Time trends and regional variation in utilization of antidiabetic medicines in China, 2015-2022.

AIM: To assess the use of non-insulin antidiabetic medicines in China. MATERIALS AND METHODS: We analysed the national procurement data for 29 non-insulin antidiabetic medicines from nine subgroups in China from 2015 to 2022. We estimated the number of defined daily doses (DDDs) procured per year in seven regions of China for nine subgroups and adjusted the data by the number of patients with diabetes. For each subgroup, the regional ratio was calculated by comparing the procurement per patient in each region with the procurement nationwide. The regional disparity was the difference between the highest and lowest regional ratios. We compared the medication patterns across regions. RESULTS: Nationally, between 2015 and 2022, the number of DDDs per patient increased from 14.45 to 47.37. The two most commonly used categories were sulphonylurea and biguanides, which increased from 7.04 to 15.39 (119%) and 3.28 to 11.11 (239%) DDDs per patient, respectively. The procurement of new drugs (dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter type 2 inhibitors and glucagon-like peptide-1 receptor agonists) increased quickly and had >5000% relative changes. Particularly for sodium-glucose cotransporter type 2 inhibitors, it increased from 0.08 to 5.03 DDDs (6662%). The southwest region had the highest relative change (319%), while the southern region had the lowest (118%). Biguanide and thiazolidinediones had the lowest (1.19) and highest level (2.21) of regional disparity in 2022, respectively. CONCLUSION: The procurement of non-insulin antidiabetic medicines in China has increased a lot from 2015 to 2022. In terms of DDDs per patient, sulphonylurea ranked first, followed by metformin. The procurement of new drugs increased greatly. A large regional disparity existed in medicine usage and patterns.

Patterns in the Reporting of Aggressive Histologic Subtypes in Papillary Thyroid Cancer.

INTRODUCTION: The tall cell, columnar, and diffuse sclerosing subtypes are aggressive histologic subtypes of papillary thyroid cancer (PTC) with increasing incidence, yet there is a wide variation in reporting. We aimed to identify and compare factors associated with the reporting of these aggressive subtypes (aPTC) to classic PTC (cPTC) and secondarily identify differences in outcomes. METHODS: The National Cancer Database was utilized to identify cPTC and aPTC from 2004 to 2017. Patient and facility demographics and clinicopathologic variables were analyzed. Independent predictors of aPTC reporting were identified and a survival analysis was performed. RESULTS: The majority of aPTC (67%) were reported by academic facilities. Compared to academic facilities, all other facility types were 1.4-2.0 times less likely to report aPTC (P < 0.05). Regional variation in reporting was noted, with more cases reported in the Middle Atlantic, despite there being more total facilities in the South Atlantic and East North Central regions. Compared to the Middle Atlantic, all other regions were 1.4-5 times less likely to report aPTC (P < 0.001). Patient characteristics including race and income were not associated with aPTC reporting. Compared to cPTC, aPTC had higher rates of aggressive features and worse 5-y overall survival (90.5% versus 94.5%, log rank P < 0.001). CONCLUSIONS: Aggressive subtypes of PTC are associated with worse outcomes. Academic and other facilities in the Middle Atlantic were more likely to report aPTC. This suggests the need for further evaluation of environmental or geographic factors versus a need for increased awareness and more accurate diagnosis of these subtypes.

Evaluation of pharmaceutical consumption between urban and suburban catchments in China by wastewater-based epidemiology.

Wastewater-based epidemiology (WBE) is amply used for estimating human consumption of chemicals, yet information on regional variation of pharmaceuticals and their environmental fate are scarce. Thus, this study aims to estimate the consumption of three cardiovascular, four non-steroidal anti-inflammatory pharmaceuticals (NSAIDs), and four psychoactive pharmaceuticals between urban and suburban catchments in China by WBE, and to explore their removal efficiencies and ecological risks. Eleven analytes were detected in both influent and effluent samples. The estimated consumptions ranged from

Higher participation rates for specific health checkups are associated with a lower incidence of treated ESKD in Japan.

