Disparities in diabetes-related multiple chronic conditions and mortality: The influence of race

The mediating role of systemic inflammation and moderating role of racialization in disparities in incident dementia

BACKGROUND

Exposure to systemic racism is linked to increased dementia burden. To assess systemic inflammation as a potential pathway linking exposure to racism and dementia disparities, we investigated the mediating role of C-reactive protein (CRP), a systemic inflammation marker, and the moderating role of the racialization process in incident dementia.

METHODS

In the US Health and Retirement Study (n = 6,908), serum CRP was measured at baseline (2006, 2008 waves). Incident dementia was classified by cognitive tests over a six-year follow-up. Self-reported racialized categories were a proxy for exposure to the racialization process. We decomposed racialized disparities in dementia incidence (non-Hispanic Black and/or Hispanic vs. non-Hispanic white) into 1) the mediated effect of CRP, 2) the moderated portion attributable to the interaction between racialized group membership and CRP, and 3) the controlled direct effect (other pathways through which racism operates).

RESULTS

The 6-year cumulative incidence of dementia is 12%. Among minoritized participants (i.e., non-Hispanic Black and/or Hispanic), high CRP levels ( ≥ 75th percentile or 4.73μg/mL) are associated with 1.26 (95%CI: 0.98, 1.62) times greater risk of incident dementia than low CRP ( < 4.73μg/mL). Decomposition analysis comparing minoritized versus non-Hispanic white participants shows that the mediating effect of CRP accounts for 3% (95% CI: 0%, 6%) of the racial disparity, while the interaction effect between minoritized group status and high CRP accounts for 14% (95% CI: 1%, 27%) of the disparity. Findings are robust to potential violations of causal mediation assumptions.

CONCLUSIONS

Minoritized group membership modifies the relationship between systemic inflammation and incident dementia.

The Disproportionate Impact of Primary Care Disruption and Telehealth Utilization During COVID-19

PURPOSE

The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected.

METHODS

We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation.

RESULTS

Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%).

CONCLUSIONS

Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions.

Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban

Importance

Diltiazem, a commonly prescribed ventricular rate-control medication for patients with atrial fibrillation, inhibits apixaban and rivaroxaban elimination, possibly causing overanticoagulation.

Objective

To compare serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol.

Design, Setting, and Participants

This retrospective cohort study included Medicare beneficiaries aged 65 years or older with atrial fibrillation who initiated apixaban or rivaroxaban use and also began treatment with diltiazem or metoprolol between January 1, 2012, and November 29, 2020. Patients were followed up to 365 days through November 30, 2020. Data were analyzed from August 2023 to February 2024.

Exposures

Diltiazem and metoprolol.

Main Outcomes and Measures

The primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Secondary outcomes were ischemic stroke or systemic embolism, major ischemic or hemorrhagic events (ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding, or death with recent evidence of bleeding), and death without recent evidence of bleeding. Hazard ratios (HRs) and rate differences (RDs) were adjusted for covariate differences with overlap weighting.

Results

The study included 204 155 US Medicare beneficiaries, of whom 53 275 received diltiazem and 150 880 received metoprolol. Study patients (mean [SD] age, 76.9 [7.0] years; 52.7% female) had 90 927 person-years (PY) of follow-up (median, 120 [IQR, 59-281] days). Patients receiving diltiazem treatment had increased risk for the primary outcome (RD, 10.6 [95% CI, 7.0-14.2] per 1000 PY; HR, 1.21 [95% CI, 1.13-1.29]) and its components of bleeding-related hospitalization (RD, 8.2 [95% CI, 5.1-11.4] per 1000 PY; HR, 1.22 [95% CI, 1.13-1.31]) and death with recent evidence of bleeding (RD, 2.4 [95% CI, 0.6-4.2] per 1000 PY; HR, 1.19 [95% CI, 1.05-1.34]) compared with patients receiving metoprolol. Risk for the primary outcome with initial diltiazem doses exceeding 120 mg/d (RD, 15.1 [95% CI, 10.2-20.1] per 1000 PY; HR, 1.29 [95% CI, 1.19-1.39]) was greater than that for lower doses (RD, 6.7 [95% CI, 2.0-11.4] per 1000 PY; HR, 1.13 [95% CI, 1.04-1.24]). For doses exceeding 120 mg/d, the risk of major ischemic or hemorrhagic events was increased (HR, 1.14 [95% CI, 1.02-1.27]). Neither dose group had significant changes in the risk for ischemic stroke or systemic embolism or death without recent evidence of bleeding. When patients receiving high- and low-dose diltiazem treatment were directly compared, the HR for the primary outcome was 1.14 (95% CI, 1.02-1.26).

Conclusions and Relevance

In Medicare patients with atrial fibrillation receiving apixaban or rivaroxaban, diltiazem was associated with greater risk of serious bleeding than metoprolol, particularly for diltiazem doses exceeding 120 mg/d.

Epidemiological patterns of chronic kidney disease attributed to type 2 diabetes from 1990-2019

Background

This study investigates the burden of chronic kidney disease attributed to type 2 diabetes (CKD-T2D) across different geographical locations and time periods from 1990 to 2019. A total of 204 countries and regions are included in the analysis, with consideration given to their socio-demographic indexes (SDI). The aim is to examine both spatial and temporal variations in CKD-T2D burden.

Methods

This research utilized data from the 2019 Global Burden of Diseases Study to evaluate the age-standardized incidence rates (ASIR), Disability-Adjusted Life Years (DALYs), and Estimated Annual Percentage Change (EAPC) associated with CKD-T2D.

Results

Since 1990, there has been a noticeable increase of CKD age-standardized rates due to T2D, with an EAPCs of 0.65 (95% confidence interval [CI]: 0.63 to 0.66) for ASIR and an EAPC of 0.92 (95% CI: 0.8 to 1.05) for age-standardized DALYs rate. Among these regions, Andean Latin America showed a significant increase in CKD-T2D incidence [EAPC: 2.23 (95% CI: 2.11 to 2.34) and North America showed a significant increase in CKD-T2D DALYs [EAPC: 2.73 (95% CI: 2.39 to 3.07)]. The burden was higher in male and increased across all age groups, peaking at 60-79 years. Furthermore, there was a clear correlation between SDI and age-standardized rates, with regions categorized as middle SDI and High SDI experiencing a significant rise in burden.

Conclusion

The global burden of CKD-T2D has significantly risen since 1990, especially among males aged 60-79 years and in regions with middle SDI. It is imperative to implement strategic interventions to effectively address this escalating health challenge.

