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Objectives. To examine 47 years of US urban and rural mortality trends at the county level, controlling for effects of education, income, poverty, and race. Methods. We obtained (1) Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) data (1970–2016) on 104 million deaths; (2) US Census data on education, poverty, and race; and (3) Bureau of Economic Analysis data on income. We calculated ordinary least square regression models, including interaction models, for each year. We graphed standardized parameter estimates for 47 years. Results. Rural–urban mortality disparities increased from the mid-1980s through 2016. We found education, race, and rurality to be strong predictors; we found strong interactions between percentage poverty and percentage rural, indicating that the largest penalty was in high-poverty, rural counties. Conclusions. The rural–urban mortality disparity was persistent, growing, and large when compared to other place-based disparities. The penalty had evolved into a high-poverty, rural penalty that rivaled the effects of education and exceeded the effects of race by 2016. Public Health Implications. Targeting public health programs that focus on high-poverty, rural locales is a promising strategy for addressing disparities in mortality.

BACKGROUND: Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care. OBJECTIVE: To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control. DESIGN: Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017. PARTICIPANTS: Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010–2011. MAIN MEASURES: Census tract–level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure

Introduction: Hypertension and diabetes control are leading modifiable risk factors for cardiovascular disease (CVD) risk. Contemporary epidemiological research suggests that individual and health system characteristics are associated with control. Yet, there is little evidence examining how the neighborhood environment influences hypertension or diabetes control among patients engaged in primary care. Methods: We analyzed data of adult patients (n = 5,711) with hypertension or diabetes who received primary care at 1 of 3 clinics of a statewide health care organization in Baltimore, MD and lived within the Baltimore city limits. The neighborhood environment exposures were tertiles of neighborhood socioeconomic status (SES), crime, and healthy food availability index (HFAI) assessed at the census tract level. Separate multivariate logistic regression models were constructed to estimate the odds ratio (OR) for each of these neighborhood environment characteristics and hypertension and diabetes control, adjusting for patient demographics, and health behaviors; and for physician demographic characteristics. Results: The overall mean age was 57.8 ± 14.3 years, 67.2% were female, and 89.6% were Black. There were 5,325 patients with hypertension and 2,094 patients with diabetes (not mutually exclusive). In bivariate analyses, high neighborhood SES (p= 0.030) and low crime (p= 0.006) were associated with hypertension control, and none of the neighborhood exposures were associated with diabetes control. In fully adjusted analyses, being Black was significantly associated with decreased odds of hypertension control in all models (OR range: 0.63 – 0.65), independent of neighborhood exposures. Among those with hypertension, living in a low or moderate SES neighborhood or a high crime neighborhood was associated with lower odds of hypertension control; however, these associations were attenuated in adjusted models. None of the neighborhood exposures were significantly associated with odds of diabetes control in models that adjusted for patient characteristics. Yet, compared to high SES neighborhoods, living in a low or moderate SES neighborhood (OR=0.74, 95% CI: 0.57 - 0.97 and OR=0.75, 95% CI: 0.57 - 0.98, respectively) was associated with reduced diabetes control after adjusting for both patient and physician characteristics. Conclusion: Exposure to neighborhood disadvantage may contribute to poor diabetes and hypertension control among patients in primary care, independent of patient and physician characteristics. Patient-centered risk assessments including measures of social need and preventive interventions adapted to neighborhood environments could be useful for optimizing hypertension and diabetes control in clinical settings.

