The Neighborhood Atlas Area Deprivation Index For Measuring Socioeconomic Status: An Overemphasis On Home Value

Disparities in Infection Risk Among Home Health Care Patients: A Study Using Area Deprivation Index

OBJECTIVE

To examine the association between neighborhood deprivation and infection-related hospitalizations among home health care (HHC) patients across different rurality levels.

DESIGN

Retrospective observation analysis of 2019 national data sets, including Medicare data linked to 2019 Area Deprivation Index (ADI) data and Rural-Urban Continuum Codes (RUCCs).

SETTING AND PARTICIPANTS

The sample includes 3,656,810 HHC patients from 8135 HHC agencies nationwide. Patients were predominantly White (77.6%), with an average age of 80 years, and mostly female (61.7%). The sample included 24% dual-eligible patients and those living in large metropolitan (53.8%), small metro (30.2%), rural adjacent (11.4%), and remote rural areas (4.6%).

METHODS

Hospital admissions due to infection were identified through International Classification of Diseases, Tenth Revision (ICD-10), codes. Neighborhood deprivation was measured by the 2019 ADI. Patients were stratified by RUCC (large metro, small metro, rural adjacent, or remote rural). Within each rurality stratum, ADI quartiles were constructed, with higher quartiles indicating greater neighborhood deprivation. Multivariable logistic regression was conducted, adjusting for multiple-level variables.

RESULTS

As neighborhood deprivation increased, there was a rise in the proportion of dual-eligible, female, Black, and Hispanic patients, whereas the proportion of White patients decreased, especially in rural areas. Rural areas with higher ADI rankings showed lower quality metrics and reduced health care resources. Higher ADI quartiles were significantly associated with increased infection risks after adjusting for covariates, but this was only observed in remote rural areas, not in urban areas.

CONCLUSIONS AND IMPLICATIONS

The findings highlight significant policy and clinical implications for remote rural areas. Policymakers should increase investments in rural health infrastructure, enhance telehealth, improve transportation services, and offer incentives for health care providers to practice in these areas. The nonsignificant association between neighborhood deprivation and infection outcomes in metropolitan areas may stem from the ADI's limited sensitivity to urban contexts, highlighting the need for more nuanced indices that better capture urban socioeconomic challenges.

Supporting Primary Care for Medically and Socially Complex Patients in Medicaid Managed Care

Importance

In 2023, the Massachusetts Medicaid and Children's Health Insurance Program (MassHealth) required accountable care organizations (ACOs) to increase payments to primary care practices and shift to monthly payments, currently calibrated to historical revenues and enhanced practice capabilities, such as being staffed to address behavioral health needs. To prevent rewarding practices for avoiding difficult patients, future payments to primary care practices should reflect their patients' apparent need.

Objective

To describe MassHealth's initiative and a complexity-adjusted payment model.

Design, Setting, and Participants

This cross-sectional study of payment model development and performance was conducted between February 2022 and November 2024. Participants included all 2019 Massachusetts Medicaid managed-care eligible members who were enrolled for 183 days or longer.

Exposures

Medical and social complexity.

Main Outcomes and Measures

For each member, the primary care activity level (PCAL) outcome proxies the resources that primary care clinicians need to provide comprehensive, coordinated care. Models were evaluated via R2 and through ratios of observed-to-expected (ie, estimated by the model) outcomes for selected subgroups, which will be approximately 1.0 when payments and expected costs are well matched. The implications of paying practices using PCAL (vs a model based only on age and sex) were explored by examining financial and practice-level characteristics in high and low deciles of practice-level estimated mean.

Results

Among 1 092 742 MassHealth members enrolled in 3602 primary care practices (1 014 252 person-years; mean [SD] age, 25.9 [18.4] years; 538 065 [53.1%] female), the PCAL model achieved R2 = 69.6% and estimates within 10% of observed PCAL spending for high-risk populations (mental health disorders, substance use disorders, complex chronic conditions, and disabilities) and across racial and ethnic groups. Age-adjusted and sex-adjusted payments would overpay practices in the lowest-need decile by 10% and underpay those in the highest-need decile by 34%, while the PCAL model would match payment to estimated need almost exactly in the lowest decile and underpay by just 6% in the highest decile.

Conclusions and Relevance

MassHealth's 2023 reform invests in primary care. This cross-sectional study developed a risk model that can adjust primary care payments to patient needs. Neither age and sex adjustments nor inflated historical payments would provide adequate resources to primary care practices caring for the most complex patients.

Neighborhood socioeconomic deprivation and patient-reported outcomes in symptom management trials for women with breast cancer

PURPOSE

Neighborhood socioeconomic deprivation (NSD) is associated with worse outcomes among patients with cancer, but little is known about NSD-related disparities in patient-reported outcomes (PRO) in clinical trials. We examined the relationship between PROs and NSD in symptom management trials among women with breast cancer.

METHODS

We pooled data from three SWOG randomized trials to examine four outcomes: physical and functional wellbeing (PWB, FWB), average pain, and pain interference. NSD was measured using participants' zip code linked to the area deprivation index (ADI) score, categorized into tertiles. Multivariable linear regression adjusted for sociodemographic and clinical characteristics was used to analyze baseline PROs. Linear mixed models were used to examine if trajectory of PROs from baseline through 24 weeks varied by ADI.

RESULTS

We examined 761 participants, of whom 51% were from least deprived neighborhoods. Participants in the most deprived neighborhoods had worse average pain at baseline (β = .38, 95% CI = .03 to .72, p = .03) while participants in somewhat deprived areas also had worse FWB (β = -1.07, 95% CI = -1.95 to -.20, p = .02) and pain interference (β = 0.42, 95% CI = .09 to .75, p = .01) compared to those from least deprived areas. Hispanic ethnicity and having Medicaid/no insurance were associated with worse outcomes. After adjusting for baseline score, ADI was not associated with any outcome over time.

CONCLUSIONS

Breast cancer patients living in areas with NSD had worse FWB, joint pain, and pain interference at baseline. Clinical trial participants should be screened for community-level needs. Implementing interventions to address those needs could help mitigate disparities.

Neighborhood Socioeconomic Disadvantage and Acute Care Utilization in Washington State Medicaid: A Retrospective Cohort Study

BACKGROUND

Neighborhood disadvantage has been associated with potentially preventable acute care utilization among Medicare beneficiaries, but this association has not been studied in a Medicaid population, which is important for informing more equitable care and policies for this population.

OBJECTIVE

To describe the association between Area Deprivation Index (ADI) and acute care utilization (including potentially preventable utilization) among Medicaid beneficiaries in Washington State.

DESIGN

Retrospective cohort study of 100% Medicaid claims. Mixed effects logistic regression was applied to estimate the association between state-level ADI decile and acute care utilization, adjusting for age, sex, self-identified race and ethnicity, Charlson Comorbidity Index, primary spoken language, individual Federal Poverty Level, homelessness, and rurality. Standard errors were clustered at the Census block group level.

PARTICIPANTS

1.5 million unique adult Medicaid beneficiaries enrolled for at least 11 months of a calendar year during the period 2017-2021.

MAIN MEASURES

Binary measures denoting receipt of ED visits, low-acuity ED visits, hospitalizations in a calendar year.

