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Porter SB, Martin-McGrew Y, Njathi-Ori C, Bruns DL, LeMahieu AM, Mantilla CB, Milam AJ, Ladlie BL. Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity. J Perianesth Nurs 2024; 39:659-665. [PMID: 38323973 DOI: 10.1016/j.jopan.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia. DESIGN Single tertiary care academic medical center retrospective matched cohort. METHODS We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest. FINDINGS Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR = 0.80; 95% CI: 0.69, 0.94; P = .005), PACU length of stay was 9.56 minutes longer (95% CI: 2.62, 16.49; P = .007), and time between arrival to PACU and first pain score was 2.30 minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P = .001). There were no statistically significant differences in the other secondary outcomes. CONCLUSIONS The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.
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Affiliation(s)
- Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL.
| | - Yvette Martin-McGrew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Catherine Njathi-Ori
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Danette L Bruns
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Carlos B Mantilla
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Adam J Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Beth L Ladlie
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
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Fu CE, Teng M, Tung D, Ramadoss V, Ong C, Koh B, Lim WH, Tan DJH, Koh JH, Nah B, Syn N, Tamaki N, Siddiqui MS, Wijarnpreecha K, Ioannou GN, Nakajima A, Noureddin M, Sanyal AJ, Ng CH, Muthiah M. Sex and Race-Ethnic Disparities in Metabolic Dysfunction-Associated Steatotic Liver Disease: An Analysis of 40,166 Individuals. Dig Dis Sci 2024:10.1007/s10620-024-08540-4. [PMID: 38940975 DOI: 10.1007/s10620-024-08540-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/20/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND To overcome the limitations of the term "non-alcoholic fatty liver disease" (NAFLD), the term metabolic-associated steatotic liver disease (MASLD) was introduced. While epidemiologic studies have been conducted on MASLD, there is limited evidence on its associated sex and ethnic variations. AIMS This study assesses the differences across sex and race-ethnicity on the prevalence, associated risk factors and adverse outcomes in individuals with MASLD. METHODS Data retrieved from the National Health and Nutrition Examination Survey between 1999 to 2018 was analyzed. Prevalence, clinical characteristics, and outcomes were evaluated according to sex and race-ethnicity. Adverse outcomes and mortality events were analyzed using multivariate analyses. RESULTS Of 40,166 individuals included, 37.63% had MASLD. There was a significant increase in MASLD prevalence from 1999 to 2018 among Mexican Americans (Annual Percentage Change [APC] + 1.889%, p < 0.001), other Hispanics (APC + 1.661%, p = 0.013), NH Whites (APC + 1.084%, p = 0.018), NH Blacks (APC + 1.108%, p = 0.007), and females (APC + 0.879%, p = 0.030), but not males. Females with MASLD were at lower risk of all-cause (HR: 0.766, 95%CI 0.711 to 0.825, p < 0.001), cardiovascular disease-related (CVD) (SHR: 0.802, 95% CI 0.698 to 0.922, p = 0.002) and cancer-related mortality (SHR: 0.760, 95% CI 0.662 to 0.873, p < 0.001). Significantly, NH Blacks have the highest risk of all-cause and CVD-related mortality followed by NH Whites then Mexican Americans. CONCLUSION There has been an increase in prevalence in most race-ethnicities over time. While the change in definition shows no significant differences in previous associations found in NAFLD, the increased mortality in NH Whites relative to Mexican Americans remains to be explored.
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Affiliation(s)
- Clarissa Elysia Fu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
| | - Margaret Teng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Daniel Tung
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Vijay Ramadoss
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christen Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
| | - Benjamin Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
| | - Jia Hong Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Benjamin Nah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
| | - Nobuharu Tamaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Karn Wijarnpreecha
- Division of Gastroenterology and Hepatology, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - Atsushi Nakajima
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Mazen Noureddin
- Houston Research Institute, Houston Methodist Hospital, Houston, USA
| | - Arun J Sanyal
- Department of Internal Medicine, Stravitz-Sanyal Institute of Liver Disease and Metabolic Health,, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore.
- Ministry of Health Holdings, Singapore, Singapore.
