How Socioeconomic Status Affects Patient Perceptions of Health Care: A Qualitative Study

Profiles and predictors of access to human and veterinary healthcare in multispecies households

This study extends a behavioral-ecological framework for healthcare access and utilization to explore patterns of healthcare and veterinary care access within pet-owning households in the United States. Using Latent Class Analysis, a person-centered analytic approach, we identified five subgroups of pet owners in a diverse national sample (n = 750), each characterized by unique patterns of perceived access and actual usage of both human and veterinary healthcare. The first subgroup, "Good access/unfair system" (27%) and the second subgroup, "Good access/fair system" (30%) reported high probabilities of good healthcare and veterinary care access and limited financial burden but differed in their perceptions of healthcare fairness. The third subgroup, "Good access/Medicare" (14%), primarily comprised of older adults with Medicare, reported good access to both human and veterinary care and limited financial burden, underscoring Medicare's role in stable healthcare access. The fourth subgroup, "Moderate access" (11%), characterized by financial barriers despite non-employer health insurance, showed a lower likelihood of recent dental and veterinary visits. The fifth subgroup, "Poor access" (18%), with the poorest healthcare access and highest probability of Medicaid or no insurance, highlighted significant inequalities in healthcare and veterinary care access. Sociodemographic and social environmental factors were associated with subgroup membership. For example, the groups with better access were likely to have low financial fragility (Good access/unfair system OR = 4.61, p < 0.001), and those with poorer access were unlikely (Poor access OR = 0.14). Additionally, the groups with better access were less likely to experience discrimination (Good access/fair system OR = 0.58, p < 0.001) and those with poorer access were more likely (Moderate and Poor access both ORs = 1.37, p < 0.001). These findings emphasize the need for policies addressing factors such as economic inequality and discrimination to improve healthcare and veterinary care access and utilization. Tailored interventions at individual and systemic levels are also suggested (i.e., the Colorado "Peticaid" proposal and the Seattle One Health Clinic) to mitigate disparities and enhance healthcare and veterinary care access for vulnerable populations.

Days at Home After Cancer Surgery: Impact of Area Deprivation and Association with Long-Term Outcomes

BACKGROUND

Poor infrastructure in deprived areas may hinder access to health care, and a lack of socioeconomic resources can prevent patients from remaining at home after discharge. This study sought to assess the association between the Area Deprivation Index (ADI) and days at home within 90 days (DAH-90) after a complex operative procedure.

METHODS

Patients who underwent an elective operation for a gastrointestinal cancer between 2016 and 2020 were identified from the Medicare Standard Analytic Files. County-level ADI was calculated using a weighted average of ADI percentiles for each census block within a county. The association between ADI and DAH-90 and the impact of DAH-90 on 1-year expenditures and 1-year mortality were evaluated.

RESULTS

Among 72,452 patients who underwent a surgical procedure, median patient age was 75 years (interquartile range [IQR] 71-81) and 54.3% of patients had a Charlson Comorbidity Index higher than 2. A +0.2 increase in ADI was associated with 12.6% lower odds of achieving high DAH-90 (adjusted odds ratio [aOR], 0.874; 95% confidence interval [CI], 0.845-0.903) compared with low DAH-90. Notably, high DAH-90 (mean difference, -55,614$; 95% CI, -56,540$ to -54,687$) and medium DAH-90 (mean difference, -39,538$; 95% CI, -40,194$ to -38,882$) were associated with markedly decreased 1-year total expenditures, as well as lower 1-year mortality compared with patients who spent fewer days at home after surgery.

CONCLUSIONS

Increasing area deprivation was associated with higher likelihood of spending fewer days at home after a complex cancer surgical procedure. Patients spending fewer days at home were far more likely to die within 1 year and experienced higher health care costs.

Shedding light on eating disorders in adolescents with type 1 diabetes: insights and implications

Eating disorders (EDs) are complex medical conditions that pose a considerable health burden for individuals with type 1 diabetes mellitus (T1DM). EDs in individuals with T1DM are linked to poor metabolic control, which heightens the risk of diabetes complications. Consequently, regular screening for EDs is essential. This study investigates the prevalence of EDs in adolescents with T1DM, investigating the associations with diabetes duration, pubertal stage, glycemic control, and diabetes-related complications. In this cross-sectional study, 350 adolescents (155 males, 195 females) with T1DM, aged 12-18, were recruited from Mansoura University Children's Hospital. Participants completed the Diabetes Eating Problem Survey-Revised (DEPS-R) questionnaire, with scores ≥ 20 prompting clinical interviews to confirm EDs. Clinical data, including HbA1c, BMI, and body composition, were analyzed. Socioeconomic status (SES) and family factors were assessed. The prevalence of EDs was 22.6%, including other specified feeding or eating disorders (OSFED) (68.4%), binge eating (11.4%), bulimia nervosa (7.6%), avoidant restrictive (7.6%), and anorexia nervosa (5.1%). Binary logistic regression analysis showed that the significant predictors of ED in the study cohort were diabetes duration (OR = 1.75 (1.66-1.84), p < 0.001), and HbA1c (OR = 5.94 (2.4-14.6), p < 0.001). Conclusions: Adolescents with EDs had higher (SES), more family conflicts, longer diabetes duration, and were more prone to diabetic nephropathy and poor glycemic control. Screening for EDs is recommended from pre-adolescence through early adulthood. What Is Known: • Adolescents with T1DM are more vulnerable to develop EDs compared to their peers without T1DM What Is New: • The DEPS-R and DSM-V were useful clinical tools for screening and for diagnosis of EDs respectively among adolescents with T1DM • We advise to screen for EDs in adolescents with T1DM who aged around 13.6 years, at Tanner stage 3, with duration of T1DM >5 years, and/or with HbA1c >7.5.

Exploring patient perspectives, socioeconomic status and beliefs on rehabilitation after arthroscopic rotator cuff repair: A qualitative study

Background

Arthroscopic rotator cuff repair (ARCR) surgery is often recommended to reduce pain, restore function, and improve quality of life in patients with rotator cuff tears. Several factors can influence how effectively patients manage their pain, follow rehabilitation guidelines, and perceive their overall recovery, including patient perspectives, socioeconomic status, and beliefs on rehabilitation. Understanding these characteristics is crucial to optimizing patient outcomes and modifying rehabilitation approaches to meet specific patient requirements.

Objective

To obtain an in-depth understanding of patient perspectives, socioeconomic status, and beliefs on rehabilitation after ARCR.

Methods

This qualitative study consisted of face-to-face semi-structured interviews with 13 participants who underwent ARCR. Interviews were recorded, transcribed, and analysed using a six-step approach as proposed by Braun and Clarke.

Results

The mean age of the included participants was 53 ± 8.07 years, with 76% being male with most of the participants belonging to lower middle and upper lower socioeconomic status. Three major themes emerged from the interview: 1) Role of healthcare provider, 2) Socio-environmental factors, and 3) Cognitive-behavioural response.

Conclusion

Our findings imply that rehabilitation strategies should incorporate a more comprehensive patient-centred approach that considers a wider range of factors influencing compliance with therapy and overall rehabilitation.

A Comparative Analysis of Stroke Presentation, Severity of Carotid Stenosis, and Need for Reoperation between African American and White Women Undergoing Carotid Endarterectomy

BACKGROUND

Racial and gender disparities in healthcare outcomes including surgery is a well-known phenomenon. Some of these disparities have been attributed to social determinants of health which affect access to quality care and preventative medicine. In this study, we analyze differences in outcomes by race and gender following carotid endarterectomy for carotid stenosis.

METHODS

Adult females undergoing carotid endarterectomy for an indication of carotid stenosis in the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2021 were stratified between White females (group I) and African American females (group II). Primary outcomes include 30-day mortality, stroke, and return to the operating room (OR). Secondary outcomes included length of stay, discharge destination, operative time, and being in hospital >30 days.

RESULTS

The study population included 8,773 patients, of which 8,165 (93.1%) in group I and 608 (6.9%) in group II. Of these, 5,334 (60.8%) were asymptomatic (6.62% African American females and 93.38% White females). Patients in group II were more likely to present with ipsilateral stroke (16.8% vs. 23.2%, P < 0.001), as well as severe ipsilateral stenosis (80-99%) (66.8% vs. 72.1%; P value <0.005) and contralateral stenosis (6.93% vs. 10.2%; P value <0.026) as compared to group I. Group II was also observed to less likely to be on aspirin (89.3% vs. 84.7%, P < 0.001) and less likely to undergo an elective procedure (84.5% vs. 80.6%, P < 0.001). For postoperative outcomes, patients in group II had higher risk of return to the OR (2.19% vs. 3.45%, P = 0.044), longer operative time (mean:110.8 min [SD ± 44.0] vs. 123.8 min [±43.2], P < 0.001), longer length of stay (2.6 days [±4.8] vs. 3.8 days [±6.5], P < 0.001), and were more likely to be discharged to a nonhome location (14.1% vs. 18.5, P = 0.003). There were no statistically significant differences in postoperative 30-day mortality (P = 0.290) and stroke (P = 0.210) between the 2 groups. Risk-adjusted model also showed a 42% increased risk for patients in group II for preoperative stroke compared to patients in group I.

CONCLUSION

African American females tend to present symptomatic with more severe forms of carotid disease with poorer outcomes. After adjusting for associated risk factors, they were still found to be at a higher risk for preoperative stroke. This study highlights disparities in healthcare, its effect on clinical outcomes and the importance of early access to quality preventative care along with healthcare education and access for minorities including early referrals for vascular care.

[Ageing in the host country]

OBJECTIVE

To explore the perceptions of elderly people from diverse cultures regarding the factors relevant to aging, identifying similarities and differences, and describing elements that facilitate or hinder this process, with a focus on the impact of care services.

