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Jointly financed by the federal government and the states, Medicaid represents the second largest form of public-sector investment in children. Research documents direct positive effects of Medicaid on children’s well-being, but little is known about the effects of Medicaid expansions on the wealth of families with children. Using state variation in Medicaid access during the prenatal and infant period, linked to longitudinal data from the children of National Longitudinal Survey of Youth 79, we ask whether state-level Medicaid generosity is associated with family wealth among families with children and whether these effects vary by parental education and race-ethnicity. We find that greater state-level Medicaid access is associated with a larger total amount held in savings and retirement accounts, as well as in mortgages. These effects are largely driven by non-Hispanic white families, and those with more highly educated mothers.

Medicaid reimbursements for physician services are determined by each state. However, how these reimbursements vary between states, and how these reimbursements vary in comparison to Medicare reimbursements is unknown for musculoskeletal radiology studies.To evaluate the variability in Medicaid and Medicare physician reimbursements for musculoskeletal imaging studies between states.We evaluated the Medicare and Medicaid physician reimbursements for the most commonly performed musculoskeletal radiology studies (15 radiographs and 10 MRIs) based on Medicare's 2017 National Summary Data File. Medicare and Medicaid reimbursements for these studies were compared by dollar difference (difference in reimbursement in dollars between Medicare and Medicaid). State-wide variability in these reimbursements was quantified by the coefficient of variation (COV) and by the dollar difference in reimbursement amounts. Medicaid and Medicare reimbursement rates were compared using a paired t-test, since the data was paired by state.The mean Medicaid reimbursement rates were lower for musculoskeletal radiographs (p 0.05) but higher for musculoskeletal MRI studies than the Medicare rates (p 0.05). As hypothesized, there was variation in both Medicare and Medicaid imaging reimbursements between states, however, the variation was substantially higher for Medicaid reimbursements. We found the Medicare reimbursement COV between states was 0.07 for all imaging studies, whereas the Medicaid reimbursement COV between states varied from 0.23 to 0.55 for radiographs and from 0.31 to 0.45 for MRIs.The data show that there is mild, but constant variation across imaging studies in Medicare reimbursement for musculoskeletal imaging studies between states. However, there is more variation in the Medicaid reimbursements across imaging studies and between states. More appropriate reimbursement may increase access to care for Medicaid patients.

For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called “welcome mat” effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an “on-ramp” effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.

Importance Substantial increases in both neonatal abstinence syndrome (NAS) and maternal opioid use disorder have been observed through 2014. Objective To examine national and state variation in NAS and maternal opioid-related diagnoses (MOD) rates in 2017 and to describe national and state changes since 2010 in the US, which included expanded MOD codes (opioid use disorder plus long-term and unspecified use) implemented inInternational Classification of Disease, 10th Revision, Clinical Modification. Design, Setting, and Participants Repeated cross-sectional analysis of the 2010 to 2017 Healthcare Cost and Utilization Project’s National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community nonrehabilitation hospitals in 47 states and the District of Columbia. Exposures State and year. Main Outcomes and Measures NAS rate per 1000 birth hospitalizations and MOD rate per 1000 delivery hospitalizations. Results In 2017, there were 751 037 birth hospitalizations and 748 239 delivery hospitalizations in the national sample; 5375 newborns had NAS and 6065 women had MOD documented in the discharge record. Mean gestational age was 38.4 weeks and mean maternal age was 28.8 years. From 2010 to 2017, the estimated NAS rate significantly increased by 3.3 per 1000 birth hospitalizations (95% CI, 2.5-4.1), from 4.0 (95% CI, 3.3-4.7) to 7.3 (95% CI, 6.8-7.7). The estimated MOD rate significantly increased by 4.6 per 1000 delivery hospitalizations (95% CI, 3.9-5.4), from 3.5 (95% CI, 3.0-4.1) to 8.2 (95% CI, 7.7-8.7). Larger increases for MOD vs NAS rates occurred with newInternational Classification of Disease, 10th Revision, Clinical Modificationcodes in 2016. From a census of 47 state databases in 2017, NAS rates ranged from 1.3 per 1000 birth hospitalizations in Nebraska to 53.5 per 1000 birth hospitalizations in West Virginia, with Maine (31.4), Vermont (29.4), Delaware (24.2), and Kentucky (23.9) also exceeding 20 per 1000 birth hospitalizations, while MOD rates ranged from 1.7 per 1000 delivery hospitalizations in Nebraska to 47.3 per 1000 delivery hospitalizations in Vermont, with West Virginia (40.1), Maine (37.8), Delaware (24.3), and Kentucky (23.4) also exceeding 20 per 1000 delivery hospitalizations. From 2010 to 2017, NAS and MOD rates increased significantly for all states except Nebraska and Vermont, which only had MOD increases. Conclusions and Relevance In the US from 2010 to 2017, estimated rates of NAS and MOD significantly increased nationally and for the majority of states, with notable state-level variation.

Early life stress (ELS) may become embedded into an individual's stress physiology, changing their hypothalamic-pituitary-adrenal (HPA)-axis in an enduring, trait-like fashion. Cortisol is often utilized to investigate HPA-axis function. However, for "trait" cortisol to be a useful construct, it needs to be internally consistent within measurement occasions and show temporal stability of this reliability. These estimates of physiometrics are rarely tested with biological variables such as cortisol. Identifying reliable and stable individual differences in cortisol may be particularly important when examining questions related to the long-term impact of ELS on HPA-axis function. Using confirmatory factor analysis (CFA) to model latent trait cortisol (LTC) may be a useful statistical approach to capture trait-like indexes of HPA-axis functioning. CFA identifies commonalities among repeated cortisol samples to differentiate characteristic patterns (i.e. a trait) from day-to-day or state variation and measurement error. It is unclear whether LTC estimates are stable prospectively, or if ELS is prospectively associated with LTC. Therefore, we derived LTC factors for 84 adolescent girls (ages 10-17 years) using two-morning salivary cortisol samples, collected sequentially for three days at baseline and again at a one-year follow-up. LTC was internally consistent at both assessments and stable over one year. Greater exposure to ELS was associated with lower LTC over a one-year follow-up. Findings support LTC modeling as a useful strategy to estimate trait-like HPA-axis functioning and suggest that exposure to ELS is associated with lower trait-like cortisol.