Racial and Ethnic Differences in Social Determinants of Health and Health-Related Social Needs Among Adults - Behavioral Risk Factor Surveillance System, United States, 2022

Social determinants of health (SDOH) are a broad array of social and contextual conditions where persons are born, live, learn, work, play, worship, and age that influence their physical and mental wellbeing and quality of life. Using 2022 Behavioral Risk Factor Surveillance System data, this study assessed measures of adverse SDOH and health-related social needs (HRSN) among U.S. adult populations. Measures included life satisfaction, social and emotional support, social isolation or loneliness, employment stability, food stability/security, housing stability/security, utility stability/security, transportation access, mental well-being, and health care access. Prevalence ratios were adjusted for age, sex, education, marital status, income, and self-rated health. Social isolation or loneliness (31.9%) and lack of social and emotional support (24.8%) were the most commonly reported measures, both of which were more prevalent among non-Hispanic (NH) American Indian or Alaska Native, NH Black or African American, NH Native Hawaiian or other Pacific Islander, NH multiracial, and Hispanic or Latino adults than among NH White adults. The majority of prevalence estimates for other adverse SDOH and HRSN were also higher across all other racial and ethnic groups (except for NH Asian) compared with NH White adults. SDOH and HRSN data can be used to monitor needed social and health resources in the U.S. population and help evaluate population-scale interventions.

Worldwide burden and trends of diabetes among people aged 70 years and older, 1990-2019: A systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Diabetes places a significant burden on personal and public health. However, a comprehensive assessment of the burden of diabetes in older adults is lacking. We aimed to estimate the global burden of diabetes and explore trends for the population aged ≥70 from 1990 to 2019.

METHODS

Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, the prevalence, mortality, and disability-adjusted life-years (DALYs) of diabetes among people aged ≥70 were estimated by sex and age group in 2019. We also assessed the epidemiological trend of diabetes from 1990 to 2019.

RESULTS

In 2019, 110.1 million (95% uncertainty interval [UI]: 101.2-119.4) people aged ≥70 years were living with diabetes (types 1 and 2 combined) with a global prevalence of 23.7% (21.8%-25.8%). Worldwide, 181.9 deaths (163.0-194.7) per 100,000 population and 4512.3 DALYs (3861.3-5264.2) per 100,000 population occurred due to diabetes. In 2019, minor sex-related disparities in the burden of diabetes were identified among specific age and sex groups. From 1990 to 2019, the prevalence of diabetes increased by 39.7% (37.7%-41.7%), and the related mortality and DALY rates also increased (16.4% [9.43%-22.9%] and 22.3% [17.2%-27.0%], respectively).

CONCLUSION AND RELEVANCE

The global burden of diabetes in adults aged ≥70 has increased markedly from 1990 to 2019. As the population continues to age, there is an urgent need to combat the increasing disease burden.

Current State and Future Perspective of Diabetic Wound Healing Treatment: Present Evidence from Clinical Trials

Diabetes is a chronic metabolic condition that is becoming more common and is characterised by sustained hyperglycaemia and long-term health effects. Diabetes-related wounds often heal slowly and are more susceptible to infection because of hyperglycaemia in the wound beds. The diabetic lesion becomes harder to heal after planktonic bacterial cells form biofilms. A potential approach is the creation of hydrogels with many functions. High priority is given to a variety of processes, such as antimicrobial, pro-angiogenesis, and general pro-healing. Diabetes problems include diabetic amputations or chronic wounds (DM). Chronic diabetes wounds that do not heal are often caused by low oxygen levels, increased reactive oxygen species, and impaired vascularization. Several types of hydrogels have been developed to get rid of contamination by pathogens; these hydrogels help to clean up the infection, reduce wound inflammation, and avoid necrosis. This review paper will focus on the most recent improvements and breakthroughs in antibacterial hydrogels for treating chronic wounds in people with diabetes. Prominent and significant side effects of diabetes mellitus include foot ulcers. Antioxidants, along with oxidative stress, are essential to promote the healing of diabetic wounds. Some of the problems that can come from a foot ulcer are neuropathic diabetes, ischemia, infection, inadequate glucose control, poor nutrition, also very high morbidity. Given the worrying rise in diabetes and, by extension, diabetic wounds, future treatments must focus on the rapid healing of diabetic wounds.

Variation in multimorbidity by sociodemographics and social drivers of health among patients seen at community-based health centers

Purpose

Understanding variation in multimorbidity across sociodemographics and social drivers of health is critical to reducing health inequities.

Methods

From the multi-state OCHIN network of community-based health centers (CBHCs), we identified a cross-sectional cohort of adult (> 25 years old) patients who had a visit between 2019-2021. We used generalized linear models to examine the relationship between the Multimorbidity Weighted Index (MWI) and sociodemographics and social drivers of health (Area Deprivation Index [ADI] and social risks [e.g., food insecurity]). Each model included an interaction term between the primary predictor and age to examine if certain groups had a higher MWI at younger ages.

Results

Among 642,730 patients, 28.2% were Hispanic/Latino, 42.8% were male, and the median age was 48. The median MWI was 2.05 (IQR: 0.34, 4.87) and was higher for adults over the age of 40 and American Indians and Alaska Natives. The regression model revealed a higher MWI at younger ages for patients living in areas of higher deprivation. Additionally, patients with social risks had a higher MWI (3.16; IQR: 1.33, 6.65) than those without (2.13; IQR: 0.34, 4.89) and the interaction between age and social risk suggested a higher MWI at younger ages.

Conclusions

Greater multimorbidity at younger ages and among those with social risks and living in areas of deprivation shows possible mechanisms for the premature aging and disability often seen in community-based health centers and highlights the need for comprehensive approaches to improving the health of vulnerable populations.

Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals

INTRODUCTION

This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care.

METHODS

The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis between January and December 2021. An additional chart review was conducted to ensure the accuracy of racial/ethnic categorization. The sample was dichotomized into white vs. non-white groups and compared with univariate analysis.

RESULTS

The study sample comprised 1408 encounters (1347 patients) with Mean age of 71 ± 15 years, 51% women, 82% white patients, 15% non-white patients, 72% acute ischemic stroke (AIS); 15% transient ischemic attack (TIA), 9% intracerebral hemorrhage (ICH), 3% subarachnoid hemorrhage (SAH), and 1% stroke not otherwise specified. Non-white patients were younger and had fewer concomitant diagnoses, a lower proportion of TIA, and a higher proportion of ICH (p = 0.004). In the AIS cohort, compared to white patients, non-white patients had less frequent ambulance (p = 0.009), arrived at the hospital later than white patients (7.7 h longer; p < 0.001), had more severe strokes, and had less frequent IV thrombolysis utilization (7% vs. 13%; p = 0.042). Similarly, in the TIA cohort, non-white patients' utilization of EMS was lower than that of white patients, and their hospital arrival was delayed. In the ICH cohort, non-white patients were younger and had a lower frequency of atrial fibrillation and a non-significant trend toward higher disease severity. The SAH cohort had only eight non-white patients, six of whom were transferred to a higher level of hospital care within a few hours of arrival. Importantly, the hospital-based quality metrics, such as door-to-CT time, door-to-needle time, and the Joint Commission stroke quality metrics, were similar between the two groups.

CONCLUSIONS

There is a racial disparity in the pre-hospital phase of the stroke chain of survival of non-white patients, impacting IV thrombolysis utilization. The younger age and worse lipid profile and hemoglobin A1c of non-white patients suggest the need for better preventative care starting at a young age.

Multimorbidity in African ancestry populations: a scoping review

OBJECTIVES

Multimorbidity (MM) is a growing concern linked to poor outcomes and higher healthcare costs. While most MM research targets European ancestry populations, the prevalence and patterns in African ancestry groups remain underexplored. This study aimed to identify and summarise the available literature on MM in populations with African ancestry, on the continent, and in the diaspora.