METHOD

Qualitative study with 48 participants over 50 years old, residing in the Alt Empordà region, Catalonia. Seven focus groups were conducted, including one exploratory multicultural group and six stratified by origin: native, Western Europe, Eastern Europe, Latin America, North Africa, and West Africa.

RESULTS

All groups valued health and the desire to remain in their homes or communities for as long as possible. African groups emphasized the importance of free health services, while the Latin American group valued personalized end-of-life care. The native group pointed out deficiencies in home care and residential care services. Western European participants mentioned language barriers and challenges with digitalization as the only means of accessing information, and Eastern European participants highlighted the need for empowerment and social participation. Additionally, the importance of new family models, restrictions on non-Catholic funeral practices, and the need for community integration were mentioned.

CONCLUSION

While there are differences in perceptions of aging among the different groups, common factors were identified that either facilitate or hinder this process, regardless of whether there is a migration background.

Patient Experiences of a Postpartum Cardiovascular Disease Intervention Clinic for Pregnancy Complications

OBJECTIVES

Experiencing a maternal complication of pregnancy conveys a significantly higher risk of developing premature cardiovascular disease compared to having an uncomplicated pregnancy. Postpartum interventions that aim to improve lifestyle and modifiable risk factors for people in this cohort may reduce cardiovascular disease risk. This study will explore the experiences and barriers to attendance of patients referred to one such clinic located in South Australia.

METHODS

This qualitative study conducted six focus groups comprised of two-six patients who had attended at least one postpartum intervention clinic appointment (N = 19). Audio recordings were captured and transcribed and NVivo was used to perform a thematic analysis.

RESULTS

Participants found the clinic informative as it educated them on their greater risk of cardiovascular disease and how to reduce this risk. They reported wanting more frequent appointments and the ability to opt in for additional contact, including newsletters and social media groups. We also identified several barriers to attendance, including an unclear clinic referral and appointment booking process, and missing clinic correspondence including appointment letters and pathology forms.

CONCLUSIONS FOR PRACTICE

This study provides insight into the experiences of patients who attended a postpartum cardiovascular disease prevention clinic. The clinic model can be operated in different health care settings to become part of standardized care in the postpartum period for patients who have had a pregnancy complication. Refinement of the clinic model referral and booking processes could reduce potential barriers to patient attendance.

Comparison of the Effect of Teleconsultations, Hybrid Visits, and In-Person Visits on Glycemic and Metabolic Parameters Among Individuals With Type 2 Diabetes in India

AIM

We compared biochemical and clinical data of individuals with type 2 diabetes (T2D) who opted for only teleconsultation (ie, no in-person visit at all), hybrid visits (combining home blood tests and in-person consultation), and fully in-person visits (both tests and consultation in person) at a tertiary care diabetes center.

METHODS

In this observational cohort study, we retrieved demographic, anthropometric, and biochemical data of 8197 individuals with T2D who sought diabetes care between 2021 and 2023 (384 participants with only teleconsultations, 721 with hybrid visits, and 7092 with fully in-person visits) from the electronic medical records of a chain of tertiary diabetes care centers across India.

RESULTS

Individuals who opted for teleconsultation had a shorter duration of diabetes compared with those who opted for hybrid or fully in-person visits. Although participants who opted for a teleconsultation had better glycemic and lipid control at baseline, those who underwent hybrid and in-person visits showed greater improvements in fasting plasma glucose, glycated hemoglobin (A1c), and LDL cholesterol (LDL-C) during follow-up. Improvements in overall ABC target achievement (A1c, Blood pressure, and LDL-C) were greater in participants who had in-person visits compared with the other two groups.

CONCLUSION

While teleconsultation is a useful complement to in-person visits, the latter results in better glycemic and lipid control, perhaps due to more effective engagement with the diabetes care team.

Socioeconomic disparities in healthcare access and implications for all-cause mortality among US adults: a 2000-2019 record linkage study

The United States (US) has witnessed a notable increase in socioeconomic disparities in all-cause mortality since 2000. While this period is marked by significant macroeconomic and health policy changes, the specific drivers of these mortality trends remain poorly understood. In this study, we assessed healthcare access variables and their association with socioeconomic status (SES)-related differences (exposure) in US all-cause mortality (outcome) since 2000. Our research drew upon cross-sectional data from the National Health Interview Survey (NHIS, 2000-2018), linked to death records from the National Death Index (NDI, 2000-2019; n = 486 257). The findings reveal that the odds of a lack of health insurance and unaffordability of needed medical care were over 2-fold higher among individuals with lower education compared to those with high education, following differential time trends. Moreover, elevated mortality risk was associated with lower education (up to 77%), uninsurance (17%), unaffordability (43%), and delayed care (12%). Uninsurance and unaffordability accounted for 4%-6% of the disparities in time to mortality between low- and high-education groups. These findings were corroborated by income-based sensitivity analyses, emphasizing that inadequate healthcare access partially contributed to socioeconomic disparities in mortality. Effective policies promoting equitable healthcare access are imperative to mitigate socioeconomic disparities in mortality.

The culture of healthy living - The international perspective

A culture of health or healthy living can be envisioned as a society where well-being, including essential aspects like sleep, stress management, social connections, and leisure - is not merely an aspiration but a tangible reality for diverse communities, free from systemic inequities. However, the concept of a healthy lifestyle, and by extension a culture of healthy living, varies widely across the globe, shaped by cultural norms, government policies, and social structures. Defining a universally acceptable "culture of healthy living" for every population or subgroup is inherently complex, making it more practical to focus on addressing the barriers and leveraging the enablers associated with leading a healthy life. At its core, discussing the foundational elements of a healthy life - such as diet and nutrition, physical activity, mental health, and access to healthcare - is crucial. To ensure the sustainability of healthy living practices, a multifaceted approach is needed, emphasizing these pillars alongside equity. Existing global initiatives offer promising frameworks to tackle these challenges, highlighting the importance of collaboration, innovation, and systemic change. By fostering mutual support and collective action, we can advance toward a global culture of healthy living that benefits all individuals and communities, leaving no one behind.

Nursing students' experiences of a service-learning programme with older adults living in poverty in a high-income country: A phenomenological study

AIM

To understand the experiences of nursing students participating in a service-learning programme with older adults living in poverty in a high-income country.

BACKGROUND

Nursing students should be competent in assessing the needs of older people living in poverty as well as in implementing and evaluating the effect of individualised health promotion interventions. Service-learning is a strategy that not only improves the biopsychosocial health of older adults, but also enables nursing students to acquire competence in promoting health and self-care among older adults living in poverty. In addition, these service-learning programmes are known to break down stereotypes and improve attitudes towards older adults. However, there is a lack of research on experiences with service-learning programmes aimed at promoting health and self-care amongst older adults living in poverty in high-income countries.

DESIGN

Qualitative study based on Husserl's phenomenology.

METHOD

Thirty-three interviews were conducted with nursing students who had participated in a service-learning programme. The data were recorded, transcribed and analysed following the procedure developed by Colaizzi. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

RESULTS

Three main themes were drawn from the data analysis: (1) 'From feeling overwhelmed to gratitude: an emotional journey', (2) 'From perceiving poverty as a threat to seeing it as a condition of vulnerability', (3) 'Growing as a person and as a nurse'.

CONCLUSION

Service-learning programmes with older adults living in poverty have a positive impact on the personal and professional growth of nursing students; their involvement in such programmes could help them to break down social stereotypes, overcome fears of intervening in socially deprived neighbourhoods and become more socially responsible.

Perceptions of primary care services among Afro-Peruvians in Lima, Peru

INTRODUCTION

The Peruvian public healthcare system is characterized by various shortcomings that adversely affect healthcare quality as perceived by the general and minority populations, including the Afro-Peruvian community. This population has demonstrated reduced healthcare access due to discrimination and differential treatment, reflecting broader societal inequities.

OBJECTIVE

This study explores the experiences and perceptions of Afro-Peruvian individuals regarding the treatment they receive from public primary healthcare providers in metropolitan Lima.

METHODS

In-depth qualitative interviews were conducted with Afro-Peruvian individuals recruited from Lima. They were selected based on their responses to a survey conducted in a previous study, which indicated a high or low perception of intercultural adaptation in healthcare. The interviews explored their experiences with healthcare services and their perceptions about their interactions with health providers. The qualitative analysis involved topic coding to interpret the data.

RESULTS

We interviewed 19 Afro-Peruvians, including 15 women and 4 men, ages 26 to 70. The findings reveal that Afro-Peruvians generally experience mistreatment in the healthcare system. In their opinion, this is associated with systemic issues such as poor infrastructure, low salaries, and insufficient time allocated for patient care. Furthermore, participants perceive receiving poor quality and inefficient service not only from providers but also from the system presents difficulties in other processes, such as getting the appointment.

CONCLUSIONS

This study highlights significant areas for improvement in the public healthcare system, specifically enhancing the quality of patient care, improving communication, and upgrading healthcare infrastructure to serve the Afro-Peruvian community better. These insights could guide the development of targeted policy recommendations and practical interventions to address healthcare disparities and improve access to quality healthcare services for minority populations.

Navigating diabetes care inequities: an observational study linking chronic care model's structural elements to process and outcomes of type 2 diabetes care in Belgium

BACKGROUND

Although the Chronic Care Model (CCM) provides the essential structural components of practice organisation to deliver high-quality type 2 diabetes (T2D) care, little is known about which of its elements are most important, and the extent to which it may reduce social inequities in the quality of T2D care. This study aims to assess the association between the implementation of CCM's structural elements and the quality of T2D care processes and outcomes in Flanders (Belgium), paying specific attention to differences by patients' socioeconomic vulnerability.

