Time trends and regional variation in utilization of antidiabetic medicines in China, 2015-2022

AIM

To assess the use of non-insulin antidiabetic medicines in China.

MATERIALS AND METHODS

We analysed the national procurement data for 29 non-insulin antidiabetic medicines from nine subgroups in China from 2015 to 2022. We estimated the number of defined daily doses (DDDs) procured per year in seven regions of China for nine subgroups and adjusted the data by the number of patients with diabetes. For each subgroup, the regional ratio was calculated by comparing the procurement per patient in each region with the procurement nationwide. The regional disparity was the difference between the highest and lowest regional ratios. We compared the medication patterns across regions.

RESULTS

Nationally, between 2015 and 2022, the number of DDDs per patient increased from 14.45 to 47.37. The two most commonly used categories were sulphonylurea and biguanides, which increased from 7.04 to 15.39 (119%) and 3.28 to 11.11 (239%) DDDs per patient, respectively. The procurement of new drugs (dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter type 2 inhibitors and glucagon-like peptide-1 receptor agonists) increased quickly and had >5000% relative changes. Particularly for sodium-glucose cotransporter type 2 inhibitors, it increased from 0.08 to 5.03 DDDs (6662%). The southwest region had the highest relative change (319%), while the southern region had the lowest (118%). Biguanide and thiazolidinediones had the lowest (1.19) and highest level (2.21) of regional disparity in 2022, respectively.

CONCLUSION

The procurement of non-insulin antidiabetic medicines in China has increased a lot from 2015 to 2022. In terms of DDDs per patient, sulphonylurea ranked first, followed by metformin. The procurement of new drugs increased greatly. A large regional disparity existed in medicine usage and patterns.

Regional Variation of Infectious Agents Causing Inpatient Endogenous Endophthalmitis in the US: A National Analysis

OBJECTIVE

To describe regional variation in microbes causing infectious endogenous endophthalmitis (EE) in the US.

DESIGN

This is a retrospective, national database analysis utilizing the 2002-2014 National Inpatient Sample (NIS) database.

SUBJECTS, PARTICIPANTS, AND/OR CONTROLS

Using the International Classification of Disease 9 (ICD-9) codes, we identified cases with EE. Cases were stratified regionally into Northeast, South, West, or Midwest.

METHODS

Unadjusted chi-square analysis followed by adjusted multivariate logistic regression was performed to evaluate variation in demographic factors, comorbidities using the Elixhauser Comorbidity Index (ECI), microbial variation, mortality, and use of vitrectomy or enucleation by region.

MAIN OUTCOME MEASURES

Proportion of microbes, mortality, and vitrectomy by region in addition to factors with significant odds ratios for mortality and for in-hospital vitrectomy.

RESULTS

A total of 10,912 patients with infectious EE were identified, with 2,063 cases in the Northeast (18.9%), 2,145 cases in the Midwest (19.7%), 4,134 cases in the South (37.9%), and 2,570 cases in the West (23.6%). Chi-square analysis indicated significant regional variation in patient demographics, microbes causing the infection, Elixhauser Comorbidity Index, mortality, and surgical intervention. The four most common microbes for all regions were methicillin-sensitive Staphylococcus aureus (MSSA), Streptococcus, Candida, and methicillin-resistant Staphylococcus aureus. MSSA was the most common cause of EE in all regions, though the proportion of MSSA infection did not significantly vary by region (p=0.027). Further, there was significant regional variation in the proportion of other microbes causing the infection (p<0.001). Higher rates of vitrectomies were seen in the South and Midwest regions compared to the Northeast and West (p=0.041).

CONCLUSIONS

Regional variation exists in the infectious microbes causing EE. Further studies are needed to elucidate the etiology of these variations.

Regional factors associated with pneumococcal vaccination coverage among U.S. adults with underlying chronic or immunocompromising conditions

The Centers for Disease Control recommends pneumococcal vaccination for U.S. adults aged 19-64 years with chronic or immunocompromising conditions, however, vaccination coverage is low and regional variations in coverage are rarely studied. This study examined pneumococcal vaccination coverage at the metropolitan statistical area (MSAs) level and identified regional factors associated with pneumococcal vaccination using the combined IBM® Watson Health MarketScan® Commercial and Medicare Supplemental databases. Pneumococcal vaccination coverage, clinical and socioeconomic factors were calculated for each MSA. Ordinary least square and spatial regression models were used to examine factors associated with vaccination. Results indicated that the national pneumococcal vaccination coverage was 13.4% with a large variation across MSAs (0-34%). The spatial error model, model with the best fit, showed that proportions of the population who were ≥50 years of age, received an influenza vaccine, or had health maintenance organization health plans were positively associated with pneumococcal vaccination coverage. In summary, we found that national pneumococcal vaccination coverage was low and there was substantial variation across MSAs. Regional factors identified may help inform interventions to improve pneumococcal vaccination coverage across geographies.

Factors influencing the likelihood of dental service checkup: results from a survey in Saudi Arabia

Background

The funding and delivery of healthcare including dental care in the Kingdom of Saudi Arabia (KSA, or Saudi Arabia) is undergoing a process of reform. To inform this process, it is important that policymakers are aware of the relationships between service use, specific types of use, and the factors that influence this. Currently, there is a paucity of research in this area in KSA that examines dental service use for checkups at a national level and none that examines differences in this use across regions or that examines explicitly the role of income.

Aims

This study uses the most recent version of the Saudi Health Interview Survey (SHIS) to examine the relationships between the use of dental services for a checkup and socio-demographic characteristics of respondents. Particular focus is given to the differences between regions in service use and the role of socio-demographics within regions.

Methods

Data were taken from SHIS 2013. Descriptive statistics (means and standard errors) were used to characterize the sample. Logistic regression analyses were used to examine the relationship between checkups in the past 12 months and a range of covariates including income and region. The analysis was repeated for sub-samples based on specific regions. No attempt was made to impute missing values.

Results

A sample of 7603 respondents provided complete data for analysis. Fifty-one per cent of the respondents were male, 29% were educated at least to degree level, 25% reported that they floss at least once per day, 69% reported that they brushed their teeth at least once per day, and 11% reported that they had visited the dentist for a checkup in the preceding 12 months. Logistic regression analyses revealed income, region, and oral hygiene habits to be among the significant determinants of the likelihood of dental checkup in the preceding 12 months. In logistic regression analyses at the regional level, different relationships were evident between checkups and socio-demographic characteristics across regions.

Conclusion

Region and income are significant determinants of dental service use for checkups. Differences exist between regions in the relationship between socio-demographic characteristics and the likelihood of getting checkups. Policy changes should reflect the potential differences they might have across regions for which the role of socio-demographic characteristics varies.

Virulence Dynamics of the Barley Leaf Rust Pathogen (Puccinia hordei) in the United States from 1989 to 2020

Barley leaf rust, caused by Puccinia hordei, is an important disease of barley worldwide. The pathogen can develop new races that overcome resistance genes, emphasizing the need for monitoring its virulence. This study characterized 519 P. hordei isolates collected in the United States from the 1989 to 2000 and 2010 to 2020 survey periods on 15 Rph (Reaction to Puccinia hordei) genes. We analyzed linearized infection type data to detect virulence patterns across the United States and in five geographical regions: Pacific/West (PW), Southwest (SW), Midwest (MW), Northeast (NE), and Southeast (SE). Over 32 years, we observed high mean infection scores for Rph1.a, Rph4.d, and Rph8.h; intermediate scores for Rph2.b, Rph9.i, Rph10.o, Rph11.p, and Rph13.x; and low scores for Rph3.c, Rph5.e, Rph5.f, Rph7.g, Rph9.z, Rph14.ab, and Rph15.ad. Virulence for Rph2.b, Rph3.c, Rph5.e, Rph9.z, Rph10.o, Rph11.p, and Rph13.x significantly differed between the two survey periods. From 1989 to 2020, regional patterns of virulence were found for Rph5.e, Rph5.f, Rph7.g, and Rph14.ab, while regionalities of virulence for Rph3.c, Rph9.i, Rph9.z were only observed in the 2010 to 2020 survey period. Virulence associations were also detected in the P. hordei population. Notably, isolates that were virulent to Rph5.e and Rph6.f were more likely to be avirulent to Rph7.g and Rph13.x, and vice versa. In decreasing order of effectiveness, Rph15.ad, Rph5.e, Rph3.c, Rph9.z, Rph7.g, Rph5.f, and Rph14.ab were the most effective Rph genes in the United States from 1989 to 2020. Pyramiding Rph15.ad with other widely effective Rph and adult plant resistance genes may provide long-lasting resistance against P. hordei.