BACKGROUND: A Japanese cohort study previously reported that not attending health checkups was associated with an increased risk of treated end-stage kidney disease (ESKD). The present study aimed to examine this association at the prefecture level. METHODS: We conducted an ecological study of all prefectures in Japan (n = 47) using five sources of nationwide open data. We explored associations of participation rates for Specific Health Checkups (SHC participation rates), the estimated prevalence of chronic kidney disease (CKD), and the ratio of nephrology specialists for each prefecture with prefecture-specific standardized incidence rates (SIRs) of treated ESKD using structural equation modeling. RESULTS: Prefecture-specific SHC participation rates ranged from 44.2% to 65.9%, and were negatively correlated with prefecture-specific SIRs and prevalence of CKD, and positively correlated with the ratio of nephrology specialists. SHC participation rates had significant negative effects on prefecture-specific SIRs (standardized estimate (ß) = - 0.38, p = 0.01) and prefecture-specific prevalence of CKD (ß = - 0.32, p = 0.02). Through SHC participation rates, the ratio of nephrology specialists had a significant indirect negative effect on prefecture-specific SIRs (ß= - 0.14, p = 0.02). The model fitted the data well and explained 14% of the variance in SIRs. CONCLUSIONS: Our findings support the importance of increasing SHC participation rates at the population level and may encourage people to undergo health checkups.

Concerns for others increases the likelihood of vaccination against influenza and COVID-19 more in sparsely rather than densely populated areas.

Vaccination yields the direct individual benefit of protecting recipients from infectious diseases and also the indirect social benefit of reducing the transmission of infections to others, often referred to as herd immunity This research examines how prosocial concern for vaccination, defined as people's preoccupation with infecting others if they do not vaccinate themselves, motivates vaccination in more and less populated regions of the United States. A nationally representative, longitudinal survey of 2,490 Americans showed that prosocial concern had a larger positive influence on vaccination against influenza in sparser regions, as judged by a region's nonmetropolitan status, lesser population density, and lower proportion of urban land area. Two experiments (total n = 800), one preregistered, provide causal evidence that drawing attention to prosocial (vs. individual) concerns interacted with social density to affect vaccination intentions. Specifically, prosocial concern led to stronger intentions to vaccinate against influenza and COVID-19 but only when social density was low (vs. high). Moderated mediation analyses show that, in low-density conditions, the benefits of inducing prosocial concern were due to greater perceived impact of one's vaccination on others. In this light, public health communications may reap more benefits from emphasizing the prosocial aspects of vaccination in sparser environments.

What explains regional variation in privately provided out-of-area residential placement costs for people with intellectual disability in Ireland?

BACKGROUND: Expenditure on residential placements for people with intellectual disability (ID) in Ireland is considerable and expected to increase. Despite this, there is limited evidence on the factors driving variation in privately provided 'out-of-area' residential placement costs, including across Community Health Organisations (CHOs)/regions. This is important to help inform the delivery of services at best value. METHODS: We analyse unit cost data from 2019 for a sample of 278 high-cost publicly funded privately provided out-of-area residential placements for people with ID in Ireland. We undertake univariate analysis of the relationship between costs and a wide range of variables using t-tests and one-way analysis of variance. We employ multivariable regression analysis to examine how raw differentials in unit costs across regions can be accounted for by individual-level characteristics. RESULTS: We estimate average unit costs of €264 170 per annum in our sample. The univariate analysis shows considerable variation in costs across a range of personal, disability, psychiatry/psychological, forensic issues, behaviour and supports and plans related variables. We also find wide variation in average unit costs across CHOs/regions (F = 4.58, P < 0.001), ranging from €213 380 to €331 880. The multivariable analysis shows that regional differences remain even after accounting for a wide range of individual characteristics that influence costs. CONCLUSIONS: Our analysis shows that while the majority of differences in costs across regions can be explained, there is potential for cost savings in the provision of high-cost publicly funded out-of-area residential placements in Ireland. Overall this can help to develop and implement a more sustainable disability residential funding model in a context of rising demand for services. It also has potential implications for the approach to procurement of services.

Regional variation in patient selection, practice patterns, and outcomes based on techniques for carotid artery revascularization in the Vascular Quality Initiative.

