Racial disparities in health outcomes after spinal cord injury: mediating effects of education and income

GestaltMML: Enhancing Rare Genetic Disease Diagnosis through Multimodal Machine Learning Combining Facial Images and Clinical Texts

Individuals with suspected rare genetic disorders often undergo multiple clinical evaluations, imaging studies, laboratory tests and genetic tests, to find a possible answer over a prolonged period of time. Addressing this "diagnostic odyssey" thus has substantial clinical, psychosocial, and economic benefits. Many rare genetic diseases have distinctive facial features, which can be used by artificial intelligence algorithms to facilitate clinical diagnosis, in prioritizing candidate diseases to be further examined by lab tests or genetic assays, or in helping the phenotype-driven reinterpretation of genome/exome sequencing data. Existing methods using frontal facial photos were built on conventional Convolutional Neural Networks (CNNs), rely exclusively on facial images, and cannot capture non-facial phenotypic traits and demographic information essential for guiding accurate diagnoses. Here we introduce GestaltMML, a multimodal machine learning (MML) approach solely based on the Transformer architecture. It integrates facial images, demographic information (age, sex, ethnicity), and clinical notes (optionally, a list of Human Phenotype Ontology terms) to improve prediction accuracy. Furthermore, we also evaluated GestaltMML on a diverse range of datasets, including 528 diseases from the GestaltMatcher Database, several in-house datasets of Beckwith-Wiedemann syndrome (BWS, over-growth syndrome with distinct facial features), Sotos syndrome (overgrowth syndrome with overlapping features with BWS), NAA10-related neurodevelopmental syndrome, Cornelia de Lange syndrome (multiple malformation syndrome), and KBG syndrome (multiple malformation syndrome). Our results suggest that GestaltMML effectively incorporates multiple modalities of data, greatly narrowing candidate genetic diagnoses of rare diseases and may facilitate the reinterpretation of genome/exome sequencing data.

Multimorbidity in persons with non-traumatic spinal cord injury and its impact on healthcare utilization and health outcomes

STUDY DESIGN

Cross-sectional survey in Canada.

OBJECTIVES

To explore multimorbidity (the coexistence of two/more health conditions) in persons with non-traumatic spinal cord injury (NTSCI) and evaluate its impact on healthcare utilization (HCU) and health outcomes.

SETTING

Community-dwelling persons.

METHODS

Data from the Spinal Cord Injury Community Survey (SCICS) was used. A multimorbidity index (MMI) consisting of 30 secondary health conditions (SHCs), the 7-item HCU questionnaire, the Short Form-12 (SF-12), Life Satisfaction-11 first question, and single-item Quality of Life (QoL) measure were administered. Additionally, participants were grouped as "felt needed healthcare was received" (Group 1, n = 322) or "felt needed healthcare was not received" (Group 2, n = 89) using the HCU question. Associations among these variables were assessed using multivariable analysis.

RESULTS

408 of 412 (99%) participants with NTSCI reported multimorbidity. Constipation, spasticity, and fatigue were the most prevalent self-reported SHCs. Group 1 had a higher MMI score compared to Group 2 (p < 0.001). A higher MMI score correlated with the feeling of not receiving needed care (OR 1.4, 95% CI 1.08-1.21), lower SF-12 (physical/mental component summary scores), being unsatisfied with life, and lower QoL (all p < 0.001). Additionally, Group 1 had more females (p < 0.001), non-Caucasians (p = 0.034), and lower personal annual income (p = 0.025).

CONCLUSIONS

Persons with NTSCI have multimorbidity, and the MMI score was associated with increased HCU and worse health outcomes. This work emphasizes the critical need for improved healthcare and monitoring. Future work determining specific thresholds for the MMI could be helpful for triage screening to identify persons at higher risk of poor outcomes.

Use of Community-Engaged Research Approaches in Clinical Interventions for Neurologic Disorders in the United States: A Scoping Review and Future Directions for Improving Health Equity Research

BACKGROUND AND OBJECTIVES

Evidence suggests a significant prevalence of race and ethnic disparities in the United States among people with neurologic conditions including stroke, Alzheimer disease and related dementia (ADRD), Parkinson disease (PD), epilepsy, spinal cord injury (SCI), and traumatic brain injury (TBI). Recent neurologic research has begun the paradigm shift from observational health disparities research to intervention research in an effort to narrow the disparities gap. There is an evidence base that suggests that community engagement is a necessary component of health equity. While the increase in disparities focused neurologic interventions is encouraging, it remains unclear whether and how community-engaged practices are integrated into intervention design and implementation. The purpose of this scoping review was to identify and synthesize intervention studies that have actively engaged with the community in the design and implementation of interventions to reduce disparities in neurologic conditions and to describe the common community engagement processes used.

METHODS

Two databases, PubMed and CINAHL, were searched to identify eligible empirical studies within the United States whose focus was on neurologic interventions addressing disparities and using community engagement practices.

RESULTS

We identified 392 disparity-focused interventions in stroke, ADRD, PD, epilepsy, SCI, and TBI, of which 53 studies incorporated community engagement practices: 32 stroke studies, 15 ADRD, 2 epilepsy studies, 2 PD studies, 1 SCI study, and 1 TBI study. Most of the interventions were designed as randomized controlled trials and were programmatic in nature. The interventions used a variety of community engagement practices: community partners (42%), culturally tailored materials and mobile health (40%), community health workers (32%), faith-based organizations and local businesses (28%), focus groups/health need assessments (25%), community advisory boards (19%), personnel recruited from the community/champions (19%), and caregiver/social support (15%).

