OBJECTIVES: Childbirth is the leading reason for hospitalization in the United States, and maternity related expenditures are substantial for many health insurance programs, including Medicaid. We studied the relationship between primary payer and trends in hospital-based childbirth care. STUDY DESIGNS: Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, a 20% stratified sample of US hospitals. METHODS: Data on 6,717,486 hospital-based births for the years 2002 through 2009 came from the NIS. We used generalized estimating equations to measure associations over time between primary payer (Medicaid, private insurance, or self) and cesarean delivery, vaginal birth after cesarean (VBAC), labor induction, and episiotomy. RESULTS: Controlling for clinical, demographic, and hospital factors, births covered by Medicaid had lower odds of cesarean delivery (adjusted odds ratio [AOR], 0.91), labor induction (AOR, 0.73), and episiotomy (AOR, 0.62) and higher odds of VBAC (AOR, 1.20; P <.001 for all AORs) compared with privately insured births. Cesarean rates increased 6% annually among births paid by private insurance (AOR, 1.06; P <.001) and less rapidly (5% annually) among those covered by Medicaid. CONCLUSIONS: US hospital-based births covered by private insurance were associated with higher rates of obstetric intervention than births paid for by Medicaid. After controlling for clinical, demographic, and hospital factors, cesarean delivery rates increased more rapidly among births covered by private insurance, compared with Medicaid. Changes in insurance coverage associated with healthcare reform may impact costs and quality of care for women giving birth in US hospitals.

OBJECTIVES We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression. METHODS Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938). RESULTS Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76). CONCLUSIONS Mental health programming and health care providers who focus on Black Americans' mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.

The School Attendance Boundary Information System is a social science data infrastructure project that assembles, processes, and distributes spatial data delineating K through 12th grade school attendance boundaries for thousands of school districts in U.S. Although geography is a fundamental organizing feature of K to 12 education, until now school attendance boundary data have not been made readily available on a massive basis and in an easy-to-use format. The School Attendance Boundary Information System removes these barriers by linking spatial data delineating school attendance boundaries with tabular data describing the demographic characteristics of populations living within those boundaries. This paper explains why a comprehensive GIS database of K through 12 school attendance boundaries is valuable, how original spatial information delineating school attendance boundaries is collected from local agencies, and techniques for modeling and storing the data so they provide maximum flexibility to the user community. An important goal of this paper is to share the techniques used to assemble the SABINS database so that local and state agencies apply a standard set of procedures and models as they gather data for their regions.

BACKGROUND: While Medicaid is an important source of insurance coverage for persons with disabilities, barriers remain to accessing care for this population. OBJECTIVES: This study addresses 3 research questions: (1) do adults with disabilities experience greater unmet need/delayed care?; (2) do barriers related to cost, providers, or structure vary by disability status?; and (3) do barriers mediate the relationship between disability and access to care? RESEARCH DESIGN: Data were obtained from a 2008 stratified random sample of Minnesota Health Care Program's nonelderly adult enrollees (n=1880). The survey was administered by mail, with a telephone follow-up for nonresponders. MEASURES: Disability is defined by self-report. Access to care is measured by reported delayed and unmet need for medical care within the past year. Respondents were asked about their experiences with a variety of cost-related, provider-related, and structural barriers to care. RESULTS: Respondents with a disability were more likely to experience delayed (40%) and unmet need (23%) for medical care than persons without disabilities (24% and 10%, respectively). Persons with disabilities also reported multiple barriers to health care, especially structural barriers, such as making a timely appointment and accessing transportation (74% vs. 59%). The greater likelihood of facing a structural barrier partially explained increased risk of delayed or unmet care among adults with disabilities. CONCLUSIONS: Disparities in access to health care based on disability status remain even for persons who have insurance. These disparities deserve further research and policy attention to better address the particular needs of this population.

PURPOSE: Little is known about mental health disorders (MHDs) and their associated health care expenditures for the dual eligible elders across long-term care (LTC) settings. We estimated the 12-month diagnosed prevalence of MHDs among dual eligible older adults in LTC and non-LTC settings and calculated the average incremental effect of MHDs on medical care, LTC, and prescription drug expenditures across LTC settings. METHODS: Participants were fee-for-service dual eligible elderly beneficiaries from 7 states. We obtained their 2005 Medicare and Medicaid claims data and LTC program participation data from federal and state governments. We grouped beneficiaries into non-LTC, community LTC, and institutional LTC groups and identified enrollees with any of 5 MHDs (anxiety, bipolar, major depression, mild depression, and schizophrenia) using the International Classification of Diseases Ninth Revision codes associated with Medicare and Medicaid claims. We obtained medical care, LTC, and prescription drug expenditures from related claims. RESULTS: Thirteen percent of all dual eligible elderly beneficiaries had at least 1 MHD diagnosis in 2005. Beneficiaries in non-LTC group had the lowest 12-month prevalence rates but highest percentage increase in health care expenditures associated with MHDs. Institutional LTC residents had the highest prevalence rates but lowest percentage increase in expenditures. LTC expenditures were less affected by MHDs than medical and prescription drug expenditures. IMPLICATIONS: MHDs are prevalent among dual eligible older persons and are costly to the health care system. Policy makers need to focus on better MHD diagnosis among community-living elders and better understanding in treatment of MHDs in LTC settings.