OBJECTIVE: Significant regional variation is known with multiple surgical procedures. This study describes regional variation in carotid revascularization within the Vascular Quality Initiative (VQI). METHODS: Data from the VQI carotid endarterectomy (CEA) and carotid artery stenting (CAS) databases from 2016 to 2021 were used. Nineteen geographic VQI regions were divided into three tertiles based on the average annual volume of carotid procedures performed per region (low-volume: 956 cases [range, 144-1382]; medium-volume: 1533 cases [range, 1432-1589]; and high-volume: 1845 cases [range, 1642-2059]). Patients' characteristics, indications for carotid revascularization, practice patterns, and outcomes (perioperative and 1-year stroke/death) of different revascularization techniques were compared between these regional groups. Regression models that adjust for known risk factors and allow for random effects at the center level were used. RESULTS: CEA was the most common revascularization procedure (>60%) across all regional groups. Significant regional variation was observed in the practice of CEA such as variability in the use of shunting, drain placement, stump pressure and electroencephalogram monitoring, intraoperative protamine, and patch angioplasty. For transfemoral CAS, high-volume regions had a higher proportion of asymptomatic patients with <80% stenosis (30.5% vs 27.8%) in addition to higher use of local/regional anesthesia (80.4% vs 76.2%), protamine (16.1% vs 11.8%), and completion angiography (81.6% vs 77.6%) during transfemoral carotid artery stenting (TF-CAS) compared with low-volume regions. For transcarotid artery revascularization (TCAR), high-volume regions were less likely to intervene on asymptomatic patients with <80% stenosis (32.2% vs 35.8%) than low-volume regions. They also had a higher proportion of urgent/emergent procedures (13.6% vs 10.4%) and were more likely to use general anesthesia (92.0% vs 82.1%), completion angiography (67.3% vs 63.0%), and poststent ballooning (48.4% vs 36.8%). For each carotid revascularization technique, no significant differences were noted in perioperative and 1-year outcomes between low-, medium-, and high-volume regions. Finally, there were no significant differences in outcomes between TCAR and CEA across the different regional groups. In all regional groups, TCAR was associated with a 40% reduction in perioperative and 1-year stroke/death compared with TF-CAS. CONCLUSIONS: Despite significant variation in clinical practices for the management of carotid disease, no regional variation exists in the overall outcomes of carotid interventions. TCAR and CEA continue to show superior outcomes to TF-CAS across all VQI regional groups.

Life-history characteristics and historical factors are important to explain regional variation in reproductive traits and genetic diversity in perennial mosses.

BACKGROUND AND AIMS: Plants have evolved an unrivalled diversity of reproductive strategies, including variation in the degree of sexual vs. clonal reproduction. This variation has important effects on the dynamics and genetic structure of populations. We examined the association between large-scale variation in reproductive patterns and intraspecific genetic diversity in two moss species where sex is manifested in the dominant haploid generation and sex expression is irregular. We predicted that in regions with more frequent realized sexual reproduction, populations should display less skewed sex ratios, should more often express sex and should have higher genetic diversity than in regions with largely clonal reproduction. METHODS: We assessed reproductive status and phenotypic sex in the dioicous long-lived Drepanocladus trifarius and D. turgescens, in 248 and 438 samples across two regions in Scandinavia with frequent or rare realized sexual reproduction, respectively. In subsets of the samples, we analysed genetic diversity using nuclear and plastid sequence information and identified sex with a sex-specific molecular marker in non-reproductive samples. KEY RESULTS: Contrary to our predictions, sex ratios did not differ between regions; genetic diversity did not differ in D. trifarius and it was higher in the region with rare sexual reproduction in D. turgescens. Supporting our predictions, relatively more samples expressed sex in D. trifarius in the region with frequent sexual reproduction. Overall, samples were mostly female. The degree of sex expression and genetic diversity differed between sexes. CONCLUSIONS: Sex expression levels, regional sex ratios and genetic diversity were not directly associated with the regional frequency of realized sexual reproduction, and relationships and variation patterns differed between species. We conclude that a combination of species-specific life histories, such as longevity, overall degree of successful sexual reproduction and recruitment, and historical factors are important to explain this variation. Our data on haploid-dominated plants significantly complement plant reproductive biology.

