Unhealthy and uninsured: exploring racial differences in health and health insurance coverage using a life table approach

Social and Biological Determinants in Lung Cancer Disparity

Lung cancer remains a leading cause of death in the United States and globally, despite progress in treatment and screening efforts. While mortality rates have decreased in recent years, long-term survival of patients with lung cancer continues to be a challenge. Notably, African American (AA) men experience significant disparities in lung cancer compared to European Americans (EA) in terms of incidence, treatment, and survival. Previous studies have explored factors such as smoking patterns and complex social determinants, including socioeconomic status, personal beliefs, and systemic racism, indicating their role in these disparities. In addition to social factors, emerging evidence points to variations in tumor biology, immunity, and comorbid conditions contributing to racial disparities in this disease. This review emphasizes differences in smoking patterns, screening, and early detection and the intricate interplay of social, biological, and environmental conditions that make African Americans more susceptible to developing lung cancer and experiencing poorer outcomes.

The effect of prescription drug insurance on the incidence of potentially inappropriate prescribing: Evidence from Medicare Part D

The Medicare Part D program has been documented to increase the affordability and accessibility of drugs and improve the quality of prescription drug use; however, less is known about the equity impact of the Part D program on potentially inappropriate prescribing-specifically, incidences of polypharmacy and potentially inappropriate medication (PIM) use based on different racial/ethnic groups. Using a difference in the regression discontinuity design, we found that among Whites, Part D was associated with increases in polypharmacy and "broadly defined" PIM use, while the use of "always avoid" PIM remained unchanged. Conversely, Blacks and Hispanics reported no changes in such drug utilization patterns.

Alzheimer's disease and Alzheimer's disease-related dementias in Hispanics: Identifying influential factors and supporting caregivers

Alzheimer's disease (AD) and Alzheimer's disease-related dementias (ADRD) are the primary public health concerns in the United States and around the globe. AD/ADRD are irreversible mental illnesses that primarily impair memory and thought processes and may lead to cognitive decline among older individuals. The prevalence of AD/ADRD is higher in Native Americans, followed by African Americans and Hispanics. Increasing evidence suggests that Hispanics are the fastest-growing ethnic population in the USA and worldwide. Hispanics develop clinical symptoms of AD/ADRD and other comorbidities nearly seven years earlier than non-Hispanic whites. The consequences of AD/ADRD can be challenging for patients, their families, and caregivers. There is a significant increase in the burden of illness, primarily affecting Hispanic/Latino families. This is partly due to their strong sense of duty towards family, and it is exacerbated by the inadequacy of healthcare and community services that are culturally and linguistically suitable and responsive to their needs. With an increasing age population, low socioeconomic status, low education, high genetic predisposition to age-related conditions, unique cultural habits, and social behaviors, Hispanic Americans face a higher risk of AD/ADRD than other racial/ethnic groups. Our article highlights the status of Hispanic older adults with AD/ADRD. We also discussed the intervention to improve the quality of life in Hispanic caregivers.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Predictors and outcomes of acute kidney injury after bariatric surgery: analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry

BACKGROUND

Acute kidney injury (AKI) after surgery increases long-term risk of kidney dysfunction. The major risk factor for AKI after bariatric surgery is having preoperative renal insufficiency. Little is known about the outcomes and risk factors for developing AKI in patients undergoing bariatric surgery with normal renal function.

OBJECTIVE

We aimed to describe factors that may increase risk of AKI after primary bariatric surgery in patients without history of kidney disease.

SETTING

Academic hospital, United States.

METHODS

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2015 to 2019. Patients with diagnosis of chronic kidney disease were excluded. The primary outcome was incidence of AKI. Secondary outcomes included 30-day complications, readmissions, reoperations, and mortality. Univariate and multivariate analyses were performed to identify differences between patients with and without AKI.

RESULTS

A total of 747,926 patients were included in our analysis (laparoscopic sleeve gastrectomy = 73.1%, LRYGB = 26.8%). Mean age was 44.40 ± 11.94 years, with female predominance (79.7%). AKI occurred in 446 patients (.05%). Patients with postoperative AKI had higher rates of complications, readmissions, reoperations, and mortality. Significant predictors of AKI were male sex, history of venous thromboembolism, hypertension, limitation for ambulation, and LRYGB. High albumin levels and White race were protective factors.

CONCLUSIONS

New-onset AKI was associated with adverse 30-day outcomes in patients undergoing bariatric surgery. Male sex, venous thromboembolism, hypertension, limited ambulation, and LRYGB were independent predictors of AKI. Prospective studies are needed to better describe these results.

Life Course Patterns of Prescription Drug Use in the United States

Prescription drug use has reached historic highs in the United States-a trend linked to increases in medicalization, institutional factors relating to the health care and pharmaceutical industries, and population aging and growing burdens of chronic disease. Despite the high and rising prevalence of use, no estimates exist of the total number of years Americans can expect to spend taking prescription drugs over their lifetimes. This study provides the first estimates of life course patterns of prescription drug use using data from the 1996-2019 Medical Expenditure Panel Surveys, the Human Mortality Database, and the National Center for Health Statistics. Newborns in 2019 could be expected to take prescription drugs for roughly half their lives: 47.54 years for women and 36.84 years for men. The number of years individuals can expect to take five or more drugs increased substantially. Americans also experienced particularly dramatic increases in years spent taking statins, antihypertensives, and antidepressants. There are also important differences in prescription drug use by race and ethnicity: non-Hispanic Whites take the most, Hispanics take the least, and non-Hispanic Blacks fall in between these extremes. Americans are taking drugs over a wide and expanding swathe of the life course, a testament to the centrality of prescription drugs in Americans' lives today.

Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey

Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.

The effect of "failed" community mental health centers on non-white mortality

The Community Mental Health Act of 1963 established Community Mental Health Centers (CMHCs) across the country with the goal of providing continuous, comprehensive, community-oriented care to people suffering from mental illness. Despite this program being considered a failure by most contemporary accounts, the World Health Organization advocates for a transition from the institutionalization of the mentally ill to a system of community-centered care. In this paper, we construct a novel dataset documenting the rollout of CMHCs from 1971 to 1981 to identify the effect of establishing a CMHC on county level mortality rates, focusing on causes of death related to mental illness. Though we find little evidence that access to a CMHC impacted mortality rates in the white population, we find large and robust effects for the non-white population, with CMHCs reducing suicide and homicide rates by 8% and 14%, respectively. CMHCs also reduced deaths from alcohol in the female non-white population by 18%. These results suggest the historical narrative surrounding the failure of this program does not represent the non-white experience and that community care can be effective at reducing mental health related mortality in populations with the least access to alternative treatment options.

