Meaningful Causal Decompositions in Health Equity Research: Definition, Identification, and Estimation Through a Weighting Framework

Association of Disability Status and Type With Binge Drinking and Prescription Opioid Misuse Among Adults From a 3-State Sample

BACKGROUND

Research examining at-risk substance use by disability status is limited, with little investigation into differences by disability type. We investigated binge drinking and prescription opioid misuse among adults with and without disabilities, and by type of disability, to inform need for assessment and intervention within these populations.

METHODS

Secondary analyses of adults who completed the disability, alcohol, and prescription opioid misuse items in the 2018 Ohio, Florida, or Nebraska Behavioral Risk Factor Surveillance System surveys (n = 28 341), the only states that included prescription opioid misuse in 2018. Self-reported disability status (yes/no) relied on 6 standardized questions assessing difficulties with: vision, hearing, mobility, cognition, self-care, and independent living (dichotomous, nonmutually exclusive, for each disability). Logistic regression models estimated the association of disability status and type with (1) past 30-day binge drinking and (2) past-year prescription opioid misuse. Additional models were restricted to separate subsamples of adults who: (a) currently drink, (b) received a past-year prescription opioid, and (c) did not receive a past-year prescription opioid.

RESULTS

One-third reported at least one disability, with mobility (19.5%), cognitive (11.5%), and hearing (10.2%) disability being the most common. Disability status was associated with lower odds of binge drinking (adjusted odds ratio [AOR] = 0.74, 95% confidence interval [CI] 0.68-0.80, P ≤ .01). However, among adults who currently drink, people with disabilities had higher odds of binge drinking (AOR = 1.11, 95% CI 1.01-1.22, P ≤ .05]. Disability was associated with higher odds of past-year prescription opioid misuse (AOR = 2.51, 95% CI 2.17-2.91, P ≤ .01).

CONCLUSIONS

Adults with disabilities had higher odds of prescription opioid misuse, and among adults who currently drink, higher odds for binge drinking were observed. The magnitude of the association between disability status and prescription opioid misuse was particularly concerning. Providers should be trained to screen and treat for substance use problems for people with disabilities.

Evaluating Effects of Multilevel Interventions on Disparity in Health and Healthcare Decisions

In this paper, we introduce an analytic approach for assessing effects of multilevel interventions on disparity in health outcomes and health-related decision outcomes (i.e., a treatment decision made by a healthcare provider). We outline common challenges that are encountered in interventional health disparity research, including issues of effect scale and interpretation, choice of covariates for adjustment and its impact on effect magnitude, and the methodological challenges involved with studying decision-based outcomes. To address these challenges, we introduce total effects of interventions on disparity for the entire sample and the treated sample, and corresponding direct effects that are relevant for decision-based outcomes. We provide weighting and g-computation estimators in the presence of study attrition and sketch a simulation-based procedure for sample size determinations based on precision (e.g., confidence interval width). We validate our proposed methods through a brief simulation study and apply our approach to evaluate the RICH LIFE intervention, a multilevel healthcare intervention designed to reduce racial and ethnic disparities in hypertension control.

Social Risk Factors and Racial and Ethnic Disparities in Health Care Resource Utilization Among Medicare Advantage Beneficiaries With Psychiatric Disorders

The intersection of social risk and race and ethnicity on mental health care utilization is understudied. This study examined disparities in health care treatment, adjusting for clinical need, among 25,780 Medicare Advantage beneficiaries with a diagnosis of a psychiatric disorder. We assessed contributions to disparities from racial and ethnic differences in the composition and returns of social risk variables. Black and Hispanic beneficiaries had lower rates of mental health outpatient visits than Whites. Assessing composition, Black and Hispanic beneficiaries experienced greater financial, food, and housing insecurity than White beneficiaries, factors associated with greater mental health treatment. Assessing returns, food insecurity was associated with an exacerbation of Hispanic-White disparities. Health care systems need to address the financial, food and housing insecurity of racial and ethnic minority groups with psychiatric disorder. Accounting for racial and ethnic differences in social risk adjustment-based payment reforms has significant implications for provider reimbursement and outcomes.

Geographic Variation in Racial Disparities in Receipt of High-Dose Influenza Vaccine Among US Older Adults

BACKGROUND

Racial disparities in receipt of high-dose influenza vaccine (HDV) have been documented nationally, but whether small-area geographic variation in such disparities exists remains unknown. We assessed the distribution of disparities in HDV receipt between Black and White traditional Medicare beneficiaries vaccinated against influenza within states and hospital referral regions (HRRs).

METHODS

We conducted a nationally representative retrospective cohort study of 11,768,724 community-dwelling traditional Medicare beneficiaries vaccinated against influenza during the 2015-2016 influenza season (94.3% White and 5.7% Black). Our comparison was marginalized versus privileged racial group measured as Black versus White race. Vaccination and type of vaccine were obtained from Medicare Carrier and Outpatient files. Differences in the proportions of individuals who received HDV between Black and White beneficiaries within states and HRRs were used to measure age- and sex-standardized disparities in HDV receipt. We restricted to states and HRRs with ≥ 100 beneficiaries per age-sex strata per racial group.

