Patterns in Geographic Access to Health Care Facilities Across Neighborhoods in the United States Based on Data From the National Establishment Time-Series Between 2000 and 2014

Association Between Socioeconomic Factors and Childhood Acute Lymphoblastic Leukemia Treatment- and Survival-Related Outcomes in Canada

BACKGROUND AND AIMS

Studies examing the impact of socioeconomic factors on outcomes in childhood acute lymphoblastic leukemia (ALL) have yielded inconsistent findings. We aimed to determine whether socioeconomic status (SES) or healthcare access are associated with the presence of potentially time-sensitive high-risk features at diagnosis, times to diagnosis or treatment, or survival among children with ALL in Canada.

METHODS

We conducted a retrospective cohort study of all children aged less than 15 years diagnosed with first primary ALL between 2001 and 2019 using the Cancer in Young People in Canada national Data Tool, which is population-based. SES was measured using neighborhood income quintiles, and healthcare access proxy measured as distance to treating center. We used logistic regression to examine the associations between income quintile and distance and two potentially time-sensitive indicators of high-risk ALL at diagnosis, white blood cell count (WBC) ≥50 × 109/L, and central nervous system (CNS) disease. We used Cox proportional hazards to examine associations with time-to-event outcomes (times to diagnosis and treatment, event-free survival [EFS], and overall survival [OS]).

RESULTS

We included 4189 patients. In multivariable analyses, no associations were found between income quintile and potentially time-sensitive high-risk features at diagnosis, time to diagnosis or treatment, or OS. The only significant SES measure in multivariable survival analysis was superior EFS among those in income quintile 4 as compared to those in the lowest income quintile with a hazard ratio (HR) of 0.70 (confidence interval [CI]: 0.54-0.91). Living at increased distance from treating center was not associated with high WBC at diagnosis, time to diagnosis, EFS, or OS. Associations were seen between distance to treating center and CNS disease at diagnosis and time to treatment, but without a clear pattern across distance quartiles.

CONCLUSIONS

Children diagnosed with ALL and treated within Canada's universal healthcare system experience similar treatment and survival outcomes regardless of SES and distance to treatment center. Further work is required using individual-level SES and demographic data to determine if any associations exist, and qualitative assessments to understand barriers to care.

Community-Based Organizations Leading Research Efforts: Preliminary Findings from the Chicagoland CEAL Program's COVID-19 Vaccine Uptake and Intention Survey

BACKGROUND

To foster community engaged research in the communities most impacted by COVID-19, the National Institutes of Health (NIH) formed 21 teams of Community Engagement Alliance Against COVID-19 Disparities (CEAL). The national CEAL initiative developed a Common Survey to investigate attitudes and behaviors to the COVID-19 vaccine and clinical trials. This article describes survey implementation at the Chicagoland CEAL Program (CCP).

METHODS

This community-based participatory research project was the result of a strong collaboration between academic institutions, and a community-based non-profit health equity-focused partner organization. The survey implementation was developed and refined with strong input from CHWs, participants, and staff in the partner organizations and institutions. Survey data were collected with Qualtrics, a web-based survey tool.

RESULTS

Survey implementation resulted in data collection for 852 participants during the period 12/18/2021-02/18/2023. Excluding participants on the basis of missing data resulted in a sample of 690, 601 of which (87.10%) indicated that they had received at least one dose or intended to get vaccinated. Overall, 54 (7.83%) respondents reported that they had not received the vaccine and were not planning to.

CONCLUSION

Hard to reach populations present two unique challenges in emerging infectious disease events. Reaching populations vulnerable to poor outcomes with vaccines was essential to addressing the COVID-19 pandemic. Additionally, learning about barriers and hesitancy toward vaccine uptake is difficult in these communities. CCP's partnership of five academic institutions, a community research center, and a community-based non-profit health equity-focused organization shows what is possible when traditional models of research and inquiry are reconsidered for community-based participatory research. Results shown here are drawn from a collaboratively designed and implemented survey, collected in person, with over 90% completion.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

The Relationship Between a Hospital's Magnet Status and LGBTQ+ Inclusivity in Policies and Practices in US Hospitals

LGBTQ+ individuals face discrimination in healthcare settings. Magnet hospitals have been associated with positive patient outcomes, yet it remains uncertain whether Magnet designation is associated with hospitals' LGBTQ+ inclusivity in policies and practices. This study examined 801 American hospitals across 47 states that participated in the Healthcare Equality Index (HEI) in 2021. Multilevel modeling was utilized to investigate the association between Magnet status and HEI scores, adjusting for hospital type and state-level covariates, including LGBTQ+ inclusiveness in laws, political climate, racial/ethnic minority population, and Medicaid expansion status. Among the 801 hospitals, 32.1% (257 hospitals) held Magnet status. Magnet hospitals demonstrated higher HEI scores compared to non-Magnet hospitals (γ = 2.13, p = 0.022), despite significant variations across states (intraclass correlation = 0.22). No significant cross-level interactions were found. Overall, Magnet designation is independently associated with improved LGBTQ+ inclusivity in hospitals regardless of the state in which the hospital is located. Policymakers and healthcare leaders should consider leveraging the Magnet Recognition Program as a benchmark for promoting LGBTQ+ inclusivity within hospitals. Additionally, all healthcare institutions should prioritize comprehensive evaluations and improvements to their policies and practices to ensure inclusivity for LGBTQ+ patients.

It's Time to Define the Global Burden of Velopharyngeal Insufficiency

Velopharyngeal insufficiency (VPI) predominantly affects children with cleft palate, undermining their ability to communicate. As a result, intelligible speech generation is one of the most important outcomes following cleft palate repair. In low- and middle-income countries (LMICs), the elevated incidence of cleft palate, unavailability of speech services, and suboptimal surgical outcomes has contributed to a substantial yet poorly defined global burden of VPI. Tracking speech outcomes in LMICs is essential to assessing VPI severity and identifying patients needing care. Artificial intelligence and machine learning are well-suited to accommodate this goal.

Speaking Out: Factors Influencing Black Americans' Engagement in COVID-19 Testing and Research

Black communities in the United States (U.S.) have faced stark inequalities in COVID-19 outcomes. The underrepresentation of Black participants in COVID-19 testing research is detrimental to the understanding of the burden of the disease as well as the impact of risk factors for disease acquisition among Black Americans. Prior scholarship notes that the reluctance to engage in medical research among Black people is, in part, due to the exploitation and abuse this community has seen from the medical field and other social institutions. To better understand the barriers and motivations for COVID-19 testing among Black Americans, this study utilized intersectionality as methodological and theoretical frameworks to examine and investigate the barriers and motivations influencing participation in COVID-19 serosurveys (blood test and interview) among the metro-Atlanta Black communities. From May to October 2021, we took a community-based participatory research approach and conducted 52 semi-structured interviews to uncover different Black communities' feelings and opinions towards COVID-19 testing. Key reasons participants agreed to the blood test include (1) curiosity; (2) health upkeep; (3) family/community/social responsibility; and (4) importance of research. Participants' reasons for rejecting the blood test were (1) unnecessary/no benefit; (2) fear (of the known and unknown); (3) fear of needles and/or blood; and (4) discomfort with test setting/procedure. Our findings show that perspectives on willingness to engagement in testing or to not participate varied across gender and age for Black individuals.

