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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.

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.

Do minimum wages and the earned income tax credit (EITC) mitigate rising "deaths of despair?" We leverage state variation in these policies over time to estimate event study and difference-in-differences models of deaths due to drug overdose, suicide, and alcohol-related causes. Our causal models find no significant effects on drug or alcohol-related mortality, but do find significant reductions in non-drug suicides. A 10 percent minimum wage increase reduces non-drug suicides among low-educated adults by 2.7 percent, and the comparable EITC figure is 3.0 percent. Placebo tests and event-study models support our causal research design. Increasing both policies by 10 percent would likely prevent a combined total of more than 700 suicides each year.

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.

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.

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 number of intensive longitudinal studies that investigate affective experiences at the within-person rather than the between-person level is rapidly increasing. This paradigmatic shift comes with new challenges, such as questions revolving around how to measure within-person affect variation or more fundamental questions about the reliability and validity of constructs at the within-person level. We provide a review of substantive research published in Emotion since 2005, which revealed that to date no consensus has been established on measurement instruments for assessing within-person affective experiences. Our review also showed that researchers who are interested in within-person affect variation sometimes rely on measurement instruments that were established at the between-person level, which we think should be reconsidered. Finally, reliability estimates of state variation have been developed but are not comprehensively reported in studies on within-person affect variation. The purpose of this article is therefore to alert the reader to these issues and to highlight relevant criteria for selecting items and measurement instruments when studying within-person affect variation in intensive longitudinal studies. We recommend establishing common standards for measuring within-person affect variation and drawing from a common pool of instruments, which would allow direct comparison of results across studies. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

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.

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.

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 low employment rates of individuals with intellectual disability (ID) are a major concern. This study examined the effect of postsecondary education on employment atrnd earnings for individuals with ID and the effect of state variation on those outcomes. Rehabilitation Services Administration 911 (RSA-911) files for 2008–2013 were analyzed (n = 11,280 individuals with ID). Multilevel modeling techniques were used to understand state variation, such as various economic and programmatic features that influence outcomes. Postsecondary education was associated with increased employment, increased weekly earnings, decreased reliance on Supplemental Security Income (SSI) benefits. Policy implications are discussed.

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.

The study's objective was to investigate whether attention-deficit hyperactivity disorder (ADHD) diagnoses from 2003 to 2011 were associated with either public school consequential accountability reforms initiated by the No Child Left Behind (NCLB) Act, particularly for low-income children, or with state psychotropic medication laws that prohibit public schools from recommending or requiring medication use.Logistic regression difference-in-differences models were estimated with repeated U.S. and state-representative cross-sections of responses to the 2003, 2007, and 2011 National Survey of Children's Health. Each wave included approximately 35,000 public school children between ages six and 13.From 2003 to 2007, the change in adjusted diagnostic prevalence was 2.8 percentage points higher for children ages six to 13 in households with incomes ≤185% of the federal poverty level residing in states first exposed to consequential accountability through NCLB (from 8.5% to 13.2%), compared with demographically similar children residing in other states (from 10.2% to 12.1%). From 2003 to 2011, the change in adjusted diagnostic prevalence was 2.2 percentage points lower for children ages six to 13 residing in states with a psychotropic medication law (from 8.1% to 7.8%), compared with children residing in other states (from 8.1% to 10.1%).NCLB-initiated consequential accountability reforms were associated with more ADHD diagnoses among low-income children, consistent with increased academic pressures from NCLB for this subgroup. In contrast, psychotropic medication laws were associated with fewer ADHD diagnoses, because they may indirectly reduce diagnoses via restrictions on recommending or requiring medication use. Future research should investigate whether children most affected by these policies are receiving appropriate diagnoses.

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.

Contains fulltext : 153313.pdf (Publisher’s version ) (Open Access) Hypothalamic-pituitary-adrenal (HPA)-axis dysregulation is a prominent finding in more severe Major Depressive Disorder (MDD), and is characterized by increased baseline cortisol levels at awakening (BCL), blunted cortisol awakening response (CAR) and increased area under the cortisol curve (AUC). Selective serotonin reuptake inhibitors (SSRIs) appear to normalize HPA-axis dysfunction, but this is hardly investigated longitudinally. We studied salivary BCL, CAR and AUC at awakening and 30min thereafter. We compared measurements in initially drug-free MDD-patients with healthy controls (HCs) at study-entry. In patients, we repeated measures after 6 and 12 weeks' treatment with the SSRI paroxetine. Non-responding patients received a randomized dose-escalation after six weeks' treatment. We found no significant study-entry differences in BLC, CAR or AUC between MDD-patients (n=70) and controls (n=51). In MDD-patients, we found general decreases of BCL and AUC during paroxetine treatment (p

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.