DISCUSSION

Our scoping review reports that the proportion of neurologic intervention studies incorporating community engagement practices is limited and that the practices used within those studies are varied. The major practices used included collaboration with community partners and utilization of culturally tailored materials. We also found inconsistent reporting and dissemination of results from studies that implemented community engagement measures in their interventions. Future directions include involving the community in research early and continuously, building curricula that address challenges to community engagement, prioritizing the inclusion of community engagement reporting in peer-reviewed journals, and prioritizing and incentivizing research of subpopulations that experience disparities in neurologic conditions.

Does gender moderate the association between socioeconomic status and health? Results from an observational study in persons with spinal cord injury living in Morocco

Background

Socioeconomic status (SES) and gender are well-known social determinants of health. However, their impact on health in populations with physical disabilities in low-resource countries is still lacking. Therefore, the objective of this study was to investigate associations of individual SES with health and the moderating effect of gender on this association in a Moroccan population with a physical disability, namely spinal cord injury.

Methods

Cross-sectional survey data from 385 participants with spinal cord injury living in Morocco were analyzed. SES was operationalized by education level, household income, financial hardship, and subjective social status. Health indicators included secondary conditions, pain, vitality, quality of life, and general health. Associations between SES and health indicators were investigated using linear and logistic regressions. To test the potential moderation of gender, interaction terms between SES and gender were introduced in regression models.

Results

Financial hardship and lower subjective social status were associated with poorer health outcomes in four out of five indicators in the total sample. In contrast, education and income were inconsistently associated with health. Overall, gender did not moderate the association between SES and health, except that educational inequalities in general health were more pronounced in women, and the observation of a trend for a stronger negative effect of subjective social status on men's than woman's health (p &gt; 0.05).

Conclusion

This study revealed that subjective indicators of SES negatively impact on health, whereas evidence for the moderating role of gender in this association was weak. These findings underline the importance to reduce social marginalization and poverty in populations with disabilities in low-resource countries to reduce their double burden of living with a disability and encountering social disadvantages through low SES.

Disparities in Morbidity After Spinal Cord Injury Across Insurance Types in the United States

OBJECTIVE

To compare the prevalence and incidence of, and adjusted hazards for comorbidities among adults with traumatic spinal cord injuries (TSCIs) across insurance types (private vs governmental insurance) in the United States.

PATIENTS AND METHODS

Privately insured (N=9081) and Medicare (N=7645) beneficiaries with a diagnosis of TSCI were included. Prevalence and incidence estimates of common psychological, cardiometabolic, and musculoskeletal morbidities were compared at baseline and at 4-years after index diagnosis, respectively. Survival models were used to quantify hazard ratios (HRs) for outcomes, controlling for insurance type, sociodemographic characteristics, and other comorbidities. Sensitivity analyses were conducted to determine the effects of insurance and race/ethnicity.

RESULTS

Adults with TSCIs on Medicare had a higher prevalence of any psychological (54.7% vs 35.4%), cardiometabolic (74.7% vs 70.1%), and musculoskeletal (72.8% vs 66.3%) morbidity than privately insured adults with TSCIs. Similarly, the 4-year incidences of most psychological (eg, depression: 37.6% [Medicare] vs 24.2% [private]), cardiometabolic (eg, type 2 diabetes: 22.5% [Medicare] vs 12.9% [private], and musculoskeletal (eg, osteoarthritis: 42.1% [Medicare] vs 34.6% [private]) morbidities were considerably higher among adults with TSCIs on Medicare. Adjusted survival models found that adults with TSCIs on Medicare had a greater hazard for developing psychological (HR, 1.40; 95% CI, 1.31-1.50) and cardiometabolic (HR, 1.21; 95% CI, 1.10-1.33) morbidities compared with privately insured adults with TSCI. There was evidence of both insurance and racial disparities.

CONCLUSION

Adults with TSCIs on Medicare had significantly higher prevalence and risk for developing common physical and mental health comorbidities, compared with privately insured adults with TSCIs.

Pediatric Traumatic Spinal Cord Injury in the United States: A National Inpatient Analysis

BACKGROUND

Traumatic spinal cord injury (tSCI) is a debilitating neurological condition often associated with lifelong disability. Despite this, there are limited data on pediatric tSCI epidemiology in the United States.

OBJECTIVES

Our primary objective was to estimate tSCI hospitalization rates among children, including by age, sex, and race. Secondary objectives were to characterize tSCI hospitalizations and examine associations between sociodemographic characteristics and tSCI etiology.

METHODS

We used the 2016 Kids' Inpatient Database to examine tSCI hospitalizations among children (<21 years). Descriptive statistics were used to report individual and care setting characteristics for initial tSCI hospitalizations. We used Census Bureau data to estimate tSCI hospitalization rates (number of pediatric tSCI hospitalizations / number of US children) and logistic regression modeling to assess associations between documented sociodemographic characteristics and injury etiology.