Regional Variation in Pulmonary Arterial Hypertension in the United States: The Pulmonary Hypertension Association Registry

Rationale: Pulmonary arterial hypertension (PAH) is a heterogeneous disease within a complex diagnostic and treatment environment. Other complex heart and lung diseases have substantial regional variation in characteristics and outcomes; however, this has not been previously described in PAH. Objectives: To identify baseline differences between U.S. census regions in the characteristics and outcomes for participants in the Pulmonary Hypertension Association Registry (PHAR). Methods: Adults with PAH were divided into regional groups (Northeast, South, Midwest, and West), and baseline differences between census regions were presented. Kaplan-Meier survival analyses and Cox proportional hazards were used to estimate the association between region and mortality in unadjusted and adjusted models. Results: Substantial differences by census regions were seen in age, race, ethnicity, marital status, employment, insurance payor breakdown, active smoking, and current alcohol use. Differences were also seen in PAH etiology and baseline 6-minute walk distance test results. Treatment characteristics varied by census region, and mortality appeared to be lower in PHAR participants in the West (hazard ratio, 0.60; 95% confidence interval, 0.43-0.83, P = 0.005). This difference was not readily explained by differences in demographic characteristics, PAH etiology, baseline severity, baseline medication regimen, or disease prevalence. Conclusions: The present study suggests significant regional variation among participants at accredited pulmonary vascular disease centers in multiple baseline characteristics and mortality. This variation may have implications for clinical research planning and represent an important focus for further study to better understand whether there are remediable care aspects that can be addressed in the pursuit of providing equitable care in the United States.

Sociophonetic Variation in Vowel Categorization of Australian English

This study involves a perceptual categorization task for Australian English, designed to investigate regional and social variation in category boundaries between close-front vowel contrasts. Data are from four locations in southeast Australia. A total of 81 listeners from two listener groups took part: (a) so-called mainstream Australian English listeners from all four locations, and (b) L1 Aboriginal English listeners from one of the locations. Listeners heard front vowels /ɪ e æ/ arranged in 7-step continua presented at random. Varied phonetic contexts were analyzed, with a focus on coda /l/ because of a well-known prelateral merger of /e æ/ through mid-vowel lowering (e.g., celery-salary) reported to occur in some communities in this part of Australia. The results indicate that regional variation in Australian English is evident in perception. In particular, merging of /el/-/æl/ is shown to occur in the southernmost regions analyzed, but rarely in the northern regions of the geographical area under investigation. Aside from regional variation observed, age was also a factor in how participants responded to the task: older speakers had more merger than younger speakers in many locations, which is a new finding-previously, the merger was thought to be increasing in frequency over time, yet here we see this in only one location. Aboriginal English listeners also responded differently when compared with mainstream Australian English listeners. By analyzing the perception results across a variety of regional locations, with data from two different Australian social groups in the same location, this study adds a new dimension to our understanding of regional and social variations in Australian English.

Life-history characteristics and historical factors are important to explain regional variation in reproductive traits and genetic diversity in perennial mosses

BACKGROUND AND AIMS

Plants have evolved an unrivalled diversity of reproductive strategies, including variation in the degree of sexual vs. clonal reproduction. This variation has important effects on the dynamics and genetic structure of populations. We examined the association between large-scale variation in reproductive patterns and intraspecific genetic diversity in two moss species where sex is manifested in the dominant haploid generation and sex expression is irregular. We predicted that in regions with more frequent realized sexual reproduction, populations should display less skewed sex ratios, should more often express sex and should have higher genetic diversity than in regions with largely clonal reproduction.

METHODS

We assessed reproductive status and phenotypic sex in the dioicous long-lived Drepanocladus trifarius and D. turgescens, in 248 and 438 samples across two regions in Scandinavia with frequent or rare realized sexual reproduction, respectively. In subsets of the samples, we analysed genetic diversity using nuclear and plastid sequence information and identified sex with a sex-specific molecular marker in non-reproductive samples.

KEY RESULTS

Contrary to our predictions, sex ratios did not differ between regions; genetic diversity did not differ in D. trifarius and it was higher in the region with rare sexual reproduction in D. turgescens. Supporting our predictions, relatively more samples expressed sex in D. trifarius in the region with frequent sexual reproduction. Overall, samples were mostly female. The degree of sex expression and genetic diversity differed between sexes.

CONCLUSIONS

Sex expression levels, regional sex ratios and genetic diversity were not directly associated with the regional frequency of realized sexual reproduction, and relationships and variation patterns differed between species. We conclude that a combination of species-specific life histories, such as longevity, overall degree of successful sexual reproduction and recruitment, and historical factors are important to explain this variation. Our data on haploid-dominated plants significantly complement plant reproductive biology.

Increased Oxygen Saturation in Retinal Venules During Isometric Exercise Is Accompanied With Increased Peripheral Blood Flow in Normal Persons

Purpose

A recent study has shown that an increase in the arterial blood pressure of approximately 10 mm Hg in healthy persons can increase the oxygen saturation in venules from the retinal periphery but not from the macular area. The purpose of the present study was to investigate whether a higher increase in blood pressure has further effects on oxygen saturations and whether this is accompanied with changes in retinal blood flow.

Methods

In 30 healthy persons, oxygen saturation, diameter, and blood flow were measured in arterioles to and venules from the retinal periphery and the macular area. The experiments were performed before and during an experimental increase in arterial blood pressure of (mean ± SD) 18.3 ± 6.2 mm Hg.

Results

A higher number of venules than arterioles branching from the temporal vascular arcades to the macular area was balanced by a smaller diameter of the venules. Isometric exercise induced significant contraction of both peripheral and macular arterioles (P < 0.01 for both comparisons) and significant increase in oxygen saturation in both peripheral and macular venules (P < 0.001 for both comparisons). This was accompanied with a significant increase in the blood flow in the peripheral arterioles and venules (P = 0.4 for both comparisons), but not in their macular counterparts (P > 0.06 for both comparisons).

Conclusions

Increased systemic blood pressure leading to arterial contraction and increased venous oxygen saturation in the retina in normal persons can increase peripheral blood flow without significant effects on macular blood flow. This may contribute to explaining regional differences in the response pattern of retinal vascular disease.

Do regional labor market conditions matter for temporary work disability duration? A multilevel analysis of workers' compensation claims in five Canadian provinces

BACKGROUND

Research has shown how regionally varying labor market conditions are associated with differences in work disability duration. However, the majority of these studies have not used multilevel models to appropriately account for the hierarchical clustering of individuals nested within contextual units (e.g., regions). Studies that have used multilevel models have focused on privately insured workers or on disability not specifically caused by work-related injury or illness.

METHODS

Using claims data from five Canadian provincial workers' compensation systems, linear random-intercept models were used to estimate how much variance in temporary work disability duration ('work disability duration' for brevity) for work-related injuries and musculoskeletal disorders was due to differences between economic regions, what economic region-level labor market characteristics were associated with work disability duration, and what characteristics best explained economic region differences in work disability duration.

RESULTS

Economic region characteristics, such as the unemployment rate and proportion of goods-producing employment, were independently associated with individual-level work disability duration. However, economic region variation only accounted for 1.5%-2% of total variation in work disability duration. The majority (71%) of economic region-level variation was explained by the provincial jurisdiction where the worker lived and was injured. Regional variation tended to be greater for female workers than males.

CONCLUSIONS

The findings suggest that while regional labor market conditions matter for work disability duration, system-level differences in workers' compensation and health care are more important factors influencing work disability duration. Furthermore, while this study includes both temporary and permanent disability claims, the work disability duration measure only captures temporary disability.