The drug felony lifetime ban on Temporary Assistance for Needy Families (TANF) affects thousands of individuals with felony drug convictions in the United States. Federal law allows states to choose to opt out or modify the full ban. Prior research has treated the ban as a binary outcome, characterizing anything but a full ban as a sign of state reform of this harsh collateral consequence. We argue that modified versions of the ban, which simultaneously allow greater access to public aid while also monitoring and sanctioning recipient behavior, have been overlooked but pose important theoretical and empirical challenges to this narrative. To address this gap, we analyze state discretion in the implementation of the drug felony lifetime ban on TANF receipt between 1997 and 2010 utilizing a multilevel multinomial modeling strategy. Results reveal that distinct patterns of state-level factors are associated with each form of the ban, highlighting the need to treat modified bans as unique policy choices in their own right. Our study informs the understanding of state implementation of collateral consequences that straddle both the penal and welfare systems in the United States.

Plume-spatter signatures during Selective Laser Melting (SLM) are a good indication of their corresponding melt states. It is important to build the relationship between the signatures and defects for the SLM process monitoring. In this work, the mechanism of the plume and the spatter was investigated for the melted state detection. Single tracks were produced on the 304L stainless steel powder with monitoring by a Near-Infrared (NIR) camera. Signatures of the plume and spatter during the SLM process were collected for the analyses of the characteristics. Results provided the properties of the plume, the spatter, and the entire target region of the image as well as their relations with the melted tracks. Plume-spatter signatures had distinct behaviors among the underheating, normal, and overheating melting processes. In the melted state variation, laser power played a more decisive role than scanning speed by changing laser energy density. This work contributed to the feasibility and possibility for the SLM process monitoring by the plume and spatter signatures.

Highlights • In 2005–2017, US states liberalized statutes on cause of death signature authority. • State variation in signature authority contributes to cause of death inaccuracies. • Logistic regressions suggest certifier type influences death certificate accuracy. • Death certificate training is needed across the array of professional certifiers. • Cause of Death Signature Authority database allows for more robust analysis of certification errors., This study utilized a convergent mixed-methods design to examine whether variation in death certificate certifier type predicts the accuracy of cause of death reporting in the US. We analyzed the content of state statutes, amendments, and policies concerning cause of death signature authority in 2005–2017 to create the Cause of Death Signature Authority (CoDSA) database. After merging the CoDSA data with 2005–2017 National Vital Statistics System Multiple Cause of Death Mortality files for adults with cerebral palsy (CP) (N = 29,996), we employed logistic regression models to determine the likelihood that different certifier groups made one particular type of death certification error – inaccurately reporting CP as the underlying cause of death (UCOD). The content analysis provided evidence of significant liberalization of cause of death signature authority, with 23 states expanding signature authority to include physician extenders. Logistic regression analysis revealed differences in UCOD accuracy based on certifier type. Compared to medical examiners, the likelihood of CP being reported as the UCOD, was: 41% higher (CI 1.12, 1.78) for coroners; 25% higher (1.05, 1.49) for mixed-system death investigators; 24% higher (1.08, 1.42) for physicians; and 16% higher (1.00, 1.34) for physician extenders. Inaccuracies limit public health efforts aimed at improving the health and longevity for disadvantaged populations, such as people with CP. Poor performance among cause of death certifiers may indicate systemic problems with death certification that should be addressed with more robust training for all professional groups with signature authority.

Consumers play a key role in the U.S. nursing home (NH) oversight through a federally established complaint process. However, past variation by state in complaint numbers and rates raised questions about the uniformity of the process. We examined state variation in numbers of complaints at intake and substantiated complaints, percentages of NHs with at least one complaint and one substantiated complaint, number of allegations per complaint, and complaint substantiation rates. We found state variation most prominently at the intake level, ranging from 0.4 to 30.4 complaints per NH. The investigation process appears to reduce this variation: however, variation remains among states in frequency and prevalence of substantiated complaints. Further work is needed to ensure federal standards concerning the handling of consumer complaints are applied equally across the states. This includes policies affecting how complaints are initially filed, in addition to how complaints are investigated.

BackgroundAlthough cross-state variation of the opioid epidemic in the United States are well documented in general, little are known about the epidemic in privately insured individuals.ObjectivesTo describe cross-state variation in Opioid Use Disorder (OUD) among privately insured individuals in the US for the years 2005-2015 and investigate demographic differences of OUD patients between a group of hard-hit states and the rest states.MethodsThe MarketScan® Commercial Claims and Encounters database was used to calculate prevalence of opioid use disorder for the 50 states in the US, respectively. We analyzed level and change of OUD prevalence in each state from 2005 to 2015 and identified the states which were affected most by the epidemic. One-sided exact fisher test was used to analyze demographic difference of the epidemic in the hard-hit states and the remaining states.ResultsCross-state variations of the opioid epidemic among privately insured population were substantial, both in terms of severity and acceleration of the epidemic. Demographic patterns of the epidemic were similar across states. The 18-34 age group was the most affected group with the highest prevalence. The 55-64 group experienced the most rapid increase of OUD prevalence, especially in states that suffered most in the epidemic.ConclusionsResults can assist policy makers to design better clinical and policy interventions on the opioid epidemic, especially on privately insured individuals. Drastic increase of OUD prevalence among the 55-64 group might indicate the need to improve prescription drug monitoring programs for chronic pain, especially in states more affected by the epidemic.