RESULTS

There were 1.48 tSCI admissions per 100,000 children; highest rates of hospitalization involved older (15-20 years), male, and Black children. Hospitalization involving male (adjusted odds ratio [AOR] 0.43; 95% CI, 0.33-0.58) or Black (AOR 0.37; 95% CI, 0.25-0.55) children were less likely to involve a motor traffic accident. Hospitalizations of Black children were significantly more likely to have a diagnosis of tSCI resulting from a firearm incident (AOR 18.97; 95% CI, 11.50-31.28) or assault (AOR 11.76; 95% CI, 6.75-20.50) compared with hospitalizations of White children.

CONCLUSION

Older, male, and Black children are disproportionately burdened by tSCI. Implementation of broad health policies over time may be most effective in reducing pediatric tSCI hospitalizations and preventable injuries.

The role of socioeconomic status on outcomes following cerebellopontine angle tumor resection

PURPOSE

It is well documented that the interaction between many social factors can affect clinical outcomes. However, the independent effects of economics on outcomes following surgery are not well understood. The goal of this study is to investigate the role socioeconomic status has on postoperative outcomes in a cerebellopontine angle (CPA) tumor resection population.

MATERIALS AND METHODS

Over 6 years (07 June 2013 to 24 April 2019), 277 consecutive CPA tumor cases were reviewed at a single, multihospital academic medical center. Patient characteristics obtained included median household income, Charlson Comorbidity Index (CCI), race, BMI, tobacco use, amongst 23 others. Outcomes studied included readmission, ED evaluation, unplanned return to surgery (during and after index admission), return to surgery after index admission, and mortality within 90 days, in addition to reoperation and mortality throughout the entire follow-up period. Univariate analysis was conducted amongst the entire population with significance set at a p value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (Q1) and highest (Q4) socioeconomic quartiles, with significance set at a p value <0.05. Stepwise regression was conducted to determine the correlations amongst study variables and identify confounding factors.

RESULTS

Regression analysis of 273 patients did not find household income to be associated with any of the long-term outcomes assessed. Similarly, a Q1 vs Q4 comparison did not yield significantly different odds of outcomes assessed.

CONCLUSION

Although not statistically significant, the odds ratios suggest socioeconomic status may have a clinically significant effect on postsurgical outcomes. Further studies in larger, matched populations are necessary to validate these findings.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

High-Risk Subgroup Membership Is a Predictor of 30-Day Morbidity Following Anterior Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if membership in a high-risk subgroup is predictive of morbidity and mortality following anterior lumbar fusion (ALF).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was utilized to identify patients undergoing ALF between 2010 and 2014. Multivariate analysis was utilized to identify high-risk subgroup membership as an independent predictor of postoperative complications.

RESULTS

Members of the elderly (≥65 years) (OR = 1.3, P = .02) and non-Caucasian (black, Hispanic, other) (OR = 1.7, P < .0001) subgroups were at greater risk for a LOS ≥5 days. Obese patients (≥30 kg/m² ) were at greater risk for an operative time ≥4 hours (OR = 1.3, P = .005), and wound complications (OR = 1.8, P = .024) compared with nonobese patients. Emergent procedures had a significantly increased risk for LOS ≥5 days (OR = 4.9, P = .021), sepsis (OR = 14.8, P = .018), and reoperation (OR = 13.4, P < .0001) compared with nonemergent procedures. Disseminated cancer was an independent risk factor for operative time ≥4 hours (OR = 8.4, P < .0001), LOS ≥5 days (OR = 15.2, P < .0001), pulmonary complications (OR = 7.4, P = .019), and postoperative blood transfusion (OR = 3.1, P = .040).

CONCLUSIONS

High-risk subgroup membership is an independent risk factor for morbidity following ALF. These groups should be targets for aggressive preoperative optimization, and quality improvement initiatives.

Income Gradient in Renal Disease Mortality in the United States

Background

Non-communicable diseases and associated mortality follow a social gradient and chronic kidney disease is not an exception to this rule. Intermediate behavioral and medical factors that may explain such social gradients are, however, still unknown.

Objectives

Using nationally representative data in the United States, this study was conducted to investigate the mediating effect of medical and behavioral risk factors on the association between socioeconomic status (SES) and renal disease mortality.

Patients and methods

Americans’ Changing Lives Study (ACL), 1986–2011, is a 25-year nationally representative prospective cohort study. ACL followed 3,361 adults for up to 25 years. Income, education, and unemployment were the main predictors of interest. Death due to renal disease was the main outcome. Health behaviors (smoking, drinking, and exercise) and medical risk factors (diabetes, hypertension, and obesity) were the mediators. Cox proportional hazards models were used for data analysis.

Results

Higher income (HR = 0.75; 95% CI = 0.62–0.89) was associated with lower risk of death due to renal disease over the 25-year follow-up period. Although health behaviors and medical risk factors at baseline were also predictors of the outcome, they failed to explain the effect of income on death due to renal disease. That is, income was associated with death due to renal disease above and beyond all potential mediators including behavioral and medical risk factors.

Conclusion

Socioeconomic inequalities in the United States cause disparities in renal disease mortality; however, such differences are not due to health behaviors (smoking and drinking) and medical risk factors (hypertension and diabetes). To reduce disparities in renal disease mortality in the United States, policies should go beyond health behaviors and medical risk factors. While programs should help low-income individuals maintain exercise and avoid smoking, reduction of income disparities should be regarded as a strategy for reduction of disparities in renal disease mortality. By increasing minimum pay and minimizing the income gap, we may reduce disparities in renal disease mortality.

How Are Race, Cultural, and Psychosocial Factors Associated With Outcomes in Veterans With Spinal Cord Injury?

