Association Between Neighborhood Disadvantage and Functional Well-being in Community-Living Older Persons

Neighborhood Deprivation and Recovery Following Traumatic Brain Injury Among Older Adults

OBJECTIVE

Understanding the extent to which neighborhood impacts recovery following traumatic brain injury (TBI) among older adults could spur targeting of rehabilitation and other services to those living in more disadvantaged areas. The objective of the present study was to determine the extent to which neighborhood disadvantage influences recovery following TBI among older adults.

Setting and Participants: Community-dwelling Medicare beneficiaries aged ≥65 years hospitalized with TBI 2010-2018.

DESIGN AND MAIN MEASURES

In this retrospective cohort study, the Area Deprivation Index (ADI) was used to assess neighborhood deprivation by linking it to 9-digit beneficiary zip codes. We used national-level rankings to divide the cohort into the top 10% (highest neighborhood disadvantage), middle 11-90%, and bottom 10% (lowest neighborhood disadvantage). Recovery was operationalized as days at home, calculated by subtracting days spent in a care environment or deceased from monthly follow-up over the year post-TBI.

RESULTS

Among 13,747 Medicare beneficiaries with TBI, 1713 (12.7%) were in the lowest decile of ADI rankings and 1030 (7.6%) were in the highest decile of ADI rankings. Following covariate adjustment, beneficiaries in neighborhoods with greatest disadvantage [rate ratio (RtR) 0.96; 95% confidence interval (CI) 0.94, 0.98] and beneficiaries in middle ADI percentiles (RtR 0.98; 95% CI 0.97, 0.99) had fewer days at home per month compared to beneficiaries in neighborhoods with lowest disadvantage.

CONCLUSION

This study provides evidence that neighborhood is associated with recovery from TBI among older adults and highlights days at home as a recovery metric that is responsive to differences in neighborhood disadvantage.

Exposure to School Racial Segregation and Late-Life Cognitive Outcomes

Importance

Disparities in cognition, including dementia occurrence, persist between non-Hispanic Black (hereinafter, Black) and non-Hispanic White (hereinafter, White) older adults, and are possibly influenced by early educational differences stemming from structural racism. However, the association between school racial segregation and later-life cognition remains underexplored.

Objective

To investigate the association between childhood contextual exposure to school racial segregation and cognitive outcomes in later life.

Design, Setting, and Participants

This cross-sectional study examined a nationally representative sample of US older adults from the Health and Retirement Study. Both restricted childhood residence data and publicly available cognitive assessment data (survey years 1995-2018) were used for Black and White participants aged 65 years and older. Data analyses were performed from March 2, 2023, to October 22, 2024.

Exposures

State-level Black and White dissimilarity index for public elementary schools in the late 1960s (range, 0-100) was used to measure school segregation. States were categorized into high segregation (≥83.6) and low segregation (<83.6) based on the top quintile.

Main Outcomes and Measures

Cognitive scores, cognitive impairment, and dementia were assessed using the Telephone Interview for Cognitive Status and proxy assessment. Multilevel regression analyses were conducted stratified by race and ethnicity, adjusting for sociodemographic covariates. Potential early-life and midlife mediators, including educational attainment, were assessed.

Results

The study sample included 3566 Black (16 104 observations) and 17 555 White (90 874 observations) participants. The mean (SD) age of the sample was 75.6 (7.5) years, and 62 187 (58.1%) were female. Participants exposed to high vs low segregation exhibited lower cognitive scores (13.6 vs 14.5) and a higher prevalence of cognitive impairment (37.0% vs 28.0%) and dementia (14.1% vs 9.3%). Multilevel analyses revealed a significant negative association between school segregation and later-life cognitive outcomes among Black participants, but not among White participants, after adjusting for covariates. Potential mediators across the life course, including educational attainment, explained 57.6% to 72.6% of the association, yet the findings were significant among Black participants for all outcomes. In the model including all mediators and covariates, Black participants exposed to high segregation exhibited significantly lower cognitive scores (coefficient, -0.26; 95% CI, -0.43 to -0.09) and a higher likelihood of cognitive impairment (adjusted odds ratio [AOR], 1.35; 95% CI, 1.12-1.63) and dementia (AOR, 1.26; 95% CI, 1.03-1.54).

Conclusions and Relevance

This cross-sectional study of Black and White older individuals found that childhood exposure to school segregation was associated with late-life cognition among the Black population. Given the increasing amount of school segregation in the US, educational policies aimed at reducing segregation are needed to address health inequities. Clinicians may leverage patients' early-life educational circumstances to promote screening, prevention, and management of cognitive disorders.

Neighborhood disadvantage is associated with working memory and hippocampal volumes among older adults

It is not well understood how neighborhood disadvantage is associated with specific domains of cognitive function and underlying brain health within older adults. Thus, the objective was to examine associations between neighborhood disadvantage, brain health, and cognitive performance, and examine whether associations were more pronounced among women. The study included 136 older adults who underwent cognitive testing and MRI. Neighborhood disadvantage was characterized using the Area Deprivation Index (ADI). Descriptive statistics, bivariate correlations, and multiple regressions were run. Multiple regressions, adjusted for age, sex, education, and depression, showed that higher ADI state rankings (greater disadvantage) were associated with poorer working memory performance (p < .01) and lower hippocampal volumes (p < .01), but not total, frontal, and white matter lesion volumes, nor visual and verbal memory performance. There were no significant sex interactions. Findings suggest that greater neighborhood disadvantage may play a role in working memory and underlying brain structure.

Changes in neighborhood disadvantage over the course of 22 years among community-living older persons

BACKGROUND

Among older persons, neighborhood disadvantage is a granular and increasingly used social determinant of health and functional well-being. The frequency of transitions into or out of a disadvantaged neighborhood over time is not known. These transitions may occur when a person moves from one location to another or when the Neighborhood Atlas, the data source for the area deprivation index (ADI) that is used to identify disadvantaged neighborhoods at the census-block level, is updated.

METHODS

From a prospective longitudinal study of community-living persons, aged 70 years or older in South Central Connecticut, neighborhood disadvantage was ascertained every 18 months for 22 years (from March 1998 to March 2020). ADI scores higher than the 80th state percentile were used to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80).

RESULTS

At baseline, 205 (29.3%) of the 699 participants were living in a disadvantaged neighborhood. Changes in neighborhood disadvantage during 14 consecutive 18-month intervals were relatively uncommon, ranging from 1.5% to 11.8%. Nearly 80% of participants had no change in neighborhood disadvantage and less than 4% had more than one change over a median follow-up of more than 9 years. Overall, the rate of transitions into or out of neighborhood disadvantage was only 2.7 per 100 person-years. These transitions were most common when the Neighborhood Atlas was updated (2013, 2015, 2018, and 2020). Comparable results were observed when decile changes in ADI scores during the 18-month intervals were evaluated.

CONCLUSIONS

In longitudinal studies of older persons with extended follow-up, it may not be necessary to update information on disadvantaged neighborhoods in circumstances when it is possible, and the degree of misclassification of neighborhood disadvantage should be relatively low in circumstances when updated information cannot be obtained.

Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management

IMPORTANCE

Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation.

OBJECTIVE

The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status.

STUDY DESIGN

This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI.

RESULTS

Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% ( P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures ( P = 0.01). When controlling for age, no clinically significant difference was demonstrated.

CONCLUSIONS

Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.

Neighborhood Disadvantage in a Nationally Representative Sample of Community-Living Older US Adults

Importance

Although neighborhood socioeconomic disadvantage has become the standard for evaluating contextual socioeconomic deprivation at the Census-block level, little is known about its prevalence or association with long-term mortality in nationally representative samples of older persons.

Objectives

To estimate the prevalence of neighborhood disadvantage among a nationally representative sample of community-living older adults; to identify how prevalence estimates differ based on relevant demographic, socioeconomic, geographic, clinical, and geriatric characteristics; and to evaluate the association between neighborhood disadvantage and all-cause mortality.