RESULTS

We detected a national disparity in HDV receipt of 12.8 percentage points (pps). At the state level, the median standardized HDV receipt disparity was 10.7 pps (minimum, maximum: 2.9, 25.6; n = 30 states). The median standardized HDV receipt disparity among HRRs was 11.6 pps (minimum, maximum: 0.4, 24.7; n = 54 HRRs).

CONCLUSION

Black beneficiaries were less likely to receive HDV compared to White beneficiaries in almost every state and HRR in our analysis. The magnitudes of disparities varied substantially across states and HRRs. Local interventions and policies are needed to target geographic areas with the largest disparities to address these inequities.

Lack of racial and ethnic disparities in mortality in minority patients hospitalised with COVID-19 in a mid-Atlantic healthcare system

INTRODUCTION

In the USA, minoritised communities (racial and ethnic) have suffered disproportionately from COVID-19 compared with non-Hispanic white communities. In a large cohort of patients hospitalised for COVID-19 in a healthcare system spanning five adult hospitals, we analysed outcomes of patients based on race and ethnicity.

METHODS

This was a retrospective cohort analysis of patients 18 years or older admitted to five hospitals in the mid-Atlantic area between 4 March 2020 and 27 May 2022 with confirmed COVID-19. Participants were divided into four groups based on their race/ethnicity: non-Hispanic black, non-Hispanic white, Latinx and other. Propensity score weighted generalised linear models were used to assess the association between race/ethnicity and the primary outcome of in-hospital mortality.

RESULTS

Of the 9651 participants in the cohort, more than half were aged 18-64 years old (56%) and 51% of the cohort were females. Non-Hispanic white patients had higher mortality (p<0.001) and longer hospital length-of-stay (p<0.001) than Latinx and non-Hispanic black patients.

DISCUSSION

In this large multihospital cohort of patients admitted with COVID-19, non-Hispanic black and Hispanic patients did not have worse outcomes than white patients. Such findings likely reflect how the complex range of factors that resulted in a life-threatening and disproportionate impact of incidence on certain vulnerable populations by COVID-19 in the community was offset through admission at well-resourced hospitals and healthcare systems. However, there continues to remain a need for efforts to address the significant pre-existing race and ethnicity inequities highlighted by the COVID-19 pandemic to be better prepared for future public health emergencies.

Breast (female), colorectal, and lung cancer survival in people with intellectual or developmental disabilities: A population-based retrospective cohort study

OBJECTIVES

Cancer is a leading cause of death among people living with intellectual or developmental disabilities (IDD). There is little empirical evidence documenting survival or comparing outcomes to those without IDD. This study investigated the association between IDD and cancer survival among adults with breast (female), colorectal, or lung cancer.

METHODS

A population-based retrospective cohort study was conducted in Ontario, Canada, with routinely collected data. Patients with breast, colorectal, or lung cancer were included (2007‒2019). IDD status before cancer was determined using an established administrative data algorithm. The outcomes of interest included death from any cause and death from cancer. Cox proportional hazards models and competing events analyses using multivariable cause-specific hazards regression were completed. Analyses were stratified by cancer type. Interactions with age, sex, and stage at diagnosis, as well as sensitivity analyses, were completed.

RESULTS

The final cohorts included 123,695 breast, 98,809 colorectal, and 116,232 lung cancer patients. Individuals with IDD experienced significantly worse survival than those without IDD. The adjusted hazard ratios of all-cause death were 2.74 (95% CI 2.41‒3.12), 2.42 (95% CI 2.18‒2.68), and 1.49 (95% CI 1.34‒1.66) times higher for breast, colorectal, and lung cancer patients with IDD relative to those without. These findings were consistent for cancer-specific deaths. With few exceptions, worse survival for people with IDD persisted regardless of stage at diagnosis.

CONCLUSION

People with IDD experienced worse cancer survival than those without IDD. Identifying and intervening on the factors and structures responsible for survival disparities is imperative.