- Department of Medicine, Kurume University School of Medicine, Kurume, Japan.
| | - Mark Muthiah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore, 117597, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore
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Tantillo GB, Sullivan-Baca E, Rehman R, López MR, Haneef Z. Health care utilization of Hispanic/Latino veterans with epilepsy: A national population-based study. Epilepsia 2024; 65:1668-1678. [PMID: 38557951 DOI: 10.1111/epi.17948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Hispanic/Latino people with epilepsy are a growing population that has been understudied in clinical epilepsy research. U.S. veterans are at a higher risk of epilepsy due to greater exposures including traumatic brain injury. Hispanic/Latino Veterans with Epilepsy (HL-VWEs) represent a growing population; however the treatment utilization patterns of this population have been vastly understudied. METHODS HL-VWE were identified from administrative databases during fiscal year 2019. Variables compared between Hispanic and non-Hispanic VWEs included demographics, rurality, service era, utilization of clinical services/investigations, and service-connected injury. Chi-square and Student's t tests were used for comparisons. RESULTS Among 56 556 VWEs, 3247 (5.7%) were HL. HL-VWEs were younger (59.2 vs 63.2 years; p < .01) and more commonly urban-dwelling (81.6% vs 63.2%, p < .01) compared to non-HL-VWEs. They were also more likely to have served in recent missions such as the Persian Gulf War and post- 9/11 wars (p < .01). HL-VWEs had a higher utilization of all neurology services examined including neurology clinic visits, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, electroencephalography (EEG), epilepsy monitoring, and comprehensive epilepsy care (p < .01 for all). HL-VWEs were more likely to visit an emergency room or have seizure-related hospitalizations (p < .01). HL-VWEs were more likely to have a service-connected disability greater or equal to 50% (p < .01). SIGNIFICANCE This study is one of the largest cohorts examining HL-VWEs. We found higher utilization of services in neurology, epilepsy, and neuroimaging by HL-VWEs. HL-VWE are younger, more commonly urban-dwelling, and more likely to have served during recent combat periods and have higher amounts of service-connected disability. Given that the proportion of Hispanic veterans is projected to rise over time, more research is needed to provide the best interventions and mitigate the long-term impact of epilepsy on this diverse patient group.
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Affiliation(s)
| | - Erin Sullivan-Baca
- Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Houston VA Medical Center, Houston, Texas, USA
| | - Rizwana Rehman
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
- Durham VA Medical Center, Durham, North Carolina, USA
| | - María Raquel López
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
- University of Miami Medical Center, Miami, Florida, USA
| | - Zulfi Haneef
- Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Houston VA Medical Center, Houston, Texas, USA
- Veterans' Administration Epilepsy Centers of Excellence (VA ECoE), Washington DC, USA
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Krishnamurthy S, Li Y, Sileanu F, Essien UR, Vanneman ME, Mor M, Fine MJ, Thorpe CT, Radomski T, Suda K, Gellad WF, Roberts ET. Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021. J Gen Intern Med 2024:10.1007/s11606-024-08818-3. [PMID: 38822210 DOI: 10.1007/s11606-024-08818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/13/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner. OBJECTIVE To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021. DESIGN Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. PARTICIPANTS Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. MEASURES Care ratings in nine domains. KEY RESULTS The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted. CONCLUSIONS This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care.
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Affiliation(s)
- Sudarshan Krishnamurthy
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Yaming Li
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina Sileanu
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Utibe R Essien
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Megan E Vanneman
- Decision Enhancement and Analytic Sciences Center, VA Informatics, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Maria Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas Radomski
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katie Suda
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric T Roberts
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Shannon EM, Jones KT, Moy E, Steers WN, Toyama J, Washington DL. Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users. Health Serv Res 2024. [PMID: 38808495 DOI: 10.1111/1475-6773.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024] Open
Abstract
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.
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Affiliation(s)
- Evan Michael Shannon
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Kenneth T Jones
- Office of Health Equity, Veterans Health Administration, Washington, DC, USA
| | - Ernest Moy
- Office of Health Equity, Veterans Health Administration, Washington, DC, USA
| | - W Neil Steers
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Joy Toyama
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna L Washington
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Clair KS, Bean-Mayberry B, Schweizer CA, Chanfreau C, Jackson L, Than CT, Finley EP, Hamilton A, Farmer MM. Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care. J Womens Health (Larchmt) 2024; 33:604-612. [PMID: 38386795 DOI: 10.1089/jwh.2023.0227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.