Design, Setting, and Participants

This cohort study analyzed linked data of community-living persons aged 65 years or older in the contiguous US participating in the National Health and Aging Trends Study (NHATS) from 2011 to 2021. Data on demographic, socioeconomic, geographic, clinical, and geriatric characteristics were obtained primarily from the baseline NHATS assessment. NHATS survey weights were used for all analyses. Data analysis was conducted from February to July 2024.

Main Outcomes and Measures

Neighborhood disadvantage-the main measure for each of the 3 objectives-was assessed using the area deprivation index, which was dichotomized at the worst quintile (defined as the worst 2 deciles). Ascertainment of mortality over 10 years was 100% complete.

Results

Among the 7505 participants, with a weighted mean (SD) age of 75.3 (7.4) years, 56.8% were female, 6.6% were Hispanic, 8.2% were non-Hispanic Black, and 81.7% were non-Hispanic White individuals. The prevalence of neighborhood disadvantage was 15.8% (95% CI, 14.9%-16.7%), but it differed greatly across multiple subgroups. The largest differences after adjustment for age and sex were observed for non-Hispanic Black compared with non-Hispanic White participants (rate ratio [RR], 3.11; 95% CI, 2.56-3.79); those with less than a high school diploma vs college degree or higher educational level (RR, 3.47; 95% CI, 2.75-4.39); and those in several Census divisions, with an RR as high as 7.31 (95% CI, 2.98-17.90) for West South Central vs Pacific. The mortality rates were 48.5% (95% CI, 44.6%-52.1%) and 43.5% (95% CI, 42.2%-44.7%) among participants in a disadvantaged and a nondisadvantaged neighborhood. Neighborhood disadvantage was associated with mortality after adjustment for demographic characteristics (hazard ratio [HR], 1.25; 95% CI, 1.11-1.40) but not after further adjustment for socioeconomic characteristics (HR, 1.11; 95% CI, 0.98-1.25).

Conclusions and Relevance

In this cohort study of community-living older adults, population-based estimates of neighborhood disadvantage differed greatly across multiple subgroups. This contextual indicator of socioeconomic deprivation was associated with long-term mortality, but the association was diminished and no longer significant after accounting for individual-level socioeconomic characteristics.

Association Between Restricting Symptoms and Disability After Critical Illness Among Older Adults

OBJECTIVES

Older adults who survive critical illness are at risk for increased disability, limiting their independence and quality of life. We sought to evaluate whether the occurrence of symptoms that restrict activity, that is, restricting symptoms, is associated with increased disability following an ICU hospitalization.

DESIGN

Prospective longitudinal study of community-living adults 70 years old or older who were interviewed monthly between 1998 and 2018.

SETTING

South Central Connecticut, United States.

PATIENTS

Two hundred fifty-one ICU admissions from 202 participants who were discharged alive from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Occurrence of 15 restricting symptoms (operationalized as number of symptoms and presence of ≥ 2 symptoms) and disability in activities of daily living, instrumental activities of daily living, and mobility was ascertained during monthly interviews throughout the study period. We constructed multivariable Poisson regression models to evaluate the association between post-ICU restricting symptoms and subsequent disability over the 6 months following ICU hospitalization, adjusting for known risk factors for post-ICU disability including pre-ICU disability, frailty, cognitive impairment, mechanical ventilation, and ICU length of stay. The mean age of participants was 83.5 years ( sd , 5.6 yr); 57% were female. Over the 6 months following ICU hospitalization, each unit increase in the number of restricting symptoms was associated with a 5% increase in the number of disabilities (adjusted rate ratio, 1.05; 95% CI, 1.04-1.06). The presence of greater than or equal to 2 restricting symptoms was associated with a 29% greater number of disabilities over the 6 months following ICU hospitalization as compared with less than 2 symptoms (adjusted rate ratio, 1.29; 95% CI, 1.22-1.36).

CONCLUSIONS

In this longitudinal cohort of community-living older adults, symptoms restricting activity were independently associated with increased disability after ICU hospitalization. These findings suggest that management of restricting symptoms may enhance functional recovery among older ICU survivors.

Associations between the urban neighbourhood built and social environment characteristics with physical functioning among mid- and older-aged adults: A systematic review

There is growing recognition of the association between neighbourhood factors and individuals' health. This systematic review examines the associations between urban neighbourhood built and social environment characteristics with different measures of physical functioning among mid- and older-aged adults over 45 years, focusing on cross-sectional and longitudinal study designs. It responds to the increase in publications on this topic following the COVID-19 pandemic. The systematic review included 25 studies written in English from 2018 onwards sourced from 8 databases. Studies were imported into Covidence and reviewed following the 'Preferred Reporting Items for Systematic Reviews and Meta-Analysis' (PRISMA) protocols. Findings were assessed according to 13 neighbourhood environment variables: aesthetics, crime safety, greenness and parks, land use mix and destinations, neighbourhood disadvantage, pedestrian/street infrastructure, public transport, residential density, social environment, street connectivity, traffic safety, walkability, and composite variables. Significant associations in the expected direction were found for land use mix and destinations, walkability, crime safety, greenness and parks, social environment, and neighbourhood disadvantage with physical functioning in mid- and older-aged adults. Weaker evidence of expected associations was found for residential density and aesthetics. Future research avenues on this topic include investigating built and social neighbourhood environments in diverse geographies and populations, considering housing status and length of exposure to the neighbourhood environment, using longitudinal surveys over longer time periods and objective measurements.

Neighborhood Socioeconomic Deprivation and Health Care Costs in Older Community-Dwelling Adults: Importance of Functional Impairment and Frailty

BACKGROUND

Low neighborhood socioeconomic status is associated with adverse health outcomes, but its association with health care costs in older adults is uncertain.

OBJECTIVES

To estimate the association of neighborhood Area Deprivation Index (ADI) with total, inpatient, outpatient, skilled nursing facility (SNF), and home health care (HHC) costs among older community-dwelling Medicare beneficiaries, and determine whether these associations are explained by multimorbidity, phenotypic frailty, or functional impairments.

DESIGN

Four prospective cohort studies linked with each other and with Medicare claims.

PARTICIPANTS

In total, 8165 community-dwelling fee-for-service beneficiaries (mean age 79.2 years, 52.9% female).

MAIN MEASURES

ADI of participant residence census tract, Hierarchical Conditions Category multimorbidity score, self-reported functional impairments (difficulty performing four activities of daily living), and frailty phenotype. Total, inpatient, outpatient, post-acute SNF, and HHC costs (US 2020 dollars) for 36 months after the index examination.

KEY RESULTS

Mean incremental annualized total health care costs adjusted for age, race/ethnicity, and sex increased with ADI ($3317 [95% CI 1274 to 5360] for the most deprived vs least deprived ADI quintile, and overall p-value for ADI variable 0.009). The incremental cost for the most deprived vs least deprived ADI quintile was increasingly attenuated after separate adjustment for multimorbidity ($2407 [95% CI 416 to 4398], overall ADI p-value 0.066), frailty phenotype ($1962 [95% CI 11 to 3913], overall ADI p-value 0.22), or functional impairments ($1246 [95% CI -706 to 3198], overall ADI p-value 0.29).

CONCLUSIONS

Total health care costs are higher for older community-dwelling Medicare beneficiaries residing in the most socioeconomically deprived areas compared to the least deprived areas. This association was not significant after accounting for the higher prevalence of phenotypic frailty and functional impairments among residents of socioeconomically deprived neighborhoods.

Neighborhood deprivation in relation to ovarian reserve and outcomes of ovarian stimulation among oocyte donors

OBJECTIVE

To study the relationship between neighborhood deprivation index (NDI) and markers of ovarian reserve and outcomes of controlled ovarian stimulation among young, healthy oocyte donors.

DESIGN

Retrospective cohort study.

PATIENTS

A total of 547 oocyte donors who underwent 905 oocyte retrieval cycles (2008-2020) at a private fertility center in Sandy Springs, Georgia, United States.

INTERVENTIONS

Neighborhood deprivation index was calculated using principal component analysis applied to census-level measures of poverty, employment, household composition, and public assistance, which was then standardized and linked to donor information on the basis of donor residence.

