Clouds and Silver Linings: COVID-19 Pandemic Is an Opportune Moment to Democratize Diabetes Care Through Telehealth

With the recent pivot to telehealth as a direct result of the COVID-19 pandemic, there is an imperative to ensure that access to affordable devices and technologies with remote monitoring capabilities for people with diabetes becomes equitable. In addition, expanding the use of remote Diabetes Self-Management Education and Support (DSMES) and Medical Nutrition Therapy (MNT) services will require new strategies for achieving long-term, effective, continuous, data-driven care. The current COVID-19 pandemic has especially impacted underserved US communities that were already disproportionately impacted by diabetes. Historically, these same communities have faced barriers in accessing timely and effective diabetes care including access to DSMES and MNT services, and diabetes technologies. Our call to action encourages all involved to urge US Federal representatives to widen access to the array of technologies necessary for successful telehealth-delivered care beyond COVID-19.

Current Practice and Clinical Utility of Thrombophilia Testing in Hospitalized Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Testing for thrombophilic disorders is often performed in patients after cryptogenic ischemic stroke in an attempt to identify a hematologic explanation for the event. However, the role of commonly tested thrombophilias in ischemic stroke is poorly defined. There is limited evidence to quantify how these disorders affect ischemic stroke risk and testing practices are highly variable.

METHODS

Retrospective evaluation of thrombophilia testing practices and clinical outcomes was performed in hospitalized patients with acute ischemic stroke (n = 1898) at a large academic hospital over a two-year period. Variables assessed included testing components, timing of testing, number of abnormal results, and frequency of change in clinical management prompted by abnormal results. A provider survey was also performed to assess perceptions of current testing practices and provider understanding of testing indications.

RESULTS

Thrombophilia testing was performed in 190 (10%) patients admitted for acute ischemic stroke. Of those tested, 137 (72.1%) had at least one abnormal result, but this decreased to 37.4% when elevated factor VIII activity was excluded. An abnormal result prompted initiation of anticoagulation in only 4 patients (2%). The provider survey indicated that all providers (100%) were selecting thrombophilia tests using a pre-existing order set and were interested in additional education on testing indications and interpretation. Comparison to similar studies at other institutions revealed significant variation in testing practices, and a small proportion of patients in which testing prompted a change in management (1-8%).

CONCLUSIONS

Thrombophilia testing is frequently obtained in hospitalized patients with acute ischemic stroke, yet testing only changed management in 2% of patients. Efforts to improve provider education and the stewardship of testing are needed to ensure appropriate evaluation and treatment of patients with acute ischemic stroke.

Demographic and socioeconomic disparities of benign and malignant spinal meningiomas in the United States

INTRODUCTION

Spinal meningiomas constitute the majority of primary spinal neoplasms, yet their pathogenesis remains elusive. By investigating the distribution of these tumors across sociodemographic variables can provide direction in etiology elucidation and healthcare disparity identification.

METHODS

To investigate benign and malignant spinal meningioma incidences (per 100,000) with respect to sex, age, income, residence, and race/ethnicity, we queried the largest American administrative dataset (1997-2016), the National (Nationwide) Inpatient Sample (NIS), which surveys 20% of United States (US) discharges.

RESULTS

Annual national incidence was 0.62 for benign tumors and 0.056 for malignant. For benign meningiomas, females had an incidence of 0.81, larger (P=0.000004) than males at 0.40; yet for malignant meningiomas, males had a larger (P=0.006) incidence at 0.062 than females at 0.053. Amongst age groups, peak incidence was largest for those 65-84 years old (2.03) in the benign group, but 45-64 years old (0.083) for the malignant group. For benign and malignant meningiomas respectively, individuals with middle/high income had an incidence of 0.67 and 0.060, larger (P=0.000008; P=0.04) than the 0.48 and 0.046 of low income patients. Incidences were statistically similar (P=0.2) across patient residence communities. Examining race/ethnicity (P=0.000003) for benign meningiomas, incidences for Whites, Asian/Pacific Islanders, Hispanics, and Blacks were as follows, respectively: 0.83, 0.42, 0.28, 0.15.