DESIGN

A scoping review was conducted in five databases (PubMed, Web of Science, Scopus, Science Direct and JSTOR) in July 2022. Studies were selected based on predefined criteria, with data extraction focusing on methodology and findings. Descriptive statistics summarised the data, and a narrative synthesis highlighted key themes.

RESULTS

Of the 232 publications on MM in African-ancestry groups from 2010 to June 2022-113 examined continental African populations, 100 the diaspora and 19 both. Findings revealed diverse MM patterns within and beyond continental Africa. Cardiovascular and metabolic diseases are predominant in both groups (80% continental and 70% diaspora). Infectious diseases featured more in continental studies (58% continental and 16% diaspora). Although many papers did not specifically address these features, as in previous studies, older age, being women and having a lower socioeconomic status were associated with a higher prevalence of MM, with important exceptions. Research gaps identified included limited data on African-ancestry individuals, inadequate representation, under-represented disease groups, non-standardised methodologies, the need for innovative data strategies, and insufficient translational research.

CONCLUSION

The growing global MM prevalence is mirrored in African-ancestry populations. Recognising the unique contexts of African-ancestry populations is essential when addressing the burden of MM. This review emphasises the need for additional research to guide and enhance healthcare approaches for African-ancestry populations, regardless of their geographic location.

Risk analysis of COVID-19 hospitalization and critical care by race and region in the United States: a cohort study

BACKGROUND

This study aimed to identify the current risk factors for coronavirus disease 2019 severity and examine its association with medication use.

METHODS

We used data from a large United States electronic health record database to conduct an anonymized cohort study of 171,491 patients with coronavirus disease 2019. The study was conducted from January 1, 2020, to August 27, 2021. Data on age, race, sex, history of diseases, and history of medication prescriptions were analyzed using the Cox proportional hazards model analysis to calculate hazard ratios for hospitalization and severe risk.

RESULTS

Factors that increased the risk of hospitalization and critical care were age ≥ 65 years, male sex, type 2 diabetes, hypertension, interstitial pneumonia, and cardiovascular disease. In particular, age ≥ 65 years significantly increased the risk of hospitalization (hazard ratio, 2.81 [95% confidence interval, 2.58-3.07]; P < 0.001) and critical care (hazard ratio, 3.45 [2.88-4.14]; P < 0.001). In contrast, patients with hyperlipidemia had a reduced risk. However, patients with hyperlipidemia who were not taking statins had a significantly increased risk of hospitalization (hazard ratio, 1.24 [1.16-1.34]; P < 0.001). Sodium-glucose cotransporter-2 inhibitors, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, glucocorticoids, and statins significantly reduced the risk of hospitalization and critical care. The risk of hospitalization and critical care increased in patients of all ethnicities with type 2 diabetes. The factors that significantly increased the risk of hospitalization in all regions were older age, hypertension, chronic obstructive pulmonary disease, and cardiovascular disease.

CONCLUSION

This study identified factors that increase or reduce the risk of severe coronavirus disease. The provision of appropriate drug treatment and modification of lifestyle-related risk factors may reduce coronavirus disease severity.

Histopathologic Features of Chronic Rhinosinusitis in Diabetic Patients

OBJECTIVE

To explore how diabetes mellitus impacts chronic rhinosinusitis clinically and on structured histopathology to provide insights on new potential chronic rhinosinusitis endotypes.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic center.

METHODS

A retrospective study of chronic rhinosinusitis patients who underwent functional endoscopic sinus surgery from 2015 to 2020 was performed. Structured 13-variable histopathology reports were generated from intraoperative sinonasal specimens. These variables were compared against demographic factors, comorbidities, culture data, and preoperative Lund-Mackay and SNOT-22 scores using logistic regression.

RESULTS

There were 411 patients, including 52 diabetics. Diabetes was associated with higher mean body mass index (34.9 vs 29.2; p < .001), age (57.8 vs 48.0; p < .001), and Gram-negative (40.2% vs 22.7%; p < .030) and coagulase-negative Staphylococcus (49.0% vs 28.5%; p = .008) culture rates. Black (23.1% vs 18.7%) and Hispanic (23.1% vs 8.6%) races were more common with diabetes (p = .026). Gender, smoking, polyp status, and Lund-Mackay and SNOT-22 scores did not differ between groups. Diabetics had more fungal elements (13.5% vs 3.3%, p = .018); no other histopathological differences were seen. When controlling for demographic variables and comorbidities, diabetes independently predicted the presence of fungal elements (HR 4.38, p = .018).

CONCLUSION

Diabetic chronic rhinosinusitis patients demonstrated increased fungal elements on structured histopathology. Other histopathological features were unaffected by diabetes. These findings may have important implications on the medical and surgical management of diabetic chronic rhinosinusitis patients in which early fungal disease assessment is paramount.

Geriatric Nutrition Risk Index as a predictor of cardiovascular and all-cause mortality in older Americans with diabetes

BACKGROUND AND AIMS

Few studies have examined the relationship between malnutrition, as defined by the Geriatric Nutrition Risk Index (GNRI), and all-cause mortality and cardiovascular mortality events, particularly in persons with diabetes. The study aimed at the association between GNRI and all-cause mortality and cardiovascular mortality in older Americans with diabetes.

METHODS

Data from this retrospective study were obtained from the National Health and Nutrition Examination (NHANES) 1999-2016. Using data from The NHANES Public-Use Linked Mortality Files to assess all-cause mortality (ACM) and cardiovascular mortality (CVM). After excluding participants younger than 60 years and without diabetes, and with missing follow-up data, 4400 cases were left in this study. Persons with diabetes were divided by GNRI into 3 groups: GNRI ≥ 98; 92 ≤ GNRI < 98; and GNRI < 92; (No; Low; Moderate/Severe (M/S) group). We used Cox proportional hazard regression model to explore the predictive role of GNRI on ACM and CVM in elderly persons with diabetes. Restricted cubic splines to investigate the existence of a dose-response linear relationship between them.

RESULT

During a median follow-up period of 89 months, a total of 538 (12.23%) cardiovascular deaths occurred and 1890 (42.95%) all-cause deaths occurred. Multifactorial COX regression analysis showed all-cause mortality (hazard ratio [HR]: 2.58, 95% CI: 1.672-3.994, p < 0.001) and cardiovascular mortality (HR: 2.29, 95% CI: 1.063-4.936, p = 0.034) associated with M/S group risk of malnutrition in GNRI compared to no group. A negative association between GNRI and all-cause mortality was observed across gender and ethnicity. However, the same negative association between GNRI and cardiovascular mortality was observed only for males (HR:0.94, 95% CI:0.905-0.974, p < 0.001) and other races (HR:0.92, 95% CI:0.861-0.976, p = 0.007). And there was no significant correlation between low malnutrition and cardiovascular mortality (p = 0.076). Restricted cubic splines showed a nonlinear relationship between GNRI and all-cause mortality and cardiovascular mortality (non-linear p < 0.001, non-linear p = 0.019).

CONCLUSIONS

Lower GNRI levels are associated with mortality in older patients with diabetes. GNRI may be a predictor of all-cause mortality and cardiovascular mortality risk in older patients with diabetes.