MAIN OUTCOME MEASURES

Markers of ovarian reserve, including antral follicle count (AFC) and antimüllerian hormone (AMH) levels, and outcomes of controlled ovarian stimulation including number of total and mature oocytes retrieved and ovarian sensitivity index (OSI) (defined as the number of oocytes retrieved/total gonadotropin dose × 1,000). Multivariable generalized estimating equations with Poisson and normal distribution were used to model the relationship between NDI and outcome measures adjusting for age, body mass index, and year of retrieval.

RESULTS

The mean (SD) age of donors was 25.0 (2.8) years and 29% of the donors were racial or ethnic minorities. There were no associations between donor NDI and ovarian reserve markers. For every interquartile range increase in NDI, there was a reduction of -1.5% (95% confidence interval: -5.3% to 2.4%) in total oocytes retrieved although the effect estimate was imprecise. Associations of NDI with a number of mature oocytes retrieved and OSI were in a similar direction. We observed evidence for effect modification of the NDI and OSI association by donor race. There was a suggestive positive association between NDI and OSI in Black donors but no association in White donors.

CONCLUSION

In this cohort of young, healthy, racially diverse oocyte donors, we found little evidence of associations between NDI and markers of ovarian reserve or outcomes of ovarian stimulation.

Association of Childhood Exposure to School Racial Segregation with Late-Life Cognitive Outcomes among Older Americans

IMPORTANCE

Disparities in cognition, including dementia occurrence, persist between White and Black older adults, and are possibly influenced by early educational differences stemming from structural racism. However, the relationship between school racial segregation and later-life cognition remains underexplored.

OBJECTIVE

To investigate the association between childhood contextual exposure to school racial segregation and cognitive outcomes in later life.

DESIGN SETTING AND PARTICIPANTS

Data from 16,625 non-Hispanic White (hereafter, White) and 3,335 non-Hispanic Black (hereafter, Black) Americans aged 65 or older were analyzed from the Health and Retirement Study.

EXPOSURES

State-level White-Black dissimilarity index for public elementary schools in the late 1960s (range: 0-100) was used to measure school segregation. States were categorized into high segregation (383.6) and low segregation (<83.6) based on the top quintile.

MAIN OUTCOMES AND MEASURES

Cognitive scores, cognitive impairment (with or without dementia), and dementia were assessed using the Telephone Interview for Cognitive Status (TICS) and proxy assessment. Multilevel regression analyses were conducted, adjusting for demographic covariates, socioeconomic status, and health factors. Stratified analyses by race were performed.

RESULTS

The mean (SD) age of participants was 78.5 (5.7) years, and 11,208 (56.2%) were female. Participants exposed to high segregation exhibited lower cognitive scores (12.6 vs. 13.6; P<0.001) and higher prevalence of cognitive impairment (50.8% vs 41.4%; P<0.001) and dementia (26.0% vs. 19.5%; P<0.001), compared to those with low segregation exposure. Multilevel analyses revealed a significant negative association between school segregation and later-life cognitive even after adjusting sequentially for potential confounders, and these associations were stronger among Black than White participants. Notably, in the fully adjusted model, Black participants exposed to high segregation displayed significantly lower cognitive scores (-0.51; 95% CI: -0.94, -0.09) and higher likelihood of cognitive impairment (adjusted Odds Ratio [aOR]: 1.45, 95% CI: 1.22, 1.72) and dementia (aOR: 1.31, 95% CI: 1.06, 1.63).

CONCLUSIONS AND RELEVANCE

Our study underscores that childhood exposure to state-level school segregation is associated with late-life cognition, especially for Black Americans. Given the rising trend of school segregation in the US, educational policies aimed at reducing segregation are crucial to address health inequities. Clinicians can leverage patients' early-life educational circumstances to promote screening, prevention, and management of cognitive disorders.

Relationship between health-related quality of life, depression, and anxiety in older primary care patients and their family members

OBJECTIVES

Patient-family member dyads experience transitions through illness as an interdependent team. This study measures the association of depression, anxiety, and health-related quality of life (HRQOL) of older adult primary care patient-family member dyads.

METHODS

Baseline data from 1,808 patient-family member dyads enrolled in a trial testing early detection of Alzheimer's disease and related dementias in primary care. Actor-Partner Independence Model was used to analyze dyadic relationships between patients' and family members' depression (PHQ-9), anxiety (GAD-7), and HRQOL (SF-36 Physical Component Summary score and Mental Component Summary score).

RESULTS

Family member mean (SD) age is 64.2 (13) years; 32.2% male; 84.6% White; and 64.8% being the patient's spouse/partner. Patient mean (SD) age is 73.7 (5.7) years; 47% male; and 85.1% White. For HRQOL, there were significant actor effects for patient and family member depression alone and depression and anxiety together on their own HRQOL (p < 0.001). There were significant partner effects where family member depression combined with anxiety was associated with the patient's physical component summary score of the SF-36 (p = 0.010), and where the family member's anxiety alone was associated with the patient's mental component summary score of the SF-36 (p = 0.031).

CONCLUSION

Results from this study reveal that many dyads experience covarying health status (e.g. depression, anxiety) even prior to entering a caregiving situation.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia

PURPOSE

Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge.

METHOD

A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated.

RESULTS

ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided.

CONCLUSIONS

These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

Neighborhood Disadvantage and Breast Cancer-Specific Survival in the US

Importance

Despite improvements in breast cancer screening, treatment, and survival, disparate breast cancer-specific survival outcomes persist, particularly in disadvantaged neighborhoods. Most of these disparities are attributed to disparities in individual, tumor, and treatment characteristics. However, a critical knowledge gap exists as to whether disparities in breast cancer-specific survival remain after accounting for individual, tumor, and treatment characteristics.

Objective

To evaluate if neighborhood disadvantage is associated with shorter breast cancer-specific survival after controlling for individual, tumor, and treatment characteristics in a national population.

Design, Setting, and Participants

This national retrospective cohort study included patients with breast cancer diagnosed from 2013 to 2018 from the Surveillance, Epidemiology, and End Results 17 Census tract-level socioeconomic status and rurality database of the National Cancer Institute. Data analysis was performed from September 2022 to December 2023.

Exposures

Neighborhood disadvantage measured by Yost index quintiles.

Main Outcomes and Measures

Breast cancer-specific survival was evaluated using a competing risks cause-specific hazard model controlling for age, race, ethnicity, rurality, stage, subtype, insurance, and receipt of treatment.

Results

A total of 350 824 patients with breast cancer were included; 41 519 (11.8%) were Hispanic, 39 631 (11.3%) were non-Hispanic Black, and 234 698 (66.9%) were non-Hispanic White. A total of 87 635 patients (25.0%) lived in the most advantaged neighborhoods (group 5) and 52 439 (14.9%) lived in the most disadvantaged neighborhoods (group 1). A larger number of non-Hispanic White patients (66 529 patients [76.2%]) lived in advantaged neighborhoods, while disadvantaged neighborhoods had the highest proportion of non-Hispanic Black (16 141 patients [30.9%]) and Hispanic patients (10 168 patients [19.5%]). Breast cancer-specific survival analysis found the most disadvantaged neighborhoods (group 1) had the highest risk of mortality (hazard ratio, 1.43; 95% CI, 1.36-1.50; P < .001) compared with the most advantaged neighborhoods.

Conclusions and Relevance

In this national cohort study of patients with breast cancer, neighborhood disadvantage was independently associated with shorter breast cancer-specific survival even after controlling for individual-level factors, tumor characteristics, and treatment. This suggests potential unaccounted-for mechanisms, including both nonbiologic factors and biologic factors.