Racial disparities in post-operative complications and discharge destination following total joints arthroplasty: a national database study

INTRODUCTION

The objective of this study was to explore race-based differences in 30-day complication rates following total joint arthroplasty (TJA) using a large national database.

METHODS

Patients undergoing primary, elective THA and TKA between 2012 and 2018 were retrospectively reviewed using the ACS-NSQIP. We compared Black and Hispanic patients with non-Hispanic White patients using multivariate statistical models adjusting for demographic, operative, and medical characteristics.

RESULTS

A total of 324,795 and 200,023 patients undergoing THA and TKA, respectively, were identified. After THA, compared to White patients, Black and Hispanic patients were more likely to be diagnosed with VTE (p < 0.001), receive a blood transfusion (p < 0.001), and to be discharged to an inpatient facility (p < 0.001). After TKA, compared to White patients, Black and Hispanic patients were more likely to experience a major complication (p < 0.001 and p = 0.008, respectively), be diagnosed with VTE (p < 0.001), and be discharged to a facility (p < 0.001).

CONCLUSIONS

Our findings indicate higher rates of VTE, blood transfusions, and discharge to an inpatient facility for Black and Hispanic patients when compared to White patients following TJA, though we are unable to comment on the etiology of these disparities. These results may contribute to a growing divide with respect to outcomes and access to TJA for these at-risk patient populations.

Racial Disparities in Rates of Revision and use of Modern Features in Total Knee Arthroplasty, a National Registry Study

BACKGROUND

The purpose of our study was to investigate the association of race and ethnicity with rates of modern implant use and postoperative outcomes in total knee arthroplasty (TKA) using the American Academy of Orthopaedic Surgeons American Joint Replacement Registry.

METHODS

Adult TKAs from 2012 to 2020 were queried from the American Joint Replacement Registry. A total of 1,121,457 patients were available for analysis for surgical features and 1,068,210 patients for analysis of outcomes. Mixed-effects multivariable logistic regression models were used to examine the association of race with each individual surgical feature (unicompartmental knee arthroplasty (UKA) and robotic-assisted TKA (RA-TKA)) and 30- and 90-day readmission. A proportional subdistribution hazard model was used to model the risk of revision TKA.

RESULTS

On multivariate analyses, compared to White patients, Black (odds ratio (OR): 0.52 P < .0001), Hispanic (OR 0.75 P < .001), and Native American (OR: 0.69 P = .0011) patients had lower rates of UKA, while only Black patients had lower rates of RA-TKA (OR = 0.76 P < .001). White (hazard ratio (HR) = 0.8, P < .001), Asian (HR = 0.51, P < .001), and Hispanic-White (HR = 0.73, P = .001) patients had a lower risk of revision TKA than Black patients. Asian patients had a lower revision risk than White (HR = 0.64, P < .001) and Hispanic-White (HR = 0.69, P = .011) patients. No significant differences existed between groups for 30- or 90-day readmissions.

CONCLUSION

Black, Hispanic, and Native American patients had lower rates of UKA compared to White patients, while Black patients had lower rates of RA-TKA compared to White, Asian, and Hispanic patients. Black patients also had higher rates of revision TKA than other races.

Race and socioeconomic status interact with HPV to influence survival disparities in oropharyngeal squamous cell carcinoma

BACKGROUND

HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the emergence of HPV has impacted race and SES survival disparities in OPSCC.

METHODS

A retrospective cohort of 18,362 OPSCC cases from 2010 to 2017 was assembled using the SEER (Surveillance, Epidemiology, and End Results) database. Cox proportional regression and Fine and Gray regression models were used to calculate hazard ratios (HRs) adjusting for race, SES, age, subsite, stage, and treatment.

RESULTS

Black patients had lower overall survival than patients of other races in HPV-positive and HPV-negative OPSCC (HR 1.31, 95% CI 1.13-1.53 and HR 1.23, 95% CI 1.09-1.39, respectively). Higher SES was associated with improved survival in all patients. Race had a diminished association with survival among high SES patients. Low SES Black patients had considerably worse survival than low SES patients of other races.

CONCLUSION

Race and SES interact variably across cohorts. High SES was protective of the negative effects of race, although there remains a disparity in outcomes among Black and non-Black patients, even in high SES populations. The persistence of survival disparities suggests that the HPV epidemic has not improved outcomes equally across all demographic groups.

Racial and Ethnic Disparities: Essential Workers, Mental Health, and the Coronavirus Pandemic

Evidence is emerging of the pandemic disproportionately impacting communities of color. This study investigates mental health distress among essential workers during the coronavirus pandemic across race and ethnicity. We evaluate individual responses to the patient health questionnaire and general anxiety disorder questionnaire using a unique, nationally representative data set. Our findings suggest that essential healthcare workers reported the highest rates of mental health distress at the beginning of the coronavirus pandemic. However, when evaluated across race and ethnicity, we find that Black essential healthcare workers disproportionately report symptoms of anxiety; while, Hispanic essential healthcare workers disproportionately report symptoms of depression. Additionally, we find that being a Black or Hispanic essential nonhealthcare worker is associated with higher levels of distress related to anxiety and depression. These findings highlight the additional dimensions to which Black and Hispanic Americans may be disproportionately affected by the coronavirus pandemic. Furthermore, it calls into question how the essential worker classification, compounded by US unemployment policies, is potentially amplifying the mental health distress experienced by workers.

Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured

BACKGROUND

Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care.

METHODS

This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion.

RESULTS

Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult.

CONCLUSION

PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.

Disparities in dialysis modality decision-making using a social-ecological lens: a qualitative approach

BACKGROUND

Patients with end-stage kidney disease (ESKD) may choose to undergo dialysis in-center or at home, but uptake of home dialysis in the US has been minimal despite its benefits over in-center dialysis. Factors that may have led patients to select home dialysis over in-center dialysis are poorly understood in the literature, and interventions to improve selection of home dialysis have focused on patient knowledge and shared decision-making processes between patients and providers. The purpose of this study was to explore micro- and macro-level factors surrounding dialysis modality decision-making among patients undergoing in-center and home dialysis, and explore what leads patients to select home dialysis over in-center dialysis.

METHODS

Semi-structured qualitative interviews were conducted in a dialysis clinic at a large Midwestern research hospital, from September 2019 to December 2020. Participants were 18 years or older, undergoing dialysis for ESKD, and had the cognitive ability to provide consent. Surveys assessing demographic and clinical information were administered to participants following their interviews.