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.

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.

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.

Recent evidence suggests that the cortisol awakening response (CAR) on any single day is determined by a combination of trait and state factors; however, the nature of such state associations remains largely unexplored. In this study we examined day-to-day changes in the CAR and their covariance with simultaneous changes in sleep-related variables, alcohol consumption, and motility levels. We employed a novel approach to this field of research in the form of a detailed case study of a 27-year-old healthy male (TS) over 50 measurement days, occurring at 3-day intervals. On each measurement day, salivary free cortisol was determined at 0, 15, 30, and 45min post-awakening and sleep-related variables, alcohol consumption on the previous evening, and post-awakening motility were measured. Our findings show considerable day-to-day variability in the CAR, particularly the dynamic increase, which averaged 17.2nmol/l and ranged from 3.6 to 39.0nmol/l (max-min values). We also report a strong relationship between changes in awakening time and changes in the first waking sample (explaining approximately 38% of its variability) such that later awakening was associated with a higher first waking sample. This relationship was found to be stronger on days when awakening time was earlier in the morning than on days when it was later. Our findings also provide a preliminary indication for an inverse association between alcohol consumption on the evening before a sampling day and the dynamic of the AUC(I), while no associations between sleep quality, post-awakening motility levels, and mode of awakening and measures of the CAR were found.

A relationship between individual differences in trait estimates of the cortisol-awakening response (CAR) and indices of executive function (EF) has been reported. However, it is difficult to determine causality from such studies. The aim of the present study was to capitalise upon state variation in both variables to seek stronger support for causality by examining daily co-variation. A 50 days researcher–participant case study was employed, ensuring careful adherence to the sampling protocol. A 24-year-old healthy male collected saliva samples and completed an attention-switching index of EF on the morning of each study day. Subsidiary control measures included wake time, sleep duration, morning fatigue, and amount of prior day exercise and alcohol consumption. As the CAR preceded daily measurement of EF, we hypothesised that, over time, a greater than average CAR would predict better than average EF. This was confirmed by mixed regression modelling of variation in cortisol concentrations, which indicated that the greater the increase in cortisol concentrations from 0 to 30 min post-awakening (CAR) the better was subsequent EF performance at 45 min post-awakening (t = 2.29, p = 0.024). This effect was independent of all potential confounding measures. Results are discussed in terms of implications for the understanding of the relationship between the CAR and the cognitive function, and the previously suggested role of the CAR in “boosting” an individual’s performance for the day ahead.

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.

Allocations for the State Children's Health Insurance Program (SCHIP) varied 22% per state between 1999 and 2002. The funding fluctuations present significant problems for states as they develop budget priorities under difficult fiscal conditions. We examine sources of the variation in state allocations during the first four years of SCHIP, focusing on the Current Population Survey's “child component” of the allocation formula. We consider the trade-offs in using alternative estimates from the American Community Survey and model-based estimation. Obtaining reliable estimates of need for SCHIP allocations is critical for states dependent on federal support for insurance programs.

States are given considerable discretion in designing their Medicaid programs and, as a result, Medicaid is made up of 51 different programs. Using data from the 1997 National Survey of America's Families, the authors examine variation in health care access and use by adults in 13 states and then compare those differences with national estimates of access and use. The authors find significant differences in access and use among the 13 study states. This variation persisted after differences in state Medicaid caseload characteristics, including demographic, socioeconomic, and health status, were controlled for. State variation in beneficiaries' access and use also persisted after differences in health care market characteristics, such as supply of health care providers, level of employer-sponsored coverage, and level of HMO penetration, and characteristics of the state Medicaid programs were controlled for.