Exploring the impacts of neighborhood disadvantage on Medicare beneficiaries' early COVID-19 vaccine uptake

A variety of factors influenced the American public's experiences with the COVID-19 pandemic and initial availability and uptake of COVID-19 vaccines. To examine variation in early COVID-19 vaccine uptake based on neighborhood disadvantage along with individual sociodemographic and health characteristics, we used Spring 2021 data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative, longitudinal survey of the Medicare population conducted by the Centers for Medicare & Medicaid Services. Bivariate analyses showed that beneficiaries in disadvantaged neighborhoods were less likely to have received at least one vaccine dose than those in less disadvantaged neighborhoods (49.7%, SE = 1.6 versus 66.6%, SE = 1.0, p < 0.0001). After accounting for individual characteristics, the relationship between neighborhood disadvantage and vaccine uptake was not statistically significant. However, interaction effects of neighborhood disadvantage by urbanicity showed a more complex picture, where those in disadvantaged urban areas had the lowest odds of vaccine uptake (p < 0.01). The relationship between neighborhood disadvantage and vaccination is multifaceted, requiring further research to inform future vaccination efforts targeting the most vulnerable beneficiaries.

Evidence of COVID-19 fatalities in Swedish neighborhoods from a full population study

The COVID-19 pandemic has highlighted a debate about whether marginalized communities suffered the disproportionate brunt of the pandemic's mortality. Empirical studies addressing this question typically suffer from statistical uncertainties and potential biases associated with uneven and incomplete reporting. We use geo-coded micro-level data for the entire population of Sweden to analyze how local neighborhood characteristics affect the likelihood of dying with COVID-19 at individual level, given the individual's overall risk of death. We control for several individual and regional characteristics to compare the results in specific communities to overall death patterns in Sweden during 2020. When accounting for the probability to die of any cause, we find that individuals residing in socioeconomically disadvantaged neighborhoods were not more likely to die with COVID-19 than individuals residing elsewhere. Importantly, we do find that individuals show a generally higher probability of death in these neighborhoods. Nevertheless, ethnicity is an important explanatory factor for COVID-19 deaths for foreign-born individuals, especially from East Africa, who are more likely to pass away regardless of residential neighborhood.

Impact of Neighborhood Disadvantage on Tumor Biology and Breast Cancer Survival

OBJECTIVE

The aim of this study was to evaluate the association between neighborhood disadvantage and Oncotype DX score, a surrogate for tumor biology, among a national cohort.

BACKGROUND

Women living in disadvantaged neighborhoods have shorter breast cancer (BC) survival, even after accounting for individual-level, tumor, and treatment characteristics. This suggests unaccounted social and biological mechanisms by which neighborhood disadvantage may impact BC survival.

METHODS

This cross-sectional study included stage I and II, ER + /HER2 - BC patients with Oncotype DX score data from the National Cancer Database (NCDB) from 2004 to 2019. Multivariate regression models tested the association of neighborhood-level income on Oncotype DX score controlling for age, race/ethnicity, insurance, clinical stage, and education. Cox regression assessed overall survival.

RESULTS

Of the 294,283 total BC patients selected, the majority were non-Hispanic White (n=237,197, 80.6%) with 7.6% non-Hispanic Black (n=22,495) and 4.5% other (n=13,383). 27.1% (n=797,254) of the population lived in the disadvantaged neighborhoods with an annual neighborhood-level income of <$48,000, while 59.62% (n=175,305) lived in advantaged neighborhoods with a neighborhood-level income of >$48,000. On multivariable analysis controlling for age, race/ethnicity, insurance status, neighborhood-level education, and pathologic stage, patients in disadvantaged neighborhoods had greater odds of high-risk versus low-risk Oncotype DX scores compared with those in advantaged neighborhoods [odds ratio=1.04 (1.01-1.07), P =0.0067].

CONCLUSION AND RELEVANCE

This study takes a translational epidemiologic approach to identify that women living in the most disadvantaged neighborhoods have more aggressive tumor biology, as determined by the Oncotype DX score.

Examining and Addressing Telemedicine Disparities Through the Lens of the Social Determinants of Health: A Qualitative Study of Patient and Provider During the COVID-19 Pandemic

Accelerated use of telemedicine during the COVID-19 pandemic enabled uninterrupted healthcare delivery while unmasking care disparities for several vulnerable communities. The social determinants of health (SDOH) serve as a critical model for understanding how the circumstances in which people are born, work, and live impact health outcomes. We performed semi-structured interviews to understand patients and providers' experiences with telemedicine encounters during the COVID-19 pandemic. Through a deductive approach, we applied the SDOH to determine telemedicine's role and impact within this framework. Overall, patient and provider interviews supported the use of existing SDOH domains to describe disparities in Internet access and telemedicine use, rather than reframing technology as a sixth SDOH. In order to mitigate the digital divide, we identify and propose solutions that address SDOH-related barriers that shape the use of health information technologies.

Relationship Between Distressing Symptoms and Changes in Disability After Major Surgery Among Community-living Older Persons

OBJECTIVES

To evaluate the relationship between distressing symptoms and changes in disability after major surgery and to determine whether this relationship differs according to the timing of surgery (nonelective vs elective), sex, multimorbidity, and socioeconomic disadvantage.

BACKGROUND

Major surgery is a common and serious health event that has pronounced deleterious effects on both distressing symptoms and functional outcomes in older persons.

METHODS

From a cohort of 754 community-living persons, aged 70 or older, 392 admissions for major surgery were identified from 283 participants who were discharged from the hospital. The occurrence of 15 distressing symptoms and disability in 13 activities were assessed monthly for up to 6 months after major surgery.

RESULTS

Over the 6-month follow-up period, each unit increase in the number of distressing symptoms was associated with a 6.4% increase in the number of disabilities [adjusted rate ratio (RR): 1.064; 95% CI: 1.053, 1.074]. The corresponding increases were 4.0% (adjusted RR: 1.040; 95% CI: 1.030, 1.050) and 8.3% (adjusted RR: 1.083; 95% CI: 1.066, 1.101) for nonelective and elective surgeries. Based on exposure to multiple (ie, 2 or more) distressing symptoms, the adjusted RRs (95% CI) were 1.43 (1.35, 1.50), 1.24 (1.17, 1.31), and 1.61 (1.48, 1.75) for all, nonelective, and elective surgeries. Statistically significant associations were observed for each of the other subgroups with the exception of individual-level socioeconomic disadvantage for the number of distressing symptoms.

CONCLUSIONS

Distressing symptoms are independently associated with worsening disability, providing a potential target for improving functional outcomes after major surgery.

Pounding the Pavement: Is the Path to Brain Health Steeper for People Experiencing Greater Socioeconomic Deprivation?

Dementia is a global public health priority. Physical activity has myriad health benefits, including for reducing dementia risk. To increase physical activity, detailed understanding of influencing factors is needed. Socioeconomic deprivation affects many aspects of health and wellbeing. Qualitative research with older people experiencing socioeconomic deprivation is needed to explore barriers and enablers to engaging in physical activity, with the view to co-designing interventions for implementation trials. A whole of society approach is pivotal to improving effectiveness of physical activity interventions for older adults with cognitive impairment, and target support for people experiencing socioeconomic deprivation, to improve their health outcomes.

Changes in Restricting Symptoms after Critical Illness among Community-Living Older Adults

Rationale: Survivors of critical illness have multiple symptoms, but how restricting symptoms change after critical illness and whether these changes differ among vulnerable subgroups is unknown. Objectives: To evaluate changes in restricting symptoms over the six months after critical illness among older adults and to determine whether these changes differ by sex, multimorbidity, and individual- and neighborhood-level socioeconomic disadvantage. Methods: From a prospective longitudinal study of 754 community-living adults ⩾70 years old interviewed monthly (1998-2018), we identified 233 admissions from 193 participants to the ICU. The occurrence of 15 restricting symptoms, defined as those leading to restricted activity, were ascertained during interviews in the month before ICU admission (baseline) and each of the six months after hospital discharge. Measurements and Main Results: The occurrence and number of restricting symptoms increased more than threefold in the six months after a critical illness hospitalization (adjusted rate ratio [95% confidence interval], 3.1 [2.1-4.6] and 3.3 [2.1-5.3], respectively), relative to baseline. These increases were largest in the first month after hospitalization (adjusted rate ratio [95% confidence interval], 5.3 [3.8-7.3] and 5.4 [3.9-7.5], respectively] before declining and becoming nonsignificant in the third month. Increases in restricting symptoms did not differ significantly by sex, multimorbidity, or individual- or neighborhood-level socioeconomic disadvantage. Conclusions: Restricting symptoms increase substantially after a critical illness before returning to baseline three months after hospital discharge. Our findings highlight the need to incorporate symptom management into post-ICU care and for further investigation into whether addressing restricting symptoms can improve quality of life and functional recovery among older ICU survivors.

