Race: predictor versus proxy variable? Outcomes after spinal cord injury

Racial and Ethnical Discrepancies and Similarities in the Epidemiology, Survival, and Neurological Outcomes After Acute Traumatic Spinal Cord Injury: A Retrospective Cohort Study Using Data from the NASCIS-1 Trial

Background

Little is known about the impact of race/ethnicity on the clinical and neurological outcomes after acute traumatic spinal cord injury (tSCI).

Objectives

This study examined the influence of race/ethnicity on the individuals' survival and neurological recovery within the first year after tSCI.

Methods

The 306 cases enrolled in the First National Acute Spinal Cord Injury Study (NASCIS-1) were grouped as African American individuals (n = 84), non-Hispanic White individuals (n = 159), and other races/ethnicities that included Hispanic individuals (n = 60) and Asian individuals (n = 3). Outcome measures included survival and neurological recovery within the first year after tSCI. Data analyses were adjusted for major potential confounders.

Results

There were 39 females and 267 males with mean age of 31 years who mostly sustained cervical severe tSCI after motor vehicle accidents or falls. The three groups were comparable regarding sex distribution, level and severity of tSCI, level of consciousness at admission, and total received dose of methylprednisolone. African American individuals were significantly older than non-Hispanic White individuals (p = .0238). African American individuals and individuals of other races/ethnicities more often had a tSCI with open wound caused by missile and water-related accidents than non-Hispanic White individuals (p < .0001). Survival rates within the first year after tSCI were comparable among the three groups (p = .3191). Among the survivors, there were no significant differences among the three groups regarding motor and pinprick and light-touch sensory recovery (p > .0500).

Conclusions

The results of this study suggest that, while there were few differences among the racial/ethnical groups regarding the epidemiology of tSCI, race/ethnicity did not influence survival rate or neurological recovery within the first year post-tSCI.

Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries

OBJECTIVE

To determine if and how race impacts the 30-day outcomes of gender-affirming chest surgeries.

BACKGROUND

Little is currently known about how race may affect the outcomes of gender-affirming surgeries.

METHODS

We analyzed data from the National Surgical Quality Improvement Program (NSQIP) database of 30-day complications of gender-affirming chest surgeries from 2005 to 2019. All participants had a postoperative diagnosis code for gender dysphoria and at least one procedure code for bilateral mastectomy, bilateral breast reduction, or bilateral augmentation mammoplasty. Differences by racial group were analyzed through Pearson χ 2 and multivariate logistic regression.

RESULTS

There were no racial differences in the all-complication rates for both transmasculine and transfeminine individuals undergoing gender-affirming chest surgeries. Black patients undergoing masculinizing procedures were significantly more likely to experience mild systemic [adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.02-4.65] and severe complications (aOR: 5.63, 95% CI: 1.99-15.98) when compared with White patients. Patients of unknown race had increased odds of experiencing severe complications for masculinizing procedures compared with White patients (aOR: 3.77, 95% CI: 1.39-10.24). Transmasculine individuals whose race was unknown were 1.98 times more likely (95% CI: 1.03-3.81) to experience an unplanned reoperation compared with White individuals. Black transfeminine individuals were 10.50 times more likely to experience an unplanned reoperation (95% CI: 1.15-95.51) than their White peers.

CONCLUSIONS

Although overall complications are uncommon, there is evidence to suggest that there are racial disparities in certain 30-day outcomes of gender-affirming chest surgeries.

Demographic and Geospatial Analysis of Buprenorphine and Methadone Prescription Rates

Background

The medical community continues to seek to understand both the causes and consequences of opioid use disorder (OUD). The recent 2019 public release of the Automation of Reports and Consolidated Orders System (ARCOS) database from the years 2006 to 2012 provides a unique opportunity to analyze a critical period of the opioid epidemic with unprecedented data granularity.

Objectives

This study aims to use the ARCOS dataset to (1) determine significant contributory variables to opioid overdose death rates, (2) determine significant contributory variables to the relative prescription of buprenorphine and methadone, and (3) evaluate the existence of statistically significant geospatial clusters in buprenorphine and methadone prescription rates.

