Health Care System Overstretch and In-Hospital Mortality of Intubated Patients With COVID-19 in Greece From September 2020 to April 2022: Updated Retrospective Cohort Study

Background

Our previous analysis showed how in-hospital mortality of intubated patients with COVID-19 in Greece is adversely affected by patient load and regional disparities.

Objective

We aimed to update this analysis to include the large Delta and Omicron waves that affected Greece during 2021-2022, while also considering the effect of vaccination on in-hospital mortality.

Methods

Anonymized surveillance data were analyzed from all patients with COVID-19 in Greece intubated between September 1, 2020, and April 4, 2022, and followed up until May 17, 2022. Time-split Poisson regression was used to estimate the hazard of dying as a function of fixed and time-varying covariates: the daily total count of intubated patients with COVID-19 in Greece, age, sex, COVID-19 vaccination status, region of the hospital (Attica, Thessaloniki, or rest of Greece), being in an intensive care unit, and an indicator for the period from September 1, 2021.

Results

A total of 14,011 intubated patients with COVID-19 were analyzed, of whom 10,466 (74.7%) died. Mortality was significantly higher with a load of 400-499 intubated patients, with an adjusted hazard ratio (HR) of 1.22 (95% CI 1.09-1.38), rising progressively up to 1.48 (95% CI 1.31-1.69) for a load of ≥800 patients. Hospitalization away from the Attica region was also independently associated with increased mortality (Thessaloniki: HR 1.22, 95% CI 1.13-1.32; rest of Greece: HR 1.64, 95% CI 1.54-1.75), as was hospitalization after September 1, 2021 (HR 1.21, 95% CI 1.09-1.36). COVID-19 vaccination did not affect the mortality of these already severely ill patients, the majority of whom (11,944/14,011, 85.2%) were unvaccinated.

Conclusions

Our results confirm that in-hospital mortality of severely ill patients with COVID-19 is adversely affected by high patient load and regional disparities, and point to a further significant deterioration after September 1, 2021, especially away from Attica and Thessaloniki. This highlights the need for urgent strengthening of health care services in Greece, ensuring equitable and high-quality care for all.

Factors Influencing Athletic Training Services in California Secondary Schools: A Five- Year Update

CONTEXT

California is the only state that does not regulate the athletic training profession, allowing unqualified personnel to be hired and call themselves athletic trainers. The benefits of employing a certified athletic trainer in the secondary school setting are numerous but efforts to push regulation legislation continue to fail in California.

OBJECTIVE

To describe the availability of certified athletic trainers in California secondary schools and explore factors influencing athletic trainer employment.

DESIGN

Cross-Sectional Study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

Participants from 1538 California Secondary Schools.

MAIN OUTCOME MEASURES

Officials from member schools completed the 2022-2023 California Interscholastic Federation Participation Census. Participants provided information specific to enrollment, sport participation, access to AEDs, and whether the school had athletic trainers on staff. The athletic trainer's certification status was independently verified. Enrollment data specific to ethnicity, race, and percentage of students eligible for free meals was obtained through the California Department of Education Statistics.

RESULTS

More than half (51.6%) of California secondary schools did not employ a certified athletic trainer and 8.3% employed unqualified personnel as athletic trainers. Nearly half (43%) of student athlete participants were enrolled at schools with no certified athletic trainer. Schools that employed certified athletic trainers had a lower proportion of students eligible to receive free and reduced-price meals. The average percentage of Hispanic or Latino students was greater in schools with no certified athletic trainer and schools that employed unqualified personnel as athletic trainers than schools that employed certified athletic trainers.

CONCLUSIONS

Data indicates that in a five-year period, access to athletic training services in California secondary schools has not improved. There are large gaps in access to athletic training services and there are clear socioeconomic and racial and ethnic disparities. Efforts to educate stakeholders on the importance of athletic training regulation in California should continue.

Neighborhood Environment and Poor Maternal Glycemic Control-Associated Complications of Gestational Diabetes Mellitus

Introduction

Risk of complications due to gestational diabetes mellitus is increasing in the U.S., particularly among individuals from racial minorities. Research has focused largely on clinical interventions to prevent complications, rarely on individuals' residential environments. This retrospective cohort study aims to examine the association between individuals' neighborhoods and complications of gestational diabetes mellitus.

Methods

Demographic and clinical data were extracted from electronic health records and linked to American Community Survey data from the U.S. Census Bureau for 2,047 individuals who had 2,164 deliveries in 2014-2018. Data were analyzed in 2021-2022 using Wilcoxon rank sum test and chi-square test for bivariate analyses and logistic regression for analysis of independent effects. All census tract-based variables used in the model were dichotomized at the median.

