Neighborhood deprivation index is associated with weight status among long-term survivors of childhood acute lymphoblastic leukemia

Socio-Ecologic Influences on Weight Trajectories Among Children with Obesity Living in Rural and Urban Settings

Background: Childhood obesity is a risk factor for poor cardiovascular, metabolic, and respiratory health. The studies examining influences of socio-ecologic factors on weight trajectories using longitudinal data are limited, often examine single measures (e.g., proximity to parks), and have not examined the specific trajectories of children with obesity. Methods: We examined influences on weight among 1518 children, 6-12 years of age, who had obesity using body mass index (BMI) criteria. BMI slope trajectories were categorized as decreasing, flat, or increasing, with a median of 2.1 years of follow-up. We examined socio-ecologic exposures, stratified by rural and urban settings, using census tracts to map indices, including food access, proximity to parks, normalized difference vegetation index, and area deprivation index (ADI). We used ordinal logistic regression to examine the associations between the socio-ecologic factors and BMI trajectories. Results: Among the 1518 children, 360 (24%) had a decreasing BMI trajectory with the remainder having flat (23%) or increasing (53%) trajectories. Children in rural areas were more likely to live in high disadvantage areas, 85%, compared with urban children, 46%. In the multivariable ordinal model, living in a lower ADI census tract had a 0.78 (95% CI 0.61-0.99) lower odds of being in an increasing BMI slope group, and no other socio-ecologic factor was associated. Conclusions: The area deprivation index captures a range of resources and social context compared with the built environment indicators, which had no association with BMI trajectory. Further work examining how to develop effective interventions in high deprivation areas is warranted.

The role of area deprivation index in health care disruptions among cancer survivors during the SARS-CoV-2 pandemic

OBJECTIVE

To examine the associations between demographic/medical and geographic factors with follow-up medical care and health-related quality of life (HRQoL) among cancer survivors during the SARS-CoV-2 pandemic.

STUDY DESIGN

Cross-sectional survey.

METHODS

An online survey was sent to cancer survivors between May 2020 and January 2021, exploring their experience with SARS-CoV-2, follow-up care, and HRQoL. PolicyMap was used to geocode home addresses. Both geographic and demographic/medical factors were examined for their associations with SARS-CoV-2 experience, follow-up care, and HRQoL (FACT-G7).

RESULTS

Geographic data were available for 9651 participants. Patients living in the highest area deprivation index (ADI) neighborhoods (most deprived) had higher odds of avoiding in-person general (odds ratio [OR] = 7.20; 95% confidence interval [CI] = 2.79-18.60), cancer (OR = 8.47; 95% CI = 3.73-19.30), and emergency (OR = 14.2; 95% CI = 5.57-36.30) medical care, as well as lower odds of using telemedicine (OR = 0.61; 95% CI = 0.52-0.73) compared to the lowest ADI group. Race/ethnicity was not associated with follow-up care after controlling for ADI. The effect of ADI on HRQoL was generally in the expected direction, with higher ADI being associated with worse HRQoL.

CONCLUSIONS

ADI influenced follow-up medical care more than age, race/ethnicity, or health insurance type. Healthcare providers and institutions should focus on decreasing barriers to in-person and telemedicine health care that disproportionally impact those living in more deprived communities, which are exacerbated by health care disruptions like those caused by the SARS-CoV-2 pandemic.

How I treat long-term survivors of childhood acute leukemia

ABSTRACT

The population of survivors of childhood leukemia who reach adulthood is growing due to improved therapy. However, survivors are at risk of long-term complications. Comprehensive follow-up programs play a key role in childhood leukemia survivor care. The major determinant of long-term complications is the therapeutic burden accumulated over time. Relapse chemotherapy, central nervous system irradiation, hematopoietic stem cell transplantation, and total body irradiation are associated with greater risk of long-term complications. Other parameters include clinical characteristics such as age and sex as well as environmental, genetic, and socioeconomic factors, which can help stratify the risk of long-term complications and organize follow-up program. Early diagnosis improves the management of several late complications such as anthracycline-related cardiomyopathy, secondary cancers, metabolic syndrome, development defects, and infertility. Total body irradiation is the treatment associated with worse long-term toxicity profile with a wide range of complications. Patients treated with chemotherapy alone are at a lower risk of long-term complications, although the optimal long-term follow-up remains unclear. Novel immunotherapies and targeted therapy are generally associated with a better short-term safety profile but still require careful long-term toxicity monitoring. Advances in understanding genetic susceptibility to long-term complications could enable tailored therapeutic strategies for leukemia treatment and optimized follow-up programs.