RESULTS

Forty patients completed interviews and surveys (20 [50%] in-center dialysis, 17 [43%] female, mean [SD] age, 59 [15.99] years). Qualitative findings suggested that healthcare access and engagement before entering nephrology care, after entering nephrology care, and following dialysis initiation influenced patients' awareness regarding their kidney disease status, progression toward ESKD, and dialysis options. Potential modifiers of these outcomes include race, ethnicity, and language barriers. Most participants adopted a passive-approach during decision-making. Finally, fatigue, concerns regarding one's dialyzing schedule, and problems with fistula/catheter access sites contributed to overall satisfaction with one's dialysis modality.

CONCLUSIONS

Findings point to broader factors affecting dialysis selection, including healthcare access and racial/ethnic inequities. Providing dialysis information before entering nephrology and after dialysis initiation may improve patient agency in decision-making. Additional resources should be prioritized for patients of underrepresented backgrounds. Dialysis decision-making may be appropriately modeled under the social-ecological framework to inform future interventions.

Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic

Amid the global pandemic, it becomes more apparent that diabetes is a pressing health concern because racial/ethnic minorities with underlying diabetes conditions have been disproportionately affected. The study proposes a multiyear examination to document the role of the Affordable Care Act (ACA) in racial/ethnic disparities in diabetes health. Using the Behavioral Risk Factor Surveillance System from 2011 to 2019, the study with a pre-post design investigated changes in access to care and diabetes health among non-White minorities compared with Whites before and after the ACA by conducting multivariable linear regression, with state-fixed effects and robust standard errors. Compared with Whites, racial/ethnic minorities showed significant improvements in health insurance coverage, having a personal doctor, and not seeing a doctor because of cost. Blacks (3.2% points, P ≤ 0.000), Hispanics (1.6% points, P = 0.001), and "other" racial/ethnic group (1.5% points, P = 0.003) experienced a greater increase in diagnosed prediabetes than Whites, whereas no and small differences were found in diagnosed diabetes and obesity, respectively. The yearly comparisons of changes in diagnosed prediabetes showed that Blacks compared with Whites had a growing increase from 1.2% points (P = 0.001) in 2014 to 3.3% points (P = 0.001) in 2019. Insurance coverage has declined after 2016, and obesity had an increasing trend across race/ethnicity. The ACA had a positive role in improving access to care and identifying those at risk for diabetes to a larger extent among racial/ethnic minorities. However, the policy impacts have been diminishing in recent years. Continued efforts are needed for sustained policy effects.

Moving Beyond Detection: Charting a Path to Eliminate Health Care Disparities in Otolaryngology

The coronavirus pandemic has illuminated long-standing inequities in America's health care system and societal structure. While numerous studies have identified health care disparities within our specialty, few have progressed beyond detection. Otolaryngologists have the opportunity and the responsibility to act. Within this article, leaders from otolaryngology share their experience and perspective on health care disparities, including (1) a discussion of disparities in otolaryngology, (2) a summary of health care system design and incentives, (3) an overview of implicit bias, and (4) practical recommendations for providers to advance their awareness of health care disparities and the actions to mitigate them. While the path forward can be daunting, it should not be a deterrent. Throughout the course of this article, numerous resources are provided to support these efforts. To move ahead, our specialty needs to advance our level of understanding and develop, implement, and disseminate successful interventions toward the goal of eliminating health care disparities.

Utilization of Mammography During the Last Year of Life Among Older Breast Cancer Survivors

Background: Mammography is generally recommended for breast cancer survivors. However, discussion is ongoing about stopping surveillance mammography when life expectancy is <5-10 years as the benefit of screening might be diminished toward the end of life. The utilization pattern of mammography in the last year of life among this population has not been well studied. Methods: We identified 58,736 females diagnosed with breast cancer between January 2002 and December 2015, who died at the age of at least 67, from the SEER-Medicare database. We examined the utilization patterns of mammography during their last year of life and investigated factors associated with the use of mammography at the end of life using a multivariable logistic regression model. Results: Overall, 28.5% of the patients received mammography during the last year of life. Multivariable logistic regression showed that older age (OR = 0.31, 95% CI = 0.29-0.34, p < 0.001 for 95 vs. 85 years old), more advanced cancer stage (OR = 0.22, 95% CI = 0.20-0.24 p < 0.001 for distant vs. localized disease), and higher comorbidity score (OR = 0.92, 95% CI = 0.91-0.93, p < 0.001 for every 1-point increase) were associated with less mammography use. Age was nonlinearly associated with mammography use, with a steady proportion of patients receiving a mammography until approximately age 80 and then a sharp decrease thereafter. Conclusion: This population-based study found that a sizable proportion of older breast cancer survivors received mammography during the last year of life.

Evidence-Based Medicine in Otolaryngology, Part XIII: Health Disparities Research and Advancing Health Equity

OBJECTIVE

To provide a contemporary resource for clinicians and researchers on health equity research and implementation strategies to mitigate or eliminate disparities in health care.

DATA SOURCES

Published studies and literature on health disparities, applicable research methodologies, and social determinants of health in otolaryngology.

REVIEW METHODS

Literature through October 2021 was reviewed, including consensus statements, guidelines, and scientific publications related to health care equity research. This research focus provides insights into existing disparities, why they occur, and the outcomes of interventions designed to resolve them. Progress toward equity requires intentionality in implementing quality improvement initiatives, tracking data, and fostering culturally competent care. Priority areas include improving access, removing barriers to care, and ensuring appropriate and effective treatment. Although research into health care disparities has advanced significantly in recent years, persistent knowledge gaps remain. Applying the lens of equity to data science can promote evidence-based practices and optimal strategies to reduce health inequities.

CONCLUSIONS

Health disparities research has a critical role in advancing equity in otolaryngology-head and neck surgery. The phases of disparities research include detection, understanding, and reduction of disparities. A multilevel approach is necessary for understanding disparities, and health equity extensions can improve the rigor of evidence-based data synthesis. Finally, applying an equity lens is essential when designing and evaluating health care interventions, to minimize bias.

IMPLICATIONS FOR PRACTICE

Understanding the data and practices related to disparities research may help promote an evidence-based approach to care of individual patients and populations, with the potential to eventually surmount the negative effects of health care disparities.

Life Expectancy Trends Among Integrated Health Care System Enrollees, 2014-2017

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) has reported downward trends in life expectancy and racial/ethnic differences between 2014 and 2017.

OBJECTIVE

To determine the life expectancy of the Kaiser Permanente Mid-Atlantic States (KPMAS) insured population as compared to the CDC National Vital Statistics data from 2014 to 2017. We also aimed to highlight the utilization of membership data to inform population statistical estimates such as life expectancy. We examine whether national trends in life expectancy are reflected in an insured population with relatively uniform access to care.

METHODS

This retrospective, data only study examined life expectancy between 2014 and 2017. Data from electronic medical records and the National Death Index were combined to construct complete life tables by race and sex for the KPMAS population, which was compared to the CDC National Vital Statistics data.