One Size Fits All-Venomics of the Iberian Adder (Vipera seoanei, Lataste 1878) Reveals Low Levels of Venom Variation across Its Distributional Range

European vipers (genus Vipera) are medically important snakes displaying considerable venom variation, occurring at different levels in this group. The presence of intraspecific venom variation, however, remains understudied in several Vipera species. Vipera seoanei is a venomous snake endemic to the northern Iberian Peninsula and south-western France, presenting notable phenotypic variation and inhabiting several diverse habitats across its range. We analysed the venoms of 49 adult specimens of V. seoanei from 20 localities across the species' Iberian distribution. We used a pool of all individual venoms to generate a V. seoanei venom reference proteome, produced SDS-PAGE profiles of all venom samples, and visualised patterns of variation using NMDS. By applying linear regression, we then assessed presence and nature of venom variation between localities, and investigated the effect of 14 predictors (biological, eco-geographic, genetic) on its occurrence. The venom comprised at least 12 different toxin families, of which five (i.e., PLA2, svSP, DI, snaclec, svMP) accounted for about 75% of the whole proteome. The comparative analyses of the SDS-PAGE venom profiles showed them to be remarkably similar across the sampled localities, suggesting low geographic variability. The regression analyses suggested significant effects of biological and habitat predictors on the little variation we detected across the analysed V. seoanei venoms. Other factors were also significantly associated with the presence/absence of individual bands in the SDS-PAGE profiles. The low levels of venom variability we detected within V. seoanei might be the result of a recent population expansion, or of processes other than directional positive selection.

Corrigendum: Obtaining an animal welfare status in Norwegian dairy herds-a mountain to climb

[This corrects the article DOI: 10.3389/fvets.2023.1125860.].

Wide Geographic Variation in Resource Utilization after Shoulder Arthroplasty

Background

There is growing interest in optimizing cost and resource utilization after shoulder arthroplasty, but little data to guide improvement efforts.

Objective

The purpose of this study was to evaluate geographic variation in length of stay and home discharge disposition after shoulder arthroplasty across the United States.

Methods

The Centers for Medicare and Medicaid Services database was used to identify Medicare discharges following shoulder arthroplasties performed from April 2019 through March 2020. National, regional (Northeast, Midwest, South, West), and state-level variation in length of stay and home discharge disposition rates were examined. The degree of variation was assessed using the coefficient of variation, with a value greater than 0.15 being considered as "substantial" variation. Geographic maps were created for visual representation of the data.

Results

There was substantial state-level variation in home discharge disposition rates (64% in Connecticut to 96% in West Virginia) and length of stay (1.01 days in Delaware to 1.86 days in Kansas). There was wide regional variation in length of stay (1.35 days in the West to 1.50 days in the Northeast) and home discharge disposition rates (73% in the Northeast to 85% in the West).

Conclusions

There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. This study provides important information for the implementation of targeted strategies to effectively reduce geographic variation in healthcare resource utilization.

Variation in the use of compulsory community treatment orders between district health boards in New Zealand

OBJECTIVE

To report rates of Compulsory Community Treatment Order (CTO) use by District Health Boards (DHBs) in New Zealand and analyse whether socio-demographic factors explain any variability.

METHODS

The annualised rate of CTO use per 100,000 population was calculated for the years 2009-2018 using national databases. Rates were adjusted for age, gender, ethnicity, and deprivation and are reported according to DHBs to allow comparisons between regions.

RESULTS

The annualised rate of CTO use for New Zealand was 95.5 per 100,000 population. CTO use varied between DHBs from 53 to 184 per 100,000 population. Standardising for demographic variables and deprivation made little difference to this variation. CTO use was higher in males and young adults. Rates for Māori were more than three times that of Caucasian people. CTO use increased as deprivation became more severe.

CONCLUSIONS

CTO use increases with Maori ethnicity, young adulthood, and deprivation. Adjusting for socio-demographic factors does not explain the wide variation in CTO use between DHBs in New Zealand. Other regional factors appear to be the major driver of variation in CTO use.

Regional Variation in Outpatient Antibiotic Prescribing for Acute Respiratory Tract Infections in a Commercially Insured Population, United States, 2017

Background

Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population.

Methods

We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis.

Results

Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33-1.34).

Conclusions

It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing.

Obtaining an animal welfare status in Norwegian dairy herds-A mountain to climb

Introduction

Knowing the national status of animal welfare, one can identify welfare problems and set a benchmark against which improvements can be compared. Such a status is potentially invaluable for tangible, sustained animal welfare improvement. The objective of this cross-sectional study was to report the status of animal welfare in Norwegian loose-housed dairy herds as assessed using the Welfare Quality^® Assessment Protocol. Additionally, we investigated if the welfare status varied on a regional basis.

Methods

In total, 155 herds in eight of Norway's eleven counties were assessed by six trained Welfare Quality^® assessors. This article presents the herd prevalences of common welfare issues in dairy production in Norway, as well as integrated welfare scores. To determine whether welfare status varied regionally in Norway, generalized linear modeling was used to estimate the mean welfare score for five regions in the four Welfare Quality^® principles: A. Good feeding, B. Good housing, C. Good health, and D. Appropriate behavior. These estimated mean welfare scores and their 95% confidence intervals were subsequently assessed for significant variation.

Results

Encouraging findings included the low mean herd prevalence of 'very lean' cows (3.0%) and the high proportion of cows (59.8%) which could be touched during avoidance distance testing, indicating a positive relationship between stockpeople and their cattle. Challenges affecting the welfare of Norwegian dairy cows were also identified. Of particular concern were issues related to the cows' environment such as prolonged times needed to complete lying down movements and integument alterations. No herd was completely free of changes to the integument and, on average, 77.9% of each herd were affected either mildly or severely. Animal welfare did not appear to vary much between the five regions assessed. Our investigation revealed significant regional variation between two regions (Trøndelag and Vestlandet North) in only the Welfare Quality^® principle Good housing (p < 0.01).

Discussion

The almost complete absence of regional variation demonstrates that animal welfare status generally varies most at herd level. In conclusion, both welfare challenges and encouraging findings were identified in loose-housed Norwegian dairy herds. To improve animal welfare, herd-specific interventions are most likely to be effective in these herds.

Factors of regional variations in national cancer screening rates during the COVID-19 pandemic

Objectives

The objective of this study was to analyze factors of regional variation in national cancer screening rate in Korea using regional cancer screening rate data. In addition, during the COVID-19 pandemic in 2020, we tried to identify factors affecting cancer screening rate, including COVID-19 situation in the region.

Methods

Data provided by the National Health Insurance Service Center were used for the national cancer screening rate index data in 2020 in 229 regions. A correlation analysis was conducted to find correlation between national cancer screening rate and variation factors in the national cancer screening rate in the region to be analyzed. In addition, to confirm spatial dependence of the national cancer screening rate among regions, a global spatial autocorrelation (Global Moran's I) analysis was conducted.

Results

In the 2020 COVID-19 situation, variable factors affecting the national cancer screening rate among regions in Korea were the regional number of populations of cumulative COVID-19 confirmed cases, concern of damage caused by COVID-19 infection, income level, the proportion of the population graduating from middle school or lower, the average daily access time to general hospitals by car, and the average daily access time to hospitals and clinics by public transportation or walking.

Conclusions

Results of this study can be used to establish national digital health policies that reflect regional variation factors in situations such as the COVID-19 pandemic. It is believed that they can contribute to policies to promote community health in the future.

Regional variation of medical expenditures attributable to hypertension in China's middle-aged and elderly population

BACKGROUND

Hypertension is a prevalent and costly health condition in China. Little is known about variation of the inpatient and outpatient expenditures attributable to hypertension between prefecture-level administrative regions (PARs) and the drivers of such variation among China's middle-aged and elderly population.

METHODS

We obtain data from China Health and Retirement Longitudinal Survey between 2011 and 2015, panel tobit models were used in our study to estimate differences across 122 PARs. Expenditure variation was explained by the characteristics of individuals and regions, including measures of healthcare supply.

RESULTS

The cost of treatment for patients with hypertension varies greatly geographically, with the highest outpatient and inpatient costs being 77 and 102 times the lowest, respectively. After adjustment for the individual and PAR character, there are associations between expenditure and region bed density.

CONCLUSION

There were significant regional differences in the outpatient and inpatient costs of middle-aged and elderly patients with hypertension in China, the difference between individuals may be an important reason, which has little to do with regional economic development differences, but is related to regional bed density.