BACKGROUND AND OBJECTIVES: Home nursing is essential for children with medical complexity (CMC), but provision varies substantially across states. Our objectives were to quantify state-to-state variability in distribution of posthospitalization home nursing to commercially insured CMC and to rank-order states. METHODS: Retrospective cohort study of hospitalized commercially insured children with ≥1 complex chronic condition from birth to 18 years of age in the Truven MarketScan database. Cohort eligibility criteria were hospital discharge between January 2013 and November 2016 and at least 30 days of follow-up after discharge. Two primary outcome measures were used: receipt of any home nursing within 30 days of hospital discharge (yes or no) and number of days of posthospitalization home nursing (1–30 days). A composite metric encompassing both receipt and quantity was created by evaluating the 95th percentile of days of home nursing (0–30 days). RESULTS: Overall, 9.9% of the sample received home nursing. After we adjusted for patient characteristics, the probability of receiving home nursing varied across states, ranging from 3.4% to 19.2%. Among home nursing recipients, the adjusted median home nursing days across states ranged from 6.6 to 24.5 days. The adjusted 95th percentile of days of home nursing (across the entire of sample, including recipients and nonrecipients of home nursing) ranged from 6.8 to 22.6 days. CONCLUSIONS: We observed striking state-to-state variability in receipt of home nursing and mean number of days of posthospitalization home nursing among commercially insured CMC after adjustment for demographic and clinical differences. This suggests opportunities for state-level improvement.

This paper is focused on change in shrinkage, GSM, Wales per Inch and Course per Inch due to structure and count variation and state variation. This work was carried out with 12 samples of single jersey, single lacoste and weft lock knit fabrics of different counts which were scoured with NaOH. After pretreatment process the samples were tested for widthwise shrinkage, width, GSM, Wales per Inch and Course per Inch and compared between different states like grey state and finished state. The result obtained in this research indicated that physical properties like structures with tuck stitch possess higher value of widthwise shrinkage, width, GSM and Wales per Inch and Course per Inch value lowers prominently in those structures having float or miss stitches. In both cases i.e. grey state and RFD state values of those properties are high in coarser yarn and low in finer yarn. During project knitted fabrics specification along with machine specification and major factors which are necessary to calculate different types of variation and variables on which the whole fabric construction depends were managed to watch carefully. Main efforts were to develop a dependable way so that the resulting fabric specifications with required configuration can be easily visualized and be forecasted. A great emphasization was provided to the adjustable points on which fabric GSM, stitch length, fabric width and shrinkage percentage directly or indirectly depends.

Introduction Flavors can mask the harshness of tobacco and make it appealing to young people. This study assessed flavored and menthol tobacco product sales at the national and state levels. Methods Universal Product Code tobacco sales data collected by Nielsen were combined for convenience stores and all-outlets-combined during October 22, 2011-January 9, 2016. Products were characterized as flavored, menthol, or non-flavored/non-menthol. Total unit sales, and the proportion of flavored and menthol unit sales, were assessed nationally and by state for seven tobacco products. Joinpoint regression was used to assess trends in average monthly percentage change. Results Nationally, the proportion of flavored and menthol sales in 2015 was as follows: cigarettes (32.5% menthol), large cigars (26.1% flavored), cigarillos (47.5% flavored, 0.2% menthol), little cigars (21.8% flavored, 19.4% menthol), chewing tobacco (1.4% flavored, 0.7% menthol), moist snuff (3.0% flavored, 57.0% menthol), and snus (88.5% menthol). From 2011 to 2015, sales increased for flavored cigarillos and chewing tobacco, as well as for menthol cigarettes, little cigars, moist snuff, and snus. Sales decreased for flavored large cigars, moist snuff, and snus, and for menthol chewing tobacco. State-level variations were observed by product; for example, flavored little cigar sales ranged from 4.4% (Maine) to 69.3% (Utah) and flavored cigarillo sales ranged from 26.6% (Maine) to 63.0% (Maryland). Conclusions Menthol and flavored sales have increased since 2011, particularly for the products with the highest number of units sold, and significant state variation exists. Efforts to restrict flavored tobacco product sales could reduce overall U.S. tobacco consumption. Implications Flavors in tobacco products can mask the harshness of tobacco and make these products more appealing to young people. This is the first study to assess national and state-level trends in flavored and menthol tobacco product sales. These findings underscore the importance of population-based interventions to address flavored tobacco product use at the national, state, and local levels. Additionally, further monitoring of flavored and menthol tobacco product sales can inform potential future regulatory efforts at the national, state, and local levels.

The use of NCAs is currently regulated under state law. These laws embody diverse approaches to the regulation of NCAs which generally limit enforcement of NCAs to those with reasonable and narrowly tailored terms. State law also incorporates various approaches to mitigating the negative effects NCAs might have on workers, including requiring adequate disclosure, consideration, and banning their use in certain employment contracts. These diverse approaches can leave regulatory gaps in certain states and can result in overregulation in others. But this can also be a feature—diverse approaches to legal regulation of NCAs at the state level takes advantage of the laboratory of the states to generate information that will allow economic research to better evaluate the effects of these diverse legal approaches without exposing the entire nation to potential mistakes. There has also been a growing and robust literature that has examined state variation in the regulation of NCAs and the effect of these laws on worker welfare. However, current evidence does not yet suggest a reliable and predictable link between the use of NCAs and the effect on employee welfare. Moreover, changes in employee welfare can be negatively correlated to changes in consumer welfare. Any antitrust rule that broadly prohibits the use and enforcement of NCAs would be based on incomplete evidence, would interfere with the current operation of the balanced and nuanced state by state approach to regulating NCAs, and would potentially be at odds with the antitrust laws’ focus on consumer welfare.