Results

Bivariate analysis showed that the average percentage of adults earning <$35,000 was higher in neighborhoods where individuals with complications were living than in neighborhoods where individuals without complications were living (30.40%±12.05 vs 28.94%±11.71, p=0.0145). Individuals who lived in areas with ≥8.9% of residents aged >25 years with less than high school diploma had a higher likelihood of complications than those who lived in areas with <8.9% of such residents (33.43% vs 29.02%, p=0.0272). Individuals who lived in neighborhoods that had ≥1.8% of households receiving public assistance were more likely to have complications than those who lived in areas where <1.8% of households received public assistance (33.33% vs 28.97%, p=0.0287). Logistic regression revealed that the odds of deliveries with complications were 44% higher for individuals with obesity (OR=1.44; 95% CI=1.17, 1.77), 35% greater for individuals residing in neighborhoods with higher percentages of households living below the poverty level (OR=1.35; 95% CI=1.09, 1.66), and 28% lower for individuals from neighborhoods where a higher percentage of households had no vehicles available for transportation to work (OR=0.72; 95% CI=0.59, 0.89).

Conclusions

Clinical interventions in concert with environmental changes could contribute to preventing maternal and neonatal complications of gestational diabetes mellitus.

Colorectal Cancer Screening Among Individuals With a Substance Use Disorder: A Retrospective Cohort Study

Introduction

There is limited evidence on colorectal cancer screening among individuals with a substance use disorder. This study aims to investigate the association between personal history of a substance use disorder and colorectal cancer colonoscopy screening completion rates.

Methods

This retrospective cohort study analyzed 176,300 patients, of whom 171,973 had no substance use disorder and 4,327 had a substance use disorder diagnosis from electronic health record data (January 1, 2008-December 31, 2022) in a Midwestern healthcare system. Baseline was January 1, 2013, and a 10-year follow-up period ran through December 31, 2022. The outcome was receipt of colonoscopy in the 10-year follow-up period. Patients were aged 50-65 years at baseline, meaning that they were eligible for a colonoscopy through the entirety of the 10-year follow-up period. Covariates included demographics (age, race, and neighborhood SES), health services utilization, psychiatric and physical comorbidities, and prior colonoscopy or fecal occult blood testing. Entropy balancing was used to control for confounding in weighted log-binomial models calculating RR and 95% CIs.

Results

Patients were on average aged 57.1 (±4.5) years, 58.2% were female, 81.0% were White, and 16.9% were of Black race. The most prevalent comorbidities were obesity (29.6%) and hypertension (29.4%), followed by smoking/nicotine dependence (21.0%). The most prevalent psychiatric comorbidity was depression (6.4%), followed by anxiety disorder (4.5%). During the 10-year follow-up period, 40.3% of eligible patients completed a colorectal cancer colonoscopy screening test, and individuals with a substance use disorder diagnosis were significantly less likely to receive a colorectal cancer colonoscopy screening test both prior to and after controlling for confounding (RR=0.73; 95% CI=0.70, 0.77 and RR=0.81; 95% CI=0.74, 0.89, respectively). Results were not modified by sex, race, psychiatric comorbidity, or neighborhood SES.

Conclusions

Personal history of substance use disorder was independently associated with lower screening completion rates. Healthcare professionals should recognize unique barriers among individuals with substance use disorder and then address them individually as a multidisciplinary team in the outpatient setting to reduce this health disparity.

Altered Extracellular Matrix-Related Pathways Accelerate the Transition from Normal to Pre-Fibroid Myometrium in Black Women

BACKGROUND

Black women experience a disproportionate impact of uterine fibroids compared to White women, including earlier diagnosis, higher frequency, and more severe symptoms. The etiology underlying this racial disparity remains elusive.

OBJECTIVE

The aim of this study was to evaluate the molecular differences in normal myometrium (fibroid-free uteri) and at-risk myometrium (fibroid-containing uteri) tissues in Black and White women.

STUDY DESIGN

We conducted whole-genome RNA-seq on normal and at-risk myometrium tissues obtained from both self-identified Black and White women (not Hispanic or Latino) to determine global gene expression profiles and to conduct enriched pathway analyses (n=3 per group). We initially assessed the differences within the same type of tissue (normal or at-risk myometrium) between races. Subsequently, we analyzed the transcriptome of normal myometrium compared to at-risk myometrium in each race and determined the differences between them. We validated our findings through real-time PCR (sample size range=5-12), western blot (sample size range=5-6), and immunohistochemistry techniques (sample size range=9-16).