METHODS

We developed a longitudinal database combining information on primary care practices' CCM implementation, with individual-level health insurance and medical lab data. Our sample included 7,593 T2D patients aged 40 years and above from 58 primary care practices in Flanders, followed up from 2017 to 2019. Medical lab data were available for a subsample of 4,549 patients. By estimating a series of hierarchical mixed-effects models, we assessed the association between primary care practices' CCM implementation and two process and two outcome indicators of T2D care. In addition, we explored cross-level interactions with patients' socioeconomic vulnerability.

RESULTS

Patients were more likely to have their HbA1c tested twice a year and LDL cholesterol tested yearly in practices with a higher overall CCM implementation. Regarding the different CCM elements, the clinical information system and linkages to the community were significantly associated with higher odds of being up-to-date with HbA1c testing, whereas stronger community linkages was the only dimension significantly associated with yearly LDL cholesterol testing. While socioeconomic vulnerable patients were less likely to have their HbA1c tested twice yearly, this difference disappeared in the highest-scoring practices. Regarding the outcome indicators, only a negligible proportion of variation in HbA1c and LDL cholesterol levels was due to systematic differences between practices, and hence, no clinically relevant associations with the CCM elements were found.

CONCLUSION

Our pioneering findings support the social capital pathway, as CCM implementation is associated with a reduction in the healthcare inequity gap in the T2D care process. This suggests that promoting CCM implementation may improve healthcare equity, particularly in regions with significant socioeconomic disparities or high concentrations of deprived individuals.

Patient engagement in radiation oncology: a large retrospective study of survey response dynamics

Purpose

Patient satisfaction surveys are pivotal in evaluating healthcare quality and enhancing patient care. Understanding the factors influencing patient engagement with these surveys in radiation oncology can guide improvements in patient-centered care.

Methods

This retrospective study analyzed data from radiation oncology patients at a large multi-site single-institution center from May 2021 to January 2024. We assessed the influence of demographic, clinical, and socioeconomic factors on the likelihood of survey participation using univariate (UVA) and multivariable (MVA) logistic regression analyses. Factors included age, gender, race, socioeconomic status (SES) via Area Deprivation Index (ADI), language, marital status, smoking, employment, insurance type, mental health disorders (MHD), comorbidity index (CCI), and cancer type.

Results

In a comprehensive analysis of 11,859 patients, most were female (57.2%), over 65 years old (60.7%), and primarily insured by Medicare (45.9%). MVA showed that higher socioeconomic disadvantage significantly decreased survey participation (ADI third tertile vs. first tertile OR=0.708, p<0.001), with each unit increase in ADI reducing the odds of completion by 1% (p<0.001). Older adults, and patients with head and neck or genitourinary cancers were significantly more likely to participate, while those with higher comorbidities, MHD, or other minority status were less engaged (p<0.001). Telemedicine encounters also significantly increased participation compared to in-person visits (OR=1.149, p=0.006).

Conclusions

Multiple factors including age, race, SES, insurance type, cancer type, health conditions, and modality of healthcare delivery influence patient engagement with satisfaction surveys in radiation oncology. Strategies to enhance patient engagement must consider these diverse influences to ensure comprehensive and inclusive feedback mechanisms in healthcare settings. Tailored interventions to mitigate barriers specific to underrepresented groups are crucial for capturing a broad spectrum of patient experiences and improving the overall quality of patient care.

Bridging the Gaps in Atrial Fibrillation Management in the Emergency Department

Atrial fibrillation (AF) frequently presents in emergency departments (EDs), contributing significantly to adverse cardiovascular outcomes. Despite established guidelines, ED management of AF often varies, revealing important gaps in care. This review addresses specific challenges in AF management for patients in the ED, including the nuances of rate versus rhythm control, the timing of anticoagulation initiation, and patient disposition. The updated 2024 European Society of Cardiology (ESC) guidelines advocate early rhythm control for select patients while recommending rate control for others; however, uncertainties persist, particularly regarding these strategies' long-term impact on outcomes. Stroke prevention through timely anticoagulation remains crucial, though the ideal timing, especially for new-onset AF, needs further research. Additionally, ED discharge protocols and follow-up care for AF patients are often inconsistent, leaving many without proper long-term management. Integration of emerging therapies, including direct oral anticoagulants and advanced antiarrhythmic drugs, shows potential but remains uneven across EDs. Innovative multidisciplinary models, such as "AF Heart Teams" and observation units, could enhance care but face practical challenges in implementation. This review underscores the need for targeted research to refine AF management, optimize discharge protocols, and incorporate novel therapies effectively. Standardizing ED care for AF could significantly reduce stroke risk, lower readmission rates, and improve overall patient outcomes.

Factors Impacting Patient Satisfaction at a Single Academic Sports Medicine Institution

INTRODUCTION

Patient satisfaction has become an important metric in many healthcare settings, as it relates to patient outcomes and improvement in healthcare quality. The Press Ganey tool is a common assessment used to evaluate patient satisfaction. To our knowledge, there are no studies that effectively determine what influences a patient's healthcare experience in a sports medicine setting. The purpose of this study was to determine which factors impact Press Ganey patient satisfaction at a single, academic sports medicine institution.

METHODS

Press Ganey surveys with questions about the provider, appointment date, sex, age, first visits vs. subsequent visits, and in-person vs. telehealth visits were utilized and emailed to patients within one week of their visit. Questions were rated on a Likert scale from 1 (very poor) to 5 (very good). Data from 2017 to 2022 were then aggregated retrospectively and de-identified. The 2022 Area Deprivation Index (ADI; higher scores indicate higher deprivation) was also used based on the patient's zip code. Statistical analysis with the use of a multivariate linear regression model was used to identify potential variables associated with patient-reported provider scores.

RESULTS

The study included data from 12,518 patient visits managed by eight sports medicine providers. Analysis revealed that age, appointment date (specifically the first visit), and the provider involved had statistically significant associations with Press Ganey satisfaction scores, with p-values of <0.001 for each factor. Age was positively correlated with satisfaction (coefficient = 0.160), indicating that older patients reported higher satisfaction levels compared to younger patients. Conversely, the appointment date, particularly at the initial visit, had a negative coefficient, demonstrating that patient satisfaction increased with subsequent visits. Additionally, when analyzing Press Ganey scores in relation to the ADI, it was found that patients with lower ADI scores, which indicate lower levels of social deprivation, reported higher satisfaction with their care providers.

CONCLUSION

Our study reveals that patient satisfaction seems to be affected by age, timing of visits, socioeconomic status, and provider at an academic sports medicine institution. While these factors may be somewhat unmodifiable, a better understanding of patient and provider characteristics can help maximize the patient's satisfaction with their healthcare.

Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management

IMPORTANCE

Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation.

OBJECTIVE

The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status.

STUDY DESIGN

This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI.

RESULTS

Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% ( P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures ( P = 0.01). When controlling for age, no clinically significant difference was demonstrated.

CONCLUSIONS

Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.

Association between education level and access to disease-modifying treatment in patients with multiple sclerosis in France

BACKGROUND

We hypothesized that differences in access to disease-modifying treatments (DMTs) could explain the association between socioeconomic status and disability progression in multiple sclerosis (MS).

OBJECTIVE

This study aimed to analyze the association between education level and DMT use in France.

METHODS

All patients from OFSEP network with MS onset over 1996-2014 and aged ⩾ 25 years at onset were included. Three time-to-event outcomes were investigated using flexible parametric survival regression models: time from MS onset to first DMT (any) and to platform therapy, and time from platform therapy to switch to high-efficacy therapy.

RESULTS

Overall, 7563 patients were included (mean follow-up 12.6 ± 5.9 years). The percentages of patients aged less than 40 years at MS onset and who initiated treatment before the age of 40 years were significantly higher in the groups with a higher education level. The time-to-event outcomes showed no major difference in DMT practices according to education level, except for women who had a significantly shorter time to DMT initiation in medium to very high education level groups versus low, at 5 years from MS clinical onset.

CONCLUSION

Our results suggest that the association between education level and MS disability progression does not solely reflect different therapeutic practices, particularly in men.

Socioeconomic and geographic variation in adjuvant chemotherapy among elderly patients with stage III colon cancer in Norway - a national register-based cohort study

BACKGROUND

About half of the patients diagnosed with colon cancer are 70 years or older. Standard treatment for stage III colon cancer is major surgical resection followed by adjuvant chemotherapy (ACT). Norwegian guidelines recommend initiation of ACT within 6 weeks after resection.

OBJECTIVE

This study investigated socioeconomic and geographic variation in the recommended provision of ACT to elderly patients with stage III colon cancer in Norway.

METHODS

This population-based retrospective cohort study included patients aged 70 years or older diagnosed with stage III colon cancer between 2011 and 2021 who underwent major surgical resection. Individual data were obtained from national registries. Multilevel logistic regression analysis was used to model variation in provision of ACT.

RESULTS

Of 4 501 included patients, 603 (13%) and 1 182 (26%) received ACT within 6 and 8 weeks after resection, respectively. The provision of ACT decreased with increasing age and frailty. Odds of ACT within 6 weeks decreased for patients with low socioeconomic status (SES) compared to high SES (odds ratio (OR) 0.67 (95% confidence interval (CI) 0.50-0.91)), and decreased for patients living alone compared to those living with a cohabitant (OR 0.72 (95% CI 0.58-0.91)). Geographic variation was found between hospital referral areas (OR 0.41-2.58).

CONCLUSIONS

Our study found that ACT provision to elderly stage III colon cancer patients is associated with SES and geography, indicating variation in guidelines adherence. Further research is needed to explore the impact of ACT timing among elderly patients with stage III colon cancer in Norway.