Chronic Kidney Disease Burden in Low-Resource Settings: Regional Perspectives

The burden of chronic kidney disease (CKD) has increased exponentially worldwide but more so in low- and middle-income countries. Specific risk factors in these regions expose their populations to an increased risk of CKD, such as genetic risk with APOL1 among populations of West African heritage or farmers with CKD of unknown etiology that spans various countries across several continents to immigrant/indigenous populations in both low- and high-income countries. Low- and middle-income economies also have the double burden of communicable and noncommunicable diseases, both contributing to the high prevalence of CKD. The economies are characterized by low health expenditure, sparse or nonexistent health insurance and welfare programs, and predominant out-of-pocket spending for medical care. This review highlights the challenges in populations with CKD from low-resource settings globally and explores how health systems can help ameliorate the CKD burden.

The Mediating Role of Systemic Inflammation and Moderating Role of Race/Ethnicity in Racialized Disparities in Incident Dementia: A Decomposition Analysis

Background

Exposure to systemic racism is linked to increased dementia burden. To assess systemic inflammation as a potential pathway linking exposure to racism and dementia disparities, we investigated the mediating role of C-reactive protein (CRP), a systemic inflammation marker, and the moderating role of race/ethnicity on racialized disparities in incident dementia.

Methods

In the US Health and Retirement Study (n=5,143), serum CRP was measured at baseline (2006, 2008 waves). Incident dementia was classified by cognitive tests over a six-year follow-up. Self-reported racialized categories were a proxy for exposure to the racialization process. We decomposed racialized disparities in dementia incidence (non-Hispanic Black and/or Hispanic vs. non-Hispanic White) into 1) the mediated effect of CRP, 2) the moderated portion attributable to the interaction between racialized group membership and CRP, and 3) the controlled direct effect (other pathways through which racism operates).

Results

The 6-year cumulative incidence of dementia was 15.5%. Among minoritized participants (i.e., non-Hispanic Black and/or Hispanic), high CRP levels (> 75th percentile or 4.57mcg/mL) was associated with 1.27 (95%CI: 1.01,1.59) times greater risk of incident dementia than low CRP (<4.57mcg/mL). Decomposition analysis comparing minoritized versus non-Hispanic White participants showed that the mediating effect of CRP accounted for 2% (95% CI: 0%, 6%) of the racial disparity, while the interaction effect between minoritized group status and high CRP accounted for 12% (95% CI: 2%, 22%) of the disparity. Findings were robust to potential violations of causal mediation assumptions.

Conclusions

Systemic inflammation mediates racialized disparities in incident dementia.

Older adults' experiences and perceived impacts of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) for diabetes self-management in Canada: a qualitative descriptive study

OBJECTIVES

To assess the experiences and perceived impacts of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) from the perspectives of older adults with diabetes and other chronic conditions. The ACHRU-CPP is a complex 6-month self-management evidence-based intervention for community-living older adults aged 65 years or older with type 1 or type 2 diabetes and at least one other chronic condition. It includes home and phone visits, care coordination, system navigation support, caregiver support and group wellness sessions delivered by a nurse, dietitian or nutritionist, and community programme coordinator.

DESIGN

Qualitative descriptive design embedded within a randomised controlled trial was used.

SETTING

Six trial sites offering primary care services from three Canadian provinces (ie, Ontario, Quebec and Prince Edward Island) were included.

PARTICIPANTS

The sample was 45 community-living older adults aged 65 years or older with diabetes and at least one other chronic condition.

METHODS

Participants completed semistructured postintervention interviews by phone in English or French. The analytical process followed Braun and Clarke's experiential thematic analysis framework. Patient partners informed study design and interpretation.

RESULTS

The mean age of older adults was 71.7 years, and the mean length of time living with diabetes was 18.8 years. Older adults reported positive experiences with the ACHRU-CPP that supported diabetes self-management, such as improved knowledge in managing diabetes and other chronic conditions, enhanced physical activity and function, improved eating habits, and opportunities for socialisation. They reported being connected to community resources by the intervention team to address social determinants of health and support self-management.

CONCLUSIONS

Older adults perceived that a 6-month person-centred intervention collaboratively delivered by a team of health and social care providers helped support chronic disease self-management. There is a need for providers to help older adults connect with available health and social services in the community.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov ID: NCT03664583; Results.

The Mediating Role of Systemic Inflammation and Moderating Role of Race/Ethnicity in Racialized Disparities in Incident Dementia: A Decomposition Analysis

Background

Exposure to systemic racism is linked to increased dementia burden. To assess systemic inflammation as a potential pathway linking exposure to racism and dementia disparities, we investigated the mediating role of C-reactive protein (CRP), a systemic inflammation marker, and the moderating role of race/ethnicity on racialized disparities in incident dementia.

Methods

In the US Health and Retirement Study (n=5,143), serum CRP was measured at baseline (2006, 2008 waves). Incident dementia was classified by cognitive tests over a six-year follow-up. Self-reported racialized categories were a proxy for exposure to the racialization process. We decomposed racialized disparities in dementia incidence (non-Hispanic Black and/or Hispanic vs. non-Hispanic White) into 1) the mediated effect of CRP, 2) the moderated portion attributable to the interaction between racialized group membership and CRP, and 3) the controlled direct effect (other pathways through which racism operates).

Results

The 6-year cumulative incidence of dementia was 15.5%. Among minoritized participants (i.e., non-Hispanic Black and/or Hispanic), high CRP levels (> 75th percentile or 4.57μg/mL) was associated with 1.27 (95%CI: 1.01,1.59) times greater risk of incident dementia than low CRP (≤4.57μg/mL). Decomposition analysis comparing minoritized versus non-Hispanic White participants showed that the mediating effect of CRP accounted for 2% (95% CI: 0%, 6%) of the racial disparity, while the interaction effect between minoritized group status and high CRP accounted for 12% (95% CI: 2%, 22%) of the disparity. Findings were robust to potential violations of causal mediation assumptions.

Conclusions

Systemic inflammation mediates racialized disparities in incident dementia.

Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners

Policy Points Local health departments with direct maternal and child health service provisions exhibit greater social service collaboration, thereby enhancing community capacity to improve health care access and social determinant support. These findings may prioritize collaboration as a community-based effort to reduce disparities in maternal and child health and chronic disease.

CONTEXT

Improving maternal and child health (MCH) care in the United States requires solutions to address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations, impacting local service delivery capacity. We measured MCH service provision among LHDs and examined its association with patterns of social service collaboration among community partners.

METHODS

We analyzed the 2018 National Longitudinal Survey of Public Health Systems and 2016 National Association of County and City Health Officials Profile data to measure the LHD provision of MCH services and the types of social services involved in the implementation of essential public health activities. We compared the extensive and intensive margins of social service collaboration among LHDs with any versus no MCH service provision. We then used latent class analysis (LCA) to classify collaboration and logistic regression to estimate community correlates of collaboration.