RESULTS

The transcriptomic analysis revealed distinct profiles between Black and White women in normal and at-risk myometrium tissues. Interestingly, genes and pathways related to extracellular matrix and mechanosensing were more enriched in normal myometrium from Black than White women. Transcription factor enrichment analysis detected greater activity of the serum response transcription factor positional motif in normal myometrium from Black compared to White women. Furthermore, we observed increased expression levels of myocardin-related transcription factor-serum response factor and the serum response factor in the same comparison. In addition, we noted increased expression of both mRNA and protein levels of vinculin, a target gene of the serum response factor, in normal myometrium tissues from Black women as compared to White women. Importantly, the transcriptomic profile of normal to at-risk myometrium conversion differs between Black and White women. Specifically, we observed that extracellular matrix-related pathways are involved in the transition from normal to at-risk myometrium and that these processes are exacerbated in Black women. We found increased levels of Tenascin C, type I collagen alpha 1 chain, fibronectin and, phospho-p38 MAPK (Thr180/Tyr182, active) protein levels in at-risk over normal myometrium tissues from Black women, whereas such differences were not observed in samples from White women.

CONCLUSIONS

These findings indicate that the racial disparities in uterine fibroids may be attributed to heightened production of extracellular matrix in the myometrium in Black women, even before the tumors appear. Future research is needed to understand early life determinants of the observed racial differences.

Characterizing the Use of Healthcare Access Supports Among People Who Use Drugs in Vancouver, Canada, 2017 to 2020: A Cohort Study

BACKGROUND

For structurally marginalized populations, including people who use drugs (PWUD), equitable access to healthcare can be achieved through healthcare access supports. However, few studies characterized utilization of formal (eg, outreach workers, healthcare professionals) and informal (eg, friends/family) supports. Therefore, we sought to estimate the prevalence of and factors associated with receiving each type of support among PWUD.

METHODS

We used data from 2 prospective cohort studies of PWUD in Vancouver, Canada, in 2017 to 2020. We constructed separate multivariable generalized linear mixed-effects models to identify factors associated with receiving each of the 3 types of supports (ie, healthcare professionals, outreach workers/peer navigators, and informal supports) compared to no supports.

RESULTS

Of 996 participants, 350 (35.1%) reported receiving supports in the past 6 months at baseline, through informal supports (6.2%), outreach workers (14.1%), and healthcare professionals (20.9%). In multivariable analyses, HIV positivity, chronic pain, and avoiding healthcare due to the past mistreatment were positively associated with receiving supports from each of healthcare professionals and outreach workers. Men were less likely to receive any types of the supports (all P < .05).

CONCLUSIONS

Utilization of healthcare access supports was relatively low in this sample. However, formal supports appeared to have reached PWUD exhibiting more comorbidities and experiencing discrimination in healthcare. Further efforts to make formal supports more available would benefit PWUD with unmet healthcare needs, particularly men.

Initial leadership concerns and availability of tobacco cessation services moderate changes in employee-reported concerns about tobacco-free workplace policy implementation over time

Tobacco-free workplace policies (TFWPs) are underused evidence-based interventions that reduce the elevated use of tobacco among substance use treatment center (SUTC) employees and patients. SUTC employees' anticipated concerns about stakeholder pushback are barriers to TFWP adoption. Examination of discrepancies between anticipated and actualized employee-reported TFWP concerns arising from coworkers, patients, and community members in the context of leadership concerns and tobacco cessation care availability for employees may inform strategies to increase TFWP uptake. This study analyzed changes in employee-reported TFWP concerns from before to after a comprehensive tobacco-free workplace intervention that included TFWP implementation, using Chi-square/Fisher's exact tests. Preimplementation leadership policy concerns and tobacco cessation care availability were examined as moderators in generalized linear mixed models. Overall, 452 employees and 13 leaders provided data from 13 SUTCs collectively serving >82 000 patients annually. Results revealed significant decreases over time in employee-reported concerns about TFWP resistance from coworkers. Moderation analyses indicated that employee-anticipated concerns from coworkers and patients, respectively, were less likely to be actualized in SUTCs where leadership endorsed preimplementation TFWP concerns, whereas employee-reported patient concerns rose over time in SUTCs where leadership had no initial implementation concerns. Additionally, employee-anticipated concerns from coworkers were overestimated in SUTCs that did not offer tobacco cessation care to employees. Results supporting the nonactualization of anticipated employee concerns following TFWP implementation can be used to engage other SUTCs for TFWP adoption. Furthermore, moderation effects may suggest that center characteristics translate to greater attention to rollout, ultimately enhancing TFWP stakeholder acceptance.

Investigating MRI-Associated Biological Aspects of Racial Disparities in Prostate Cancer for African American and White Men

BACKGROUND

Understanding the characteristics of multiparametric MRI (mpMRI) in patients from different racial/ethnic backgrounds is important for reducing the observed gaps in clinical outcomes.