Neighborhood Disadvantage, Race and Ethnicity, and Postpartum Depression

Importance

Postpartum depression (PPD) is a debilitating condition with higher rates among Black individuals. Increasingly, neighborhood disadvantage is being recognized as a contributor to poor health and may be associated with adverse postpartum mental health; however, associations between neighborhood disadvantage, race and ethnicity, and PPD have not been examined.

Objective

To investigate the association between neighborhood disadvantage and PPD and evaluate the extent to which these associations may differ by race and ethnicity.

Design, Setting, and Participants

This population-based cross-sectional study included 122 995 postpartum Kaiser Permanente Northern California members 15 years or older with a live birth between October 7, 2012, and May 31, 2017, and an address in the electronic health record. Analyses were conducted from June 1, 2022, through June 30, 2023.

Exposures

Neighborhood disadvantage defined using quartiles of the Neighborhood Deprivation Index (NDI), a validated census-based socioeconomic status measure; self-reported race and ethnicity ascertained from Kaiser Permanente Northern California electronic health records.

Main Outcomes and Measures

Multivariable Poisson regression was conducted to assess associations between neighborhood disadvantage, race and ethnicity, and a diagnosis of PPD.

Results

Of 122 995 included postpartum individuals, 17 554 (14.3%) were younger than 25 years, 29 933 (24.3%) were Asian, 8125 (6.6%) were Black, 31 968 (26.0%) were Hispanic, 47 527 (38.6%) were White, 5442 (4.4%) were of other race and ethnicity, and 15 436 (12.6%) had PPD. Higher neighborhood disadvantage and race and ethnicity were associated with PPD after covariate adjustment. Compared with White individuals, Black individuals were more likely to have PPD (adjusted relative risk [ARR], 1.30; 95% CI, 1.24-1.37), whereas Asian (ARR, 0.48; 95% CI, 0.46-0.50), and Hispanic (ARR, 0.92; 95% CI, 0.89-0.96) individuals and those identified as having other race and ethnicity (ARR, 95% CI, 0.90; 0.85-0.98) were less likely to have PPD. Associations between NDI and PPD differed by race and ethnicity (likelihood ratio test for interaction, χ212 = 41.36; P < .001). Among Black individuals, the risk of PPD was the greatest overall and increased with neighborhood disadvantage in a dose-response manner (quartile [Q] 2 ARR, 1.39 [95% CI, 1.13-1.71]; Q3 ARR, 1.50 [95% CI, 1.23-1.83]; Q4 ARR, 1.60 [95% CI, 1.32-1.93]; Cochrane-Armitage test for trend, P < .001). Neighborhood disadvantage was associated with PPD among Asian (Q2 ARR, 1.17 [95% CI, 1.04-1.31]; Q3 ARR, 1.20 [95% CI, 1.06-1.35]) and White (Q3 ARR, 1.14 [95% CI, 1.07-1.21]; Q4 ARR, 1.17 [95% CI, 1.09-1.26]) individuals and those of other race and ethnicity (Q3 ARR, 1.34 [95% CI, 1.09-1.63]; Q4 ARR, 1.28 [95% CI, 1.03-1.58]), but the magnitude of risk was lower. Neighborhood disadvantage was not associated with PPD among Hispanic individuals (eg, Q2 ARR, 1.04 [95% CI, 0.94-1.14]; Q3 ARR, 1.00 [95% CI, 0.91-1.10]; Q4 ARR, 0.98 [95% CI, 0.90-1.08]).

Conclusions and Relevance

In this cross-sectional study of postpartum individuals, residing in more disadvantaged neighborhoods was associated with PPD, except among Hispanic individuals. Neighborhood disadvantage may be associated with racial and ethnic differences in postpartum mental health. Geographic targeting of mental health interventions may decrease postpartum mental health inequities.

Concentrated disadvantage and functional disability: a longitudinal neighbourhood analysis in 100 US cities

BACKGROUND

Socioeconomic disadvantage related to poverty, unemployment and social disinvestment contributes to significant disparities in community health in the USA. Yet, there remains limited ecological research on the relationship between neighbourhood disadvantage and functional disability. Much of the work in this area has focused on elderly populations without attention to variation across age and sex groups.

METHODS

Using a longitudinal dataset of almost 16 000 neighbourhoods, we examine the relationship between neighbourhood disadvantage and functional disability. Leveraging a series of cross-lagged panel models, we account for reciprocal dynamics and a range of pertinent covariates while assessing differences across age- and sex-specific groups.

RESULTS

Accounting for reciprocal effects, we found that the association between concentrated disadvantage and functional disability varies across age and sex groups. Concentrated disadvantage is most consistently associated with increased functional disability among boys (5-17 years), young men (18-34 years) and middle-aged men (35-64 years). Similar associations are found among girls (5-17 years) and middle-aged women (35-64 years).

CONCLUSION

Local neighbourhood economic conditions are significantly associated with functional disability among relatively young populations of males and females. Exposure to neighbourhood disadvantage and deprivation may accelerate disablement processes and shift the age curve of disability risk.

Dementia Risk and Disadvantaged Neighborhoods

Importance

Residence in a disadvantaged neighborhood may be associated with an increased risk for cognitive impairment and dementia but is understudied in nationally representative populations.

Objective

To investigate the association between the Area Deprivation Index (ADI) and dementia.

Design, Setting, and Participants

Retrospective cohort study within the US Veterans Health Administration from October 1, 1999, to September 30, 2021, with a national cohort of older veterans receiving care in the largest integrated health care system in the United States. For each fiscal year, a 5% random sample was selected from all patients (n = 2 398 659). Patients with missing ADI information (n = 492 721) or missing sex information (n = 6) and prevalent dementia cases (n = 25 379) were excluded. Participants had to have at least 1 follow-up visit (n = 1 662 863). The final analytic sample was 1 637 484.

Exposure

Neighborhoods were characterized with the ADI, which combines several sociodemographic indicators (eg, income, education, employment, and housing) into a census block group-level index of disadvantage. Participants were categorized into ADI rank quintiles by their census block group of residence (higher ADI rank quintile corresponds with more deprivation).

Main Outcome and Measures

Time to dementia diagnosis (using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes) was estimated with Cox proportional hazards models with age as the time scale, and the sensitivity of the findings was evaluated with Fine-Gray proportional hazards models, accounting for competing risk of death.

Results

Among the 1 637 484 Veterans Health Administration patients, the mean (SD) age was 68.6 (7.7) years, and 1 604 677 (98.0%) were men. A total of 7318 patients were Asian (0.4%), 151 818 (9.3%) were Black, 10 591 were Hispanic (0.6%), 1 422 713 (86.9%) were White, and 45 044 (2.8%) were of other or unknown race and ethnicity. During a mean (SD) follow-up of 11.0 (4.8) years, 12.8% of veterans developed dementia. Compared with veterans in the least disadvantaged neighborhood quintile, those in greater disadvantage groups had an increased risk of dementia in models adjusted for sex, race and ethnicity, and psychiatric and medical comorbid conditions (first quintile = reference; second quintile adjusted hazard ratio [HR], 1.09 [95% CI, 1.07-1.10]; third quintile adjusted HR, 1.14 [95% CI, 1.12-1.15]; fourth quintile adjusted HR, 1.16 [95% CI, 1.14-1.18]; and fifth quintile adjusted HR, 1.22 [95% CI, 1.21-1.24]). Repeating the main analysis using competing risk for mortality led to similar results.

Conclusions and Relevance

Results of this study suggest that residence within more disadvantaged neighborhoods was associated with higher risk of dementia among older veterans integrated in a national health care system.

Differential effects of lifestyle activities on disability incidence based on neighborhood amenities

BACKGROUND

This study examined the effect of neighborhood amenities on disability risk among community-dwelling older adults in Japan, based on lifestyle activities.