FINDINGS

Of 620 LHDs, 527 (85%) provided at least one of seven observed MCH services. The most common service was Special Supplemental Nutrition Program for Women, Infants, and Children (71%), and the least common was obstetric care (15%). LHDs with MCH service provision were significantly more likely to collaborate with all types of social service organizations. LCA identified two classes of LHDs: high (n = 257; 49%) and low (n = 270; 51%) collaborators. Between 74% and 96% of high collaborators were engaged with social service organizations that provided basic needs services, compared with 31%-60% of low collaborators. Rurality and very high maternal vulnerability were significantly correlated with low collaboration among MCH service-providing LHDs.

CONCLUSIONS

LHDs with direct MCH service provision exhibited greater social service collaboration. Collaboration was lowest in rural communities and communities with very high maternal vulnerability. Over half of MCH service-providing LHDs were classified as low collaborators, suggesting unrealized opportunities for social service engagement in these communities.

High Rates of Multimorbidity Reported Among People of Color Despite Healthy Weight

Purpose:

Methods:

Results:

Conclusion:

Efficiency of Multifunctional Antibacterial Hydrogels for Chronic Wound Healing in Diabetes: A Comprehensive Review

Diabetic chronic wounds or amputation, which are complications of diabetes mellitus (DM), are a cause of great suffering for diabetics. In addition to the lack of oxygen, elevated reactive oxygen species (ROS) and reduced vascularization, microbial invasion is also a critical factor that induces non-healing chronic diabetic wounds, ie, wounds still remaining in the stage of inflammation, after which the wound tissue begins to age and becomes necrotic. To clear up the infection, alleviate the inflammation in the wound and prevent necrosis, many kinds of hydrogel have been fabricated to eliminate infections with pathogens. The unique properties of hydrogels make them ideally suited to wound dressings because they provide a moist environment for wound healing and act as a barrier against bacteria. This review article will mainly cover the recent developments and innovations of antibacterial hydrogels for diabetic chronic wound healing.

Racial disparities in symptomatology and outcomes of COVID-19 among adults of Arkansas

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Few reports have suggested that non-Hispanic Blacks may present with different symptoms for COVID-19 than non-Hispanic Whites.

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In this novel study comprising of representative sample of over 60,000 racially diverse population of Arkansas adults, we investigated patterns in symptomatology and outcomes of COVID-19.

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We found differences in COVID-19 symptoms by race/ethnicity, with NH-blacks and Hispanics affected more, with specific or all symptoms, compared to NH-whites.

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Acknowledging differences in presentation in symptoms at clinical setting will aid in accurate diagnoses of patients that present with COVID-19.

Few reports have suggested that non-Hispanic (NH) blacks may present with different symptoms for COVID-19 than NH-whites. The objective of this study was to investigate patterns in symptomatology and COVID-19 outcomes by race/ethnicity among adults in Arkansas. Data on COVID-19 symptoms were collected on day of testing, 7th and 14th day among participants at UAMS mobile testing units throughout the state of Arkansas. Diagnosis for SARS-CoV-2 infection was confirmed via nasopharyngeal swab and RT-PCR methods. Data analysis was conducted using Chi-square test and Poisson regression to assess the differences in characteristics by race/ethnicity. A total of 60,648 individuals were RT-PCR tested from March 29, 2020 through October 7, 2020. Among adults testing positive, except shortness of breath, Hispanics were more likely to report all symptoms than NH-whites or NH-blacks. NH-whites were more likely to report fever (19.6% vs. 16.6%), cough (27.5% vs. 26.1%), shortness of breath (13.6% vs. 9.6%), sore throat (16.7% vs. 10.7%), chills (12.5% vs. 11.8%), muscle pain (15.6% vs. 12.4%), and headache (20.3% vs. 17.8%). NH-blacks were more likely to report loss of taste/smell (10.9% vs. 10.6%). To conclude, we found differences in COVID-19 symptoms by race/ethnicity, with NH-blacks and Hispanics more often affected with specific or all symptoms, compared to NH-whites. Due to the cross-sectional study design, these findings do not necessarily reflect biological differences by race/ethnicity; however, they suggest that certain race/ethnicities may have underlying differences in health status that impact COVID-19 outcomes.

Individual and Combined Effect of Diabetes and Lifetime Criminal Justice Involvement on Healthcare Utilization in US Adults, 2015-2019

BACKGROUND

Diabetes and criminal justice involvement (CJI) are both associated with poor health outcomes and increased healthcare utilization. However, little is known about the additive effects of these risk factors when combined. This study examined the individual and combined effects of diabetes and CJI on healthcare utilization.

METHODS

Data from the National Survey of Drug Use and Health (2015-2019) was used to create a cross-sectional, nationally representative sample of US adults with diabetes, CJI, combination of both, or neither. Negative binomial regression was used to test the association between those with CJI and diabetes (compared to diabetes alone) and three utilization types (outpatient, ED, and inpatient) controlling for relevant sociodemographic and clinical covariates.

RESULTS

Of 212,079 respondents, representing 268,893,642 US adults, 8.8% report having diabetes alone, 15.2% report having CJI alone, and 1.8 % report both diabetes and lifetime CJI. After adjustment, those with diabetes and CJI had increased acute care utilization compared to those with diabetes alone (ED visits: IRR 1.13; 95% CI 1.00-1.28; nights hospitalized: IRR 1.34; 95% CI 1.08-1.67). There was no difference in outpatient utilization between those with both diabetes and CJI compared to those with diabetes alone (IRR 1.04, 95% CI 0.99-1.10).

CONCLUSION

Individuals with complex social and health risks such as diabetes and lifetime CJI experience increased acute healthcare utilization but no difference in outpatient utilization. Tailored interventions that target both diabetes and CJI are needed to reduce unnecessary utilization in this population.

Association between mental health outcomes and lifetime criminal justice involvement in U.S. adults with diabetes

BACKGROUND

Diabetes is a leading cause of death in the United States, and comorbid mental illness is associated with worse diabetes outcomes. Those with criminal justice involvement (CJI) have high rates of mental illness and diabetes prevalence. However, little is known about the relationship between CJI and mental illness among those with diabetes.

METHODS

Using a nationally representative sample of U.S. adults with diabetes from the National Survey of Drug Use and Health (2015-2018), we investigated the relationship between CJI and mental health outcomes (depression, serious psychologic distress, serious mental illness, moderate mental illness, any mental illness, functional status). Multiple linear and logistic regression models were used to assess the relationship between CJI and each mental health outcome adjusting for multiple socio-demographic and comorbidity variables.

RESULTS

Of 11,594 respondents, representing 25,834,422 adults with diabetes, 17.1% reported prior CJI. In fully adjusted models, CJI was independently associated with all mental health outcomes: depression (aOR 1.80, 95% CI: 1.41, 2.30), serious psychologic distress (aOR 1.53, 95% CI: 1.23, 1.90), serious mental illness (aOR 2.00, 95% CI: 1.58, 2.52), moderate mental illness (aOR 1.72, 95% CI 1.30, 2.26), any mental illness (aOR 1.92, 95% CI: 1.56, 2.35) and functional status (regression coefficient 3.6, 95% CI: 3.53, 3.79).

CONCLUSION

Those with diabetes and criminal justice involvement experience concentrated risk for poor mental health outcomes. Our findings suggest that mental health interventions may be imperative to achieving control of diabetes in the justice-involved population.