[Difference in soil water holding capacity and the influencing factors under different land use types in the alpine region of Tibet, China]

To investigate the variation of soil water holding capacity under different land use types can provide scientific basis for evaluating the change characteristics and regulation mechanism of water conservation capacity in alpine ecosystems. We collected soil samples at different depth intervals (0-10, 10-20 and 20-30 cm) under three land use types (farmland, forest, and grassland) in Tibet alpine region to measure the maximum water holding capacity, capillary water holding capacity, field capacity, and basic soil physicochemical properties. The associated environmental factors (mean annual precipitation, normalized difference vegetation index, altitude, slope gradient and surface roughness) were extracted to analyze the change characteristics and influencing factors of soil water holding capacity under different land use types. The results showed that soil water holding capacity (the maximum water holding capacity, capillary water holding capacity, and field capacity) of farmland, forest, and grassland all decreased with increasing soil depth. The mean values of the maximum water holding capacity, capillary water holding capacity, and field capacity in the 0-30 cm soil layer of grassland were 379.79, 329.57 and 194.39 g·kg^-1, respectively, which were significantly higher than that of farmland (301.15, 259.67, and 154.91 g·kg^-1) and forest (293.09, 251.49, and 117.01 g·kg^-1). Results of the redundancy analysis showed that soil properties significantly influenced soil water holding capacity, with explanation rate of 44.6%, 42.7%, 37.6% and 35.8% for total porosity, soil organic matter, capillary porosity and soil bulk density, respectively. Results of the principal component analysis showed that mean annual precipitation, normalized difference vegetation index, altitude, slope gradient, and surface roughness were the main environmental factors affecting the spatial variation of soil water holding capacity, with a cumulative contribution of 72.4%. The grassland in the alpine region of Tibet had the highest water holding capacity and could effectively prevent soil erosion. Therefore, the implementation of returning farmland to grassland and the enclosure management of degraded grassland would be conducive to improve soil water conservation capacity in the alpine regions.

Regional differences in utilization of 17α-hydroxyprogesterone caproate (17-OHP)

OBJECTIVES

To describe regional differences in utilization of 17α-hydroxyprogesterone caproate (17-OHP).

METHODS

Retrospective cohort study of a large, US commercial managed care plan claims database with pharmacy coverage from 2008 to 2018. Singleton pregnancies with at least one prior spontaneous preterm birth (sPTB) were included. Regional and state-based differences in 17-OHP use were compared. Data were analyzed using t-tests and Fisher's exact tests.

RESULTS

Of the 4,514 individuals with an indication for 17-OHP, 580 (12.8%) were prescribed 17-OHP. Regional and state-based differences in 17-OHP utilization were identified; Northeast 15.7%, Midwest 13.7%, South 12.0%, and West 10.4% (p=0.003).

CONCLUSIONS

While significant regional differences in 17-OHP utilization were demonstrated, 17-OHP utilization remained low despite this cohort having insurance through a US commercial managed care plan. Suboptimal utilization demonstrates a disconnect between research and uptake in clinical practice. This underscores a need for implementation science in obstetrics to translate updated recommendations more effectively and efficiently into clinical practice.

Strong variation in frequencies of male and female determiners between neighboring housefly populations

Sex-determination mechanisms evolve rapidly and vary between species. Occasionally, polymorphic systems are found, like in the housefly. Studying the dynamics and stability of such systems can provide a better understanding of the evolution of sex-determination systems. In the housefly, dominant male-determining loci (M) can lie not only on the Y chromosome (M^Y ), but also on autosomes (M^A ) or the X chromosome (M^X ). M enforces male development by inhibiting the female-determining gene transformer (tra). A mutant tra allele, tra^D , is insensitive to M and is a dominant female determiner. M^Y prevails at high latitudes and polymorphic M loci together with tra^D at low latitudes. To get more insight into the stability and frequencies of these sex determiners with mutually exclusive dominance, we investigated 5 regional Spanish populations. We found strong variation among populations. Two populations with hemizygous M^III were found, 2 contained homozygous M^X with additional hemizygous M^I and M^II in 1 population. One population contained homozygous and hemizygous M^X with additionally hemizygous M^II . All females in populations with homozygous M, had tra^D , whereas no tra^D was found in populations without homozygous M. Our results indicate locally stable systems may either harbor a single hemizygous M and no tra^D , corresponding to a male heterogametic system, or homozygous and/or multiple M and heterozygous tra^D , reminiscent of a female heterogametic system. They support that M loci can accumulate in the presence of a dominant female determiner. Limited migration between populations may contribute to the stability of these systems.

Regional variation in prescription drug spending: Evidence from regional migrants in Sweden

There is substantial variation in drug spending across regions in Sweden, which can be justified if caused by differences in health need, but an indication of inefficiencies if primarily caused by differences in place-specific supply-side factors. This paper aims to estimate the relative effect of individual demand-side factors and place-specific supply-side factors as drivers of geographical variation in drug spending in Sweden. We use individual-level register data on purchases of prescription drugs matched with demographic and socioeconomic data of a random sample of about 900,000 individuals over 2007-2016. The primary empirical approach is a two-way fixed effect model and an event study where we identify demand- and supply-side effects based on how regional and local migrants change drug spending when moving across regional and municipal borders. As an alternative approach in robustness checks, we also use a decomposition analysis. The results show that the place-specific supply-side effect accounts for only about 5%-10% of variation in drug spending and remaining variation is due to individual demand-side effects. These results imply that health policies to reduce regional variation in drug spending would have limited impact if targeted at place-specific characteristics.

Variation in the utilization of medical devices across Germany, Italy, and the Netherlands: A multilevel approach

Variation in healthcare utilization has been discussed extensively, with many studies showing that variation exists, but fewer studies investigating the underlying factors. In our study, we used a logistic multilevel-model at the patient, hospital, and regional levels to investigate (i) the levels to which variation could be attributed and (ii) the hospital and regional factors associated with treatment decisions. To do so, we used hospital discharge records for the years 2012-2016 in Germany and Italy and for 2014-2016 in the Netherlands combined with hospital and regional characteristics in nine case studies. We used a theoretical framework to categorize these case studies into effective, preference-sensitive, and supply-sensitive care. Our results suggest that most variation in the treatment decision can be attributed to the hospital level (e.g., case volume), whereas only a minor part is explained by regional characteristics. Italy had the highest share attributable to the regional level, whereas the Netherlands had the lowest. We observed less variation for procedures in the effective-care category compared to the preference- and supply-sensitive categories. Although our results were heterogeneous, we identified patterns in line with the theoretical framework for treatment categories, underlining the need to address variation differently depending on the category in question.

Periodic trends in geographical variation of prostate cancer incidence and mortality in Finland between 1985 and 2019

BACKGROUND

Evaluation of regional variation of prostate cancer (PCa) incidence and PCa-specific mortality is essential in the assessment of equity in a national healthcare system. We evaluated PCa incidence and PCa-specific mortality between different municipalities and hospital districts in Finland over 1985-2019.

MATERIAL AND METHODS

Men diagnosed with PCa in Finland from 1985 through 2019 were retrieved from Finnish Cancer Registry. Age-standardized PCa incidence and mortality rates were estimated by municipality and hospital district as well as municipality urbanization, education, and income level using hierarchical Bayesian modeling. Standard deviations (SD) of the regional rates were compared between periods from 1985-1989 to 2015-2019.

RESULTS

We identified 123,185 men diagnosed with any stage PCa between 1985 and 2019. SD of PCa incidence rate (per 100,000 person-years) showed that the total variation of PCa incidence between different municipalities was substantial and varied over time: from 22.2 (95% CI, 17.1-27.8) in 1985-1989 to 56.5 (95% CI, 49.8-64.5) in 2000-2004. The SD of PCa mortality rate between all municipalities was from 9.0 (95% CI, 6.6-11.8) in 2005-2009 to 2.4 (95% CI, 0.9-4.8) in 2015-2019. There was a trend toward a lower PCa-specific mortality rate in municipalities with higher education level.

DISCUSSION

Regional variation in the incidence rate of PCa became more evident after initiation of PSA testing in Finland, which indicates that early diagnostic practice (PSA testing) of PCa has been different in different parts of the country. Variation in the national PCa mortality rate was indeed recognizable, however, this variation diminished at the same time as the mortality rate declined in Finland. It seems that after the initiation period of PSA testing, PSA has equalized PCa mortality outcomes in Finland.

Understanding the Experience of Canadian Women Living with Ovarian Cancer through the Every Woman Study(TM)

The Every Woman StudyTM: Canadian Edition is the most comprehensive study to date exploring patient-reported experiences of ovarian cancer (OC) on a national scale. An online survey conducted in Fall 2020 included individuals diagnosed with OC in Canada, reporting responses from 557 women from 11 Canadian provinces/territories. Median age at diagnosis was 54 (11−80), 61% were diagnosed between 2016−2020, 59% were stage III/IV and all subtypes of OC were represented. Overall, 23% had a family history of OC, 75% had genetic testing and 19% reported having a BRCA1/2 mutation. Most (87%) had symptoms prior to diagnosis. A timely diagnosis of OC (≤3 months from first presentation with symptoms) was predicted by age (>50) or abdominal pain/persistent bloating as the primary symptom. Predictors of an acute diagnosis (<1 month) included region, ER/urgent care doctor as first healthcare provider or stage III/IV disease. Regional differences in genetic testing, treatments and clinical trial participation were also noted. Respondents cited substantial physical, emotional, practical and financial impacts of an OC diagnosis. Our national survey has revealed differences in the pathway to diagnosis and post-diagnostic care among Canadian women with OC, with region, initial healthcare provider, specific symptoms and age playing key roles. We have identified many opportunities to improve both clinical and supportive care of OC patients across the country.

