ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand clini... more ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand clinical telehealth for opioid use disorder (OUD).ObjectiveTo examine the association of the receipt of telehealth services and medications for OUD (MOUD) with fatal drug overdoses before and during the pandemic.Design, Setting, and ParticipantsThis cohort study used exploratory longitudinal data from 2 cohorts (prepandemic cohort: September 1, 2018, to February 29, 2020; pandemic cohort: September 1, 2019, to February 28, 2021) of Medicare Fee-for-Service beneficiaries aged 18 years or older initiating an episode of OUD-related care using Medicare Fee-for-Service data from the Centers for Medicare & Medicaid Services and National Death Index data from the Centers for Disease Control and Prevention. Data analysis was performed from September 19 to October 17, 2022.ExposuresPrepandemic vs pandemic cohort demographic, medical, substance use, and psychiatric characteristics.Main Outcomes and Mea...
ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand use o... more ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand use of telehealth for new and continued care, including provision of medications for opioid use disorder (MOUD).ObjectiveTo examine receipt of telehealth services, MOUD (methadone, buprenorphine, and extended-release [ER] naltrexone) receipt and retention, and medically treated overdose before and during the COVID-19 pandemic.Design, Setting, and ParticipantsThis exploratory longitudinal cohort study used data from the US Centers for Medicare & Medicaid Services from September 2018 to February 2021. Two cohorts (before COVID-19 pandemic from September 2018 to February 2020 and during COVID-19 pandemic from September 2019 to February 2021) of Medicare fee-for-service beneficiaries 18 years and older with an International Statistical Classification of Diseases, Tenth Revision, Clinical Modification OUD diagnosis.ExposuresPre–COVID-19 pandemic vs COVID-19 pandemic cohort demographic characterist...
Introduction: Opioid use disorder (OUD) has grown rapidly over the years and is a public health c... more Introduction: Opioid use disorder (OUD) has grown rapidly over the years and is a public health crisis in the U.S. Though OUD is widely studied, relatively little is known about OUD among older adults. The goal of this study is to gain a better understanding of OUD among older Medicare beneficiaries over time and across several sociodemographic dimensions. Methods: Data from the 2013-2018 Centers for Medicare & Medicaid Services Master Beneficiary Summary Files were analyzed in 2020 to examine trends in OUD prevalence among Fee-for-Service Medicare beneficiaries aged ≥65 years. Utilizing the overarching opioid use disorder flag, trends in OUD prevalence were examined for the following sociodemographic dimensions: age, sex, race/ethnicity, and dual eligibility status (i.e., enrolled in both Medicare and Medicaid owing to low income). Chi-square tests were used to compare OUD prevalence across groups. Results: Since 2013, estimated rates of OUD among older adults have increased >3-fold overall in the U.S. Estimated OUD is more prevalent among the "young-old" (i.e., ages 65-69 years) beneficiaries than other older adults, and dually eligible beneficiaries have consistently shared a heavier burden of OUD compared with Medicare-only beneficiaries. Regarding race/ethnicity, Blacks and American Indians/Alaskan Natives are more vulnerable to OUD than other groups. Conclusions: The descriptive trends between 2013 and 2018 indicate that estimated OUD prevalence has increased greatly over the study period in all sociodemographic subgroups of older adults, highlighting an urgent challenge for public health professionals and gerontologists.
Demographic Research a free, expedited, online journal of peer-reviewed research and commentary i... more Demographic Research a free, expedited, online journal of peer-reviewed research and commentary in the population sciences published by the
Research has shown that the prevalence of opioid use disorder (OUD) may rise substantially as soc... more Research has shown that the prevalence of opioid use disorder (OUD) may rise substantially as society ages, but this issue receives the least attention in the literature. To address this gap, this study utilizes county-level data from multiple data sources (1) to investigate whether social isolation is associated with OUD prevalence among older Medicare beneficiaries, (2) to examine whether and how residential stability moderates the association between social isolation and OUD prevalence in US counties, and (3) to determine if there are any differences in these associations between metropolitan and non-metropolitan counties. The results show that social isolation is a significant factor for county-level OUD prevalence, regardless of metropolitan status. In addition, counties with high residential stability have low prevalence of OUD among older adults and this association is stronger in metropolitan than in non-metropolitan counties. Nonetheless, high levels of residential stability reinforce the positive relationship between social isolation and OUD prevalence. As a result, when developing policies and interventions aimed at reducing OUD among older adults, place of residence must be taken into account.
