differences in spatially distinct populations of the forensically relevant blow fly Lucilia sericata - About the comparability of developmental studies (and case work application).

The cosmopolitan blow fly Lucilia sericata is often used in forensic case work for estimating the minimum postmortem interval (PMImin). For this, the age of immature specimens developing on the dead body is calculated by measuring the time taken to reach the sampled developmental stage at a given temperature. To test whether regional developmental data of L. sericata is valid on a global scale, the time taken to reach different developmental stages was compared between a population from Mexico and one from Germany at two different constant temperatures. The German population of L. sericata was collected in Frankfurt/Main, while the Mexican population originated near Oaxaca de Juarez and was transported to Germany in the larval stage. Only the F1 generation was used to avoid adaption of the Mexican flies. Eggs were immediately placed at 20 °C and 30 °C. Five times 30 freshly eclosed larvae per replicate (n = 5) were then transferred to a cup of minced meat in separate containers. The larvae were checked every 8 h for migration, pupariation or emergence of adult flies. The time at which the first individual and 50 % of the specimens per container entered each of these stages, was recorded. Significant differences in the time of development between the two populations were observed at both temperatures. At 20 °C, the first specimens of the Mexican population reached all developmental stages a little (< 1 day to < 2 days) earlier than the German L. sericata. At 30 °C, the Mexican flies also reached the post-feeding stage slightly earlier (0.2 days). However, at 30 °C, the German flies started pupariation significantly earlier (after 5 days) than the Mexican flies (6.9 days) and the adults from Germany also emerged earlier (10.5 days compared to 13.1 days). The same pattern was observed when looking at 50 % of the total number of specimens per container. A comparison with previously published developmental studies was difficult as the experimental design varied widely between studies. However, the results were within the range of most studies. Our study has shown that age estimation can vary widely depending on the population on which the reference data used for the calculations are based. This highlights the importance of using local and population-specific developmental data for estimating the age of blow flies in case work.

Socioeconomic and geographic variations of disabilities in India: evidence from the National Family Health Survey, 2019-21.

BACKGROUND: Increasing disability is of global and national concern. Lack of evidence on disability across socioeconomic groups and geographic levels (especially small areas) impeded interventions for these disadvantaged subgroups. We aimed to examine the socioeconomic and geographic variations in disabilities, namely hearing, speech, visual, mental, and locomotor, in Indian participants using cross-sectional data from the National Family Health Survey 2019-2021. METHODS: Using data from 27,93,971 individuals, we estimated age-sex-adjusted disability rates at the national and sub-national levels. The extent of socioeconomic variations in disabilities was explored using the Erreygers Concentration Index and presented graphically through a concentration curve. We adopted a four-level random intercept logit model to compute the variance partitioning coefficient (VPC) to assess the significance of each geographical unit in total variability. We also calculated precision-weighted disability estimates of individuals across 707 districts and showed their correlation with within-district or between-cluster standard deviation. RESULTS: We estimated the prevalence of any disability of 10 per 1000 population. The locomotor disability was common, followed by mental, speech, hearing, and visual. The concentration index of each type of disability was highest in the poorest wealth quintile households and illiterate 18 + individuals, confirming higher socioeconomic variations in disability rates. Clusters share the largest source of geographic variation for any disability (6.5%), hearing (5.8%), visual (24.3%), and locomotor (17.4%). However, States/Union Territories (UTs) account for the highest variation in speech (3.7%) and mental (6.5%) disabilities, where the variation at the cluster level becomes negligible. Districts with the highest disability rates were clustered in Madhya Pradesh, Maharashtra, Karnataka, Tamil Nadu, Telangana, and Punjab. Further, we found positive correlations between the district rates and cluster standard deviations (SDs) for disabilities. CONCLUSIONS: Though the growing disability condition in India is itself a concerning issue, wide variations across socioeconomic groups and geographic locations indicate the implementation of several policy-relevant implications focusing on these vulnerable chunks of the population. Further, the critical importance of small-area variations within districts suggests the design of strategies targeting these high-burden areas of disabilities.

Geographic differences in pharmacotherapy patterns and outcomes of acute ischemic stroke in China.

BACKGROUND: Vast economic and healthcare status discrepancies exist among regions in China, contributing to different treatment patterns. This study was aimed to investigate the current status of pharmacotherapy for acute ischemic stroke (AIS) and outcomes in China and explore the geographic variation in stroke care. METHODS: This study was a multicenter prospective registry study, which collected the data of patients with AIS from 80 hospitals in 46 cities in 2015-2017 across China. Poor functional outcome defined as a modified Rankin Scale score of 3-6 was assessed at 3 and 12 months. Multivariate logistic regression was used. RESULTS: Among 9973 eligible patients, the number of receiving intravenous thrombolysis (IVT), antiplatelet agents, anticoagulants, statin and human urinary kallidinogenase was 429 (4.3%), 9363 (93.9%), 1063 (10.7%), 6828 (74.7%) and 5112 (51.2%), respectively. Multivariable analysis showed IVT use in northeastern was significantly more frequent than in eastern region (OR = 3.17, 95% CI, 2.53-3.99), while the antiplatelets agents use were less frequent (OR = 0.46, 95%CI: 0.38-0.57). The proportions of poor outcomes at 3 and 12 months were 20.7% and 15.8%, respectively. Multivariate analysis showed AIS patients from northeastern and central region had significantly lower risk of poor outcome at month 3 and 12 than those from eastern region (all P < 0.05). CONCLUSIONS: There was a low IVT use and a high antiplatelet agent and statin use for AIS in China. The pharmacotherapy and prognosis of AIS had variation by geographic region. TRIAL REGISTRATION: This study was registered with ClinicalTrials.gov (NCT02470624).