CONCLUSIONS

Across sociodemographic strata, healthcare inequalities were identified with regards to spinal meningiomas. For benign spinal meningiomas, incidence was greatest for patients who were female, 65-84 years old, middle/high income, living in rural communities, White, and Asian/Pacific Islander. Meanwhile, for malignant spinal meningiomas incidence was greatest for males, those 45-65 years old, and middle/high income.

Influence of the definition of rurality on geographic differences in HIV outcomes in British Columbia: a retrospective cohort analysis

BACKGROUND

Improving rural health is often identified as a priority area for research and policy in Canada. We examined how findings on HIV outcomes (virologic suppression) can vary depending on the definition of rurality used.

METHODS

We performed retrospective cohort analyses using the Comparative Outcomes and Service Utilization Trends study population-based cohort of adults (age ≥ 19 yr) living with HIV in British Columbia between Apr. 1, 2012, and Mar. 31, 2013. We performed univariate logistic regression analyses using the following geographic variables to predict HIV virologic suppression: rurality defined by forward sortation area, by Statistical Area Classification and by health authority. We mapped suppression using geographic information systems.

RESULTS

Virologic suppression was observed in 5605 (65.2%) of 8598 participants. In univariate analysis, rurality defined by Statistical Area Classification (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.65-0.82), but not by forward sortation area, was associated with lower odds of suppression. When we examined suppression by health authority, Northern Health had the lowest odds of suppression (OR 0.46, 95% CI 0.36-0.58 compared to Vancouver Coastal Health). Geographic information systems mapping showed poorer suppression in northern areas.

INTERPRETATION

Health outcome findings can vary depending on the definition of the geographic variable. When including geographic variables, researchers should carefully consider variable definitions and whether other classification systems, such as north-south, are more appropriate than rurality for their analysis.

Sex Differences in Management and Outcomes of Critical Limb Ischemia in the Medicare Population

BACKGROUND

Evidence about sex differences in management and outcomes of critical limb ischemia (CLI) is conflicting.

METHODS

We identified Fee-For-Service Medicare patients within the 5% enhanced sample file who were diagnosed with new incident CLI between 2015 and 2017. For each beneficiary, we identified all hospital admissions, outpatient encounters and procedures, and pharmacy prescriptions. Outcomes included 90-day mortality and major amputation.

RESULTS

Incidence of CLI declined from 2.80 (95% CI, 2.72-2.88) to 2.47 (95% CI, 2.40-2.54) per 1000 person from 2015 to 2017, P<0.01. Incidence was lower in women compared with men (2.19 versus 3.11 per 1000) but declined in both groups. Women had a lower prevalence of prescription of any statin (48.4% versus 52.9%, P<0.001) or high-intensity statins (15.3% versus 19.8%, P<0.01) compared with men. Overall, 90-day revascularization rate was 52%, and women were less likely to undergo revascularization (50.1% versus 53.6%, P<0.01) compared with men. Women had a similar unadjusted (9.9% versus 10.3%, P=0.5) and adjusted 90-day mortality (adjusted rate ratio, 0.98 [95% CI, 0.85-1.12], P=0.7) compared with men. Over the study period, unadjusted 90-day mortality remained unchanged for men (10.4% in 2015 to 9.9% in 2017, Pfor trend=0.3), and women (9.5% in 2015 to 10.6% in 2017, Pfor trend=0.2). Men had higher unadjusted (12.9% versus 8.9%, P<0.001) and adjusted risk of 90-day major amputation (adjusted rate ratio, 1.30 [95% CI, 1.14-1.48], P<0.001). One-third of patients with CLI underwent major amputation without a diagnostic angiogram or trial of revascularization in the preceding 90 days regardless of the sex.

CONCLUSIONS

Women with new incident CLI are less likely to receive statin or undergo revascularization at 90 days compared with men. However, the differences were small. There was no difference in risk of 90-day mortality between both sexes. Graphic Abstract: A graphic abstract is available for this article.