Predictors of early and sustained cessation of heavy drinking over 5 years among adult primary care patients

AIMS

To identify factors asociated with early and sustained cessation of heavy drinking.

DESIGN

Retrospective cohort study over 5 years.

SETTING

Kaiser Permanente Northern California, United States.

PARTICIPANTS

Adults reporting heavy drinking during primary care-based alcohol screening between 1 June 2013 and 31 May 2014. The sample (n = 85 434) was 40.7% female and 33.8% non-white; mean age was 50.3 years (standard deviation = 18.1).

MEASUREMENTS

Following US guidelines, early and sustained cessation of heavy drinking was defined as reporting lower-risk drinking or abstinence at 1 year and to 5 years after achieving early cessation, respectively. Associations between patient characteristics and service use and cessation outcomes were examined using logistic regression with inverse probability weights addressing attrition.

FINDINGS

Nearly two-thirds of participants achieved early cessation of heavy drinking. Women [odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.35, 1.44], middle-age (35-64 years: ORs = 1.16-1.19), non-white race/ethnicity (ORs = 1.03-1.57), medical conditions (OR = 1.05, 95% CI = 1.04, 1.06), psychiatric (OR = 1.10, 95% CI = 1.06, 1.15) and drug use disorders (OR = 1.35, 95% CI = 1.17, 1.56) and addiction treatment (OR = 1.19, 95% CI = 1.09, 1.30) were associated with higher odds of early cessation, while older age (≥ 65 years: OR = 0.91, 95% CI = 0.86, 0.96), smoking (OR = 0.81, 95% CI = 0.77, 0.84), higher index drinking levels (exceeding both daily and weekly limits: OR = 0.30, 95% CI = 0.29, 0.32) and psychiatric treatment (OR = 0.91, 95% CI = 0.84, 0.99) were associated with lower odds. Among those who achieved early cessation (n = 19 200), 60.0% sustained cessation. Associations between patient factors and sustained cessation paralleled those observed in analyses of early cessation. Additionally, routine primary care (OR = 1.57, 95% CI = 1.44, 1.71) and addiction treatment post-1 year (OR = 1.41, 95% CI = 1.19, 1.66) were associated with higher odds of sustained cessation. Lower-risk drinking versus abstinence at 1 year was associated with lower odds of sustained cessation (OR = 0.62, 95% CI = 0.57, 0.66).

CONCLUSIONS

Nearly two-thirds of a large, diverse sample of patients who reported heavy drinking in a Californian health-care system achieved early and sustained cessation of heavy drinking. Vulnerable subgroups (i.e. non-white patients and those with psychiatric disorders), patients who received routine primary care and those who received addiction treatment were more likely to sustain cessation of heavy drinking than other participants.

Racial differences in all-cause mortality and future complications among people with diabetes: a systematic review and meta-analysis of data from more than 2.4 million individuals

AIMS/HYPOTHESIS

The aim of this work was to quantify racial/ethnic differences in risk for future diabetic complications and all-cause mortality by performing a meta-analysis of prospective studies.

METHODS

A systematic search in PubMed and EMBASE was performed from inception to May 2021. Prospective cohort studies that reported HRs and associated 95% CIs of diabetes complications and all-cause mortality among racial/ethnic groups, with White people as the reference group, were included. Study characteristics and HR estimates were extracted from each study. Estimates were pooled using random-effects inverse-variance model with the Hartung-Knapp-Sidik-Jonkman variance estimator.

RESULTS

A total of 23 studies were included, comprising 2,416,516 individuals diagnosed with diabetes (White 59.3%, Black 11.2%, Asian 1.3%, Hispanic-American 2.4%, Native American 0.2%, East Asian 1.9%, South Asian 0.8%, Pacific Islander 2.3%, Māori 2.4% and others 18.2%). Compared with White individuals with diabetes, individuals of Māori ethnicity were at higher risk for all-cause mortality (HR 1.88 [95% CI 1.61, 2.21]; I² = 7.1%), Hispanic-American individuals had a significantly lower risk for CVD (HR 0.66 [95% CI 0.53, 0.81]; I² = 0%) and Black individuals had higher risk for end-stage renal disease (HR 1.54 [95% CI 1.05, 2.24]; I² = 95.4%). No significant higher risk for diabetes complications was found in other racial/ethnic groups relative to White people.

CONCLUSIONS/INTERPRETATION

Racial/ethnic differences exist in the risk for future diabetic complications and all-cause mortality. Our results support the use of such categories for international diabetes clinical guideline recommendations until better predictors become available. Efforts to identify high-risk groups and to better control cardiovascular risk factors across ethnically diverse populations are therefore needed.

REGISTRATION

PROSPERO registration ID CRD42021239274.

Mental Health Issues During and After COVID-19 Vaccine Era

The COVID-19 pandemic has persisted for more than a year, and post-COVID-19 sequelae of neurological complications, including direct and indirect effects on the central nervous system (CNS), have been recognized. There is a plethora of evidence for neurological, cognitive, and emotional deficits in COVID-19 patients. Acute neurological symptoms like neuroinflammation, cognitive impairment, loss of smell, and brain stroke are common direct effects among SARS-CoV-2 infected individuals. Work-associated stress, lockdowns, social distancing, and quarantine in response to contain SARS-CoV-2 have also affected the mental health of large populations, regardless of age. Public health emergencies have affected individuals and communities, resulting in emotional reactions and unhealthy behaviors. Although vaccines have been widely distributed and administered among large populations, vaccine hesitancy still exists and may be due to apprehension about vaccine efficacy, preliminary trials, and associated side effects. This review highlights the impact of COVID-19 on the CNS by outlining direct and indirect effects and factors contributing to the decline in people's mental health throughout the COVID-19 pandemic both during and after vaccine administration. Furthermore, we also discuss reasons for vaccine hesitancy and why some groups of people are deprived of vaccines. Finally, we touched upon the social determinants of mental health and their impact on disadvantaged populations during times of crisis which may help policymakers set up some action plans to mitigate the COVID-19 mental health turmoil during this ongoing pandemic.

'How I Can Help Me': Self-Care Priorities and Structural Pressures Among Black Older Adults With Diabetes

BACKGROUND AND OBJECTIVES

Disparities in Type 2 diabetes mellitus (diabetes) represent an ongoing public health challenge. Black older adults are at high risk of diabetes and diabetes' complications. Diet, physical activity, and medication can control these risks, yet disease rates remain elevated. Utilizing an Intersectionality framework, we seek to extend understanding of the social dimensions of diabetes through an examination of the diabetes self-care process from the perspective of Black older adults.

RESEARCH DESIGN AND METHODS

This project involved a thematic analysis of diabetes illness narrative interviews with Black participants (N=41) in our National Institute on Aging-funded study of diabetes. In a narrative approach, the participant communicates the significance of actions and events.

RESULTS

The findings suggest that diabetes self-care involves interconnected struggles across four domains of care: 1) multimorbidity management, 2) financial well-being, 3) family support, and 4) formal health care.