METHOD

This was an observational prospective cohort study. Participants comprised 13,258 older adults from the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes. We calculated participants' Walk Score using their home addresses and divided them into three groups: "car-dependent," "somewhat walkable," and "very walkable." We then calculated the average value of lifestyle activities. We divided the neighborhood amenity groups into two groups, "fewer lifestyle activities" and "more lifestyle activities," for a total of six groups. After identifying interactions between neighborhood amenities and lifestyle activities, Cox proportional hazard models to calculate hazard ratios for incident disability risk, based on neighborhood amenities and lifestyle activities.

RESULTS

An interaction occurred between neighborhood amenities and lifestyle activities (p < 0.05). Survival probabilities for incident disability based on lifestyle activities were estimated for each neighborhood amenity group: car-dependent, 1.62 (95% CI 1.07 to 2.46); somewhat walkable, 1.08 (95% CI 0.84 to 1.40); and very walkable, 1.05 (95% CI 0.87 to 1.27). Those with fewer lifestyle activities in the car-dependent group exhibited the highest risk of incident disability in the unadjusted and adjusted models.

CONCLUSION

Given that the aging population is increasing steadily, considering older adults' neighborhood amenities and lifestyle activities in their day-to-day lives can help clinicians to deliver more older adult-centered care. Incorporating the lifestyle activities and neighborhood amenities of older adults into care planning will lead to the design and development of integrated clinical and community screening programs.

Distressing symptoms after major surgery among community-living older persons

BACKGROUND

Relatively little is known about how distressing symptoms change among older persons in the setting of major surgery. Our objective was to evaluate changes in distressing symptoms after major surgery and determine whether these changes differ according to the timing of surgery (nonelective vs. elective), sex, multimorbidity, and socioeconomic disadvantage.

METHODS

From a prospective longitudinal study of 754 nondisabled community-living persons, 70 years of age or older, 368 admissions for major surgery were identified from 274 participants who were discharged from the hospital from March 1998 to December 2017. The occurrence of 15 distressing symptoms was ascertained in the month before and 6 months after major surgery. Multimorbidity was defined as more than two chronic conditions. Socioeconomic disadvantage was assessed at the individual level, based on Medicaid eligibility, and neighborhood level, based on an area deprivation index (ADI) score above the 80th state percentile.

RESULTS

In the month before major surgery, the occurrence and mean number of distressing symptoms were 19.6% and 0.75, respectively. In multivariable analyses, the rate ratios, denoting proportional increases in the 6 months after major surgery relative to presurgery values, were 2.56 (95% confidence interval [CI], 1.91-3.44) and 2.90 (95% CI, 2.01-4.18) for the occurrence and number of distressing symptoms, respectively. The corresponding values were 3.54 (95% CI, 2.06-6.08) and 4.51 for nonelective surgery (95% CI, 2.32-8.76) and 2.12 (95% CI, 1.53-2.92) and 2.20 (95% CI, 1.48-3.29) for elective surgery; p-values for interaction were 0.030 and 0.009. None of the other subgroup differences were statistically significant, although men had a greater proportional increase in the occurrence and number of distressing symptoms than women.

CONCLUSIONS

Among community-living older persons, the burden of distressing symptoms increases substantially after major surgery, especially in those having nonelective procedures. Reducing symptom burden has the potential to improve quality of life and enhance functional outcomes after major surgery.

Factors Associated With Days Away From Home in the Year After Major Surgery Among Community-living Older Persons

OBJECTIVE

To identify the factors associated with days away from home in the year after hospital discharge for major surgery.

BACKGROUND

Relatively little is known about which older persons are susceptible to spending a disproportionate amount of time in hospitals and other health care facilities after major surgery.

METHODS

From a cohort of 754 community-living persons, aged 70+ years, 394 admissions for major surgery were identified from 289 participants who were discharged from the hospital. Candidate risk factors were assessed every 18 months. Days away from home were calculated as the number of days spent in a health care facility.

RESULTS

In the year after major surgery, the mean (SD) and median (interquartile range) number of days away from home were 52.0 (92.2) and 15 (0-51). In multivariable analysis, 5 factors were independently associated with the number of days away from home: age 85 years and older, low score on the Short Physical Performance Battery, low peak expiratory flow, low functional self-efficacy, and musculoskeletal surgery. Based on the presence versus absence of these factors, the absolute mean differences in the number of days away from home ranged from 31.2 for age 85 years and older to 53.5 for low functional self-efficacy.

CONCLUSIONS

The 5 independent risk factors can be used to identify older persons who are particularly susceptible to spending a disproportionate amount of time away from home after major surgery, and a subset of these factors can also serve as targets for interventions to improve quality of life by reducing time spent in hospitals and other health care facilities.

Association of Race, Ethnicity, Education, and Neighborhood Context With Dementia Prevalence and Cognitive Impairment Severity Among Older Adults Receiving Medicaid-Funded Home and Community-Based Services

OBJECTIVE

While racial, ethnic, and socioeconomic group disparities in cognitive impairment and dementia prevalence are well-documented among community-dwelling older adults, little is known about these disparity trends among older adults receiving Medicaid-funded home- and community-based services (HCBS) in lieu of nursing home admission. The authors determined how dementia prevalence and cognitive impairment severity compare by race, ethnicity, educational attainment, and neighborhood context in a Medicaid HCBS population.

DESIGN/SETTING

A cross-sectional study in Connecticut.

PARTICIPANTS

Adults age ≥65 in the HCBS program, January-March 2019 (N = 3,520).

MEASUREMENTS

The data source was Connecticut's HCBS program Universal Assessment tool. The authors employed two outcomes: Cognitive Performance Scale (CPS2), a 9-point measure ranging from cognitively intact-very severe impairment; and presence or not of either diagnosed dementia or CPS2 score ≥4 (major impairment). Neighborhood context was measured using the Social Vulnerability Index (SVI).

RESULTS

Cohort characteristics: 75.7% female; mean(SD) age = 79.1(8.2); Non-Hispanic White = 47.8%; Hispanic = 33.6%; Non-Hispanic Black = 15.9%. Covariate-adjusted multivariate analyses revealed no dementia/major impairment prevalence differences among White, Black, and Hispanic individuals, but impairment severity was greater among Hispanic participants (b = 0.22; p = 0.02). People with more than HS education had less severe impairment (b = -0.12; p <0.001) and lower likelihood of dementia/major impairment (AOR = 0.61; p <0.001). Dementia/major impairment likelihood and impairment severity were greater in less socially vulnerable neighborhoods.

CONCLUSION

Racial and ethnic group differences in cognitive impairment are less pronounced in Medicaid-funded HCBS cohorts than in other community-dwelling older adult cohorts. SVI results suggest that, among other possible explanations, older adults with dementia may move to lower social vulnerability neighborhoods where supportive family members reside.

The neighborhood context and all-cause mortality among older adults in Puerto Rico

Background

Recent efforts have been made to collect data on neighborhood-level attributes and link them to longitudinal population-based surveys. These linked data have allowed researchers to assess the influence of neighborhood characteristics on the health of older adults in the US. However, these data exclude Puerto Rico. Because of significantly differing historical and political contexts, and widely ranging structural factors between the island and the mainland, it may not be appropriate to apply current knowledge on neighborhood health effects based on studies conducted in the US to Puerto Rico. Thus, we aim to (1) examine the types of neighborhood environments older Puerto Rican adults reside in and (2) explore the association between neighborhood environments and all-cause mortality.

Methods

We linked data from the 2000 US Census to the longitudinal Puerto Rican Elderly Health Conditions Project (PREHCO) with mortality follow-up through 2021 to examine the effects of the baseline neighborhood environment on all-cause mortality among 3,469 participants. Latent profile analysis, a model-based clustering technique, classified Puerto Rican neighborhoods based on 19 census block group indicators related to the neighborhood constructs of socioeconomic status, household composition, minority status, and housing and transportation. The associations between the latent classes and all-cause mortality were assessed using multilevel mixed-effects parametric survival models with a Weibull distribution.