Epidemiological trends in notified influenza cases in Australia's Northern Territory, 2007-2016

BACKGROUND

The Northern Territory (NT) of Australia has a mix of climates, sparsely distributed population and a large proportion of the populace are Indigenous Australians, and influenza is known to have a disproportionate impact upon this group. Understanding the epidemiology of influenza in this region would inform public health strategies.

OBJECTIVES

To assess if there are consistent patterns in characteristics of influenza outbreaks in the NT.

METHODS

Laboratory confirmed influenza cases in the NT are notified to the NT Centre for Disease Control. We conducted analyses on notified cases from 2007-2016 to determine incidence rates (by age group, Indigenous status and area), seasonality of cases and spatial distribution of influenza types. Notified cases were linked to laboratory datasets to update information on influenza type or subtype RESULTS: The disparity in Indigenous and non-Indigenous notification rates varied by age group, with rate ratios for Indigenous versus non-Indigenous ranging from 1.58 (95% CI:1.39, 1.80) for ages 15-24 to 5.56 (95% CI: 4.71, 6.57) for ages 55-64. The disparity between Indigenous and non-Indigenous notification rates appeared higher in the Central Australia region. Indigenous versus non-Indigenous hospitalisation and mortality rate ratios were 6.51 (95% CI: 5.91, 7.18) and 5.46 (95% CI: 2.40, 12.71) respectively. Inter-seasonal peaks during February and March occurred in 2011, 2013 and 2014, and were due to influenza activity in the tropical north of the NT.

CONCLUSIONS

Our results highlight the importance of influenza vaccination across all age groups for Indigenous Australians. An early vaccination campaign targeted against outbreaks in February-March would be best focused on the tropical north.

Second European Society of Cardiology Cardiac Resynchronization Therapy Survey: the Italian cohort

AIM

Adherence to guidelines was not homogeneous in Europe, according to the survey on cardiac resynchronization therapy conducted in 2008-2009. The aim of our study was to compare the results in the Italian and European cohorts of the Second European Cardiac Resynchronization Therapy Survey.

METHODS

Patients' characteristics, procedural data and follow-up were collected. Italian records were compared with European countries.

RESULTS

Italian hospitals enrolled 526 patients. The italian cohort was older (71.6 ± 9.5 vs. 68.4 ± 10.8; P < 0.00001), had less severe NYHA class (>II 47.2 vs. 59.6%; P < 0.00001), higher ejection fraction (30.3 ± 7.4 vs. 28.4 ± 8.2%; P < 0.00001), and less atrial fibrillation prevalence (34.4 vs. 41.2%; P = 0.00197) than the European cohort. Italian patients were more frequently hospitalized for heart failure in the previous year (51.9 vs. 46.2%; P = 0.01118) and had lower mean QRS duration (151 ± 26 vs. 157 ± 27 ms; P < 0.0001). CRT-D were more often implanted in Italian patients (79.3 vs. 69.3%; P < 0.00001). The complication rate was similar (4.6% vs. 5.6%; ns). The rate of use of ACEi/ARBs in Italy was lower than in Europe (77.2 vs. 86.9%; P < 0.00001). Patients were followed up in the implantation centre (92.1 vs. 86%; P = 0.00014), but rarely with remote monitoring (25.9 vs. 30%; P = 0.04792).

CONCLUSION

The survey demonstrates important similarities as well as substantial differences regarding most of the aspects evaluated. Efforts to implement adherence to guidelines will be endorsed in Italy.

Differences and disparities over time: Black and White families investigated by Ontario's child welfare system

BACKGROUND

Black-White disparities in child welfare involvement have been well-documented in the United States, but there is a significant knowledge gap in Ontario about how and when these disparities emerge.

OBJECTIVE

This paper compares incidence data on Black and White families investigated by Ontario's child welfare system over a 20-year period.

METHODS

Data from the first five cycles of the Ontario Incidence Study of Reported Child Abuse and Neglect (OIS) (1993-2013) were used to examine trends in child maltreatment investigations involving Black and White families. Incidence rates were calculated. T-tests were conducted to assess statistically significant differences between and within cycles. Population and decision-based enumeration approaches were also used to examine child welfare disparities.