Smoking during pregnancy is associated with poor health outcomes for both mother and child. Howev... more Smoking during pregnancy is associated with poor health outcomes for both mother and child. However, over half of women who smoke continue to smoke while they are pregnant. Previous studies on maternal smoking during pregnancy that have considered measures of residential context have been limited by their homogenous samples of women and their omission of important contextual factors. In this paper we focus on the association between county-level social capital and the odds of women smoking during pregnancy using a 100 percent sample in the US. Mothers living in nonmetropolitan counties were 5 percent more likely to smoke during pregnancy than their metropolitan counterparts. Nonetheless, social capital may moderate the negative impact of residence on smoking. Specifically, a one unit increase in social capital index was found to reduce 8 percent of the odds of smoking during pregnancy among those mothers living in nonmetropolitan counties.
Drawing from both the place stratification and ethnic enclave perspectives, we use multilevel mod... more Drawing from both the place stratification and ethnic enclave perspectives, we use multilevel modeling to investigate the relationships between women's race/ethnicity (i.e., non-Hispanic white, non-Hispanic black, Asian, and Hispanic) and maternal smoking during pregnancy; and examine if these relationships are moderated by racial segregation in the continental United States. The results show that increased interaction with whites is associated with increased probability of maternal smoking during pregnancy for Asian and Hispanic mothers. In addition, racial segregation moderates the relationships between race/ethnicity and maternal smoking. Specifically, living in a less racially segregated area is related to a lower probability of smoking during pregnancy for black women, but it could double and almost triple the probability of smoking for Asian women and Hispanic women, respectively. Our findings provide empirical evidence for both the place stratification and ethnic enclave perspectives.
BackgroundOpioid use disorder (OUD) among older adults (age ≥ 65) is a growing yet underexplored ... more BackgroundOpioid use disorder (OUD) among older adults (age ≥ 65) is a growing yet underexplored public health concern and previous research has mainly assumed that the spatial process underlying geographic patterns of population health outcomes is constant across space. This study is among the first to apply a local modeling perspective to examine the geographic disparity in county-level OUD rates among older Medicare beneficiaries and the spatial non-stationarity in the relationships between determinants and OUD rates.MethodsData are from a variety of national sources including the Centers for Medicare & Medicaid Services beneficiary-level data from 2020 aggregated to the county-level and county-equivalents, and the 2016–2020 American Community Survey (ACS) 5-year estimates for 3,108 contiguous US counties. We use multiscale geographically weighted regression to investigate three dimensions of spatial process, namely “level of influence” (the percentage of older Medicare beneficia...
Hospital-based emergency departments (EDs) are the gateway to hospital admissions for many Americ... more Hospital-based emergency departments (EDs) are the gateway to hospital admissions for many Americans. Approximately half of all US hospital admissions originate from EDs, and more than 3 in 4 are among Medicare beneficiaries. Recent literature has demonstrated nearly 2-fold variation in both physician- and hospital-level ED admission rates. We study geographic variation at the county level in ED admission rates among Medicare fee-for-service beneficiaries. Using the 100% population data from the Centers for Medicare & Medicaid Services (CMS), we analyzed beneficiaries continuously enrolled in Medicare fee-for-service Parts A and B who resided in the 50 states and the District of Columbia in 2012. The ED admission rate was aggregated to the county level. ED admission rates were adjusted with the CMS Hierarchical Condition Categories (HCC) risk score. The resulting HCC adjusted ED admission rate was mapped to display the variation by county. The average county HCC adjusted ED admissio...
These maps show the geographic variation of standardized per capita Medicare spending, in US doll... more These maps show the geographic variation of standardized per capita Medicare spending, in US dollars, for all covered services among Medicare fee-for-service beneficiaries with 6 or more chronic conditions, United States, 2014. The maps highlight the need for targeted chronic disease prevention programs and policies in areas with the highest levels of Medicare spending.