RESULTS

From 2014 to 2017, the overall KPMAS population life expectancy at birth varied between 84.6 and 85.2 years compared to the CDC reported national average of 78.6-78.9 years (p < 0.001). While the CDC dataset reported a 3.5- to 3.7-year life expectancy gap between non-Hispanic White and non-Hispanic Black populations, in the KPMAS population, this gap was significantly smaller (0.0-0.9 years). The gap in life expectancy between males and females was consistent across KPMAS and the CDC data; however, overall KPMAS male and female patient life expectancy was extended in comparison.

CONCLUSION

Among members who disclosed their race/ethnicity, KPMAS Hispanic, non-Hispanic Black, and non-Hispanic White members had significantly higher life expectancies than the CDC dataset in all years reported.

An equity-based narrative review of barriers to timely postoperative radiation therapy for patients with head and neck squamous cell carcinoma

OBJECTIVES

The majority of patients with head and neck squamous cell carcinoma (HNSCC) do not commence postoperative radiation treatment (PORT) within the recommended 6 weeks. We explore how delayed PORT affects survival outcomes, what factors are associated with delayed PORT initiation, and what interventions exist to reduce delays in PORT initiation.

METHODS

We conducted a PubMed search to identify articles discussing timely PORT for HNSCC. We performed a narrative review to assess survival outcomes of delayed PORT as well as social determinants of health (SDOH) and clinical factors associated with delayed PORT, using the PROGRESS-Plus health equity framework to guide our analysis. We reviewed interventions designed to reduce delays in PORT.

RESULTS

Delayed PORT is associated with reduced overall survival. Delays in PORT disproportionately burden patients of racial/ethnic minority backgrounds, Medicaid or no insurance, low socioeconomic status, limited access to care, more comorbidities, presentation at advanced stages, and those who experience postoperative complications. Delays in PORT initiation tend to occur during transitions in head and neck cancer care. Delays in PORT may be reduced by interventions that identify patients who are most likely to experience delayed PORT, support patients according to their specific needs and barriers to care, and streamline care and referral processes.

CONCLUSIONS

Both SDOH and clinical factors are associated with delays in timely PORT. Structural change is needed to reduce health disparities and promote equitable access to care for all. When planning care, providers must consider not only biological factors but also SDOH to maximize care outcomes.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States

Background

Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI).

Methods

We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression.

Results

We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression.

Conclusions

Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States

BACKGROUND AND AIMS

The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity.

APPROACH AND RESULTS

We analyzed two databases retrospectively, the Center for Disease Control Wide-ranging Online Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases, from 2014 to 2018. We included patients aged 25-64 years who had a primary cause of death of ESLD and were listed for transplant in the CDC WONDER or UNOS database. Our primary outcome was the ratio of listing for LT to death from ESLD-listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between races/ethnicities. There were 135,367 patients who died of ESLD, 54,734 patients who were listed for transplant, and 26,571 who underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), P < 0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), P < 0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), P < 0.001. States that had an above-mean LDR had a lower transplant to listing ratio but a higher transplant to death ratio. Multivariable analysis confirmed that Black race is significantly associated with a lower LDR and transplant to death ratio.

CONCLUSIONS

Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.

The role of insurance status as a mediator of racial disparities in oropharyngeal cancer outcomes

BACKGROUND

To assess the role of insurance status as a mediator of racial disparities in oropharyngeal cancer outcomes.

METHODS

This was a population-based retrospective cohort study. Data were extracted from the Surveillance, Epidemiology, and End Results 18 database. The study cohort included 11 627 patients diagnosed with oropharyngeal squamous cell carcinoma between 2010 and 2015.

RESULTS

The association between black race and increased risk of unresectable disease was slightly attenuated, but persistent, after including insurance status as a covariate (odds ratio [OR] 1.34, 95%CI 1.10-1.63). Likewise, black race was no longer associated with worse disease-specific survival (hazard ratio [HR] 1.11, 95%CI 0.99-1.26), but remained associated with worse overall survival with a slightly decreased effect size (HR 1.13, 95%CI 1.01-1.25).

CONCLUSIONS

Insurance status plays a significant role in, but does not completely account for, the persistent racial disparities in oropharyngeal cancer outcomes.

Ethnic-racial inequity in health insurance in Colombia: a cross-sectional study

Objective.

Characterize the relationship between ethnic-racial inequity and type of health insurance in Colombia.

Methods.

Cross-sectional study based on data from the 2019 Quality of Life Survey. We analyzed the type of health insurance (contributory, subsidized, or none) and its relationship to ethnic-racial status and predisposing variables (sex, age, marital status), demographic variables (area and region of residence), and socioeconomic variables (education, type of employment, income, and unmet basic needs) through simple and multivariate regression analyses. The association between ethnic-racial status and type of health insurance was estimated using odds ratios (OR) and their 95% confidence intervals, through a multinomial logistic model.

Results.

A statistically significant association was found between ethnic-racial status and type of health insurance. In comparison with the contributory system, the probabilities of being a member of the subsidized system were 1.8 and 1.4 times greater in the indigenous population (OR x 1.891; 95%CI: 1.600-2.236) and people of African descent (OR = 1.415; 95%CI: 1.236-1.620), respectively (p <0.01) than in the population group that did not identify as belonging to one of those ethnic-racial groups.

Conclusions.

There is an association between ethnic-racial status and type of insurance in the contributory and subsidized health systems in Colombia. Ethnic-racial status is a structural component of inequity in access to health services and heightens the disadvantages of people and population groups with low socioeconomic status.

Emergency department-based interventions affecting social determinants of health in the United States: A scoping review

BACKGROUND

Social determinants of health (SDoH) have significant implications for health outcomes in the United States. Emergency departments (EDs) function as the safety nets of the American health care system, caring for many vulnerable populations. ED-based interventions to assess social risk and mitigate social needs have been reported in the literature. However, the breadth and scope of these interventions have not been evaluated. As the field of social emergency medicine (SEM) expands, a mapping and categorization of previous interventions may help shape future research. We sought to identify, summarize, and characterize ED-based interventions aimed at mitigating negative SDoH.

METHODS

We conducted a scoping review to identify and characterize peer-reviewed research articles that report ED-based interventions to address or impact SDoH in the United States. We designed and conducted a search in Medline, CINAHL, and Cochrane CENTRAL databases. Abstracts and, subsequently, full articles were reviewed independently by two reviewers to identify potentially relevant articles. Included articles were categorized by type of intervention and primary SDoH domain. Reported outcomes were also categorized by type and efficacy.