The state-level proportion of pregnancies that are unintended is an important social and public health indicator, and comparisons between states inform policy discussions. Unintended pregnancy is measured as a composite of abortions and unintended births, each of which is measured with error. We investigate whether between-state differences in abortion access and demand may bias comparisons between states' unintended pregnancy proportions when pregnancy intentions are misreported.We algebraically specify the model currently used to estimate unintended pregnancy, extend it to include underreporting, and simulate the impact of underreporting on observed unintended pregnancy. Comparing the impact of underreporting across states, we identify levels of underreporting at which between-state comparisons are compromised.We find that underreporting of unintended pregnancies could bias between-state comparisons when reporting of unintended pregnancies is less than 90-95%.Current methods for estimating state-level unintended pregnancy proportions may underestimate unintended pregnancy to a greater degree in places with less abortion, and between-state comparisons may be biased. Estimates of state-level unintended pregnancy proportions would be more comparable if adjustment for completeness of retrospective underreporting were included in the estimation process.Estimates of unintended pregnancy should be adjusted for nonsampling error and include variances based on sampling and nonsampling error in order to permit robust comparisons between states, between populations, and across time. More research on the fidelity of retrospective reporting of pregnancy intention would facilitate this endeavor.

State Medicaid programs have expanded home and community-based services (HCBS). This article compares trends and variations in state policies for Medicaid HCBS programs in 2005 and 2010. State limitations on financial eligibility criteria and service benefits have remained stable. Although the use of consumer direction, independent providers, and family care providers has increased, some states do not have these options. The increased adoption of state cost control policies have led to large increases in persons on waiver wait lists. Access could be improved by standardizing and liberalizing state HCBS policies, but state fiscal concerns are barriers to rebalancing between HCBS and institutional services.

Long-term care screening and assessment programs were designed by states to controllong-term care costs and to prevent unnecessary institutionalization of Medicaid participants. This study reports data collected by telephone survey of state officials in all 50 states and Washington, D.C. on state variation in LTC screening and assessment programs. The majority of the state screening and assessment programs cover an array of LTC services but this has resulted in multiple separate screening programs for different long-term care services and eligibility groups. Only three states coordinated screening and assessment across long-term care programs by operating a single state administrative agency, using uniform need criteria and standard tools, and having automated databases (Arizona, Colorado, and Maine). The design and implementation of multiple and separate screening and assessment programs in most states may create potential barriers to clientaccess, information about services and choice of services.

Many large employers prefer to self-insure health plans offered to employees rather than purchase them from insurance companies to save costs and to avoid the burden of complying with varying state mandates. This concerns state governments because they cannot directly regulate self-insured plans. This article describes the prevalence of employer self-insurance for the nation and by state in 1993 and examines what factors, especially state policies, contribute to the national and state variation in the prevalence of self-insurance. Data from the National Employer Health Insurance Survey on 34,604 private sector establishments are analyzed. Variation in the prevalence of self-insurance was largely explained by the firm size of the establishments. After all other factors were examined, very little was added to predict the rate of self-insurance for each state. While state premium taxation and benefits mandates were not associated with self-insurance, small-group reforms were significantly and positively associated with the probability of self-insurance.

Background. This study compares mortality outcomes of Medicaid-reimbursed nursing home residents with and without do-not-resuscitate (DNR) orders in two diverse states. Methods. We used 1994 Minimum Data Set Plus (MDS 1 ) information on 3215 nursing home residents from two states. We used Kaplan-Meier analyses to examine unadjusted mortality among those with and without DNR orders across states. We used a proportional hazard regression with main and interaction variables to model the likelihood of survival in the nursing home. Results. Approximately 27% of nursing home residents with DNR orders in State A die within the year, and approximately 40% of nursing home residents with DNR orders in State B die within the year. Regression results indicate that neither having a DNR order nor state of residence were independently associated with mortality. However, residing in State B and having a DNR order was associated with an increased risk of mortality compared with all others in the sample (risk ratio 5 1.73; 95% confidence interval 5 1.09, 2.75). Conclusion. This study demonstrates that DNR orders are associated with varying mortality across states. Future research is needed to identify the reasons why state level differences exist. ISCUSSIONS about end of life decisions, specifically the decision to implement a do-not-resuscitate (DNR) order, are an important component of nursing home care.

A questionnaire was sent to all radiologists in Australia using a mailing list supplied by individual State Workforce subcommittee members. A reply rate of 72% was obtained. There are currently 1061 radiologists (1010.5 full-time equivalents) or 55.5 radiologists per million population, placing Australia in the mid-range compared with other OECD countries. This has increased slightly from 54.1 in 1994. There is a small but definite State variation. Utilizing current trainee numbers and traditional attrition rates, there is no projected change in these figures (55.3 in 2001), but the continued introduction of 'migrant' radiologists is postulated to cause an increase (56.6 with 25 migrants and 58.4 with 50 migrants in 2001). Analysis of work-practice indicates a performance rate of 14,100 procedures per year per practising radiologist. There is again a State variation. It is estimated that the total number of medical imaging procedures per 1000 population per year (rendered by radiologists) is 815. These latter two figures place Australia in the mid-range compared with the United States and Great Britain. General radiography, mammography, ultrasound, and CT are the most common procedures (in that order), and are performed by the largest proportion of radiologists.