Regional variation in post-operative mortality in New Zealand

Background

There is a growing body of evidence that access to best practice perioperative care varies within our population. In this study, we use national‐level data to begin to address gaps in our understanding of regional variation in post‐operative outcomes within New Zealand.

Methods

Using National Collections data, we examined all inpatient procedures in New Zealand public hospitals between 2005 and 2017 (859 171 acute, 2 276 986 elective/waiting list), and identified deaths within 30 days. We calculated crude and adjusted rates per 100 procedures for the 20 district health boards (DHBs), both for the total population and stratified by ethnicity (Māori/European). Odds ratios comparing the risk of post‐operative mortality between Māori and European patients were calculated using crude and adjusted Poisson regression models.

Results

We observed regional variations in post‐operative mortality outcomes. Māori, compared to European, patients experienced higher post‐operative mortality rates in several DHBs, with a trend to higher mortality in almost all DHBs. Regional variation in patterns of age, procedure, deprivation and comorbidity (in particular) largely drives regional variation in post‐operative mortality, although variation persists in some regions even after adjusting for these factors. Inequitable outcomes for Māori also persist in several regions despite adjustment for multiple factors, particularly in the elective setting.

Conclusions

The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors suggests that multiple regions require additional resource and support to improve outcomes. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region‐specific intervention.

Contextualizing National Policies Regulating Access to Low-Dose Aspirin in America and Europe Using the Full Report of a Transatlantic Patient Survey of Aspirin in Preventive Cardiology

Background Aspirin is widely administered to prevent cardiovascular disease (CVD). However, appropriate use of aspirin depends on patient understanding of its risks, benefits, and indications, especially where aspirin is available over the counter (OTC). Methods and Results We did a survey of patient-reported 10-year cardiovascular risk; aspirin therapy status; form of aspirin access (OTC versus prescription); and knowledge of the risks, benefits, and role of aspirin in CVD prevention. Consecutive adults aged ≥50 years with ≥1 cardiovascular risk factor attending outpatient clinics in America and Europe were recruited. We also systematically reviewed national policies regulating access to low-dose aspirin for CVD prevention. At each site, 150 responses were obtained (300 total). Mean±SD age was 65±10 years, 40% were women, and 41% were secondary prevention patients. More than half of the participants at both sites did not know (1) their own level of 10-year CVD risk, (2) the expected magnitude of reduction in CVD risk with aspirin, or (3) aspirin's bleeding risks. Only 62% of all participants reported that aspirin was routinely indicated for secondary prevention, whereas 47% believed it was routinely indicated for primary prevention (P=0.048). In America, 83.5% participants obtained aspirin OTC compared with 2.5% in Europe (P<0.001). Finally, our review of European national policies found only 2 countries where low-dose aspirin was available OTC. Conclusions Many patients have poor insight into their objectively calculated 10-year cardiovascular risk and do not know the risks, benefits, and role of aspirin in CVD prevention. Aspirin is mainly obtained OTC in America in contrast to Europe, where most countries restrict access to low-dose aspirin.

Regional variation in percutaneous absorption in in vitro human models: a systematic review

Percutaneous absorption is of importance given its role in topical medicaments, transdermal drug systems, and dermatotoxicology. Many factors influence percutaneous penetration, including anatomical region, although little is currently known regarding this parameter. Hence, the aim of this study was to summarize existing data on regional variation in percutaneous penetration in in vitro human models. PubMed, Embase, Web of Science, and US patent literature were explored, and relevant data collected. Eight eligible articles were identified, which together, explored 15 anatomical locations. Four investigations compared percutaneous penetration between scalp and abdominal skin, and all concluded that the former was more permeable. Within those four studies, 10 penetrants of varying physical/chemical properties were tested indicating that in those particular study conditions, anatomical location exerted a greater effect on percutaneous absorption than the physicochemical properties of the penetrants. In addition, torso area was less absorptive than scrotum in both studies in which these sites were compared. In conclusion, the scrotum and scalp appear to be highly susceptible to percutaneous absorption compared to other locations such as the abdomen. This is postulated to be largely due to the high density of hair follicles in these areas, enabling greater penetration via the appendageal pathway. However, there is a paucity of conclusive data regarding the penetrability of other anatomical locations. Investigations testing and ranking the susceptibility of different anatomical regions is of vital importance given the importance of (1) transdermal drug delivery and decontamination protocols and (2) understanding the underlying mechanisms and degree of these variances might aid our pharmacologic/toxicologic judgments.

Geographic Differences in Rates of Primary Total Knee Arthroplasty in Young and Older Adults: A Comparison of 3 US States

OBJECTIVE

Rates of total knee arthroplasty (TKA) among Medicare beneficiaries (adults aged ≥ 65 yrs) vary across the United States, with higher rates in the Midwest and West than in the South. It is not known if a similar variation is present among younger patients, or if findings in Medicare reflect selective postponement of TKA in some regions.

METHODS

Data on all primary TKA performed in adults aged ≥ 20 years in 3 states (Iowa, Utah, and Florida) in 2016 were obtained from state inpatient databases. Rates of TKA were computed based on population census data. Age-, sex-, and race-standardized rates were compared between Iowa and Florida, and between Utah and Florida, among adults aged 20-64 years and adults aged ≥ 65 years.

RESULTS

There were 10,074, 8954, and 43,908 primary TKAs in Iowa, Utah, and Florida, respectively. Standardized rates were higher in Iowa and Utah than in Florida among both adults aged 20-64 years (Iowa:Florida rate ratio [RR] 1.89, 95% CI 1.79-1.99; Utah:Florida RR 2.31, 95% CI 2.18-2.45) and those aged ≥ 65 years (Iowa:Florida RR 1.41, 95% CI 1.35-1.47; Utah:Florida RR 1.77, 95% CI 1.70-1.85). Results were similar in sensitivity analyses limited to White patients, urban residents, and those with a diagnosis of knee osteoarthritis.

CONCLUSION

TKA rates were higher in Iowa and Utah than in Florida among both younger adults and those aged ≥ 65 years, indicating that geographic differences are not specific to elderly patients.

Measuring the quality of dental care among privately insured children in the United States

OBJECTIVE

To examine whether quality of dental care varies by age and over time and whether community-level characteristics explain these patterns.

DATA SOURCE

Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019.

STUDY DESIGN

A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person- and zip code-level factors associated with the quality.

DATA COLLECTION/EXTRACTION METHODS

Continuously enrolled US dental insurance beneficiaries younger than 21 years of age.

PRINCIPAL FINDINGS

Quality was assessed for 4.88 million person-years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0-5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0-5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less-educated populations at the zip code level were associated with the composite score.

CONCLUSION

Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low-performing localities should be explored.

Variation in chemotherapy prescribing rates and mortality in early breast cancer over two decades: a national data linkage study

Background

Regional variation in clinical practice may identify differences in care, reveal inequity in access, and explain inequality in outcomes. The study aim was to measure geographical variation in Scotland for adjuvant chemotherapy use and mortality in early-stage breast cancer.

Patients and methods

In this retrospective cohort study using population cancer registry-based data linkage, patients with surgically treated early breast cancer between 2001 and 2018 were identified from the Scottish Cancer Registry. Geographical regions considered were based on NHS Scotland organisational structure including 14 territorial Health Boards as well as three regional Cancer Networks. Regional variation in the proportion receiving chemotherapy, breast cancer mortality and all-cause mortality was investigated. Inter-regional comparisons of chemotherapy use were adjusted for differences in case mix using logistic regression. Comparison of breast cancer-specific mortality and all-cause mortality used regression with a parametric survival model. Time trends were assessed using moving average plots.