RESULTS

The incidence of investigations involving White families almost doubled between 1998 and 2003, but for Black families the incidence increased almost fourfold during the same period. These increases and the difference between Black and White families in 2003 were statistically significant. The results further indicate that Black families experience disparate representation in Ontario's child welfare system over time for most service dispositions.

CONCLUSIONS

Several possible explanations are offered for the study's outcome, including changes in risk related to social safety net, the threshold for risk of harm, and bias and racist institutional policies and practices. This study invites policy-makers and child welfare authorities to rethink service delivery in addressing the disparate representation of Black families in the child welfare system.

Monitoring the decomposition of wealth-related inequality in the use of regular antenatal care in Egypt (1995-2014)

BACKGROUND

Between 1995 and 2014 Egypt successfully increased the use of regular antenatal care (URAC) among women from 30.4 to 82.9%. The same period saw a decrease in the wealth-based inequality in URAC. This paper investigates the changes in the main determinants contributing to the wealth-based inequality in URAC for the 2 years of 1995 and 2014, and the determinants that underlined the declines in this inequality.

METHODS

The secondary analysis was based on data from the 1995 and 2014 rounds of the Egypt Demographic and Health Survey. Logistic regression was implemented to model URAC for the 2 years and inequality was measured using the concentration index. Decomposition of the concentration index and Blinder -Oaxaca decomposition were implemented to assess the contribution of the URAC determinants to its inequality and the changes between 1995 and 2014.

RESULTS

Decomposition of inequalities in URAC in 1995 and 2014 showed that social determinants were the main contributors to these inequalities. More than 90% of the inequalities were explained by the living in rural Upper Egypt, women and their husbands secondary and higher education, the household standard of living, and birth order. These same determinants were responsible for more than 76% of the decline in the inequality in URAC between 1995 and 2014. Wide spread of poverty in rural Upper Egypt was found to contribute significantly to the inequality in URAC. Women and their husbands who have secondary or higher education maintained their high odds of URAC.

CONCLUSION

Since poverty in rural Upper Egypt, and inequality in education and parity are crucial social determinants of URAC inequality and its change overtime, new policies and interventions need to focus not only on the health system but on social initiatives with an equity lens to tackle the structural causes underlying these factors and their inequalities.

Patterns of Medications for Atrial Fibrillation Among Older Women: Results From the Australian Longitudinal Study on Women's Health

PURPOSE

Examine patterns of medication use, changes in medication patterns over time, and investigate factors associated with medication patterns among older Australian women with Atrial Fibrillation (AF).

METHODS

It is a retrospective analysis of the 1921-26 birth cohort of the Australian Longitudinal Study on Women's Health (ALSWH), diagnosed with AF between 2000-2015 (N = 1206). Survey data of these women was linked with national registries for medications and death. Latent Transition Analysis (LTA) identified distinct patterns of medication use and transitions among these patterns for 3 consecutive years following AF diagnosis. LTA with co-variates determined the factors associated with latent status membership.

RESULTS

One-tenth (9.6%, 11.7%, 11.4%) of the study population did not receive any medication for AF in all 3 years following AF diagnosis and about 60% did not receive any medication for the prevention of thromboembolism. Among those who received medications, almost three-quarters (76.6%, 68.4%, 68.5%) received some kind of combination of medications. LTA indicated at least 6 different patterns of AF medications. These patterns had transition probabilities >85% for most of the latent statuses. All factors but diabetes mellitus among the CHA₂DS₂-VA scoring scheme were independently associated with latent status membership at the time of AF diagnosis.

CONCLUSIONS

Evaluation of pharmacological treatment indicates that prevention of thromboembolism is inadequate among women with AF. There exists wide variations in medication patterns. However, once in a particular pattern, women are likely to continue the same medications long-term. This underscores the importance of initial assessment of patient profile and stroke risk score in determining the treatment for AF. Failure to assess risk makes women susceptible to devastating AF complications.