Item does not contain fulltext OBJECTIVE: To investigate the association between individual and area-level socioeconomic status and hypertension risk among individuals later in life. METHODS: We used Cox proportional hazards models to examine the association of socioeconomic status with incident hypertension using race-specific neighborhood socioeconomic status, median household income, and education among 3372 participants (mean age, 61 years) from the Atherosclerosis Risk in Communities Study at Visit 4 (1996-1998). Incident hypertension was defined as self-reported diagnosis or reported use of antihypertensive medications. RESULTS: Over a median follow-up time of 9.4 years, there were 1874 new cases of hypertension (62.1 per 1000 person-years). Overall, being in high as compared with low socioeconomic status categories was associated with a lower risk of developing hypertension in late life, with hazard ratios (95% confidence intervals) of 0.87 (0.77-0.98) for high neighborhood socioeconomic status tertile, 0.79 (0.69-0.90) for high individual income, and 0.75 (0.63-0.89) for college education after adjustment for traditional risk factors. These findings were consistent and robust whenever accounting for competing risks of all-cause mortality. No significant interactions by race and age (dichotomized at age 65) were observed. CONCLUSION: Among participants free of hypertension in midlife, high neighborhood and individual socioeconomic status are associated with a decreased risk of incident hypertension. Our findings support population-level interventions, such as blood pressure screening at senior centers and faith-based organizations, that are tailored to shift the distribution of blood pressure and reduce hypertension health inequalities among older adults.

OBJECTIVE:To evaluate the economic benefit of prophylactic negative pressure wound therapy on a closed laparotomy incision after cesarean delivery in comparison with standard postoperative dressing.METHODS:We designed a decision-analytic model from a third-party payer's perspective to determine the

As black women over age 50 represent a growing share of women living with HIV, understanding what helps them persist and engage in ongoing HIV care will become increasingly important. Delineating the specific roles of social support and stigma on HIV care experiences among this population remains unclear. We qualitatively examined how experiences with stigma and social support either facilitated or inhibited engagement in HIV care, from the perspective of older black women. Semi-structured interviews were conducted with 20 older black women currently receiving HIV care at primary care clinics in the Metropolitan Boston area. Women expressed that experiences with stigma and seeking support played an important role in evaluating the risks and benefits of engaging in care. Social support facilitated their ability to engage in care, while stigma interfered with their ability to engage in care throughout the course of their illness. Providers in particular, can facilitate engagement by understanding the changes in these women's lives as they struggle with stigma and disclosure while engaging in HIV care. The patient's experiences with social support and stigma and their perceptions about engagement are important considerations for medical teams to tailor efforts to engage older black women in regular HIV care.

Introduction: Individual and area-level socioeconomic status (SES) are associated with hypertension incidence and blood pressure changes in midlife. However, examination of the relationship between SES and late-life hypertension incidence are limited. Methods: ARIC Study participants free of hypertension at visit 4 (1996-1998) were followed by annual and semi-annual calls through December 31, 2013 for incidence of hypertension, defined as a self-reported diagnosis or use of antihypertensive medications. Individual and neighborhood SES indicators were assessed at study baseline (using criteria listed in the Table). Among individuals with follow-up and complete data (N=3,374) associations were examined using Cox regression models. Results: Among men and women with a median baseline blood pressure of 118/68 mg Hg, mean age was 61 years (SD ± 5.5), 45% were female, 12% were Black, and 21.7% had an annual household income of Conclusion: Both neighborhood and individual SES are related to late life incidence of hypertension, at least among Whites. Understanding the mechanisms, such as the role of access to care, for these associations can guide prevention strategies.

People with disabilities (PWD) are more likely than those without disabilities to experience barriers when accessing healthcare, often leading to unmet needs. The chasm between what providers perceive as adequate care for PWD and the actual health care needs as perceived by PWD remains significant. Using data from 360 health care providers and 540 Medicaid eligible PWD, we compared perceived barriers to care faced by PWD from the perspective of both providers and PWD. Our results indicated major variations in provider and PWD perceptions about barriers to care. PWD and providers both perceived transportation issues as the highest ranked barriers and physical access issues as the lowest ranked barriers. Multivariate results indicated that PWD reported barriers when communicating with providers, although providers did not consider communication as a major barrier. Among PWD, those with multiple types of disabilities were more likely to experience barriers when communicating with providers compared with other PWD. In addition, providers considered insurance a barrier to care, although this was not the perception of PWD. Particularly in the era of health care reform, policy responses to these findings should address the specific needs of people with different types of disabling conditions rather than assuming all PWD face similar challenges in accessing and utilizing health care.