KEY RESULTS

Increasing levels of neighborhood socioeconomic disadvantage (by ADI decile) were associated with greater odds of any ED visits (adjusted odds ratio (aOR) 1.07, 95% confidence interval (CI) 1.06-1.07), low-acuity ED visits (aOR 1.08, CI 1.08-1.08), and any hospitalizations (aOR 1.02, CI 1.02-1.02).

CONCLUSIONS

Among Medicaid beneficiaries, greater neighborhood socioeconomic disadvantage was associated with increased acute care utilization, including potentially preventable utilization. These findings signal potential barriers to outpatient care access that could be amenable to future intervention by health systems and payers.

Access barriers to anti-CD19+ CART therapy for NHL across a community transplant and cellular therapy network

ABSTRACT

We analyzed access barriers to anti-CD19+ chimeric antigen receptor T cells (CARTs) for non-Hodgkin lymphoma (NHL) within a community-based transplant and cell therapy network registry. A total of 357 intended recipients for approved anti-CD19+ CARTs were identified between 2018 to 2022. The median age at referral was 61 years; referral years were 2018 (4%), 2019 (14%), 2020 (18%), 2021 (26%), and 2022 (38%). Diagnoses included diffuse large B cell (69%), follicular (13%), follicular/large (7%), mantle cell (4%), or other (7%). Axicabtagene ciloleucel (62%), tisagenlecleucel (16%), brexucabtagene autoleucel (13%), and lisocabtagene maraleucel (9 %) were infused into 182 patients. The median durations between referral to consultation, consultation to apheresis, and collection to infusion were 11, 107, and 32 days, respectively. The median duration from consultation to CART infusion declined steadily from 207 days in 2019 to 108 days in 2022 (P < .0001). A total of 124 patients (41%) did not receive CART, mostly for disease progression (34%) or poor health (15%). Multivariable logistic regression showed no significant differences in demographic, financial, or social determinants compared with those receiving CART. Notably, the proportion of ineligible patients declined from 53% in 2018-2020 to 34% by 2021-2022 (P = .001). In conclusion, 41% of community patients were unable to access timely CART therapy, mostly due to attrition from disease-related causes, and the overall time to infusion exceeded 4 months. Time to infusion and the proportion receiving CARTs improved over time. Reducing time to apheresis, early referral, and attention to salvage/bridging strategies are necessary.

Neighborhood-level socioeconomic disadvantage is associated with multiple cognitive domains in a community sample of older adults

Greater neighborhood disadvantage is associated with poorer global cognition. However, less is known about the variation in the magnitude of neighborhood effects across individual cognitive domains and whether the strength of these associations differs by individual-level factors. The current study investigated these questions in a community sample of older adults (N = 166, mean age = 72.5 years, 51% women), who reported current addresses, linked to state-level Area Deprivation Index rankings, and completed remote and validated neuropsychological tests of verbal intelligence (North American Adult Reading Test), verbal fluency (Controlled Oral Word Association Test), attention (Digit Span Forward), and working memory (Digit Span Backward and Sequencing, Letter-Number Sequencing). Linear regressions tested associations between neighborhood disadvantage and each cognitive test, controlling for individual-level factors (age, sex, education). Exploratory analyses tested moderation by each individual-level factor. Independent of individual-level factors, greater neighborhood disadvantage was associated with lower cognitive performance across domains: verbal intelligence (β = 0.30, p < .001), verbal fluency (β = -0.19, p = .014), attention (β = -0.19, p = .024), and two of three tests of working memory (β = -0.17- -0.22, ps = .004-.039). Results were robust to correction for multiple comparisons and tests of spatial autocorrelation. In addition, higher neighborhood disadvantage was associated with lower verbal fluency for older - but not younger-older adults (p = .035) and with poorer working memory in women but not men (p < .001). Education did not moderate associations. Findings suggest that older adults living in more disadvantaged neighborhoods exhibit lower cognitive performance, particularly in the domain of verbal intelligence. Continued investigation of effect modification may be fruitful for uncovering for whom associations are strongest.

Neighborhood disadvantage is associated with working memory and hippocampal volumes among older adults

It is not well understood how neighborhood disadvantage is associated with specific domains of cognitive function and underlying brain health within older adults. Thus, the objective was to examine associations between neighborhood disadvantage, brain health, and cognitive performance, and examine whether associations were more pronounced among women. The study included 136 older adults who underwent cognitive testing and MRI. Neighborhood disadvantage was characterized using the Area Deprivation Index (ADI). Descriptive statistics, bivariate correlations, and multiple regressions were run. Multiple regressions, adjusted for age, sex, education, and depression, showed that higher ADI state rankings (greater disadvantage) were associated with poorer working memory performance (p < .01) and lower hippocampal volumes (p < .01), but not total, frontal, and white matter lesion volumes, nor visual and verbal memory performance. There were no significant sex interactions. Findings suggest that greater neighborhood disadvantage may play a role in working memory and underlying brain structure.

A Scoping Review and Assessment of the Area-Level Composite Measures That Estimate Social Determinants of Health Across the United States

OBJECTIVES

Evidence-informed population health initiatives often leverage data from various sources, such as epidemiologic surveillance data and administrative datasets. Recent interest has arisen in using area-level composite measures describing a community's social risks to inform the development and implementation of health policies, including payment reform initiatives. Our objective was to capture the breadth of available area-level composite measures that describe social determinants of health (SDH) and have potential for application in population health and policy work.

METHODS

We conducted a scoping review of the scientific literature from 2010 to 2022 to identify multifactorial indices and rankings reflected in peer-reviewed literature that estimate SDH and that have publicly accessible data sources. We discovered several additional composite measures incidental to the scoping review process. Literature searches for each composite measure aimed to contextualize common applications in public health investigations.

RESULTS

From 491 studies, we identified 31 composite measures and categorized them into 8 domains: environmental conditions and pollution, opportunity and infrastructure, deprivation and well-being, COVID-19, rurality, food insecurity, emergency response and community resilience, and health. Composite measures are applied most often as an independent variable associated with disparities, risk factors, and/or outcomes affecting individuals, populations, communities, and health systems.

CONCLUSIONS

Area-level composite measures describing SDH have been applied to wide-ranging population health work. Social risk indicators may enable policy makers, evaluators, and researchers to better assess community risks and needs, thereby facilitating the evidence-informed development, implementation, and study of initiatives that aim to improve population health.

Comparative Analysis of Indices for Social Determinants of Health in Pediatric Surgical Populations

Importance

Conclusions vary substantially among studies examining associations between area-based social determinants of health (SDOH) and pediatric health disparities based on the selected patient population and SDOH index. Most national studies use zip codes, which encompass a wide distribution of communities, limiting the generalizability of findings.

Objectives

To characterize the distributions of composite SDOH indices for pediatric surgical patients within a national sample of academic children's hospitals and to assess SDOH index precision in classifying patients at similar levels of disadvantage.

Design, Setting, and Participants

This multicenter retrospective cohort study included patients younger than 18 years who underwent surgery from January 1, 2016, to December 31, 2021, at 8 American College of Surgeons National Surgical Quality Improvement Program Pediatric children's hospitals. Data were analyzed November 15, 2023, to September 25, 2024.

Exposures

Exposures included the Social Vulnerability Index (SVI), Area Deprivation Index (ADI), and Child Opportunity Index (COI), which are composite scores of SDOH factors within a geographic area. A standardized, high-fidelity process was developed to link individual patients to SDOH indices at the US census tract and census block group level.

