Neighborhood Socioeconomic Status Predicts Health After Hospitalization for Acute Coronary Syndromes: Findings From TRACE-CORE (Transitions, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education)

Association of neighborhood deprivation and hypertension: A systematic review and meta-analysis

BACKGROUND

Hypertension impacts nearly one billion individuals and is a primary health challenge. While traditional perspectives have focused on individual behavior and genetics as principal risk factors, recent research underscores the profound influence of socioeconomic factors within neighborhoods on the risk of hypertension. This systematic review and meta-analysis is aimed to elucidate the association between neighborhood deprivation and the risk of hypertension.

METHODS

A comprehensive literature search was conducted across PubMed, Embase, and Web of Science from inception until December 25, 2023. Observational studies defining neighborhood deprivation and reporting hypertension incidence were included. Nested Knowledge software was used for screening and data extraction, with study quality assessed using the Newcastle-Ottawa Scale. Statistical analysis was performed with R software (V 4.3), using a random-effects model to calculate the pooled relative risk (RR).

RESULTS

Twenty-six studies were included in the qualitative analysis and 22 in the meta-analysis, covering over 62 million participants. The pooled RR was 1.139 (95% CI: 1.006 - 1.290), p=0.04, indicating a higher hypertension risk in deprived neighborhoods. Subgroup analyses showed variability by country and deprivation assessment methods. RR varied from 1.00 in Japan (95% CI: 0.93-1.08) to 1.60 (95% CI: 1.07-2.39) in France and 1.57 (95% CI: 0.67-3.70) in Germany, with significant heterogeneity observed in measures of neighborhood deprivation.

CONCLUSION

Our analysis confirms a significant association between neighborhood deprivation and hypertension, underscoring the importance of socioeconomic factors in public health. It highlights the need for targeted local assessments and interventions. Future research should explore the causal mechanisms and effectiveness of interventions addressing neighborhood deprivation.

Environmental factors affecting the risk of generalization for ocular-onset myasthenia gravis: a nationwide cohort study

BACKGROUND

The environmental effects on the prognosis of ocular myasthenia gravis (OMG) remain largely unexplored.

AIM

To investigate the association between specific environmental factors and the generalization of OMG.

DESIGN

The cohort study was conducted in China based on a nationwide multicenter database.

METHODS

Adult patients with OMG at onset, who were followed up for at least 2 years until May 2022, were included. We collected data on demographic and clinical factors, as well as environmental factors, including latitude, socioeconomic status (per capita disposable income [PDI] at provincial level and education) and smoking. The study outcome was the time to the development of generalized myasthenia gravis (GMG). Cox models were employed to examine the association between environmental exposures and generalization. Restricted cubic spline was used to model the association of latitude with generalization risk.

RESULTS

A total of 1396 participants were included. During a median follow-up of 5.15 (interquartile range [IQR] 3.37-9.03) years, 735 patients developed GMG within a median of 5.69 (IQR 1.10-15.66) years. Latitude of 20-50°N showed a U-shaped relation with generalization risk, with the lowest risk at around 30°N; both higher and lower latitudes were associated with the increased risk (P for non-linearity <0.001). Living in areas with lower PDI had 1.28-2.11 times higher risk of generalization. No significant association was observed with education or smoking.

CONCLUSIONS

Latitude and provincial-level PDI were associated with the generalization of OMG in China. Further studies are warranted to validate our findings and investigate their potential applications in clinical practice and health policy.

Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices

BACKGROUND

Low socioeconomic status (SES) is an important prognosticator amongst patients with acute coronary syndrome (ACS). This paper analysed the effects of SES on ACS outcomes.

METHODS

Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by SES using a multidimensional index, comprising at least 2 of the following components: Income, Education and Employment. A comparative meta-analysis was conducted using random-effects models to estimate the risk ratio of all-cause mortality in low SES vs high SES populations, stratified according to geographical region, study year, follow-up duration and SES index.

