Rethinking rurality: using hospital referral regions to investigate rural-urban health outcomes.

BACKGROUND: Rural residents in the United States face disproportionately poorer health outcomes compared to urban residents. This study aims to establish a continuous rural-urban measure for the 306 hospital referral regions (HRRs) in the U.S. and to investigate the relationship between the proportion of rural population served in each HRR and health outcomes, healthcare spending and utilization, and access to and quality of primary care. METHODS: Cross-sectional analysis using data from The Dartmouth Atlas and the U.S. Census. The sample is limited to fee-for-service Medicare beneficiaries aged 65-99 years and living during 2015. The primary outcomes were measured at the HRR-level: mortality rates, Medicare reimbursements, percent Medicare enrollees who have at least one visit to a primary care physician, diabetic hemoglobin A1c testing rates, and mammography rates. We calculate a population-weighted rural proportion and population-weighted area deprivation index (ADI) for each HRR by aggregating zip-code level data. RESULTS: The most rural quartile of HRRs had significantly greater mean mortality rate of 4.50%, compared to 3.95% in most urban quartile of HRRs (p < 0.001). Increasing rural proportion was associated with decreasing price-adjusted Medicare reimbursements. In the multivariate, linear regression model, increasing area deprivation (ADI) was associated with increasing rates of mortality and greater utilization. CONCLUSION: Disparities in rural mortality are driven by sociodemographic disadvantage, rather than the quality of care provided at hospitals serving rural areas. After accounting for sociodemographic disadvantage, rural areas achieve similar quality of primary care in measured domains at an overall lower cost.

Marriage, Children, and Sex-Based Differences in Physician Hours and Income.

Importance: A better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities. Objective: To investigate differences in earnings and hours worked for male and female physicians at various ages and family status. Design, Setting, and Participants: This retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019. Exposures: Earned income and work hours. Main Outcomes and Measures: Outcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022. Results: The sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children. Conclusions and Relevance: In this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.

Association Between the Growth of Accountable Care Organizations and Physician Work Hours and Self-employment.

Importance: The share of the population covered by accountable care organizations (ACOs) is growing, but the association between this increase and physician employment is unknown. Objective: To investigate the association between the growth of ACOs and changes in physician work hours, probability of being self-employed, and probability of working in a hospital. Design, Setting, and Participants: A fixed-effects design was used in this cross-sectional study to compare changes in physician employment in hospital referral regions with high vs low ACO growth. A nationally representative 1% sample of all working US physicians obtained annually from 2011 through 2015 from the American Community Survey (N = 49 582) was included. Data analysis was conducted from March 28, 2017, to April 10, 2018. Main Outcomes and Measures: Physician hours worked per week, probability of being self-employed, and probability of working in a hospital. Results: Of the 49 582 physicians included in the study, 63.5% were men; the mean (SD) age of sampled physicians was 46.01 (11.59) years. In 2011, sampled physicians worked a mean (SD) of 52.2 (16.1) hours per week, 24.43% were self-employed, and 42.03% worked in a hospital. A 10-percentage point increase in ACO enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 (95% CI, -1.52 to -0.13; P = .02) work hours in men and a decrease of 2% (95% CI, -3.8% to -0.1%; P = .04) in the probability of all physicians being self-employed. The association with self-employment was strongest (-5.0%; 95% CI, -8.7% to -1.4%; P = .006) in physicians aged 50 to 69 years, who were also more likely (4.0%; 95% CI, 1.0% to 6.9%; P = .009) to work in a hospital. Conclusions and Relevance: The growth of ACOs within hospital referral regions appears to be associated with a reduction in hours of work and self-employment among physicians. These results suggest that ACOs may affect physician employment patterns.

Molecular biology of Rh proteins and relevance to molecular medicine.

The Rhesus (Rh) blood group system is expressed by a pair of 12-transmembrane-domain-containing proteins, the RhCcEe and RhD proteins. RhCcEe and RhD associate as a Rh core complex that comprises one RhD/CcEe protein and most likely two Rh-associated glycoproteins (RhAG) as a trimer. All these Rh proteins are homologous and share this homology with two human non-erythroid proteins, RhBG and RhCG. All Rh protein superfamily members share homology and function in a similar manner to the Mep/Amt ammonium transporters, which are highly conserved in bacteria, plants and invertebrates. Significant advances have been made in our understanding of the structure and function of Rh proteins, as well as in the clinical management of Rh haemolytic disease. This review summarises our current knowledge concerning the molecular biology of Rh proteins and their role in transfusion and pregnancy incompatibility.

Epigenetic and genetic burden measures are associated with tumor characteristics in invasive breast carcinoma.

The development and progression of invasive breast cancer is characterized by alterations to the genome and epigenome. However, the relationship between breast tumor characteristics, disease subtypes, and patient outcomes with the cumulative burden of these molecular alterations are not well characterized. We determined the average departure of tumor DNA methylation from adjacent normal breast DNA methylation using Illumina 450K methylation data from 700 invasive breast tumors and 90 adjacent normal breast tissues in The Cancer Genome Atlas. From this we generated a novel summary measure of altered DNA methylation, the DNA methylation dysregulation index (MDI), and examined the relation of MDI with tumor characteristics and summary measures that quantify cumulative burden of genetic mutation and copy number alterations. Our analysis revealed that MDI was significantly associated with tumor stage (P = 0.017). Across invasive breast tumor subtypes we observed significant differences in genome-wide DNA MDIs (P = 4.9E-09) and in a fraction of the genome with copy number alterations (FGA) (P = 4.6E-03). Results from a linear regression adjusted for subject age, tumor stage, and estimated tumor purity indicated a positive significant association of MDI with both MCB and FGA (P = 0.036 and P < 2.2E-16). A recursively partitioned mixture model of all 3 somatic alteration burden measures resulted in classes of tumors whose epigenetic and genetic burden profile were associated with the PAM50 subtype and mutations in TP53, PIK3CA, and CDH1. Together, our work presents a novel framework for characterizing the epigenetic burden and adds to the understanding of the aggregate impact of epigenetic and genetic alterations in breast cancer.