Main Outcomes and Measures

The primary outcome was composite SDOH index distribution, which was assessed using interrater reliability scores. Substantial agreement was defined as a Cohen κ statistic higher than 0.60.

Results

Of 55 865 included patients, 54.6% were male; 34.8% were infants and toddlers (0-3 years of age), 39.0% were school age (4-12 years), and 26.2% were adolescents (13-17 years). A total of 3468 patients (6.2%) could not be matched to either an SVI, ADI, or COI. Patients with missing geocodes were more likely to be Hispanic (20.1% vs 17.1%; P < .001) and have Medicaid insurance (48.1% vs 44.6%; P < .001) compared with patients with addresses that could be geocoded. With all institutions grouped, SDOH indices showed only minor variations. However, within each institution and among institutions, indices varied considerably, especially the ADI. Indices had low-to-fair interrater reliability within institutions (κ range, 0.15-0.33), indicating that each index classified individual patients differently according to disadvantage.

Conclusions and Relevance

In this multicenter retrospective cohort study of 55 865 pediatric surgical patients, 3 different composite measures of SDOH classified disadvantage for individual patients differently. The SDOH index components should be understood and carefully considered prior to inclusion of a composite measure in the analysis of children's surgical outcomes.

The development of the Community Deprivation Index and its application to accountable care organizations

There is strong interest among policymakers to adjust for area-level deprivation when making payments to providers because such areas have traditionally been underserved. The Medicare Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model provides higher payments to ACOs serving areas with greater deprivation. Area Deprivation Index (ADI) is the primary component to measure deprivation for ACO REACH. The ADI is a commonly used deprivation index, but there are concerns about its methodology, primarily its use of nonstandardized deprivation factors. Prior research indicates the ADI is mainly determined by home values, which does not allow it to adequately capture deprivation in urban areas. This paper revises and updates the ADI, using American Community Survey data to compute a census block group deprivation index, the Community Deprivation Index (CDI). The CDI standardizes the deprivation factors to be unit neutral, applies statistical shrinkage to account for the imprecise measurement of the factors, updates several factors, and reweights the factors using the most recently available data. Validation tests suggest the CDI exhibits higher correlations with several health outcome/utilization measures than the ADI. The CDI will better serve policymakers by improving identification of urban areas with higher deprivation.

Standardizing social determinants of health data: a proposal for a comprehensive screening tool to address health equity a systematic review

Social determinants of health (SDoH) significantly impacts health outcomes and disparities. While the Centers for Medicare and Medicaid Services has mandated hospitals to collect standardized SDoH data, existing tools lack key elements. This systematic review identified 78 studies and 20 screening tools addressing various SDoH domains. However, most tools were missing several key domains and lacked standardization. We propose a comprehensive tool meeting essential criteria: validated questions, brevity, actionability, cultural appropriateness, workflow integration, and community linkage. Our tool addresses gaps in available tools and incorporates standardized and validated questions to enable patient-centered screening for diverse social and environmental determinants of health. It uniquely includes detailed race/ethnicity data collection, housing characteristics, physical activity assessment, access to healthy food measures, and environmental exposure evaluation. The tool aims to provide actionable data for immediate interventions while informing broader population health strategies and policy initiatives. By offering a holistic assessment of SDoH across multiple domains, our tool enables standardized data collection, risk stratification, and focused initiatives to address health inequities at both individual and population levels. Further research is needed to develop evidence-based pathways for integrating SDoH data into real-world patient care workflows, improve risk prediction algorithms, address health-related social needs, and reduce disparities.

Comparing Deprivation vs Vulnerability Index Performance Using Medicare Beneficiary Surgical Outcomes

Importance

Health care researchers, professionals, payers, and policymakers are increasingly relying on publicly available composite indices of area-level socioeconomic deprivation to address health equity. Implications of index selection, however, are not well understood.

Objective

To compare the performance of 2 frequently used deprivation indices using policy-relevant outcomes among Medicare beneficiaries undergoing 3 common surgical procedures.

Design, Setting, and Participants

This cross-sectional study examined outcomes among Medicare beneficiaries (65 to 99 years old) undergoing 1 of 3 common surgical procedures (hip replacement, knee replacement, or coronary artery bypass grafting) between 2016 and 2019. Index discriminative performance was compared for beneficiaries residing in tracts with high- and low-deprivation levels (deciles) according to each index. Analyses were conducted between December 2022 and August 2023.

Main Outcomes and Measures

Tract-level deprivation was operationalized using 2020 releases of the area deprivation index (ADI) and the social vulnerability index (SVI). Binary outcomes were unplanned surgery, 30-day readmissions, and 30-day mortality. Multivariable logistic regression models, stratified by each index, accounted for beneficiary and hospital characteristics.

Results

A total of 2 433 603 Medicare beneficiaries (mean [SD] age, 73.8 [6.1] years; 1 412 968 female beneficiaries [58.1%]; 24 165 Asian [1.0%], 158 582 Black [6.5%], and 2 182 052 White [89.7%]) were included in analyses. According to both indices, beneficiaries residing in high-deprivation tracts had significantly greater adjusted odds of all outcomes for all procedures when compared with beneficiaries living in low-deprivation tracts. However, compared to ADI, SVI resulted in higher adjusted odds ratios (adjusted odds ratios, 1.17-1.31 for SVI vs 1.09-1.23 for ADI), significantly larger outcome rate differences (outcome rate difference, 0.07%-5.17% for SVI vs outcome rate difference, 0.05%-2.44% for ADI; 95% CIs excluded 0), and greater effect sizes (Cohen d, 0.076-0.546 for SVI vs 0.044-0.304 for ADI) for beneficiaries residing in high- vs low-deprivation tracts.

Conclusions and Relevance

In this cross-sectional study of Medicare beneficiaries, SVI had significantly better discriminative performance-stratifying surgical outcomes over a wider range-than ADI for identifying and distinguishing between high- and low-deprivation tracts, as indexed by outcomes for common surgical procedures. Index selection requires careful consideration of index differences, index performance, and contextual factors surrounding use, especially when informing resource allocation and health care payment adjustment models to address health equity.

Effects of Air Pollution on Respiratory Events and Pain Crises among Children with Sickle Cell Disease in New York City

