Background: Travel distance to care facilities may shape urban-rural cancer survival disparities by creating barriers to specific treatments. Guideline-supported treatment options for women with early stage breast cancer involves considerations of breast conservation and travel burden: Mastectomy requires travel for surgery, whereas breast-conserving surgery (BCS) with adjuvant radiation therapy (RT) requires travel for both surgery and RT. This provides a unique opportunity to evaluate the impact of travel distance on surgical decisions and receipt of guideline-concordant treatment. Materials and Methods: We included 61,169 women diagnosed with early stage breast cancer between 2004 and 2013 from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Driving distances to the nearest radiation facility were calculated by using Google Maps. We used multivariable regression to model treatment choice as a function of distance to radiation and Cox regression to model survival. Results: Women living farthest from radiation facilities (>50 miles vs. <10 miles) were more likely to undergo mastectomy versus BCS (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.22-1.79). Among only those who underwent BCS, women living farther from radiation facilities were less likely to receive guideline-concordant RT (OR: 1.72, 95% CI: 1.32-2.23). These guideline-discordant women had worse overall (hazards ratio [HR]: 1.50, 95% CI: 1.42-1.57) and breast-cancer specific survival (HR: 1.44, 95% CI: 1.29-1.60). Conclusions: We report two breast cancer treatments with different clinical and travel implications to show the association between travel distance, treatment decisions, and receipt of guideline-concordant treatment. Differential access to guideline-concordant treatment resulting from excess travel burden among rural patients may contribute to rural-urban survival disparities among cancer patients.

Data are needed on the use of oral anticoagulation in patients with atrial fibrillation (AF) in rural versus urban areas, including the initiation of direct oral anticoagulants (DOACs). We used Medicare data to examine rural/urban differences in anticoagulation use in patients with AF. We identified incident AF in a 20% sample of fee-for-service Medicare beneficiaries (aged ≥&nbsp;65&nbsp;years) from 2011 to 2016 and collected ZIP code and covariates at the time of AF. We identified the first anticoagulant prescription filled, if any, following AF diagnosis. We categorized beneficiaries into four rural/urban areas using rural–urban commuting area codes and used Poisson regression models to compare anticoagulant use. We included 447,252 patients with AF (mean age 79&nbsp;±&nbsp;8&nbsp;years), of which 82% were urban, 9% large rural, 5% small rural, and 4% isolated. The percentage who initiated an anticoagulant rose from 34% in 2011 to 53% in 2016, paralleling the uptake of DOACs. In a multivariable-adjusted analysis, those in rural areas (vs. urban) were more likely to initiate an anticoagulant. However, rural beneficiaries (vs. urban) were less likely to initiate a DOAC; those in isolated areas were 17% less likely (95% confidence interval [CI] 13–20), those in small rural areas were 12% less likely (95% CI 9–15), and those in large rural areas were 10% less likely (95% CI 8–12). Among Medicare beneficiaries with AF, anticoagulation use was low but increased over time with the introduction of DOACs. Rural beneficiaries were less likely to receive a DOAC.

BACKGROUND AND OBJECTIVES: The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective is to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains. RESEARCH DESIGN AND METHODS: We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together. RESULTS: Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions. DISCUSSION AND IMPLICATIONS: High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.

Given the high prevalence of overweight/obesity and the low prevalence of engaging in physical activity in children, it is important to identify barriers that impede child physical activity. One potential barrier is parental stress. The current study examined the association between parental stress levels and girls' and boys' moderate to vigorous physical activity. Children aged 5-7 years and their families (n = 150) from 6 racial/ethnic groups (n = 25 each Black, Hispanic, Hmong, Native American, Somali, andWhite families) were recruited for the Family Matters mixed-methods study in 2015 through primary care clinics in Minneapolis and St Paul, MN. Two in-home visits were carried out with families 10 days apart for data collection, with an 8-day observational period in between when children wore accelerometers. Higher parental stress levels were associated with fewer minutes of moderate to vigorous physical activity in girls (P < .05) compared with boys. On average, girls with a parent reporting a stress rating of 10 engaged in 24 minutes less of physical activity per day than girls with a parent with a stress rating of 1. The results suggest that parental stress may reduce girls' engagement in physical activity. The implications of these results include targeting parental stress and coping skills in future physical activity interventions. In addition, when addressing child physical activity in health care visits with parents and daughters, providers may want to focus their anticipatory guidance on parental stress and coping skills in addition to providing resources to help parents manage stress.