Demographic Disparities and Outcomes Following Hip Arthroscopy: Exploring the Impact of Social Determinants of Health in Femoroacetabular Impingement Syndrome

BACKGROUND

The purpose of this study was to explore the impact of social deprivation on preoperative characteristics and postoperative outcomes following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing primary HA for FAIS were identified, and their social deprivation index (SDI) score was assigned on the basis of the provided ZIP code. Quartiles (Q1 to Q4) were established using national percentiles, with Q4 representing patients from the areas of greatest deprivation. Patient-reported outcomes (PROs) were collected preoperatively and at a minimum follow-up of 2 years. Achievement rates for clinically meaningful outcomes, including the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB), were determined. The incidences of revision HA and conversion to total hip arthroplasty (THA) were recorded. SDI groups were compared with respect to preoperative characteristics and postoperative outcome measures. Predictors of MCID, PASS, and SCB achievement; revision HA; and conversion to THA were identified with use of multivariable logistic regression.

RESULTS

In total, 2,060 hips were included, which had the following SDI distribution: Q1 = 955, Q2 = 580, Q3 = 281, and Q4 = 244. The composition of the included patients with respect to race and/or ethnicity was 85.3% Caucasian, 3.8% African American, 3.7% Hispanic, 1.7% Asian, and 5.4% "other." Patients with more social deprivation presented at a later age and with a higher body mass index (BMI), a longer duration of preoperative hip pain, and greater joint degeneration (p ≤ 0.035 for all). The most socially deprived groups had higher proportions of African American and Hispanic individuals, less participation in physical activity, and greater prevalences of smoking, lower back pain, and Workers' Compensation (p ≤ 0.018 for all). PRO scores and achievement of the PASS and SCB were worse among patients from areas of greater social deprivation (p ≤ 0.017 for all). Age, BMI, activity status, race and/or ethnicity classified as "other," SDI quartile, Workers' Compensation, preoperative back pain, duration of preoperative hip pain, and Tönnis grade were independent predictors of clinically meaningful outcome achievement, revision arthroscopy, and/or THA conversion (p ≤ 0.049 for all).

CONCLUSIONS

Individuals with more social deprivation demonstrated inferior postoperative outcome measures. This was driven primarily by preoperative characteristics such as SDI, hip pain duration, joint degeneration, and overall health at presentation. Despite differential outcomes, patients still showed clinical improvement regardless of SDI quartile.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association Between County-Level Social Vulnerability and Vaccine-Related Attitudes and Hesitancy Toward COVID-19 Vaccination in the United States

BACKGROUND/OBJECTIVES

Understanding attitudes and behaviors related to vaccination is critical for enhancing COVID-19 vaccination acceptance and reducing disparities in vaccination coverage. This study examines disparities in vaccine-related attitudes and COVID-19 vaccine hesitancy in the United States in relation to community-level social vulnerability.

METHODS

This study analyzed cross-sectional national surveys conducted repeatedly between July 2020 and August 2021 (n = 6716). We assessed the association between county-level social vulnerability and general vaccine-related attitudes, as well as COVID-19 vaccine hesitancy. We developed Poisson models with robust variance estimation. The analysis also included the association of county social vulnerability with parental COVID-19 vaccine hesitancy.

RESULTS

Living in counties with high Socioeconomic Status vulnerability was associated with less vaccine support (adjusted Prevalence Ratio (aPR) 1.10; 95% CI 1.05-1.14) and residing in counties with high Household Characteristics vulnerability was associated with higher likelihood of COVID-19 vaccine hesitancy (aPR 1.13; 95% CI 1.07-1.20). In contrast, high vulnerability in the Racial and Ethnic Minority was associated with more positive attitudes toward vaccines (aPR 0.91; 95% CI 0.88-0.94) and lower COVID-19 vaccine hesitancy for both themselves (aPR 0.81; 95% CI 0.76-0.87) and children (aPR 0.84; 95% CI 0.75-0.94), after adjusting for sociodemographic factors.

CONCLUSIONS

Our study highlights the importance of addressing vulnerabilities related to socioeconomic status and household characteristics to reduce disparities in vaccine perceptions and hesitancy in socially vulnerable populations. The findings provide evidence for targeted public health interventions at the community level. They also demonstrate that the relationship between social vulnerability and vaccine attitudes varies across different vulnerability components.

Perspectives on Long-Term Follow-Up among Living Kidney Donors

Key Points

In a survey of 685 previous living kidney donors, donors wanted lifelong annual follow-up with a primary care provider. Living donors wanted information on clinical and laboratory assessment and health reassurance. Donors also wanted access to specialized care in the event of hospitalization or change in health.

Background

The long-term follow-up of living kidney donors is highly variable in Canada.

Methods

We surveyed perspectives on postdonation follow-up among 685 living donors in the two largest transplant programs in Canada (43% survey response rate). The anonymous survey was informed by semistructured interviews with 12 living kidney donors. The survey was developed on the basis of themes identified in the semistructured interviews, guidance from the research and clinical teams, and feedback from pilot testing with six previous donors.

Results

Most (73%) of the respondents received follow-up after the first donation year from a primary care provider, and 70% reported annual follow-up visits, including blood and urine tests. Most (71%) received a follow-up reminder from their transplant center, and follow-up was higher (86% versus 68%) among those receiving reminders. Donors wanted specialist involvement if new health or kidney-related events occurred. Most (70%) were satisfied with their follow-up, and 66% endorsed annual lifelong follow-up. Donors wanted more information about lifestyle and living donor outcomes and wanted to contribute to research to increase understanding of long-term donor health outcomes.

Conclusions

Donors wanted annual lifelong follow-up, including clinical assessment and laboratory tests, and more information about their postdonation health. A transplant center–led, primary care provider–administered model of long-term follow-up may best meet the care and information needs of most donors.

Socioeconomic disadvantage and its impact on patient satisfaction at a multi-site radiation oncology center

Purpose

Despite the importance of patient satisfaction (PS) on healthcare outcomes, the factors that influence PS in radiation oncology remain unexplored. This study assesses the influence of socioeconomic status (SES) on PS in radiation oncology, using the Area Deprivation Index (ADI) as a measure of SES.

Methods

This single-institution cross-sectional study used the National Research Council (NRC) PS survey at four radiation oncology sites from 2021 to 2023. SES was measured using ADI data from the Neighborhood Atlas. Univariate (UVA) and multivariable (MVA) logistic regression analyses were conducted on recommendation scores (0-10 scale, with 9 or higher indicating a likelihood to recommend).

Results

In our analysis of 7,501 survey responses, most patients were female (55.3 %), had curative treatment intent (81.5 %), and were diagnosed with breast cancer (30.4 %), with most being follow-up visits (69.0 %). Average scores for state and national ADI were 3.94 and 50.75, respectively. UVA identified factors such as curative intent (OR 1.68, p < 0.001), follow-up visits (OR 1.69, p < 0.001), and breast cancer diagnosis (OR 1.42, p = 0.018) as enhancing the likelihood of recommending the facility or provider. Those with a national ADI above the mean showed lower propensity to recommend the facility (OR 0.81, p = 0.050) or provider (OR 0.71, p = 0.002). MVA confirmed the significance of national ADI on provider recommendations (OR 0.730, p = 0.005) but not facility recommendations (OR 0.832, p = 0.089).

Conclusion

Patients facing higher SES disadvantages are less inclined to recommend their healthcare provider. These results highlight the role of SES in PS assessments and advocate for further investigation into how SES impacts PS and patient-provider relationships.

A Qualitative Exploration of the Socioecological Influences Shaping the Diagnostic Experience and Self-Management Practices Among People Newly Diagnosed With Multiple Sclerosis

BACKGROUND

People newly diagnosed with multiple sclerosis (MS) often pursue 'health-related' behaviour changes to feel in control of their diagnosis. However, little is known about the specific factors that may influence behaviour change during this crucial time. Therefore, we conducted an in-depth exploration of the socioecological influences impacting the diagnostic experience and self-management practices following an MS diagnosis.

METHODS

We followed a qualitative study design using a phenomenological approach to explore the lived experiences of people newly diagnosed with MS. Analysis was conducted via an iterative process, starting with deductive open coding to map onto the socioecological model, followed by inductive focused coding to extract key themes from participants' reported experiences.

RESULTS

Eight participants diagnosed with MS within the past 12 months were interviewed. Four themes were reported across the MS journey, reflecting the different levels of the socioecological model: (1) taking control of a new diagnosis to retain a sense of personal identity-individual level; (2) grief and acceptance guided by community-social connection, community and social environment; (3) practical management of MS in the wider society-policy and government regulation; and (4) global events that greatly upheave the MS journey-natural disasters and societal conflicts, such as a pandemic. These themes highlighted the complex interrelationship between socioecological factors and self-management abilities in people living with MS.

CONCLUSIONS

The diagnostic experience of those with MS is highly complex. Although it varies for each person living with MS, there are shared experiences that often reflect a common cycle of grief. An MS diagnosis provides an opportunity for self-rediscovery, which can both influence and be influenced by socioecological factors. The social and technical nature of self-managing MS strongly shapes the diagnostic experience, underpinning many aspects of daily living, social interaction and physical and psychological well-being.

PATIENT OR PUBLIC CONTRIBUTION

The research team worked closely with an MS-specific consumer panel for the study design. This project was raised with this group, and preliminary results were shared at a national conference for MS during a lived-experience consumer stream to gain additional insights.

Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users

OBJECTIVE

To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level.

DATA SOURCE AND STUDY SETTING

We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019.

STUDY DESIGN

We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender.

DATA COLLECTION/EXTRACTION METHODS

We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence.

PRINCIPAL FINDINGS

Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination.

CONCLUSIONS

We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation.

Timing of Carpal Tunnel Syndrome Treatment Based on Social Deprivation

INTRODUCTION

This study sought to investigate the impact of the area deprivation index (ADI) on the treatment timeline from carpal tunnel syndrome (CTS) to carpal tunnel release (CTR). We hypothesize that increased social deprivation will correlate with increased time between care milestones from presentation to surgery.