Racial, Socioeconomic, and Geographic Disparities in Preamputation Vascular Care for Patients With Chronic Limb-Threatening Ischemia

BACKGROUND

Black patients, those with low socioeconomic status (SES), and those living in rural areas have elevated rates of major lower extremity amputation, which may be related to a lack of subspecialty chronic limb-threatening ischemia care. We evaluated the association between race, rurality, SES, and preamputation vascular care.

METHODS

Among patients aged 66 to 86 years with fee-for-service Medicare who underwent major lower extremity amputation for chronic limb-threatening ischemia from July 2010 to December 2019, we compared the proportion who received vascular care in the 12 months before amputation by race (Black versus White), rurality, and SES (dual eligibility for Medicaid versus no dual eligibility) using multivariable logistic regression adjusting for clinical and demographic covariates.

RESULTS

Among 73 237 patients who underwent major lower extremity amputation, 40 320 (55.1%) had an outpatient vascular subspecialist visit, 60 109 (82.1%) had lower extremity arterial testing, and 28 345 (38.7%) underwent lower extremity revascularization in the year before amputation. Black patients were less likely to have an outpatient vascular specialist visit (adjusted odds ratio [adjOR], 0.87 [95% CI, 0.84-0.90]) or revascularization (adjOR, 0.90 [95% CI, 0.86-0.93]) than White patients. Compared with patients without low SES or residing in urban areas, patients with low SES or residing in rural areas were less likely to have an outpatient vascular specialist visit (adjOR, 0.62 [95% CI, 0.60-0.64]; low SES versus nonlow SES; adjOR, 0.82 [95% CI, 0.79-0.85]; rural versus urban), lower extremity arterial testing (adjOR, 0.78 [95% CI, 0.75-0.81]; low SES versus nonlow SES; adjOR, 0.90 [95% CI, 0.0.86-0.94]; rural versus urban), or revascularization (adjOR, 0.65 [95% CI, 0.63-0.67]; low SES versus nonlow SES; adjOR, 0.89 [95% CI, 0.86-0.93]; rural versus urban).

CONCLUSIONS

Black race, rural residence, and low SES are associated with failure to receive subspecialty chronic limb-threatening ischemia care before amputation. To reduce disparities in amputation, multilevel interventions to facilitate equitable chronic limb-threatening ischemia care are needed.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

Measuring the One Health impacts associated with creating access to veterinary care before and during the COVID-19 pandemic

Integrating community perceptions into One Health assessments is critical to understanding the structural barriers that create disproportionate health outcomes for community members, their pets, and the ecosystems that encompass them, particularly in historically marginalized and under-resourced communities. The validated One Health Community Assessment (OHCA) survey instrument was used to evaluate the associated impacts of The Humane Society of the United States' Pets for Life (PFL) programming on communities' perceptions of One Health. This evaluation took place across two phases, totaling four years. In phase one (May 2018 - December 2019), the PFL intervention was administered to one urban and one rural under-resourced community, while two demographically-paired communities served as comparison sites. Five OHCA subscales (human health, pet health, environmental health, community health, perceived links) were employed to measure changes in perceptions of One Health and fourteen OHCA items were used to measure perceptions of access to human healthcare, pet care, and the environment. Initiation of the confirmatory second phase of the study (May 2020-October 2021), in which all four communities received the intervention, coincided with the onset of the COVID-19 pandemic. The pandemic and its resulting public health mandates hindered both PFL programming and data collection. Generalized Estimating Equations were employed in both the first and second phase analyses to model changes in perceptions of One Health associated with the PFL intervention. In the study's first phase, PFL in the urban community was associated with significant increases in perceptions of community health and environmental health, and perceived access to human health care, pet care, and the environment. The presence of PFL during the study's second phase was associated with increased perceptions of environmental health. The variables of PFL and the pandemic were not able to be isolated within the analyses. However, due to the severe, negative One Health implications associated with the COVID-19 pandemic, the phase two results were interpreted from the perspective of the pandemic being the largest driver of the results. The results are consistent with previous research on the effects of the pandemic on community perceptions of health. These findings offer initial support for the hypothesis that deployment of resources focused on companion animals may affect perceptions across the One Health triad and confirms previous research on effects of the COVID-19 pandemic.

Geographic disparities in Alzheimer's disease and related dementia mortality in the US: Comparing impacts of place of birth and place of residence

Objective

This study investigates geographic variations in ADRD mortality in the US. By considering both state of residence and state of birth, we aim to discern the relative importance of these geospatial factors.

Methods

We conducted a secondary data analysis of the National Longitudinal Mortality Study (NLMS), that has 3.5 million records from 1973 to 2011 and over 0.5 million deaths. We focused on individuals born in or before 1930, tracked in NLMS cohorts from 1979 to 2000. Employing multi-level logistic regression, with individuals nested within states of residence and/or states of birth, we assessed the role of geographical factors in ADRD mortality variation.

Results

We found that both state of birth and state of residence account for a modest portion of ADRD mortality variation. Specifically, state of residence explains 1.19% of the total variation in ADRD mortality, whereas state of birth explains only 0.6%. When combined, both state of residence and state of birth account for only 1.05% of the variation, suggesting state of residence could matter more in ADRD mortality outcomes.

Conclusion

Findings of this study suggest that state of residence explains more variation in ADRD mortality than state of birth. These results indicate that factors in later life may present more impactful intervention points for curbing ADRD mortality. While early-life environmental exposures remain relevant, their role as primary determinants of ADRD in later life appears to be less pronounced in this study.

Fertility services for gay men: A website content analysis of US fertility clinics and sperm banks

BACKGROUND

Fertility preservation and subsequent third-party reproduction represents a principal pathway by which gay and bisexual cisgender men may have biologically related children. Previous studies of a similar design have commented on the availability of fertility services for sexually and gender diverse communities, but none have investigated access to the aforementioned services for this specific population.

OBJECTIVES

To assess the availability of fertility preservation and third-party reproduction services for gay and bisexual cisgender men across US fertility clinics and sperm banks.

MATERIALS AND METHODS

A content analysis was performed on a sample of fertility clinic and sperm bank websites compiled from three online sources. Sample construction and analysis were completed in 2023. Each website was systematically examined by two separate coders with a third coder deciding any discrepancies. Website coding followed a pre-constructed standardized questionnaire. Logistic regression analysis was used to identify statistically significant differences.