PURPOSE: To determine whether periodontal disease is positively associated with incident diabetes across the continuum of body mass levels (BMI) and test the hypothesis that the periodontal risk for incident diabetes is modified by BMI. METHODS: We included 5569 diabetes-free participants from Visit 4 (1996-1998) of the Atherosclerosis Risk in Communities (ARIC) Study and followed them until 2018. Periodontal disease status was classified by periodontal profile class (PPC)-Stages and incident diabetes was based on participant report of physician diagnosis. We estimated the hazard ratios (HR) for diabetes using a competing risk model for each PPC-Stage. We assessed multiplicative interactions between periodontal disease and BMI (as a continuous variable) on risk of diabetes. RESULTS: During a median time of 19.4 years of follow-up, 1,348 incident diabetes cases and 1,529 deaths occurred. Compared to &quot;healthy/incidental disease&quot; Stage , participants with PPC-&quot;severe periodontal disease&quot; or &quot;severe tooth loss&quot; Stage and lower BMI had elevated risk for diabetes adjusting for demographic, smoking, education and biological variables when accounting for death as a competing risk with HRs 1.76 (95%CI 1.10-2.80) and 2.11 (95% CI 1.46-3.04), respectively. The interaction between PPC-stages and BMI was significant (p= 0.01). No significant associations of PPC-Stages with incident diabetes were present when BMI was above 31 kg/m 2. CONCLUSION: Periodontal disease was associated with incident diabetes, especially in non-obese participants. Dentists should be aware that periodontal disease is associated with incident diabetes but the association may be modified for patient&#039;s at higher BMI levels.

The Census Bureau plans a new approach to disclosure control for the 2020 census that will add noise to every statistic the agency produces for places below the state level. The Bureau argues the new approach is needed because the confidentiality of census responses is threatened by "database reconstruction," a technique for inferring individual-level responses from tabular data. The Census Bureau constructed hypothetical individual-level census responses from public 2010 tabular data and matched them to internal census records and to outside sources. The Census Bureau did not compare these results to a null model to demonstrate that their success in matching would not be expected by chance. This is analogous to conducting a clinical trial without a control group. We implement a simple simulation to assess how many matches would be expected by chance. We demonstrate that most matches reported by the Census Bureau experiment would be expected randomly. To extend the metaphor of the clinical trial, the treatment and the placebo produced similar outcomes. The database reconstruction experiment therefore fails to demonstrate a credible threat to confidentiality. 2

<h3>Importance</h3><p>Police contact may have negative psychological effects on pregnant people, and psychological stress has been linked to preterm birth (ie, birth at &lt;37 weeks’ gestation). Existing knowledge of racial disparities in policing patterns and their associations with health suggest redesigning public safety policies could contribute to racial health equity.</p><h3>Objective</h3><p>To examine the association between community-level police contact and the risk of preterm birth among White pregnant people, US-born Black pregnant people, and Black pregnant people who were born outside the US.</p><h3>Design, Setting, and Participants</h3><p>This cross-sectional study used medical record data of 745 White individuals, 121 US-born Black individuals, and 193 Black individuals born outside the US who were Minneapolis residents and gave birth to a live singleton at a large health system between January 1 and December 31, 2016. Data were analyzed from March 2019 to October 2020.</p><h3>Exposures</h3><p>Police contact was measured at the level of the census tract where the pregnant people lived. Police incidents per capita (ie, the number of police incidents divided by the census tract population estimate) were dichotomized into high if the value was in the fourth quartile and low for the remaining three quartiles.</p><h3>Main Outcomes and Measures</h3><p>Preterm birth status was based on the<i>International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification </i>(<i>ICD-10-CM</i>) code. Preterm infants were those with<i>ICD-10-CM</i>codes P07.2 and P07.3 documented in their charts.</p><h3>Results</h3><p>Of 1059 pregnant people (745 [70.3%] White, 121 [11.4%] US-born Black, 193 [18.2%] Black born outside the US) in the sample, 336 White individuals (45.1%) and 62 Black individuals who were born outside the US (32.1%) gave birth between the ages of 30 and 34 years, while US-born Black individuals gave birth at younger ages, with 49 (40.5%) aged 25 years or younger. The incidence of preterm birth was 6.7% for White individuals (50 pregnant people), 14.0% for US-born Black individuals (17 pregnant people), and 5.7% for Black individuals born outside the US (11 pregnant people). In areas with high police contact vs low police contact, the odds of preterm birth were 90% higher for White individuals (odds ratio [OR], 1.9; 95% CI, 1.9-2.0), 100% higher for US-born Black individuals (OR, 2.0; 95% CI, 1.8-2.2), and 10% higher for Black individuals born outside the US (OR, 1.1; 95% CI, 1.0-1.2). Secondary geospatial analysis further revealed that the proportion of Black residents in Minneapolis census tracts was correlated with the number of police incidents reported between 2012 and 2016 (<i>P</i> = .001).</p><h3>Conclusions and Relevance</h3><p>In this study, police contact was associated with preterm birth for both Black and White pregnant people. Predominantly Black neighborhoods had greater police contact than predominantly White neighborhoods, indicating that Black pregnant people were more likely to be exposed to police than White pregnant people. These findings suggest that racialized police patterns borne from a history of racism in the United States may contribute to racial disparity in preterm birth.</p>

Purpose: For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD. Methods: Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question “Please give an objective play-by-play of the description of what happened in this conversation.” Findings: Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers. Conclusions: Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.