Rationale: The disease burden of sickle cell disease (SCD) is highest among U.S. Black and Hispanic populations, which are often disproportionately represented in communities with poor air quality. There are limited data on the effects of air pollution exposure and social environmental factors on health outcomes in children with SCD. Objectives: The objectives of our study were to examine the associations between air pollution exposure and acute respiratory and vaso-occlusive pain crises (VOCs) and to further study the associations when stratifying by asthma status and neighborhood disadvantages. Methods: We conducted a retrospective study, collecting data on outpatient sick and emergency department visits, hospital admissions for respiratory events (i.e., respiratory tract infections, asthma exacerbation, acute chest syndrome), and hospitalizations for VOCs among children with SCD in a tertiary care center in New York City from 2015 to 2018. Modeled data from the New York City Community Air Survey data using home addresses' estimated street-level annual average exposure to air pollution (i.e., black carbon, particulate matter with an aerodynamic diameter ≤2.5 μm, and nitrogen dioxide). The area deprivation index (ADI) continuous national ranking percentile (1-100) was used, representing a composite index for neighborhood-level social disadvantage. We further dichotomized study participants at the upper tertile (high vs. low ADI). Multivariable Poisson regression in generalized estimating equation models were used to estimate relative risks (RRs) after adjusting for potential covariates. Results: A total of 114 children with SCD were included in this study and had between one and four annual repeated measures of annual average air pollutants over a total of 425 visits. Overall, there were no significant associations between air pollution levels and acute respiratory pain crises and VOCs among children with SCD and when stratified by asthma status. We found significant interactions between air pollution levels and the continuous ADI variable on respiratory outpatient and frequent respiratory outpatient/ED visits (P < 0.1). When stratified by high ADI, increased exposure to particulate matter with an aerodynamic diameter ≤2.5 μm was significantly associated with more frequent respiratory outpatient/emergency department visits among children residing in higher ADI neighborhoods (RR [95% confidence interval], 1.13 [1.01, 1.27]; P < 0.05), but not among those in lower ADI neighborhoods. Increased exposure to nitrogen dioxide was associated with more outpatient respiratory events for children in high ADI neighborhoods (RR [95% confidence interval], 2.74 [1.24, 6.08]; P < 0.05) compared with low ADI neighborhoods. Conclusions: Air pollution exposures increased respiratory complications among children with SCD living in deprived neighborhoods.

Patient Photograph Association With Radiologist Recommendations for Additional Imaging

OBJECTIVE

Assess whether display of a patient photograph in the electronic health record (EHR) alongside head and neck CT or MRI radiology examinations is associated with recommendations for additional imaging (RAI) and whether self-reported race modifies that association.

METHODS

This multi-institution health care system retrospective observational study from June 1, 2021 to May 31, 2022 included all patients with a head/neck CT or MRI report. We investigated association of photograph with RAIs using mixed-effects models adjusting for age, sex, complexity score, race, and area deprivation index while conditioning on patient and radiologist. Race was subsequently included as an interaction term. Multiple imputation was used as sensitivity analysis to address missing race data.

RESULTS

In all, 60,543 reports were included from 48,143 patients (55.6% female; median age 58 years, interquartile range 40-70). The EHR included a photograph at the time 18.2% (11,048 of 60,543) of reports were signed. RAIs were included in 7.5% (4,522 of 60,543) of reports. Reports signed when a photograph was displayed had lower estimated odds of containing RAIs (odds ratio: 0.85, 95% confidence interval: 0.77-0.93, P < .001), consistent in sensitivity analysis, with no clear interaction between race and photograph (odds ratio: 0.99, 95% confidence interval: 0.69-1.46, P = .97).

DISCUSSION

Patients with a photograph in the EHR had a lower probability of receiving RAIs and this difference did not seem to be the result of implicit racial bias but may be due to personalization of the encounter. This effect may influence radiology reporting for millions of patients per year. Further research is needed to determine whether the association has a positive or negative impact on care quality and outcomes.

Health Disparities Research: What Every Pediatric Surgeon Should Know

While the earliest published health disparity research in the United States dates to 1899, the field was not formally established until the late 20th century. Initially focused on race and ethnicity, the field has broadened to include socioeconomic status. Several measures have been developed to quantify socioeconomic disadvantage, including the Social Vulnerability Index, Area Deprivation Index, and Child Opportunity Index. These indices have been validated and demonstrate correlation with health outcomes. However, socioeconomic status cannot fully explain health inequities experienced by people of minoritized racial and ethnic identities. Three generations of health disparities research have been described-identification of disparities, root analysis, and development of interventions to mitigate health inequities. While there has been an increase in publication of health disparity research, there is little third generation work. It is imperative that health disparities research move beyond defining the problem and toward interventions that will reduce health inequities. LEVELS OF EVIDENCE: Level IV.

Prone to Stones?: Evaluating the association between food insecurity, psychiatric comorbidity, and pediatric stone management

INTRODUCTION

Pediatric stone disease incidence has increased steadily over the last few decades. Several interrelated factors have been proposed to contribute to these epidemiologic trends including increased ambient temperature, body habitus, and food insecurity.

OBJECTIVE

Given the significant cohort of children living with food insecurity in the United States, the aim of this study is to explore the relationship between food desert residence and obstructing stone disease resulting in surgical intervention in a cohort of pediatric patients.

STUDY DESIGN

Records of pediatric patients who presented to a single tertiary pediatric medical center for urolithiasis between 2009 and 2023 were retrospectively reviewed. Patients were included in the study if they had an obstructing stone; were older than 5 years of age; lacked anatomical predispositions to stone formation; and were regularly consuming a solid diet. Variables studied included demographics, BMI, medical comorbidities and family history, procedures performed, and stone burden. Patients' likelihood of living in a food desert was approximated using the United States Department of Agriculture Food Access Research Atlas.

RESULTS

Of 637 patients reviewed, 199 pediatric patients (90 male and 109 female) were included in our analysis. One hundred and thirty patients (65.3%) had undergone ureteroscopy. Fifty-seven patients (28.6%) had a documented psychiatric comorbidity at time of presentation, with ADHD being the most common psychiatric comorbidity treated via medical management (n = 25, 43.9%). Our analysis demonstrated a significant association between surgical intervention, food desert residence (p = 0.003), and increased stone size (p = 0.001). Additionally, increased time between discharge on medical expulsive therapy and surgery decision was associated with past medical history of stones (p = 0.033) and food desert residence while undergoing stimulant treatment for ADHD (p < 0.001).

CONCLUSION

In this study, we found a significant association between food desert residence and obstructing pediatric stone disease resulting in surgical intervention. We also discuss a potential new association with pediatric stone disease: psychiatric comorbidity and the medical management of such diagnoses. To our knowledge, our study is among the first to assess the association between food insecurity and surgical intervention of pediatric urolithiasis. Given the importance diet plays in medical management of stone development, clinicians should take care to assess food security status of pediatric urolithiasis patients. Limitations to our study include a patient cohort from a singular hospital system, small sample size, and the changing nature of a patients' food security status.

Neighborhood Environment and Longitudinal Follow-Up of Glycosylated Hemoglobin for Youth with Overweight or Obesity

Background: Neighborhood environment, which includes multiple social drivers of health, has been associated with a higher incidence of chronic conditions in adult cohorts. We examine if neighborhood environment is associated with glycosylated hemoglobin (HbA1c) and body mass index (BMI) as a percentage of the 95th percentile (BMIp95) for youth with overweight and obesity. Methods: Cohort study using electronic health record data from a large Midwestern Children's Hospital. Youth aged 8-16 years qualified for the study with a documented BMI ≥ 85th percentile and two HbA1c test results between January 1, 2017, and December 31, 2019. Neighborhood environment was measured using area deprivation index (ADI). Results: Of the 1,309 youth that met eligibility, mean age was 14.0 ± 3.2 years, 58% female, 48% Black, and 39% White. At baseline, the average (SD) of BMIp95 was 126.1 (26.14) and HbA1c5.4 (0.46). 670 (51%) lived in a more deprived (MD) area. The median time to follow-up was 15-months. Youth that lived in a MD area had a significantly higher follow-up HbA1c (β = 0.034, p = 0.03, 95% confidence interval [CI]: [0.00, 0.06]) and BMIp95 (β = 1.283, p = 0.03, 95% CI: [0.13, 2.44]). An increase in BMIp95 was associated with worse HbA1c for most youth that lived in a MD area. Conclusions: Youth that lived in an MD area had a small but statistically significant higher level of HbA1c and BMIp95 at follow-up. Public health surveillance systems should include ADI as a risk factor for longitudinal progression of cardiometabolic diseases.