This study investigates the effects of variation of Vds and Vg on trapped charge in SONOS NVSM using Synopsis Sentaurus TCAD Simulator. We variate both drain voltage (0 volt/1volt/3volt/5 volt), gate voltage (3volt/4volt/5 volt). The result show that the trapped charge in SONOS memory vary when the programming voltage is changed. Moreover, we investigate the amount charge in 10 years after programming state. In this condition, Programming state of 3V gate and 5V drain have the smallest change in the rate of trapped charge after 10 years compared to the other variated voltage.

e24064 Background: The number of cancer survivors in the United States (U.S.) is projected to exceed 20 million by 2024. More and more U.S. states are legalizing marijuana use for both recreational and medicinal purposes. This study estimated the prevalence of marijuana use by state among adult cancer survivors. Methods: U.S nationally representative, cross-sectional data from the 2018-2019 Behavioral Risk Factor Surveillance System Survey (BRFSS) Marijuana Use module were used. A total of 13,174 cancer survivors in 17 states was included. Analyses were weighted to account for BRFSS’s complex survey design with results generalizable to 5.7 million cancer survivors. The outcome variable was marijuana use in the past 30 days. Weighted prevalence estimates were computed. Weighted, multivariable logistic regression model estimated the association between state and marijuana use, adjusting for sociodemographic, health, and healthcare factors. Analyses were performed in January 2021. Results: The prevalence of past-month marijuana use among adult cancer survivors in these states was 9.2%. States varied widely in terms of the prevalence of marijuana use. Marijuana use was higher among those who resided in Guam (15.9%), followed by New Hampshire (13.1%), and lowest for those in Puerto Rico (3.3%) ( p< 0.0001). In the adjusted models, compared with the adult cancer survivors residing in California, those living in Maryland, Minnesota, North Dakota, Ohio, South Carolina, Tennessee, Utah, West Virginia, and Wyoming were significantly less likely to use marijuana. Conclusions: Nearly 9% of adult cancer survivors used marijuana, and those who resided in Guam, New Hampshire, Florida, and California are at higher risk for marijuana use. Given the increasing number of cancer survivors and the proliferation of marijuana legalization, identifying high-risk cancer survivors for marijuana use and informing physicians and patients about safe uses and doses and the potential adverse effects of marijuana use is critical.

Background Diagnosis and treatment of acute or impending compartment syndrome (ACS) remains a clinical challenge. ACS is a clinical diagnosis, and may be associated with variation in its definition, as well as individual threshold for fasciotomy. We examined regional and state variation in rates of lower extremity fasciotomy associated with operatively managed tibia fractures. Methods A total of 313,344 surgically treated tibia fractures were identified via Current Procedural Terminology (CPT) codes using PearlDiver, a private-payer medical record database. Data from the PearlDiver database was compared to the National Trauma Data Bank trauma registry data to corroborate calculated fasciotomy rates. Results The aggregate United States fasciotomy rate derived from PearlDiver was 2.57%. State fasciotomy rates were wide-ranging (0.03%–11.86%) with an average state rate of 2.22% (n = 47, SD = 2.27). Conclusions There was significant state-to-state variation in the use of fasciotomy during operative management of tibial fractures. Various factors may have contributed to the observed difference of state fasciotomy rates. Level of evidence This is a Level III epidemiological study retrospectively comparing geographic rates of fasciotomy during operative management of tibia fractures.

Medicaid is vastly more important than Medicare or private insurance in funding long-term care (LTC). However, states vary tremendously in their commitment to Medicaid LTC. This article advances knowledge of the origins, nature, and implications of this variation. After examining the degree of variation in state spending on Medicaid LTC, we show how federal policy has over the past fifty years steadily increased state discretion to shape these services. This decentralization largely reflects the potency of the intergovernmental lobby—governors and other state officials—in influencing federal policy. While fueling state variation, the intergovernmental lobby has also provided valuable political support that has helped Medicaid grow and resist retrenchment. After considering policy options that could mitigate Medicaid LTC inequities rooted in state differences, we assess how the catalytic forces that have fueled growth in Medicaid LTC may be insufficient to protect the program from future erosion.

To understand the role of Medicaid in financing health services delivered through special education, program characteristics and covered services were compared from all 50 states and Washington, D.C. Data were collected from school-based fee schedules and policy manuals available through state Medicaid or education agencies. Except Wyoming, all states bill Medicaid for school-based health services, but there is substantive variation across states in services covered. The service categories most often covered by states’ Medicaid special education programs are speech–language/audiology, occupational/physical therapy, and behavioral health. Almost all states use a fee-for-service payment methodology to reimburse for services. Implications for the delivery of care to and health outcomes of students with disabilities are discussed.

Objectives To ascertain differences across states in children's oral health care access and oral health status and the factors that contribute to those differences. Study design Observational study using cross-sectional surveys. Methods Using the 2007 National Survey of Children's Health, we examined state variation in parents' report of children's oral health care access (absence of a preventive dental visit) and oral health status. We assessed the unadjusted prevalences of these outcomes, then adjusted with child-, family-, and neighbourhood-level variables using logistic regression; these results are presented directly and graphically. Using multilevel analysis, we then calculated the degree to which child-, family-, and community-level variables explained state variation. Finally, we quantified the influence of state-level variables on state variation. Results Unadjusted rates of no preventive dental care ranged 9.0–26.8% (mean 17.5%), with little impact of adjusting (10.3–26.7%). Almost 9% of the population had fair/poor oral health; unadjusted range 4.1–14.5%. Adjusting analyses affected fair/poor oral health more than access (5.7–10.7%). Child, family and community factors explained ∼¼ of the state variation in no preventive visit and ∼½ of fair/poor oral health. State-level factors further contributed to explaining up to a third of residual state variation. Conclusion Geography matters: where a child lives has a large impact on his or her access to oral health care and oral health status, even after adjusting for child, family, community, and state variables. As state-level variation persists, other factors and richer data are needed to clarify the variation and drive changes for more egalitarian and overall improved oral health.