Beyond individual-level factors, researchers have adopted a spatial perspective to explore potent... more Beyond individual-level factors, researchers have adopted a spatial perspective to explore potentially modifiable environmental determinants of health. A spatial perspective can be integrated into health research by incorporating spatial data into studies or analysing georeferenced data. Given the rapid changes in data collection methods and the complex dynamics between individuals and environment, we argue that geographical information system (GIS) functions have shortcomings with respect to analytical capability and are limited when it comes to visualizing the temporal component in spatio-temporal data. In addition, we maintain that relatively little effort has been made to handle spatial heterogeneity. To that end, health researchers should be persuaded to better justify the theoretical meaning underlying the spatial matrix in analysis, while spatial data collectors, GIS specialists, spatial analysis methodologists and the different breeds of users should be encouraged to work together making health research move forward through addressing these issues.
BACKGROUND-Limited information is available about teenage pregnancy and childbearing in rural are... more BACKGROUND-Limited information is available about teenage pregnancy and childbearing in rural areas, even though approximately 20 percent of the nation's youth live in rural areas. Identifying whether there are differences in the teenage birth rate (TBR) across metropolitan and nonmetropolitan areas is important, because these differences may reflect modifiable ecologicallevel influences such as education, employment, laws, healthcare infrastructure, and policies that could potentially reduce the TBR. OBJECTIVES-The goals of this study are to investigate whether there are spatially varying relationships between the TBR and the independent variables, and if so, whether these associations differ between metropolitan and nonmetropolitan counties. METHODS-We explore the heterogeneity within metropolitan/nonmetropolitan county groups separately using geographically weighted regression (GWR), and investigate the difference between metropolitan/nonmetropolitan counties using spatial regime models with spatial errors. These analyses were applied to county-level data from the National Center for Health Statistics and the US Census Bureau. RESULTS-GWR results suggested that non-stationarity exists in the associations between TBR and determinants within metropolitan/nonmetropolitan groups. The spatial regime analysis indicated that the effect of socioeconomic disadvantage on TBR significantly varied by the metropolitan status of counties. CONCLUSIONS-While the spatially varying relationships between the TBR and independent variables were found within each metropolitan status of counties, only the magnitude of the impact of the socioeconomic disadvantage index is significantly stronger among metropolitan counties than nonmetropolitan counties. Our findings suggested that place-specific policies for the disadvantaged groups in a county could be implemented to reduce TBR in the US.
ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand clini... more ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand clinical telehealth for opioid use disorder (OUD).ObjectiveTo examine the association of the receipt of telehealth services and medications for OUD (MOUD) with fatal drug overdoses before and during the pandemic.Design, Setting, and ParticipantsThis cohort study used exploratory longitudinal data from 2 cohorts (prepandemic cohort: September 1, 2018, to February 29, 2020; pandemic cohort: September 1, 2019, to February 28, 2021) of Medicare Fee-for-Service beneficiaries aged 18 years or older initiating an episode of OUD-related care using Medicare Fee-for-Service data from the Centers for Medicare & Medicaid Services and National Death Index data from the Centers for Disease Control and Prevention. Data analysis was performed from September 19 to October 17, 2022.ExposuresPrepandemic vs pandemic cohort demographic, medical, substance use, and psychiatric characteristics.Main Outcomes and Mea...
ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand use o... more ImportanceFederal emergency authorities were invoked during the COVID-19 pandemic to expand use of telehealth for new and continued care, including provision of medications for opioid use disorder (MOUD).ObjectiveTo examine receipt of telehealth services, MOUD (methadone, buprenorphine, and extended-release [ER] naltrexone) receipt and retention, and medically treated overdose before and during the COVID-19 pandemic.Design, Setting, and ParticipantsThis exploratory longitudinal cohort study used data from the US Centers for Medicare & Medicaid Services from September 2018 to February 2021. Two cohorts (before COVID-19 pandemic from September 2018 to February 2020 and during COVID-19 pandemic from September 2019 to February 2021) of Medicare fee-for-service beneficiaries 18 years and older with an International Statistical Classification of Diseases, Tenth Revision, Clinical Modification OUD diagnosis.ExposuresPre–COVID-19 pandemic vs COVID-19 pandemic cohort demographic characterist...