RESULTS

A total of 10,856 abstracts were identified and reviewed, and 596 potentially relevant studies were identified. Full article review identified 135 articles for inclusion. These articles were further subdivided into three intervention types: a) provider educational intervention (18%), b) disease modification with SDoH focus (26%), and c) direct SDoH intervention (60%), with 4% including two "types." Articles were subsequently further grouped into seven SDoH domains: 1) access to care (33%), 2) discrimination/group disparities (7%), 3) exposure to violence/crime (34%), 4) food insecurity (2%), 5) housing issues/homelessness (3%), 6) language/literacy/health literacy (12%), 7) socioeconomic disparities/poverty (10%). The majority of articles reported that the intervention studied was effective for the primary outcome identified (78%).

CONCLUSION

Emergency department-based interventions that address seven different SDoH domains have been reported in the peer-reviewed literature over the past 30 years, utilizing a variety of approaches including provider education and direct and indirect focus on social risk and need. Characterization and understanding of previous interventions may help identify opportunities for future interventions as well as guide a SEM research agenda.

Ethnicity and multiple sclerosis - moving beyond preconceptions

Historically, multiple sclerosis (MS) was thought to be substantially more common in individuals from European ancestral backgrounds. Recent studies have challenged this preconception, with a concerning increase in incidence in Black British and African American individuals. In this review we provide a brief overview of the evidence for ethnic variation in MS risk, summarise potential explanations for this variation, and illustrate how these observations could be used to provide potential insights into disease biology.

Stigma, beliefs and perceptions regarding prostate cancer among Black and Latino men and women

BACKGROUND

Health disparities in prostate cancer (PC) are thought to reflect the complex interplay of socioeconomics, environment and biology. The potential impact of beliefs and perceptions about PC among Black and Latino populations on clinical disparities are not well understood. This qualitative study was conducted to assess current prevalent and pervasive stigma, beliefs and perceptions regarding PC among Blacks and Latinos living in a large metropolitan area, thereby identifying potentially modifiable barriers to care.

METHODS

Qualitative data were collected through four separate focus groups of self-identified Black and Latino adult men and women living in Philadelphia to better understand their perceptions of PC diagnosis, screening and treatment. Each focus group was single-sex and conducted by racial/ethnic group in order to assess possible differences in beliefs about PC based on gender and racial/ethnic affiliation. Audio recordings were transcribed verbatim by trained research assistants and qualitative data analysis was conducted using modified grounded theory.

RESULTS

There were a total of 34 participants: 19 Hispanics/Latinos and 15 Blacks, with equal numbers of men and women (n=17). Median age was 57 years (range: 18 to 85 years). Dominant themes that emerged with respect to PC diagnosis included the stigma surrounding this condition and the perceived role of an "unhealthy lifestyle" and certain sexual behaviors as risk factors for PC development. While the majority of participants acknowledged the importance of PC screening and early detection, discussion centered around the barriers to both the interest in seeking medical care and the likelihood of securing it. These barriers included misunderstanding of PC etiology, distrust of the medical profession, and financial/access limitations. Men expressed substantial confusion about PC screening guidelines. In the Black female group, the role of faith and religion in the course of disease was a major theme. Both Black and Latina females discussed the role of fear and avoidance around PC screening and treatment, as well as the prevalence of misinformation about PC in their familial and social communities.

CONCLUSION

Black and Latino focus groups revealed the existence of cultural beliefs, misunderstandings and fears pertaining to PC which could influence health-related behaviors. Some themes were common across groups; others suggested racial and gender predilections. Future targeted efforts focused on directly addressing prevalent misperceptions among underserved communities in urban settings could help to improve health literacy and equity in PC outcomes in these populations.

Hospital Outcomes in Uninsured Patients With Disease and Disorders of Nervous System: A National Cohort Study During a Decade in the United States

Objectives

Health insurance is associated with better outcomes in the admitted patient population, even after adjusting for other factors such as race and socioeconomic status. However, the literature is limited on the relationship between insurance status and hospital outcomes in patients hospitalized with the disease of nervous system.

Methods

This cross-sectional study used the Nationwide Inpatient Sample (NIS) database to achieve the results. All Major Diagnostic Category (MDC) codes from patients discharged for disease and disorders of nervous system between the years 2005 to 2014 were queried and analyzed for the impact of lack of insurance on patient outcome.

Results

Among 4,737,999 discharges, 5.6% had no insurance. The hospital mortality rate among uninsured and insured patients was 4.1% and 3.7%, respectively (P<0.001). In the multivariate analysis, hospital mortality of uninsured patients was higher in the elderly (aOR: 4.74[CI:4.52-4.97], P<0.001), those with comorbidities (aOR: 2.23[CI:2.18-2.27], P<0.001), Asians (aOR: 1.16[CI:1.12-1.20]. P<0.001), in rural areas (aOR: 1.44[ 95%CI:1.41-1.48], P<0.001) and those in the lowest household income quartile (aOR: 1.03[CI:1.01-1.05], P<0.001). The average length of stay (LOS) was shorter for the uninsured (4.79±8.26 vs 4.96±7.55 days, P<0.001).

Conclusions

The findings suggest that lack of health insurance is correlated with hospital mortality in patients hospitalized with disease and disorders of nervous system, with an increased disparity in vulnerable populations.

Prognostic Impact of Tumor Size on Pancreatic Neuroendocrine Tumor Recurrence May Have Racial Variance

OBJECTIVE

The incidence of pancreatic neuroendocrine tumors (PNETs) has increased over the last decade. Black patients have worse survival outcomes. This study investigates whether oncologic outcomes are racially disparate at a single institution.

METHODS

Retrospective analysis was performed on 151 patients with resected PNETs between 2010 and 2019.

RESULTS

More White males and Black females presented with PNETs (P = 0.02). White patients were older (65 years vs 60 years; P = 0.03), more likely to be married (P < 0.01), and had higher median estimated yearly incomes ($28,973 vs $17,767; P < 0.01) than Black patients. Overall and disease-free survival were not different. Black patients had larger median tumor sizes (30 mm vs 23 mm; P = 0.02). Tumor size was predictive of recurrence only for White patients (hazard ratio, 1.02; P = 0.01). Collectively, tumors greater than 20 mm in size were more likely to have recurrence (P = 0.048), but this cutoff was not predictive in either racial cohort independently.

CONCLUSIONS

Black patients undergoing curative resection of PNETs at our institution presented with larger tumors, but that increased size is not predictive of disease-free survival in this population.

[Ethnic-racial inequity in health insurance in Colombia: a cross-sectional studyIniquidades étnico-raciais no seguro de saúde na Colômbia: um estudo transversal]

Objetivo.

Caracterizar la relación entre la inequidad por la condición étnico-racial y el tipo de aseguramiento de salud en Colombia.

Métodos.

