Black Patients With Cirrhosis Have Higher Mortality and Lower Transplant Rates: Results From a Metropolitan Cohort Study

BACKGROUND AND AIMS

Estimates of racial disparity in cirrhosis have been limited by lack of large-scale, longitudinal data, which track patients from diagnosis to death and/or transplant.

APPROACH AND RESULTS

We analyzed a large, metropolitan, population-based electronic health record data set from seven large health systems linked to the state death registry and the national transplant database. Multivariate competing risk analyses, adjusted for sex, age, insurance status, Elixhauser score, etiology of cirrhosis, HCC, portal hypertensive complication, and Model for End-Stage Liver Disease-Sodium (MELD-Na), examined the relationship between race, transplant, and cause of death as defined by blinded death certificate review. During the study period, 11,277 patients met inclusion criteria, of whom 2,498 (22.2%) identified as Black. Compared to White patients, Black patients had similar age, sex, MELD-Na, and proportion of alcohol-associated liver disease, but higher comorbidity burden, lower rates of private insurance, and lower rates of portal hypertensive complications. Compared to White patients, Black patients had the highest rate all-cause mortality and non-liver-related death and were less likely to be listed or transplanted (P < 0.001 for all). In multivariate competing risk analysis, Black patients had a 26% increased hazard of liver-related death (subdistribution HR, 1.26; 95% CI, [1.15-1.38]; P < 0.001).

CONCLUSIONS

Black patients with cirrhosis have discordant outcomes. Further research is needed to determine how to address these real disparities in the field of hepatology.

Racial Disparities in the Surgical Management of Benign Craniomaxillofacial Bone Lesions

PURPOSE

Racial disparities can influence surgical care in the United States. The purpose of this study was to determine if race and ethnicity were independent risk factors for adverse 30-day outcomes after surgical management of benign craniomaxillofacial bone tumors.

METHODS

This was a retrospective cohort study from 2012 to 2018 National Surgical Quality Improvement Program databases. Patients undergoing surgical removal of craniomaxillofacial benign lesions based on Current Procedural Terminology and International Classification of Diseases codes were included. Patients who had unrelated concurrent surgeries, or malignant, skull-based or soft tissue lesions were excluded. Primary outcomes were surgical complications and hospital length of stay (LOS). Univariate analyses were used with race as the independent variable to identify predictors of primary outcomes. Statistically significant factors were added to a multivariable logistic regression model.

RESULTS

This study included 372 patients. Postoperative complications were highest among Black patients, who had a 4-fold increase in minor complications (P = 0.023) and over a 6-fold increase in major complications (P = 0.008) compared to White patients. Black patients also had a mean increase of 2.3 days in LOS compared to White patients (P < 0.001). The multivariate regression model showed higher rates of major complications and longer LOS for Black patients (P = 0.003, P = 0.006, respectively).

CONCLUSIONS

Even when controlling for other variables, Black race was an independent risk factor for major complications and increased LOS. Further research should seek to identify the root cause of these findings in order to ensure safe and equitable surgery for all patients, regardless of race or ethnicity.

Associations of Baseline Frailty Status and Age With Outcomes in Patients Undergoing Vestibular Schwannoma Resection

Importance

Although numerous studies have evaluated the influence of advanced age on surgical outcomes following vestibular schwannoma (VS) resection, few if any large-scale investigations have assessed the comparative prognostic effects of age and frailty. As the population continues to age, it is imperative to further evaluate treatment and management strategies for older patients.

Objective

To conduct a population-based evaluation of the independent associations of chronological age and frailty (physiological age) with outcomes following VS resection.

Design, Setting, and Participants

In this large-scale, multicenter, cross-sectional analysis, weighted discharge data from the National Inpatient Sample were searched to identify adult patients (≥18 years old) who underwent VS resection from 2002 through 2017 using International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision, Clinical Modification codes. Data collection and analysis took place September to December 2020.

Main Outcomes and Measures

Complex samples regression models and receiver operating characteristic curve analysis were used to evaluate the independent associations of frailty and age (along with demographic confounders) with complications and discharge disposition. Frailty was evaluated using the previously validated 11-point modified frailty index (mFI).