Background:. As the national opioid epidemic escalates, rates of the Hepatitis C (HCV) infection have similarly risen. Surgeons exposed intraoperatively secondary to sharp instrument or needle-sticks are affected both socioeconomically and physically. Current treatment strategies involve antiretroviral agents that have not been universally available. This study evaluates the current risk of surgeon exposure to HCV. Methods:. CDC data regarding state-by-state HCV diagnosis reporting were combined with the plastic surgery workforce data from the ASPS. Proxy variables for exposure risk to HCV were generated for each state and compared. Results:. West Virginia plastic surgeons were found to have a significantly elevated risk of exposure (60.0 versus 18.7, P < 0.0001). Their exposure risk is a notable outlier compared with the rest of the country (Risk >3 × IQR + 75th percentile). Similarly, states within the Ohio Valley were found to be at increased risk (34.8 versus 16.0, P = 0.05). States most heavily burdened by the opioid crisis were found to be at an increased risk for HCV exposure (40.8 versus 13.6, P = 0.0003). Conclusions:. Plastic surgeons employed in states within the Ohio Valley were found to be at an increased risk of exposure to HCV. Plastic surgeons operating in states severely impacted by the opioid crisis were found to be at an increased risk of exposure. These findings underscore the importance of reducing the risk in the operating room and the need for better data collection to better understand this association and mitigate the risk to the operating surgeon.

Engineering remains the least gender diverse of the science, technology, engineering and mathematics fields. Chemical engineering (ChE) and electrical engineering (EE) are exemplars of relatively high and low gender diversity, respectively. Here, we investigate departmental, institutional, and regional factors associated with gender diversity among BS graduates within the US, 2010–2016. For both fields, gender diversity was significantly higher at private institutions (p < 1x10-6) and at historically black institutions (p < 1x10-5). No significant association was observed with gender diversity among tenure-track faculty, PhD-granting status, and variations in departmental name beyond the standard “chemical engineering” or “electrical engineering”. Gender diversity among EE graduates was significantly decreased (p = 8x10-5) when a distinct degree in computer engineering was available; no such association was observed between ChE gender diversity and the presence of biology-associated degrees. States with a highly gender diverse ChE workforce had a significantly higher degree of gender diversity among BS graduates (p = 3x10-5), but a significant association was not observed for EE. State variation in funding of support services for K-12 pupils significantly impacted gender diversity of graduates in both fields (p < 1x10-3), particularly in regards to instructional staff support (p < 5x10-4). Nationwide, gender diversity could not be concluded to be either significantly increasing or significantly decreasing for either field.

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is used across the country to document the treatment preferences of seriously ill or frail patients as medical orders. The National POLST Paradigm Task Force maintains consensus-based standards for POLST programs and uses these to determine whether a state POLST program is developing, endorsed, or mature.To evaluate state program form adherence to national standards.Document review.Forms from endorsed/mature (n = 21) and developing (n = 23) states were compared with national standards to assess adherence to required and optional form elements.Required elements were present on 84% of endorsed/mature state POLST forms and 73% of the developing state POLST forms. Compliance with required elements in endorsed states ranged from 50% to 100%. Three endorsed/mature states (14%) had forms that met all of the required elements fully and 14 (67%) had forms that met the all of the elements fully or partially.There is variability in adherence to required and optional standards as well as challenges in interpreting and applying existing standards. Although there may be legal and logistical barriers to the existence of a national POLST form, standardization remains an important goal to support patient-centered care.

Our research group is currently focused on research and development of Internet of Things-based robust emergency and disaster prevention systems to transmit tsunami information retrieved from infrasound sensors. To constantly test the effective sensor operation, it is necessary generate infrasound. Therefore, we considered the infrasound generated when opening and closing doors in this study, and used one sensor to detect the state variation of multiple doors. We constructed and verified the detection system for various doors.

This paper examines the outcomes and characteristics of corporate acquisitions from the perspective of stakeholder-shareholder agency conflicts. Using state variation in labor protections, we find that acquirers with strong labor rights experience lower announcement returns. Combined acquirer and target announcement returns are also lower in the presence of strong labor rights. Our findings remain statistically and economically significant after we control for a range of deal, firm, industry and state characteristics and explore various channels for the labor rights effect. Overall, the evidence indicates that employee-shareholder conflicts of interest reduce shareholder gains from acquisitions.

Medicaid reimbursements are determined by each state and are subject to variability. We sought to quantify this variation for commonly performed inpatient orthopaedic procedures.The 10 most commonly performed inpatient orthopaedic procedures, as ranked by the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, were identified for study. Medicaid reimbursement amounts for those procedures were benchmarked to state Medicare reimbursement amounts in 3 ways: (1) ratio, (2) dollar difference, and (3) dollar difference divided by the relative value unit (RVU) amount. Variability was quantified by determining the range and coefficient of variation for those reimbursement amounts.The range of variability of Medicaid reimbursements among states exceeded $1,500 for all 10 procedures. The coefficients of variation ranged from 0.32 (hip hemiarthroplasty) to 0.57 (posterior or posterolateral lumbar interbody arthrodesis) (a higher coefficient indicates greater variability), compared with 0.07 for Medicare reimbursements for all 10 procedures. Adjusted as a dollar difference between Medicaid and Medicare per RVU, the median values ranged from -$8/RVU (total knee arthroplasty) to -$17/RVU (open reduction and internal fixation of the femur).Variability of Medicaid reimbursement for inpatient orthopaedic procedures among states is substantial. This variation becomes especially remarkable given recent policy shifts toward focusing reimbursements on value.