Racial Inequities in the Control of Hypertension and the Explanatory Role of Residential Segregation: a Decomposition Analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

The mechanisms underlying racial inequities in uncontrolled hypertension have been limited to individual factors. We investigated racial inequities in uncontrolled hypertension and the explanatory role of economic segregation in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). All 3897 baseline participants with hypertension (2008-2010) were included. Uncontrolled hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg), self-reported race (White/Brown/Black people), and neighborhood economic segregation (low/medium/high) were analyzed cross-sectionally. We used decomposition analysis, which describes how much a disparity would change (disparity reduction; explained portion) and remain (disparity residual; unexplained portion) upon removing racial differences in economic segregation (i.e., if Black people had the distribution of segregation of White people, how much we would expect uncontrolled hypertension to decrease among Black people). Age- and gender-adjusted prevalence of uncontrolled hypertension (39.0%, 52.6%, and 54.2% for White, Brown, and Black participants, respectively) remained higher for Black and Brown vs White participants, regardless of economic segregation. Uncontrolled hypertension showed a dose-response pattern with increasing segregation levels for White but not for Black and Brown participants. After adjusting for age, gender, education, and study center, unexplained portion (disparity residual) of race on uncontrolled hypertension was 18.2% (95% CI 13.4%; 22.9%) for Black vs White participants and 12.6% (8.2%; 17.1%) for Brown vs White participants. However, explained portion (disparity reduction) through economic segregation was - 2.1% (- 5.1%; 1.3%) for Black vs White and 0.5% (- 1.7%; 2.8%) for Brown vs White participants. Although uncontrolled hypertension was greater for Black and Brown vs White people, racial inequities in uncontrolled hypertension were not explained by economic segregation.

Social and psychosocial determinants of racial and ethnic differences in cardiovascular health: The MASALA and MESA studies

Background

Social and psychosocial determinants are associated with cardiovascular health (CVH).

Objectives

To quantify the contributions of social and psychosocial factors to racial/ethnic differences in CVH.

Methods

In the Multi-Ethnic Study of Atherosclerosis and Mediators of Atherosclerosis in South Asians Living in America cohorts, Kitagawa-Blinder-Oaxaca decomposition quantified the contributions of social and psychosocial factors to differences in mean CVH score (range 0-14) in Black, Chinese, Hispanic, or South Asian compared with White participants.

Results

Among 7,978 adults (mean age 61 [SD 10] years, 52 % female), there were 1,892 Black (mean CVH score for decomposition analysis 7.96 [SD 2.1]), 804 Chinese (CVH 9.69 [1.8]), 1,496 Hispanic (CVH 8.00 [2.1]), 1,164 South Asian (CVH 9.16 [2.0]), and 2,622 White (CVH 8.91 [2.1]) participants. The factors that were associated with the largest magnitude of explained differences in mean CVH score were income for Black participants (if mean income in Black participants were equal to White participants, Black participants' mean CVH score would be 0.14 [SE 0.05] points higher); place of birth for Chinese participants (if proportion of US-born and foreign-born individuals among Chinese adults were equivalent to White participants, Chinese participants' mean CVH score would be 0.22 [0.10] points lower); and education for Hispanic and South Asian participants (if educational attainment were equivalent to White participants, Hispanic and South Asian participants' mean CVH score would be 0.55 [0.11] points higher and 0.37 [0.11] points lower, respectively).

Conclusions

In these multiethnic US cohorts, social and psychosocial factors were associated with racial/ethnic differences in CVH.

Selection Bias in Health Research: Quantifying, Eliminating, or Exacerbating Health Disparities?

Purpose of review

To summarize recent literature on selection bias in disparities research addressing either descriptive or causal questions, with examples from dementia research.

Recent findings

Defining a clear estimand, including the target population, is essential to assess whether generalizability bias or collider-stratification bias are threats to inferences. Selection bias in disparities research can result from sampling strategies, differential inclusion pipelines, loss to follow-up, and competing events. If competing events occur, several potentially relevant estimands can be estimated under different assumptions, with different interpretations. The apparent magnitude of a disparity can differ substantially based on the chosen estimand. Both randomized and observational studies may misrepresent health disparities or heterogeneity in treatment effects if they are not based on a known sampling scheme.

Conclusion

Researchers have recently made substantial progress in conceptualization and methods related to selection bias. This progress will improve the relevance of both descriptive and causal health disparities research.

Stage IV breast, colorectal, and lung cancer at diagnosis in adults living with intellectual or developmental disabilities: A population-based cross-sectional study

BACKGROUND

Cancer is a leading cause of death among people living with intellectual or developmental disabilities (IDD). Although studies have documented lower cancer screening rates, there is limited epidemiological evidence quantifying potential diagnostic delays. This study explores the risk of metastatic cancer stage for people with IDD compared to those without IDD among breast (female), colorectal, and lung cancer patients in Canada.

METHODS

Separate population-based cross-sectional studies were conducted in Ontario and Manitoba by linking routinely collected data. Breast (female), colorectal, and lung cancer patients were included (Manitoba: 2004-2017; Ontario: 2007-2019). IDD status was identified using established administrative algorithms. Modified Poisson regression with robust error variance models estimated associations between IDD status and the likelihood of being diagnosed with metastatic cancer. Adjusted relative risks were pooled between provinces using random-effects meta-analyses. Potential effect modification was considered.

RESULTS

The final cohorts included 115,456, 89,815, and 101,811 breast (female), colorectal, and lung cancer patients, respectively. Breast (female) and colorectal cancer patients with IDD were 1.60 and 1.44 times more likely to have metastatic cancer (stage IV) at diagnosis compared to those without IDD (relative risk [RR], 1.60; 95% confidence interval [CI], 1.16-2.20; RR, 1.44; 95% CI, 1.24-1.67). This increased risk was not observed in lung cancer. Significant effect modification was not observed.