Disparities in Premature Cardiac Death Among US Counties From 1999-2017: Temporal Trends and Key Drivers

Background Disparities in premature cardiac death (PCD) might stagnate the progress toward the reduction of PCD in the United States and worldwide. We estimated disparities across US counties in PCD rates and investigated county-level factors related to the disparities. Methods and Results We used US mortality data for cause-of-death and demographic data from death certificates and county-level characteristics data from multiple databases. PCD was defined as any death that occurred at an age between 35 and 74 years with an underlying cause of death caused by cardiac disease based on International Classification of Diseases, Tenth Revision (ICD-10), codes. Of the 1 598 173 PCDs that occurred during 1999-2017, 60.9% were out of hospital. Although the PCD rates declined from 1999-2017, the proportion of out-of-hospital PCDs among all cardiac deaths increased from 58.3% to 61.5%. The geographic disparities in PCD rates across counties widened from 1999 (Theil index=0.10) to 2017 (Theil index=0.23), and within-state differences accounted for the majority of disparities (57.4% in 2017). The disparities in out-of-hospital PCD rates (and in-hospital PCD rates) associated with demographic composition were 36.51% (and 37.51%), socioeconomic features were 18.64% (and 18.36%), healthcare environment were 18.64% (and 13.90%), and population health status were 23.73% (and 30.23%). Conclusions Disparities in PCD rates exist across US counties, which may be related to the decelerated trend of decline in the rates among middle-aged adults. The slower declines in out-of-hospital rates warrants more precision targeting and sustained efforts to ensure progress at better levels of health (with lower PCD rates) against PCD.

Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study

BACKGROUND

Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD.

METHODS AND FINDINGS

We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts.

CONCLUSIONS

Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.

Cardiac surgery in North America and coronavirus disease 2019 (COVID-19): Regional variability in burden and impact

Objective

The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in hospital resource utilization and the need to defer nonurgent cardiac surgery procedures. The present study aims to report the regional variations of North American adult cardiac surgical case volume and case mix through the first wave of the COVID-19 pandemic.

Methods

A survey was sent to recruit participating adult cardiac surgery centers in North America. Data in regard to changes in institutional and regional cardiac surgical case volume and mix were analyzed.

Results

Our study comprises 67 adult cardiac surgery institutions with diverse geographic distribution across North America, representing annualized case volumes of 60,452 in 2019. Nonurgent surgery was stopped during the month of March 2020 in the majority of centers (96%), resulting in a decline to 45% of baseline with significant regional variation. Hospitals with a high burden of hospitalized patients with COVID-19 demonstrated similar trends of decline in total volume as centers in low burden areas. As a proportion of total surgical volume, there was a relative increase of coronary artery bypass grafting surgery (high +7.2% vs low +4.2%, P = .550), extracorporeal membrane oxygenation (high +2.5% vs low 0.4%, P = .328), and heart transplantation (high +2.7% vs low 0.4%, P = .090), and decline in valvular cases (high –7.6% vs low –2.6%, P = .195).

Conclusions

The present study demonstrates the impact of COVID-19 on North American cardiac surgery institutions as well as helps associate region and COVID-19 burden with the impact on cardiac surgery volumes and case mix.

Medical students' knowledge of and attitudes towards LGBT people and their health care needs: Impact of a lecture on LGBT health

Objectives

Lesbian, gay, bisexual, and transgender (LGBT) adolescents have specific health care needs and are susceptible to health care disparities. Lack of skills and knowledge on the part of health care providers have a negative effect on their access to care and health outcomes. This study 1) explores the knowledge and attitudes of medical students regarding LGBT people, and 2) assesses the impact of a one-hour lecture targeting adolescent LGBT health needs.

Methods

Fourth-year medical students attended a compulsory one-hour lecture on sexual orientation and gender identity development in adolescence, highlighting health issues. We created a questionnaire with items to elicit students’ knowledge and attitudes about LGBT health issues. Students were invited to complete this questionnaire online anonymously one week before the lecture and one month after the lecture.