Results

Among the 27 313 patients identified for VS resection, the mean (SEM) age was 50.4 (0.2) years, 15 031 (55.0%) were women, and 4720 (21.0%) were of non-White race/ethnicity, as determined by the National Inpatient Sample data source. Of the included patients, 15 090 (55.2%) were considered robust (mFI score = 0), 8204 (30.0%) were prefrail (mFI score = 1), 3022 (11.1%) were frail (mFI score = 2), and 996 (3.6%) were severely frail (mFI score ≥3). On univariable analysis, increasing frailty was associated with development of postoperative hemorrhagic or ischemic stroke (odds ratio [OR], 2.44 [95% CI, 2.07-2.87]; area under the curve, 0.73), while increasing age was not. Following multivariable analysis, increasing frailty and non-White race/ethnicity were independently associated with both mortality (adjusted OR [aOR], 2.32 [95% CI, 1.70-3.17], and aOR, 3.05 [95% CI, 1.02-9.12], respectively) and extended hospital stays (aOR, 1.54 [95% CI, 1.41-1.67], and aOR, 1.71 [95% CI, 1.42-2.05], respectively), while increasing age was not. Increasing frailty (aOR, 0.61 [95% CI, 0.56-0.67]), age (aOR, 0.98 [95% CI, 0.97-0.99]), and non-White race/ethnicity (aOR, 0.62 [95% CI 0.51-0.75]) were all independently associated with routine discharge.

Conclusions and Relevance

In this cross-sectional study, findings suggest that frailty may be more accurate for predicting outcomes and guiding treatment decisions than advanced patient age alone following VS resection.

Prevalence of Cardiovascular Disease Risk Factors by Key Demographic Variables Among Mid-South Church Leaders from 2012 to 2017

Cardiovascular disease (CVD) risk factors were examined among church leaders (n = 2309) who attended Mid-South United Methodist Church annual meetings between 2012 and 2017 using repeated cross-sectional data. There was a significant increase in body mass index (BMI) (b = 0.24, p = 0.001) and significant decreases in blood pressure (systolic: b = - 1.08, p < 0.001; diastolic: b = - 0.41, p = 0.002), total cholesterol (b = - 1.76, p = 0.001), and blood sugar (b = - 1.78, p = 0.001) over time. Compared to Whites, a significant increase was seen in BMI (b = 1.14, p = 0.008) among participants who self-identified as "Other," and a significant increase was seen in blood pressure (systolic: b = 1.36, p = 0.010; diastolic: b = 1.01, p = 0.004) among African Americans over time. Results indicate BMI and blood pressure are important CVD risk factors to monitor and address among church leaders, especially among race/ethnic minority church leaders.

Racial-ethnic disparities in self-reported health status among US adults adjusted for sociodemographics and multimorbidities, National Health and Nutrition Examination Survey 2011-2014

Objective: To investigate racial-ethnic disparities in self-reported health status adjusting for sociodemographic factors and multimorbidities.Design: A total of 9499 adult participants aged 20 years and older from the United States (US); reported by the National Health and Nutrition Examination Survey (NHANES), a cross-sectional survey - for years 2011-2014. The main outcome measure was self-reported health status categorized as excellent/very good, good (moderate), and fair/poor.Results: Of the NHANES participants, 40.7% reported excellent/very good health, 37.2% moderate health and 22.1% fair/poor health. There were 42.8% who were non-Hispanic whites, 20.2% were Hispanic, 23.8% were non-Hispanic blacks, and 13.2% were non-Hispanic Asians. Compared to non-Hispanic whites, Hispanics [Odds Ratio (OR) = 2.91, 95% Confidence Interval (CI) = 2.28-3.71] and non-Hispanic blacks [OR = 1.51, 95% CI = 1.26-1.83] were more likely to report fair/poor health, whereas, non-Hispanic Asians [OR = 1.42, 95% CI = 1.14-1.76] were more likely to report moderate health than excellent/very good health. Compared to those with no chronic conditions, participants with two or three chronic conditions [OR = 9.35, 95% CI = 7.26-12.00] and with four or more chronic conditions [OR = 38.10, 95% CI = 26.50-54.90] were more likely to report fair/poor health than excellent/very good health status.Conclusion: The racial-ethnic differences in self-reported health persisted even after adjusting for sociodemographics and number of multimorbidities. The findings highlight the potential importance of self-reported health status and the need to increase health awareness through health assessment and health-promotional programs among the vulnerable minority US adults.