CONCLUSIONS

People with IDD were more likely to have stage IV breast and colorectal cancer identified at diagnosis compared to those without IDD. Identifying factors and processes contributing to stage disparities such as lower screening rates and developing strategies to address diagnostic delays is critical.

Trends in Chiropractic Care and Physical Rehabilitation Use Among Adults with Low Back Pain in the United States, 2002 to 2018

BACKGROUND

While nonpharmacologic treatments are increasingly endorsed as first-line therapy for low back pain (LBP) in clinical practice guidelines, it is unclear if use of these treatments is increasing or equitable.

OBJECTIVE

Examine national trends in chiropractic care and physical rehabilitation (occupational/physical therapy (OT/PT)) use among adults with LBP.

DESIGN/SETTING

Serial cross-sectional analysis of the National Health Interview Survey, 2002 to 2018.

PARTICIPANTS

146,087 adults reporting LBP in prior 3 months.

METHODS

We evaluated the association of survey year with chiropractic care or OT/PT use in prior 12 months. Logistic regression with multilevel linear splines was used to determine if chiropractic care or OT/PT use increased after the introduction of clinical guidelines. We also examined trends in use by age, sex, race, and ethnicity. When trends were similar over time, we present differences by these demographic characteristics as unadjusted ORs using data from all respondents.

RESULTS

Between 2002 and 2018, less than one-third of adults with LBP reported use of either chiropractic care or OT/PT. Rates did not change until 2016 when uptake increased with the introduction of clinical guidelines (2016-2018 vs 2002-2015, OR = 1.15; 95% CI: 1.10-1.19). Trends did not differ significantly by sex, race, or ethnicity (p for interactions > 0.05). Racial and ethnic disparities in chiropractic care or OT/PT use were identified and persisted over time. For example, compared to non-Hispanic adults, either chiropractic care or OT/PT use was lower among Hispanic adults (combined OR = 0.62, 95% CI: 0.65-0.73). By contrast, compared to White adults, Black adults had similar OT/PT use (OR = 0.98; 95% CI: 0.94-1.03) but lower for chiropractic care use (OR = 0.50; 95% CI: 0.47-0.53).

CONCLUSIONS

Although use of chiropractic care or OT/PT for LBP increased after the introduction of clinical guidelines in 2016, only about a third of US adults with LBP reported using these services between 2016 and 2018 and disparities in use have not improved.

Nunavimmi puvakkut kaggutimik aanniaqarniq: Qanuilirqitaa? Lung cancer in Nunavik: How are we doing? A retrospective matched cohort study

BACKGROUND

Whether Inuit in Canada experience disparities in lung cancer survival remains unknown. When requiring investigation and treatment for lung cancer, all residents of Nunavik, the Inuit homeland in Quebec, are sent to the McGill University Health Centre (MUHC), in Montréal. We sought to compare survival among patients with lung cancer at the MUHC, who were residents of Nunavik and Montréal, Quebec, respectively.

METHODS

We conducted a retrospective cohort study. Using lung cancer registry data, we identified Nunavik residents with histologically confirmed lung cancer diagnosed between 2005 and 2017. We aimed to match 2 Montréal residents to each Nunavik resident on sex, age, calendar year of diagnosis, and histology (non-small cell lung cancer v. small cell lung cancer). We reviewed medical records for data on additional patient characteristics and treatment, and obtained vital status from a provincial registry. We compared survival using Kaplan-Meier analysis and Cox proportional hazards regression.

RESULTS

We included 95 residents of Nunavik and 185 residents of Montréal. For non-small cell lung cancer, median survival times were 321 (95% confidence interval [CI] 184-626) days for Nunavik (n = 71) and 720 (95% CI 536-1208) days for Montréal residents (n = 141). For small cell lung cancer, median survival times were 190 (95% CI 159-308) days for Nunavik (n = 24) and 270 (95% CI 194-766) days for Montréal residents (n = 44). Adjusting for matching variables, stage, performance status, and comorbidity, Nunavik residents had a higher hazard of death (hazard ratio 1.68, 95% CI 1.17-2.41).

INTERPRETATION

Nunavik residents experience disparities in survival after lung cancer diagnosis. Although studies in other Inuit Nunangat regions are needed, our findings point to an urgent need to ensure that interventions aimed at improving lung cancer survival, including lung cancer screening, are accessible to Inuit Nunangat residents.