PURPOSE

To investigate the diagnostic performance of mpMRI and quantitative MRI parameters of prostate cancer (PCa) in African American (AA) and matched White (W) men.

STUDY TYPE

Retrospective.

SUBJECTS

One hundred twenty-nine patients (43 AA, 86 W) with histologically proven PCa who underwent mpMRI before radical prostatectomy.

FIELD STRENGTH/SEQUENCE

3.0 T, T2-weighted turbo spin echo imaging, a single-shot spin-echo EPI sequence diffusion-weighted imaging, and a gradient echo sequence dynamic contrast-enhanced MRI with an ultrafast 3D spoiled gradient-echo sequence.

ASSESSMENT

The diagnostic performance of mpMRI in AA and W men was assessed using detection rates (DRs) and positive predictive values (PPVs) in zones defined by the PI-RADS v2.1 prostate sector map. Quantitative MRI parameters, including Ktrans and ve of clinically significant (cs) PCa (Gleason score ≥ 7) tumors were compared between AA and W sub-cohorts after matching age, prostate-specific antigen (PSA), and prostate volume.

STATISTICAL TESTS

Weighted Pearson's chi-square and Mann-Whitney U tests with a statistically significant level of 0.05 were used to examine differences in DR and PPV and to compare parameters between AA and matched W men, respectively.

RESULTS

A total number of 264 PCa lesions were identified in the study cohort. The PPVs in the peripheral zone (PZ) and posterior prostate of mpMRI for csPCa lesions were significantly higher in AA men than in matched W men (87.8% vs. 68.1% in PZ, and 89.3% vs. 69.6% in posterior prostate). The Ktrans of index csPCa lesions in AA men was significantly higher than in W men (0.25 ± 0.12 vs. 0.20 ± 0.08 min-1; P < 0.01).

DATA CONCLUSION

This study demonstrated race-related differences in the diagnostic performances and quantitative MRI measures of csPCa that were not reflected in age, PSA, and prostate volume.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Invited Commentary: Is the Polysocial Score Approach Valuable for Advancing Social Determinants of Health Research?

Social determinants of health (SDOH) encompass the social environmental factors and lived experiences that collectively shape an individual's health. Recently, the polysocial score approach has been introduced as an innovative method for capturing the cumulative impact of a broad spectrum of social factors. This approach offers a promising opportunity to complement and enhance conventional methodologies in the advancement of SDOH research. In this issue of the Journal, Jawadekar et al. (Am J Epidemiol. XXXX;XXX(XX):XX-X-XXXX) evaluated the value of the polysocial score for predicting cognitive performance and mortality among middle-aged and older adults. Models built on a smaller set of social determinants, including race, gender, and education, performed comparably to the polysocial score models where a more complex set of social factors were included. In this invited commentary, I welcome the evaluation of the predictive ability of the polysocial score and the discussion of its merits and limitations. I also summarize the practical utility of the polysocial score in predicting health outcomes and its mechanistic significance in unveiling the relationship between genetics, social environment, and lifestyles in shaping an individual's health and elucidate health disparities. Lastly, I propose several avenues for future research.

Gait Features in Different Environments Contributing to Participation in Outdoor Activities in Old Age (GaitAge): Protocol for an Observational Cross-Sectional Study

BACKGROUND

The ability to walk is a key issue for independent old age. Optimizing older peoples' opportunities for an autonomous and active life and reducing health disparities requires a better understanding of how to support independent mobility in older people. With increasing age, changes in gait parameters such as step length and cadence are common and have been shown to increase the risk of mobility decline. However, gait assessments are typically based on laboratory measures, even though walking in a laboratory environment may be significantly different from walking in outdoor environments.

OBJECTIVE

This project will study alterations in biomechanical features of gait by comparing walking on a treadmill in a laboratory, level outdoor, and hilly outdoor environments. In addition, we will study the possible contribution of changes in gait between these environments to outdoor mobility among older people.

METHODS

Participants of the study were recruited through senior organizations of Central Finland and the University of the Third Age, Jyväskylä. Inclusion criteria were community-dwelling, aged 70 years and older, able to walk at least 1 km without assistive devices, able to communicate, and living in central Finland. Exclusion criteria were the use of mobility devices, severe sensory deficit (vision and hearing), memory impairment (Mini-Mental State Examination ≤23), and neurological conditions (eg, stroke, Parkinson disease, and multiple sclerosis). The study protocol included 2 research visits. First, indoor measurements were conducted, including interviews (participation, health, and demographics), physical performance tests (short physical performance battery and Timed Up and Go), and motion analysis on a treadmill in the laboratory (3D Vicon and next-generation inertial measurement units [NGIMUs]). Second, outdoor walking tests were conducted, including walking on level (sports track) and hilly (uphill and downhill) terrain, while movement was monitored via NGIMUs, pressure insoles, heart rate, and video data.