Association Between Neighborhood Deprivation and Number of Ophthalmology Providers

PURPOSE

The Area Deprivation Index (ADI) is a quantitative measurement of neighborhood socioeconomic disadvantage used to identify high-risk communities. The distribution of physicians with respect to ADI can indicate decreased healthcare access in deprived neighborhoods. This study applies ADI to the distribution of ophthalmologists and demonstrates how practice patterns in the national Medicare Part D program may vary with ADI.

METHODS

The Centers for Medicare and Medicaid Services Data "Medicare Part D Prescribers by Provider" data for 2021 was analyzed. Geocodio identified ADIs corresponding to the practice addresses listed in the dataset. The national rank ADIs were compared against the number of ophthalmologists. Spearman's correlation test and one-way ANOVA determined statistically significant differences in Medicare data extracted between quintiles of ADI ranks.

RESULTS

We identified 14,668 ophthalmologists who provided care to Medicare beneficiaries. Each time ADI increased by 10, there was an average 9.4% decrease in ophthalmologists (p < 0.001). The distribution of ophthalmologists practicing throughout the United States by increasing ADI quintile are: 32%, 23%, 19%, 16%, and 9%. Providers practicing in neighborhoods in the first-ADI quintile were more likely to see Medicare beneficiaries compared to providers in the fifth-ADI quintile (p < 0.001).

CONCLUSION

The lack of ophthalmologists in high-ADI areas results in reduced eye care access in deprived neighborhoods. Many factors contribute to these disparities including limited access to metropolitan areas/academic institutions and fewer residency programs. Future programs and policies should focus efforts on creating an even distribution of ophthalmologists across the United States and improving access to eye care.

Addressing cost barriers to healthy eating with Eat Well, a prescription produce subsidy, for patients with diabetes and at risk for food insecurity: Study protocol for a type 1 hybrid effectiveness-implementation pragmatic randomized controlled trial

BACKGROUND

Patients with diabetes at risk of food insecurity face cost barriers to healthy eating and, as a result, poor health outcomes. Population health management strategies are needed to improve food security in real-world health system settings. We seek to test the effect of a prescription produce program, 'Eat Well' on cardiometabolic health and healthcare utilization. We will also assess the implementation of an automated, affirmative outreach strategy.

METHODS

We will recruit approximately 2400 patients from an integrated academic health system in the southeastern United States as part of a two-arm parallel hybrid type 1 pragmatic randomized controlled trial. Patients with diabetes, at risk for food insecurity, and a recent hemoglobin A1c reading will be eligible to participate. The intervention arm receives, 'Eat Well', which provides a debit card with $80 (added monthly) for 12 months valid for fresh, frozen, or canned fruits and vegetables across grocery retailers. The control arm does not. Both arms receive educational resources with diabetes nutrition and self-management materials, and information on existing care management resources. Using an intent-to-treat analysis, primary outcomes include hemoglobin A1C levels and emergency department visits in the 12 months following enrollment. Reach and fidelity data will be collected to assess implementation.

DISCUSSION

Addressing food insecurity, particularly among those at heightened cardiometabolic risk, is critical to equitable and effective population health management. Pragmatic trials provide important insights into the effectiveness and implementation of 'Eat Well' and approaches like it in real-world settings.

REGISTRATION

ClinicalTrials.gov Identifier: NCT05896644; Clinical Trial Registration Date: 2023-06-09.

Racial, ethnic, and neighborhood socioeconomic disparities in local cannabis retail policy in California

BACKGROUND

Policies governing legal cannabis commerce can vary widely within a U.S. state when local control exists. Disproportionate distribution of policies allowing retail sale, protecting public health, or promoting equity in licensing may contribute to differences in health and economic outcomes between sociodemographic subgroups. This cross-sectional study jointly examined racial, ethnic, and neighborhood socioeconomic characteristics of Californians subject to specific local cannabis policies to identify such disparities.

METHODS

Local laws in effect January 1, 2020, governing retail cannabis sales (bans, expanding buffers from youth-serving sites, restricting advertising, promoting equity in licensing, and capping outlets) were determined for California's 539 jurisdictions. The number of Asian, Black, Latinx, and white residents in socioeconomic advantaged versus disadvantaged neighborhoods (Census block groups) was determined using 2015-2019 American Community Survey data. We estimated proportions of the sociodemographic subpopulations covered by specific policies based on the block group's jurisdiction. To ascertain disparities in coverage proportions were compared across subgroups using Z-tests with the Bonferroni correction.

RESULTS

Residents of socioeconomically advantaged neighborhoods were more likely to live in jurisdictions allowing retail cannabis commerce than those in disadvantaged neighborhoods (61.7 % versus 54.8 %). Black residents in advantaged neighborhoods were most likely to live where retailing was allowed (69 %), and white residents in disadvantaged neighborhoods least likely (49 %). Latinx and Black populations from disadvantaged neighborhoods were most likely to live in jurisdictions with stronger advertising restrictions (66 %). Equity in licensing policy was more prevalent for Black residents living in advantaged neighborhoods (57 %) than disadvantaged neighborhoods (49 %).

CONCLUSIONS

Local cannabis policies potentially protecting public health and social equity are unequally distributed across race, ethnicity, and socioeconomic characteristics in California. Research examining whether differential policy exposure reduces, creates, or perpetuates cannabis-related health and socioeconomic disparities is needed.

A retrospective cohort study of socioeconomic deprivation and post-liver transplant survival in adults

The Area Deprivation Index is a granular measure of neighborhood socioeconomic deprivation. The relationship between neighborhood socioeconomic deprivation and recipient survival following liver transplantation (LT) is unclear. To investigate this, the authors performed a retrospective cohort study of adults who underwent LT at the University of Washington Medical Center from January 1, 2004, to December 31, 2020. The primary exposure was a degree of neighborhood socioeconomic deprivation as determined by the Area Deprivation Index score. The primary outcome was posttransplant recipient mortality. In a multivariable Cox proportional analysis, LT recipients from high-deprivation areas had a higher risk of mortality than those from low-deprivation areas (HR: 1.81; 95% CI: 1.03-3.18, p =0.04). Notably, the difference in mortality between area deprivation groups did not become statistically significant until 6 years after transplantation. In summary, LT recipients experiencing high socioeconomic deprivation tended to have worse posttransplant survival. Further research is needed to elucidate the extent to which neighborhood socioeconomic deprivation contributes to mortality risk and identify effective measures to improve survival in more socioeconomically disadvantaged LT recipients.

Development and validation of a community risk score for sexual and reproductive health in the United States

Equitable access to sexual and reproductive health (SRH) care is key to reducing inequities in SRH outcomes. Publicly funded family-planning services are an important source of SRH care for people with social risk factors that impede their access. This study aimed to create a new index (Local Social Inequity in SRH [LSI-SRH]) to measure community-level risk of adverse SRH outcomes based on social determinants of health (SDoH). We evaluated the validity of the LSI-SRH scores in predicting adverse SRH outcomes and the need for publicly funded services. The data were drawn from more than 200 publicly available SDoH and SRH measures, including availability and potential need for publicly supported family planning from the Guttmacher Institute. The sample included 72 999 Census tracts (99.9%) in the 50 states and the District of Columbia. We used random forest regression to predict the LSI-SRH scores; 42 indicators were retained in the final model. The LSI-SRH model explained 81% of variance in the composite SRH outcome, outperforming 3 general SDoH indices. LSI-SRH scores could be a useful for measuring community-level SRH risk and guiding site placement and resource allocation.