The Importance of Equity Value Judgments and Estimator-Estimand Alignment in Measuring Disparity and Identifying Targets to Reduce Disparity

The choice of which covariates to adjust for (so-called allowability designation (AD)) in health disparity measurements reflects value judgments about inequitable versus equitable sources of health differences, which is paramount for making inferences about disparity. Yet, many off-the-shelf estimators used in health disparity research are not designed with equity considerations in mind, and they imply different ADs. We demonstrated the practical importance of incorporating equity concerns in disparity measurements through simulations, motivated by the example of reducing racial disparities in hypertension control via interventions on disparities in treatment intensification. Seven causal decomposition estimators, each with a particular AD (with respect to disparities in hypertension control and treatment intensification), were considered to estimate the observed outcome disparity and the reduced/residual disparity under the intervention. We explored the implications for bias of the mismatch between equity concerns and the AD in the estimator under various causal structures (through altering racial differences in covariates or the confounding mechanism). The estimator that correctly reflects equity concerns performed well under all scenarios considered, whereas the other estimators were shown to have the risk of yielding large biases in certain scenarios, depending on the interaction between their ADs and the specific causal structure.

Evaluating Clinic-Based Interventions to Reduce Racial Differences in Mortality Among People With Human Immunodeficiency Virus in the United States

BACKGROUND

Mortality remains elevated among Black versus White adults receiving human immunodeficiency virus (HIV) care in the United States. We evaluated the effects of hypothetical clinic-based interventions on this mortality gap.

METHODS

We computed 3-year mortality under observed treatment patterns among >40 000 Black and >30 000 White adults entering HIV care in the United States from 1996 to 2019. We then used inverse probability weights to impose hypothetical interventions, including immediate treatment and guideline-based follow-up. We considered 2 scenarios: "universal" delivery of interventions to all patients and "focused" delivery of interventions to Black patients while White patients continued to follow observed treatment patterns.

RESULTS

Under observed treatment patterns, 3-year mortality was 8% among White patients and 9% among Black patients, for a difference of 1 percentage point (95% confidence interval [CI], .5-1.4). The difference was reduced to 0.5% under universal immediate treatment (95% CI, -.4% to 1.3%) and to 0.2% under universal immediate treatment combined with guideline-based follow-up (95% CI, -1.0% to 1.4%). Under the focused delivery of both interventions to Black patients, the Black-White difference in 3-year mortality was -1.4% (95% CI, -2.3% to -.4%).

CONCLUSIONS

Clinical interventions, particularly those focused on enhancing the care of Black patients, could have significantly reduced the mortality gap between Black and White patients entering HIV care from 1996 to 2019.

The potential of intervening on childhood adversity to reduce socioeconomic inequities in body mass index and inflammation among Australian and UK children: A causal mediation analysis

BACKGROUND

Lower maternal education is associated with higher body mass index (BMI) and higher chronic inflammation in offspring. Childhood adversity potentially mediates these associations. We examined the extent to which addressing childhood adversity could reduce socioeconomic inequities in these outcomes.

METHODS

We analysed data from two early-life longitudinal cohorts: the Longitudinal Study of Australian Children (LSAC; n=1873) and the UK Avon Longitudinal Study of Parents and Children (ALSPAC; n=7085).

EXPOSURE

low/medium (below university degree) versus high maternal education, as a key indicator of family socioeconomic position (0-1 year).

OUTCOMES

BMI and log-transformed glycoprotein acetyls (GlycA) (LSAC: 11-12 years; ALSPAC: 15.5 years). Mediator: multiple adversities (≥2/<2) indicated by family violence, mental illness, substance abuse and harsh parenting (LSAC: 2-11 years; ALSPAC: 1-12 years). A causal mediation analysis was conducted.

RESULTS

Low/medium maternal education was associated with up to 1.03 kg/m2 higher BMI (95% CI: 0.95 to 1.10) and up to 1.69% higher GlycA (95% CI: 1.68 to 1.71) compared with high maternal education, adjusting for confounders. Causal mediation analysis estimated that decreasing the levels of multiple adversities in children with low/medium maternal education to be like their high maternal education peers could reduce BMI inequalities by up to 1.8% and up to 3.3% in GlycA.

CONCLUSIONS

Our findings in both cohorts suggest that slight reductions in socioeconomic inequities in children's BMI and inflammation could be achieved by addressing childhood adversities. Public health and social policy efforts should help those affected by childhood adversity, but also consider underlying socioeconomic conditions that drive health inequities.

Access to symptom screening and severe symptom risk among cancer patients with major mental illness

INTRODUCTION

Cancer symptom screening has the potential to improve cancer outcomes, including reducing symptom burden among patients with major mental illness (MMI). We determined rates of symptom screening with the Edmonton Symptom Assessment System (ESAS-r) and risk of severe symptoms in cancer patients with MMI.

METHODS

This retrospective cohort study used linked administrative health databases of adults diagnosed with cancer between 2007 and 2020. An MMI was measured in the 5 years prior to cancer diagnosis and categorized as inpatient, outpatient, or no MMI. Outcomes were defined as time to first ESAS-r screening and time to first moderate-to-severe symptom score. Cause-specific and Fine and Gray competing events models were used for both outcomes, controlling for age, sex, rural residence, year of diagnosis and cancer site.