RESULTS

A total of 40 people (n=26, 65% women; mean age 76.3, SD 5.45 years) met the inclusion criteria and took part in the study. Data collection took place between May and September 2022. The first result is expected to be published in the spring of 2024.

CONCLUSIONS

This multidisciplinary study will provide new scientific knowledge about how gait biomechanics are altered in varied environments, and how this influences opportunities to participate in outdoor activities for older people.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/52898.

The Influence of Social Dynamics on Biological Aging and the Health of Historically Marginalized Populations: A Biopsychosocial Model for Health Disparities

Historically marginalized populations are susceptible to social isolation resulting from their unique social dynamics; thus, they incur a higher risk of developing chronic diseases across the course of life. Research has suggested that the cumulative effect of aging trajectories per se, across the lifespan, determines later-in-life disease risks. Emerging evidence has shown the biopsychosocial effects of social stress and social support on one's wellbeing in terms of inflammation. Built upon previous multidisciplinary findings, here, we provide an overarching model that explains how the social dynamics of marginalized populations shape their rate of biological aging through the inflammatory process. Under the framework of social stress and social support theories, this model aims to facilitate our understanding of the biopsychosocial impacts of social dynamics on the wellbeing of historically marginalized individuals, with a special emphasis on biological aging. We leverage this model to advance our mechanistic understanding of the health disparity observed in historically marginalized populations and inform future remediation strategies.

Use of Machine Learning for Early Detection of Maternal Cardiovascular Conditions: Retrospective Study Using Electronic Health Record Data

BACKGROUND

Cardiovascular conditions (eg, cardiac and coronary conditions, hypertensive disorders of pregnancy, and cardiomyopathies) were the leading cause of maternal mortality between 2017 and 2019. The United States has the highest maternal mortality rate of any high-income nation, disproportionately impacting those who identify as non-Hispanic Black or Hispanic. Novel clinical approaches to the detection and diagnosis of cardiovascular conditions are therefore imperative. Emerging research is demonstrating that machine learning (ML) is a promising tool for detecting patients at increased risk for hypertensive disorders during pregnancy. However, additional studies are required to determine how integrating ML and big data, such as electronic health records (EHRs), can improve the identification of obstetric patients at higher risk of cardiovascular conditions.

OBJECTIVE

This study aimed to evaluate the capability and timing of a proprietary ML algorithm, Healthy Outcomes for all Pregnancy Experiences-Cardiovascular-Risk Assessment Technology (HOPE-CAT), to detect maternal-related cardiovascular conditions and outcomes.

METHODS

Retrospective data from the EHRs of a large health care system were investigated by HOPE-CAT in a virtual server environment. Deidentification of EHR data and standardization enabled HOPE-CAT to analyze data without pre-existing biases. The ML algorithm assessed risk factors selected by clinical experts in cardio-obstetrics, and the algorithm was iteratively trained using relevant literature and current standards of risk identification. After refinement of the algorithm's learned risk factors, risk profiles were generated for every patient including a designation of standard versus high risk. The profiles were individually paired with clinical outcomes pertaining to cardiovascular pregnancy conditions and complications, wherein a delta was calculated between the date of the risk profile and the actual diagnosis or intervention in the EHR.

RESULTS

In total, 604 pregnancies resulting in birth had records or diagnoses that could be compared against the risk profile; the majority of patients identified as Black (n=482, 79.8%) and aged between 21 and 34 years (n=509, 84.4%). Preeclampsia (n=547, 90.6%) was the most common condition, followed by thromboembolism (n=16, 2.7%) and acute kidney disease or failure (n=13, 2.2%). The average delta was 56.8 (SD 69.7) days between the identification of risk factors by HOPE-CAT and the first date of diagnosis or intervention of a related condition reported in the EHR. HOPE-CAT showed the strongest performance in early risk detection of myocardial infarction at a delta of 65.7 (SD 81.4) days.

CONCLUSIONS

This study provides additional evidence to support ML in obstetrical patients to enhance the early detection of cardiovascular conditions during pregnancy. ML can synthesize multiday patient presentations to enhance provider decision-making and potentially reduce maternal health disparities.

Evaluating Algorithmic Bias in 30-Day Hospital Readmission Models: Retrospective Analysis

BACKGROUND

The adoption of predictive algorithms in health care comes with the potential for algorithmic bias, which could exacerbate existing disparities. Fairness metrics have been proposed to measure algorithmic bias, but their application to real-world tasks is limited.

OBJECTIVE

This study aims to evaluate the algorithmic bias associated with the application of common 30-day hospital readmission models and assess the usefulness and interpretability of selected fairness metrics.