Results

A five-class model was fit on 2,477 census block groups in Puerto Rico with varying patterns of social (dis)advantage. Our results show that older adults residing in neighborhoods classified as Urban High Deprivation and Urban High-Moderate Deprivation in Puerto Rico were at higher risk of death over the 19-year study period relative to the Urban Low Deprivation cluster, controlling for individual-level covariates.

Conclusions

Considering Puerto Rico's socio-structural reality, we recommend that policymakers, healthcare providers, and leaders across industries to (1) understand how individual health and mortality is embedded within larger social, cultural, structural, and historical contexts, and (2) make concerted efforts to reach out to residents living in disadvantaged community contexts to understand better what they need to successfully age in place in Puerto Rico.

The Experience of BIPOC Living with Chronic Pain in the USA: Biopsychosocial Factors that Underlie Racial Disparities in Pain Outcomes, Comorbidities, Inequities, and Barriers to Treatment

PURPOSE OF REVIEW

This review synthesizes recent findings related to the biopsychosocial processes that underlie racial disparities in chronic pain, while highlighting opportunities for interventions to reduce disparities in pain treatment among BIPOC.

RECENT FINDINGS

Chronic pain is a prevalent and costly public health concern that disproportionately burdens Black, Indigenous, and people of color (BIPOC). This unequal burden arises from an interplay among biological, psychological, and social factors. Social determinants of health (e.g., income, education level, and lack of access or inability to utilize healthcare services) are known to affect overall health, including chronic pain, and disproportionately affect BIPOC communities. This burden is exacerbated by exposure to psychosocial stressors (i.e., perceived injustice, discrimination, and race-based traumatic stress) and can affect biological systems that modulate pain (i.e., inflammation and pain epigenetics). Further, there are racial/ethnic disparities in pain treatment, perpetuating the cycle of undermanaged chronic pain among BIPOC.

Neighborhood disadvantage and dementia incidence in a cohort of Asian American and non-Latino White older adults in Northern California

INTRODUCTION

Some evidence suggests that neighborhood socioeconomic disadvantage is associated with dementia-related outcomes. However, prior research is predominantly among non-Latino Whites.

METHODS

We evaluated the association between neighborhood disadvantage (Area Deprivation Index [ADI]) and dementia incidence in Asian American (n = 18,103) and non-Latino White (n = 149,385) members of a Northern California integrated health care delivery system aged 60 to 89 at baseline. Race/ethnicity-specific Cox proportional hazards models adjusted for individual-level age, sex, socioeconomic measures, and block group population density estimated hazard ratios (HRs) for dementia.

RESULTS

Among non-Latino Whites, ADI was associated with dementia incidence (most vs. least disadvantaged ADI quintile HR = 1.09, 95% confidence interval [CI] = 1.02-1.15). Among Asian Americans, associations were close to null (e.g., most vs. least disadvantaged ADI quintile HR = 1.01, 95% CI = 0.85-1.21).

DISCUSSION

ADI was associated with dementia incidence among non-Latino Whites but not Asian Americans. Understanding the potentially different mechanisms driving dementia incidence in these groups could inform dementia prevention efforts.

Does Age Younger Than 65 Affect Clinical Outcomes in Medicare Patients Undergoing Lumbar Fusion?

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To determine if age (younger than 65) and Medicare status affect patient outcomes following lumbar fusion.

SUMMARY OF BACKGROUND DATA

Medicare is a common spine surgery insurance provider, but most qualifying patients are older than age 65. There is a paucity of literature investigating clinical outcomes for Medicare patients under the age of 65.

MATERIALS AND METHODS

Patients 40 years and older who underwent lumbar fusion surgery between 2014 and 2019 were queried from electronic medical records. Patients with >2 levels fused, >3 levels decompressed, incomplete patient-reported outcome measures (PROMs), revision procedures, and tumor/infection diagnosis were excluded. Patients were placed into 4 groups based on Medicare status and age: no Medicare under 65 years (NM<65), no Medicare 65 years or older (NM≥65), yes Medicare under 65 (YM<65), and yes Medicare 65 years or older (YM≥65). T tests and χ 2 tests analyzed univariate comparisons depending on continuous or categorical type. Multivariate regression for ∆PROMs controlled for confounders. Alpha was set at 0.05.

RESULTS

Of the 1097 patients, 567 were NM<65 (51.7%), 133 were NM≥65 (12.1%), 42 were YM<65 (3.8%), and 355 were YM≥65 (32.4%). The YM<65 group had significantly worse preoperative Visual Analog Scale back ( P =0.01) and preoperative and postoperative Oswestry Disability Index (ODI), Short-Form 12 Mental Component Score (MCS-12), and Physical Component Score (PCS-12). However, on regression analysis, there were no significant differences in ∆PROMs for YM <65 compared with YM≥65, and NM<65. NM<65 (compared with YM<65) was an independent predictor of decreased improvement in ∆ODI following surgery (β=12.61, P =0.007); however, overall the ODI was still lower in the NM<65 compared with the YM<65.

CONCLUSION

Medicare patients younger than 65 years undergoing lumbar fusion had significantly worse preoperative and postoperative PROMs. The perioperative improvement in outcomes was similar between groups with the exception of ∆ODI, which demonstrated greater improvement in Medicare patients younger than 65 compared with non-Medicare patients younger than 65.

LEVEL OF EVIDENCE

Level III (treatment).

Association of Sociodemographic Characteristics With US Medical Student Attrition

Importance

Diversity in the medical workforce is critical to improve health care access and achieve equity for resource-limited communities. Despite increased efforts to recruit diverse medical trainees, there remains a large chasm between the racial and ethnic and socioeconomic composition of the patient population and that of the physician workforce.

Objective

To analyze student attrition from medical school by sociodemographic identities.

Design, Setting, and Participants

This retrospective cohort study included allopathic doctor of medicine (MD)-only US medical school matriculants in academic years 2014-2015 and 2015-2016. The analysis was performed from July to September 2021.

Main Outcomes and Measures

The main outcome was attrition, defined as withdrawal or dismissal from medical school for any reason. Attrition rate was explored across 3 self-reported marginalized identities: underrepresented in medicine (URiM) race and ethnicity, low income, and underresourced neighborhood status. Logistic regression was assessed for each marginalized identity and intersections across the 3 identities.

Results

Among 33 389 allopathic MD-only medical school matriculants (51.8% male), 938 (2.8%) experienced attrition from medical school within 5 years. Compared with non-Hispanic White students (423 of 18 213 [2.3%]), those without low income (593 of 25 205 [2.3%]), and those who did not grow up in an underresourced neighborhood (661 of 27 487 [2.4%]), students who were URiM (Hispanic [110 of 2096 (5.2%); adjusted odds ratio (aOR), 1.41; 95% CI, 1.13-1.77], non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander [13 of 118 (11.0%); aOR, 3.20; 95% CI, 1.76-5.80], and non-Hispanic Black/African American [120 of 2104 (5.7%); aOR, 1.41; 95% CI, 1.13-1.77]), those who had low income (345 of 8184 [4.2%]; aOR, 1.33; 95% CI, 1.15-1.54), and those from an underresourced neighborhood (277 of 5902 [4.6%]; aOR, 1.35; 95% CI, 1.16-1.58) were more likely to experience attrition from medical school. The rate of attrition from medical school was greatest among students with all 3 marginalized identities (ie, URiM, low income, and from an underresourced neighborhood), with an attrition rate 3.7 times higher than that among students who were not URiM, did not have low income, and were not from an underresourced neighborhood (7.3% [79 of 1086] vs 1.9% [397 of 20 353]; P < .001).

Conclusions and Relevance

This retrospective cohort study demonstrated a significant association of medical student attrition with individual (race and ethnicity and family income) and structural (growing up in an underresourced neighborhood) measures of marginalization. The findings highlight a need to retain students from marginalized groups in medical school.

Association Between Financial Distress with Patient and Caregiver Outcomes in Home-Based Palliative Care: A Secondary Analysis of a Clinical Trial

BACKGROUND

Serious illness often causes financial hardship for patients and families. Home-based palliative care (HBPC) may partly address this.