Prior studies have reported that community health centers perform as well as other sites of care, despite serving more vulnerable patient populations. However, there is little prior study of geographic variation in quality outcomes and disparities in outcomes in this setting. Quantifying geographic variation is important so as to target quality improvement efforts and funding and to learn from states where total quality is highest and racial/ethnic disparities are lowest.To estimate between-state variation in hypertension, diabetes, and pregnancy outcomes and racial/ethnic disparities in these outcomes for health center patients.Using data on all US health centers from 2010 to 2014 (N=1047 health centers/year, or 21.2 million patients in 2014), we used linear regression models to estimate adjusted quality outcomes and racial/ethnic disparities in quality outcomes by state for hypertension control, diabetes control, and normal birthweight.We found wide variation in both outcomes and racial/ethnic disparities in outcomes between states for patients seen at health centers. For instance, between states, the mean proportion of patients with hypertension control ranged from 58% to 70% for white patients, from 49% to 64% for black patients, and from 53% to 74% for Hispanic patients (P0.001). Racial/ethnic disparities in outcomes ranged from negative or nonsignificant in some states to positive in others.Wide variation in health center patient outcomes and disparities in outcomes is observed between states. This variation suggests that policymakers should target funding and interventions to underperforming states, and identify determinants of high quality in higher performing states.

Objectives. To examine state variation in minimum stocking requirements for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)–authorized small food retailers. Methods. We obtained minimum stocking requirements for 50 states and the District of Columbia in 2017 from WIC Web pages or e-mail from the state WIC agency. We developed a coding protocol to compare minimum quantities and varieties required for 12 food and beverage categories. We calculated the median, range, and interquartile range for each measure. Results. Nearly all states set minimum varieties and quantities of fruits and vegetables, 100% juice, whole grain–rich foods, breakfast cereal, milk, cheese, eggs, legumes, and peanut butter. Fewer states set requirements for canned fish, yogurt, and tofu. Most measures had a large range in minimum requirements (e.g., $8–$100 of fruits and vegetables, 60–144 oz of breakfast cereal). Conclusions. WIC-participating retailers must adhere to very different minimum stocking requirements across states, which may result in disparities in food and beverage products available to WIC recipients. Public Health Implications. The results provide benchmarks that can inform new local, state, and federal program and policy efforts to increase healthy food availability in retail settings.

Variation in Medicaid policies among states may lead to differences in coverage for complex treatments. This article uses hematopoietic cell transplantation (HCT), an established treatment for patients with hematologic cancers, as a case study to highlight state variation in Medicaid coverage of complex oncology treatments.Information on HCT coverage benefits for 2012 was collected from state Medicaid Web sites and was compared with recommended HCT benefits developed by multiple stakeholders. Coverage was reviewed for five categories: one, transplantation procedure; two, donor search; three, prescriptions; four, clinical trials; and five, patient food, lodging, and transportation. Coverage was coded on a three-point scale for each category for each state. States were ranked by the number of variables for which they met recommended benefits criteria (maximum rank score, 5).Detailed information on Medicaid coverage was available for 47 states. No state provided the recommended coverage benefits in all five categories. Prescription coverage most often met the recommended criteria, whereas only a small number of states provided clinical trial coverage for HCT. There was substantial variation in Medicaid coverage for HCT by state.Findings highlight substantial variation in Medicaid coverage for HCT by state, which may increase disparities in access for already medically underserved populations.

States vary in their overall rates of nursing home deficiency citations as well as deficiencies for actual harm or jeopardy (Harrington et al., 2018). Civil Money Penalty (CMP) fines collected by the Centers for Medicare and Medicaid Services (CMS) are one enforcement action imposed to promote nursing home compliance with regulations. Collected CMP funds are redistributed to states for the sole purpose of improving nursing home resident care and quality of life through reinvestment in quality improvement projects. Using CASPER data available for US skilled nursing homes in 2015 and 2016 through the CMS QCOR database we examined the distribution of quality of care (QOC) and quality of life (QOL) deficiencies and CMP enforcement action across states. Guided by the systems framework for evaluating nursing home quality (Unruh & Wan, 2004) we further explored how contextual factors such as state spending for nursing home care, structural characteristics of facilities in states, and inadequate care processes indicated by deficiencies contribute to CMP enforcement actions and fines. Findings indicate that 27% of enforcement actions resulting in a CMP between 2015 and 2016 were imposed for a QOL deficiency while 61.7% represented QOC deficiencies. QOL deficiencies represented only 8% of the highest severity deficiency category but 81.7% of enforcement actions for QOC were for those causing immediate harm or jeopardy. QOC deficiencies are a focus of enforcement actions as they represent critical care processes influencing resident basic needs for hydration, ambulation, skin integrity and care for other special physical and behavioral needs.

Coating induced polarization state variation cannot be neglected, if the angle of incidence (AOI) is too large. LaF3 and MgF2 are chosen as high and low index material to design the low polarization anti-reflection (LPAR) coating. After proper fabrication and measurement, the transmittance of the LPAR coating is 98.6%, and the differential transmittance between P and S polarized direction of the LPAR one is about 3%, which is much smaller than 15% caused by the common anti-reflection (AR) coating. Moreover, with and without the LPAR coating, the Peak and Valley (PV) values of the substrate were 1.572λ and 1.457λ (λ = 632.8 nm), which meant the mechanical stress of the coating was well controlled.

National statistics on drug intoxication deaths are based solely on data derived from death certificates. This study examines the variation in the manner of death classification by state, and the specificity of drugs involved in drug intoxication deaths by state and by type of death investigation system. The National Vital Statistics System Multiple Cause of Death mortality files (2008–2010) were analyzed. Drug intoxication deaths were those with ICD-10 Underlying Cause of Death of X40-X44 (unintentional), X60-X64 (suicide), X85 (homicide), or Y10-Y14 (undetermined intent). Among drug intoxication deaths, deaths involving non-specified drug(s) were those with Multiple Cause of Death (MCOD) of T50.9, and no MCOD in the range T36-T50.8. State death investigation systems were categorized as follows: centralized state medical examiner offices, county/district medical examiners, hybrid, and decentralized county coroners. In 2008–2010, there was an average of over 37,250 drug intoxication deaths per year in the U.S. The manner was undetermined for 8% for the U.S., ranging from 1% to 85% among the states. During 2008–2010, 75% of the drug intoxication deaths had at least one specific drug reported on the death certificate. States with centralized state medical examiner systems had a higher percent (92%) of drugs specified than did those with other systems. Across the U.S., there is variation in the percent of drug intoxication deaths classified as having undetermined manner of death and with specific drugs identified on death certificates. This variation has significant implications for public health surveillance and for prevention efforts.