Methods

This study utilizes multiple databases, including the Centers for Disease Control and Prevention (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER), the Drug Enforcement Administration (DEA) prescription drug data, and the United States (US) Census demographics, to examine the relationship between the different treatments of OUD. Linear regressions are used to determine significant contributory factors in overdose rate and the buprenorphine-to-methadone ratio. Geospatial analysis is used to identify geographic clusters in opioid overdoses and treatment patterns.

Results

Methadone prescriptions, racial demographics, and poverty were found to significantly correspond to opioid overdose death rates (p < 0.05). Buprenorphine prescriptions were not found to be significant (p = 0.20). Opioid overdoses, metro character, racial categorization, and education were found to significantly correspond to the ratio of buprenorphine to methadone prescribed (p < 0.05). Cluster analysis demonstrated different geospatial distributions in the prescriptions of buprenorphine and methadone (p < 0.05).

Conclusion

Historically, methadone prescriptions have been higher in areas with high overdose rates. Buprenorphine and methadone prescribing patterns have historically demonstrated different geographic trends.

Mental disorder prevalence among U.S. Department of Veterans Affairs outpatients with spinal cord injuries

OBJECTIVES

Depression and other mental disorders are more prevalent among individuals living with spinal cord injury (SCI) than in the community at large, and have a strong association with quality of life. Yet little is known about the prevalence and predictors of mental disorders among U.S. military Veterans living with SCI. The primary aim of this study was to present an estimate of mental disorder point prevalence in this population. The secondary aim was to examine the relationship of mental disorders to demographics, injury characteristics, and other clinically relevant features such as impairment from mental health problems and life satisfaction.

DESIGN

Cross-sectional.

SETTING

A SCI & Disorders Center at a U.S. Veterans Affairs Medical Center.

PARTICIPANTS/METHODS

Administrative and medical records of 280 Veterans who attended annual comprehensive SCI evaluations were evaluated. Demographics, injury characteristics, self-reported mental and emotional functioning (i.e. SF-8 Health Survey), and clinician-determined mental disorder diagnoses were attained.

RESULTS

Overall, 40% of patients received at least one mental disorder diagnosis, most commonly depressive disorders (19%), posttraumatic stress disorder (12%), and substance or alcohol use disorders (11%). Several patient characteristics predicted mental disorders, including age, racial minority identity, non-traumatic SCI etiology, and incomplete (i.e. AIS D) vs. complete injury. Mental disorders were associated with greater impairment from health and mental health-related problems and less satisfaction with life.

CONCLUSIONS

Mental disorders are common among outpatients receiving VA specialty care for SCI. These findings highlight the importance of having adequate and effective available mental health services available for Veterans with SCI.

Racial Differences in Mental Health Recovery among Veterans with Serious Mental Illness

Black consumers with serious mental illness (SMI) face significant challenges in obtaining quality mental health care and are at risk for experiencing significant disparities in mental health care outcomes, including recovery from mental illness. Patient-provider interactions may partly contribute to this disparity. The purpose of the current study was to understand the effects of race, psychosis, and therapeutic alliance on mental health recovery orientation among Veterans with SMI. Participants were Veterans who had an SMI being treated at two Veteran Affairs outpatient mental health clinics by a psychiatrist or nurse practitioner. Participants completed the Behavior and Symptom Identification Scale (BASIS-24), Mental Health Recovery Measure, and patient-report Scale to Assess the Therapeutic Relationship (STAR-P) which includes three subscales: positive collaboration, positive clinician input, and non-supportive clinician input. Regression analyses were used to determine interactive effects of race, psychosis severity, and therapeutic alliance variables. The sample was 226 Veterans (50% black, 50% white). Black participants were slightly older (p < .05), had higher baseline psychosis (p < .05), higher mental health recovery (p < .05), and perceived less non-supportive clinician input (p < .01) than white participants. Regression analyses indicated a significant three-way interaction among race, psychosis, and positive collaboration (p < .01). Greater positive collaboration attenuated the negative effect of higher levels of psychosis on mental health recovery orientation for black participants. Conversely, for white participants, positive collaboration had little effect on the negative relationship between psychosis severity and mental health recovery orientation. Increased levels of psychosis may inhibit patients' perceptions of their ability to recover from SMI. However, for black participants, positive collaboration with mental health providers may moderate the effects of psychotic symptomatology.

Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury

OBJECTIVE

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

PARTICIPANTS

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

RESULTS

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

CONCLUSIONS

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.

Evaluating the quality of acute rehabilitation care for patients with spinal cord injury: an extended Donabedian model

OBJECTIVE

In this study, the researchers examined the quality of rehabilitation care for patients with spinal cord injury (SCI), using an extension of Donabedian's structure, process, outcome model that included environmental and patient characteristic.

METHODS

Cluster analysis, univariate variance analysis, and multilevel analysis were used to examine the quality of care for patients with SCI (N = 1974) enrolled in SCI Model Systems between 2000 and 2004.

RESULTS

Patients were classified into low-, intermediate-, and high-functioning groups on the basis of admission functional status profiles as measured by the Functional Independence Measure (FIM). Patient profiles and therapy received were found to be related to outcomes measured by FIM gain. Care structure measured by patient volume was found to be negatively associated with outcomes, but facility-level therapist-bed ratios were not related to FIM gain. Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) interacted with patient profiles influencing FIM gain.

CONCLUSION

The results from this study indicated a clear disconnection between the number of therapists and the amount of therapy delivered. This would suggest that potential inefficiency of therapy delivery due to the deployment and allocation of therapy services could be addressed by further consideration of patient profiles that reflect their specific needs and characteristics.

Perceived information needs of community-dwelling persons with chronic spinal cord injury: findings of a survey and impact of race

OBJECTIVE

To examine the perceived information needs of community-dwelling individuals with chronic spinal cord injury (SCI) and to determine factors that influence these needs.

DESIGN AND PARTICIPANTS

Cross-sectional survey mailed to 620 persons with chronic SCI who completed acute inpatient rehabilitation.

RESULTS

Of 103 (17%) returned surveys, 82 contained complete information and were useable for this study. Individuals with chronic SCI (M time since injury = 7 +/- 6 years) endorsed a multitude of information needs across a broad range of domains. Participant endorsements were most commonly observed in the areas of aging (73%), research (72%), financial aid (66%), and education (63%). Independent variables expected to influence information needs, including Internet use, whether the rehabilitation specialist also served as the primary care physician, and time since injury, showed no significant effect. Race/ethnicity was found to predict perceived information needs, with nonwhite participants endorsing a significantly greater degree of needs than white participants in 11 of 23 (48%) domains.

CONCLUSIONS

Perceived information needs of community-dwelling persons with SCI are not fully met years after discharge from acute inpatient rehabilitation, which may have implications with respect to psychological adjustment. Race/ethnicity appears to exert a significant influence on the endorsement of perceived information needs, but this finding must be investigated further considering other possible mediating/moderating variables. Results must be considered in light of the relatively low response rate of eligible participants.

The utility of non-proportional quota sampling for recruiting at-risk women for microbicide research

In the context of a measurement development study designed to contextualize microbicide acceptability, a sample that represented a range of at-risk women and maintained the statistical power needed for validity analyses was required. A non-proportional quota sampling strategy focused on race/ethnicity and number of sexual partners was utilized. This strategy resulted in enrollment of approximately equal proportions of Latina (31%), Black (36%), and White (32%) women, and an approximately 1:2 ratio of single-partnered (29%) and multi-partnered (71%) women. About 17% of women screened were ineligible based on eligibility criteria; an additional 16% were ineligible based on quota closures. Most participants were recruited through word of mouth (39%), community-based organizations (19%), or media sources (19%). Women recruited through word of mouth had the highest screen-to-interview completion percentage (67%). Non-proportional quota sampling is a feasible option for ensuring adequate representation of sample characteristics in microbicide research, but this goal should be weighed against cost and staff burden.