Estudio de corte transversal basado en datos de la Encuesta de Calidad de Vida 2019. Se analizó el tipo de aseguramiento de salud (contributivo, subsidiado o ninguno) y su relación con la condición étnico-racial y variables predisponentes (sexo, edad, estado civil), demográficas (zona y región de residencia) y socioeconómicas (educación, tipo de empleo, ingresos y necesidades básicas insatisfechas) mediante análisis de regresión simple y multifactorial. La asociación entre la condición étnico-racial y el tipo de aseguramiento de salud fue estimada utilizando razones de posibilidades (OR) y sus intervalos de confianza de 95%, mediante un modelo logístico multinomial.

Resultados.

Se encontró asociación estadísticamente significativa entre la condición étnico-racial y el tipo de aseguramiento de salud. En comparación con el régimen contributivo, las probabilidades de estar afiliado al régimen subsidiado fueron 1,8 y 1,4 veces mayores en los indígenas (OR = 1,891; IC95%: 1,600-2,236) y afrodescendientes (OR = 1,415; IC95%: 1,236-1,620), respectivamente (p < 0,01), que el grupo de la población que no se reconoció como perteneciente a uno de esos grupos étnico-raciales.

Conclusiones.

Existe una asociación entre la condición étnico-racial y el tipo de aseguramiento en el régimen contributivo y subsidiado de salud en Colombia. La condición étnico-racial se manifiesta como un componente estructural de la inequidad en el acceso a los servicios de salud y profundiza las desventajas de las personas y grupos poblacionales con un bajo estatus socioeconómico.

Racial and Ethnic Differences in Emergency Department Diagnostic Imaging at US Children's Hospitals, 2016-2019

IMPORTANCE

Diagnostic imaging is frequently performed as part of the emergency department (ED) evaluation of children. Whether imaging patterns differ by race and ethnicity is unknown.

OBJECTIVE

To evaluate racial and ethnic differences in the performance of common ED imaging studies and to examine patterns across diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated visits by patients younger than 18 years to 44 US children's hospital EDs from January 1, 2016, through December 31, 2019.

EXPOSURES

Non-Hispanic Black and Hispanic compared with non-Hispanic White race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of visits for each race/ethnicity group with at least 1 diagnostic imaging study, defined as plain radiography, computed tomography, ultrasonography, and magnetic resonance imaging. The major diagnostic categories classification system was used to examine race/ethnicity differences in imaging rates by diagnoses.

RESULTS

A total of 13 087 522 visits by 6 230 911 children and adolescents (mean [SD] age, 5.8 [5.2] years; 52.7% male) occurred during the study period. Diagnostic imaging was performed during 3 689 163 visits (28.2%). Imaging was performed in 33.5% of visits by non-Hispanic White patients compared with 24.1% of visits by non-Hispanic Black patients (odds ratio [OR], 0.60; 95% CI, 0.60-0.60) and 26.1% of visits by Hispanic patients (OR, 0.66; 95% CI, 0.66-0.67). Adjusting for confounders, visits by non-Hispanic Black (adjusted OR, 0.82; 95% CI, 0.82-0.83) and Hispanic (adjusted OR, 0.87; 95% CI, 0.87-0.87) patients were less likely to include any imaging study compared with visits by non-Hispanic White patients. Limiting the analysis to only visits by nonhospitalized patients, the adjusted OR for imaging was 0.79 (95% CI, 0.79-0.80) for visits by non-Hispanic Black patients and 0.84 (95% CI, 0.84-0.85) for visits by Hispanic patients. Results were consistent in analyses stratified by public and private insurance groups and did not materially differ by diagnostic category.

CONCLUSIONS AND RELEVANCE

In this study, non-Hispanic Black and Hispanic children were less likely to receive diagnostic imaging during ED visits compared with non-Hispanic White children. Further investigation is needed to understand and mitigate these potential disparities in health care delivery and to evaluate the effect of these differential imaging patterns on patient outcomes.

High fructose corn syrup, excess-free-fructose, and risk of coronary heart disease among African Americans- the Jackson Heart Study

BACKGROUND

Researchers have sought to explain the black-white coronary heart disease (CHD) mortality disparity that increased from near parity to ~ 30% between 1980 and 2010. Contributing factors include cardiovascular disease prevention and treatment disparities attributable to disparities in insurance coverage. Recent research suggests that dietary/environmental factors may be contributors to the disparity. Unabsorbed/luminal fructose alters gut bacterial load, composition and diversity. There is evidence that such microbiome disruptions promote hypertension and atherosclerosis. The heart-gut axis may, in part, explain the black-white CHD disparity, as fructose malabsorption prevalence is higher among African Americans. Between 1980 and 2010, consumption of excess-free-fructose-the fructose type that triggers malabsorption-exceeded dosages associated with fructose malabsorption (~ 5 g-10 g), as extrapolated from food availability data before subjective, retroactively-applied loss adjustments. This occurred due to an industrial preference shift from sucrose to high-fructose-corn-syrup (HFCS) that began ~ 1980. During this period, HFCS became the main sweetener in US soda. Importantly, there has been more fructose in HFCS than thought, as the fructose-to-glucose ratio in popular sodas (1.9-to-1 and 1.5-to-1) has exceeded generally-recognized-as-safe levels (1.2-to-1). Most natural foods contain a ~ 1-to-1 ratio. In one recent study, ≥5 times/wk. consumers of HFCS sweetened soda/fruit drinks/and apple juice-high excess-free-fructose beverages-were more likely to have CHD, than seldom/never consumers.

METHODS

Jackson-Heart-Study data of African Americans was used to test the hypothesis that regular relative to low/infrequent intake of HFCS sweetened soda/fruit drinks increases CHD risk, but not orange juice-a low excess-free-fructose juice. Cox proportional hazards models were used to calculate hazard ratios using prospective data of 3407-3621 participants, aged 21-93 y (mean 55 y).

RESULTS

African Americans who consumed HFCS sweetend soda 5-6x/wk. or any combination of HFCS sweetened soda and/or fruit drinks ≥3 times/day had ~ 2 (HR 2.08, 95% CI 1.03-4.20, P = 0.041) and 2.5-3 times higher CHD risk (HR 2.98, 95% CI 1.15-7.76; P = 0.025), respectively, than never/seldom consumers, independent of confounders. There were no associations with diet-soda or 100% orange-juice, which has a similar glycemic profile as HFCS sweetened soda, but contains a ~ 1:1 fructose-to-glucose ratio.

CONCLUSION

The ubiquitous presence of HFCS in the food supply may pre-dispose African Americans to increased CHD risk.

Outcomes of Bariatric Surgery in African Americans: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Data Registry

Background

The incidence of obesity is disproportionally high in African Americans (AA) in the United States. This study compared outcomes for AA patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with non-AA patients.