RESULTS

A total of 675 clinic and sperm bank websites (136 academic and 539 private) were analyzed. Five hundred and two (74.4%) offered third-party reproduction and 326 (48.3%) offered fertility preservation for gay and bisexual cisgender men. Furthermore, 248 websites (36.7%) featured some form of disqualifying language either directly communicating or implying exclusion of gay and bisexual cisgender men from these services. Private facilities were more likely to offer third-party reproduction (odds ratio [OR] = 1.88, p < 0.01) but less likely to offer fertility preservation (OR = 0.68, p < 0.05) compared with academic affiliated facilities. Lastly, states in the highest Human Rights Campaign Equality Index tier were significantly more likely to offer third-party reproduction (OR = 2.50, p < 0.01) than the lowest tier.

DISCUSSION AND CONCLUSION

These findings demonstrate great variability in access to fertility preservation and third-party reproduction services. Geography and ambiguity in facility-specific policies represent persistent barriers to family building for gay and bisexual cisgender men.

Uncovering the state of knowledge about healthcare gentrification: a scoping review protocol

INTRODUCTION

Healthcare gentrification is the process in which the distribution of healthcare resources within a neighbourhood affects residents' access to healthcare services. To understand the complexity of healthcare access and to consider the socio-structural dimensions affecting equity in access to care, we aim to explore how healthcare gentrification has been described in the scientific literature and to document the reported relations between gentrification and healthcare access.

METHODS AND ANALYSIS

We will conduct a scoping review from data published from inception to September 2024 based on the methodology developed by Arksey and O'Malley (2005) and improved by Levac et al (2010). We will search the following databases: MEDLINE (OVID), Embase (embase.com), CINAHL Plus with Full Text (EBSCO), Web of Science and Geobase (Engineering Village). The review will be conducted from February 2024 to September 2024. The search strategy will be elaborated in conjunction with a professional librarian. Screening of titles and abstracts and full-text screening will be done in duplicates. A third reviewer will arbitrate discrepancies during the screening process. We will present our results narratively.

ETHICS AND DISSEMINATION

This scoping review does not require ethical approval since it will be collected from publicly available documents. The results of this scoping review will also be presented as a scientific article, scientific conferences, research webinars also in social media, workshops and conferences organised by healthcare organisations or academic institutions or on any appropriate platform.

Geospatial and Socioeconomic Disparities Influencing the Management and Outcomes of Nonsyndromic Craniosynostosis: A Systematic Review

Geospatial and socioeconomic health disparities are potential barriers to timely diagnosis and treatment of nonsyndromic craniosynostosis. This systematic review aims to assess published literature describing disparities in craniosynostosis care and to summarize the findings surrounding patient proximity to care centers and familial socioeconomic status as predictors of surgical management and outcomes. The data sources used include PubMed, MEDLINE, and Google Scholar. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used for appraisal of the quality of the studies included. Generally, the literature reviewed suggested that socioeconomic variables including race, insurance payor, and median zip code income quartile are predictors of suboptimal craniosynostosis surgical management outcomes including older age at time of surgery and more invasive surgical approach performed. The only geospatial data element assessed was the general region of the hospital where the patient was treated. The review highlighted various knowledge gaps within published literature describing health-related disparities in patients with craniosynostosis. There is a paucity of research assessing geospatial access to craniosynostosis care centers, suggesting that further research should be performed to evaluate this potential disparity. In addition, previous studies lack granularity when assessing socioeconomic factors and only one study accounted for suture fused, which is a potential confounding variable across the other published work. These considerations should be addressed in future studies addressing this topic. The limitations of this review include potential publication bias given that unpublished work was not included. An element of reviewer bias also exists considering only one reviewer screened the articles and extracted the data.

The impact of historical redlining on neurosurgeon distribution and reimbursement in modern neighborhoods

Background

This study examines the lasting impact of historical redlining on contemporary neurosurgical care access, highlighting the need for equitable healthcare in historically marginalized communities.

Objective

To investigate how redlining affects neurosurgeon distribution and reimbursement in U.S. neighborhoods, analyzing implications for healthcare access.

Methods

An observational study was conducted using data from the Center for Medicare and Medicaid Services (CMS) National File, Home Owner's Loan Corporation (HOLC) neighborhood grades, and demographic data to evaluate neurosurgical representation across 91 U.S. cities, categorized by HOLC Grades (A, B, C, D) and gentrification status.

Results

Of the 257 neighborhoods, Grade A, B, C, and D neighborhoods comprised 5.40%, 18.80%, 45.8%, and 30.0% of the sample, respectively. Grade A, B, and C neighborhoods had more White and Asian residents and less Black residents compared to Grade D neighborhoods (p < 0.001). HOLC Grade A (OR = 4.37, 95%CI: 2.08, 9.16, p < 0.001), B (OR = 1.99, 95%CI: 1.18, 3.38, p = 0.011), and C (OR = 2.37, 95%CI: 1.57, 3.59, p < 0.001) neighborhoods were associated with a higher representation of neurosurgeons compared to Grade D neighborhoods. Reimbursement disparities were also apparent: neurosurgeons practicing in HOLC Grade D neighborhoods received significantly lower reimbursements than those in Grade A neighborhoods ($109,163.77 vs. $142,999.88, p < 0.001), Grade B neighborhoods ($109,163.77 vs. $131,459.02, p < 0.001), and Grade C neighborhoods ($109,163.77 vs. $129,070.733, p < 0.001).

Conclusion

Historical redlining continues to shape access to highly specialized healthcare such as neurosurgery. Efforts to address these disparities must consider historical context and strive to achieve more equitable access to specialized care.

Systematic Review of Longitudinal Evidence and Methodologies for Research on Neighborhood Characteristics and Brain Health

Objective: Synthesize longitudinal research evaluating neighborhood environments and cognition to identify methodological approaches, findings, and gaps. Methods: Included studies evaluated associations between neighborhood and cognition longitudinally among adults >45 years (or mean age of 65 years) living in developed nations. We extracted data on sample characteristics, exposures, outcomes, methods, overall findings, and assessment of disparities. Results: Forty studies met our inclusion criteria. Most (65%) measured exposure only once and a majority focused on green space and/or blue space (water), neighborhood socioeconomic status, and recreation/physical activity facilities. Similarly, over half studied incident impairment, cognitive function or decline (70%), with one examining MRI (2.5%) or Alzheimer's disease (7.5%). While most studies used repeated measures analysis to evaluate changes in the brain health outcome (51%), many studies did not account for any type of correlation within neighborhoods (35%). Less than half evaluated effect modification by race/ethnicity, socioeconomic status, and/or sex/gender. Evidence was mixed and dependent on exposure or outcome assessed. Conclusion: Although longitudinal research evaluating neighborhood and cognitive decline has expanded, gaps remain in types of exposures, outcomes, analytic approaches, and sample diversity.