Motion sequence segmentation is a fundamental work in human motion analysis, which can promote the deep understanding as well as wide application of human motion sequences. Mainstream human motion sequence segmentation methods only focus on the data characteristics of the sequence and neglect the physical characteristics of the motions. This paper proposes a hashing based state variation segmentation (HBSVS) method to realize human motion sequence segmentation by analyzing the changing characteristics of the motions on time series. To improve the computational efficiency and merge motions from the same class, HBSVS adopts hashing method to construct the state descriptor of each motion on the sequence. Experiments on CMU motion capture database and UT-Interaction standard dataset show that HBSVS outperforms several state-of-the-art human motion sequence segmentation methods.

OBJECTIVES To assess state variations in eligibility criteria based on enrollment length and sexual activity on chlamydia testing rates among Medicaid female enrollees aged 15 to 25 years and potential impact of the representatives of testing rates. METHODS We used 2010 Medicaid Analytic eXtract to estimate and compare the overall and state-level prevalence of gaps in coverage of ≥ 2 consecutive months, service utilization associated with sexuality, and chlamydia testing rates among Medicaid female enrollees aged 15 to 25 years who had ≥ 1 month of the full scope of Medicaid benefits and had ≥ 1 health service claim. The chlamydia testing rate was calculated as the proportion of sexually active Medicaid female enrollees who received a chlamydia test in 2010. RESULTS Of 5.7 million women aged 15 to 25 years enrolled in Medicaid in 2010, 42.3% had a 2-month gap of enrollment coverage in 2010. The proportion of women who had a 2-month gap varied from 26.1% to 73.2% across states. The proportion of women identified as sexually active was 59.8% among women who had a 2-month gap and 57.1% among women who had no 2-month gap. The chlamydia testing rate was 44.0% among sexually active women with a 2-month gap and 44.2% among sexually active women without a 2-month gap. Eleven states had ≥10% difference in sexual activity or chlamydia testing rates between women with a 2-month gap and women without a 2-month gap. CONCLUSIONS States which exclude a substantial proportion of Medicaid enrollees from inclusion in the chlamydia testing denominator may have less representative testing estimates because those excluded tend to be women aged 19 to 25 years.

A rectangular signal is supplied to the input of an electromechanical system to perform technical diagnostics of the latter. Passing the system, the signal undergoes certain changes caused by modified state of the object. The state variation estimating algorithm involves the energy of the output signal. Energy deviation from a reference value is computed by the metric method.

For solving the difficult problem of leakage detection in city gas pipelines, a method using acoustic technique based on instantaneous energy (IE) distribution and correlation analysis was proposed. Firstly, the basic theory of leakage detection and location was introduced. Then the physical relationship between instantaneous energy and structural state variation of a system was analyzed theoretically. With HILBERT-HUANG transformation (HHT), the instantaneous energy distribution feature of an unstable acoustic signal was obtained. According to the relative contribution method of the instantaneous energy, the noise in signal was eliminated effectively. Furthermore, in order to judge the leakage, the typical characteristic of the instantaneous energy of signal in the input and output end was discussed using correlative analysis. A number of experiments were carried out to classify the leakage from normal operations, and the results show that the leakages are successfully detected and the average recognition rate reaches 93.3% among three group samples. It is shown that the method using acoustic technique with IED and correlative analysis is effective and it may be referred in other pipelines.

Our aim is to assess state variation in renal trauma outcomes. We hypothesize that states with more hospitals participating in a trauma system will have lower nephrectomy and mortality rates.The Healthcare Cost and Utilization Project State Inpatient Database was used to conduct a retrospective cohort study of all patients hospitalized with renal injury from partnering states during 2001, 2004, and 2007. State trauma systems were categorized based on the proportion of all acute care hospitals designated as a trauma center (Levels I-V) with higher proportions correlating to a more inclusive system. Poisson regression for relative risks (RRs) of inpatient nephrectomy and case fatality were performed adjusting for patient and state level factors.Patients in states with the "most inclusive" trauma systems had a 30% lower risk of nephrectomy (RR, 0.70; 95% confidence interval [CI], 0.56-0.88) and a 2.06% lower unadjusted inpatient case fatality rate compared with states with "exclusive" trauma systems. Inpatient case fatality risk varied significantly by trauma system inclusiveness. Patients treated in states with either a "more inclusive" (RR, 0.85; 95% CI, 0.74-0.97) or "most inclusive" (RR, 0.74; 95% CI, 0.64-0.85) trauma system were independently associated with a lower inpatient case fatality risk compared with states with "exclusive" systems.A reduced risk of nephrectomy and inpatient case fatality are more common among states that have a higher proportion of acute care hospitals participating as a trauma center (Levels I-V). Standardization of care may correlate with improved patient outcomes after renal trauma.II, exploratory cohort analysis.

Apparent per-capita alcohol consumption in 2001 in four U.S. regions (West, Northeast, South, and Midwest), and in 50 states was examined in relation to mortality rates (1999-2004) from liver cirrhosis and for the subcategory alcoholic liver disease. Alcohol consumption and mortality rates were highest in the west. The alcoholic liver disease mortality rate by state was strongly correlated with alcohol consumption, but several outlier or mismatch states were identified. Per-capita alcohol consumption should be useful for US public health policy, as suggested for Europe and Canada, but outlier states require further study.