BACKGROUND—There is some evidence that tobacco companies marketing efforts undermine the effects of comprehensive tobacco control programmes. OBJECTIVE—To determine whether point-of-purchase advertising and promotions are more pervasive in states where comprehensive tobacco control programmes are underway. DESIGN—Cross sectional survey using 1996 data, with merged records of the existence of local tobacco advertising restrictions. PARTICIPANTS AND SETTING—581 tobacco retail stores located in close proximity to high schools in mainland USA. MAIN OUTCOME MEASURES—Existence of gift-with-purchase, number of interior advertisements, and exterior store advertisements for Marlboro cigarettes. RESULTS—After controlling for store type and existence of advertising restrictions, offer of a gift-with-purchase for Marlboro cigarettes was significantly more likely in states with comprehensive tobacco control programmes than those without programmes (odds ratio 2.59, 95% confidence interval 1.57 to 4.26). Although not significant, results show an increase in the number of interior and exterior store advertisements for stores located in states with a comprehensive tobacco control programme than those in other states. CONCLUSION—Results suggest some point-of-purchase tobacco promotions and advertising are more pervasive in states with comprehensive tobacco control programmes. These efforts are likely to act against the objectives of programmes and need to be accounted for in programme evaluations. Keywords: advertising; public policy; value added promotions

In this paper we compare health insurance coverage for U.S. citizen children in all-citizen and mixed families in the fifteen states with the largest share of children in mixed families. Insurance coverage is lower and state variation in coverage is higher for children in mixed families vis-a-vis children in all-citizen families. The main challenges for states are tackling uninsurance among all low-income children and addressing the very low rates of employer-sponsored insurance for all low-income children and for children in all mixed families, regardless of income. We discuss state policy options to address the needs of children in mixed families.

Using the National Survey of America's Families (NSAF) in 1997 and 1999, this paper investigates the sources behind variation in employer-sponsored health insurance (ESI) across states. We find that demographics and family characteristics (such as race/ethnicity and citizenship status), individual employment characteristics (such as firm size, labor force attachment), and local labor market characteristics (such as unionization) consistently explain the relative position of all of the states with either high or low rates of ESI coverage. Income plays a lesser role in explaining the state variation, but is still an important determinant, especially among states whose average income deviates substantially from the national average. (Health Affairs 22(1): 241?51, January/February 2003.)

Objective:The authors explore state variation in expenditures for Medicaid communitybased care services for the period 1990 to 1997. Method:A random effects panel model is used to explore the relationship between state demographic, supply, economic, programmatic, and political factors and states’ Medicaid community-based care expenditures. Results:Although states increased provision of services over the study period, significant state-level variation was evident. Expenditures were positively associated with state per capita income, regulation of nursing home bed supply, and the number of Medicare home health users but were negatively related to nursing home bed supply. Conclusions:Recent legal rulings, combined with the demonstrated preferences of most individuals to receive care in the community, require policies to foster the expansion of Medicaid community-based care. The most consistent relationships that are amenable to policy intervention relate to state fiscal resources and long-term care supply regulation.

BACKGROUND: The number of dementia patients will increase over the next decades. However, we lack information on the geographic distribution of these patients. We aimed to describe the variation of dementia prevalence and to then compare the observed to expected prevalence. METHODS: This study is based on a 20% sample of Medicare beneficiaries in 2008. The crude dementia prevalence was calculated and age/sex standardized to the US population for states. We used the World Alzheimer Report 2009 prevalence to compare estimates. RESULTS: 4.8 million persons were included. The adjusted prevalence is 8.24%, varying from 5.96 to 9.55% across states. The diagnosed prevalence is lower than the expected in most states. Overall, we estimate over 100 000 undiagnosed dementia patients in Medicare. CONCLUSIONS: The high state variation suggests that the number of diagnosed dementia cases does not fall evenly across all states and hence may require different levels of state-level planning.