Reduced economic disparity in biologics use for psoriasis after introducing the reducing copayment program

Biologics for psoriasis are efficient and safe, but very expensive. We investigated the association of the reducing copayment program (RCP) with changes in biologics use patterns depending on the income levels of patients with moderate-to-severe psoriasis. This nationwide cohort study included patients identified as having moderate-to-severe psoriasis between 2014 and 2020. Logistic regression models were used to estimate the odds ratio for the use of biologics according to income levels. Among 57,139 patients with moderate-to-severe psoriasis, 3464 (6.1%) used biologics for psoriasis from 2014 to 2020. After the introduction of RCP in 2017, the proportion of patients with moderate-to-severe psoriasis using biologics rapidly increased from 5.0% in 2016 to 19.2% in 2020; the increase was more remarkable in patients with the lowest or mid-low income compared to those with Medical Aid. Drug survival of biologics was higher in patients with the highest income before the RCP, but became comparable between those with high and low incomes after RCP introduction. The introduction of RCP was associated with an increased use of biologics in patients with moderate-to-severe psoriasis of all income levels; however, the effect was more pronounced in low-income patients. The RCP may contribute to alleviating the disparity in access to biologics.

Delivering COVID-19 Vaccine via Trusted Social Services: Program Evaluation Results from the Chicagoland CEAL Program

To describe the reach, implementation, and sustainability of COVID-19 vaccination programs delivered by social service community organizations. Five academic institutions in the Chicagoland CEAL (Community Engagement Alliance) program partnered with 17 community organizations from September 2021-April 2022. Interviews, community organizations program implementation tracking documents, and health department vaccination data were used to conduct the evaluation. A total of 269 events were held and 5,432 COVID-19 vaccines delivered from May 2021-April 2022. Strategies that worked best included offering vaccinations in community settings with flexible and reliable hours; pairing vaccinations with ongoing social services; giving community organizations flexibility to adjust programs; offering incentives; and vaccinating staff first. These strategies and partnership structures supported vaccine uptake, community organization alignment with their missions and communities' needs, and trust. Community organizations delivering social services are local community experts and trusted messengers. Pairing social service delivery with COVID-19 vaccination built individual and community agency. Giving COs creative control over program implementation enhanced trust and vaccine delivery. When given appropriate resources and control, community organizations can quickly deliver urgently needed health services in a public health crisis.

Geographic Disparities in Access to Neurologists and Multiple Sclerosis Care in the United States

BACKGROUND AND OBJECTIVES

A shortage of neurology clinicians and healthcare disparities may hinder access to neurologic care. This study examined disparities in geographic access to neurologists and subspecialty multiple sclerosis (MS) care among various demographic segments of the United States.

METHODS

Neurologist practice locations from 2022 CMS Care Compare physician data and MS Center locations as defined by the Consortium of Multiple Sclerosis Centers were used to compute spatial access for all U.S. census tracts. Census tract-level community characteristics (sex, age, race, ethnicity, education, income, insurance, % with computer, % without a vehicle, % with limited English, and % with hearing, vision, cognitive, and ambulatory difficulty) were obtained from 2020 American Community Survey 5-year estimates. Rural-urban status was obtained from 2010 rural-urban commuting area codes. Logistic and linear regression models were used to examine access to a neurologist or MS Center within 60 miles and 60-mile spatial access ratios.

RESULTS

Of 70,858 census tracts, 388 had no neurologists within 60 miles and 17,837 had no MS centers within 60 miles. Geographic access to neurologists (spatial access ratio [99% CI]) was lower for rural (-80.49%; CI [-81.65 to -79.30]) and micropolitan (-60.50%; CI [-62.40 to -58.51]) areas compared with metropolitan areas. Tracts with 10% greater percentage of Hispanic individuals (-4.53%; CI [-5.23 to -3.83]), men (-6.76%; CI [-8.96 to -4.5]), uninsured (-7.99%; CI [-9.72 to -6.21]), individuals with hearing difficulty (-40.72%; CI [-44.62 to -36.54]), vision difficulty (-13.0%; [-18.72 to -6.89]), and ambulatory difficulty (-15.68%; CI [-19.25 to -11.95]) had lower access to neurologists. Census tracts with 10% greater Black individuals (3.50%; CI [2.93-10.71]), college degree holders (-7.49%; CI [6.67-8.32]), individuals with computers (16.57%, CI [13.82-19.40]), individuals without a vehicle (9.57%; CI [8.69-10.47]), individuals with cognitive difficulty (25.63%; CI [19.77-31.78]), and individuals with limited English (18.5%; CI [16.30-20.73]), and 10-year older individuals (8.85%; CI [7.03-10.71]) had higher spatial access to neurologists. Covariates for access followed similar patterns for MS centers.

DISCUSSION

Geographic access to neurologists is decreased in rural areas, in areas with higher proportions of Hispanics, populations with disabilities, and those uninsured. Access is further limited for MS subspecialty care. This study highlights disparities in geographic access to neurologic care.

Asian American Enclaves and Healthcare Accessibility: An Ecologic Study Across Five States

INTRODUCTION

Access to primary care has been a long-standing priority for improving population health. Asian Americans, who often settle in ethnic enclaves, have been found to underutilize health care. Understanding geographic primary care accessibility within Asian American enclaves can help to ensure the long-term health of this fast-growing population.

METHODS

U.S. Census data from five states (California, Florida, New Jersey, New York, and Texas) were used to develop and describe census-tract level measures of Asian American enclaves and social and built environment characteristics for years 2000 and 2010. The 2-step floating catchment area method was applied to National Provider Identifier data to develop a tract-level measure of geographic primary care accessibility. Analyses were conducted in 2022-2023, and associations between enclaves (versus nonenclaves) and geographic primary care accessibility were evaluated using multivariable Poisson regression with robust variance estimation, adjusting for potential area-level confounders.

RESULTS

Of 24,482 census tracts, 26.1% were classified as Asian American enclaves. Asian American enclaves were more likely to be metropolitan and have less poverty, lower crime, and lower proportions of uninsured individuals than nonenclaves. Asian American enclaves had higher primary care accessibility than nonenclaves (adjusted prevalence ratio=1.23, 95% CI=1.17, 1.29).

CONCLUSIONS

Asian American enclaves in five of the most diverse and populous states in the U.S. had fewer markers of disadvantage and greater geographic primary care accessibility. This study contributes to the growing body of research elucidating the constellation of social and built environment features within Asian American enclaves and provides evidence of health-promoting characteristics of these neighborhoods.

Hidalgo B, Aroke EN. Neighborhood Environment and Epigenetic Age: A Scoping Review

BACKGROUND

Interest in how the neighborhood environment impacts age-related health conditions has been increasing for decades. Epigenetic changes are environmentally derived modifications to the genome that alter the way genes function-thus altering health status. Epigenetic age, a biomarker for biological age, has been shown to be a useful predictor of several age-related health conditions. Consequently, its relation to the neighborhood environment has been the focus of a growing body of literature.