METHODS

This is a retrospective review of patients diagnosed with CTS who underwent CTR at a single academic institution. Variables including gender, race, ethnicity, smoking status, medical comorbidities, ADI, timing of visits and surgery, and electrodiagnostic (EDX) studies were collected. The analysis included univariate chi-square tests, ANOVA, and multivariate linear and logistic regressions.

RESULTS

In total, 501 patients were divided by ADI national percentiles from least to most deprived tertiles. Univariate analysis demonstrated increased time from EDX to CTR comparing the least and most deprived tertiles (52 days vs. 95 days). On multivariate analysis, this correlation was no longer significant. Multivariate analysis also revealed a non-significant trend towards least deprived ADI correlating with a trial of corticosteroid injections. Injections prior to surgery correlated with an increased time from EDX to CTR and time from initial presentation to CTR. A diagnosis of severe CTS on EDX correlated with a decreased likelihood of corticosteroid injections.

CONCLUSIONS

Although previous studies have demonstrated mixed outcome results in CTS, we found that social deprivation does not correlate with delays in the treatment timeline. Factors other than delays in the treatment timeline may be contributing to the potentially worse outcomes in CTS patients with greater social deprivation.

Understanding Medication Nonadherence in Crohn's Disease Patients: A Qualitative Evaluation

BACKGROUND

Immune-modifying medications are widely available and recognized as valuable by most gastroenterologists. However, approximately 40% of patients with Crohn's disease (CD) do not comply with regimens using these medications, resulting in complications, hospitalization, and surgeries. We sought to identify factors that motivate adherence or nonadherence with medication recommendations for CD.

METHODS

We conducted qualitative interviews with patients living with CD who were identified as adherent or nonadherent to immune-modifying medication recommendations by their treating gastroenterologist. Semistructured interview guides were developed based on an established framework for understanding health behaviors. We conducted content analysis of the resulting qualitative data using an inductive-deductive approach to identify emergent themes that influence medication decision-making.

RESULTS

Twenty-five patients with CD completed interviews for this study. Interviews were independently coded and analyzed for thematic content. Two broad domains emerged comprising (1) themes reflected in the Theoretical Domains Framework and (2) novel themes specific to medication decision-making in CD. Adherent patients conveyed a sense of trust in science and healthcare provider expertise, while nonadherent patients were more likely to express beliefs in their ability to self-manage CD, concern about risks associated with medication, and a general ambivalence to treatment.

CONCLUSIONS

There are clear cognitive, behavioral, and relational factors that guide patients' medication-related decision-making. Several of the factors share features of other behavioral change and decision-making processes, while others are specific to the experience of patients with CD. A fuller understanding of these factors is essential to developing effective behavioral interventions to improve adherence to evidence-based treatment recommendations.

Bias in medical AI: Implications for clinical decision-making

Biases in medical artificial intelligence (AI) arise and compound throughout the AI lifecycle. These biases can have significant clinical consequences, especially in applications that involve clinical decision-making. Left unaddressed, biased medical AI can lead to substandard clinical decisions and the perpetuation and exacerbation of longstanding healthcare disparities. We discuss potential biases that can arise at different stages in the AI development pipeline and how they can affect AI algorithms and clinical decision-making. Bias can occur in data features and labels, model development and evaluation, deployment, and publication. Insufficient sample sizes for certain patient groups can result in suboptimal performance, algorithm underestimation, and clinically unmeaningful predictions. Missing patient findings can also produce biased model behavior, including capturable but nonrandomly missing data, such as diagnosis codes, and data that is not usually or not easily captured, such as social determinants of health. Expertly annotated labels used to train supervised learning models may reflect implicit cognitive biases or substandard care practices. Overreliance on performance metrics during model development may obscure bias and diminish a model's clinical utility. When applied to data outside the training cohort, model performance can deteriorate from previous validation and can do so differentially across subgroups. How end users interact with deployed solutions can introduce bias. Finally, where models are developed and published, and by whom, impacts the trajectories and priorities of future medical AI development. Solutions to mitigate bias must be implemented with care, which include the collection of large and diverse data sets, statistical debiasing methods, thorough model evaluation, emphasis on model interpretability, and standardized bias reporting and transparency requirements. Prior to real-world implementation in clinical settings, rigorous validation through clinical trials is critical to demonstrate unbiased application. Addressing biases across model development stages is crucial for ensuring all patients benefit equitably from the future of medical AI.

Impact of Social Deprivation on Cubital Tunnel Syndrome Treatment Timeline

Purpose

The purpose of this study was to establish the impact of area deprivation index (ADI) on treatment timelines of patients with cubital tunnel syndrome (CuTS). We hypothesize that increased social deprivation will correlate with increased time between care milestones from presentation to surgery.

Methods

This is a retrospective study of patients diagnosed with CuTS who underwent surgical intervention at a single academic institution. Variables including age, sex, body mass index, ADI, electrodiagnostic (EDX) severity classification, and time elapsed between treatment milestones were obtained. Treatment milestones included time elapsed between initial presentation to hand surgery and EDX studies, and surgery. Analysis included univariate χ2 tests and analysis of variance, as well as multivariate linear and logistic regressions.

Results

Six hundred and fifty-three patients were divided by ADI national percentiles from the least to most deprived tertiles. Univariate analysis found no differences in care timelines across ADI tertiles. Multivariate analysis revealed a nonsignificant trend toward higher ADI predicting longer time from presentation to surgery. Moderate EDX rating correlated with increased time from presentation to surgery. Mild EDX ratings correlate with increased time from EDX studies to surgery. Age was a significant predictor of decreased time between initial presentation and surgery and between EDX and surgery. Completion of EDX studies prior to presentation significantly decreased time to surgery.

Conclusions

Social deprivation does not significantly correlate with delays in the treatment timeline for CuTS. Increased age was significantly correlated with shorter treatment timelines, which may reflect differences in physicians' approaches to patients of different ages. Electrodiagnostic testing obtained prior to initial presentation expedited care following presentation to hand clinic. However, this could reflect either an overall delay in care (if EDX were obtained because of a delay from referral to presentation) or truly expedited care.

Type of study/level of evidence

Prognostic II.

Patients with type 2 diabetes and surgical foot wounds: Overtrust in primary care physicians, isolation, and difficulties contemplating the future

AIMS

In Europe, 27 % of patients with a podiatric complication of diabetes are referred to a specialized structure for surgery after more than 3 months' disease progression. Our study aimed to analyze access to healthcare and future self-projection in patients with severe diabetic foot conditions.

METHODS

We performed a qualitative study with semi-structured interviews in patients hospitalized with diabetic foot conditions requiring surgical treatment. We collected quantitative data on the diabetes characteristics, levels of social precariousness, anxiety and depression.

RESULTS

We conducted 13 interviews with 2 females and 11 males; mean age 62.7 years. Five had undergone surgical debridement, six toe amputation, and two mid-tarsal amputation. Most were socioeconomically deprived and/or isolated. Three discourse themes emerged: 1) heterogeneity in the care pathway, with systemic barriers, negligence or overtrust 2) relationship between social support and the ability to project oneself into the future, 3) poverty of speech.

CONCLUSIONS

Education should emphasize the importance of prompt referral to a specialized structure after the onset of a wound. The lack of support from loved ones and social support appeared to be associated with patients' failure to plan for their future. We advocate for a psychological evaluation and support for all these patients.

The Influences of SES on Patient Choice of Doctor: A Systematic Review

INTRODUCTION

As patients become increasingly involved in healthcare decision-making, it is important to examine the drivers behind patient choice of doctor (PCOD); the initial decision can have lasting impacts on patients' trust in providers and health outcomes. However, limited studies have explored PCOD relative to socioeconomic status (SES) or health disparity. This review identified similar preferences and varied decision criteria in PCOD across SES groups.

METHODS

PubMed, PsycINFO, Web of Science, and relevant cross-references were searched for articles published between January 2007-September 2022. Papers were screened using Covidence. Included studies examined PCOD by income and/or educational levels. Analysis was performed in 2022-2023.

RESULTS

From 4,449 search results, 29 articles were selected (16 countries, 14 medical specialties, total of 32,651 participants). Individuals of higher SES ranked physician characteristics (e.g., qualifications, empathy) or performance more important than cost or convenience. Individuals of lower SES often had to prioritize logistical factors (e.g., insurance coverage, distance) due to resource constraints and gaps in knowledge or awareness about options. Despite differing healthcare systems, such divergence in PCOD were relatively consistent across countries. Some patients, especially females and disadvantaged groups, favored gender-concordant physicians for intimate medical matters (e.g., gynecologist); this partiality was not limited to conservative cultures. Few researchers investigated the outcomes of PCOD and indicated that lower-SES populations inadvertently chose, experienced, or perceived lower quality of care.

DISCUSSION

Patients' decision criteria varied by SES, even under national systems intended for universal access, indicating the impacts of social determinants and structural inequities. Health education supporting patient decision-making and research on how SES affects PCOD and outcomes could help reduce health disparity.

Low socioeconomic indicators correlate with critical preoperative glenoid bone loss and care delays

BACKGROUND

Chronic and recurrent shoulder dislocations prior to stabilization can increase the risk of glenoid bone loss. Glenoid bone loss exceeding critical levels can lead to further instability and decreased outcomes following arthroscopic labral repair. Indicators of low socioeconomic status (SES), such as high Area Deprivation Index (ADI) and noncommercial insurance, are related to generalized delays to orthopedic care, which can cause recurrent instability and increase glenoid bone loss.

HYPOTHESIS

Higher national ADI and noncommercial insurance would be associated with greater levels of radiographic glenoid bone loss after glenoid instability.