Prefecture-specific prevalence of overweight/obesity is associated with regional variation in the incidence of treated ESKD in Japan.

BACKGROUND: Overweight/obesity is a significant risk factor for chronic kidney disease and end-stage kidney disease (ESKD) in the general population. This study evaluated the impact of sex- and prefecture-specific prevalence of overweight/obesity on standardized incidence rates (SIRs) of treated ESKD in Japan. METHODS: We conducted an ecological study of all prefectures in Japan (n = 47) using data from the Japanese Society of Dialysis Therapy, national census, the NDB Open Data, and the Statistics of Physicians, Dentists and Pharmacists. We calculated the prevalence of overweight/obesity and proteinuria, standardized mortality ratio, and ratio of nephrology specialists for each prefecture, and explored associations of these variables with sex- and prefecture-specific SIRs of treated ESKD using bivariate association analysis, multiple regression analysis, and structural equation modeling (SEM). RESULTS: Prefecture-specific SIRs ranged from 0.72 to 1.24 for men and 0.69-1.41 for women. Prefecture-specific SIRs were significantly correlated with both the prevalence of overweight/obesity and prevalence of proteinuria. The prevalence of overweight/obesity showed direct, positive, and significant associations with prefecture-specific SIRs in men (standardized estimate (ß) = 0.43, p < 0.001) and women (ß = 0.40, p < 0.001). The prevalence of proteinuria showed a significant association with prefecture-specific SIRs only in women (ß = 0.33, p = 0.01). The SEM models explained 26% of the variance in SIR for men and 28% for women. CONCLUSIONS: Our findings provide evidence that the prefecture-specific prevalence of overweight/obesity in Japan can explain regional variation in prefecture-specific SIRs of treated ESKD in both sexes.

Attrition of health extension workers in Ethiopia: trends, regional variations and determinants - a mixed methods study of 15 years of experience.

BACKGROUND: Ensuring regular supervision, capacity building and motivation are crucial for the successful retention of health extension workers (HEWs). Failure in these aspects could increase the attrition rate of HEWs. To date, there has not been a comprehensive nationwide study on HEW attrition that could act as a source of evidence for policy makers. This study explored HEW attrition, including leaving the health sector entirely and its regional variation, trends and predictors of attrition out of the health system. METHODS: This study explored the attrition of HEWs from the beginning of the program until the end of 2018. A district-based mixed method study was conducted to review the personnel files of HEWs. A multistage sampling technique was employed to select 3,476 HEWs, and a probability weight was assigned for each observation. Descriptive statistics were calculated for the outcome and predictor variables. A logistic regression model was used to model attrition out of the health system. A qualitative study was conducted to understand the reasons why HEWs leave their jobs. Thematic analysis was performed using Nvivo version 12. RESULTS: The magnitude of attrition of HEWs was found to be 21.1% during the fifteen years of HEP implementation. Of the total 704 who left their job as an HEW, 530 (73%) left the health system altogether. Number of biological children [AOR = 0.61, 95% CI; 0.42-0.89], having an additional education [AOR = 8.34, 95% CI; 3.67-18.98], obtaining official recognition [AOR = 0.29, 95% CI; 0.10-0.83], administrative reprimand [AOR = 1.66, 95% CI; 1.07 -2. 56), distance between district health office and health post [AOR = 1.75, 95%CI; 1.18-2.59) and COC status [AOR = 2.06, 95%CI 1.39-3.06) were independent predictors of leaving the health sector. High regional variation in attrition was observed, ranging from 38.5% in Addis Ababa to just 6.1% in the Harari region. The trend of attrition has steadily increased over time, with a high of 1,999 attritions per 10,000 HEW in 2018. Psychosocial factors, administrative issues, career advancement incentives, and workplace-related problems were the themes that emerged from the qualitative study as reasons for attrition of HEWs. CONCLUSION: Even though the magnitude of attrition was relatively low, there was high regional variation and incremental trends. Moreover, the out-of-health sector attrition is also high. Critically examining the HEP policy environment to increase the number of HEWs deployed per health post to reduce workload and improving HEW incentives, including career development, may assist in increasing HEW job satisfaction, which in turn could help to reduce attrition, including leaving the health sector.