METHODS

We used 10.6 million adult inpatient discharges from Maryland and Florida from 2016 to 2019 in this retrospective study. Models predicting 30-day hospital readmissions were evaluated: LACE Index, modified HOSPITAL score, and modified Centers for Medicare & Medicaid Services (CMS) readmission measure, which were applied as-is (using existing coefficients) and retrained (recalibrated with 50% of the data). Predictive performances and bias measures were evaluated for all, between Black and White populations, and between low- and other-income groups. Bias measures included the parity of false negative rate (FNR), false positive rate (FPR), 0-1 loss, and generalized entropy index. Racial bias represented by FNR and FPR differences was stratified to explore shifts in algorithmic bias in different populations.

RESULTS

The retrained CMS model demonstrated the best predictive performance (area under the curve: 0.74 in Maryland and 0.68-0.70 in Florida), and the modified HOSPITAL score demonstrated the best calibration (Brier score: 0.16-0.19 in Maryland and 0.19-0.21 in Florida). Calibration was better in White (compared to Black) populations and other-income (compared to low-income) groups, and the area under the curve was higher or similar in the Black (compared to White) populations. The retrained CMS and modified HOSPITAL score had the lowest racial and income bias in Maryland. In Florida, both of these models overall had the lowest income bias and the modified HOSPITAL score showed the lowest racial bias. In both states, the White and higher-income populations showed a higher FNR, while the Black and low-income populations resulted in a higher FPR and a higher 0-1 loss. When stratified by hospital and population composition, these models demonstrated heterogeneous algorithmic bias in different contexts and populations.

CONCLUSIONS

Caution must be taken when interpreting fairness measures' face value. A higher FNR or FPR could potentially reflect missed opportunities or wasted resources, but these measures could also reflect health care use patterns and gaps in care. Simply relying on the statistical notions of bias could obscure or underplay the causes of health disparity. The imperfect health data, analytic frameworks, and the underlying health systems must be carefully considered. Fairness measures can serve as a useful routine assessment to detect disparate model performances but are insufficient to inform mechanisms or policy changes. However, such an assessment is an important first step toward data-driven improvement to address existing health disparities.

Rural-urban disparities in the diagnosis and treatment of hypertension and diabetes among aging Indians

INTRODUCTION

Hypertension and diabetes are modifiable risk factors for dementia. We aimed to assess rural-urban disparities in the diagnosis and treatment of these conditions among aging Indians.

METHODS

Participants (n = 6316) were from two parallel, prospective aging cohorts in rural and urban India. Using self-report and clinical/biochemical assessments, we subdivided participants with diabetes and hypertension into undiagnosed and untreated groups. Logistic regression and Fairlie decomposition analysis were the statistical methods utilized.

RESULTS

There was a significant rural-urban disparity in undiagnosed hypertension (25.14%), untreated hypertension (11.75%), undiagnosed diabetes (16.94%), and untreated diabetes (11.62%). Further, sociodemographic and lifestyle factors, such as age and tobacco use were the common contributors to the disparities in both undiagnosed hypertension and undiagnosed diabetes, whereas education and body mass index (BMI) were significant contributors to the disparity in untreated hypertension.

DISCUSSION

Rural Indians face significant healthcare disadvantages as compared to their urban counterparts, which prompts the urgent need for strategies for equitable healthcare.

Racial and Ethnic Differences in Initiation and Discontinuation of Antiarrhythmic Medications in Management of Atrial Fibrillation

Background

Atrial fibrillation (AF) is associated with considerable morbidity and mortality. Timely management and treatment are critical in alleviating AF disease burden. There is significant heterogeneity in patterns of AF care. It is unclear whether there are racial and ethnic differences in treatment of AF following antiarrhythmic drug (AAD) prescription.

Methods

Using the Optum Clinformatics Data Mart-Socioeconomic Status database from January, 2009, through March, 2022, multivariable logistic regression techniques were used to examine the impact of race and ethnicity on rate of AAD initiation, as well as receipt of catheter ablation within two years of initiation. We compared AAD discontinuation rate by race and ethnicity groups using Cox regression models. Log-rank analyses were used to examine the rate of AF-related hospitalization.

Results

Among 143,281 patients identified with newly diagnosed AF, 30,019 patients (21%) were initiated on an AAD within 90 days. Patients identified as Non-Hispanic Black (NHB) were significantly less likely to receive an AAD compared to Non-Hispanic White patients (NHW) (Odds Ratio [OR] 0.90, 95% confidence interval [CI] 0.85-0.94). Compared to NHW, Hispanic (Hazard Ratio [HR] 1.08, 95% CI 1.02-1.14) and Asian patients (HR 1.17, 95% CI 1.06-1.29) have a higher rate of AAD discontinuation. Following AAD initiation, NHB patients were significantly more likely to have an AF-related hospitalization (p < 0.01). However, NHB patients were significantly less likely to receive ablation compared to NHW (HR 0.83, 95% CI 0.70-0.97), and less likely to change AAD (p < 0.01).