Introduction: Opioid use disorder (OUD) has grown rapidly over the years and is a public health c... more Introduction: Opioid use disorder (OUD) has grown rapidly over the years and is a public health crisis in the U.S. Though OUD is widely studied, relatively little is known about OUD among older adults. The goal of this study is to gain a better understanding of OUD among older Medicare beneficiaries over time and across several sociodemographic dimensions. Methods: Data from the 2013-2018 Centers for Medicare & Medicaid Services Master Beneficiary Summary Files were analyzed in 2020 to examine trends in OUD prevalence among Fee-for-Service Medicare beneficiaries aged ≥65 years. Utilizing the overarching opioid use disorder flag, trends in OUD prevalence were examined for the following sociodemographic dimensions: age, sex, race/ethnicity, and dual eligibility status (i.e., enrolled in both Medicare and Medicaid owing to low income). Chi-square tests were used to compare OUD prevalence across groups. Results: Since 2013, estimated rates of OUD among older adults have increased >3-fold overall in the U.S. Estimated OUD is more prevalent among the "young-old" (i.e., ages 65-69 years) beneficiaries than other older adults, and dually eligible beneficiaries have consistently shared a heavier burden of OUD compared with Medicare-only beneficiaries. Regarding race/ethnicity, Blacks and American Indians/Alaskan Natives are more vulnerable to OUD than other groups. Conclusions: The descriptive trends between 2013 and 2018 indicate that estimated OUD prevalence has increased greatly over the study period in all sociodemographic subgroups of older adults, highlighting an urgent challenge for public health professionals and gerontologists.
Demographic Research a free, expedited, online journal of peer-reviewed research and commentary i... more Demographic Research a free, expedited, online journal of peer-reviewed research and commentary in the population sciences published by the
Research has shown that the prevalence of opioid use disorder (OUD) may rise substantially as soc... more Research has shown that the prevalence of opioid use disorder (OUD) may rise substantially as society ages, but this issue receives the least attention in the literature. To address this gap, this study utilizes county-level data from multiple data sources (1) to investigate whether social isolation is associated with OUD prevalence among older Medicare beneficiaries, (2) to examine whether and how residential stability moderates the association between social isolation and OUD prevalence in US counties, and (3) to determine if there are any differences in these associations between metropolitan and non-metropolitan counties. The results show that social isolation is a significant factor for county-level OUD prevalence, regardless of metropolitan status. In addition, counties with high residential stability have low prevalence of OUD among older adults and this association is stronger in metropolitan than in non-metropolitan counties. Nonetheless, high levels of residential stability reinforce the positive relationship between social isolation and OUD prevalence. As a result, when developing policies and interventions aimed at reducing OUD among older adults, place of residence must be taken into account.
Smoking during pregnancy is associated with poor health outcomes for both mother and child. Howev... more Smoking during pregnancy is associated with poor health outcomes for both mother and child. However, over half of women who smoke continue to smoke while they are pregnant. Previous studies on maternal smoking during pregnancy that have considered measures of residential context have been limited by their homogenous samples of women and their omission of important contextual factors. In this paper we focus on the association between county-level social capital and the odds of women smoking during pregnancy using a 100 percent sample in the US. Mothers living in nonmetropolitan counties were 5 percent more likely to smoke during pregnancy than their metropolitan counterparts. Nonetheless, social capital may moderate the negative impact of residence on smoking. Specifically, a one unit increase in social capital index was found to reduce 8 percent of the odds of smoking during pregnancy among those mothers living in nonmetropolitan counties.
Drawing from both the place stratification and ethnic enclave perspectives, we use multilevel mod... more Drawing from both the place stratification and ethnic enclave perspectives, we use multilevel modeling to investigate the relationships between women's race/ethnicity (i.e., non-Hispanic white, non-Hispanic black, Asian, and Hispanic) and maternal smoking during pregnancy; and examine if these relationships are moderated by racial segregation in the continental United States. The results show that increased interaction with whites is associated with increased probability of maternal smoking during pregnancy for Asian and Hispanic mothers. In addition, racial segregation moderates the relationships between race/ethnicity and maternal smoking. Specifically, living in a less racially segregated area is related to a lower probability of smoking during pregnancy for black women, but it could double and almost triple the probability of smoking for Asian women and Hispanic women, respectively. Our findings provide empirical evidence for both the place stratification and ethnic enclave perspectives.