Objective To evaluate whether the use of placental alpha-microglobulin-1 (PAMG-1) for the diagnosis of preterm premature rupture of membranes is cost-effective in resource-limited settings. Methods We designed a decision-analytic model from a third-party payer's perspective to determine the cost-effectiveness of the PAMG-1 test compared with the traditional diagnostic test of pooling, Nitrazine, and ferning in diagnosing preterm premature rupture of membranes in a resource-limited setting. The primary health outcome of interest is the number of hospital transfers averted by each strategy per 1,000 patients screened. Baseline probabilities and cost assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2015 U.S. dollars. Results Under our baseline parameters, the use of a PAMG-1 test was the preferred cost-effective strategy. The PAMG-1 test averted hospital transfers of 447 true-negative patients per 1,000 tested at a cost of $143,407 ($320.82 per hospital transfer averted). The traditional test averted hospital transfers of 395 true-negative patients per 1,000 tested at a cost of $172,652 ($437.40 per hospital transfer averted). In a Monte Carlo simulation of 10 million trials, the PAMG-1 test was selected as the most cost-effective strategy with a frequency of 74%. The traditional test was only selected with a frequency of 26%. The "do-nothing" strategy was not selected throughout the trial. Conclusion Among women presenting at resource-limited settings with a history suspicious of preterm premature rupture of membranes between 24 and 36 weeks of gestation, our analysis provides evidence suggesting that PAMG-1 is the most cost-effective testing strategy.

Despite the importance of continuous care, a large proportion of persons with HIV are not engaged or retained in care at any one time, leading to poor outcomes. Identifying the risk factors associated with lack of engagement and retention in HIV care is needed in order to target patients for interventions. While both engagement and retention in care have been studied using multiple measures, the observation period for the majority of studies is less than one year, few studies have examined both initial engagement and retention, and the effect of comorbidities has typically not been included. This study extends the literature by examining how comorbidities, in addition to demographics, HIV clinical indicators and transmission risk factors, were associated with engagement and retention in a cohort study of 485 HIV-infected persons seen for an initial HIV visit at an urban safety-net hospital. Using the electronic medical record, demographic, risk factor, health status and comorbidity data were gathered at the time of initial visits. To measure engagement and retention, appointment data were obtained for a 24-month period following the initial visit. Key findings were that unknown HIV transmission risk factor and being homeless at initial visit were associated with both lack of engagement and retention. Conversely being diagnosed with a psychiatric disorder was predictive of retention. Our findings have important implications for program structure, including the integration of care, as well as regarding key components to be addressed holistically in early clinic visits.

We sought to evaluate if the placental alpha-microglobulin (PAMG)-1 test vs the combined traditional diagnostic test (CTDT) of pooling, nitrazine, and ferning would be a cost-beneficial screening strategy in the setting of potential preterm premature rupture of membranes.A decision analysis model was used to estimate the economic impact of PAMG-1 test vs the CTDT on preterm delivery costs from a societal perspective. Our primary outcome was the annual net cost-benefit per person tested. Baseline probabilities and costs assumptions were derived from published literature. We conducted sensitivity analyses using both deterministic and probabilistic models. Cost estimates reflect 2013 US dollars.Annual net benefit from PAMG-1 was $20,014 per person tested, while CTDT had a net benefit of $15,757 per person tested. If the probability of rupture is38%, PAMG-1 will be cost-beneficial with an annual net benefit of $16,000-37,000 per person tested, while CTDT will have an annual net benefit of $16,000-19,500 per person tested. If the probability of rupture is38%, CTDT is more cost-beneficial. Monte Carlo simulations of 1 million trials selected PAMG-1 as the optimal strategy with a frequency of 89%, while CTDT was only selected as the optimal strategy with a frequency of 11%. Sensitivity analyses were robust.Our cost-benefit analysis provides the economic evidence for the adoption of PAMG-1 in diagnosing preterm premature rupture of membranes in uncertain presentations and when CTDT is equivocal at 34 to37 weeks' gestation.