Conclusion

Patients identified as NHB are 10% less likely to receive an AAD for treatment of newly diagnosed AF. Compared to NHW, Hispanic and Asian patients were more likely to discontinue AAD treatment. Once initiated on an AAD, NHB patients were significantly more likely to have an AF -related hospitalization, but were 17% less likely to receive ablation compared to NHW patients. The etiology of, and interventions to reduce, these disparities require further investigation.

Trends in pediatric firearm-related injuries and disparities in acute outcomes

Background

Firearm-related injuries (FRI) are an increasing cause of death and injury in children. The etiology for this rise is multifactorial and includes socioeconomic factors. Despite its prevalence and documented increase over COVID-19, there is a paucity of research on disparities and the influence of social determinants of health (SDH) in pediatric FRI. This study aims to explore the epidemiology of this vulnerable population in Atlanta, trends over time and relevant dates such as COVID-19 and a state firearm law, and disparities in clinical outcomes.

Methods

Retrospective cohort of patients with FRI (0-20 years-old, x̄=9.8, Median = 11) presenting to our hospital EDs from January 2014 to April 2023 (N = 701) and eligible for the Trauma Registry. This period includes two major events, namely the COVID-19 pandemic (March 2020), and passage of state law Constitutional Carry Act (SB 319) (April 2022), allowing for permit-less concealed firearm carry. Single series interrupted time series (ITS) models were run and clinical outcome differences between race and insurance groups were calculated unadjusted and adjusted for confounders using inverse propensity treatment weights (IPTW). The primary outcome was mortality; secondary are admission and discharge.

Results

Majority of FRI involved patients who were male (76.7%), Black (74.9%), publicly insured (82.6%), ≤12 years-old (61.8%), and injured by unintentional shootings (45.6%) or assault (43.7%). During COVID-19, there was a sustained increase in FRI rate by 0.42 patients per 1,000 trauma visits per month (95% CI 0.02-0.82, p = 0.042); post-SB 319 it was 2.3 patients per 1,000 trauma visits per month (95% CI 0.23-4.31, p = 0.029). Publicly insured patients had 58% lower odds of mortality than privately insured patients (OR 0.42, 95% CI 0.18-0.99, p = 0.047). When controlled for race and mechanism of injury, among other confounding factors, this association was not significant (p = 0.652).

Conclusion

Pediatric FRI are increasing over time, with disproportionate burdens on Black patients, at our hospitals. Disparities in mortality based on insurance necessitate further study. As social and economic repercussions of COVID-19 are still present, and state firearm law SB 319 is still in effect, assessment of ongoing trends is warranted to inform preventative strategies.

Impact of the COVID-19 Pandemic on Latino Families With Alzheimer Disease and Related Dementias: Qualitative Interviews With Family Caregivers and Primary Care Providers

Background

Latino individuals experience disparities in the care of Alzheimer disease and related dementias (ADRD) and have disproportionately high COVID-19 infection and death outcomes.

Objective

We aimed to gain an in-depth understanding of the impact of the COVID-19 pandemic among Latino families with ADRD in the United States.

Methods

This was a qualitative study of 21 informal caregivers of Latino individuals with ADRD and 23 primary care providers who serve Latino patients. We recruited participants nationwide using convenience and snowball sampling methods and conducted remote interviews in English and Spanish. We organized the transcripts for qualitative review to identify codes and themes, using a pragmatic approach, a qualitative description methodology, and thematic analysis methods.

Results

Qualitative analysis of transcripts revealed eight themes, including (1) the pandemic influenced mental and emotional health; (2) the pandemic impacted physical domains of health; (3) caregivers and care recipients lost access to engaging activities during the confinement; (4) the pandemic impacted Latino caregivers' working situation; (5) the pandemic impacted health care and community care systems; (6) health care and community care systems took measures to reduce the impact of the pandemic; (7) Latino families experienced barriers to remote communication during the pandemic; and (8) caregiver social support was critical for reducing social isolation and its sequalae.

Conclusions

Latino families with ADRD experienced similar but also unique impacts compared to those reported in the general population. Unique impacts may result from Latino individuals' underserved status in the United States, commonly held cultural values, and their intersectionality with ADRD-related disability. Family caregiver social support was crucial during this time of adversity. These findings suggest the need for more equitable access, culturally appropriate and trustworthy content and delivery of health care and community services, as well as stronger financial and social supports for family caregivers.