OBJECTIVE

To understand the role of cultural and psychosocial factors in the outcomes of veteran wheelchair users with spinal cord injury (SCI) to help clinicians identify unique factors faced by their patients and help researchers identify target variables for interventions to reduce disparities in outcomes.

DESIGN

Cross-sectional cohort study.

SETTING

Three urban Veterans Affairs medical centers affiliated with academic medical centers.

PARTICIPANTS

Of the patients (N=516) who were eligible to participate, 482 completed the interview and 439 had SCI. Because of small numbers in other race groups, analyses were restricted to white and African American participants, resulting in a final sample of 422.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Quality of life (QOL, Veterans RAND 12-Item Health Survey); satisfaction (Client Satisfaction Questionnaire); and participation (Craig Handicap Assessment and Reporting Technique Short Form).

RESULTS

African American Veterans reported poorer physical QOL but better mental QOL than did white Veterans. No other significant race differences were found in unadjusted analyses. Multivariable analyses showed that psychosocial factors were predominantly associated with patients' QOL outcomes and satisfaction with service, but demographic and medical factors were predominantly associated with participation outcomes. Interaction analyses showed that there was a stronger negative association between anxiety and mental QOL for African Americans than for whites, and a positive association between higher self-esteem and social integration for whites but not African Americans.

CONCLUSIONS

Findings suggest that attempts to improve the outcomes of Veterans with SCI should focus on a tailored approach that emphasizes patients' demographic, medical, and psychosocial assets (eg, building their sense of self-esteem or increasing their feelings of mastery), while providing services targeted to their specific limitations (eg, reducing depression and anxiety).

Latent Structural Analysis of Health Outcomes in People Living With Spinal Cord Injury

OBJECTIVE

To develop a latent structural model of health outcomes in people with spinal cord injury (SCI) that accounts for the measurement of underlying factors and their association with demographic and injury-related exogenous variables.

DESIGN

Cross-sectional study.

SETTING

Specialty hospital and medical university.

PARTICIPANTS

Participants with traumatic SCI (N=1871) of at least 1-year duration.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Exploratory factor analysis was used to identify latent health outcome structures. Several key exogenous variables were also linked with the latent health outcome factors.

RESULTS

Six latent health outcome factors were identified by the exploratory factor analysis with excellent model fit (root mean square error of approximation=.040). These latent factors included (1) global health problems; (2) chronic disease; (3) acute treatments; (4) symptoms of SCI complications, (5) pressure ulcers; and (6) subsequent injuries. Sex, race/ethnicity, age, years since injury, and injury severity were all significantly associated with at least 1 latent health outcome factor, which indicates that these latent health outcomes varied as a function of the exogenous variables.

CONCLUSIONS

This study improved our understanding of the structure of health outcomes, and utilization of latent health outcome factors provides more stable and comprehensive composite scores than does utilization of a single observed health outcome indicator.

Diabetes, hypertension, obesity, and long-term risk of renal disease mortality: Racial and socioeconomic differences

AIMS/INTRODUCTION

Diabetes, hypertension, and obesity increase the risk of chronic kidney disease and associated mortality. Race and socioeconomic status (SES) differences in the effects of these risk factors are, however, still unknown. The current study aimed to investigate whether or not race and SES alter the effects of diabetes, hypertension, and obesity on mortality due to renal disease.

MATERIALS AND METHODS

Data came from the Americans' Changing Lives Study, 1986-2011, a nationally representative prospective cohort of adults with 25 years of follow up. The study included 3,361 adults aged 25 years and older who were followed for up to 25 years. The outcome was death from renal disease. Diabetes, hypertension, and obesity were the main predictors. Race and SES (education, income, and employment) were moderators. Health behaviors and health status at baseline were covariates. We used Cox proportional hazards models for data analysis.

RESULTS

In separate models, diabetes, hypertension, and obesity at baseline were associated with a higher risk of death from renal disease. From our SES indicators, education and income interacted with diabetes, hypertension, and obesity on death from renal disease. In a consistent pattern, diabetes, hypertension, and obesity showed stronger effects on the risk of death from renal disease among high-SES groups compared with low-SES individuals. Race and employment did not alter the effects of diabetes, hypertension and obesity on the risk of death from renal disease.

CONCLUSIONS

Social groups differ in how diabetes, hypertension, and obesity influence health outcomes over long-term periods. Elimination of disparities in renal disease mortality in the USA requires understanding of the complex and non-linear effects of socioeconomic and medical risk factors on health outcomes. Multidisciplinary programs and policies are required to reduce social inequality in renal disease burden caused by diabetes, hypertension, and obesity.

Race and rehabilitation following spinal cord injury: equality of access for American Indians/Alaska Natives compared to other racial groups

Background

Representing 2 % of the general population, American Indians/Alaska Natives (AIs/ANs) were associated with 0.5 % (63) of the estimated 12,500 new cases of spinal cord injury (SCI) reported to the National Spinal Cord Injury Statistic Center in 2013. To date, the trend in health care disparities among AIs/ANs in the SCI community has not been examined. We sought to compare the rate of discharge to rehabilitation facilities (DRF) following traumatic SCI among adult AIs/ANs to other racial/ethnic groups for patients 15 to 64 years old.