Methods

The MBSAQIP database was reviewed for RYGB and SG patients (2015–2017). Patients were identified as AA or non-AA and grouped to RYGB or SG. Combined and univariate analyses were performed on unmatched/propensity matched populations to assess outcomes.

Results

After applying exclusion criteria, 75,409 AA and 354,305 non-AA patients remained. Univariate analysis identified AA-RYGB and AA-SG patients were heavier and younger than non-AA patients. Overall, AA patients tended to have fewer preoperative comorbidities than non-AA patients with the majority of AA comorbidities related to hypertension and renal disease. Analysis of propensity matched data confirmed AA bariatric surgery patients had increased cardiovascular-related disease incidence compared with non-AA patients. Perioperatively, AA-RYGB patients had longer operative times, increased rates of major complications/ICU admission, and increased incidence of 30-day readmission, re-intervention, and reoperation, concomitant with lower rates of minor complications/superficial surgical site infection (SSI) compared with non-AA patients. For SG, AA patients had longer operative times and higher rates of major complications and 30-day readmission, re-intervention, and mortality, coupled with fewer minor complications, superficial/organ space SSI, and leak.

Conclusion

African American patients undergoing bariatric surgery are younger and heavier than non-AA patients and present with different comorbidity profiles. Overall, AAs exhibit worse outcomes following RYGB or SG than non-AA patients, including increased mortality rates in AA-SG patients.

Racial/Ethnic Disparities in Health Care Access Are Associated with Adverse Childhood Experiences

There is a growing body of research documenting racial/ethnic differences in the relationship between adverse childhood experiences (ACEs) and negative health outcomes in adulthood. However, few studies have examined racial/ethnic differences in the association between ACEs and health care access. Cross-sectional data collected from South Carolina's Behavioral Risk Factor Surveillance System (2014-2016; n = 15,436) was used to examine associations among ACEs, race/ethnicity, and health care access among South Carolina adults. Specifically, logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for three health care access outcomes: having a personal doctor, routine checkup in the last 2 years, and delay in seeking medical care due to cost. Without adjusting for any covariates, in the overall population, the odds of having no personal doctor, no checkup in the last 2 years, and delay in medical care due to cost was significantly higher among those with at least one ACE, compared with those with no ACEs; and health care access varied by race, with significant relationships detected among Whites and Blacks. Among White adults, the odds of having no checkup in the last 2 years and delay in medical care due to cost was significantly higher among those with at least one ACE, compared with those with no ACEs. Among Black adults, a delay in medical care due to cost was significantly higher among those who reported ACEs compared with their counterparts. The results from this study suggest that ACEs may be an underrecognized barrier to health care for adults. Investing in strategies to mitigate ACEs may help improve health care access among adults.

Progress in research of enhanced recovery after surgery and surgery related differences

Enhanced recovery after surgery (ERAS) refers to the use of standardized, multimodal perioperative strategies to reduce physiological stress and organ dysfunction caused by surgery. Since the ERAS concept was put forward, it has been widely respected in the surgical field. Its benefits in the surgical field for the vast majority of patients, medical staff and healthcare systems are obvious. However, for some specific people undergoing surgery, the benefits are not certain, which is the so-called surgery-related differences. This article analyzes recent studies of different surgical fields related to surgical-related differences in different ethnic groups, reviews a large number of positive effects of the implementation of ERAS on surgical-related differences, and elaborates its possible mechanism. It is finally concluded that ERAS, a standardized model for resolving surgical-related differences, should become the gold standard for surgical perioperative management.

The Association Of Race With Outcomes Among Parturients Undergoing Cesarean Section With Perioperative Epidural Catheter Placement: A Nationwide Analysis

Background: In obstetrical health care, disparities have been documented in different aspects of maternal care and outcomes. Prior epidemiological studies have shown that labor analgesia is underused in African-American and Hispanic groups, which means there may be inadequate labor pain control in these groups. Differences in usage have been attributed primarily to insurance, educational levels and perceptional influences such as fear of paralysis and chronic low back pain. In cesarean section deliveries, race and ethnicity affect the choice of anesthesia considered. How race and ethnicity affect maternal outcomes in cesarean sections with epidural placements generally has been unexplored. Disparities in health care utilization are shown to contribute to the disparities in health outcomes.

Methods: This is a retrospective analysis using data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (AHRQ-HCUP), the National Inpatient Sample (NIS) database from January 2003 to December 2013, which is a 20% stratified sample of the nonfederal hospitals in the United States. Women undergoing cesarean section (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes 74.0, 74.1, 74.2, 74.4, 74.99) with perioperative epidural catheter placement (ICD-9-CM procedure codes 3.90, 3.91) were included for analysis.

Results: The final cohort used for analysis included 87,076 patients. There were significant differences in the distribution of patient characteristics across the race groups. The majority of health care coverage for Caucasians and Asians was private insurance, while for African-American, Hispanic and Native American was Medicare and Medicaid. Almost all the examined comorbid conditions were statistically significant and highest in the African-American group, including hypertension, obesity, diabetes, and renal failure, except for congestive heart failure that was highest in the Asian group. Cesarean sections took place mostly in an urban teaching hospital across all groups. Discharge to home was the predominant destination after recovery. The mean cost of hospitalization was 14,604 dollars per stay and the mean length of stay was 3.7 days. In our cohort, the adverse event rate was very small. Our findings indicate racial differences in comorbidities which occurred more often in minorities. Adverse maternal outcomes of hematoma, blood transfusion, cardiac arrest, and ventricular fibrillation occurred more frequently in minority groups undergoing cesarean sections with epidural catheter placements throughout the period of 2003-2013.

Conclusion: From using the NIS database, our findings indicate racial differences in comorbidities which occurred more often in minorities. Adverse maternal outcomes of hematoma, blood transfusion, cardiac arrest, and ventricular fibrillation occurred more frequently in minority groups undergoing cesarean sections with epidural catheter placements throughout the period of 2003-2013. Further population studies are warranted to determine the biological or perception etiologies that are contributing to these disparities.

Inpatient burden of gastric cancer in the United States

Background

Gastric cancer is associated with significant morbidity and mortality. Over one-half of patients have advanced disease at the time of presentation, leading to a significant burden on the healthcare system. Limited epidemiological data exists on national inpatient hospitalization trends. The aim of this study is to determine the inpatient burden of gastric cancer in the United States.

Methods

We analyzed the Nationwide Inpatient Sample (NIS) database for all subjects with the diagnosis of malignant neoplasm of the stomach (ICD-9 code 151.x) as primary diagnosis during the period from 2001-2011. NIS is the largest all-payer inpatient care database in the U.S. Statistical significance of variation in the number of hospitalizations, patient demographics, and comorbidity measures was determined using Cochran-Armitage trend test.