Results

Chemotherapy use ranged from 35% to 46% of patients across Health Boards without adjustment. Variation reduced between 2001 and 2018. Following adjustment for clinical case mix, variation between cancer networks was within 3 percentage points, but up to 10 percentage points from the national average in some Health Boards. Differences in breast cancer mortality and all-cause mortality between cancer networks were modest, with hazard ratios of between 0.933 (95% confidence interval 0.893-0.975) and 1.041 (1.002-1.082) compared with the national average. Survival improved over the time period studied.

Conclusion

With adequate case mix adjustment, variation in adjuvant chemotherapy use for early breast cancer in Scotland is small, with a trend towards greater convergence in practice and improved mortality outcomes in more recent cohorts. This suggests very limited regional inequity in access and convergence of clinical practice towards risk-stratified treatment recommendations. Outliers require assessment to understand the reasons for variance.

•

A cohort study including the Scottish population of surgically treated early breast cancer patients from 2001 to 2018.

•

With adequate case mix adjustment, regional variation in adjuvant chemotherapy use was small, but with notable outliers.

•

Over time there was a trend towards greater convergence in practice towards risk-stratified treatment recommendations.

Remote Testing of the Familiar Word Effect With Non-dialectal and Dialectal German-Learning 1-2-Year-Olds

Variability is pervasive in spoken language, in particular if one is exposed to two varieties of the same language (e.g., the standard variety and a dialect). Unlike in bilingual settings, standard and dialectal forms are often phonologically related, increasing the variability in word forms (e.g., German Fuß "foot" is produced as [fus] in Standard German and as [fs] in the Alemannic dialect). We investigate whether dialectal variability in children's input affects their ability to recognize words in Standard German, testing non-dialectal vs. dialectal children. Non-dialectal children, who typically grow up in urban areas, mostly hear Standard German forms, and hence encounter little segmental variability in their input. Dialectal children in turn, who typically grow up in rural areas, hear both Standard German and dialectal forms, and are hence exposed to a large amount of variability in their input. We employ the familiar word paradigm for German children aged 12-18 months. Since dialectal children from rural areas are hard to recruit for laboratory studies, we programmed an App that allows all parents to test their children at home. Looking times to familiar vs. non-familiar words were analyzed using a semi-automatic procedure based on neural networks. Our results replicate the familiarity preference for non-dialectal German 12-18-month-old children (longer looking times to familiar words than vs. non-familiar words). Non-dialectal children in the same age range, on the other hand, showed a novelty preference. One explanation for the novelty preference in dialectal children may be more mature linguistic processing, caused by more variability of word forms in the input. This linguistic maturation hypothesis is addressed in Experiment 2, in which we tested older children (18-24-month-olds). These children, who are not exposed to dialectal forms, also showed a novelty preference. Taken together, our findings show that both dialectal and non-dialectal German children recognized the familiar Standard German word forms, but their looking pattern differed as a function of the variability in the input. Frequent exposure to both dialectal and Standard German word forms may hence have affected the nature of (prelexical and/or) lexical representations, leading to more mature processing capacities.

International, national and local trends in the spread of COVID-19: a geographic view of COVID-19 spread and the role to be played by coproduction

BACKGROUND

COVID-19, a respiratory disease caused by the SARS-CoV-2 virus, emerged in 2019 and led to a worldwide pandemic in 2020. The COVID-19 pandemic has been a massive natural experiment in the formation of mitigation strategies to prevent cases and to provide effective healthcare for those afflicted. Regional differences in the impact of the pandemic on morbidity and mortality have been driven by political and regional differences in the coproduction of public health and social policy. We explored the United States (US) experience of COVID-19 for trends and correlations with other nations and also at the national, regional, state and local levels.

OBJECTIVE

To identify geographic and temporal trends in the spread of COVID-19 in the United States.

METHODS

Population data on COVID-19 cases and mortality were acquired on a daily basis from multiple publicly available databases, including the New York Times and Johns Hopkins University. At each geographic level (national, state and county), geographic entities' reported cases were evaluated for correlations using linear least-squares methods to identify patterns of correlation in the cases independent of scale. We evaluated for two specific characteristics: (i) the nature of the curvature of the line linking across percentile scores, ranging from concave to convex and (ii) the area under this curve, indicating how effectively a selected region (nation, state and county) is linked to its entire containing unit (world, country and state). We used this approach to identify three distinct COVID behavior phenotypes, each of which consisted of a number of states in the USA.

RESULTS

We found that COVID activity in the USA follows a unique trend compared to other countries and that within the USA during the first year of the pandemic, three initial COVID phenotypes emerged: (i) the metropolitan outbreak (early outbreak phenotype); (ii) the regional outbreak (summer peak phenotype) and (iii) trans-regional outbreak (fall/winter peak phenotype), which, taken in sum, represent the overall USA national trend. Each phenotype has specific behavioral characteristics and is composed of a cluster of different states experiencing different conditions.

CONCLUSION

Our findings suggest a new opportunity for public health strategy in the pandemic, namely to apply targeted public health approaches to address the specific needs of each phenotype. In the future, we should create databases that capture key health and hardship data elements at the smallest geographic level possible and use these to track trends, predict the future and apply targeted coproduction approaches to more effectively and efficiently safeguard population health, economic vitality and social well-being.

Locum doctor use in English general practice: analysis of routinely collected workforce data 2017-2020

Background

Numbers of GP locums in the NHS have grown in recent years, yet evidence on the scale and scope of the locum workforce in general practice is sparse.

Aim

To identify characteristics, geographical patterns, and drivers of GP locum use.

Design and setting

Observational study of routine data from general practices in England.

Method

Descriptive analyses of national GP workforce data between December 2017 and September 2020 were conducted to determine the volume and geographical distribution of locum use and examine the characteristics of locums compared with other GP types. Locum full-time equivalent (FTE) was modelled using negative binomial regression and estimated incidence rate ratios (IRRs) for associations between outcome and characteristics of practices and population.

Results

In December 2019, total locum FTE was 1217.9 compared with 33 996.6 for total GP FTE. Locums represented 3.3% of total GP FTE, which was fewer than other GP types. Median locum age was 42 years (interquartile range [IQR] 36 to 51) FTE and the majority were UK qualified (660 of 1034 [63.8%] total locum FTE), were male (642.6 of 1178.9 [54.5%] total locum FTE), and had long-term employment (834.1 of 1127.9 [74.0%]) total locum FTE. Rurality (IRR 1.250 [95% CI = 1.095 to 1.428]), inadequate Care Quality Commission ratings (IRR 2.108 [95% CI = 1.370 to 3.246), and single-handed practice (IRR 4.611 [95% CI = 4.101 to 5.184) were strong predictors of locum use. There was substantial variation in locum use between regions.

Conclusion

GP locum use remained stable over time. Compared with other GPs, locums were younger male GPs, a substantial percentage of whom did not qualify in the UK, and those who served underperforming practices in rural areas. This is likely to reflect recruitment or high turnover challenges in these practices/areas and can provide a greater understanding of general practice workforce challenges in England.

Levels, Spatial Distribution, and Impact Factors of Heavy Metals in the Hair of Metropolitan Residents in China and Human Health Implications

Chronic exposure to low levels of heavy metals threatens human health. However, few studies evaluated the health effects and spatial distributions of chronic exposure to heavy metals in metropolitan residents throughout mainland China using unified sampling methods and evaluation indicators at the national level. Here, the concentrations and spatial distributions of heavy metals (As, Cd, Cr, Sb, Pb, and Hg) in the hair of 1202 metropolitan residents from mainland China were analyzed, and differences in age and sex were evaluated. Most target metals exhibited higher concentrations in the hair of residents from South Central China. Generally, male hair had higher As and Se concentrations, whereas female hair had higher Cd and Pb levels (p < 0.05). A significant pairwise correlation existed between most metals in hair, especially Cd-Pb (r = 0.638, p < 0.05). The Se/heavy metal molar ratio is used as an indicator to assess the detoxification ability. The results demonstrated that protecting metropolitan residents in South Central China from heavy metals in their daily life is crucial, particularly for Hg, Pb, and Cr with Se/(Hg, Pb, or Cr) molar ratios < 1. This is the first study to comprehensively consider the antagonistic effects of Se and heavy metals using the molar ratio of Se/heavy metals to evaluate health implications and propose health management policies for metropolitan residents in China.