Do regional labor market conditions matter for temporary work disability duration? A multilevel analysis of workers' compensation claims in five Canadian provinces.

BACKGROUND: Research has shown how regionally varying labor market conditions are associated with differences in work disability duration. However, the majority of these studies have not used multilevel models to appropriately account for the hierarchical clustering of individuals nested within contextual units (e.g., regions). Studies that have used multilevel models have focused on privately insured workers or on disability not specifically caused by work-related injury or illness. METHODS: Using claims data from five Canadian provincial workers' compensation systems, linear random-intercept models were used to estimate how much variance in temporary work disability duration ('work disability duration' for brevity) for work-related injuries and musculoskeletal disorders was due to differences between economic regions, what economic region-level labor market characteristics were associated with work disability duration, and what characteristics best explained economic region differences in work disability duration. RESULTS: Economic region characteristics, such as the unemployment rate and proportion of goods-producing employment, were independently associated with individual-level work disability duration. However, economic region variation only accounted for 1.5%-2% of total variation in work disability duration. The majority (71%) of economic region-level variation was explained by the provincial jurisdiction where the worker lived and was injured. Regional variation tended to be greater for female workers than males. CONCLUSIONS: The findings suggest that while regional labor market conditions matter for work disability duration, system-level differences in workers' compensation and health care are more important factors influencing work disability duration. Furthermore, while this study includes both temporary and permanent disability claims, the work disability duration measure only captures temporary disability.

Sub-regional variation in atmospheric and land variables regulates tea yield in the Dooars region of West Bengal, India.

Climatic variables can have localized variations within a region and these localized climate patterns can have significant effect on production of climate-sensitive crops such as tea. Even though tea cultivation and industries significantly contribute to employment generation and foreign earnings of several South Asian nations including India, sub-regional differences in the effects of climatic and soil variables on tea yield have remained unexplored since past studies focused on a tea-producing region as a whole and did not account for local agro-climatic conditions. Here, using a garden-level panel dataset based on tea gardens of Dooars region, a prominent tea-producing region in India, we explored how sub-regional variations in climatic and land variables might differently affect tea yield within a tea-producing region. Our analysis showed that the Dooars region harboured significant spatial variability for different climatic (temperature, precipitation, surface solar radiation) and soil temperature variables. Using graph-based Louvain clustering of tea gardens, we identified four spatial sub-regions which varied in terms of topography, annual and seasonal distribution of climatic and land variables and tea yield. Our sub-region-specific panel regression analyses revealed differential effects of climatic and land variables on tea yield of different sub-regions. Finally, for different emission scenario, we also projected future (2025-2100) tea yield in each sub-region based on predictions of climatic variables from three GCMs (MIROC5, CCSM4 and CESM1(CAM5)). A large variation in future seasonal production changes was projected across sub-regions (-23.4-35.7% changes in premonsoon, -4.2-3.1% changes in monsoon and -10.9-10.7% changes in postmonsoon tea production, respectively).

Virulence Dynamics of the Barley Leaf Rust Pathogen (Puccinia hordei) in the United States from 1989 to 2020.

Barley leaf rust, caused by Puccinia hordei, is an important disease of barley worldwide. The pathogen can develop new races that overcome resistance genes, emphasizing the need for monitoring its virulence. This study characterized 519 P. hordei isolates collected in the United States from the 1989 to 2000 and 2010 to 2020 survey periods on 15 Rph (Reaction to Puccinia hordei) genes. We analyzed linearized infection type data to detect virulence patterns across the United States and in five geographical regions: Pacific/West (PW), Southwest (SW), Midwest (MW), Northeast (NE), and Southeast (SE). Over 32 years, we observed high mean infection scores for Rph1.a, Rph4.d, and Rph8.h; intermediate scores for Rph2.b, Rph9.i, Rph10.o, Rph11.p, and Rph13.x; and low scores for Rph3.c, Rph5.e, Rph5.f, Rph7.g, Rph9.z, Rph14.ab, and Rph15.ad. Virulence for Rph2.b, Rph3.c, Rph5.e, Rph9.z, Rph10.o, Rph11.p, and Rph13.x significantly differed between the two survey periods. From 1989 to 2020, regional patterns of virulence were found for Rph5.e, Rph5.f, Rph7.g, and Rph14.ab, while regionalities of virulence for Rph3.c, Rph9.i, Rph9.z were only observed in the 2010 to 2020 survey period. Virulence associations were also detected in the P. hordei population. Notably, isolates that were virulent to Rph5.e and Rph6.f were more likely to be avirulent to Rph7.g and Rph13.x, and vice versa. In decreasing order of effectiveness, Rph15.ad, Rph5.e, Rph3.c, Rph9.z, Rph7.g, Rph5.f, and Rph14.ab were the most effective Rph genes in the United States from 1989 to 2020. Pyramiding Rph15.ad with other widely effective Rph and adult plant resistance genes may provide long-lasting resistance against P. hordei.