Health Literacy and Health-care Resource Utilization Following Gastrostomy Tube Placement in Pediatric Patients

INTRODUCTION

Parental health literacy and neighborhood socioeconomic disadvantage are associated with adverse health outcomes and increased health-care resource utilization in children. We sought to evaluate the association between community-level health literacy and neighborhood socioeconomic disadvantage and their relationships with outcomes of pediatric patients undergoing gastrostomy tube (GT) placement.

METHODS

Pediatric patients who underwent GT placement from 2000 to 2019 were identified using the IBM MarketScan Research database. Claims data were merged with the health literacy index (HLI) and area deprivation index (ADI), measures of community-level health literacy and neighborhood socioeconomic disadvantage, respectively. We used multivariate logistic regression to estimate factors associated with postoperative 30- and 90-day ED visits (EVs) and 30-day readmissions.

RESULTS

A total of 4374 pediatric patients underwent GT placement. In this cohort, 6.1% and 11.4% had 30-day and 90-day EV; and 30-day readmissions in 19.75%. HLI was lower in those with 30-(244.6 ± 6.1 versus 245.4 ± 6.1; P = 0.0482) and 90-(244.5 ± 5.8 versus 245.5 ± 6.1; P = 0.001) day EV, and 30-day readmission (244.5 ± 5.56 versus 245.4 ± 6.1; P = 0.001) related to GT. ADI was lower in those with 90-day EV (55.1 ± 13.1 versus 55.9 ± 14.6; P = 0.0244). HLI was associated with decreased odds of 30- (adjusted odds ratio: 0.968; 95% confidence interval: 0.941-0.997) and 90-day (adjusted odds ratio: 0.975; 95% confidence interval: 0.954-0.998) EV following GT placement. ADI was also significantly associated with 30 and 90-day EV following GT placement.

CONCLUSIONS

In pediatric patients undergoing GT placement, higher ecologically-measured health literacy and neighborhood socioeconomic disadvantage are associated with decreased health-care resource utilization, as evidenced by decreased ED visits. Future studies should focus on the role of individual parental health literacy in outcomes of pediatric surgical patients.

The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy in the world. Advances in treatment protocols have resulted in survival rates of >80% in most high-income countries (HIC); however, children and young people (CYP) with ALL continue to face significant nutrition-related challenges during treatment.

METHODS

This narrative review outlines the changing landscape of treatment and survivorship for CYP with ALL and the advances in nutrition knowledge that call for changes to clinical nutrition practice.

RESULTS

The incidence of ALL has remained stable in HIC; however, there have been significant advances in survival over the past 30 years. Overweight and obesity are increasingly prevalent in CYP with ALL at diagnosis, during treatment and in survivorship. Coupled with poor diet quality, high-energy and saturated fat intakes, altered eating behaviours and inactivity, this necessitates the need for a shift in nutrition intervention. Undernutrition remains a concern for CYP with high-risk treatment protocols where oral or enteral nutrition support remains a cornerstone of maintaining nutrition status.

CONCLUSIONS

With improved treatment protocols and high survival rates, a shift to focusing on diet quality, prevention of excessive weight gain and obesity during treatment and survivorship is necessary.

Impact of social disparities on 10 year survival rates in paediatric cancers: a cohort study

Background

Studies reporting on the impact of social determinants of health on childhood cancer are limited. The current study aimed to examine the relationship between health disparities, as measured by the social deprivation index, and mortality in paediatric oncology patients using a population-based national database.

Methods

In this cohort study of children across all paediatric cancers, survival rates were determined using the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. The social deprivation index was used to measure and assess healthcare disparities and specifically the impact on both overall and cancer-specific survival. Hazard ratios were used to assess the association of area deprivation.

Findings

The study cohort was composed of 99,542 patients with paediatric cancer. Patients had a median age of 10 years old (IQR: 3-16) with 46,109 (46.3%) of female sex. Based on race, 79,984 (80.4%) of patients were identified as white while 10,801 (10.9%) were identified as Black. Patients from socially deprived areas had significantly higher hazard of death overall for both non-metastatic [1.27 (95% CI: 1.19-1.36)] and metastatic presentations [1.09 (95% CI: 1.05-1.15)] compared to in more socially affluent areas.

Interpretation

Patients from the most socially deprived areas had lower rates of overall and cancer-specific survival compared to patients from socially affluent areas. With an increase in childhood cancer survivors, implementation of social determinant indices, such as the social deprivation index, might aid improvement in healthcare outcomes for the most vulnerable patients.

Funding

There was no study sponsor or extramural funding.