METHODS

A retrospective study was performed with patients who underwent anterior labral repair. Chart review included demographics, course of care data, preoperative instability data, national ADI, and insurance status. The Neighborhood Atlas Website and patients' home addresses were used to obtain national ADI. Glenoid bone loss was measured using the best-fit circle Pico method on three-dimensionally aligned magnetic resonance images. Researchers were blinded to SES indicators during radiographic analysis. Glenoid bone loss was compared between SES indicators using one-way analysis of variance.

RESULTS

One hundred forty-six patients met inclusion criteria and had complete datasets (23.3% female; 22.4 ± 7.0-year-old; national ADI = 16.1 ± 15.3). Patients experienced on average 9.12 ± 6.63% glenoid bone loss. A curve fitting tool determined a quadratic nonlinear regression best characterized the association of glenoid bone loss and ADI (R2 = 0.392, P < .001). Individuals with commercial insurance experienced 8.58% ± 6.69% glenoid bone loss as compared to 11.78% ± 6.30% in individuals with Medicaid insurance (P = .03). Critical bone loss at a threshold of 13.5% was more likely with higher national ADI (P < .001) and Medicaid insurance (OR = 2.49, CI = 1.02-6.09). However, only national ADI was predictive of subcritical bone loss at a threshold of 10% (P < .001).

CONCLUSION

Patients with greater national ADI and Medicaid insurance status had greater rates of critical preoperative glenoid bone loss at a threshold of 13.5%. Greater national ADI is also predictive of subcritical glenoid bone loss at a threshold of 10% and overall glenoid bone loss. Further study is needed to assess the postoperative implications of these findings in this population.

Reducing No-Show Appointments in Preanesthesia Screening

PURPOSE

Preanesthesia screening is critical to evaluate the patient's medical and surgical history before any procedure or surgery to assess for risks and to optimize outcomes during the perioperative period. The purpose of this quality improvement project was to decrease the number of missed appointments in the outpatient preanesthesia and surgical screening clinic and the impact on provider satisfaction.

DESIGN

The design of this quality improvement project was pre and post design. Automated and live phone calls reminders were provided for patients scheduled in the outpatient preanesthesia. Data were collected to compare missed appointment rates from a 3-month period before the project implementation and a 3-month period afterward.

METHODS

Predata collection included the number of no-shows in the electronic health record system from the previous 3 months. Participants included all adult patients who are scheduled for a preanesthesia surgical screening appointment. Provider satisfaction was assessed using a 5-question survey, pre and postinnovation.

FINDINGS

Reminder systems had a statistically significant impact on reducing the number of no-shows in the preanesthesia and surgical screening clinic. No significant impact was shown in provider satisfaction.

CONCLUSIONS

Implementation of a reminder system can help to reduce no-show rates in clinics. Patient no-shows overload the health system by reducing the productivity of providers and waste resources including use of clinic staff, longer wait times for other patients, and the timing providers put into chart preparation.

Conceptualizing bias in EHR data: A case study in performance disparities by demographic subgroups for a pediatric obesity incidence classifier

Electronic Health Records (EHRs) are increasingly used to develop machine learning models in predictive medicine. There has been limited research on utilizing machine learning methods to predict childhood obesity and related disparities in classifier performance among vulnerable patient subpopulations. In this work, classification models are developed to recognize pediatric obesity using temporal condition patterns obtained from patient EHR data in a U.S. study population. We trained four machine learning algorithms (Logistic Regression, Random Forest, Gradient Boosted Trees, and Neural Networks) to classify cases and controls as obesity positive or negative, and optimized hyperparameter settings through a bootstrapping methodology. To assess the classifiers for bias, we studied model performance by population subgroups then used permutation analysis to identify the most predictive features for each model and the demographic characteristics of patients with these features. Mean AUC-ROC values were consistent across classifiers, ranging from 0.72-0.80. Some evidence of bias was identified, although this was through the models performing better for minority subgroups (African Americans and patients enrolled in Medicaid). Permutation analysis revealed that patients from vulnerable population subgroups were over-represented among patients with the most predictive diagnostic patterns. We hypothesize that our models performed better on under-represented groups because the features more strongly associated with obesity were more commonly observed among minority patients. These findings highlight the complex ways that bias may arise in machine learning models and can be incorporated into future research to develop a thorough analytical approach to identify and mitigate bias that may arise from features and within EHR datasets when developing more equitable models.

The impact of health disparities on peripheral vascular access outcomes in hospitalized patients: an observational study

BACKGROUND

Placement of peripheral intravenous catheters (PIVC) is a routine procedure in hospital settings. The primary objective is to explore the relationship between healthcare inequities and PIVC outcomes.

METHODS

This study was a multicenter, observational analysis of adults with PIVC access established in the emergency department requiring inpatient admission between January 1st, 2021, and January 31st, 2023, in metro Detroit, Michigan, United States. Epidemiological, demographic, therapeutic, clinical, and outcomes data were collected. Health disparities were defined by the National Institute on Minority Health and Health Disparities. The primary outcome was the proportion of PIVC dwell time to hospitalization length of stay, expressed as the proportion of dwell time (hours) to hospital stay (hours) x 100%. Multivariable linear regression and a machine learning model were used for variable selection. Subsequently, a multivariate linear regression analysis was utilized to adjust for confounders and best estimate the true effect of each variable.

RESULTS

Between January 1st, 2021, and January 31st, 2023, our study analyzed 144,524 ED encounters, with an average patient age of 65.7 years and 53.4% female. Racial demographics showed 67.2% White, and 27.0% Black, with the remaining identifying as Asian, American Indian Alaska Native, or other races. The median proportion of PIVC dwell time to hospital length of stay was 0.88, with individuals identifying as Asian having the highest ratio (0.94) and Black individuals the lowest (0.82). Black females had a median dwell time to stay ratio of 0.76, significantly lower than White males at 0.93 (p < 0.001). After controlling for confounder variables, a multivariable linear regression demonstrated that Black males and White males had a 10.0% and 19.6% greater proportion of dwell to stay, respectively, compared to Black females (p < 0.001).

CONCLUSIONS

Black females face the highest risk of compromised PIVC functionality, resulting in approximately one full day of less reliable PIVC access than White males. To comprehensively address and rectify these disparities, further research is imperative to improve understanding of the clinical impact of healthcare inequities on PIVC access. Moreover, it is essential to formulate effective strategies to mitigate these disparities and ensure equitable healthcare outcomes for all individuals.

Hotspot analysis of anaemia among pregnant women in Ethiopia: hotspot analysis of national demographic and health survey data

BACKGROUND

Anaemia is a significant global health problem, especially, in developing nations like Ethiopia. Despite increasing rates over the past two decades, there is limited research on the specific prevalence of anaemia among pregnant women in the country.

OBJECTIVE

To identify hotspot areas of anaemia-associated factors among pregnant women in Ethiopia.

STUDY DESIGN

Cross-sectional.

SETTING

Ethiopian demographic study from 2005 to 2016.

PARTICIPANTS

This study analysed 3350 pregnant women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hotspot area of anaemia among pregnant women, trend of anaemia and associated factors.

RESULTS

The prevalence of anaemia among pregnant women has shown significant fluctuations over the years. Between 2005 and 2011, there was a notable decrease from 30.9% to 21.5% while the prevalence increased from 21.5% in 2011 to 29.58% in 2016. The identified determinants of anaemia among pregnant women were female-headed household, belonging to the highest wealth quintile, being in the second or third trimester of pregnancy, being a working woman and residing in the Somalia region. Hotspot areas, where the prevalence of anaemia was particularly high, were identified in Somalia, Dire Dawa, Afar and Harari regions.

CONCLUSION

Anaemia during pregnancy is a major public health concern in Ethiopia, with a concerning increase between 2011 and 2016. Hotspot areas like Somali, Dire Dawa, Afar and Harari are particularly affected. Shockingly, nearly one in three pregnant women in Ethiopia suffer from anaemia. To address this issue effectively, targeted interventions prioritising economically disadvantaged households and pregnant women in their second and third trimesters are crucial. Monitoring spatial patterns and contributing factors is vital to develop tailored interventions and improve maternal health outcomes in these high-risk areas. By strategically targeting hotspot areas nationwide, significant progress can be made in reducing anaemia among pregnant women.

Postoperative racial disparities following spine surgery are less pronounced in the outpatient setting

BACKGROUND CONTEXT

Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, whether similar differences have developed in the outpatient (OP) setting remains to be elucidated.

PURPOSE

This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021.

OUTCOME MEASURES

Thirty-day rates of serious and minor adverse events, readmission, reoperation, nonhome discharge, and mortality.

METHODS

A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) nonhome discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences.

RESULTS

Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs 11.8%) and OP (92.7% vs 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077-1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113-1.705, p=.003), readmission (OR 1.284, 95% CI 1.130-1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013-1.407, p=.035), and nonhome discharge (OR 2.304, 95% CI 2.101-2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036-1.735, p=.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, nonhome discharge, or death (p>.050 for all).

CONCLUSIONS

Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.

Treating the whole patient: Facilitating health care for patients facing health inequity

Social determinants of health (SDOH) are conditions in which people are born, grow, live, work, and age. Variations in these conditions are largely responsible for health inequities, the differences in health status or distribution of health resources within a population. Despite recent increases in attention to SDOH in research and clinical practice, few, if any, resources exist to describe how these complex dynamics impact patients with inborn errors of metabolism. Recognizing the role real-life narratives have as a powerful educational tool, we compiled a series of 3 original cases, published as part of this special supplement, to illustrate challenges and learnings related to SDOH within the context of urea cycle disorders and phenylketonuria.

Fatal consequences of limited health literacy in a patient with a rare metabolic disease

A Black young adult female diagnosed with argininosuccinate lyase deficiency at 6 months of age encountered significant barriers to care for the first 16 years of her life due to socioeconomic factors and parental neglect. Once in the care of her paternal grandmother, she received appropriate treatment with a nitrogen scavenger, amino acid supplementation, and a low-protein diet. However, due to repeated hyperammonemic crises early in her life, she was minimally communicative and unable to perform activities of daily living. During her final hyperammonemic crisis, she presented to a hospital unfamiliar with urea cycle disorders and without a metabolic service. As a result, she did not receive optimal care and died.