Patients in high- and low-revision hospitals have similar outcomes after primary knee arthroplasty: 1-year postoperative results from the Danish prospective multicenter cohort study, SPARK.

PURPOSE: It is well-known that revision rates after primary knee arthroplasty vary widely. However, it is uncertain whether hospital revision rates are reliable indicators of general surgical quality as defined by patients. The SPARK study compared primary knee arthroplasty surgery at three high-volume hospitals whose revision rates differed for unknown reasons. METHODS: This prospective observational study included primary knee arthroplasty patients (total, medial/lateral unicompartmental and patellofemoral) in two low-revision hospitals (Aarhus University Hospital and Aalborg University Hospital Farsø) and one high-revision hospital (Copenhagen University Hospital Herlev-Gentofte). Patients were followed from preoperatively (2016-17) to 1-year postoperatively with patient-reported outcome measures including Oxford Knee Score (OKS), EQ-5D-5L and Copenhagen Knee ROM (range of motion) Scale. The surgical outcomes were compared across hospitals for patients with comparable grades of radiographic knee osteoarthritis and preoperative OKS. Statistical comparisons (parametric and non-parametric) included all three hospitals. RESULTS: 97% of the 1452 patients who provided baseline data (89% of those included and 56% of those operated) responded postoperatively (90% at 1 year). Hospitals' utilization of unicompartmental knee arthroplasties differed (Aarhus 49%, Aalborg 14%, and Copenhagen 22%, p < 0.001). 28 patients had revision surgery during the first year (hospital independent, p = 0.1) and were subsequently excluded. 1-year OKS (39 ± 7) was independent of hospital (p = 0.1), even when adjusted for age, sex, Body Mass Index, baseline OKS and osteoarthritis grading. 15% of patients improved less than Minimal Important Change (8 OKS) (Aarhus 19%, Aalborg 13% and Copenhagen 14%, p = 0.051 unadjusted). Patients with comparable preoperative OKS or osteoarthritis grading had similar 1-year results across hospitals (OKS and willingness to repeat surgery, p ≥ 0.087) except for the 64 patients with Kellgren-Lawrence grade-4 (Aarhus 4-6 OKS points lower). 86% of patients were satisfied, and 92% were "willing to repeat surgery", independent of hospital (p ≥ 0.1). Hospital revision rates differences diminished during the study period. CONCLUSIONS: Patients in hospitals with a history of differing revision rates had comparable patient-reported outcomes 1 year after primary knee arthroplasty, supporting that surgical quality should not be evaluated by revision rates alone. Future studies should explore if revision rate variations may depend as much on revision thresholds and indications as on outcomes of primary surgery. LEVEL OF EVIDENCE: Level II (Prospective cohort study).

Variation in the use of compulsory community treatment orders between district health boards in New Zealand.