OBJECTIVE: Drawing from cumulative inequality theory, the authors examine the relationship between perceived work trajectories and mortality risk among Black and White women over 36 years. METHOD: Panel data from the National Longitudinal Survey of Mature Women (1967-2003) are used to evaluate how objective and subjective elements of work shape mortality risk for Black and White women born between 1923 and 1937. RESULTS: Estimates from Cox proportional hazards models reveal that Black working women manifest higher mortality risk than White working women even after accounting for occupation, personal income, and household wealth. Perceived work trajectories were also associated with mortality risk for Black women but not for White women. DISCUSSION: The findings reveal the imprint of women's work life on mortality, especially for Black women, and illustrate the importance of considering personal meanings associated with objective work characteristics.

OBJECTIVE: Drawing from cumulative inequality theory, this research examines how accumulated financial strain affects women's self-rated health in middle and later life. METHOD: Using data from the National Longitudinal Survey of Mature Women (1967-2003), we employ random-coefficient growth curve models to examine whether recurring financial strain influences women's health, above and beyond several measures of objective social status. Predicted probabilities of poor health were estimated by the frequency of financial strain. RESULTS: Financial strain is associated with rapid declines in women's health during middle and later life, especially for those women who reported recurrent strain. Changes in household income and household wealth were also associated with women's health but did not eliminate the effects due to accumulated financial strain. DISCUSSION: Accumulated financial strain has long-term effects on women's health during middle and later life. The findings demonstrate the importance of measuring life course exposure to stressors in studies of health trajectories.

In this article, the authors describe a new data infrastructure project being developed at the Minnesota Population Center. The Integrated Spatio-Temporal Aggregate Data Series (ISTADS) will make it easier for researchers to use publicly available aggregate data for the United States over a time span that covers virtually the entire life of the nation: 17902012. In addition to facilitating access and ease of use, ISTADS will facilitate the use of thesevarious data sets in mapping and spatial analysis.

In 2011, about 25 percent of the Medicare fee-for-service population had diabetes. Among Medicare beneficiaries with diabetes, approximately 14 percent had type 1, 85 percent had type 2 but did not use insulin, and less than 1 percent had type 2 diabetes and used insulin to manage their condition. Between 2007 and 2011, beneficiaries with type 2 diabetes who used insulin had the highest burden of comorbidity, hospitalization rates, and allowed payment, followed by those with type 1 diabetes. Most beneficiaries with diabetes had evaluation and management visits. Most also received needed preventive care, including HbA1c and LDL testing, and about half received an annual flu shot and eye exam. However, beneficiaries with type 2 diabetes using insulin had the lowest rates of receipt of preventive care. Most beneficiaries with diabetes visited both primary care and specialty providers. The number of providers with whom they had contact is high, indicating potential fragmentation in both primary and specialty care.

Objective: To determine whether the postnatal growth rate of infants with intrauterine growth restriction (IUGR) is associated with later cognitive function and body mass index (BMI). Study design: Infants with IUGR (<2211 g at ≥37 weeks' gestation) were identified in data from the Collaborative Perinatal Project, excluding those with diagnoses affecting cognition or growth. Wechsler Scale of Children's Intelligence (WISC) scores at age 7 years and data on postnatal growth at 16 weeks were available for 463 infants with IUGR. Linear regression relating postnatal growth and WISC score, adjusting for potential confounders, was performed for these infants. BMI at 7 years also was examined. Results: Weight gain at 16 postnatal weeks ranged from 1059 to 5119 g in the infants with IUGR, with lower achieved cognitive testing scores apparent at both extremes (ie, an inverted J-shape; P < .001). Infants gaining 1200 and 5000 g scored 15.5 and 2.4 fewer points, respectively, on the full scale compared with infants with score-maximizing growth. In contrast, BMI at 7 years was linearly related to postnatal weight gain (P < .001). Conclusions: Growth in the first 4 postnatal months is an independent risk factor for cognitive outcome at age 7 years, with both extremes associated with negative effects. © 2009 Mosby, Inc. All rights reserved.

BACKGROUND AND PURPOSE Depression and hopelessness are associated with increased cardiovascular disease (CVD) morbidity and mortality; however, few studies have compared these constructs early in the atherogenic process, particularly in women or minorities. METHODS This cross-sectional study examined associations of hopelessness and depressive symptoms with carotid artery intimal-medial thickening (IMT) in 559 women (62% white, 38% black; mean+/-SD age, 50.2+/-2.8 years) without evidence of clinical CVD from the Study of Women's Health Across the Nation (SWAN) Heart Study. Hopelessness was measured by 2 questionnaire items; depressive symptoms were measured with the 20-item Center for Epidemiological Studies Depression Scale. Mean and maximum IMT were assessed by B-mode ultrasonography of the carotid arteries. RESULTS Increasing hopelessness was significantly related to higher mean (P=0.0139) and maximum (P=0.0297) IMT in regression models adjusted for age, race, site, income, and CVD risk factors. A weaker pattern of associations was noted for depressive symptoms and mean (P=0.1056) and maximum (P=0.0691) IMT. Modeled simultaneously in a risk factor-adjusted model, hopelessness was related to greater mean IMT (P=0.0217) and maximum IMT (P=0.0409), but depressive symptoms were unrelated to either outcome (P>0.4). No interactions with race or synergistic effects of depressive symptoms and hopelessness were observed. CONCLUSIONS Among middle-aged women, higher levels of hopelessness are associated with greater subclinical atherosclerosis independent of age, race, income, CVD risk factors, and depressive symptoms.