Remote Care Adoption in Underserved Congenital Heart Disease Patients During the COVID-19 Era

The COVID-19 pandemic restricted in-person appointments and prompted an increase in remote healthcare delivery. Our goal was to assess access to remote care for complex pediatric cardiology patients. We performed a retrospective chart review of Texas Children's Hospital (TCH) pediatric cardiology outpatient appointments from March 2020 to December 2020 for established congenital heart disease (CHD) patients 1 to 17 yo. Primary outcome variables were remote care use of telemedicine and patient portal activation. Primary predictor variables were age, sex, insurance, race/ethnicity, language, and location. Descriptive statistics were used to analyze patient demographics. Multivariate logistic regression determined associations with remote care use (p < 0.05). We identified 5,410 established patients with clinic appointments during the identified timeframe. Adopters of telemedicine included 13% of patients (n = 691). Of the prior non patient portal users, 4.5% activated their accounts. On multivariate analysis, older age (10-17 yo) was associated with increased telemedicine (OR 2.04, 95%CI 1.71, 2.43) and patient portal use (OR 1.70, 95%CI 1.33, 2.17). Public insurance (OR 1.66, 95%CI 1.25, 2.20) and Spanish speaking were associated with increased patient portal adoption. Race/ethnicity was not significantly associated with telemedicine use or patient portal adoption. Telehealth adoption among older children may be indicative of their ability to aid in the use of these technologies. Higher participation in patient portal activation among publicly insured and Spanish speaking patients is encouraging and demonstrates ability to navigate some degree of remote patient care. Adoption of remote patient care may assist in reducing access to care disparities.

Mediating Effects of Neighborhood-Level Socioeconomic Deprivation on the Association Between Race/Ethnicity and Advanced Hepatocellular Carcinoma

BACKGROUND

Racial/ethnic minorities are more likely than non-Hispanic whites (NHW) to be diagnosed with advanced stage hepatocellular carcinoma (HCC). We examined the role of neighborhood disadvantage as a mediator of the association between race/ethnicity and HCC stage at diagnosis.

METHODS

We used data from HCC cases diagnosed in Texas from 2007 to 2015. HCC cases were classified as local versus regional/advanced stage. A mediation model approach was used to estimate the average direct effect, average mediated (indirect) effect, total effect, and proportion mediated by the Area Deprivation Index (ADI), a composite measure of disadvantage.

RESULTS

7,622 had local while 6303 had regional/advanced HCC. 46.1% of cases were NHW, 15.0% non-Hispanic Black (NHB), and 38.9% Hispanic. NHBs were less likely than NHWs to be diagnosed with local stage HCC [total effect RR, 0.921; 95% confidence interval (95% CI), 0.898-0.947]; however, only 2.26% of this effect was mediated through ADI. Conversely, Hispanics were more likely than NHWs to be diagnosed with local stage HCC (total effect RR, 1.019; 95% CI, 1.001-1.037) and ADI mediated 12.56% of the effect of race/ethnicity on HCC stage. ADI was not associated with HCC stage and therefore was not a mediator of the association with HCC stage when we compared Hispanics with NHBs.

CONCLUSIONS

Neighborhood socioeconomic disadvantage may explain/mediate some of the association between race/ethnicity and HCC stage; however, the mediating effect was not uniform across populations.

IMPACT

For NHBs, other individual and neighborhood level factors, not reflected in the ADI, contribute to their lower likelihood of being diagnosed with local HCC. See related commentary by Lazo et al., p. 1254.

Care for Chiari malformation type I: the role of socioeconomic disadvantage and race

OBJECTIVE

There is little research on the effect of social determinants of health on Chiari malformation type I (CM-I). The authors analyzed data on all children evaluated for CM-I at a single institution to assess how socioeconomic factors and race affect the surgical treatment of this population.

METHODS

Medical records of patients treated for CM-I at the authors' institution between 1992 and 2017 were reviewed. Area Deprivation Index (ADI) and Rural-Urban Commuting Area (RUCA) codes for each patient were used to measure neighborhood disadvantage. Non-Hispanic White patients were compared to non-White patients and Hispanic patients of any race (grouped together as non-White in this study) in terms of insurance status, ADI, and RUCA. Patients with initially benign CM-I, defined as not having undergone surgery within 9 months of their initial visit, were then stratified by having delayed symptom presentation or not, and compared on these same measures.