Using Electronic Referrals to Address Health Disparities and Improve Blood Pressure Control

Introduction

Massachusetts developed and used bidirectional electronic referrals to connect clinical patients across the state to interventions run by community organizations. The objective of our study was to determine whether the use of Massachusetts’s electronic referral system (MA e-Referral) reached racial/ethnic groups experiencing health disparities and whether it was associated with improved health outcomes.

Methods

We assembled encounter-level medical records from September 2013 through June 2017 for patients at Massachusetts clinics funded by the Clinical Community Partnerships for Prevention into 2 cohorts. First, all patients meeting program eligibility guidelines for an e-Referral (N = 21,701) were examined to assess the distribution of e-Referrals among populations facing health disparities; second, a subset of 3,817 people with hypertension were analyzed to detect changes in blood pressure after e-Referral to an evidence-based community intervention.

Results

Non-Hispanic black (OR, 1.4; 95% confidence interval [CI], 1.2–1.6) and Hispanic patients (OR, 1.3; 95% CI, 1.1–1.4) had higher odds than non-Hispanic white patients of being referred electronically. Patients completing their hypertension intervention had 74% (95% CI, 1.2–2.5) higher odds of having an in-control blood pressure reading than patients who were not electronically referred.

Conclusion

Clinical to community linkage to interventions through MA e-Referral reached non-Hispanic black, Hispanic, and Spanish-speaking populations and was associated with improved blood pressure control.

Disparities in Gynecological Malignancies

Objectives

Health disparities and inequalities in access to care among different socioeconomic, ethnic, and racial groups have been well documented in the U.S. healthcare system. In this review, we aimed to provide an overview of barriers to care contributing to health disparities in gynecological oncology management and to describe site-specific disparities in gynecologic care for endometrial, ovarian, and cervical cancer.

Methods

We performed a literature review of peer-reviewed academic and governmental publications focusing on disparities in gynecological care in the United States by searching PubMed and Google Scholar electronic databases.

Results

There are multiple important underlying issues that may contribute to the disparities in gynecological oncology management in the United States, namely geographic access and hospital-based discrepancies, research-based discrepancies, influence of socioeconomic and health insurance status, and finally the influence of race and biological factors. Despite the reduction in overall cancer-related deaths since the 1990s, the 5-year survival for Black women is significantly lower than for White women for each gynecologic cancer type and each stage of diagnosis. For ovarian and endometrial cancer, black patients are less likely to receive treatment consistent with evidence-based guidelines and have worse survival outcomes even after accounting for stage and comorbidities. For cervical and endometrial cancer, the mortality rate for black women remains twice that of White women.

Conclusion

Health care disparities in the incidence and outcome of gynecologic cancers are complex and involve biologic factors as well as racial, socioeconomic, and geographic barriers that influence treatment and survival. These barriers must be addressed to provide optimal care to women in the U.S. with gynecologic cancer.

Differences between physician social networks for cardiac surgery serving communities with high versus low proportions of black residents

BACKGROUND

Compared with white patients, black patients are more likely to undergo cardiac surgery at low-quality hospitals, even when they live closer to high-quality ones. Opportunities for organizational interventions to alleviate this problem remain elusive.

OBJECTIVES

To explore physician isolation in communities with high proportions of black residents as a factor contributing to racial disparities in access to high-quality hospitals for cardiac surgery.

RESEARCH DESIGN

Using national Medicare data (2008-2011), we mapped physician social networks at hospitals where coronary artery bypass grafting procedures were performed, measuring their degree of connectedness. We then fitted a series of multivariate regression models to examine for associations between physician connectedness and the proportion of black residents in the hospital service area (HSA) served by each network.

MEASURES

Measures of physician connectedness (ie, repeat-tie fraction, clustering, and number of external ties).

RESULTS

After accounting for regional differences in healthcare capacity, the social networks of physicians practicing in areas with more black residents varied in many important respects from those of HSAs with fewer black residents. Physicians serving HSAs with many black residents had a smaller number of repeated interactions with each other than those in other HSAs (P<0.001). When these physicians did interact, they tended to assemble in smaller groups of highly interconnected colleagues (P<0.001). They also had fewer interactions with physicians outside their immediate geographic area (P=0.048).

CONCLUSIONS

Physicians in HSAs with many black residents are more isolated than those in HSAs with fewer black residents. This isolation may negatively impact on care coordination and information sharing. As such, planned delivery system reforms that encourage minorities to seek care within their established local networks may further exacerbate existing surgical disparities.