The National Institute on Disability and Rehabilitation Research Burn Model System Database: A Tool for the Multicenter Study of the Outcome of Burn Injury

Advances in critical care and surgical management have significantly improved survival after burn injury over the past several decades. However, today, survival alone is an insufficient outcome. In 1994, the National Institute on Disability and Rehabilitation Research (NIDRR) created a burn model system program to evaluate the long-term sequelae of burn injuries. As part of this multicenter program, a comprehensive demographic and outcome database was developed to facilitate the study of a number of functional and psychosocial outcomes after burns. The purpose of this study is to review the database design and structure as well as the data obtained during the last 10 years. This is a descriptive study of the NIDRR database structure as well as the patient data obtained from the four participating burn centers from 1994 to 2004. Data obtained during hospitalization and at 6, 12, and 24 months after discharge were reviewed and descriptive statistics were calculated for select database fields. The database is divided into several subsections, including demographics, injury complications, patient disposition, and functional and psychological surveys. A total of 4600 patients have been entered into the NIDRR database. To date, 3449 (75%) patients were alive at discharged and consented to follow-up data collection. The NIDRR database provides an expansive repository of patient, injury, and outcome data that can be used to analyze the impact of burn injury on physical and psychosocial function and for the design of interventions to enhance the quality of life of burn survivors.

Preliminary reliability and validity of a Spinal Cord Injury Secondary Conditions Scale

BACKGROUND/OBJECTIVE

Although the impact of secondary conditions after spinal cord injury (SCI) on health, well being, and financial burden have been studied, there are psychometrically sound scales of secondary conditions in the extant literature. The use of such scales allows for cross-sample comparison of secondary condition prevalence rates and associations with functional, medical, and psychosocial factors. Thus, the purpose of this study was to evaluate the preliminary reliability of a SCI secondary conditions scale.

METHODS

The Spinal Cord Injury Secondary Conditions Scale (SCI-SCS) is a 16-item scale based on the Seekins Secondary Conditions Scale. Sixty-five individuals with SCI completed written surveys at 5 time-points over 2 years.

RESULTS

Internal consistency across each of the time-points exceeded 0.76; test-retest reliability ranged from 0.569 to 0.805. Convergent validity was assessed with 6 physical functioning items from the SF-12. Spearman (coefficients were all statistically significant and ranged from 0.317 (accomplished less because of health problems) to 0.644 (pain). The most prevalent secondary conditions were chronic pain, joint and muscle pain, and sexual dysfunction.

CONCLUSIONS

Preliminary testing of the SCI-SCS suggests that it is a reliable and valid scale, and further development (ie, factor analysis, item revision) and examination of validity are recommended with larger and more diverse SCI samples.

The influence of ethnicity on health-related quality of life in diabetes mellitus: a population-based, multiethnic study

OBJECTIVES

The aims of this study were to evaluate the influence of ethnicity on health-related quality of life (HRQoL) in diabetic participants using both profile [the Short-Form 36 (SF-36)] and single-index (the SF-6D) instruments and to evaluate the usefulness of the SF-6D as a summary measure for the SF-36.

RESEARCH DESIGN AND METHODS

Using data from a cross-sectional, population-based survey of Chinese, Malay, and Indians in Singapore, we analyzed the influence of ethnicity and other variables on each SF-36 scale and SF-6D scores using linear regression models to adjust for the influence of known determinants of HRQoL.

RESULTS

Data from 309 diabetic respondents were analyzed. Compared with other ethnicities, Indians were most likely to report impaired HRQoL. The unadjusted influence of ethnicity on HRQoL exceeded the minimum clinically important difference (MCID) for all SF-36 scales (MCID: 5 points) and the SF-6D (MCID: 0.033 points). After adjusting for gender, age, and education, the influence of Chinese ethnicity exceeded the MCID for all SF-36 scales, except vitality (VT) and mental health (MH), as well as for the SF-6D. The influence of Malay ethnicity exceeded the MCID only for the SF-36 MH scale and the SF-6D. The influence of ethnicity on HRQoL persisted after adjusting further for other determinants of HRQoL. The SF-6D reflected the ethnic trends for some but not all SF-36 scales.

CONCLUSIONS

After adjusting for demographic, socioeconomic, and other factors known to influence HRQoL, ethnicity remained an important factor influencing HRQoL in this population-based multiethnic sample of diabetic Asians. Further studies to identify modifiable factors explaining the ethnic disparities in HRQoL among diabetic participants are needed. The SF-6D may be a useful summary measure for the SF-36.

