Associations among race, residential segregation, community income, and emergency department use by adults with end-stage renal disease

Factors contributing to nurses' intent to leave during COVID-19

To examine the association between demographic characteristics (i.e., gender, race, age, and years of experience), burnout, and nurses' intent to leave their jobs during the first wave of COVID-19 in New Jersey. COVID-19 has exacerbated burnout and intent to leave among acute care nurses. Nonetheless, little is known about demographic factors contributing to nurses' desire to leave their jobs. A cross-sectional survey of actively licensed registered nurses who provided direct patient care in an acute care hospital in New Jersey during COVID-19. Among 2760 nurses, those who reported burnout were 4.78 times more likely to report intent to leave their job within 1 year as compared to nurses who did not report burnout. Black RNs were 2.06 times more likely to report intent to leave as compared to White RNs. Older nurses (aged 40-49) were 36% less likely to report intent to leave as compared to younger nurses (aged 21-29). RNs with 30 years of experience or more were 58% less likely to report intent to leave as compared to RNs with less than 5 years of experience. In addition, Black RNs with 6-12 years of experience were 2.07 times more likely to report intent to leave as compared to White RNs with less than 5 years of experience. Nurses' intent to leave during the first wave of the pandemic was influenced by burnout, race, age, and years of experience. Based on the results of the current study, Black nurses were more likely to report intent to leave their job within 1 year as compared to White RNs. Nurses' intention to leave is one of the most important global issues facing the healthcare system. Findings of the current study demonstrate that burnout, race, age, and years of experience are significant predictors of nurses' intent to leave their jobs. Therefore, organizations should prioritize strategies to reduce burnout and create diverse and inclusive work environments.

Structural Racism, Historical Redlining, and Incidence of Kidney Failure in US Cities, 2012-2019

SIGNIFICANCE STATEMENT

Residing in neighborhoods designated as grade D (hazardous) by the Home Owners' Loan Corporation (HOLC) under historical redlining-a discriminatory housing policy beginning in the 1930s-has been associated with present-day adverse health outcomes such as diabetes mortality. Historical redlining might underlie conditions in present-day neighborhoods that contribute to inequitable rates of kidney failure incidence, particularly for Black individuals, but its association with kidney disease is unknown. The authors found that among adults with incident kidney failure living in 141 metropolitan areas, residence in a historically redlined neighborhood rated grade D was associated with significantly higher kidney failure incidence rates compared with residence in a redlined grade A (best) neighborhood. These findings suggest that historical racist policies continue to affect current-day racial inequities in kidney health.

BACKGROUND

Historical redlining was a 1930s federally sponsored housing policy that permitted the Home Owners' Loan Corporation (HOLC) to develop color-coded maps and grade neighborhoods' mortgage lending risk on the basis of characteristics that included racial makeup. This practice has been associated with present-day health disparities. Racial inequities in kidney disease-particularly for Black individuals-have been linked to residential segregation and other structural inequities.

METHODS

Using a registry of people with incident kidney failure and digitized HOLC maps, we examined the association between residence in a historically redlined US census tract (CT) with a historical HOLC grade of D or hazardous) and present-day annual CT-level incidence of kidney failure incidence among adults in 141 US metropolitan areas, in 2012 through 2019.

RESULTS

Age-adjusted and sex-adjusted kidney failure incidence rates were significantly higher in CTs with a historical HOLC grade D compared with CTs with a historical HOLC grade of A or best (mean, 740.7 per million versus 326.5 per million, respectively, a difference of 414.1 per million). Compared with national averages of all adults in our sample, rates of kidney failure incidence were higher for Black adults in our study sample, irrespective of CT HOLC grade. Age-adjusted and sex-adjusted incidence rates for Black persons in CTs with a HOLC grade D were significantly higher than for Black persons residing in HOLC grade A CTs (mean, 1227.1 per million versus 1030.5 per million, respectively [a difference of 196.6 per million]).

CONCLUSIONS

Historical redlining is associated with present-day disparities in kidney failure incidence, demonstrating the legacy of historical racist policies on contemporary racial inequities in kidney health.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_08_24_JASN0000000000000165.mp3.