Students of color are disproportionately affected by exposure to adverse childhood experiences (ACEs), racial trauma, and traumatic stress. Trauma-informed interventions in schools can promote healing among ACE-impacted students of color. These interventions require collaboration with family members to decide upon services and referrals; however, educators commonly face challenges with engaging families. The study purpose is to understand barriers and facilitators to engaging families in trauma-informed mental health interventions for ACE-impacted students of color. As part of a larger school-based trauma-informed trial (Link for Equity), 6 focus groups were conducted with parents/guardians of color and school staff (n = 39) across 3 Midwestern school districts. Participants were asked open-ended questions about trauma, discrimination, school supports, and family engagement. Transcripts were coded by two team members, and thematic analysis was used to identify barriers/facilitators to family involvement. Results indicated that families of ACE-impacted students of color commonly experienced racism including microaggressions and stereotypes from the school community, which deterred engagement and prevented trusting relationships between families and school staff. Parents highlighted feeling excluded from decisions related to their child’s education and that their voices were not heard or understood. Participants discussed the need for schools to consider how family obstacles (such as mental health and trauma) may prevent families from engaging with staff, and they recommended structural changes, such as anti-racism trainings for educators. Findings highlight the need for anti-racist work that addresses interpersonal and structural racism in schools, in order to promote family engagement in trauma-informed mental health interventions.

Background and Objectives: Prevalence of nursing home residents with Alzheimer's

Aim: Evidence for an association of foetal growth with acute myeloid leukaemia (AML) is inconclusive. AML is a rare childhood cancer, relatively more frequent in girls, with distinct features in infancy. In the context of the Childhood Leukemia International Consortium (CLIC), we examined the hypothesis that the association may vary by age, sex and disease subtype using data from 22 studies and a total of 3564 AML cases. Methods: Pooled estimates by age, sex and overall for harmonised foetal growth markers in association with AML were calculated using the International Fetal and Newborn Growth Consortium for the 21st Century Project for 17 studies contributing individual-level data; meta-analyses were, thereafter, conducted with estimates provided ad hoc by five more studies because of administrative constraints. Subanalyses by AML subtype were also performed. Results: A nearly 50% increased risk was observed among large-for-gestational-age infant boys (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.03–2.14), reduced to 34% in boys aged <2 years (OR: 1.34, 95% CI: 1.05–1.71) and 25% in boys aged 0–14 years (OR: 1.25, 95% CI: 1.06–1.46). The association of large for gestational age became stronger in boys with M0/M1subtype (OR: 1.80, 95% CI: 1.15–2.83). Large birth length for gestational age was also positively associated with AML (OR: 1.38, 95% CI: 1.00–1.92) in boys. By contrast, there were null associations in girls, as well as with respect to associations of decelerated foetal growth markers. Conclusions: Accelerated foetal growth was associated with AML, especially in infant boys and those with minimally differentiated leukaemia. Further cytogenetic research would shed light into the underlying mechanisms.

Human papillomavirus (HPV) infection is common in women and also the main cause of cervical cancer. Based on a dynamic compartmental model, we aimed to evaluate the population impact and cost-effectiveness of strategies that combined cervical cancer screening and HPV schoolgirl vaccination for Chinese women. The effectiveness of interventions was assessed by comparing modeled scenarios to the status quo, where a 3-y cervical cancer screening program remained at a 20% coverage and without a universal HPV vaccination program. Our study demonstrated that increasing screening coverage from 20% to 50% would reduce the high-risk HPV (HR-HPV) prevalence to 5.4%, whereas a universal schoolgirl vaccination program using the quadrivalent vaccine (qHPV) with a coverage of 50% would reduce the prevalence to 2.9% by 2069. Scaling-up the cervical screening coverage to 50% will prevent 16,012 (95% CI: 8,791 to 25,913) Disability-Adjusted Life-Years (DALYs) per year, with an incremental cost-effectiveness ratio (ICER) of US$ 10,958 (95% CI: $169 to $26,973)/DALY prevented. At the current qHPV price, vaccinating 50% of school girls will prevent 13,854 (95% CI: 8,355 to 20,776) DALYs/year, but the corresponding incremental cost-effectiveness ratio (ICER, US$ 83,043, 95% CI: $52,234 to $138,025) exceeds cost-effectiveness threshold (i.e., 3 times GDP per-capita of China: $30,792). The qHPV vaccine requires at least a 50% price reduction to be cost-effective. Vaccinating schoolgirls will result in a large population health benefit in the long term, but such a universal HPV vaccination program can only be cost-effective with a substantial price reduction.