OBJECTIVE

Describe the prevalence and characteristics of patients and family caregivers with high financial distress at HBPC admission and examine the relationship between financial distress and patient and caregiver outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

Data for this cohort study were drawn from a pragmatic comparative-effectiveness trial testing two models of HBPC in Kaiser Permanente. We included 779 patients and 438 caregivers from January 2019 to January 2020.

MEASUREMENTS

Financial distress at admission to HBPC was measured using a global question (0-10-point scale: none=0; mild=1-5; moderate/severe=6+). Patient- (Edmonton Symptom Assessment Scale, distress thermometer, PROMIS-10) and caregiver (Preparedness for Caregiving, Zarit-12 Burden, PROMIS-10)-reported outcomes were measured at baseline and 1 month. Hospital utilization was captured using electronic medical records and claims. Mixed-effects adjusted models assessed survey measures and a proportional hazard competing risk model assessed hospital utilization.

RESULTS

Half of the patients reported some level of financial distress with younger patients more likely to have moderate/severe financial distress. Patients with moderate/severe financial distress at HBPC admission reported worse symptoms, general distress, and quality of life (QoL), and caregivers reported worse preparedness, burden, and QoL (all, p<.001). Compared to patients with no financial distress, moderate/severe financial distress patients had more social work contacts, improved symptom burden at 1 month (ESAS total score: -4.39; 95% CI: -7.61, -1.17; p<.01), and no increase in hospital-based utilization (adjusted hazard ratio: 1.11; 95% CI: 0.87-1.40; p=.41); their caregivers had improved PROMIS-10 mental scores (+2.68; 95% CI: 0.20, 5.16; p=.03). No other group differences were evident in the caregiver preparedness, burden, and physical QoL change scores.

CONCLUSION

These findings highlight the importance and need for routine assessments of financial distress and for provision of social supports required to help families receiving palliative care services.

Bayesian Multistate Life Table Methods for Large and Complex State Spaces: Development and Illustration of a New Method

Multistate life table methods are an important tool for producing easily understood measures of population health. Most contemporary uses of these methods involve sample data, thus requiring techniques for capturing uncertainty in estimates. In recent decades, several methods have been developed to do so. Among these methods, the Bayesian approach proposed by Lynch and Brown has several unique advantages. However, the approach is limited to estimating years to be spent in only two living states, such as "healthy" and "unhealthy." In this article, the authors extend this method to allow for large state spaces with "quasi-absorbing" states. The authors illustrate the new method and show its advantages using data from the Health and Retirement Study to investigate U.S. regional differences in years of remaining life to be spent with diabetes, chronic conditions, and disabilities. The method works well and yields rich output for reporting and subsequent analyses. The expanded method also should facilitate the use of multi-state life tables to address a wider array of social science research questions.

Area Deprivation Index and Gut-Brain Axis in Cirrhosis

INTRODUCTION

Neighborhood deprivation has been associated with chronic diseases and with gut microbial alterations. Although cirrhosis is associated with gut microbiome changes and hepatic encephalopathy (HE), their association is unclear.

METHODS

Demographics and cirrhosis details (model for end-stage liver disease [MELD], prior HE, and medications) were recorded from outpatients with cirrhosis. Area deprivation index (ADI), which ranks neighborhoods by socioeconomic disadvantage, was recorded as state decile and national percentile (high = worse for both) and dichotomized on the median. Patients underwent cognitive testing to diagnose minimal HE (MHE). Stool microbiota was analyzed using 16S ribosomal RNA for α/β-diversity. Multivariable analysis was used to evaluate the factors independently associated with MHE.

RESULTS

A total of 321 people with cirrhosis (60 years, 78% men, 75% non-Hispanic White, 24% non-Hispanic African American, 4% Hispanic) were included. 45% had prior HE and 56% MHE. For ADI, the national percentile was 49.1 ± 21.8 while the state decile was 6.1 ± 2.3. ADI was not associated with race, ethnicity, MELD, or HE-related variables on regression. Regarding microbiota, α-diversity was lower in MHE and prior HE patients but similar across ADI rankings. Low vs high ADIs were associated with different β-diversity in univariable but not multivariable analyses. Multivariable analyses showed positive associations with MELD, prior HE, and lactate producers ( Lactobacillus and Lacticaseibacillus ) and negative associations with short-chain fatty acid producers ( Blautia , Lachnoclostridium , and Anaerobutyricum ) with MHE.

DISCUSSION

Cirrhosis-related variables may be more influential in determining gut microbiome composition and cognitive impairment than ADI. Therefore, the focus should be on improving cirrhosis care, regardless of ADI, but studies evaluating other measures of social determinants are needed in cirrhosis.

Neighborhood Socioeconomic Disadvantage and Disability After Critical Illness

OBJECTIVES

Factors common to socioeconomically disadvantaged neighborhoods, such as low availability of transportation, may limit access to restorative care services for critical illness survivors. Our primary objective was to evaluate whether neighborhood socioeconomic disadvantage was associated with an increased disability burden after critical illness. Our secondary objective was to determine if the effect differed for those discharged to the community compared with those discharged to a facility.

DESIGN

Longitudinal cohort study with linked Medicare claims data.

SETTING

United States.

PATIENTS

One hundred ninety-nine older adults, contributing to 239 ICU admissions, who underwent monthly assessments of disability for 12 months following hospital discharge in 13 different functional tasks from 1998 to 2017.

MEASUREMENTS AND MAIN RESULTS

Neighborhood disadvantage was assessed using the area deprivation index, a 1-100 ranking evaluating poverty, housing, and employment metrics. Those living in disadvantaged neighborhoods (top quartile of scores) were less likely to self-identify as non-Hispanic White compared with those in more advantaged neighborhoods. In adjusted models, older adults living in disadvantaged neighborhoods had a 9% higher disability burden over the 12 months following ICU discharge compared with those in more advantaged areas (rate ratio, 1.09; 95% Bayesian credible interval, 1.02-1.16). In the secondary analysis adjusting for discharge destination, neighborhood disadvantage was associated with a 14% increase in disability burden over 12 months of follow-up (rate ratio, 1.14; 95% credible interval, 1.07-1.21). Disability burden was 10% higher for those living in disadvantaged neighborhoods and discharged home as compared with those discharged to a facility, but this difference was not statistically significant (interaction rate ratio, 1.10; 95% credible interval, 0.98-1.25).

CONCLUSIONS

Neighborhood socioeconomic disadvantage is associated with a higher disability burden in the 12 months after a critical illness. Future studies should evaluate barriers to functional recovery for ICU survivors living in disadvantaged neighborhoods.

Geriatric vulnerability and the burden of disability after major surgery

BACKGROUND

Strong epidemiologic evidence linking indicators of geriatric vulnerability to long-term functional outcomes after major surgery is lacking. The objective of this study was to evaluate the association between geriatric vulnerability and the burden of disability after hospital discharge for major surgery.

METHODS

From a prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older, 327 admissions for major surgery were identified from 247 participants who were discharged from the hospital from March 1997 to December 2017. The indicators of geriatric vulnerability were ascertained immediately prior to the major surgery or during the prior comprehensive assessment, which was completed every 18 months. Disability in 13 essential, instrumental and mobility activities was assessed each month.

RESULTS

The burden of disability over the 6 months after major surgery was considerably greater for non-elective than elective surgery. In multivariable analysis, 10 factors were independently associated with disability burden: age 85 years or older, female sex, Black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking, and obesity. The burden of disability increased with each additional vulnerability factor, with mean values (credible intervals) increasing from 1.6 (1.4-1.9) disabilities for 0-1 vulnerability factors to 6.6 (6.0-7.2) disabilities for 7 or more vulnerability factors. The corresponding values were 1.2 (0.9-1.5) and 5.9 (5.0-6.7) disabilities for elective surgery and 2.6 (2.1-3.1) and 8.2 (7.3-9.2) disabilities for non-elective surgery.

CONCLUSIONS

The burden of disability after hospital discharge for major surgery increases progressively as the number of geriatric vulnerability factors increases. These factors can be used to identify older persons who are particularly susceptible to poor functional outcomes after major surgery, and a subset may be amenable to intervention, including frailty, low functional self-efficacy, smoking, and obesity.