The adaptive polarization mode dispersion (PMD) compensation in high-speed transmission system has become more and more necessary for the link PMD causing strong signal distortions. A dynamic adaptive PMD compensator in 40 Gb/s polar-multiplex differential quadrature phase shift keying (PM-DQPSK) system is reported. Experimental results show that the PMD compensator can track the average polarization state variation at 65 rad/s without any lost of the optimum tracking. The 1st-order PMD compensation is demonstrated experimentally, and the compensator can increase the maximal tolerable PMD value by 26 ps from 17 ps to 43 ps in an optical transmission system.

OBJECTIVE: The objective of this study was to compare on a national cohort of children with autism spectrum disorder (ASD) the concurrent use of ≥3 psychotropic medications between children in foster care and children who have disabilities and receive Supplemental Security Income, and to describe variation among states in the use of these medications by children in foster care.METHODS: Studied was the concurrent use of ≥3 classes of psychotropic medications, identified from the 2001 Medicaid claims of 43406 children who were aged 3 to 18 years and had ≥1 annual claim for ASD. Medicaid enrollment as a child in foster care versus a child with disabilities was compared. Multilevel logistic regression, clustered at the state level and controlling for demographics and comorbidities, yielded standardized (adjusted) estimates of concurrent use of ≥3 medications and estimated variation in medication use within states that exceeded 1 and 2 SDs from the average across states.RESULTS: Among children in foster care, 20.8% used ≥3 classes of medication concurrently, compared with 10.1% of children who were classified as having a disability. Differences grew in relationship to overall use of medications within a state; for every 5% increase in concurrent use of ≥3 medication classes by a state's population with disabilities, such use by children in a state's foster care population increased by 8.3%. Forty-three percent (22) of states were >1 SD from the adjusted mean for children who were using ≥3 medications concurrently, and 14% (7) of the states exceeded 2 SDs.CONCLUSIONS: Among children with ASD, children in foster care were more likely to use ≥3 medications concurrently than children with disabilities. State-level differences underscore policy or programmatic differences that might affect the receipt of medications in this population.

The prevalence of Autism and other Autism Spectrum Disorders (ASDs) has increased dramatically in recent years. The criterion for a clinical diagnosis of Autism, however, is independent from the special education eligibility requirements for Autism services. While the DSM-IV-TR provides a nationally-accepted definition for Autism and ASD, under federal law, the special education criteria for Autism services can vary from state to state. By analyzing federal, special education child-count data as well as each state’s legal code, this study examines and compares eligibility criteria in all 50 states and Washington DC. Our results reveal inter-state variability in Autism eligibility requirements within special education, and this variability can have an impact on prevalence rates. Implications and recommendations for researchers and practitioners in clinical psychology, public health, education, pediatrics, and public policy are discussed.

The Affordable Care Act (ACA) of 2010 expanded eligibility for public health insurance, Medicaid, to nearly all adults ages 18-64 with household incomes below 138% of the federal poverty line and living in states that opted to participate in the Medicaid expansion. The ACA Medicaid expansion can potentially decrease reliance of disabled adults on the Supplemental Security Income program which provides Medicaid coverage as well as cash assistance to low-income individuals with disabilities. In the paper we estimate the effects of Medicaid expansion on the entry into the Supplemental Security Income in the first two years following the expansion launch in January 2014. We use data from the Social Security Administration and identify causal effects by exploiting cross state variation in Medicaid eligibility resulting from states’ decisions about whether to participate in the Medicaid expansion.

OBJECTIVE Examine overall level of and variation in local health department (LHD) use and perceived impact of the County Health Rankings report (Rankings) in Florida (2010, 2011) and North Carolina (2010-2012, 2013). DESIGN Two cross-sectional surveys among LHDs. PARTICIPANTS Local health directors and relevant staff. MAIN OUTCOME MEASURES Use of the Rankings was measured by asking respondents if their LHD had used the Rankings in any of 10 ways and through assessment of community engagement. Perceived impact was measured by amount of attention the Rankings received from various stakeholders and whether they had already produced or would likely produce any of 7 possible results. RESULTS Overall, LHDs used the Rankings most often to educate staff in Florida (78%) and North Carolina (56%). Engagement with community groups around the Rankings was variable. Media engagement, through press releases (41%; 40%) or interviews (51%; 36%) in Florida and North Carolina, was moderate. Florida LHDs used the Rankings in more ways and significantly more frequently than North Carolina LHDs. There were few significant differences in perceived impact by state. At least a moderate amount of attention was received from media in Florida (52%) and North Carolina (46%). Twenty-percent of LHDs reported the Rankings received at least moderate attention from the general public in both states and 38% (Florida) and 33% (North Carolina) from policy makers. Tangible benefits to communities from the Rankings, such as having already influenced adoption of new policies, were modest in Florida (3%) and North Carolina (11%). CONCLUSIONS Results suggest that tangible benefits to communities from use of the Rankings have yet to be fully realized but are encouraging. More effective media engagement could produce the community awareness necessary to maximize the Rankings' potential to mobilize communities for health improvement. State variation in Rankings use suggests that more support to LHDs may be helpful.

Prior research suggested that when community members are notified that a sex offender is residing in their neighborhood they are likely to engage in precautionary behavior to prevent potential victimization. Since states employ different processes in notifying community members of the presence of a sex offender, it is important to examine the advantages and disadvantages of the various notification processes. The current exploratory study compared the proactive sex offender notification process in Hamilton County, Ohio, with the passive notification process in Jefferson County, Kentucky. Not surprisingly, study findings indicated that the proactive sex offender notification process used in Ohio resulted in better community dissemination of information.

The question of this analysis is how the production of college graduates at the state level affects the stock of college-educated workers in the state. The potential mobility of skilled workers implies that the number of college students graduating in an area need not affect the number of college graduates living in the area. However, the production of relatively large numbers of college graduates in a state may lead to increases in the employment of university-trained manpower if industries expand production of goods and services that use college-educated workers intensively. We find at best only a modest link between the production and stock of baccalaureate degree recipients.