Effects of altitude on thyroid disorders according to Chinese three-rung, ladder-like topography: national cross-sectional study.

BACKGROUND: Chinese topography appears a three-rung ladder-like distribution of decreasing elevation from northwest to southeast, which is divided by two sloping edges. Previous studies have reported that prevalence of thyroid diseases differed by altitude, and geographical factors were associated with thyroid disorders. To explore the association between three-rung ladder-like regions and thyroid disorders according to unique Chinese topographic features, we conducted an epidemiological cross-sectional study from 2015-2017 that covered all 31 mainland Chinese provinces. METHODS: A total of 78,470 participants aged ≥ 18 years from a nationally representative cross-sectional study were included. Serum thyroid peroxidase antibody, thyroglobulin antibody, and thyroid-stimulating hormone levels; urine iodine concentration; and thyroid volume were measured. The three-rung ladder-like distribution of decreasing elevation from northwest to southeast in China was categorized into three topographic groups according to elevation: first ladder, > 3000 m above sea level; second ladder, descending from 3000-500 m; and third ladder, descending from 500 m to sea level. The third ladder was further divided into groups A (500-100 m) and B (< 100 m). Associations between geographic factors and thyroid disorders were assessed using linear and binary logistic regression analyses. RESULTS: Participants in the first ladder group were associated with lower thyroid peroxidase (ß = -4.69; P = 0.00), thyroglobulin antibody levels (ß = -11.08; P = 0.01), and the largest thyroid volume (ß = 1.74; P = 0.00), compared with the other groups. The second ladder group was associated with autoimmune thyroiditis (odds ratio = 1.30, 95% confidence interval [1.18-1.43]) and subclinical hypothyroidism (odds ratio = 0.61, 95%confidence interval [0.57-0.66]) (P < 0.05) compared with the first ladder group. Group A (third ladder) (500-100 m) was associated with thyroid nodules and subclinical hypothyroidism (P < 0.05). Furthermore, group B (< 100 m) was positively associated with autoimmune thyroiditis, thyroid peroxidase and thyroglobulin antibody positivity, and negatively associated with overt hypothyroidism, subclinical hypothyroidism, and goiter compared with the first ladder group(P < 0.05). CONCLUSION: We are the first to investigate the association between different ladder regions and thyroid disorders according to unique Chinese topographic features. The prevalence of thyroid disorders varied among the three-rung ladder-like topography groups in China, with the exception of overt hyperthyroidism.

Understanding Factors Influencing Geographic Variation in Healthcare Expenditures: A Small Areas Analysis Study.

Dramatic geographic variations in healthcare expenditures were documented by developed countries, but little is known about such variations under China's context, and what causes such variations. This study aims to examine variations of healthcare expenditures among small areas and to determine the associations between demand-, supply-factors, and per capita inpatient expenditures. This cross-sectional study utilized hospital discharge data aggregated within delineated hospital service areas (HSAs) using the small-area analysis approach. Linear multivariate regression modeling with robust standard errors was used to estimate the sources of variation of per capita inpatient expenditures across HSAs covering the years 2017 to 2019; the Shapley value decomposition method was used to measure the respective contributions of demand-, supply-side to such variations. Among 149 HSAs, demand factors explained most of the (87.4%) overall geographic variation among HSAs. With each 1% increase in GDP per capita and urbanization rate was associated with 0.099% and 0.9% increase in inpatient expenditure per capita, respectively, while each 1% increase in the share of females and the unemployment rate was associated with a 0.7% and 0.4% reduction in the per capita inpatient expenditures, respectively. In supply-side, for every 1 increase in hospital beds per 1000 population, the per capita inpatient expenditures rose by 2.9%, while with every 1% increase in the share of private hospitals, the per capita inpatient expenditures would decrease by 0.4%. With Herfindahl-Hirschman Index decrease 10%, the per capita inpatient expenditures would increase 1.06%. This study suggests demand-side factors are associated with large geographic variation in per capita inpatient expenditures among HSAs, while supply-side factors played an important role. The evaluation of geographic variations in per capita inpatient expenditures as well as its associated factors have great potential to provide an indirect approach to identify possibly existing underutilized or overutilized healthcare procedures.