OBJECTIVE

We aimed to describe the scope of the evidence on the relationship between neighborhood environmental characteristics and epigenetic age.

METHODS

Using scoping review following methods established by Arksey and O'Malley, we first defined our research questions and searched the literature in PubMed, PsycINFO, and EMBASE. Next, we selected the literature to be included, and finally, we analyzed and summarized the information.

RESULTS

Nine articles met the inclusion criteria. Most studies examined deprivation as the neighborhood characteristic of interest. While all studies were observational in design, the articles included diverse participants, including men and women, adults and children, and multiple ethnicities. Results demonstrated a relationship between the neighborhood environment and epigenetic age, whether the characteristic of interest is socioeconomic or physical.

CONCLUSIONS

Overall, studies concluded there was a relationship between neighborhood characteristics and epigenetic age, whether the characteristic of interest was socioeconomic or physical. However, findings varied based on how the neighborhood characteristic and/or epigenetic age was measured. Furthermore, a paucity of investigations on physical characteristics was noticeable and warrants increased attention.

Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study

OBJECTIVE

To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States.

DESIGN

Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18).

PARTICIPANTS

Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States.

MAIN OUTCOME MEASURES

Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt.

RESULTS

The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems.

CONCLUSIONS

Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.

Geographic Differences in Semen Quality among a Cohort of American Men Using Mail-in Sperm Testing Kits

PURPOSE

To evaluate the relationship between regional geography and sperm parameters in a cohort of American men using at-home mail-in semen collection kits with no previous self-reported history of male factor infertility.

MATERIALS AND METHODS

In this study, 5,822 men from six different regions of the United States (Northeast, Southeast, Midwest, West, Pacific, and Southwest) who self-requested semen analysis between 2019 and 2021 were enrolled.

RESULTS

Across the entire cohort, the mean sperm concentration was 43.79±55.43 ×106 sperm/mL; total sperm count 138.93±149.96 ×106 sperm/mL; total motile sperm 54.73±81.90 ×106/ejaculate; total motility 30.18%±22.87%; progressive motility 21.61%±17.32%; sperm with normal morphology 8.79%±8.87%. Patients from the West region displayed lower median sperm concentration, total motile sperm, and total motility than men from the other four regional areas. A lower median total sperm count, and lower median progressive motility were also detected among patients in the Southwest region. Conversely, higher results were detected in patients from the Midwest (higher median total motile sperm, total and motility) and from the Northeast (higher median sperm concentration and total sperm count) regions. Men from the Southeast (OR, 1.3168; 95% CI, 1.1142-1.5563) and Southwest (OR, 1.3145; 95% CI, 1.0735-1.6096) regions were more likely to have oligozoospermia than those living elsewhere.

CONCLUSIONS

This study provides the most comprehensive and up-to-date report on semen parameter variability among a cohort of men living in six different regions of the continental USA. This study will pave the way into a deeper discussion of the interplay between geography, social determinants of fertility care and semen quality.

'I just need a plan': Consumer perceptions of waiting for healthcare

RATIONALE

Wait lists are common in the provision of publicly funded services in outpatient and community settings.

AIMS AND OBJECTIVES

We aimed to explore the experiences of consumers on wait lists across a broad range of services and to understand the impact of delays in access to services on people's lives.

METHODS

Consumers with experience of being on a wait list for an outpatient or community-based health service participated in one of three focus groups. Data were transcribed and analysed inductively using a thematic approach.

RESULTS

Waiting for healthcare has detrimental impacts on health and well-being. Consumers on wait lists want their health needs addressed, but they also want the ability to plan, clear communication and to feel like someone cares. Instead, they feel forgotten by impersonal and inflexible systems with very little communication, with emergency departments and general practitioners often left to fill in the gaps.

CONCLUSIONS

More consumer-centred approaches are needed for access systems for outpatient and community services, featuring honesty about what services can realistically be provided, early access to initial assessment and information and clear lines of communication.

Epigenetic age acceleration mediates the relationship between neighborhood deprivation and pain severity in adults with or at risk for knee osteoarthritis pain

An estimated 250 million people worldwide suffer from knee osteoarthritis (KOA), with older adults having greater risk. Like other age-related diseases, residents of high-deprivation neighborhoods experience worse KOA pain outcomes compared to their more affluent neighbors. The purpose of this study was to examine the relationship between neighborhood deprivation and pain severity in KOA and the influence of epigenetic age acceleration (EpAA) on that relationship. The sample of 128 participants was mostly female (60.9%), approximately half non-Hispanic Black (49.2%), and had a mean age of 58 years. Spearman bivariate correlations revealed that pain severity positively correlated with EpAA (ρ = 0.47, p ≤ 0.001) and neighborhood deprivation (ρ = 0.25, p = 0.004). We found a positive significant relationship between neighborhood deprivation and EpAA (ρ = 0.47, p ≤ 0.001). Results indicate a mediating relationship between neighborhood deprivation (predictor), EpAA (mediator), and pain severity (outcome variable). There was a significant indirect effect of neighborhood deprivation on pain severity through EpAA, as the mediator accounted for a moderate portion of the total effect, PM = 0.44. Epigenetic age acceleration may act as a mechanism through which neighborhood deprivation leads to worse KOA pain outcomes and may play a role in the well-documented relationship between the neighborhood of residence and age-related diseases.

The Association of Mobility, Social Deprivation, and Pediatric Primary Care Outcomes in Community Health Centers

OBJECTIVE

To examine how social deprivation and residential mobility are associated with primary care use in children seeking care at community health centers (CHCs) overall and stratified by race and ethnicity.

STUDY DESIGN

We used electronic health record open cohort data from 152 896 children receiving care from 15 U S CHCs belonging to the OCHIN network. Patients were aged 3-17 years, with ≥2 primary care visits during 2012-2017 and had geocoded address data. We used negative binomial regression to calculate adjusted rates of primary care encounters and influenza vaccinations relative to neighborhood-level social deprivation.

RESULTS

Higher rates of clinic utilization were observed for children who always lived in highly deprived neighborhoods (RR = 1.11, 95% CI = 1.05-1.17) and those who moved from low-to-high deprivation neighborhoods (RR = 1.05, 95% CI = 1.01-1.09) experienced higher rates of CHC encounters compared with children who always lived in the low-deprivation neighborhoods. This trend was similar for influenza vaccinations. When analyses were stratified by race and ethnicity, we found these relationships were similar for Latino children and non-Latino White children who always lived in highly deprived neighborhoods. Residential mobility was associated with lower rates of primary care.

CONCLUSIONS

These findings suggest that children living in or moving to neighborhoods with high levels of social deprivation used more primary care CHC services than children who lived in areas with low deprivation, but moving itself was associated with less care. Clinician and delivery system awareness of patient mobility and its impacts are important to addressing equity in primary care.