Results

Out of a total of 157 students, 107 (68.2%) responded to the pre-intervention questionnaire and 96 (61.1%) to the post-intervention questionnaire. A significant proportion—13.7% of all respondents—identified as LGBT or questioning. Our results show that most medical students already show favorable attitudes towards LGBT people and a certain degree of knowledge of LGBT health needs. They demonstrated a large and significant increase in knowledge of LGBT health issues one month after the lecture.

Discussion

A single one-hour lecture on sexual orientation and LGBT health issues may increase knowledge among medical students. Medical students and professionals should receive such training to increase their knowledge about LGBT patients as it, together with favorable attitudes, has the potential to improve health outcomes among this vulnerable population.

Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017

Importance

Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear.

Objective

To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced.

Design, Setting, and Participants

This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary's residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded.

Exposures

Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke.

Main Outcomes and Measures

Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality.

Results

The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, -35.4%). By 2017, this disparity was -26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, -0.02% to 0.6%]), respectively.

Conclusions and Relevance

In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.

Ten-Year Trends in Enrollment of Women and Minorities in Pivotal Trials Supporting Recent US Food and Drug Administration Approval of Novel Cardiometabolic Drugs

Background In 1993, the US Food and Drug Administration established guidelines to increase diversity by sex and race/ethnicity of participants in clinical trials supporting novel drug approvals. In this study we investigated the 10-year trends of participation of women and minorities in pivotal trials supporting approval of new molecular entities in cardiometabolic drugs from January 2008 to December 2017. Methods and Results A list of new molecular entities was abstracted from publicly available data at Drugs@Fda. Sex and race/ethnicity data were collected from trial publications. Linear regression analysis was performed to assess the relation between drug approval year and proportion of women and minorities enrolled. Thirty-five novel cardiovascular (n=24) and diabetes mellitus (n=11) drugs were approved by the US Food and Drug Administration during the study period. The median number of participants supporting each drug was 5930 (interquartile range, 3175-10 942). Women represented 36% (n=108 052) of trial participants (n=296 163). Women were underrepresented compared with their proportion of the disease population in trials of coronary heart disease (participation-to-prevalence ratio, 0.52), heart failure (participation-to-prevalence ratio, 0.58), and acute coronary syndrome (participation-to-prevalence ratio, 0.68). Among trial participants, 81% were white, 4% black, 12% Asian, and 11% Hispanic/Latino. There was no significant association between enrollment of women (P=0.29) or underrepresented minorities (P=0.45) with the drug approval year. Conclusions Over the past decade (2008-2017), women and minorities, particularly blacks, have continued to be inadequately represented in pivotal cardiometabolic clinical trials that support US Food and Drug Administration approval of new molecular entities. This may have major implications in determining efficacy of such therapies in these groups, and may impair generalizability of trial results to routine clinical practice.

Cohort profile: the STOP HIV/AIDS Program Evaluation (SHAPE) study in British Columbia, Canada

PURPOSE

The Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS) Program Evaluation (SHAPE) study is a longitudinal cohort developed to monitor the progress of an HIV testing and treatment expansion programme across the province of British Columbia (BC). The study considers how sociostructural determinants such as gender, age, sexual identity, geography, income and ethnicity influence engagement in HIV care.

PARTICIPANTS

Between January 2016 and September 2018, 644 BC residents who were at least 19 years old and diagnosed with HIV were enrolled in the study and completed a baseline survey. Participants will complete two additional follow-up surveys (18 months apart) about their HIV care experiences, with clinical follow-up ongoing.

FINDINGS TO DATE

Analyses on baseline data have found high levels of HIV care engagement and treatment success among SHAPE participants, with 95% of participants receiving antiretroviral therapy and 90% having achieved viral suppression. However, persistent disparities in HIV treatment outcomes related to age, injection drug use and housing stability have been identified and require further attention when delivering services to marginalised groups.

FUTURE PLANS

Our research will examine how engagement in HIV care evolves over time, continuing to identify barriers and facilitators for promoting equitable access to treatment and care among people living with HIV. A qualitative research project, currently in the formative phase, will compliment quantitative analyses by taking a strengths-based approach to exploring experiences of engagement and re-engagement in HIV treatment among individuals who have experienced delayed treatment initiation or treatment interruptions.