Cross-cultural validity of FIM in spinal cord injury

OBJECTIVE

To analyse cross-culture validity of the Functional Independence Measure (FIM) in patients with a spinal cord injury using a modern psychometric approach.

SETTINGS

A total of 19 rehabilitation facilities from four countries in Europe.

PARTICIPANTS

A total of 647 patients at admission, median age 46 years, 69% male.

METHODS

Data from the FIM, collected on inpatient admission, was fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM items was undertaken before to testing fit to the model. Categories were rescored where necessary. Fit to the model was assessed initially within country, and then in the pooled data. Analysis of differential item functioning (DIF) was undertaken in the pooled data for each of the FIM motor and social cognitive scales, respectively. Final fit to the model was tested for breach of local independence by principle components analysis (PCA).

RESULTS

The present scoring system for the FIM motor and cognitive scales, that is a seven category scale, was found to be invalid, necessitating extensive rescoring. Following this, DIF was found in a number of items within the motor scale, requiring a complex solution of splitting items by country to allow for the valid pooling of data. Five country-specific items could not be retained within this solution. The FIM cognitive scale fitted the Rasch model after rescoring, but there was a substantial ceiling effect.

CONCLUSIONS

Data from the FIM motor scale for patients with spinal cord injury should not be pooled in its raw form, or compared from country to country. Only after fit to the Rasch model and necessary adjustments could such a comparison be made, but with a loss of clinical important items. The FIM cognitive scale works well following rescoring, and data may be pooled, but many patients were at the maximum score.

Factors affecting outpatient rehabilitation outcomes in elders

PURPOSE

To identify factors affecting outpatient rehabilitation outcomes in elders.

DESIGN

A retrospective cohort design was used to explore factors affecting outpatient rehabilitation outcomes in elders.

METHODS

Analyses of health records from a nurse-managed comprehensive outpatient rehabilitation facility were conducted. Data pertinent to the study were abstracted from 201 health records, including scores from three standard instruments: the Functional Independence Measure, the Mini-Mental State Examination, and the Geriatric Depression Scale, to construct study variables. Multivariate and stepwise regression analyses were performed.

FINDINGS

Cognitive impairment was associated with lower admission and discharge function, but not with rehabilitation outcomes (functional gain, rehabilitation efficiency, days of service, and discharge location). Age > or = 80 years, admission function, and the interaction of age > or = 80 years and admission function affected functional gain and rehabilitation efficiency. Older age, being Black, and having more medical comorbidities were associated with days of service. None of these factors contributed to discharge location.

CONCLUSIONS

Cognitive impairment was not associated with outpatient rehabilitation outcomes. Rather, age > or = 80 years and function when admitted affected functional gain and rehabilitation efficiency in elders who participated in outpatient rehabilitation services.

Community Outcomes Following Traumatic Brain Injury

OBJECTIVE

To investigate the contribution of preinjury differences and potential biases in outcome measurement in explaining outcome differences between white and African American persons with moderate and severe traumatic brain injury (TBI).

DESIGN

Prospective, 2 group longitudinal study with retrospective self-assessment of preinjury status.

SETTING

Inpatient and outpatient TBI rehabilitation program.

PARTICIPANTS

Ninety-four persons with moderate and severe TBI (55 whites and 39 African Americans) who provided data on both preinjury status and 1-year outcome.

MEASURES

Community Integration Questionnaire, aggression and depression subscales of Neurobehavioral Functioning Inventory-Revised, Satisfaction With Life Scale, other questions on demographic and social status; all measures were selected by a biracial focus group.

RESULTS

Whites and African Americans did not differ significantly on demographic factors except gender; nor on retrospective, self-reported preinjury status on any of the outcome measures. At 1 year post-TBI, African Americans reported significantly lower social integration subscale scores than whites. African Americans may also have lost more income than did whites. All other outcome measures were comparable between groups and showed declines in community productivity, increases in depression symptoms, and lower satisfaction with life for both whites and African Americans compared to preinjury. A higher rate of change in living situation post-TBI may partially account for lower levels of social integration for African Americans.

CONCLUSION

Whites and African Americans who are comparable prior to injury may experience generally similar outcomes, but differences in social and financial outcomes require further investigation.