Disparities in Travel-Related Barriers to Accessing Health Care From the 2017 National Household Travel Survey

Importance

Geographic access, including mode of transportation, to health care facilities remains understudied.

Objective

To identify sociodemographic factors associated with public vs private transportation use to access health care and identify the respondent, trip, and community factors associated with longer distance and time traveled for health care visits.

Design, Setting, and Participants

This cross-sectional study used data from the 2017 National Household Travel Survey, including 16 760 trips or a nationally weighted estimate of 5 550 527 364 trips to seek care in the United States. Households that completed the recruitment and retrieval survey for all members aged 5 years and older were included. Data were analyzed between June and August 2022.

Exposures

Mode of transportation (private vs public transportation) used to seek care.

Main Outcomes and Measures

Survey-weighted multivariable logistic regression models were used to identify factors associated with public vs private transportation and self-reported distance and travel time. Then, for each income category, an interaction term of race and ethnicity with type of transportation was used to estimate the specific increase in travel burden associated with using public transportation compared a private vehicle for each race category.

Results

The sample included 12 092 households and 15 063 respondents (8500 respondents [56.4%] aged 51-75 years; 8930 [59.3%] females) who had trips for medical care, of whom 1028 respondents (6.9%) were Hispanic, 1164 respondents (7.8%) were non-Hispanic Black, and 11 957 respondents (79.7%) were non-Hispanic White. Factors associated with public transportation use included non-Hispanic Black race (compared with non-Hispanic White: adjusted odds ratio [aOR], 3.54 [95% CI, 1.90-6.61]; P < .001) and household income less than $25 000 (compared with ≥$100 000: aOR, 7.16 [95% CI, 3.50-14.68]; P < .001). The additional travel time associated with use of public transportation compared with private vehicle use varied by race and household income, with non-Hispanic Black respondents with income of $25 000 to $49 999 experiencing higher burden associated with public transportation (mean difference, 81.9 [95% CI, 48.5-115.3] minutes) than non-Hispanic White respondents with similar income (mean difference, 25.5 [95% CI, 17.5-33.5] minutes; P < .001).

Conclusions and Relevance

These findings suggest that certain racial, ethnic, and socioeconomically disadvantaged populations rely on public transportation to seek health care and that reducing delays associated with public transportation could improve care for these patients.

The unequal burden of time toxicity

Many cancer treatments impose large time investments on patients. We have termed these time burdens 'time toxicity' and have urged their consideration as adverse events of treatment. Here, we discuss time toxicity measures while considering inequitable access to healthcare, time as a resource, and patterns of time toxicity.

National trends and disparities in retail food environments in the USA between 1990 and 2014

OBJECTIVE

To describe national disparities in retail food environments by neighbourhood composition (race/ethnicity and socio-economic status) across time and space.

DESIGN

We examined built food environments (retail outlets) between 1990 and 2014 for census tracts in the contiguous USA (n 71 547). We measured retail food environment as counts of all food stores, all unhealthy food sources (including fast food, convenience stores, bakeries and ice cream) and healthy food stores (including supermarkets, fruit and vegetable markets) from National Establishment Time Series business data. Changes in food environment were mapped to display spatial patterns. Multi-level Poisson models, clustered by tract, estimated time trends in counts of food stores with a land area offset and independent variables population density, racial composition (categorised as predominantly one race/ethnicity (>60 %) or mixed), and inflation-adjusted income tertile.

SETTING

The contiguous USA between 1990 and 2014.

PARTICIPANTS

All census tracts (n 71 547).

RESULTS

All food stores and unhealthy food sources increased, while the subcategory healthy food remained relatively stable. In models adjusting for population density, predominantly non-Hispanic Black, Hispanic, Asian and mixed tracts had significantly more destinations of all food categories than predominantly non-Hispanic White tracts. This disparity increased over time, predominantly driven by larger increases in unhealthy food sources for tracts which were not predominantly non-Hispanic White. Income and food store access were inversely related, although disparities narrowed over time.

CONCLUSIONS

Our findings illustrate a national food landscape with both persistent and shifting spatial patterns in the availability of establishments across neighbourhoods with different racial/ethnic and socio-economic compositions.

Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018

BACKGROUND

Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear.

OBJECTIVE

To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA.

DESIGN

Repeated cross-sectional.

SETTING

National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018.

PARTICIPANTS

Office-based physicians.

MEASURES

Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration.

RESULTS

Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care.

LIMITATION

Self-reported visit length.

CONCLUSION

Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.

Evaluation of Inequities in Cancer Treatment Delay or Discontinuation Following SARS-CoV-2 Infection

IMPORTANCE

There is a disproportionately greater burden of COVID-19 among Hispanic and non-Hispanic Black individuals, who also experience poorer cancer outcomes. Understanding individual-level and area-level factors contributing to inequities at the intersection of COVID-19 and cancer is critical.

OBJECTIVE

To evaluate associations of individual-level and area-level social determinants of health (SDOH) with delayed or discontinued cancer treatment following SARS-CoV-2 infection.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, registry-based cohort study used data from 4768 patients receiving cancer care who had positive test results for SARS-CoV-2 and were enrolled in the American Society for Clinical Oncology COVID-19 Registry. Data were collected from April 1, 2020, to September 26, 2022.

EXPOSURES

Race and ethnicity, sex, age, and area-level SDOH based on zip codes of residence at the time of cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Delayed (≥14 days) or discontinued cancer treatment (any cancer treatment, surgery, pharmacotherapy, or radiotherapy) and time (in days) to restart pharmacotherapy.

RESULTS

A total of 4768 patients (2756 women [57.8%]; 1558 [32.7%] aged ≥70 years at diagnosis) were included in the analysis. There were 630 Hispanic (13.2%), 196 non-Hispanic Asian American or Pacific Islander (4.1%), 568 non-Hispanic Black (11.9%), and 3173 non-Hispanic White individuals (66.5%). Compared with non-Hispanic White individuals, Hispanic and non-Hispanic Black individuals were more likely to experience a delay of at least 14 days or discontinuation of any treatment and drug-based treatment; only estimates for non-Hispanic Black individuals were statistically significant, with correction for multiple comparisons (risk ratios [RRs], 1.35 [95% CI, 1.22-1.49] and 1.37 [95% CI, 1.23-1.52], respectively). Area-level SDOH (eg, geography, proportion of residents without health insurance or with only a high school education, lower median household income) were associated with delayed or discontinued treatment. In multivariable Cox proportinal hazards regression models, estimates suggested that Hispanic (hazard ratio [HR], 0.87 [95% CI, 0.71-1.05]), non-Hispanic Asian American or Pacific Islander (HR, 0.79 [95% CI, 0.46-1.35]), and non-Hispanic Black individuals (HR, 0.81 [95% CI, 0.67-0.97]) experienced longer delays to restarting pharmacotherapy compared with non-Hispanic White individuals.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that race and ethnicity and area-level SDOH were associated with delayed or discontinued cancer treatment and longer delays to the restart of drug-based therapies following SARS-CoV-2 infection. Such treatment delays could exacerbate persistent cancer survival inequities in the United States.