Methods

Utilizing data from the National Trauma Data Bank (NTDB), we performed a retrospective analysis of SCI cases occurring between January 1, 2008 and December 31, 2012. SCI injuries were identified by International Classification of Diseases 9th Revision-Clinical Modification (ICD-9) codes or Abbreviated Injury Scale (AIS) scores. Injury severity was determined using the Trauma Mortality Prediction Model (TMPM) which empirically estimates each patient’s probability of death given their individual complement of injuries. A series of seven logistic regression models were used to predict DRF between racial groups.

Results

Among the 29,443 patients in our cohort, 52.4 % were discharged to rehabilitation facilities. AIs/ANs comprised 1.1 % of the population, with 63.8 % dismissed to rehabilitation. AIs/ANs were significantly younger, had a higher probability of death, had longer hospital length of stay (HLOS), and were proportionately more likely to be discharged to rehabilitation compared to non-AIs. Regression models demonstrated increased odds of DRF for AIs/ANs compared to Hispanic and Asian racial/ethnic groups.

Conclusions

American Indians/Alaska Natives who sustain SCI access rehabilitative care at a rate equitable to or greater than other races when multiple factors are taken into account. Further research is needed to assess the effect of those patient, physician, and health care system determinants as they relate to a patient’s ability to access post-trauma rehabilitative care. Recommendations include advancing the level of racial, insurance, and geographic data necessary to adequately explore disparities related to such ubiquitously life-altering conditions as SCI.

Distal, intermediate, and proximal mediators of racial disparities in renal disease mortality in the United States

Background: Kidney failure and associated mortality is one of the major components of racial disparities in the United States.

Objectives: The current study aimed to investigate the role of distal (socioeconomic status, SES), intermediate (chronic medical diseases), and proximal (health behaviors) factors that may explain Black-White disparities in mortality due to renal diseases.

Patients and Methods: This is a nationally representative prospective cohort with 25 years of follow up. Data came from the Americans’ Changing Lives (ACL) study, 1986 to 2011. The study included 3361 Black (n = 1156) or White (n = 2205) adults who were followed for up to 25 years. Race was the main predictor and death due to renal disease was the outcome. SES, chronic medical disease (diabetes, hypertension, obesity), and health behaviors (smoking, drinking, and exercise) at baseline were potential mediators. We used Cox proportional hazards models for data analysis.

Results: In age and gender adjusted models, Blacks had higher risk of death due to renal disease over the follow up period. Separate models suggested that SES, health behaviors and chronic medical disease fully explained the effect of race on renal disease mortality.

Conclusions: Black-White disparities in rate of death due to renal diseases in the United States are not genuine but secondary to racial differences in income, health behaviors, hypertension, and diabetes. As distal, intermediate, and proximal factors contribute to racial disparities in renal disease mortality, elimination of such disparities requires a wide range of policies and programs that target income, medical conditions, and health behaviors.

Differences in the Community Built Environment Influence Poor Perceived Health Among Persons With Spinal Cord Injury

OBJECTIVE

To assess the association between characteristics of the built environment and differences in perceived health among persons with spinal cord injury (SCI) using objective measures of the local community derived from Geographic Information Systems data.

DESIGN

Secondary analysis of cross-sectional survey data.

SETTING

Community.

PARTICIPANTS

Persons with chronic SCI enrolled in the Spinal Cord Injury Model Systems database (N=503). All cases were residents of New Jersey, completed an interview during the years 2000 through 2012, had a complete residential address, and were community living at the time of follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Perceived health.

RESULTS

Bivariate tests indicated that persons with SCI residing in communities with more (vs less) mixed land use and small (vs large) amounts of open space were more likely to report poor perceived health. No associations were found between perceived health and differences in the residential or destination density of the community. Adjusting for variation in demographic, impairment, quality of life, and community socioeconomic characteristics accounted for the gap in the odds of reporting poor health between persons living in areas with large versus small amounts of open space (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.28-1.02). However, even after accounting for individual background differences, persons living in communities characterized by more heterogeneous land use were twice as likely to report poor health compared with persons living in less mixed areas (OR, 2.14; 95% CI, 1.12-4.08).

CONCLUSIONS

Differences in the built characteristics of communities may be important to the long-term health and well-being of persons with SCI who may have greater exposure to the features of their local area because of limited mobility. The results of this study suggest living in a community with more heterogeneous land use was not beneficial to the perceived health of persons with chronic SCI living in New Jersey. Further investigation is needed to assess if the relationships observed in this analysis are influenced by differences in infrastructure and resources across communities. Further research is also needed to investigate the role built environment plays in the long-term health and well-being of persons with SCI in other geographic locales.

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.

Is financial hardship associated with reduced health in disability? The case of spinal cord injury in Switzerland

Objective

To investigate socioeconomic inequalities in a comprehensive set of health indicators among persons with spinal cord injury in a wealthy country, Switzerland.

Methods

Observational cross-sectional data from 1549 participants of the Swiss Spinal Cord Injury Cohort Study (SwiSCI), aged over 16 years, and living in Switzerland were analyzed. Socioeconomic circumstances were operationalized by years of formal education, net equivalent household income and financial hardship. Health indicators including secondary conditions, comorbidities, pain, mental health, participation and quality of life were used as outcomes. Associations between socioeconomic circumstances and health indicators were evaluated using ordinal regressions.