This contribution to the special issue celebrating Dr. Kane’s legacy in the Journal of Gerontological Social Work highlights her significant scholarly achievements in the measurement of quality of life in long-term care. Following a synthesis of Dr. Kane’s groundbreaking work in this area, we summarize how her study of the measurement of quality of life has served as the foundation for significant practice/policy advancements. We conclude that Dr. Kane and her ongoing legacy in the rigorous measurement of quality of life has achieved her ultimate aspiration: the elevation of quality of life as the central concern when selecting, using, delivering, and valuing long-term care.

<p>The 2019 Minnesota Legislature requested the Department of Human Services (DHS) and Minnesota Board on Aging to develop and administer a report card for assisted living (AL), including conducting annual resident and family surveys in Minnesota AL settings. This presentation includes the perspectives of representatives from MN DHS and Vital Research, as well as the University of Minnesota team who worked together to develop survey items, carry out the cognitive testing, and conduct analyses. Survey items were developed from published literature and existing tools on assisted living quality and underwent testing with MN stakeholders and cognitive testing with MN AL residents. Pilot testing assessed any further changes that needed to take place for resident and family satisfaction with AL quality (n=400). Presenters will share lessons learned with implementing the new tools and different aspects of the of the report card development and implementation process as well as the survey findings.</p>

What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

Objectives: This study examines racial/ethnic differences in self-rated health (SRH) and sense of control among older adults receiving publicly funded home- and community-based services (HCBS) and tests the mediating role of functional, emotional, and financial stressors. Methods: Data are from 2015 National Core Indicators-Aging and Disability Survey collected from face-to-face interviews with 1936 older adults aged 65 years or older receiving HCBS in Minnesota. Path analysis based on logistic regression was used. Results: Racial/ethnic minority HCBS users had lower SRH and sense of control than white participants, with Asian participants reporting the lowest scores. Whereas functional impairment was a common explanatory factor for the racial/ethnic differences, negative mood and financial strain were mediators for Asian and Hispanic/Latino participants, respectively. Discussion: Racial/ethnic disparities in well-being exist among older HCBS users, with different mediators at play. Customized services are needed to meet diverse needs of older adults of different racial/ethnic groups.

Great gains have been made in providing researchers geo-spatial data that can be combined with population health data. This development is crucial given concerns over the human health outcomes associated with a changing climate. Merging population and environmental data remains both conceptually and technically challenging because of a large range of temporal and spatial scales. Here we propose a framework that addresses and advances both conceptual and technical aspects of population-environment research. This framework can be useful for considering how any time or space-based environmental occurrence influences population health outcomes and can be used to guide different data aggregation strategies. The primary consideration discussed here is how to properly model the space and time effects of environmental context on individual-level health outcomes, specifically maternal, child and reproductive health outcomes. The influx of geospatial health data and highly detailed environmental data, often at daily scales, provide an opportunity for population-environment researchers to move towards a more theoretically and analytically sound approach for studying environment and health linkages.

Background: Relapsing-onset multiple sclerosis (MS) typically starts in early- to mid-adulthood, yet the trajectory of disease activity over the subsequent lifetime remains poorly defined. Previous studies have not quantified the age-specific portion of decreases in annualized relapse rates (ARR). Objective: The aim of this article is to determine, under a range of disease-related assumptions, the age-specific component of decreases in ARR over time among adults with relapsing-onset MS. Methods: We used a simulation modeling approach to examine a range of assumptions about changes in ARR due to age versus disability status. Scenarios included variations in initial ARR and rate of worsening on the Expanded Disability Status Scale. Model parameters were developed through analysis of MS patients in British Columbia, Canada, and literature review. Results: We found a substantial age-specific decrease in ARR in all simulated scenarios, independent of disability worsening. Under a range of clinically plausible assumptions, 88%–97% of the decrease was attributed to age and 3%–13% to disability. The age-specific decrease ranged from 22% to 37% per 5 years for a wide range of initial ARR (0.33–1.0). Conclusion: Decreases in ARR were due mostly to age rather than disability status. To facilitate informed decision making in MS, it is important to quantify the dynamic relationship between relapses and age.