Long-Term Implications of Socioeconomic Status on Major Adverse Cardiovascular, Cerebrovascular Events (MACCE), and All-Cause Mortality

BACKGROUND

Socio-economic status (SES) has a large impact on health through a complex interplay of upstream, midstream and downstream factors. However, little is known about the predictive role of SES on long-term major adverse cardiovascular, cerebrovascular events, and mortality (MACCE).

AIM

To determine the long-term relationship between SES and MACCE for men and women. The secondary endpoint was to determine the relationship between SES and all-cause mortality.

METHOD

A total of 3,034 participants (1,494 women and 1,540 men) were assessed at baseline in the Geelong Osteoporosis Study, a large regional Australian population cohort study. Area-based SES was assessed, utilising the Index of Relative Socio-Economic Disadvantage (IRSD) and grouped into quintiles. The primary endpoint, MACCE, was defined as a composite of myocardial infarction, heart failure hospitalisation, malignant arrhythmias, stroke, and all-cause mortality. The secondary endpoint was all-cause mortality. Baseline data including age, sex, smoking status and alcohol use, and comorbidities were collected between 1993-1997 for women, and 2001-2006 for men, with follow-up over 30 and 22 years, respectively. Logistic regression was utilised to assess MACCE and all-cause mortality outcomes across the SES quintiles.

RESULTS

Participants lost to follow-up or with incomplete data collection were excluded leaving 2,173 participants eligible for analysis. SES was associated with MACCE outcomes. Compared with Quintile I (lowest SES stratum), the odds of MACCE for each IRSD stratum were: Quintile II, odds ratio (OR) 0.85 (95% confidence interval [CI] 0.65-1.13); Quintile III, OR 0.69 (95% CI 0.51-0.91); Quintile IV, OR 0.66 (95% CI 0.50-0.88); and, Quintile V, OR 0.55 (95% CI 0.41-0.72). In the adjusted model, an inverse trend was noted, with reducing MACCE outcomes with an increasing SES status; IRSD Quintile II, OR 0.85 (95% CI 0.62-1.17); Quintile III, OR 0.70 (95% CI 0.50-0.97); Quintile IV, OR 0.73 (95% CI 0.52-1.02); and, Quintile V, OR 0.54 (95% CI 0.39-0.74). SES was inversely associated with all-cause mortality; IRSD Quintile II (OR 0.87, 95% CI 0.66-1.16) failed to achieve significance however IRSD Quintile III (OR 0.65, 95% CI 0.48-0.88), Quintile IV (OR 0.59, 95% CI 0.44-0.80) and Quintile V (OR 0.46, 95% CI 0.34-0.62) had a lower risk of mortality compared with Quintile I. In the adjusted model, an inversely proportional trend was noted between SES and all-cause mortality; IRSD Quintile II (OR 0.82, 95% CI 0.59-1.15), IRSD Quintile III (OR 0.63, 95% CI 0.49-0.95), Quintile IV (OR 0.59, 95% CI 0.45-0.90) and Quintile V (OR 0.44, 95% CI 0.31-0.61) had fewer mortality events compared with IRSD Quintile I.

CONCLUSIONS

Our research indicates that being part of a lower socio-economic stratum is linked to a higher likelihood of experiencing negative cardiovascular and cerebrovascular events, along with an increased risk of overall mortality. SES is an important risk stratification marker for long-term prognosis of cardiovascular diseases and stroke, and warrants further investigation.

Addressing AMR and planetary health in primary care: the potential of general practitioners as change agents

Introduction

Antimicrobial resistance is closely linked with the health and stability of environmental systems and therefore a challenge for the health of the planet. General Practitioners, owing to their trusted positions and close patient relationships, can play a crucial role in addressing antimicrobial resistance within the framework of Planetary Health. The goal of our study was to examine General Practitioners' knowledge, attitude, and practice regarding the linkage of antimicrobial resistance with Planetary Health to understand their potential as agents of change in this domain.

Materials and methods

We conducted 19 guided interviews with General Practitioners from four different German federal states (August-September 2022). Participants were selected from the intervention group of the RedAres randomized controlled trial, a study designed to optimize therapy and prescribing practices for uncomplicated urinary tract infections in general practice. Data were analyzed using Mayring's structured qualitative content analysis and the typology approach by Kelle and Kluge.

Results

General Practitioners generally demonstrated the ability to identify the interlinkages between antimicrobial resistance and Planetary Health. However, they exhibited varying levels of knowledge, problem awareness, and accountability for the associated challenges and partially outsourced the responsibility for Planetary Health. Some General Practitioners were capable of integrating Planetary Health arguments into patient counseling. They recognized rational prescribing practice, self-reflection on antimicrobial resistance and Planetary Health, interprofessional exchange, and raising awareness among patients as potential avenues for engagement in promoting Planetary Health.

Discussion

As antimicrobial resistance is increasingly recognized as a Planetary Health challenge, empowering General Practitioners as change agents requires tailored measures based on their level of previous knowledge and their attitude toward Planetary Health. General Practitioners express a need for concrete advice on how to integrate antimicrobial resistance as a Planetary Health topic into their daily activities. Developing and evaluating adaptable training materials is essential. Additionally, the integration of Planetary Health outcomes into clinical guidelines could accelerate the adoption of this dimension in antibiotic prescribing practices within primary care settings.

Health professionals implicit bias of patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review

OBJECTIVES

Research indicates that people with lower socioeconomic status (SES) receive inferior healthcare and experience poorer health outcomes compared with those with higher SES, in part due to health professional (HP) bias. We conducted a scoping review of the impact of HP bias about SES on clinical decision-making and its effect on the care of adults with lower SES.

DESIGN

JBI scoping review methods were used to perform a systematic comprehensive search for literature. The scoping review protocol has been published in BMJ Open.

DATA SOURCES

Medline, Embase, ASSIA, Scopus and CINAHL were searched, from the first available start date of the individual database to March 2023. Two independent reviewers filtered and screened papers.

ELIGIBILITY CRITERIA

Studies of all designs were included in this review to provide a comprehensive map of the existing evidence of the impact of HP bias of SES on clinical decision-making and its effect on the care for people with lower SES.

DATA EXTRACTION AND SYNTHESIS

Data were gathered using an adapted JBI data extraction tool for systematic scoping reviews.

RESULTS

Sixty-seven papers were included from 1975 to 2023. 35 (73%) of the included primary research studies reported an association between HP SES bias and decision-making. Thirteen (27%) of the included primary research studies did not find an association between HP SES bias and decision-making. Stereotyping and bias can adversely affect decision-making when the HP is fatigued or has a high cognitive load. There is evidence of intersectionality which can have a powerful cumulative effect on HP assessment and subsequent decision-making. HP implicit bias may be mitigated through the assertiveness of the patient with low SES.

CONCLUSION

HP decision-making is at times influenced by non-medical factors for people of low SES, and assumptions are made based on implicit bias and stereotyping, which compound or exacerbate health inequalities. Research that focuses on decision-making when the HP has a high cognitive load, would help the health community to better understand this potential influence.

Examining Injustices: Transfusion Medicine and Race

Race and ethnicity are sociopolitical and not biological constructs, and assertions that these population descriptors have scientific meaning has caused significant harm. A critical assessment of the transfusion medicine literature is an important aspect of promoting race-conscious as opposed to race-based medicine. Utilizing current definitions and health equity frameworks, this review will provide a critical appraisal of transfusion medicine studies at the intersection of race and healthcare disparities, with a focus on larger methodological challenges facing the transfusion medicine community. Moving forward, risk modelling accounting for upstream factors, patient input, as well as an expert consensus on how to critically conduct and evaluate this type of literature are needed. Further, when using race and ethnicity in research contexts, investigators must be aware of existing guidelines for such reporting.

Differences in total shoulder arthroplasty utilization and 30-day outcomes among White, Black, and Hispanic patients: do disparities exist in the outpatient setting?

BACKGROUND

In the United States, efforts to improve efficiency and reduce healthcare costs are shifting more total shoulder arthroplasty (TSA) surgeries to the outpatient setting. However, whether racial and ethnic disparities in access to high-quality outpatient TSA care exist remains to be elucidated. The purpose of this study was to assess racial/ethnic differences in relative outpatient TSA utilization and perioperative outcomes using a large national surgical database.

METHODS

White, Black, and Hispanic patients who underwent TSA between 2017 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Baseline demographic and clinical characteristics were collected, and rates of outpatient utilization, adverse events, readmission, reoperation, nonhome discharge, and mortality within 30 days of surgery were compared between racial/ethnic groups. Race/ethnicity-specific trends in utilization of outpatient TSA were assessed, and multivariable logistic regression was used to adjust for baseline demographic factors and comorbidities.

RESULTS

A total of 21,186 patients were included, consisting of 19,135 (90.3%) White, 1093 (5.2%) Black, and 958 (4.5%) Hispanic patients and representing 17,649 (83.3%) inpatient and 3537 (16.7%) outpatient procedures. Black and Hispanic patients were generally younger and less healthy than White patients, yet incidences of complications, nonhome discharge, readmission, reoperation, and death within 30 days were similar across groups following outpatient TSA (P > .050 for all). Relative utilization of outpatient TSA increased by 28.7% among White patients, 29.5% among Black patients, and 38.6% among Hispanic patients (ptrend<0.001 for all). Hispanic patients were 64% more likely than White patients to undergo TSA as an outpatient procedure across the study period (OR: 1.64, 95% CI 1.40-1.92, P < .001), whereas odds did not differ between Black and White patients (OR: 1.04, 95% CI 0.87-1.23, P = .673).