Results

Financial hardship was consistently associated with more secondary conditions (OR 3.37, 95% CI 2.18–5.21), comorbidities (OR 2.88, 95% CI 1.83–4.53) and pain (OR 3.32, 95% CI 2.21–4.99), whereas mental health (OR 0.23, 95% CI 0.15–0.36), participation (OR 0.30, 95% CI 0.21–0.43) and quality of life (OR 0.22, 95% CI 0.15–0.33) were reduced. Persons with higher education reported better mental health (OR 1.04, 95% CI 1.00–1.07) and higher quality of life (OR 1.06, 95% CI 1.02–1.09); other health indicators were not associated with education. Household income was not related to any of the studied health indicators when models were controlled for financial hardship.

Conclusions

Suffering from financial hardship goes along with significant reductions in physical health, functioning and quality of life, even in a wealthy country with comprehensive social and health policies.

Racial disparities in outcomes of spinal surgery for lumbar stenosis

STUDY DESIGN

A retrospective, cross-sectional study.

OBJECTIVE

To evaluate racial disparities in outcomes of lumbar stenosis surgery.

SUMMARY OF BACKGROUND DATA

Racial inequalities have been described in the outcomes of cardiovascular and orthopedic procedures. There have been minimal investigation of racial disparities in complications and costs of lumbar laminectomies and fusions.

METHODS

We analyzed the Medicaid data set of Thomson Reuter's MarketScan database. African-American and non-Hispanic white patients who underwent laminectomy or fusion for lumbar stenosis with at least 2 years postoperative data were included. We examined the effect of race on the rate of reoperations, complications, and the cost associated with surgery.

RESULTS

African-American patients in the Medicaid database were at no higher risk for reoperation in the 2 years after an operation for lumbar stenosis than white patients (7.14% vs. 7.89%, P = 0.7895). However, we did find that African-American patients were more likely to experience postoperative complications of any kind, even after adjusting for length of hospital stay, comorbidities, sex, and age (adjusted odds ratio = 1.819, P = 0.0123 for immediate complication; adjusted odds ratio = 1.746, P = 0.0141 for 30-d complication; and adjusted odds ratio = 1.611, P = 0.0410 for 90-d complication). White patients had a significantly shorter length of stay (3 vs. 5 d, P < 0.007) and accrued fewer hospital-related costs ($16,148 vs. $24,267, P < 0.0007). African-American patients, despite having more comorbidities in our sample, were prescribed significantly fewer medications in the 2 years after index procedures (91 vs. 138 prescriptions, P < 0.0007) and had fewer medication costs during the 2 years after surgery ($5297 vs. $8450, P < 0.0007).

CONCLUSION

At the national level, there are several racial disparities in the rate of complications, length of stay, and costs after surgery for lumbar spinal stenosis.

LEVEL OF EVIDENCE

3.

Conducting intervention research among underserved populations: lessons learned and recommendations for researchers

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

Factors associated with the development of pressure ulcers after spinal cord injury

STUDY DESIGN

Cross-sectional observational study.

OBJECTIVES

To examine variables associated with the development of pressure ulcers in subjects with spinal cord injury (SCI).

SETTING

SCI patients under coverage of the State Welfare Organization of Iran.

METHODS

Mobile rehabilitation teams gathered data from 20 of the 30 provinces in Iran. There were 8104 SCI patients registered in the database; 7489 patients were included in the analysis. The prevalence of PU in patients aged <10 years was lower than those aged >10; therefore, we used different logistic models for these groups. Likewise, separate models were created for patients who had experienced SCI during the past year versus patients injured >1 year before the evaluation.

RESULTS

PU was present in 34.6% of the patients. The variables associated with PU in patients aged <10 years were female gender and the time passed since SCI. In patients aged >11 years, male gender, the time passed since SCI, lower level of education, lack of an intimate partner, quadriplegia and older age presented a significant association with PU. Patients for whom <1 year has passed since SCI, male gender, quadriplegia and older age were associated with PU. And patients for whom >1 year had passed since SCI, male gender, quadriplegia, older age, lower level of education and lack of an intimate partner were associated with PU.

CONCLUSION

SCI patients are a heterogeneous group and the risk factors associated with PU may vary in specific subgroups. Different models are needed to describe PU in SCI patients depending on the patient's age and the time passed since SCI.

Racial Disparities in Depression and Life Satisfaction After Spinal Cord Injury: A Mediational Model

PURPOSE: To identify the relationship of race and gender with 3 aspects of life satisfaction and depressive symptoms after spinal cord injury (SCI), evaluating the extent to which socioeconomic factors mediate any observed relationships. METHODS: Adults with traumatic SCI of at least 1-year duration (N = 1,549) were identified through a Southeastern United States SCI Model System of care, and cross-sectional survey data were collected at a Southeastern United States medical university. Three aspects of life satisfaction (home life satisfaction, vocational satisfaction, global satisfaction) were measured using 20 satisfaction items from the Life Situation Questionnaire-Revised. The Older Adult Health and Mood Questionnaire measured depressive symptoms. MANCOVA assessed mediation of socioeconomic status between race and life satisfaction and depression. RESULTS: Home life satisfaction and vocational satisfaction were significantly related to race, with White participants scoring higher than Black participants during the first stage of the regression. However, socioeconomic factors mediated the relationships such that race was no longer significant after considering economic factors. Race was significantly associated with global satisfaction after adjusting for socioeconomic factors. Depression was not significantly related to race. Gender was unrelated to all study outcomes. Of the socioeconomic mediators, family income was a significant predictor of each outcome, whereas education was only predictive of vocational satisfaction. CONCLUSION: Socioeconomic factors are important mediators of the relationship between race and certain aspects of life satisfaction among persons with SCI. Family income and, to a lesser extent, education should be considered when evaluating race differences in life satisfaction after SCI.