BackgroundOpioid use disorder (OUD) among older adults (age ≥ 65) is a growing yet underexplored ... more BackgroundOpioid use disorder (OUD) among older adults (age ≥ 65) is a growing yet underexplored public health concern and previous research has mainly assumed that the spatial process underlying geographic patterns of population health outcomes is constant across space. This study is among the first to apply a local modeling perspective to examine the geographic disparity in county-level OUD rates among older Medicare beneficiaries and the spatial non-stationarity in the relationships between determinants and OUD rates.MethodsData are from a variety of national sources including the Centers for Medicare & Medicaid Services beneficiary-level data from 2020 aggregated to the county-level and county-equivalents, and the 2016–2020 American Community Survey (ACS) 5-year estimates for 3,108 contiguous US counties. We use multiscale geographically weighted regression to investigate three dimensions of spatial process, namely “level of influence” (the percentage of older Medicare beneficia...
Hospital-based emergency departments (EDs) are the gateway to hospital admissions for many Americ... more Hospital-based emergency departments (EDs) are the gateway to hospital admissions for many Americans. Approximately half of all US hospital admissions originate from EDs, and more than 3 in 4 are among Medicare beneficiaries. Recent literature has demonstrated nearly 2-fold variation in both physician- and hospital-level ED admission rates. We study geographic variation at the county level in ED admission rates among Medicare fee-for-service beneficiaries. Using the 100% population data from the Centers for Medicare & Medicaid Services (CMS), we analyzed beneficiaries continuously enrolled in Medicare fee-for-service Parts A and B who resided in the 50 states and the District of Columbia in 2012. The ED admission rate was aggregated to the county level. ED admission rates were adjusted with the CMS Hierarchical Condition Categories (HCC) risk score. The resulting HCC adjusted ED admission rate was mapped to display the variation by county. The average county HCC adjusted ED admissio...
These maps show the geographic variation of standardized per capita Medicare spending, in US doll... more These maps show the geographic variation of standardized per capita Medicare spending, in US dollars, for all covered services among Medicare fee-for-service beneficiaries with 6 or more chronic conditions, United States, 2014. The maps highlight the need for targeted chronic disease prevention programs and policies in areas with the highest levels of Medicare spending.
Beyond individual-level factors, researchers have adopted a spatial perspective to explore potent... more Beyond individual-level factors, researchers have adopted a spatial perspective to explore potentially modifiable environmental determinants of health. A spatial perspective can be integrated into health research by incorporating spatial data into studies or analysing georeferenced data. Given the rapid changes in data collection methods and the complex dynamics between individuals and environment, we argue that geographical information system (GIS) functions have shortcomings with respect to analytical capability and are limited when it comes to visualizing the temporal component in spatio-temporal data. In addition, we maintain that relatively little effort has been made to handle spatial heterogeneity. To that end, health researchers should be persuaded to better justify the theoretical meaning underlying the spatial matrix in analysis, while spatial data collectors, GIS specialists, spatial analysis methodologists and the different breeds of users should be encouraged to work together making health research move forward through addressing these issues.
BACKGROUND-Limited information is available about teenage pregnancy and childbearing in rural are... more BACKGROUND-Limited information is available about teenage pregnancy and childbearing in rural areas, even though approximately 20 percent of the nation's youth live in rural areas. Identifying whether there are differences in the teenage birth rate (TBR) across metropolitan and nonmetropolitan areas is important, because these differences may reflect modifiable ecologicallevel influences such as education, employment, laws, healthcare infrastructure, and policies that could potentially reduce the TBR. OBJECTIVES-The goals of this study are to investigate whether there are spatially varying relationships between the TBR and the independent variables, and if so, whether these associations differ between metropolitan and nonmetropolitan counties. METHODS-We explore the heterogeneity within metropolitan/nonmetropolitan county groups separately using geographically weighted regression (GWR), and investigate the difference between metropolitan/nonmetropolitan counties using spatial regime models with spatial errors. These analyses were applied to county-level data from the National Center for Health Statistics and the US Census Bureau. RESULTS-GWR results suggested that non-stationarity exists in the associations between TBR and determinants within metropolitan/nonmetropolitan groups. The spatial regime analysis indicated that the effect of socioeconomic disadvantage on TBR significantly varied by the metropolitan status of counties. CONCLUSIONS-While the spatially varying relationships between the TBR and independent variables were found within each metropolitan status of counties, only the magnitude of the impact of the socioeconomic disadvantage index is significantly stronger among metropolitan counties than nonmetropolitan counties. Our findings suggested that place-specific policies for the disadvantaged groups in a county could be implemented to reduce TBR in the US.
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Papers by Carla Shoff