CONCLUSION

Relative utilization of outpatient TSA remains highest among Hispanic patients but has been significantly increasing across all racial and ethnic groups, now accounting for more than one-third of all TSA procedures. Considering outpatient TSA is associated with fewer complications and lower costs, increasing utilization may represent a promising avenue for reducing disparities in orthopedic shoulder surgery.

Factors associated with initiation of pharmacological therapy and treatment changes in postural orthostatic tachycardia syndrome

Purpose

Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogenous disorder of the autonomic nervous system that is often disabling. There are no FDA-approved therapies for the treatment of this condition. While some patients recover with baseline non-pharmacological intervention, others require repeated trials of off-label pharmacological therapies. The reasoning for this variable treatment response is unknown. The purpose of this work is to identify potential factors that are associated with higher odds of starting pharmacotherapy and/or a higher rate of POTS treatment changes.

Methods

Chart review of demographic, disease and treatment descriptions, medical history, and tilt table examinations of 322 POTS patients who were diagnosed between 2018 and 2020 at our tertiary care center was completed. We first identified the most significant factors associated with an increased odds of starting pharmacotherapy using variable selection techniques and logistic regression. We then identified the most significant factors associated with changes in POTS treatment strategies using variable selection techniques and negative binomial regression modeling. A significance level of 0.05 was utilized.

Results

A total of 752 POTS-specific treatment courses were cataloged, and 429 treatment changes were observed. The most cited reason for a change in management was uncontrolled symptoms. History of migraine headaches, reported fatigue, reported palpitations and a previous POTS diagnosis at an outside institution were found to be associated with a higher odds of starting pharmacotherapy for POTS symptoms (Odds Ratio of 2.40, 1.94, 2.62, 2.08, respectively). History of migraine headaches, reported fatigue, and higher heart rate differences on tilt table examination were found to be associated with an increase in the rate of POTS treatment changes (44, 66, 13% increase in incidence rate, respectively), while reported neck pain was associated with a decrease (27% decrease in incidence rate).

Conclusion

Our work identifies important areas of focus in the development of high-quality trials involving both the non-pharmacological and pharmacological treatment of POTS and highlights several characteristics of patients that may be more refractory to both baseline non-pharmacological treatments and current pharmacological treatment strategies.

Social transition, socioeconomic status and self-rated health in China: evidence from a national cross-sectional survey (CGSS)

Background

Social transition is one of the multi-level mechanisms that influence health disparities. However, it has received less attention as one of the non-traditional social determinants of health. A few studies have examined China's social transition and its impact on health inequality in self-rated health (SRH). Therefore, this study explores the impact of China's market-oriented reforms-social transition and socioeconomic status (SES)-on residents' SRH.

Methods

Using the cross-sectional data from the Chinese General Social Survey (CGSS) in 2017, we analyzed the effects of social transition and SES on the SRH of Chinese residents using the RIF (Recentered influence function) method. The RIF decomposition method investigated health differences among different populations and their determinants.

Results

Social transition and SES have significant positive effects on the SRH of Chinese residents. The correlation between SES and the SRH of Chinese residents is moderated by social transition, implying that social transition can weaken the correlation between SES and the SRH of Chinese residents. The impacts of SES and social transition on SRH vary across populations.

Conclusion

Promoting social transition and favoring disadvantaged groups with more resources are urgently needed to promote equitable health outcomes.

Factors Associated with College Students' Attitudes Toward Telehealth for Primary Care

Introduction: Establishing routine primary care visits helps to prevent serious health issues. College students are less likely than the general population to have a regular primary care provider and engage in routine health visits. Recent research provides evidence that telehealth is a convenient alternative to in-person primary care and that college students are comfortable using this technology, suggesting that telehealth has the potential to mitigate this disparity. As attitudes toward telehealth are one critical precursor to behavioral intention and actual utilization of telehealth, the goal of this study was to investigate which factors predict positive or negative attitudes toward telehealth. Methods: Data for this study were collected from a sample of 621 college students at a large southeastern university between September 19, 2022 and December 19, 2022. Results: The study found that college students who reported more trust in physicians, less medical mistrust, and less discrimination in health care settings reported more positive attitudes toward telehealth. Conclusions: These findings suggest that health care providers' skills in delivering patient-centered culturally informed care and building trust and rapport with patients might promote more positive attitudes toward telehealth and, potentially, greater overall utilization of health care services (including both telehealth and in-person services) among college students. This study lays the foundation for future research to examine psychological mechanisms underlying individuals' utilization of telehealth.

The Socioeconomic Distressed Communities Index Predicts 90-Day Mortality Among Intracranial Tumor Patients

BACKGROUND

Socioeconomic status (SES) is a major determinant of quality of life and outcomes. However, SES remains difficult to measure comprehensively. Distress communities index (DCI), a composite of 7 socioeconomic factors, has been increasingly recognized for its correlation with poor outcomes. As a result, the objective of the present study is to determine the predictive value of the DCI on outcomes following intracranial tumor surgery.

METHODS

A single institution, retrospective review was conducted to identify adult intracranial tumor patients undergoing resection (2016-2021). Patient ZIP codes were matched to DCI and stratified by DCI quartiles (low:0-24.9, low-intermediate:25-49.9, intermediate-high:50-74.9, high:75-100). Univariate followed by multivariate regressions assessed the effects of DCI on postoperative outcomes. Receiver operating curves were generated for significant outcomes.

RESULTS

A total of 2389 patients were included: 1015 patients (42.5%) resided in low distress communities, 689 (28.8%) in low-intermediate distress communities, 445 (18.6%) in intermediate-high distress communities, and 240 (10.0%) in high distress communities. On multivariate analysis, risk of fracture (adjusted odds ratio = 1.60, 95% confidence interval 1.26-2.05, P < 0.001) and 90-day mortality (adjusted odds ratio = 1.58, 95% confidence interval 1.21-2.06, P < 0.001) increased with increasing DCI quartile. Good predictive accuracy was observed for both models, with receiver operating curves of 0.746 (95% CI 0.720-0.766) for fracture and 0.743 (95% CI 0.714-0.772) for 90-day mortality.

CONCLUSIONS

Intracranial tumor patients from distressed communities are at increased risk for adverse events and death in the postoperative period. DCI may be a useful, holistic measure of SES that can help risk stratifying patients and should be considered when building healthcare pathways.

Anaemia prevalence and socio-demographic factors among women of reproductive age (WRA): A geospatial analysis of empowered action group (EAG) states in India

Anaemia remains a major nutritional-related health concern for women under reproductive age (WRA) in developing nations like India as well as the Indian EAG states. According to NFHS round-5, EAG states constitute 57% of WRA having any form of anaemia, higher than many other states of India and other developed and developing nations. This study aimed to assess the frequency of anaemia among the WRA in India's eight EAG states. Also, it attempts to analyse the causes associated with anaemia by the women's background characteristics with spatial correlation with its co-variates across 291 districts of the EAG states. One of the most current Demographic and Health Survey's (DHS) cross-sectional data is the NFHS-5th (2019-21) round taken, conducted by the IIPS under the administration of MoHFW, India. This study only included 315,069 women under reproductive age (WRA). The variables related to anaemia among women's (WRA) background socio-demographic characteristics were assessed using bivariate statistics and multinominal logistic regression analysis to comprehend the spatial correlation between women and their determinant factors. Among the EAG states, the overall prevalence of anaemia was 57%, varying from 42.6% in Uttarakhand to 65.3% in Jharkhand. Multinominal logistic regression analyses reveal that the chances of anaemia are remarkably more prevalent in younger women (15-19 years of age), women living in rural areas, no educated and primary level educated women, women belonging to the middle to poorest wealth quintile, women no longer living together, women of the Christian religion, women who are not exposed to reading newspapers, underweight BMI women, and scheduled tribe women. Mainly, the prevalence is observed in the North-eastern and southeastern states of Bihar, Jharkhand, Odisha, Chhattisgarh, some parts of Madhya Pradesh, Uttar Pradesh, and Rajasthan, which is shown by the hotspot map. According to the findings of this study, numerous factors like family, socioeconomic, educational, awareness, and individual characteristics such as caste and domicile all lead to a risk of anaemia. The WRA suffers from anaemia as a result of their socioeconomic background and awareness, which leads to a lack of nourishment, and they seek nutrient deficiencies. To overcome this anaemia, multiple discipline policies and initiatives need to be taken targeting women's wellness and nutritional status by increasing women's education and socioeconomic status.

Improving Diverse and Equitable Involvement of Patients and Caregivers in Research in CKD: Report of a Better Evidence and Translation-Chronic Kidney Disease (BEAT-CKD) Workshop

Patient and caregiver involvement can enhance the uptake and impact of research, but the involvement of patients and caregivers who are underserved and marginalized is often limited. A better understanding of how to make involvement in research more broadly accessible, supportive, and inclusive for patients with chronic kidney disease (CKD) and caregivers is needed. We conducted a national workshop involving patients, caregivers, clinicians, and researchers from across Australia to identify strategies to increase the diversity of patients and caregivers involved in CKD research. Six themes were identified. Building trust and a sense of safety was considered pivotal to establishing meaningful relationships to support knowledge exchange. Establishing community and connectedness was expected to generate a sense of belonging to motivate involvement. Balancing stakeholder goals, expectations, and responsibilities involved demonstrating commitment and transparency by researchers. Providing adequate resources and support included strategies to minimize the burden of involvement for patients and caregivers. Making research accessible and relatable was about nurturing patient and caregiver interest by appealing to intrinsic motivators. Adapting to patient and caregiver needs and preferences required tailoring the approach for individuals and the target community. Strategies and actions to support these themes may support more diverse and equitable involvement of patients and caregivers in research in CKD.