DISCUSSION AND IMPLICATIONS

Black older adult self-care reflects an active process of pursuing meaningful social goals and critical health needs. An Intersectional framework, however, reveals the ongoing histories of inequity that shape this process. Further intervention to address the racist policies and practices found in Black older adults' communities and clinical care is needed to make true progress on diabetes disparities.

An emulated target trial analysis based on Medicare data suggested non-inferiority of Dabigatran versus Rivaroxaban

OBJECTIVES

Rivaroxaban and Dabigatran were the first two non-vitamin K antagonist oral anticoagulants (NOACs) for preventing stroke among non-valvular Atrial Fibrillation patients. This article aimed to evaluate the relative efficacy and safety of Rivaroxaban versus Dabigatran.

STUDY DESIGN AND SETTING

An emulated target trial analysis was conducted based on Medicare, in which we constructed three "randomized clinical trials" with well-defined inclusion/exclusion criteria, treatment regimens, and analysis procedures. We analyzed the individual trials, examined temporal variations, and generated unified results via pooled analysis.

RESULTS

With a two-year data collection window (2012-2013), 70,129 subjects were enrolled in the three emulated trials, with 36,269 and 34,089 in the Rivaroxaban and Dabigatran arms, respectively. Dabigatran (the reference group for hazard ratio - HR) was superior regarding time to any primary event (including ischemic stroke, other thromboembolic events, major bleeding, and death; HR 1.232, P-value 0.0025), major bleeding (HR 1.187, P-value <0.0001), and mortality (HR 1.488, P-value <0.0001). Differences regarding stroke and other thromboembolic events were not significant.

CONCLUSION

Dabigatran was found as superior for the Medicare patients with multiple chronic conditions. Temporal variations, which had been largely neglected in the literature, were observed. This study may provide new insight into treating AF with NOACs.

Inappropriately sweet: Environmental endocrine-disrupting chemicals and the diabetes pandemic

Afflicting hundreds of millions of individuals globally, diabetes mellitus is a chronic disorder of energy metabolism characterized by hyperglycemia and other metabolic derangements that result in significant individual morbidity and mortality as well as substantial healthcare costs. Importantly, the impact of diabetes in the United States is not uniform across the population; rather, communities of color and those with low income are disproportionately affected. While excessive caloric intake, physical inactivity, and genetic susceptibility are undoubted contributors to diabetes risk, these factors alone fail to fully explain the rapid global rise in diabetes rates. Recently, environmental contaminants acting as endocrine-disrupting chemicals (EDCs) have been implicated in the pathogenesis of diabetes. Indeed, burgeoning data from cell-based, animal, population, and even clinical studies now indicate that a variety of structurally distinct EDCs of both natural and synthetic origin have the capacity to alter insulin secretion and action as well as global glucose homeostasis. This chapter reviews the evidence linking EDCs to diabetes risk across this spectrum of evidence. It is hoped that improving our understanding of the environmental drivers of diabetes development will illuminate novel individual-level and policy interventions to mitigate the impact of this devastating condition on vulnerable communities and the population at large.

Undercutting efforts of precision medicine: roadblocks to minority representation in breast cancer clinical trials

Precision (or personalized) medicine holds great promise in the treatment of breast cancer. The success of personalized medicine is contingent upon inclusivity and representation for minority groups in clinical trials. In this article, we focus on the roadblocks for the African American demographic, including the barriers to access and enrollment in breast oncology trials, the prevailing classification of race and ethnicity, and the need to refine monolithic categorization by employing genetic ancestry mapping tools for a more accurate determination of race or ethnicity.

Link between redemption of a medical food pantry voucher and reduced hospital readmissions

This study investigated the relationship between redeeming a voucher at hospital-based Medical Food Pantry (MFP) and hospital readmissions in Greenville, NC. Admitted patients at Vidant Medical Center identified as food insecure were given a voucher to the MFP. A retrospective chart review identified demographic information, type of insurance, voucher provision, and redemption dates, food bag type and number of subsequent hospital readmissions for all patients issued a voucher (n = 542) between June 21, 2018 and July 1, 2019. Negative binomial regression analysis assessed the relationship between readmissions and voucher redemption. Sixty percent of patients receiving a voucher were minority (African American) with an average age of 55. Nearly half (48 percent) had Medicare. Thirty-eight percent of those vouchers that were issued were redeemed, usually within five days. Regression results indicate that the number of readmissions was higher among women and non-whites in the sample relative to men and whites. Those patients who redeemed a food voucher had a seven percent lower likelihood of being readmitted (CI, 0.05–0.27). Food insecure patients who redeemed MFP vouchers had a comparatively lower likelihood of subsequent readmissions. These findings suggest that programs targeting modifiable social determinants of health like food insecurity could improve health outcomes and reduce utilization of the healthcare system.

Racial disparities in COVID-19 outcomes exist despite comparable Elixhauser comorbidity indices between Blacks, Hispanics, Native Americans, and Whites

Factors contributing to racial inequities in outcomes from coronavirus disease 2019 (COVID-19) remain poorly understood. We compared by race the risk of 4 COVID-19 health outcomes--maximum length of hospital stay (LOS), invasive ventilation, hospitalization exceeding 24 h, and death--stratified by Elixhauser comorbidity index (ECI) ranking. Outcomes and ECI scores were constructed from retrospective data obtained from the Cerner COVID-19 De-Identified Data cohort. We hypothesized that racial disparities in COVID-19 outcomes would exist despite comparable ECI scores among non-Hispanic (NH) Blacks, Hispanics, American Indians/Alaska Natives (AI/ANs), and NH Whites. Compared with NH Whites, NH Blacks had longer hospital LOS, higher rates of ventilator dependence, and a higher mortality rate; AI/ANs, higher odds of hospitalization for ECI = 0 but lower for ECI ≥ 5, longer LOS for ECI = 0, a higher risk of death across all ECI categories except ECI ≥ 5, and higher odds of ventilator dependence; Hispanics, a lower risk of death across all ECI categories except ECI = 0, lower odds of hospitalization, shorter LOS for ECI ≥ 5, and higher odds of ventilator dependence for ECI = 0 but lower for ECI = 1-4. Our findings contest arguments that higher comorbidity levels explain elevated COVID-19 death rates among NH Blacks and AI/ANs compared with Hispanics and NH Whites.

COVID-19 and metabolic diseases: a heightened awareness of health inequities and a renewed focus for research priorities

Chronic metabolic disorders such as diabetes and obesity are major public health issues in the United States. However, significant disparities in their prevalence and incidence place a greater burden on US racial and ethnic minority groups, contributing to worse COVID-19 outcomes in many. Improving treatment and prevention of diabetes and obesity is critical to the NIDDK. In this Perspective, we will review the burden of metabolic diseases in the United States, the observed disparities for metabolic diseases in relation to COVID-19, and research opportunities to address underlying causes of metabolic diseases, their associated health disparities, and COVID-19.

Global, Regional, and National Burden of Diabetes-Related Chronic Kidney Disease From 1990 to 2019

BACKGROUND

Chronic kidney disease (CKD) is a public health problem largely caused by diabetes. The epidemiology of diabetes mellitus-related CKD (CKD-DM) could provide specific support to lessen global, regional, and national CKD burden.