Integrating population health into a general surgical residency curriculum

The once disparate fields of public health and medicine are slowly converging and reintegrating. Public health principles of community interventions and partnerships to effect better population health are included in the curricula of more medical schools. For graduate medical education, the specialties of internal medicine, family medicine, and preventive medicine are intuitively obvious population health partners, whereas surgeons have been relatively silent in this area. Despite the fact that many common surgical diseases are directly attributable to preventable causes, including cancer, trauma, and obesity, surgical residents receive little formal population health education. However, surgeons have always been and are increasingly active within the public health sphere. Examples of surgical population health initiatives include trauma systems development and improvement, research on disparities, and global health initiatives, including disaster relief. This article describes a single institution experience utilizing modest curriculum changes, increased global health opportunities, and direct service learning to help integrate population health principles into a general surgical residency program.

The association of race, cultural factors, and health-related quality of life in persons with spinal cord injury

OBJECTIVE

To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI).

DESIGN

Cross-sectional multisite study using structured questionnaires.

SETTING

Six National SCI Model Systems centers.

PARTICIPANTS

People with SCI (N=275; age ≥16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey).

RESULTS

African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001-<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.07-2.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.12-2.43; P<.05) and greater perceived health (β=.36; 95% CI, .05-.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06-.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.05-2.13; P<.05) and better general health (β=.27; 95% CI, .01-.53; P<.05).

CONCLUSIONS

In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being. These associations are different from those reported in other study populations and warrant confirmation in future prospective studies.

Vulnerable Groups Living with Spinal Cord Injury

There is considerable variation in rehabilitation outcomes within the population of spinal cord-injured individuals across racial and socioeconomic groups. This suggests that the long-term health following spinal cord injury (SCI) is determined, at least in part, by group differences in exposure to advantages and disadvantages among persons living in the community. This article conceptualizes the nature of vulnerability and how increased vulnerability leads to disparities in SCI outcomes. Demographic, socioeconomic, and geographic determinants of adverse outcomes among vulnerable groups are discussed. Finally, a research model that outlines potential processes that elicit vulnerability following SCI and clinical implications is reviewed.

Changes in emergency department access between 2001 and 2005 among general and vulnerable populations

OBJECTIVES

We analyzed how ease of geographic access to emergency departments (EDs), defined as driving time to the closest ED, changed between 2001 and 2005, and whether access deterioration was more likely to occur in vulnerable communities.

METHODS

We classified communities on the basis of American Hospital Association and Census data into 3 categories according to driving time to the nearest ED: no increase, less than a 10-minute increase, and a 10-minute or more increase. We estimated a multinomial logit model to examine the relative risk ratio (RRR) of various community characteristics.

RESULTS

More than 95% of communities experienced no ED access deterioration. However, 11.4 million people experienced increased driving time to their nearest ED. Low-income communities had a higher risk of facing deteriorating access compared with high-income communities (urban: RRR = 3.67; P < .01; rural: RRR = 1.75; P < .10), and communities with higher shares of Hispanics also had higher risks of facing declines (urban: RRR = 3.41; P < .10; rural: RRR = 2.67; P < .01).

CONCLUSIONS

Deteriorating access to EDs is more likely to occur in communities with economic hardship and high shares of Hispanic populations. The uneven access to critical services warrants increased attention from policymaking bodies.

The relationship of pressure ulcers, race, and socioeconomic conditions after spinal cord injury

OBJECTIVE

To identify risks factors associated with pressure ulcers (PrU) after spinal cord injury (SCI) by examining race and indicators of socioeconomic status (measured by income and education). We hypothesize African Americans will have a greater risk for PrUs than whites, but this relationship will be mediated by the 2 socioeconomic status indicators.

DESIGN

Cohort study.

SETTING

A large rehabilitation hospital in the southeastern US.

PARTICIPANTS

1466 white and African American adults at least 1-year post-traumatic SCI.

OUTCOME MEASURES

(a) PrUs in the past year, (b) current PrU, (c) surgery to repair a PrU since injury.

RESULTS

In preliminary analyses, race was significantly associated with having a current PrU and with having surgery to repair a PrU since injury. In multivariable analyses, the relationships of PrU with having a current PrU and with having surgery to repair a PrU were both mediated by income and education such that the relationships were no longer significant. Lower income was associated with increased odds of each PrU outcome. After controlling for other variables in the model, education was associated with increased odds of having a current PrU.

CONCLUSION

These findings help clarify the relationships between race and socioeconomic status with PrUs after SCI. Specifically, a lack of resources, both financial and educational, is associated with worse PrU outcomes. These results can be used by both providers and policy makers when considering prevention and intervention strategies for PrUs among people with SCI.

Understanding the risk factors of trauma center closures: do financial pressure and community characteristics matter?

OBJECTIVES

We analyze whether hazard rates of shutting down trauma centers are higher due to financial pressures or in areas with vulnerable populations (such as minorities or the poor).

MATERIALS AND METHODS

This is a retrospective study of all hospitals with trauma center services in urban areas in the continental US between 1990 and 2005, identified from the American Hospital Association Annual Surveys. These data were linked with Medicare cost reports, and supplemented with other sources, including the Area Resource File. We analyze the hazard rates of trauma center closures among several dimensions of risk factors using discrete-time proportional hazard models.