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Affiliation(s)
- Kimberly S Clair
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Bevanne Bean-Mayberry
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - C Amanda Schweizer
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Catherine Chanfreau
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - LaShawnta Jackson
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Claire T Than
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Erin P Finley
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Alison Hamilton
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Jane and Terry Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California, USA
| | - Melissa M Farmer
- VA Health Service Research and Development, Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Howard JT, Stewart IJ, Walker LE, Amuan M, Rayha K, Janak JC, Pugh MJ. Comparison of Racial and Ethnic Mortality Disparities among Post-9/11 Veterans with and without Traumatic Brain Injury to the Total U.S. Adult Population. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02004-1. [PMID: 38622427 DOI: 10.1007/s40615-024-02004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/27/2024] [Accepted: 04/07/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION The extent of racial/ethnic disparities and whether they are attenuated in the Veteran population compared to the total US population is not well understood. We aimed to assess racial/ethnic mortality disparities from all-cause, cardiovascular (CVD) and cancer among post-9/11 military Veterans with and without exposure to TBI, compared to the total US population. METHODS This cohort study included 2,502,101 US military Veterans (18,932,083 person-years) who served after 09/11/2001 with 3 or more years of care in the Military Health System (MHS); or had 3 or more years of care in the MHS and 2 or more years of care in the Veterans Health Administration. Mortality follow-up occurred from 01/01/2002 to 12/31/2020. Mortality rate ratios (MRR) from negative binomial regression models were reported for racial/ethnic groups compared to White non-Hispanic Veterans for all-cause, CVD and cancer mortality. Veteran MRR were compared to the total US population. RESULTS Mortality rates for Black Non-Hispanic Veterans were higher for all-cause (MRR = 1.21;95%CI: 1.13-1.29; p < 0.001), CVD (MRR = 1.78;95%CI: 1.62-1.96; p < 0.001) and cancer (MRR = 1.17;95%CI: 1.10-1.25; p < 0.001) than in White Non-Hispanic Veterans. Among Veterans with TBI, only Black Non-Hispanics had higher mortality than White Non-Hispanics and only for CVD (MRR = 1.32;95%CI: 1.12-1.54; p < 0.001), while CVD mortality was higher among Veterans without TBI (MRR = 1.77;95%CI: 1.63-1.93;p < 0.001). MRR for Black Non-Hispanics in the total US population, were consistently higher than those in the Veteran population for all-cause (MRR = 1.52;95%CI: 1.46-1.58; p < 0.001), CVD (MRR = 2.03;95%CI: 1.95-2.13; p < 0.001) and cancer (MRR = 1.26;95%CI: 1.22-1.30; p < 0.001). CONCLUSION This Veteran cohort experienced less racial/ethnic disparity in mortality than the total US population, especially among Veterans with TBI.
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Affiliation(s)
- Jeffrey T Howard
- Department of Public Health, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, 78249, USA.
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
- Military Cardiovascular Outcomes Research Program, Bethesda, MD, USA
| | - Lauren E Walker
- Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Megan Amuan
- University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA
- United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA
| | - Kara Rayha
- Department of Psychology, University of Texas at San Antonio, One UTSA Circle, San Antonio, TX, USA
| | | | - Mary Jo Pugh
- University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, Utah, USA
- United States Department of Veterans Affairs, 550 Foothill Dr, Salt Lake City, Utah, USA
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Jain S, Priya A, Pekow P, Spitzer K, Walkey AJ, Opara I, Krumholz HM, Lindenauer PK. Racial Differences in 1-Year Mortality after Hospitalization for Chronic Obstructive Pulmonary Disease in the United States. Ann Am Thorac Soc 2024; 21:585-594. [PMID: 37943953 PMCID: PMC10995557 DOI: 10.1513/annalsats.202304-359oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/07/2023] [Indexed: 11/12/2023] Open
Abstract
Rationale: One quarter of Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) die within 1 year. Although overall mortality rates are higher among White patients with COPD, racial and ethnic differences in the vulnerable period following hospitalization are unknown.Objectives: To determine the association between race and ethnicity and mortality following COPD hospitalization and to evaluate the extent to which differences are explained by clinical, geographic, socioeconomic, and post-acute care factors among Medicare beneficiaries in the United States.Methods: In this retrospective cohort study of Medicare beneficiaries hospitalized for COPD exacerbation, we constructed Cox regression models for 1-year mortality accounting for hospital-level clustering; sequentially adjusting for clinical, geographic, neighborhood socioeconomic, and post-acute care characteristics; and stratifying by sex and individual socioeconomic status.Results: Among 244,624 hospitalizations, Medicare beneficiaries of racial and ethnic minority groups had a lower risk of dying within 1 year of hospitalization than those of White race (hazard ratios, 0.78 [95% confidence interval, 0.75-0.80] for Black patients, 0.79 [0.76-0.82] for Hispanic patients, and 0.82 [0.77-0.86] for others). Differences in visits to physicians, attendance of pulmonary rehabilitation, and discharge disposition explained some of the mortality gap among dual-eligible beneficiaries but not among non-dual-eligible beneficiaries.Conclusions: Medicare beneficiaries of White race are at greater risk of mortality following COPD hospitalization compared with beneficiaries of minority race and ethnicity groups. Our findings should be interpreted in the context of the selection of a hospitalized population and a potentially incomplete assessment of illness severity in administrative data, and warrant further investigation.