Impact of Social Determinants of Health on Predictive Models for Outcomes After Congenital Heart Surgery

BACKGROUND

Despite documented associations between social determinants of health and outcomes post-congenital heart surgery, clinical risk models typically exclude these factors.

OBJECTIVES

The study sought to characterize associations between social determinants and operative and longitudinal mortality as well as assess impacts on risk model performance.

METHODS

Demographic and clinical data were obtained for all congenital heart surgeries (2006-2021) from locally held Congenital Heart Surgery Collaborative for Longitudinal Outcomes and Utilization of Resources Society of Thoracic Surgeons Congenital Heart Surgery Database data. Neighborhood-level American Community Survey and composite sociodemographic measures were linked by zip code. Model prediction, discrimination, and impact on quality assessment were assessed before and after inclusion of social determinants in models based on the 2020 Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model.

RESULTS

Of 14,173 total index operations across New York State, 12,321 cases, representing 10,271 patients at 8 centers, had zip codes for linkage. A total of 327 (2.7%) patients died in the hospital or before 30 days, and 314 children died by December 31, 2021 (total n = 641; 6.2%). Multiple measures of social determinants of health explained as much or more variability in operative and longitudinal mortality than clinical comorbidities or prior cardiac surgery. Inclusion of social determinants minimally improved models' predictive performance (operative: 0.834-0.844; longitudinal 0.808-0.811), but significantly improved model discrimination; 10.0% more survivors and 4.8% more mortalities were appropriately risk classified with inclusion. Wide variation in reclassification was observed by site, resulting in changes in the center performance classification category for 2 of 8 centers.

CONCLUSIONS

Although indiscriminate inclusion of social determinants in clinical risk modeling can conceal inequities, thoughtful consideration can help centers understand their performance across populations and guide efforts to improve health equity.

Regional variation in financial hardship among US veterans during the COVID-19 pandemic

Geographic variation in hardship, especially health-related hardship, was identified prior to and during the pandemic, but we do not know whether this variation is consistent among Veterans Health Administration (VHA)-enrolled veterans, who reported markedly high rates of financial hardship during the pandemic, despite general and veteran-specific federal policy efforts aimed at reducing hardship. In a nationwide, regionally stratified sample of VHA-enrolled veterans, we examined whether the prevalence of financial hardship during the pandemic varied by US Census region. We found veterans in the South, compared with those in other census regions, reported higher rates of severe-to-extreme financial strain, using up all or most of their savings, being unable to pay for necessities, being contacted by collections, and changing their employment due to the kind of work they could perform. Regional variation in veteran financial hardship demonstrates a need for further research about the role and interaction of federal and state financial-assistance policies in shaping risks for financial hardship as well as potential opportunities to mitigate risks among veterans and reduce variation across regions.

Neighborhood Deprivation and Treatment Challenges in Pediatric Musculoskeletal Infections: A Socioeconomic Analysis

Introduction Musculoskeletal (MSK) infections are prevalent in the pediatric population, with previous research highlighting the significant impact of socioeconomic status (SES) on treatment outcomes. However, the specific link in pediatric cohorts remains poorly understood. The Area Deprivation Index (ADI), a measure of neighborhood-level disadvantage, serves as a crucial marker for SES. This study aims to investigate how ADI influences disease characteristics, treatment delays, and outcomes in pediatric patients with MSK infections. Methods A single-center retrospective cohort analysis was conducted using patient charts from a large urban pediatric hospital over six years from 2017 to 2022. Patients aged 0-18 years with diagnoses of osteomyelitis, septic arthritis, cellulitis, or pyomyositis were identified using the International Classification of Diseases - 10th Revision (ICD-10) codes. Data collection included demographics, disease characteristics, treatment delay intervals, and complications. Patient zip codes were obtained and entered into the Neighborhood Atlas® mapping website to determine their ADI. Patients were then stratified into four groups based on ADI scores: 1-10, 11-20, 21-40, and 41-100. Statistical analysis included the use of the Mann-Whitney U test for continuous data and the Chi-square/Fisher's exact test for binary and categorical data comparisons among the ADI groups. Results A total of 121 patients were included. Categorization based on ADI revealed 25 (20.7%) patients in the 1-10 ADI percentile group, 36 (29.8%) in the 11-20 group, 38 (31.4%) in the 21-40 group, and 22 (18.2%) in the 41-100 group. There were no significant differences between ADI and patient demographics, disease characteristics, presentation delay interval, treatment received, and complications. Conclusion The study demonstrates that there was no significant difference between ADI groups regarding demographics, disease characteristics, presentation delay interval, treatment received, and complications in pediatric populations. Despite the lack of evidence for differences in MSK infections attributable to ADI, this does not negate the potential existence of such a relationship.

Financial hardship and neighborhood socioeconomic disadvantage in long-term childhood cancer survivors

BACKGROUND

Long-term survivors of childhood cancer face elevated risk for financial hardship. We evaluate whether childhood cancer survivors live in areas of greater deprivation and the association with self-reported financial hardships.

METHODS

We performed a cross-sectional analysis of data from the Childhood Cancer Survivor Study between 1970 and 1999 and self-reported financial information from 2017 to 2019. We measured neighborhood deprivation with the Area Deprivation Index (ADI) based on current zip code. Financial hardship was measured with validated surveys that captured behavioral, material and financial sacrifice, and psychological hardship. Bivariate analyses described neighborhood differences between survivors and siblings. Generalized linear models estimated effect sizes between ADI and financial hardship adjusting for clinical factors and personal socioeconomic status.

RESULTS

Analysis was restricted to 3475 long-term childhood cancer survivors and 923 sibling controls. Median ages at time of evaluation was 39 years (interquartile range [IQR] = 33-46 years and 47 years (IQR = 39-59 years), respectively. Survivors resided in areas with greater deprivation (ADI ≥ 50: 38.7% survivors vs 31.8% siblings; P < .001). One quintile increases in deprivation were associated with small increases in behavioral (second quintile, P = .017) and psychological financial hardship (second quintile, P = .009; third quintile, P = .014). Lower psychological financial hardship was associated with individual factors including greater household income (≥$60 000 income, P < .001) and being single (P = .048).

CONCLUSIONS

Childhood cancer survivors were more likely to live in areas with socioeconomic deprivation. Neighborhood-level disadvantage and personal socioeconomic circumstances should be evaluated when trying to assist childhood cancer survivors with financial hardships.

Living in high-poverty areas is associated with reduced survival in patients with thoracoabdominal aortic aneurysms

OBJECTIVES

Studies have demonstrated that socioeconomic status, insurance, race, and distance impact clinical outcomes in patients with abdominal aortic aneurysms. The purpose of this study was to assess if these factors also impact clinical outcomes in patients with thoracoabdominal aortic aneurysms (TAAAs).