Neighborhood Disadvantage and Poor Health: The Consequences of Race, Gender, and Age among Young Adults

The objective of this study is to examine the relationship between neighborhood disadvantage and poor self-rated health for a nationally representative sample of Blacks and Whites in young adulthood, 18 to 30 years old. Data were from 16 waves (1997–2013) of the National Longitudinal Survey of Youth 1997 cohort (N = 6820 individuals; observations = 58,901). Utilizing the stress process model and generalized estimating equations to account for the correlated nature of multiple responses over time, results show that neighborhood disadvantage increases the odds of poor health for all groups. This positive association is strongest in the most disadvantaged neighborhoods and is heightened as young adults age. There are also notable race and gender differences. For example, Blacks, who live in the most highly disadvantaged neighborhoods, seem to be somewhat shielded from the most deleterious effects of poor neighborhood conditions compared to their White counterparts. Despite greater proportions of Blacks residing in harsh neighborhood environments, Black men experience better health than all other groups, and the health of Black women is no worse compared to White men or women. Limitations and directions for future research are discussed.

Racial/Ethnic Disparities in Health Care Setting Choice for Adults Seeking Severe Acute Respiratory Syndrome Coronavirus 2 Testing

OBJECTIVES

Equitable access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing is important for reducing disparities. We sought to examine differences in the health care setting choice for SARS-CoV-2 testing by race/ethnicity and insurance. Options included traditional health care settings and mobile testing units (MTUs) targeting communities experiencing disproportionately high coronavirus disease 2019 (COVID-19) rates.

METHODS

We conducted a retrospective, observational study among patients in a large health system in the Southeastern US. Descriptive statistics and multinomial logistic regression analyses were employed to evaluate associations between patient characteristics and health care setting choice for SARS-CoV-2 testing, defined as: (1) outpatient (OP) care; (2) emergency department (ED); (3) urgent care (UC); and (4) MTUs. Patient characteristics included race/ethnicity, insurance, and the existence of an established relationship with the health care system.

RESULTS

Our analytic sample included 105,386 adult patients tested for SARS-CoV-2. Overall, 55% of patients sought care at OP, 24% at ED, 12% at UC, and 9% at MTU. The sample was 58% White, 24% Black, 11% Hispanic, and 8% other race/ethnicity. Black patients had a higher likelihood of getting tested through the ED compared with White patients. Hispanic patients had the highest likelihood of testing at MTUs. Patients without a primary care provider had a higher relative risk of being tested through the ED and MTUs versus OP.

CONCLUSIONS

Disparities by race/ethnicity were present in health care setting choice for SARS-CoV-2 testing. Health care systems may consider implementing mobile care delivery models to reach vulnerable populations. Our findings support the need for systemic change to increase primary care and health care access beyond short-term pandemic solutions.

National Trends and Outcomes Associated With Presence and Type of Usual Clinician Among Older Adults With Multimorbidity

IMPORTANCE

Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults.

OBJECTIVE

To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021.

MAIN OUTCOMES AND MEASURES

Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics.

RESULTS

A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1).

CONCLUSIONS AND RELEVANCE

In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.

No Association Between Intrauterine Contraceptive Devices and Musculoskeletal Hip Joint Pain

Purpose

To investigate the association between intrauterine device (IUD) use and hip pain, orthopaedic visits for hip pain, and arthroscopic hip surgery.

Methods

This was a retrospective cohort study of patients aged 18-44 years old using either IUDs or subdermal implants for contraception in a large commercial claims database (MarketScan) from 2012 to 2015. All patients had at least 12 months of continuous enrollment both before and after contraceptive placement. Patients with a history of hip pain or surgery were excluded. The primary outcome was new hip pain. Secondary outcomes included visiting an orthopaedic or sports medicine provider for a hip complaint, intra-articular hip injection, and arthroscopic hip surgery. Outcomes were analyzed with Cox proportional-hazard models.

Results

We identified a total of 242,383 patients, including 216,541 (89.3%) with IUDs and 25,842 (10.7%) with subdermal contraceptive implants. In time-to-event analysis, IUDs (vs implants) were not associated with increased risk of new hip pain diagnoses (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.87-1.03, P = .21). In contrast, both age (P < .001) and region (P < .001) were associated with increased risk of new hip pain. Similar results were seen for the secondary outcomes, including risk of orthopaedic visits for hip complaints (HR 1.06, 95% CI 0.83-1.35, P = .63), intra-articular injections of the hip (HR 0.94, 95% CI 0.63-1.41, P = .77), and hip arthroscopy procedures (HR 1.13, 95% CI 0.53-2.40, P = .75).

Conclusions

In this study, we found no evidence that IUDs were associated with hip pain or surgery.

Level of Evidence

Level III, retrospective cohort.

Impact of Social Vulnerability on Access to Educational Programming Designed to Enhance Living Donation

INTRODUCTION

Transplant candidate participation in the Living Donor Navigator Program is associated with an increased likelihood of achieving living donor kidney transplantation; yet not every transplant candidate participates in navigator programming.

RESEARCH QUESTION

We sought to assess interest and ability to participate in the Living Donor Navigator Program by the degree of social vulnerability.

DESIGN

Eighty-two adult kidney-only candidates initiating evaluation at our center provided Likert-scaled responses to survey questions on interest and ability to participate in the Living Donor Navigator Program. Surveys were linked at the participant-level to the Centers for Disease Control and Prevention Social Vulnerability Index and county health rankings and overall social vulnerability and subthemes, individual barriers, telehealth capabilities/ knowledge, interest, and ability to participate were assessed utilizing nonparametric Wilcoxon ranks sums tests, chi-square, and Fisher's exact tests.

RESULTS

Participants indicating distance as a barrier to participation in navigator programming lived approximately 82 miles farther from our center. Disinterested participants lived in areas with the highest social vulnerability, higher physical inactivity rates, lower college education rates, and higher uninsurance (lack of insurance) and unemployment rates. Similarly, participants without a computer, who never heard of telehealth, and who were not encouraged to participate in telehealth resided in areas of highest social vulnerability.

CONCLUSION

These data suggest geography combined with being from under-resourced areas with high social vulnerability was negatively associated with health care engagement. Geography and poverty may be surrogates for lower health literacy and fewer health care interactions.