OBJECTIVE: To report rates of Compulsory Community Treatment Order (CTO) use by District Health Boards (DHBs) in New Zealand and analyse whether socio-demographic factors explain any variability. METHODS: The annualised rate of CTO use per 100,000 population was calculated for the years 2009-2018 using national databases. Rates were adjusted for age, gender, ethnicity, and deprivation and are reported according to DHBs to allow comparisons between regions. RESULTS: The annualised rate of CTO use for New Zealand was 95.5 per 100,000 population. CTO use varied between DHBs from 53 to 184 per 100,000 population. Standardising for demographic variables and deprivation made little difference to this variation. CTO use was higher in males and young adults. Rates for Maori were more than three times that of Caucasian people. CTO use increased as deprivation became more severe. CONCLUSIONS: CTO use increases with Maori ethnicity, young adulthood, and deprivation. Adjusting for socio-demographic factors does not explain the wide variation in CTO use between DHBs in New Zealand. Other regional factors appear to be the major driver of variation in CTO use.

[Utilization of palliative care at the end of life in Germany: temporal trend (2016-2019) and regional variability]. / Inanspruchnahme von Palliativversorgung am Lebensende in Deutschland: zeitlicher Verlauf (2016­2019) und regionale Variabilität.

BACKGROUND: In Germany, palliative care (PC) is provided on a homecare, inpatient, general, and specialized basis. Since little is currently known about the temporal course and regional differences in the forms of care, the present study was aimed to investigate this. METHOD: In a retrospective routine data study with 417,405 BARMER-insured persons who died between 2016 and 2019, we determined the utilization rates of primary PC (PPC), specially qualified and coordinated palliative homecare (PPC+), specialized palliative homecare (SPHC), inpatient PC, and hospice care on the basis of services billed at least once in the last year of life. We calculated time trends and regional variability and controlled for needs-related patient characteristics and access-related county of community characteristics. RESULTS: From 2016 to 2019, total PC increased from 33.8 to 36.2%, SPHC from 13.3 to 16.0% (max: Rhineland-Palatinate), and inpatient PC from 8.9 to 9.9% (max: Thuringia). PPC decreased from 25.8 to 23.9% (min: Brandenburg) and PPC+ came in at 4.4% (max: Saarland) in 2019. Hospice care remained constant at 3.4%. Regional variability in utilization rates remained high, increased for PPC and inpatient PC from 2016 to 2019, and decreased for SPHC and hospice care. The regional differences were also evident after adjustment. CONCLUSION: Increasingly more SPHC, less PPC, and high regional variability, which cannot be explained by demand- or access-related characteristics, indicate that the use of PC forms is oriented less to demand than to regionally available care capacities. In view of the growing need for palliative care due to demographic factors and decreasing personnel resources, this development must be viewed critically.

Sales prices, social rigidity and the second home property market.

Second homes are much valued as recreational resources and also as important commodities on the property market. This study examines the trading patterns and regional price development of Danish second homes from 1992 to 2020. Second home sales volumes and prices reflect the general economic booms and busts and also the possibilities to rent out the property on sharing platforms. However, across regional clusters and over time, property price developments suggest a significant social rigidity in preferences and prospects. The investment and financialization logics and the underlying guiding conspicuous consumption behavior has not changed as an effect of the increased demand during the early phases of the COVID-19 pandemic. When controlling for factors such as house and land plot size, building year, location attractiveness the strong social class and spatial rigidity is reproduced in the data. The shifting of wealth accumulated in the second homes between generations supports the same tendency, and taxation does not rebalance regional effects. Accordingly, only to a limited extent does owning a second home contribute to social equality, even if some second-home owners and policy makers tend to think otherwise. Economic measures in planning and governance portfolios are found to be negligible.

Impact of adherence to CKD-MBD guidelines on mortality among Japanese dialysis patients: an ecological study.