RESULTS

Of 389,870 cancer patients, 4049 (1.0%) had an inpatient MMI and 9775 (2.5%) had an outpatient MMI. Individuals with inpatient MMI were least likely to complete an ESAS-r (67.5%) compared to those with outpatient MMI (72.3%) and without MMI (74.8%). Compared to those without MMI, individuals with an inpatient or outpatient MMI had a lower incidence of symptom screening records after accounting for the competing risk of death (subdistribution Hazard Ratio 0.77 (95% CI 0.74-0.80) and 0.88 (95% CI 0.86-0.90) respectively). Individuals with inpatient and outpatient MMI status consistently had a significantly higher risk of reporting high symptom scores across all symptoms.

CONCLUSIONS

Understanding the disparity in ESAS-r screening and management for cancer patients with MMI is a vital step toward providing equitable cancer care.

Tobacco Use and Tobacco Dependence Management

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

Racial and Ethnic Disparities in the Incidence of High-Impact Chronic Pain Among Primary Care Patients with Acute Low Back Pain: A Cohort Study

OBJECTIVE

We assessed whether race or ethnicity was associated with the incidence of high-impact chronic low back pain (cLBP) among adults consulting a primary care provider for acute low back pain (aLBP).

METHODS

In this secondary analysis of a prospective cohort study, patients with aLBP were identified through screening at seventy-seven primary care practices from four geographic regions. Incidence of high-impact cLBP was defined as the subset of patients with cLBP and at least moderate disability on Oswestry Disability Index [ODI >30]) at 6 months. General linear mixed models provided adjusted estimates of association between race/ethnicity and high-impact cLBP.

RESULTS

We identified 9,088 patients with aLBP (81.3% White; 14.3% Black; 4.4% Hispanic). Black/Hispanic patients compared to White patients, were younger and more likely to be female, obese, have Medicaid insurance, worse disability on ODI, and were at higher risk of persistent disability on STarT Back Tool (all P < .0001). At 6 months, more Black and Hispanic patients reported high-impact cLBP (30% and 25%, respectively) compared to White patients (15%, P < .0001, n = 5,035). After adjusting for measured differences in socioeconomic and back-related risk factors, compared to White patients, the increased odds of high-impact cLBP remained statistically significant for Black but not Hispanic patients (adjusted odds ration [aOR] = 1.40, 95% confidence interval [CI]: 1.05-1.87 and aOR = 1.25, 95%CI: 0.83-1.90, respectively).

CONCLUSIONS

We observed an increased incidence of high-impact cLBP among Black and Hispanic patients compared to White patients. This disparity was partly explained by racial/ethnic differences in socioeconomic and back-related risk factors. Interventions that target these factors to reduce pain-related disparities should be evaluated.

CLINICALTRIALS.GOV IDENTIFIER

NCT02647658.

An intersectional analysis of historical and contemporary structural racism on non-fatal shootings in Baltimore, Maryland

Introduction Non-fatal shooting rates vary tremendously within cities in the USA. Factors related to structural racism (both historical and contemporary) could help explain differences in non-fatal shooting rates at the neighbourhood level. Most research assessing the relationship between structural racism and firearm violence only includes one dimension of structural racism. Our study uses an intersectional approach to examine how the interaction of two forms of structural racism is associated with spatial non-fatal shooting disparities in Baltimore, Maryland. Methods We present three additive interaction measures to describe the relationship between historical redlining and contemporary racialized economic segregation on neighbourhood-level non-fatal shootings. Results Our findings revealed that sustained disadvantage census tracts (tracts that experience contemporary socioeconomic disadvantage and were historically redlined) have the highest burden of non-fatal shootings. Sustained disadvantage tracts had on average 24 more non-fatal shootings a year per 10 000 residents compared with similarly populated sustained advantage tracts (tracts that experience contemporary socioeconomic advantage and were not historically redlined). Moreover, we found that between 2015 and 2019, the interaction between redlining and racialized economic segregation explained over one-third of non-fatal shootings (approximately 650 shootings) in sustained disadvantage tracts. Conclusion These findings suggest that the intersection of historical and contemporary structural racism is a fundamental cause of firearm violence inequities in Baltimore. Intersectionality can advance injury prevention research and practice by (1) serving as an analytical tool to expose inequities in injury-related outcomes and (2) informing the development and implementation of injury prevention interventions and policies that prioritise health equity and racial justice.