Results

From 2001 to 2011, the number of hospitalizations with the diagnosis of malignant neoplasm of the stomach ranged between 22,430 and 25,371, however, the trend was not significant. Men were always more affected than women with no significant change in overall proportion (P<0.0001). Overall, in-hospital mortality decreased from 11.19% in 2001 to 6.47% in 2011 (P<0.0001). However, average cost of care per hospitalization increased from $21,710 in 2001 to $24,706 in 2011 (adjusted for inflation, P<0.0001).

Conclusions

The total number of hospitalizations remained relatively stable throughout the study period with higher proportion of men affected every year. Although in-hospital mortality in patients with the diagnosis of gastric cancer decreased over the study period, there was a significant rise in the cost of care.

Clinical Characteristics of Multiple Sclerosis in African-Americans

PURPOSE OF REVIEW

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system that affects nearly 1 million people in the USA and has the potential to profoundly affect physical ability and income potential at a young age. Since a landmark paper was published in 2014, few studies have looked at differences in MS disease characteristics between African-American and Caucasian patients.

RECENT FINDINGS

African-American patients often have a more severe MS disease course, as well as biomarker data which can portend a worse prognosis. While the sample sizes are usually quite small, subgroup analyses of African-American patients have been performed to evaluate efficacy of disease-modifying treatments as compared with the entire study population, made up of primarily Caucasians. In an era where we strive for personalized medicine, understanding racial differences in MS may help us better treat African-American patients in the future.

Epidemiology and health outcomes of sarcoidosis in a universal healthcare population: a cohort study

Sarcoidosis-related mortality appears to be rising in North America, with increasing rates in females and the elderly. We aimed to estimate trends in sarcoidosis incidence, prevalence and mortality in Ontario, Canada.

We performed a cohort study using health administrative data from Ontario between 1996 and 2015. International Classification of Diseases and Ontario Health Insurance Plan codes were used for case detection. Three disease definitions were created: 1) sarcoidosis, two or more physician claims within 2 years; 2) chronic sarcoidosis, five or more physician claims within 3 years; and 3) sarcoidosis with histology, two or more physician claims with a tissue biopsy performed between claims.

Overall, 18 550, 9199 and 3819 individuals with sarcoidosis, chronic sarcoidosis and sarcoidosis with histology, respectively, were identified. The prevalence of sarcoidosis was 143 per 100 000 in 2015, increasing by 116% (p<0.0001) from 1996. The increase in age-adjusted prevalence was higher in males than females (136% versus 99%; p<0.0001). The incidence of sarcoidosis declined from 7.9 to 6.8 per 100 000 between 1996 and 2014 (15% decrease; p=0.0009). A 30.3% decrease in incidence was seen among females (p<0.0001) compared with a 5.5% increase in males (p=0.47). Age- and sex-adjusted mortality rates of patients with sarcoidosis rose from 1.15% to 1.47% between 1996 and 2015 (28% increase; p=0.02), with the overall trend being nonsignificant (p=0.39). Mortality rates in patients with chronic sarcoidosis increased significantly over the study period (p=0.0008).

The prevalence of sarcoidosis is rising in Ontario, with an apparent shifting trend in disease burden from females to males. Mortality is increasing in patients with chronic sarcoidosis.

Racial, Ethnic, and Socioeconomic Inequities in the Prescription of Direct Oral Anticoagulants in Patients With Venous Thromboembolism in the United States

BACKGROUND

Beginning in 2012, direct oral anticoagulants (DOACs) were approved for treatment and prevention of venous thromboembolism. Prior investigations have demonstrated slow rates of adoption of novel therapeutics for black patients. We assessed the association of racial/ethnic and socioeconomic factors with DOAC use among commercially insured venous thromboembolism patients.

METHODS AND RESULTS

We performed a retrospective cohort analysis of adult patients with an incident diagnosis of venous thromboembolism between January 2010 and December 2016 using OptumInsight's Clinformatics Data Mart. We identified the first filled oral anticoagulant prescription within 30 days of discharge of an inpatient admission. We performed a multivariable logistic regression, adjusting for age, sex, race/ethnicity, region, zip code-linked household income, and clinical covariates to identify factors associated with the use of DOACs. Race and ethnicity were determined in this database through a combination of public records, self-report, and proprietary ethnicity code tables. There were 14 140 patients included in the analysis. Treatment with DOACs increased from <0.1% in 2010 to 65.6% in 2016. In multivariable analyses, black patients were less likely to receive a DOAC compared with white patients (odds ratio, 0.86; 95% CI, 0.77-0.97; P=0.02). There were no differences in DOAC utilization among Asian (odds ratio, 1.06; 95% CI, 0.75-1.49; P=0.74) or Hispanic patients (odds ratio, 1.04; 95% CI, 0.88-1.22; P=0.66) compared with whites. Patients with a household income over $100 000 per year were more likely to receive DOAC therapy compared with patients with a household income of <$40 000 per year (odds ratio, 1.50; 95% CI, 1.33-1.69; P<0.0001).

CONCLUSIONS

Although DOAC adoption has increased steadily since 2012, among a commercially insured population, black race and low household income were associated with lower use of DOACs for incident venous thromboembolism despite controlling for other clinical and socioeconomic factors. These findings suggest the possibility of both racial and socioeconomic inequity in access to this novel pharmacotherapy.

Association between Race and Cancer-Related Mortality among Patients with Colorectal Cancer in the United States: A Retrospective Cohort Study

Colorectal cancer (CRC) is the third most common cause of mortality in the United States (US). Differences in CRC mortality according to race have been extensively studied; however, much more understanding with regard to tumor characteristics’ effect on mortality is needed. The objective was to investigate the association between race and mortality among CRC patients in the US during 2007–2014. A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) Program, which collects cancer statistics through selected population-based cancer registries during in the US, was conducted. The outcome variable was CRC-related mortality in adult patients (≥18 years old) during 2007–2014. The independent variable was race of white, black, Asian/Pacific Islander (API), and American Indian/Alaska Native (others). The covariates were, age, sex, marital status, health insurance, tumor stage at diagnosis, and tumor size and grade. Bivariate analysis was performed to identify possible confounders (chi-square tests). Unadjusted and adjusted logistic regression models were used to study the association between race and CRC-specific mortality. The final number of participants consisted of 70,392 patients. Blacks had a 32% higher risk of death compared to whites (adjusted odds ratio (OR) 1.32; 95% confidence interval (CI) 1.22–1.43). Corresponding OR for others were 1.41 (95% CI 1.10–1.84). API had nonsignificant adjusted odds of mortality compared to whites (0.95; 95% CI 0.87–1.03). In conclusion, we observed a significant increased risk of mortality in black and American Indian/Alaska Native patients with CRC compared to white patients.