METHODS

We conducted a retrospective review of patients with TAAAs confirmed by computed tomography imaging between 2009 and 2019 at a single institution. Patients' zip codes were mapped to American Community Survey Data to obtain geographic poverty rates. We used the standard U.S. Census definition of high-poverty concentration as >20% of the population living at 100% of the poverty rate. Our primary outcome was overall survival, stratified by whether the patient underwent repair.

RESULTS

Of 578 patients, 575 had zip code data and were analyzed. In both the nonoperative (N = 268) and operative (N = 307) groups, there were no significant differences in age, race, comorbidities, clinical urgency, surgery utilization, or surgery modality between patients living in high-poverty areas (N = 95, 16.4%) vs not. In the nonoperative group, patients from high-poverty areas were more likely to have aneurysm due to dissection (37.5% vs 17.6%, P = .03). In multivariate analyses, patients from high-poverty zip codes had significantly worse nonoperative survival (hazard ratio [HR]: 1.9, 95% confidence interval [CI]: 1.1-3.3, P = .03). In the repair group, high poverty was also a significant predictor of reduced postoperative survival (HR: 1.65, 95% CI: 1-2.63, P = .04). Adding the Gagne Index, these differences persisted in both groups (nonoperative: HR: 1.93, 95% CI: 1.01-3.70, P = .05; operative: HR: 1.62, 95% CI: 1.03-2.56, P = .04). In Kaplan-Meier analysis, the difference in postoperative survival began approximately 1.5 years after repair. Private insurance was predictive of improved postoperative survival (HR: 0.42, 95% CI: 0.18-0.95, P = .04) but reduced nonoperative survival (HR: 2.05, 95% 1.01-4.14, P = .04). Data were insufficient to determine if race impacted survival discretely from poverty status. These results were found after adjusting for age, race, sex, maximum aortic diameter, coronary artery disease, distance from the hospital, insurance, and active smoking. Interestingly, in multivariate regression, traveling greater than 100 miles was correlated with increased surgery utilization (odds ratio: 1.58, 95% CI: 1.08-2.33, P = .02) and long-term survival (HR: 0.61, 95% CI: 0.41-0.92, P = .02).

CONCLUSIONS

Patients with TAAAs living in high-poverty areas had significantly more dissections and suffered a nearly doubled risk of mortality compared with patients living outside such areas. These data suggest that these disparities are attributed to the overall impacts of poverty and highlight the pressing need for research into TAAA disparities.

Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review

Importance

Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models.

Objective

To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost.

Evidence Review

A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023.

Findings

This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending.

Conclusions and Relevance

The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.

Evaluating potential disparities in geospatial access to American College of Surgeons/American Association for the Surgery of Trauma-verified emergency general surgery centers

BACKGROUND

The American Association for the Surgery of Trauma and the American College of Surgeons have recently introduced emergency general surgery (EGS) center verification, which could enhance patient outcomes. Distance and resource availability may affect access to these centers, which has been linked to higher mortality. Although many patients can receive adequate care at community centers, those with critical conditions may require specialized treatment at EGS-verified centers. We aimed to evaluate geospatial access to potential EGS-verified centers and identify disparities across different scenarios of EGS verification program uptake in the United States.

METHODS

We used hospital capabilities and verified pilot centers to estimate potential patterns of which centers would become EGS verified under four scenarios (EGS centers, high-volume EGS centers, high-volume EGS plus level 1 trauma centers, and quaternary referral centers). We calculated the spatial accessibility index using an enhanced two-step floating catchment technique to determine geospatial access for each scenario. We also evaluated social determinants of health across geospatial access using the Area Deprivation Index (ADI).

RESULTS

A total of 1,932 hospitals were categorized as EGS centers, 307 as high-volume EGS centers, 401 as high-volume EGS plus level 1trauma centers, and 146 as quaternary centers. Spatial accessibility index decreased as the stringency of EGS verification increased in each scenario (226.6 [111.7-330.7], 51.8 [0-126.1], 71.52 [3.34-164.56], 6.2 [0-62.2]; p < 0.001). Within each scenario, spatial accessibility index also declined as the ADI quartile increased ( p < 0.001). The high-volume EGS plus level 1trauma center scenario had the most significant disparity in access between the first and fourth ADI quartiles (-54.68).

CONCLUSION

Access to EGS-verified centers may vary considerably based on the program's implementation. Disadvantaged communities may be disproportionately affected by limited access. Further work to study regional needs can allow a strategic implementation of the EGS verification program to optimize outcomes while minimizing disparities.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Addressing Veteran Health-Related Social Needs: How Joint Commission Standards Accelerated Integration and Expansion of Tools and Services in the Veterans Health Administration

BACKGROUND

The Joint Commission recently named reduction of health care disparities and improvement of health care equity as quality and safety priorities (Leadership [LD] Standard LD.04.03.08 and National Patient Safety Goal [NPSG] Standard NPSG.16.01.01). As the largest integrated health system, the Veterans Health Administration (VHA) sought to leverage these new accreditation standards to further integrate and expand existing tools and initiatives to reduce health care disparities and address health-related social needs (HRSNs).

INITIATIVES AND TOOLS

A combination of existing data tools (for example, Primary Care Equity Dashboard), resource tools (for example, Assessing Circumstances and Offering Resources for Needs tool), and a care delivery approach (for example, Whole Health) are discussed as quality improvement opportunities to further integrate and expand how VHA addresses health care disparities and HRSNs. The authors detail the development timeline, building, limitations, and future plans for these tools and initiatives.

COORDINATION OF INITIATIVES

Responding to new health care equity Joint Commission standards led to new implementation strategies and deeper partnerships across VHA that facilitated expanded dissemination, technical assistance activities, and additional resources for VHA facilities to meet new standards and improve health care equity for veterans. Health care systems may learn from VHA's experiences, which include building actionable data platforms, employing user-centered design for initiative development and iteration, designing wide-reaching dissemination strategies for tools, and recognizing the importance of providing technical assistance for stakeholders.

FUTURE DIRECTIONS

VHA continues to expand implementation of a diverse set of tools and resources to reduce health care disparities and identify and address unmet individual veteran HRSNs more widely and effectively.

A research agenda for understanding how social inequality is linked to brain structure and function

Consistent evidence documents powerful effects of social inequality on health, well-being and academic achievement. Yet research on whether social inequality may also be linked to brain structure and function has, until recently, been rare. Here we describe three methodological approaches that can be used to study this question-single site, single study; multi-site, single study; and spatial meta-analysis. We review empirical work that, using these approaches, has observed associations between neural outcomes and structural measures of social inequality-including structural stigma, community-level prejudice, gender inequality, neighbourhood disadvantage and the generosity of the social safety net for low-income families. We evaluate the relative strengths and limitations of these approaches, discuss ethical considerations and outline directions for future research. In doing so, we advocate for a paradigm shift in cognitive neuroscience that explicitly incorporates upstream structural and contextual factors, which we argue holds promise for uncovering the neural correlates of social inequality.