Causal mediation analysis: From simple to more robust strategies for estimation of marginal natural (in)direct effects

This paper aims to provide practitioners of causal mediation analysis with a better understanding of estimation options. We take as inputs two familiar strategies (weighting and model-based prediction) and a simple way of combining them (weighted models), and show how a range of estimators can be generated, with different modeling requirements and robustness properties. The primary goal is to help build intuitive appreciation for robust estimation that is conducive to sound practice. We do this by visualizing the target estimand and the estimation strategies. A second goal is to provide a "menu" of estimators that practitioners can choose from for the estimation of marginal natural (in)direct effects. The estimators generated from this exercise include some that coincide or are similar to existing estimators and others that have not previously appeared in the literature. We note several different ways to estimate the weights for cross-world weighting based on three expressions of the weighting function, including one that is novel; and show how to check the resulting covariate and mediator balance. We use a random continuous weights bootstrap to obtain confidence intervals, and also derive general asymptotic variance formulas for the estimators. The estimators are illustrated using data from an adolescent alcohol use prevention study. R-code is provided.

Population-level contribution of interpersonal discrimination to psychological distress among Australian Aboriginal and Torres Strait Islander adults, and to Indigenous-non-Indigenous inequities: cross-sectional analysis of a community-controlled First Nations cohort study

BACKGROUND

International and population-specific evidence identifies elevated psychological distress prevalence among those experiencing interpersonal discrimination. We aim to quantify the potential whole-of-population contribution of interpersonal discrimination to psychological distress prevalence and Indigenous-non-Indigenous gaps in Australia.

METHODS

We did a cross-sectional analysis of data from Mayi Kuwayu: the National Study of Aboriginal and Torres Strait Islander Wellbeing. Baseline surveys were completed between June 8, 2018, and Sept 28, 2022. We analysed responses from participants who were aged 18 years or older at survey completion, whose surveys were processed between Oct 1, 2018, and May 1, 2021. Sample weights were developed on the basis of national population benchmarks. We measured everyday discrimination using an eight-item measure modified from the Everyday Discrimination Scale and classified experiences as racial discrimination if participants attributed these experiences to their Indigeneity. Psychological distress was measured using a validated, modified Kessler-5 scale. Applying logistic regression, we calculated unadjusted odds ratios (ORs), to approximate incident rate ratios (IRRs), for high or very high psychological distress in relation to everyday discrimination and everyday racial discrimination across age-gender strata. Population attributable fractions (PAFs), under the hypothetical assumption that ORs represent causal relationships, were calculated using these ORs and population-level exposure prevalence. These PAFs were used to quantify the contribution of everyday racial discrimination to psychological distress gaps between Indigenous and non-Indigenous adults.

FINDINGS

9963 survey responses were eligible for inclusion in our study, of which we analysed 9951 (99·9%); 12 were excluded due to responders identifying as a gender other than man or woman (there were too few responses from this demographic to be included as a category in stratified tables or adjusted analyses). The overall prevalence of psychological distress was 48·3% (95% CI 47·0-49·6) in those experiencing everyday discrimination compared with 25·2% (23·8-26·6) in those experiencing no everyday discrimination (OR 2·77 [95% CI 2·52-3·04]) and psychological distress prevalence was 49·0% (95% CI 47·3-50·6) in those experiencing everyday racial discrimination and 31·8% (30·6-33·1) in those experiencing no everyday racial discrimination (OR 2·06 [95% CI 1·88-2·25]. Overall, 49·3% of the total psychological distress burden among Aboriginal and Torres Strait Islander adults could be attributable to everyday discrimination (39·4-58·8% across strata) and 27·1% to everyday racial discrimination. Everyday racial discrimination could explain 47·4% of the overall gap in psychological distress between Indigenous and non-Indigenous people (40·0-60·3% across strata).

INTERPRETATION

Our findings show that interpersonal discrimination might contribute substantially to psychological distress among Aboriginal and Torres Strait Islander adults, and to inequities compared with non-Indigenous adults. Estimated PAFs include contributions from social and health disadvantage, reflecting contributions from structural racism. Although not providing strictly conclusive evidence of causality, this evidence is sufficient to indicate the psychological harm of interpersonal discrimination. Findings add weight to imperatives to combat discrimination and structural racism at its core. Urgent individual and policy action is required of non-Indigenous people and colonial structures, directed by Aboriginal and Torres Strait Islander peoples.

FUNDING

National Health and Medical Research Council of Australia, Ian Potter Foundation, Australian Research Council, US National Institutes of Health, and Sierra Foundation.

Recommendations for Using Causal Diagrams to Study Racial Health Disparities

There have been calls for race to be denounced as a biological variable and for a greater focus on racism, instead of solely race, when studying racial health disparities in the United States. These calls are grounded in extensive scholarship and the rationale that race is not a biological variable, but instead socially constructed, and that structural/institutional racism is a root cause of race-related health disparities. However, there remains a lack of clear guidance for how best to incorporate these assertions about race and racism into tools, such as causal diagrams, that are commonly used by epidemiologists to study population health. We provide clear recommendations for using causal diagrams to study racial health disparities that were informed by these calls. These recommendations consider a health disparity to be a difference in a health outcome that is related to social, environmental, or economic disadvantage. We present simplified causal diagrams to illustrate how to implement our recommendations. These diagrams can be modified based on the health outcome and hypotheses, or for other group-based differences in health also rooted in disadvantage (e.g., gender). Implementing our recommendations may lead to the publication of more rigorous and informative studies of racial health disparities.