RESULTS

A total of 29 studies comprising of 301,340 individuals were included, of whom 43.7% were classified as low SES. While patients of both SES groups had similar cardiovascular risk profiles, ACS patients of low SES had significantly higher risk of all-cause mortality (adjusted HR:1.19, 95%CI: 1.10-1.1.29, p < 0.001) compared to patients of high SES, with higher 1-year mortality (RR:1.08, 95%CI:1.03-1.13, p = 0.0057) but not 30-day mortality (RR:1.07, 95%CI:0.98-1.16, p = 0.1003). Despite having similar rates of ST-elevation myocardial infarction and non-ST-elevation ACS, individuals with low SES had lower rates of coronary revascularisation (RR:0.95, 95%CI:0.91-0.99, p = 0.0115) and had higher cerebrovascular accident risk (RR:1.25, 95%CI:1.01-1.55, p = 0.0469). Excess mortality risk was independent of region (p = 0.2636), study year (p = 0.7271) and duration of follow-up (p = 0.0604) but was dependent on the SES index used (p < 0.0001).

CONCLUSION

Low SES is associated with increased mortality post-ACS, with suboptimal coronary revascularisation rates compared to those of high SES. Concerted efforts are needed to address the global ACS-related socioeconomic inequity.

REGISTRATION AND PROTOCOL

The current study was registered with PROSPERO, ID: CRD42022334482.

Social and environmental determinants of health among children with long-term movement impairment

The healthcare research community increasingly recognizes the need to address social (SDOH) and environmental determinants of health (EDOH) to optimize health and healthcare. This is particularly relevant to disability and functioning and to those with child onset conditions that impair mobility and impact functioning and participation. Using the World Health Organization (WHO)'s International Classification of Functioning, Disability, and Health (ICF) as a comprehensive framework, this paper aims to discuss our understanding of the relationships between social and EDOH and outcomes among people with impaired mobility that impacts functioning. This paper offers suggestions for future developments and guidance to use SDOH and EDOH in research and clinical practice.

Incorporating community-level risk factors into traumatic stress research: Adopting a public health lens

Infusing community-level risk factors into traumatic stress research can broaden intervention targets. The Neighborhood Deprivation Index (NDI) and the Index of Concentration at the Extremes (ICE) are two common community-level risk factors derived from U.S. census data. We provide R scripts facilitating the computation of these risk factors and demonstrate their relationship with PTSD symptomatology in 74 injury survivors assessed at 2-weeks, 6-weeks, and 3-months post-injury. The NDI and the ICE were computed using the Census Data Application Programming Interface, then matched to participants' census tracts using their residential addresses. Results indicated that after controlling for person-level characteristics, both risk factors were associated with PTSD symptom severity at follow up time points (Cohen's f² =0.011,.14). This study provides an easy method for computing the NDI and ICE, demonstrates the increased mental health risk that they convey in the aftermath of injury, and highlights their value in intervention efforts.

Relationship of Neighborhood Deprivation and Outcomes of a Comprehensive ST Elevation Myocardial Infarction Protocol

Background

We evaluated whether a comprehensive ST‐segment–elevation myocardial infarction protocol (CSP) focusing on guideline‐directed medical therapy, transradial percutaneous coronary intervention, and rapid door‐to‐balloon time improves process and outcome metrics in patients with moderate or high socioeconomic deprivation.