Estimates of regional infectivity of COVID-19 in the United Kingdom following imposition of social distancing measures

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reproduction number has become an essential parameter for monitoring disease transmission across settings and guiding interventions. The UK published weekly estimates of the reproduction number in the UK starting in May 2020 which are formed from multiple independent estimates. In this paper, we describe methods used to estimate the time-varying SARS-CoV-2 reproduction number for the UK. We used multiple data sources and estimated a serial interval distribution from published studies. We describe regional variability and how estimates evolved during the early phases of the outbreak, until the relaxing of social distancing measures began to be introduced in early July. Our analysis is able to guide localized control and provides a longitudinal example of applying these methods over long timescales. This article is part of the theme issue 'Modelling that shaped the early COVID-19 pandemic response in the UK'.

Regional variations in prevalence and severity of autosomal dominant polycystic kidney disease in the United States

OBJECTIVES

To evaluate geographic variation in the prevalence of autosomal dominant polycystic kidney disease (ADPKD) in the US, including ADPKD at risk of rapid progression.

METHODS

Claims data from the IBM MarketScan Commercial and Medicare Supplemental databases (01/16/2016-12/31/2017) were used to estimate the 2017 annual and 2016-2017 two-year prevalence of diagnosed ADPKD and ADPKD at risk of rapid progression in the US overall, and stratified by census regions and states. Risk of rapid progression was identified based on either: hypertension <35 years, hematuria <30 years, albuminuria, stage 2 chronic kidney disease (CKD) <30 years, stage 3 CKD <50 years, and stage 4/5 CKD or kidney transplant <55 years.

RESULTS

Annual prevalence was estimated at 2.34 and two-year prevalence at 3.61 per 10,000 in the US. Across census regions, two-year prevalence per 10,000 was highest in the Northeast (4.14) and lowest in the West (3.35). Prevalence was significantly correlated with the proportion of individuals in urban areas (r = .34, one-sided p = .026). In 2017, 37.5% of patients were identified as being at risk for rapid progression, and this proportion was larger among patients in the South (42.1%, p < .001).

CONCLUSION

This estimate for ADPKD prevalence is consistent with previously reported national estimates, with regional variation suggesting that ADPKD might be under-diagnosed in rural areas with more limited access to care. More than one-third of ADPKD patients presented risk factors associated with rapid progression, highlighting the need for timely identification, as disease-modifying therapy may delay progression to end-stage renal disease.

Understanding Regional Variation in the Cost of Breast Cancer Screening Among Privately Insured Women in the United States

BACKGROUND

Breast cancer screening for women aged 40-49 years is prevalent and costly, with costs varying substantially across US regions. Newer approaches to mammography may improve cancer detection but also increase screening costs. We assessed factors associated with regional variation in screening costs.

METHODS

We used Blue Cross Blue Shield Axis, a large US commercial claims database accessed through secure portal, to assess regional variation in screening utilization and costs. We included screening mammography±digital breast tomosynthesis (DBT), screening ultrasound, diagnostic mammography±DBT, diagnostic ultrasound, magnetic resonance imaging and biopsy, and evaluated their utilization and costs. We assessed regional variation in annual per-screened-beneficiary costs and examined potential savings from reducing regional variation.

RESULTS

Of the 2,257,393 privately insured women, 41.2% received screening mammography in 2017 (range: 26.6%-54.2% across regions). Wide regional variation was found in the DBT proportion (0.7%-91.1%) and mean costs of DBT ($299; range: $113-714) and 2-dimensional (D) mammograms ($213; range: $107-471). In one-fourth of the regions, the mean DBT cost was lower than the mean 2D mammography cost in the full sample. Regional variation in the per-screened-beneficiary cost (mean: $353; range: $151-751) was mainly attributable to variation in the cost of DBT (accounting for 23.4% of regional variation) and 2D mammography (23.0%). Reducing regional variation by decreasing the highest values to the national mean was projected to save $79-335 million annually.

CONCLUSIONS

The mean mammogram cost for privately insured women ages 40-49 varies 7-fold across regions, driving substantial variation in breast cancer screening costs. Reducing this regional variation would substantially decrease the screening costs.

TB notification rates across parliamentary constituencies in India: a step towards data-driven political engagement

OBJECTIVE

National averages obscure geographic variation in program performance. We determined Parliamentary Constituency (PC)-wise estimates of TB notification to guide political engagement.

METHODS

We extracted district-level TB notification data from the 2018 annual TB report. We derived PC-level estimates by building a 'cross-walk' between districts and PCs using boundary shapefiles. We described the spatial distribution of the PC-wise estimates of Total Notification Rate and percentage of Private Sector Notification.

RESULTS

The median PC-wise Total Notification Rate was 126.24/100 000 (IQR: 94.86/100 000, 162.22/100 000). The median PC-wise Percentage Private Sector Notification was 18.03% (IQR: 9.56%, 26.84%). Only 16 (2.94%) PCs met the target of 50% private sector notification. Most of high notification rates in PCs were driven by high notification in public sector. There was geographic - both interstate and within state inter-PC - variation in the estimates of these indicators. The study identified some geographic patterns of notification - high positive outlier PCs with adjoining PCs in lower deciles of notification rates, intra-state differences in PC performance, and similarities in notification rates of adjoining PCs in different states.

CONCLUSION

In addition to regional inequality, the study identified geospatial patterns that can aid in the formulation of suitable interventions. These include decongestion of overburdened facilities by strengthening poorly performing units. The PCs with a high percentage Private Sector Notification can act as role models for neighbouring PCs to improve private sector engagement. MPs can play a crucial role in mobilising additional resources, creating awareness, and establishing inter-PC and inter-state collaboration to improve TB program performance.

External Validation of and Factors Associated with the Overuse Index: a Nationwide Population-Based Study from Taiwan

BACKGROUND

The Overuse Index (OI), previously called the Johns Hopkins Overuse Index, is developed and validated as a composite measure of systematic overuse/low-value care using United States claims data. However, no information is available concerning whether the external validation of the OI is sustained, especially for international application. Moreover, little is known about which supply and demand factors are associated with the OI.

OBJECTIVE

We used nationwide population-based data from Taiwan to externally validate the OI and to examine the association of regional healthcare resources and socioeconomic factors with the OI.

DESIGN AND PARTICIPANTS

We analyzed 1,994,636 beneficiaries randomly selected from all people enrolled in the Taiwan National Health Insurance in 2013.

MAIN MEASURES

The OI was calculated for 2013 to 2015 for each of 50 medical regions. Spearman correlation analysis was applied to examine the association of the OI with total medical costs per capita and mortality rate. Generalized estimating equation linear regression analysis was conducted to examine the association of regional healthcare resources (number of hospital beds per 1000 population, number of physicians per 1000 population, and proportion of primary care physicians [PCPs]) and socioeconomic factors (proportion of low-income people and proportion of population aged 20 and older without a high school diploma) with the OI.

RESULTS

Higher scores of the OI were associated with higher total medical costs per capita (ρ = 0.48, P < 0.001) and not associated with total mortality (ρ = - 0.01, P = 0.882). Higher proportions of PCPs and higher proportions of low-income people were associated with lower scores of the OI (β = - 0.022, P = 0.016 and β = - 0.224, P < 0.001, respectively).

CONCLUSIONS

Our study supported the external validation of the OI by demonstrating a similar association within a universal healthcare system, and it showed the association of a higher proportion of PCPs and a higher proportion of low-income people with less overuse/low-value care.

Regional variation in the use of catheter ablation for patients with arrhythmia in Japan

BACKGROUND

Regional variation in the use of percutaneous coronary intervention (PCI), especially when performed as an elective procedure, was observed in a previous study. The use of a developing technology, catheter ablation (CA), was compared between regions in Japan.

METHODS AND RESULTS

The Diagnostic Procedure Combination data, which are publicly available, were used for the analysis. The number of CAs was summarized and the rates for CA and PCI were calculated based on the prefecture's population aged ≥40 years. A linear regression model was constructed to identify the factors associated with regional variation in the use of CA. The number of CAs performed per hospital consistently increased from 2009 to 2018. The mean rate of CA across Japan was 119 per 100 000 population aged ≥40 years in 2018. The highest CA rate was 166 per 100 000 and the lowest CA rate was 29 per 100 000 in 2018, while the highest and lowest PCI rates for angina per 100 000 were 361 and 88 in 2018, respectively. The significant factor associated with regional variation in the CA rate was the number of specialists.

CONCLUSIONS

A wide regional variation was observed in the use of CA for patients with arrhythmia in Japan. Further research is needed to generate evidence of CA for decision-making as a treatment option and to appropriately deploy this health service regardless of where patients live.