Racial/Ethnic Residential Segregation, Neighborhood Health Care Provision, and Choice of Pediatric Health Care Provider Across the USA

Much research has been conducted that demonstrates a link between racial/ethnic residential segregation and health care outcomes. We suggest that minority segregated neighborhoods may have diminished access to organizations and that this differential access may contribute to differences in health care outcomes across communities. We analyze this specifically using the case of pediatric health care provider choice. To examine this association, we estimate a series of multinomial logistic regression models using restricted data with ZIP code level geoidentifiers from the 2011-2012 National Survey of Children's Health (NSCH). We find that racial/ethnic residential segregation is related to a greater reliance on non-ideal forms of health care, such as clinics, and hospital outpatient departments, instead of pediatric physician's offices. This association is at least partially attenuated by the distribution of health care facilities in the local area, physician's offices, and health care practitioners in particular. Additionally, families express greater dissatisfaction with these other forms of care compared to physician's offices, demonstrating that the lack of adequate health care provision is meaningful for health care outcomes. This study expands the literature by examining how the siting of health organizations has consequences for individuals residing within these areas.

Despite National Declines In Kidney Failure Incidence, Disparities Widened Between Low- And High-Poverty US Counties

National estimates suggest that kidney failure incidence is declining in the US. However, whether this trend is evident in areas with socioeconomic disadvantage is unknown. We examined trends in kidney failure incidence by county-level poverty between 2000 and 2017 and divided the study period into period 1 (2000-05), period 2 (2006-11), and period 3 (2012-17). The magnitude of disparity in kidney failure incidence between high- and low-poverty counties increased from 42.8 more incident cases per million in high-poverty counties in period 1 to 100.1 more in period 3. Despite a national decline, kidney failure incidence increased in high-poverty counties, and disparities between high- and low-poverty counties widened from 2000 to 2017. Achieving the Department of Health and Human Services objective of reducing incident kidney failure cases by 25 percent by 2030 will require focused attention on preventing kidney failure in counties with higher poverty.

Role of HEART score in evaluating clinical outcomes among emergency department patients with different ethnicities

Objective

We aimed to examine the role of the HEART (history, EKG, age, risk factors, and troponin) score in the evaluation of six clinical outcomes among three groups of patients in the emergency department (ED).

Methods

We performed a retrospective observational study among three ED patient groups including White, Black, and Hispanic patients. ED providers used the HEART score to assess the need for patient hospital admission and for emergent cardiac imaging tests (CITs). HEART scores were measured using classification accuracy rates. Performance accuracies were measured in terms of HEART score in relation to four clinical outcomes (positive findings of CITs, ED returns, hospital readmissions, and 30-day major adverse cardiac events [MACE]).

Results

A high classification accuracy rate (87%) was found for use of the HEART score to determine hospital admission. HEART scores showed moderate accuracy (area under the receiver operating characteristic curve 0.66–0.78) in predicting results of emergent CITs, 30-day hospital readmissions, and 30-day MACE outcomes.

Conclusions

Providers adhered to use of the HEART score to determine hospital admission. The HEART score may be associated with emergent CIT findings, 30-day hospital readmissions, and 30-day MACE outcomes, with no differences among White, Black, and Hispanic patient populations.

Racial/ethnic segregation and health disparities: Future directions and opportunities

Health researchers have investigated the association between racial segregation and racial health disparities with multilevel approaches. This study systematically reviews these multilevel studies and identifies broad trends and potential directions for future research on racial segregation and health disparities in the US. After searching databases including CINAHL and MEDLINE, we identified and systematically reviewed 66 articles published between 2003 and 2019 and found four major gaps in racial/ethnic segregation and health disparities: (a) the concept of segregation was rarely operationalized at the neighborhood level, (b) except for the evenness and exposure dimension, other dimensions of segregation are overlooked, (c) little attention was paid to the segregation between whites and non-black minorities, particularly Hispanics and Asians, and (d) mental health outcomes were largely absent. Future directions and opportunities include: First, other segregation dimensions should be explored. Second, the spatial scales for segregation measures should be clarified. Third, the theoretical frameworks for black and non-black minorities should be tested. Fourth, mental health, substance use, and the use of mental health care should be examined. Fifth, the long-term health effect of segregation has to be investigated, and finally, other competing explanations for why segregation matters at the neighborhood level should be answered.