An investigation of quantitative methods for assessing intersectionality in health research: A systematic review

Intersectionality is a theoretical framework that investigates how interlocking systems of power and oppression at the societal level influence the lived experiences of historically and socially marginalized groups. Currently, there are no consistent or widely adopted quantitative methods to investigate research questions informed by intersectionality theory. The objective of this systematic review is to describe the current landscape of quantitative methods used to assess intersectionality and to provide recommendations on analytic best practices for future research. We searched PubMed, EMBASE, and the Web of Science in December 2019 to identify studies using analytic quantitative intersectionality approaches published up to December 2019 (PROSPERO CRD42020162686). To be included in the study, articles had to: (1) be empirical research, (2) use a quantitative statistical method, (3) be published in English, and (4) incorporate intersectionality. Our initial search yielded 1889 articles. After screening by title/abstract, methods, and full text review, our final analytic sample included 153 papers. Eight unique classes of quantitative methods were identified, with the majority of studies employing regression with an interaction term. We additionally identified several methods which appear to be at odds with the key tenets of intersectionality. As quantitative intersectionality continues to expand, careful attention is needed to avoid the dilution of the core tenets. Specifically, emphasis on social power is needed as methods continue to be adopted and developed. Additionally, clear explanation of the selection of statistical approaches is needed and, when using regression with interaction terms, researchers should opt for use of the additive scale. Finally, use of methods that are potentially at odds with the tenets of intersectionality should be avoided.

Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis

BACKGROUND

Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used.

OBJECTIVE

We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality.

METHODS

We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010).

RESULTS

A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time.

CONCLUSIONS

Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. Systematic review registration: CRD42020173544.

Inequities in Children's Reading Skills: The Role of Home Reading and Preschool Attendance

OBJECTIVE

Children from socioeconomically disadvantaged backgrounds have poorer learning outcomes. These inequities are a significant public health issue, tracking forward to adverse health outcomes in adulthood. We examined the potential to reduce socioeconomic gaps in children's reading skills through increasing home reading and preschool attendance among disadvantaged children.

METHODS

We drew on data from the nationally representative birth cohort of the Longitudinal Study of Australian Children (N = 5107) to examine the impact of socioeconomic disadvantage (0-1 year) on children's reading skills (8-9 years). An interventional effects approach was applied to estimate the extent to which improving the levels of home reading (2-5 years) and preschool attendance (4-5 years) of socioeconomically disadvantaged children to be commensurate with their advantaged peers, could potentially reduce socioeconomic gaps in children's reading skills.

RESULTS

Socioeconomically disadvantaged children had a higher risk of poor reading outcomes compared to more advantaged peers: absolute risk difference = 20.1% (95% confidence interval [CI]: 16.0%-24.2%). Results suggest that improving disadvantaged children's home reading and preschool attendance to the level of their advantaged peers could eliminate 6.5% and 2.1% of socioeconomic gaps in reading skills, respectively. However, large socioeconomic gaps would remain, with disadvantaged children maintaining an 18.3% (95% CI: 14.0%-22.7%) higher risk of poor reading outcomes in absolute terms.

CONCLUSION

There are clear socioeconomic disparities in children's reading skills by late childhood. Findings suggest that interventions that improve home reading and preschool attendance may contribute to reducing these inequities, but alone are unlikely to be sufficient to close the equity gap.

Clarifying causal mediation analysis for the applied researcher: Defining effects based on what we want to learn

The incorporation of causal inference in mediation analysis has led to theoretical and methodological advancements-effect definitions with causal interpretation, clarification of assumptions required for effect identification, and an expanding array of options for effect estimation. However, the literature on these results is fast-growing and complex, which may be confusing to researchers unfamiliar with causal inference or unfamiliar with mediation. The goal of this article is to help ease the understanding and adoption of causal mediation analysis. It starts by highlighting a key difference between the causal inference and traditional approaches to mediation analysis and making a case for the need for explicit causal thinking and the causal inference approach in mediation analysis. It then explains in as-plain-as-possible language existing effect types, paying special attention to motivating these effects with different types of research questions, and using concrete examples for illustration. This presentation differentiates 2 perspectives (or purposes of analysis): the explanatory perspective (aiming to explain the total effect) and the interventional perspective (asking questions about hypothetical interventions on the exposure and mediator, or hypothetically modified exposures). For the latter perspective, the article proposes tapping into a general class of interventional effects that contains as special cases most of the usual effect types-interventional direct and indirect effects, controlled direct effects and also a generalized interventional direct effect type, as well as the total effect and overall effect. This general class allows flexible effect definitions which better match many research questions than the standard interventional direct and indirect effects. (PsycInfo Database Record (c) 2020 APA, all rights reserved).