Harmonizing Assessments of Everyday Racial Discrimination Experiences: The Multigroup Everyday Racial Discrimination Scale (MERDS)

Reliable and valid assessment of direct racial discrimination experiences in everyday life is critical to understanding one key determinant of ethnoracial minority health and health disparities. To address psychometric limitations of existing instruments and to harmonize the assessment of everyday racial discrimination, the new Multigroup Everyday Racial Discrimination Scale (MERDS) was developed and validated. This investigation included 1,355 college and graduate students of color (Mage = 21.54, 56.0% women). Factor analyses were performed to provide evidence for structural validity of everyday racial discrimination scores. Item response theory modeling was used to investigate item difficulty relative to the level of everyday racial discrimination, and measurement error conditioned on the construct. MERDS scores were reliable, supported construct unidimensionality, and distinguished individuals who reported low to very high frequency of everyday racial discrimination. Results on the associations with racial identity and psychopathology symptoms, and utility of the scale are discussed.

Grow502: Centering Community in Medical Education via a Student-Created Organization Focused on Cultivating a Healthy Community

The COVID-19 pandemic continues to disproportionately impact communities of color and expose health inequities. Minoritized communities experience disparities in chronic diseases, premature death, and cancer, and gaps continue to widen; systemic injustice in housing, nutrition, and environment are major contributors. At the height of the COVID-19 pandemic and racial justice movement, students at the University of Louisville School of Medicine created Grow502 to speak truth to the challenges of health disparities in Louisville, Kentucky. The goal was to pursue a healthier community by raising awareness. Community leaders and health professionals provided expert consultation. This partnership led to the co-creation of a curriculum focused on education, advocacy, community engagement, and creative media. Grow502 sought to support communities impacted by injustices due to racism, limited health literacy, redlining, and limited green space by creating programming centered on education and empowerment. Effective strategies to reduce disparities involve creating interventions with authentic engagement and context. Grow502 involves community stakeholders as active partners. We continue to intentionally seek effective collaborations and interventions that merge our mission and our diverse communities impacted by health disparities.

Understanding oral health from the point of view of adults with disabilities and/or complex medical conditions: A scoping review

AIM

This study aimed to review the qualitative scientific literature investigating experience of the mouth and oral health amongst adults with disabilities and/or complex health conditions.

METHODS

A scoping review methodology was applied in accordance with the methodological framework of Arksey & O'Malley and the PRISMA-SCR checklist. Electronic searching was performed using the databases Pubmed, Embase, and PsychInfo.

RESULTS

Thirty articles were included in the final selection. The populations included in the selected studies were very varied in terms of health conditions and disabilities. Three major themes relating to the experience and understanding of the mouth, oral health, and function were highlighted in the review: the representation of oral health, the influence of oral health on the participant's life, and the influence of the socio-environmental context on oral health. No study explicitly described the functional, social, and psychological roles of the mouth in a comprehensive manner.

CONCLUSIONS

Perception of the mouth and oral health differs depending on the individual and their health condition. Oral health is described as dependent on the socio-environmental context, however, outside of the experience of dental care services, this context is not investigated in the literature. This scoping review demonstrated that exhaustive understanding of the dimensions of the mouth and oral health has not been explored in published research for this population.

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture

BACKGROUND

Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries.

METHODS

PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs.

RESULTS

Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures.

CONCLUSIONS

The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Are We the Problem? A Call to Action for Addressing Institutional Challenges to Engaging Community Partners in Research

Community-engaged research (CEnR) is a potent tool for addressing health inequities and fostering equitable relationships among communities, researchers, and institutions. CEnR involves collaboration throughout the research process, demonstrating improvements in study recruitment and retention, intervention efficacy, program sustainability, capacity building among partners, and enhanced cultural relevance. Despite the increasing demand for CEnR, institutional policies, particularly human participation protection training (HPP), lag behind, creating institutional barriers to community partnerships. Here, we highlight challenges encountered in our ongoing study, Fostering Opportunities in Research through Messaging and Education (FOR ME), focused on promoting shared decision-making around clinical trial participation among Black women diagnosed with breast cancer. Grounded in CEnR methods, FOR ME has a partnership with a community-based organization (CBO) that addresses the needs of Black women with breast cancer. Our CBO partner attempted to obtain HPP training, which was administratively burdensome and time-consuming. As CEnR becomes more prevalent, academic and research institutions, along with researchers, are faced with a call to action to become more responsive to community partner needs. Accordingly, we present a guide to HPP training for community partners, addressing institutional barriers to community partner participation in research. This guide outlines multiple HPP training pathways for community partners, aiming to minimize institutional barriers and enhance their engagement in research with academic partners.