RESULTS

The sample included 665 patients with CM-I: 82% non-Hispanic White and 18% non-White. The non-White patients were more likely to reside in disadvantaged (OR 3.4, p < 0.001) and urban (OR 4.66, p < 0.001) neighborhoods and to have public health insurance (OR 3.11, p < 0.001). More than one-quarter (29%) of patients underwent surgery. The non-White and non-Hispanic White patients had similar surgery rates (29.5% vs 28.9%, p = 0.895) at similar ages (8.8 vs 9.7 years, p = 0.406). There were no differences by race/ethnicity for symptoms at presentation. Surgical and nonsurgical patients had similar ADI scores (3.9 vs 4.2, p = 0.194), RUCA scores (2.1 vs 2.3, p = 0.252), and private health insurance rates (73.6% vs 74.2%, p = 0.878). A total of 153 patients underwent surgery within 9 months of their initial visit. The remaining 512 were deemed to have benign CM-I. Of these, 40 (7.8%) underwent decompression surgery for delayed symptom presentation. Patients with delayed symptom presentation were from less disadvantaged (ADI 3.2 vs 4.2; p = 0.025) and less rural (RUCA 1.8 vs 2.3; p = 0.023) areas than those who never underwent surgery.

CONCLUSIONS

Although non-White patients were more likely to be socioeconomically disadvantaged, race and socioeconomic disadvantage were not associated with undergoing surgical treatment. However, among patients with benign CM-I, those undergoing decompression for delayed symptom presentation resided in more affluent and urban areas.

Neighborhood and Individual Socioeconomic Disadvantage and Survival Among Patients With Nonmetastatic Common Cancers

IMPORTANCE

Disadvantaged neighborhood-level and individual-level socioeconomic status (SES) have each been associated with suboptimal cancer care and inferior outcomes. However, independent or synergistic associations between neighborhood and individual socioeconomic disadvantage have not been fully examined, and prior studies using simplistic neighborhood SES measures may not comprehensively assess multiple aspects of neighborhood SES.

OBJECTIVE

To investigate the associations of neighborhood SES (using a validated comprehensive composite measure) and individual SES with survival among patients with nonmetastatic common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, population-based cohort study was derived from the Surveillance, Epidemiology, and End Results-Medicare database from January 1, 2008, through December 31, 2011, with follow-up ending on December 31, 2017. Participants included older patients (≥65 years) with breast, prostate, lung, or colorectal cancer.

EXPOSURES

Neighborhood SES was measured using the area deprivation index (ADI; quintiles), a validated comprehensive composite measure of neighborhood SES. Individual SES was assessed by Medicare-Medicaid dual eligibility (yes vs no), a reliable indicator for patient-level low income.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall mortality, and the secondary outcome was cancer-specific mortality. Hazard ratios (HRs) for the associations of ADI and dual eligibility with overall and cancer-specific mortality were estimated via Cox proportional hazards regression. Statistical analyses were conducted from January 23 to April 15, 2021.

RESULTS

A total of 96 978 patients were analyzed, including 25 968 with breast, 35 150 with prostate, 16 684 with lung, and 19 176 with colorectal cancer. Median age at diagnosis was 76 years (IQR, 71-81 years) for breast cancer, 73 years (IQR, 70-77 years) for prostate cancer, 76 years (IQR, 71-81 years) for lung cancer, and 78 years (IQR, 72-84 years) for colorectal cancer. Among lung and colorectal cancer patients, 8412 (50.4%) and 10 486 (54.7%), respectively, were female. The proportion of non-Hispanic White individuals among breast cancer patients was 83.7% (n = 21 725); prostate cancer, 76.8% (n = 27 001); lung cancer, 83.5% (n = 13 926); and colorectal cancer, 81.1% (n = 15 557). Neighborhood-level and individual-level SES were independently associated with overall mortality, and no interactions were detected. Compared with the most affluent neighborhoods (ADI quintile 1), living in the most disadvantaged neighborhoods (ADI quintile 5) was associated with higher risk of overall mortality (breast: HR, 1.34; 95% CI, 1.26-1.43; prostate: HR, 1.51; 95% CI, 1.42-1.62; lung: HR, 1.21; 95% CI, 1.14-1.28; and colorectal: HR, 1.24; 95% CI, 1.17-1.32). Individual socioeconomic disadvantage (dual eligibility) was associated with higher risk of overall mortality (breast: HR, 1.22; 95% CI, 1.15-1.29; prostate: HR, 1.29; 95% CI, 1.21-1.38; lung: HR, 1.14; 95% CI, 1.09-1.20; and colorectal: HR, 1.23; 95% CI, 1.17-1.29). A similar pattern was observed for cancer-specific mortality.

CONCLUSIONS AND RELEVANCE

In this cohort study, neighborhood-level deprivation was associated with worse survival among patients with nonmetastatic breast, prostate, lung, and colorectal cancer, even after accounting for individual SES. These findings suggest that, in order to improve cancer outcomes and reduce health disparities, policies for ongoing investments in low-resource neighborhoods and low-income households are needed.