INTRODUCTION: This study evaluated the association between prefecture-level achievement of chronic kidney disease-mineral and bone disorder (CKD-MBD) parameter targets and mortality in Japanese dialysis patients. MATERIALS AND METHODS: We conducted an ecological study of all prefectures in Japan using data from the Japanese Society of Dialysis Therapy and National Vital Statistics between 2016 and 2017. We calculated adherence rates to recommend target ranges for CKD-MBD parameters, including phosphate, corrected calcium, and parathyroid hormone (PTH), and explored associations of these rates with prefecture-specific standardized mortality rates (SMRs) among the general population and among prevalent dialysis patients using bivariate association analysis and structural equation modeling. RESULTS: Prefecture-level adherence to the target phosphate range was significantly and negatively associated with prefecture-specific SMRs in men (standardized estimate (ß) = - 0.61, p < 0.001) and women (ß = - 0.41, p < 0.001). However, prefecture-level adherence to the target corrected calcium range was significantly and negatively associated with prefecture-specific SMRs only in men (ß = - 0.28, p = 0.01). Meanwhile, prefecture-level adherence to the target PTH range was significantly and positively associated with prefecture-specific SMRs in men (ß = 0.23, p = 0.04). Prefecture-level SMRs of females in the general population had a significant impact on prefecture-level SMRs of female dialysis patients (ß = 0.27, p = 0.03). The models explained 52% of variance in SMR for men and 33% for women. CONCLUSION: A higher prefecture-level achievement rate of the target phosphate range recommended by the Japanese CKD-MBD guidelines was associated with a lower prefecture-specific SMR in the Japanese dialysis population.

Periodic trends in geographical variation of prostate cancer incidence and mortality in Finland between 1985 and 2019.

BACKGROUND: Evaluation of regional variation of prostate cancer (PCa) incidence and PCa-specific mortality is essential in the assessment of equity in a national healthcare system. We evaluated PCa incidence and PCa-specific mortality between different municipalities and hospital districts in Finland over 1985-2019. MATERIAL AND METHODS: Men diagnosed with PCa in Finland from 1985 through 2019 were retrieved from Finnish Cancer Registry. Age-standardized PCa incidence and mortality rates were estimated by municipality and hospital district as well as municipality urbanization, education, and income level using hierarchical Bayesian modeling. Standard deviations (SD) of the regional rates were compared between periods from 1985-1989 to 2015-2019. RESULTS: We identified 123,185 men diagnosed with any stage PCa between 1985 and 2019. SD of PCa incidence rate (per 100,000 person-years) showed that the total variation of PCa incidence between different municipalities was substantial and varied over time: from 22.2 (95% CI, 17.1-27.8) in 1985-1989 to 56.5 (95% CI, 49.8-64.5) in 2000-2004. The SD of PCa mortality rate between all municipalities was from 9.0 (95% CI, 6.6-11.8) in 2005-2009 to 2.4 (95% CI, 0.9-4.8) in 2015-2019. There was a trend toward a lower PCa-specific mortality rate in municipalities with higher education level. DISCUSSION: Regional variation in the incidence rate of PCa became more evident after initiation of PSA testing in Finland, which indicates that early diagnostic practice (PSA testing) of PCa has been different in different parts of the country. Variation in the national PCa mortality rate was indeed recognizable, however, this variation diminished at the same time as the mortality rate declined in Finland. It seems that after the initiation period of PSA testing, PSA has equalized PCa mortality outcomes in Finland.

Regional variation in percutaneous absorption in in vitro human models: a systematic review.

Percutaneous absorption is of importance given its role in topical medicaments, transdermal drug systems, and dermatotoxicology. Many factors influence percutaneous penetration, including anatomical region, although little is currently known regarding this parameter. Hence, the aim of this study was to summarize existing data on regional variation in percutaneous penetration in in vitro human models. PubMed, Embase, Web of Science, and US patent literature were explored, and relevant data collected. Eight eligible articles were identified, which together, explored 15 anatomical locations. Four investigations compared percutaneous penetration between scalp and abdominal skin, and all concluded that the former was more permeable. Within those four studies, 10 penetrants of varying physical/chemical properties were tested indicating that in those particular study conditions, anatomical location exerted a greater effect on percutaneous absorption than the physicochemical properties of the penetrants. In addition, torso area was less absorptive than scrotum in both studies in which these sites were compared. In conclusion, the scrotum and scalp appear to be highly susceptible to percutaneous absorption compared to other locations such as the abdomen. This is postulated to be largely due to the high density of hair follicles in these areas, enabling greater penetration via the appendageal pathway. However, there is a paucity of conclusive data regarding the penetrability of other anatomical locations. Investigations testing and ranking the susceptibility of different anatomical regions is of vital importance given the importance of (1) transdermal drug delivery and decontamination protocols and (2) understanding the underlying mechanisms and degree of these variances might aid our pharmacologic/toxicologic judgments.