Methods and Results

A total of 1761 patients with ST‐segment–elevation myocardial infarction treated with percutaneous coronary intervention at a single hospital before (January 1, 2011–July 14, 2014) and after (July 15, 2014– July 15, 2019) CSP implementation were included in an observational cohort study. Neighborhood deprivation was assessed by the Area Deprivation Index and was categorized as low (≤50th percentile; 29.0%), moderate (51st –90th percentile; 40.8%), and high (>90th percentile; 30.2%). The primary process outcome was door‐to‐balloon time. Achievement of guideline‐recommend door‐to‐balloon time goals improved in all deprivation groups after CSP implementation (low, 67.8% before CSP versus 88.5% after CSP; moderate, 50.7% before CSP versus 77.6% after CSP; high, 65.5% before CSP versus 85.6% after CSP; all P<0.001). Median door‐to‐balloon time among emergency department/in‐hospital patients was significantly noninferior in higher versus lower deprivation groups after CSP (noninferiority limit=5 minutes; P_{noninferiority} high versus moderate = 0.002, high versus low <0.001, moderate versus low = 0.02). In‐hospital mortality, the primary clinical outcome, was significantly lower after CSP in patients with moderate/high deprivation in unadjusted (before CSP 7.0% versus after CSP 3.1%; odds ratio [OR], 0.42 [95% CI, 0.25–0.72]; P=0.002) and risk‐adjusted (OR, 0.42 [95% CI, 0.23–0.77]; P=0.005) models.

Conclusions

A CSP was associated with improved ST‐segment–elevation myocardial infarction care across all deprivation groups and reduced mortality in those from moderate or high deprivation neighborhoods. Standardized initiatives to reduce care variability may mitigate social determinants of health in time‐sensitive conditions such as ST‐segment–elevation myocardial infarction.

Determining the feasibility of an index of the social determinants of health using data from public sources

Examining the feasibility of developing an index measure for the social determinants of health using public data is needed. We examined these characteristics at the ZIP code in California and New York using public data extracted from the US Census, American Community Survey, the USDA Food Research Access Atlas, and the Dartmouth Atlas. We conducted a retrospective study from 2000 to 2017. The main outcome was a novel index measure representing six domains (economic stability, neighborhood and physical environment, education, community and social context, food access, and health care) and encompassing 13 items. The index measure at the ZIP code was created using principal component analysis, normalized to "0" worse and "1" better in California (ZIP codes n = 1,447 to 1,515) and New York (ZIP codes n = 1,211 to 1,298). We assessed the reliability and conducted a nonparametric comparison to the Robert Wood Johnson Foundation County Health Rankings, Area Deprivation Index, Social Deprivation Index, and GINI Index. These measures shared similarities and differences with the novel measure. Mapping of this novel measure showed regional variation. As a result, developing a universal social determinants of health measure is feasible and more research is needed to link it to health outcomes.

Socioeconomic status and disability progression in multiple sclerosis: A multinational study

OBJECTIVE

To examine the association between socioeconomic status (SES) and disability outcomes and progression in multiple sclerosis (MS).

METHODS

Health administrative and MS clinical data were linked for 2 cohorts of patients with MS in British Columbia (Canada) and South East Wales (UK). SES was measured at MS symptom onset (±3 years) based on neighborhood-level average income. The association between SES at MS onset and sustained and confirmed Expanded Disability Status Scale (EDSS) 6.0 and 4.0 and onset of secondary progression of MS (SPMS) were assessed using Cox proportional hazards models. EDSS scores were also examined via linear regression, using generalized estimating equations (GEE) with an exchangeable working correlation. Models were adjusted for onset age, sex, initial disease course, and disease-modifying drug exposure. Random effect models (meta-analysis) were used to combine results from the 2 cohorts.

RESULTS

A total of 3,113 patients with MS were included (2,069 from Canada; 1,044 from Wales). A higher SES was associated with a lower hazard of reaching EDSS 6.0 (adjusted hazard ratio [aHR] 0.90, 95% confidence interval [CI] 0.89-0.91), EDSS 4.0 (aHR 0.93, 0.88-0.98), and SPMS (aHR 0.94, 0.88-0.99). The direction of findings was similar when all EDSS scores were included (GEE: β = -0.13, -0.18 to -0.08).

CONCLUSIONS

Lower neighborhood-level SES was associated with a higher risk of disability progression. Reasons for this association are likely to be complex but could include factors amenable to modification, such as lifestyle or comorbidity. Our findings are relevant for planning and development of MS services.