Improved prediction of Canada lynx distribution through regional model transferability and data efficiency

The application of species distribution models (SDMs) to areas outside of where a model was created allows informed decisions across large spatial scales, yet transferability remains a challenge in ecological modeling. We examined how regional variation in animal-environment relationships influenced model transferability for Canada lynx (Lynx canadensis), with an additional conservation aim of modeling lynx habitat across the northwestern United States. Simultaneously, we explored the effect of sample size from GPS data on SDM model performance and transferability. We used data from three geographically distinct Canada lynx populations in Washington (n = 17 individuals), Montana (n = 66), and Wyoming (n = 10) from 1996 to 2015. We assessed regional variation in lynx-environment relationships between these three populations using principal components analysis (PCA). We used ensemble modeling to develop SDMs for each population and all populations combined and assessed model prediction and transferability for each model scenario using withheld data and an extensive independent dataset (n = 650). Finally, we examined GPS data efficiency by testing models created with sample sizes of 5%-100% of the original datasets. PCA results indicated some differences in environmental characteristics between populations; models created from individual populations showed differential transferability based on the populations' similarity in PCA space. Despite population differences, a single model created from all populations performed as well, or better, than each individual population. Model performance was mostly insensitive to GPS sample size, with a plateau in predictive ability reached at ~30% of the total GPS dataset when initial sample size was large. Based on these results, we generated well-validated spatial predictions of Canada lynx distribution across a large portion of the species' southern range, with precipitation and temperature the primary environmental predictors in the model. We also demonstrated substantial redundancy in our large GPS dataset, with predictive performance insensitive to sample sizes above 30% of the original.

Using Crowd-Sourced Speech Data to Study Socially Constrained Variation in Nonmodal Phonation

This study examines the status of nonmodal phonation (e.g. breathy and creaky voice) in British English using smartphone recordings from over 2,500 speakers. With this novel data collection method, it uncovers effects that have not been reported in past work, such as a relationship between speakers’ education and their production of nonmodal phonation. The results also confirm that previous findings on nonmodal phonation, including the greater use of creaky voice by male speakers than female speakers, extend to a much larger and more diverse sample than has been considered previously. This confirmation supports the validity of using crowd-sourced data for phonetic analyses. The acoustic correlates that were examined include fundamental frequency, H1*-H2*, cepstral peak prominence, and harmonic-to-noise ratio.

Regional variations in adverse event reporting rates and ACR responses in placebo/standard-of-care arms of rheumatoid arthritis trials

Objective

Clinical trials are increasingly globalized, and adverse event (AE) rates and treatment responses may differ by geographical region. This study assessed regional differences in AE reporting rates and ACR response rates (ACR20/50) in patients with RA who received placebo/standard-of-care treatment in clinical trials.

Methods

Patients from the placebo arms of 7 RA trials in the TransCelerate Biopharma Inc database were grouped into 5 geographical regions (Asia, Latin America, Russian Federation and Eastern Europe [RFEE], USA, and Western Europe). Differences in demographics, AE reporting rates and ACR response were evaluated using descriptive statistics and omnibus tests for significance; pairwise comparisons were made between regions, with false discovery rate correction for multiple comparisons.

Results

Among 970 patients included, week 12 AE rates were significantly lower in the RFEE than in Asia, Latin America and the USA (22% vs 51%, 49% and 53%, respectively; P < 0.05 after false discovery rate correction). Similar differences in AE rates across geographical regions were seen at week 52. Among 747 patients with ACR data, the lowest response rates were observed in the USA (ACR20, 22%) and RFEE (ACR50, 3%); the highest response rates were seen in Western Europe (ACR20, 43%) and Latin America (ACR50, 15%). Only the differences in ACR50 response between the RFEE and Latin America remained significant after false discovery rate correction.

Conclusion

These placebo/standard-of-care arm data revealed significant regional differences in AE reporting rates and ACR50 response rates. Regional distribution of patients should be considered when conducting RA clinical trials, particularly during recruitment.

Regional factors associated with the prevalence of metabolic syndrome: Focusing on the role of healthcare providers

OBJECTIVES

Metabolic syndrome (MetS) is associated with an increased risk of cardiovascular disease, which is gradually becoming more prevalent due to changes in dietary habits and lifestyle. The aim of this study was to evaluate the association between regional factors and the prevalence of MetS, with a particular focus on access to healthcare providers.

STUDY DESIGN

Observational study.

METHODS

We used data from the annual Korea National Health and Nutrition Examination Survey (2013-2017), which included 24,695 eligible participants. Regional factors that were related to access to care and could affect the prevalence of MetS were evaluated. A generalised estimating equation model was utilised to identify variables associated with the prevalence of MetS.

MAIN FINDING

In this study, the prevalence of MetS was 25.9% (n = 7,100). Results of the generalised estimating equation model indicated that a higher density of physicians was significantly associated with a lower prevalence of MetS (odds ratio: 0.864, 95% confidence interval: 0.758-0.984). The density of community health nurses was not significantly associated with the prevalence of MetS; however, the subgroup analysis revealed that higher densities of physicians and community health nurses were significantly associated with a low prevalence of MetS in regions with a high proportion of community health centres.

CONCLUSIONS AND IMPLICATION

Regional factors related to access to care were associated with the prevalence of MetS. Higher physician density and community health centre utilisation rates were associated with a decreased prevalence of MetS. Regional differences in access to care should be addressed to reduce the health gap between regions and prevent the development of MetS.

Concerns for others increases the likelihood of vaccination against influenza and COVID-19 more in sparsely rather than densely populated areas

Vaccination yields the direct individual benefit of protecting recipients from infectious diseases and also the indirect social benefit of reducing the transmission of infections to others, often referred to as herd immunity This research examines how prosocial concern for vaccination, defined as people's preoccupation with infecting others if they do not vaccinate themselves, motivates vaccination in more and less populated regions of the United States. A nationally representative, longitudinal survey of 2,490 Americans showed that prosocial concern had a larger positive influence on vaccination against influenza in sparser regions, as judged by a region's nonmetropolitan status, lesser population density, and lower proportion of urban land area. Two experiments (total n = 800), one preregistered, provide causal evidence that drawing attention to prosocial (vs. individual) concerns interacted with social density to affect vaccination intentions. Specifically, prosocial concern led to stronger intentions to vaccinate against influenza and COVID-19 but only when social density was low (vs. high). Moderated mediation analyses show that, in low-density conditions, the benefits of inducing prosocial concern were due to greater perceived impact of one's vaccination on others. In this light, public health communications may reap more benefits from emphasizing the prosocial aspects of vaccination in sparser environments.

Prolonged Hospitalization Following Acute Respiratory Failure

BACKGROUND

A better understanding of the clinical features associated with prolonged hospitalization in acute respiratory failure may allow for better-informed care planning.

RESEARCH QUESTION

What are the incidence, mortality, cost, and clinical determinants of prolonged hospitalization among patients with acute respiratory failure (ARF)?

STUDY DESIGN AND METHODS

Using the National Inpatient Sample data from 2004 to 2014, we identified adults 18 years and older with International Classification of Diseases, 9th edition (ICD-9) codes for ARF requiring mechanical ventilation for at least 2 days (ICD-9 518.81 or 518.82, 96.7 or 96.04, and 96.05). Outcomes studied included incidence, in-hospital mortality, cost of hospitalization, and associated patient-level and hospital-level characteristics. Trends were assessed by logistic regression, linear regression, and general linear modeling with Poisson distribution.

RESULTS

Of the 5,539,567 patients with ARF, 77,665 (1.4%) had a prolonged length of stay (pLOS), defined as ≥ 60 days. Among those with pLOS, 52,776 (68%) survived to discharge. Over the study period, the incidence of pLOS decreased by 48%, in-patient mortality decreased by 18%, per-patient cost of care rose, but the percentage of the total cost of ARF care consumed by patients with pLOS did not significantly decrease (P = .06). Prolonged LOS was more likely to occur in urban teaching hospitals (OR, 6.8; 95% CI, 4.6-10.2; P < .001), hospitals located in the northeastern United States (OR, 3.6; 95% CI, 3.0-4.3; P < .001), and among patients with Medicaid insurance coverage (OR, 2.1; 95% CI, 1.9-2.4; P < .001).

INTERPRETATION

From 2004 to 2014, incidence and mortality decreased among patients with ARF and pLOS, and although per-patient costs rose, the percentage of total cost of care remained stable. There is substantial variation in length of stay for patients with ARF by US region, hospital teaching status, and patient insurance coverage.