Regional and sex differences in retinal detachment surgery: Japan-retinal detachment registry report

It is known that social factors affect the choice of treatments, and special attention has been paid to sex differences. The purpose of this study was to determine whether regional and sex differences exist in the treatment of rhegmatogenous retinal detachment (RD). We used Japan-RD Registry database of 2523 patients aged ≥ 40 years between February 2016 and March 2017 in 5 Japanese regions. Regional differences of patients' perioperative factors were analyzed. The factors affecting the proportion of patients who underwent surgery within one week of the onset, defined as early-surgery, were examined by logistic regression. We observed regional differences in perioperative factors, especially in the use of phacovitrectomy, general anesthesia, and air-tamponade, which was higher in certain regions. (Fisher's exact test, all P = 0.012) The proportion of early-surgery was significantly higher among men in Kyushu region (Odds ratio (OR) 1.83; 95% confidence interval (CI) 1.08-3.12; P = 0.02), and it was also significantly higher after adjusting for covariates (OR 1.89; 95% CI 1.06-3.42; P = 0.02). Regional and sex differences exist in the treatment of RD in Japan. Although there was no significant differences in the anatomical outcomes, women in certain regions of Japan are less likely to receive early surgical intervention for RD.

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic

IMPORTANCE

Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown.

OBJECTIVE

To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression.

EXPOSURES

A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions.

MAIN OUTCOMES AND MEASURES

Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability.

RESULTS

A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir).

CONCLUSIONS AND RELEVANCE

In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

Urban Neighborhood Characteristics and the Spatial Distribution of Home and Community-Based Service Organizations in Michigan Metropolitan Statistical Areas

Living in a neighborhood with dense HCBS organizations can promote older adults' health and well-being and may mitigate health disparities generated by living in materially deprived urban neighborhoods. Using 2016 US County Business Patterns and the American Community Survey (2013-2017), focused on 516 ZIP Codes in Michigan Metropolitan Statistical Areas, this study examines the association between neighborhood characteristics and the relative density of businesses offering services for older adults and persons with disabilities (e.g., senior centers, adult day service centers, personal care) and businesses offering home health care. Results from a series of spatial econometric models show that social care organization density tends to be high in neighborhoods with a greater number of residents who have a bachelor's degree, who are older, and who are in poverty. Home health care density was not explained by neighborhood factors. Multiple neighborhood socio-demographic indicators explain the spatial distribution of social care organizations.

Racial Disparities in Post-Acute Home Health Care Referral and Utilization among Older Adults with Diabetes

Racial and ethnic disparities exist in diabetes prevalence, health services utilization, and outcomes including disabling and life-threatening complications among patients with diabetes. Home health care may especially benefit older adults with diabetes through individualized education, advocacy, care coordination, and psychosocial support for patients and their caregivers. The purpose of this study was to examine the association between race/ethnicity and hospital discharge to home health care and subsequent utilization of home health care among a cohort of adults (age 50 and older) who experienced a diabetes-related hospitalization. The study was limited to patients who were continuously enrolled in Medicare for at least 12 months and in the United States. The cohort (n = 786,758) was followed for 14 days after their diabetes-related index hospitalization, using linked Medicare administrative, claims, and assessment data (2014–2016). Multivariate logistic regression models included patient demographics, comorbidities, hospital length of stay, geographic region, neighborhood deprivation, and rural/urban setting. In fully adjusted models, hospital discharge to home health care was significantly less likely among Hispanic (OR 0.8, 95% CI 0.8–0.8) and American Indian (OR 0.8, CI 0.8–0.8) patients compared to White patients. Among those discharged to home health care, all non-white racial/ethnic minority patients were less likely to receive services within 14-days. Future efforts to reduce racial/ethnic disparities in post-acute care outcomes among patients with a diabetes-related hospitalization should include policies and practice guidelines that address structural racism and systemic barriers to accessing home health care services.

An increase in multi-site practices: The shifting paradigm for gynecologic cancer care delivery

OBJECTIVE

To assess whether the number of practice sites per gynecologic oncologist (GO) and geographic access to GOs has changed over time.

METHODS

This is a retrospective repeated cross-sectional study using the 2015-2019 Physician Compare National File. All GOs in the 50 United States and Washington, DC, who had completed at least one year of practice were included in the study. All practice sites with complete addresses were included. Linear regression analyses estimated trends in GOs' number of practice sites and geographic dispersion of practice sites. Secondary analyses assessed temporal trends in the number of geographic areas served by at least one GO.

RESULTS

Although there was no significant change in the number of GOs from 2015 to 2019 (n = 1328), there was a significant increase in the number of practice sites (881 to 1416, p = 0.03), zip codes (642 to 984, p = 0.03), HSAs (404 to 536, p = 0.04), and HRRs (218 to 230, p = 0.03) containing a GO practice. The mean number of practice sites (1.64 versus 2.13, p < 0.001) and dispersion of practice sites (0.03 versus 0.43 miles, p = 0.049) per GO increased significantly.

CONCLUSIONS

Between 2015 and 2019, an increasing number of GOs have multi-site practices, and more geographic regions contain a GO practice. Improvements in geographic access to GOs may represent improved access to care for many women in the US, but its effect on patients, physicians, and geographic disparities is unknown.

Development of a Synthetic Population Model for Assessing Excess Risk for Cardiovascular Disease Death

Importance

Evaluating the association of social determinants of health with chronic diseases at the population level requires access to individual-level factors associated with disease, which are rarely available for large populations. Synthetic populations are a possible alternative for this purpose.

Objective

To construct and validate a synthetic population that statistically mimics the characteristics and spatial disease distribution of a real population, using real and synthetic data.

Design, Setting, and Participants

This population-based decision analytical model used data for Allegheny County, Pennsylvania, collected from January 2015 to December 2016, to build a semisynthetic population based on the synthetic population used by the modeling and simulation platform FRED (A Framework for Reconstructing Epidemiological Dynamics). Disease status was assigned to this population using health insurer claims data from the 3 major insurance providers in the county or from the National Health and Nutrition Examination Survey. Biological, social, and other variables were also obtained from the National Health Interview Survey, Allegheny County, and public databases. Data analysis was performed from November 2016 to February 2020.

Exposures

Risk of cardiovascular disease (CVD) death.

Main Outcomes and Measures

Difference between expected and observed CVD death risk. A validated risk equation was used to estimate CVD death risk.

Results

The synthetic population comprised 1 188 112 individuals with demographic characteristics similar to those of the 2010 census population in the same county. In the synthetic population, the mean (SD) age was 40.6 (23.3) years, and 622 997 were female individuals (52.4%). Mean (SD) observed 4-year rate of excess CVD death risk at the census tract level was -40 (523) per 100 000 persons. The correlation of social determinant data with difference between expected and observed CVD death risk indicated that income- and education-based social determinants were associated with risk. Estimating improved social determinants of health and biological factors associated with disease did not entirely remove the excess in CVD death rates. That is, a 20% improvement in the most significant determinants still resulted in 105 census tracts with excess CVD death risk, which represented 24% of the county population.

Conclusions and Relevance

The results of this study suggest that creating a geographically explicit synthetic population from real and synthetic data is feasible and that synthetic populations are useful for modeling disease in large populations and for estimating the outcome of interventions.