METHODS

Data were derived from the GBD 2019 study, including four measures and age-standardized rates (ASRs). Estimated annual percentage changes and 95% CIs were calculated to evaluate the variation trend of ASRs.

RESULTS

Diabetes caused the majority of new cases and patients with CKD in all regions. All ASRs for type 2 diabetes-related CKD increased over 30 years. Asia and Middle socio-demographic index (SDI) quintile always carried the heaviest burden of CKD-DM. Diabetes type 2 became the second leading cause of CKD and CKD-related death and the third leading cause of CKD-related DALYs in 2019. Type 2 diabetes-related CKD accounted for most of the CKD-DM disease burden. There were 2.62 million incident cases, 134.58 million patients, 405.99 thousand deaths, and 13.09 million disability-adjusted life-years (DALYs) of CKD-DM worldwide in 2019. Age-standardized incidence (ASIR) and prevalence rate (ASPR) of type 1 diabetes-related CKD increased, whereas age-standardized death rate (ASDR) and DALY rate decreased for females and increased for males. In high SDI quintile, ASIR and ASPR of type 1 diabetes-related CKD remained the highest, with the slowest increase, whereas the ASDR and age-standardized DALY rate remained the lowest there. In high SDI quintile, ASIR of type 2 diabetes-related CKD was the highest, with the lowest increasing rate. In addition, type 2 diabetes-related CKD occurred most in people aged 80-plus years worldwide. The main age of type 2 diabetes-related CKD patients was 55-64 years in Asia and Africa. The prevalence, mortality, and DALY rate of type 2 diabetes-related CKD increased with age. As for incidence, there was a peak at 80 years, and after age of 80, the incidence declined. CKD-DM-related anemia was mainly in mild to moderate grade.

CONCLUSIONS

Increasing burden of CKD-DM varied among regions and countries. Prevention and treatment measures should be strengthened according to CKD-DM epidemiology, especially in middle SDI quintile and Asia.

A case-control and cohort study to determine the relationship between ethnic background and severe COVID-19

BACKGROUND

People of minority ethnic backgrounds may be disproportionately affected by severe COVID-19. Whether this relates to increased infection risk, more severe disease progression, or worse in-hospital survival is unknown. The contribution of comorbidities or socioeconomic deprivation to ethnic patterning of outcomes is also unclear.

METHODS

We conducted a case-control and a cohort study in an inner city primary and secondary care setting to examine whether ethnic background affects the risk of hospital admission with severe COVID-19 and/or in-hospital mortality. Inner city adult residents admitted to hospital with confirmed COVID-19 (n = 872 cases) were compared with 3,488 matched controls randomly sampled from a primary healthcare database comprising 344,083 people residing in the same region. For the cohort study, we studied 1827 adults consecutively admitted with COVID-19. The primary exposure variable was self-defined ethnicity. Analyses were adjusted for socio-demographic and clinical variables.

FINDINGS

The 872 cases comprised 48.1% Black, 33.7% White, 12.6% Mixed/Other and 5.6% Asian patients. In conditional logistic regression analyses, Black and Mixed/Other ethnicity were associated with higher admission risk than white (OR 3.12 [95% CI 2.63-3.71] and 2.97 [2.30-3.85] respectively). Adjustment for comorbidities and deprivation modestly attenuated the association (OR 2.24 [1.83-2.74] for Black, 2.70 [2.03-3.59] for Mixed/Other). Asian ethnicity was not associated with higher admission risk (adjusted OR 1.01 [0.70-1.46]). In the cohort study of 1827 patients, 455 (28.9%) died over a median (IQR) of 8 (4-16) days. Age and male sex, but not Black (adjusted HR 1.06 [0.82-1.37]) or Mixed/Other ethnicity (adjusted HR 0.72 [0.47-1.10]), were associated with in-hospital mortality. Asian ethnicity was associated with higher in-hospital mortality but with a large confidence interval (adjusted HR 1.71 [1.15-2.56]).

INTERPRETATION

Black and Mixed ethnicity are independently associated with greater admission risk with COVID-19 and may be risk factors for development of severe disease, but do not affect in-hospital mortality risk. Comorbidities and socioeconomic factors only partly account for this and additional ethnicity-related factors may play a large role. The impact of COVID-19 may be different in Asians.

FUNDING

British Heart Foundation; the National Institute for Health Research; Health Data Research UK.

Racial disparities in medication use: imperatives for managed care pharmacy

The COVID-19 pandemic and the social unrest pervading U.S. cities in response to the killings of George Floyd and other Black citizens at the hands of police are historically significant. These events exemplify dismaying truths about race and equality in the United States. Racial health disparities are an inexcusable lesion on the U.S. health care system. Many health disparities involve medications, including antidepressants, anticoagulants, diabetes medications, drugs for dementia, and statins, to name a few. Managed care pharmacy has a role in perpetuating racial disparities in medication use. For example, pharmacy benefit designs are increasingly shifting costs of expensive medications to patients, creating affordability crises for lower income workers, who are disproportionally persons of color. In addition, the quest to maximize rebates serves to inflate list prices paid by the uninsured, among which Black and Hispanic people are overrepresented. While medication cost is a foremost barrier for many patients, other factors also propagate racial disparities in medication use. Even when cost sharing is minimal or zero, medication adherence rates have been documented to be lower among Blacks as compared with Whites. Deeper understandings are needed about how racial disparities in medication use are influenced by factors such as culture, provider bias, and patient trust in medical advice. Managed care pharmacy can address racial disparities in medication use in several ways. First, it should be acknowledged that racial disparities in medication use are pervasive and must be resolved urgently. We must not believe that entrenched health system, societal, and political structures are impermeable to change. Second, the voices of community members and their advocates must be amplified. Coverage policies, program designs, and quality initiatives should be developed in consultation with those directly affected by racial disparities. Third, the industry should commit to dramatically reducing patient cost sharing for essential medication therapies. Federal and state efforts to limit annual out-of-pocket pharmacy spending should be supported, even though increased premiums may be an undesirable (yet more equitable) consequence. Finally, information about race should be incorporated into all internal and external reporting and quality improvement activities. DISCLOSURES: No funding was received for the development of this manuscript. Kogut is partially supported by Institutional Development Award Numbers U54GM115677 and P20GM125507 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR), and the RI Lifespan Center of Biomedical Research Excellence (COBRE) on Opioids and Overdose, respectively. The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

Why African Americans Are a Potential Target for COVID-19 Infection in the United States

Since the World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic, significant changes have occurred in the United States as the infection spread reached and passed its exponential phase. A stringent analysis of COVID-19 epidemiologic data requires time and would generally be expected to happen with significant delay after the exponential phase of the disease is over and when the focus of the health care system is diverted away from crisis management. Although much has been said about high-risk groups and the vulnerability of the elderly and patients with underlying comorbidities, the impact of race on the susceptibility of ethnic minorities living in indigent communities has not been discussed in detail worldwide and specifically in the United States. There are currently some data on disparities between African American and Caucasian populations for COVID-19 infection and mortality. While health care authorities are reorganizing resources and infrastructure to provide care for symptomatic COVID-19 patients, they should not shy away from protecting the general public as a whole and specifically the most vulnerable members of society, such as the elderly, ethnic minorities, and people with underlying comorbidities.