Deciphering the Neighborhood Atlas Area Deprivation Index: the consequences of not standardizing

The Area Deprivation Index (ADI) is a widely used measure recently selected for several federal payment models that adjusts payments based on where beneficiaries live. A recent debate in Health Affairs focuses on seemingly implausible ADI rankings in major cities and across New York. At the root of the issue is the importance of standardization of measures prior to calculating index scores. Neighborhood Atlas researchers are implicitly arguing that their choice to not standardize is of little consequence. Using the same data and methods as the Neighborhood Atlas, this paper focuses on this choice by calculating and comparing standardized and unstandardized ADI scores. The calculated unstandardized ADI nearly perfectly matches the Neighborhood Atlas ADI (r > 0.9999), whereas the correlation with a standardized version is much lower (r = 0.7245). The main finding is that, without standardization, the ADI is reducible to a weighted average of just 2 measures-income and home values-certainly not the advertised multidimensional measure. Federal programs that have incorporated the ADI risk poorly allocating scarce resources meant to reduce health inequities.

Comparison of two area-level socioeconomic deprivation indices: Implications for public health research, practice, and policy

OBJECTIVES

To compare 2 frequently used area-level socioeconomic deprivation indices: the Area Deprivation Index (ADI) and the Social Vulnerability Index (SVI).

METHODS

Index agreement was assessed via pairwise correlations, decile score distribution and mean comparisons, and mapping. The 2019 ADI and 2018 SVI indices at the U.S. census tract-level were analyzed.

RESULTS

Index correlation was modest (R = 0.51). Less than half (44.4%) of all tracts had good index agreement (0-1 decile difference). Among the 6.3% of tracts with poor index agreement (≥6 decile difference), nearly 1 in 5 were classified by high SVI and low ADI scores. Index items driving poor agreement, such as high rents, mortgages, and home values in urban areas with characteristics indicative of socioeconomic deprivation, were also identified.

CONCLUSIONS

Differences in index dimensions and agreement indicated that ADI and SVI are not interchangeable measures of socioeconomic deprivation at the tract level. Careful consideration is necessary when selecting an area-level socioeconomic deprivation measure that appropriately defines deprivation relative to the context in which it will be used. How deprivation is operationalized affects interpretation by researchers as well as public health practitioners and policymakers making decisions about resource allocation and working to address health equity.

Measuring The Enduring Imprint Of Structural Racism On American Neighborhoods

A long history of discriminatory policies in the United States has created disparities in neighborhood resources that shape ethnoracial health inequities today. To quantify these differences, we organized publicly available data on forty-two variables at the census tract level within nine domains affected by structural racism: built environment, criminal justice, education, employment, housing, income and poverty, social cohesion, transportation, and wealth. Using data from multiple sources at several levels of geography, we developed scores in each domain, as well as a summary score that we call the Structural Racism Effect Index. We examined correlations with life expectancy and other measures of health for this index and other commonly used area-based indices. The Structural Racism Effect Index was more strongly associated with each health outcome than were the other indices. Its domain and summary scores can be used to describe differences in social risk factors, and they provide powerful new tools to guide policies and investments to advance health equity.

Neighborhood Characteristics and Elevated Blood Pressure in Older Adults

Importance

The local environment remains an understudied contributor to elevated blood pressure among older adults. Untargeted approaches can identify neighborhood conditions interrelated with racial segregation that drive hypertension disparities.

Objective

To evaluate independent associations of sociodemographic, economic, and housing neighborhood factors with elevated blood pressure.

Design, Setting, and Participants

In this cohort study, the sample included Health and Retirement Study participants who had between 1 and 3 sets of biennial sphygmomanometer readings from 2006 to 2014 or 2008 to 2016. Statistical analyses were conducted from February 5 to November 30, 2021.

Exposures

Fifty-one standardized American Community Survey census tract variables (2005-2009).

Main Outcomes and Measures

Elevated sphygmomanometer readings over the study period (6-year period prevalence): a value of at least 140 mm Hg for systolic blood pressure and/or at least 90 mm Hg for diastolic blood pressure. Participants were divided 50:50 into training and test data sets. Generalized estimating equations were used to summarize multivariable associations between each neighborhood variable and the period prevalence of elevated blood pressure, adjusting for individual-level covariates. Any neighborhood factor associated (Simes-adjusted for multiple comparisons P ≤ .05) with elevated blood pressure in the training data set was rerun in the test data set to gauge model performance. Lastly, in the full cohort, race- and ethnicity-stratified associations were evaluated for each identified neighborhood factor on the likelihood of elevated blood pressure.

Results

Of 12 946 participants, 4565 (35%) had elevated sphygmomanometer readings (median [IQR] age, 68 [63-73] years; 2283 [50%] male; 228 [5%] Hispanic or Latino, 502 [11%] non-Hispanic Black, and 3761 [82%] non-Hispanic White). Between 2006 and 2016, a lower likelihood of elevated blood pressure was observed (relative risk for highest vs lowest tertile, 0.91; 95% CI, 0.86-0.96) among participants residing in a neighborhood with recent (post-1999) in-migration of homeowners. This association was precise among participants with non-Hispanic White and other race and ethnicity (relative risk, 0.91; 95% CI, 0.85-0.97) but not non-Hispanic Black participants (relative risk, 0.97; 95% CI, 0.85-1.11; P = .48 for interaction) or Hispanic or Latino participants (relative risk, 0.84; 95% CI, 0.65-1.09; P = .78 for interaction).

Conclusions and Relevance

In this cohort study of older adults, recent relocation of homeowners to a neighborhood was robustly associated with reduced likelihood of elevated blood pressure among White participants but not their racially and ethnically marginalized counterparts. Our findings indicate that gentrification may influence later-life blood pressure control.

Representativeness of Patients Enrolled in the Lung Cancer Master Protocol (Lung-MAP)

PURPOSE

Lung Cancer Master Protocol (Lung-MAP), a public-private partnership, established infrastructure for conducting a biomarker-driven master protocol in molecularly targeted therapies. We compared characteristics of patients enrolled in Lung-MAP with those of patients in advanced non-small-cell lung cancer (NSCLC) trials to examine if master protocols improve trial access.

METHODS

We examined patients enrolled in Lung-MAP (2014-2020) according to sociodemographic characteristics. Proportions for characteristics were compared with those for a set of advanced NSCLC trials (2001-2020) and the US advanced NSCLC population using SEER registry data (2014-2018). Characteristics of patients enrolled in Lung-MAP treatment substudies were examined in subgroup analysis. Two-sided tests of proportions at an alpha of .01 were used for all comparisons.

RESULTS

A total of 3,556 patients enrolled in Lung-MAP were compared with 2,215 patients enrolled in other NSCLC studies. Patients enrolled in Lung-MAP were more likely to be 65 years and older (57.2% v 46.3%; P < .0001), from rural areas (17.3% v 14.4%; P = .004), and from socioeconomically deprived neighborhoods (42.2% v 36.7%, P < .0001), but less likely to be female (38.6% v 47.2%; P < .0001), Asian (2.8% v 5.1%; P < .0001), or Hispanic (2.4% v 3.8%; P = .003). Among patients younger than 65 years, Lung-MAP enrolled more patients using Medicaid/no insurance (27.6% v 17.8%; P < .0001). Compared with the US advanced NSCLC population, Lung-MAP under represented patients 65 years and older (57.2% v 69.8%; P < .0001), females (38.6% v 46.0%; P < .0001), and racial or ethnic minorities (14.8% v 21.5%; P < .0001).

CONCLUSION

Master protocols may improve access to trials using novel therapeutics for older patients and socioeconomically vulnerable patients compared with conventional trials, but specific patient exclusion criteria influenced demographic composition. Further research examining participation barriers for under represented racial or ethnic minorities in precision medicine clinical trials is warranted.