RESULTS

The number of trauma center closures increased from 1990 to 2005, with a total of 339 during this period. The hazard rate of closing trauma centers in hospitals with a negative profit margin is 1.38 times higher than those hospitals without the negative profit margin (P < 0.01). Hospitals receiving more generous Medicare reimbursements face a lower hazard of shutting down trauma centers (ratio: 0.58, P < 0.01) than those receiving below average reimbursement. Hospitals in areas with higher health maintenance organizations penetration face a higher hazard of trauma center closure (ratio: 2.06, P < 0.01). Finally, hospitals in areas with higher shares of minorities face a higher risk of trauma center closure (ratio: 1.69, P < 0.01). Medicaid load and uninsured populations, however, are not risk factors for higher rates of closure after we control for other financial and community characteristics.

CONCLUSIONS

Our findings give an indication on how the current proposals to cut public spending could exacerbate the trauma closure particularly among areas with high shares of minorities. In addition, given the negative effect of health maintenance organizations on trauma center survival, the growth of Medicaid managed care population should be monitored. Finally, high shares of Medicaid or uninsurance by themselves are not independent risk factors for higher closure as long as financial pressures are mitigated. Targeted policy interventions and further research on the causes, are needed to address these systems-level disparities.

Risk of hospitalizations after spinal cord injury: relationship with biographical, injury, educational, and behavioral factors

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

To assess the risk factors associated with hospitalization and the relationship of individual health behaviors with hospitalizations after spinal cord injury (SCI).

SETTING

A large specialty hospital in the southeastern USA.

METHODS

Persons with SCI responded (n=1386) to a mail survey assessing various aspects of their health, including health behaviors and number of hospitalizations in the past year. Logistic regression was used to assess the relationships between biographical, injury, educational, and health behavior factors with hospitalization in the past year.

RESULTS

Overall, 36.6% of participants were hospitalized on at least one occasion during the earlier year. Two biographical and injury characteristics were associated with hospitalization: race and SCI severity. Specifically, minorities and persons with non-ambulatory high cervical or non-cervical SCI were more likely to be hospitalized. Three behavioral factors were significantly associated with hospitalization after controlling for biographical and injury characteristics. Persons who used prescription medications, those who engaged more in smoking behaviors, and persons who reported more SCI-specific health behaviors were more likely to be hospitalized.

CONCLUSION

Specific health behaviors are associated with an increased hospitalization among persons with SCI. Future research is needed to assess the time sequence of these relationships.

Multiple health disparities among minority adults with mobility limitations: san application of the ICF framework and codes

PURPOSE

To examine the interface between mobility limitations and minority status and its effect on multiple health and health-related domains among adults, using the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

We combined 8 years of data from the 1997-2004 US National Health Interview Survey to investigate health disparities among minorities with mobility limitations as defined by the ICF. A total of 79,739 adults surveyed met these criteria.

RESULTS

Adults with both mobility limitations and minority status experienced the greatest disparities (p<0.001) in worsening health (adjusted odds ratio [AOR]=8.5), depressive symptoms (AOR=17.2), diabetes (AOR=5.5), hypertension (AOR=3.4), stroke (AOR=7.2), visual impairment (AOR=4.6), difficulty with activities of daily living (AOR=42.7) and instrumental activities of daily living (AOR=27.7), use of special equipment (AOR = 28.1), obesity (AOR=3.3), physical inactivity (AOR=2.7), and low workforce participation (AOR=0.35).

CONCLUSIONS

For most outcome measures, findings supported our hypothesis that persons with both mobility limitations and minority status experience greater health disparities than do adults with minority status or mobility limitations alone.

Black children experience worse clinical and functional outcomes after traumatic brain injury: an analysis of the National Pediatric Trauma Registry

BACKGROUND

Recent studies suggest racial disparities in the treatment and outcomes of children with traumatic brain injury (TBI). This study aims to identify race-based clinical and functional outcome differences among pediatric TBI patients in a national database.

METHODS

A total of 41,122 patients (ages 2-16 years) who were included in the National Pediatric Trauma Registry (from 1996-2001) were studied. TBI was categorized by Relative Head Injury Severity Score (RHISS) and patients with moderate to severe TBI were included. Individual race groups were compared with white as the majority group. Differences between races in functional outcomes at discharge in three domains-speech, locomotion, and feeding-were determined using multiple logistic regression. Cases were adjusted for age, sex, severity of head injury (using RHISS), severity of injury (using New Injury Severity Score and Pediatric Trauma Score), premorbidities, mechanism, and injury intent.

RESULTS

A total of 7,778 children had moderate or severe TBI with or without associated injuries. All races had similar demographics. Hispanics (n=1,041) had outcomes comparable to whites (n=4,762). Black children (n=1,238) had significantly increased premorbidities, penetrating trauma, and violent intent. They also had higher unadjusted mortality and longer mean intensive care unit and floor stays. After adjustment, there was no difference in the odds of death between black and white children. However, black patients were more likely to be discharged to an inpatient rehabilitation facility and had increased odds of possessing a functional deficit at discharge for all three domains studied.

CONCLUSION

Black children with traumatic brain injury have worse clinical and functional outcomes at discharge when compared with equivalently injured white children.