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Affiliation(s)
- Snigdha Jain
- Section of Pulmonary, Critical Care, and Sleep Medicine and
| | - Aruna Priya
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
| | - Penelope Pekow
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
| | - Kerry Spitzer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
| | - Allan J. Walkey
- Division of Health Systems Science, University of Massachusetts Chan Medical School, Worcester, Massachusetts; and
| | - Ijeoma Opara
- Department of Social & Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School–Baystate, Springfield, Massachusetts
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9
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Shannon EM, Steers WN, Washington DL. Investigation of the role of perceived access to primary care in mediating and moderating racial and ethnic disparities in chronic disease control in the veterans health administration. Health Serv Res 2024; 59:e14260. [PMID: 37974469 PMCID: PMC10771907 DOI: 10.1111/1475-6773.14260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To examine the role of patient-perceived access to primary care in mediating and moderating racial and ethnic disparities in hypertension control and diabetes control among Veterans Health Administration (VA) users. DATA SOURCE AND STUDY SETTING We performed a secondary analysis of national VA user administrative data for fiscal years 2016-2019. STUDY DESIGN Our primary exposure was race or ethnicity and primary outcomes were binary indicators of hypertension control (<140/90 mmHg) and diabetes control (HgbA1c < 9%) among patients with known disease. We used the inverse odds-weighting method to test for mediation and logistic regression with race and ethnicity-by-perceived access interaction product terms to test moderation. All models were adjusted for age, sex, socioeconomic status, rurality, education, self-rated physical and mental health, and comorbidities. DATA COLLECTION/EXTRACTION METHODS We included VA users with hypertension and diabetes control data from the External Peer Review Program who had contemporaneously completed the Survey of Healthcare Experience of Patients-Patient-Centered Medical Home. Hypertension (34,233 patients) and diabetes (23,039 patients) samples were analyzed separately. PRINCIPAL FINDINGS After adjustment, Black patients had significantly lower rates of hypertension control than White patients (75.5% vs. 78.8%, p < 0.01); both Black (81.8%) and Hispanic (80.4%) patients had significantly lower rates of diabetes control than White patients (85.9%, p < 0.01 for both differences). Perceived access was lower among Black, Multi-Race and Native Hawaiian and Other Pacific Islanders compared to White patients in both samples. There was no evidence that perceived access mediated or moderated associations between Black race, Hispanic ethnicity, and hypertension or diabetes control. CONCLUSIONS We observed disparities in hypertension and diabetes control among minoritized patients. There was no evidence that patients' perception of access to primary care mediated or moderated these disparities. Reducing racial and ethnic disparities within VA in hypertension and diabetes control may require interventions beyond those focused on improving patient access.
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Affiliation(s)
- Evan Michael Shannon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
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10
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West E, Jackson L, Greene H, Lucas DJ, Gadbois KD, Choi PM. Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility. Mil Med 2024:usad502. [PMID: 38241780 DOI: 10.1093/milmed/usad502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/02/2023] [Accepted: 12/19/2023] [Indexed: 01/21/2024] Open
Abstract
INTRODUCTION Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.
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Affiliation(s)
- Erin West
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Laurinda Jackson
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Howard Greene
- Clinical Investigation Department, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Kyle D Gadbois
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Pamela M Choi
- Division of Pediatric Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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11
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Yin Y, Hanes DW, Skiena S, Clouston SAP. Quantifying Healthy Aging in Older Veterans Using Computational Audio Analysis. J Gerontol A Biol Sci Med Sci 2024; 79:glad154. [PMID: 37366320 PMCID: PMC10733188 DOI: 10.1093/gerona/glad154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Researchers are increasingly interested in better methods for assessing the pace of aging in older adults, including vocal analysis. The present study sought to determine whether paralinguistic vocal attributes improve estimates of the age and risk of mortality in older adults. METHODS To measure vocal age, we curated interviews provided by male U.S. World War II Veterans in the Library of Congress collection. We used diarization to identify speakers and measure vocal features and matched recording data to mortality information. Veterans (N = 2 447) were randomly split into testing (n = 1 467) and validation (n = 980) subsets to generate estimations of vocal age and years of life remaining. Results were replicated to examine out-of-sample utility using Korean War Veterans (N = 352). RESULTS World War II Veterans' average age was 86.08 at the time of recording and 91.28 at the time of death. Overall, 7.4% were prisoners of war, 43.3% were Army Veterans, and 29.3% were drafted. Vocal age estimates (mean absolute error = 3.255) were within 5 years of chronological age, 78.5% of the time. With chronological age held constant, older vocal age estimation was correlated with shorter life expectancy (aHR = 1.10; 95% confidence interval: 1.06-1.15; p < .001), even when adjusting for age at vocal assessment. CONCLUSIONS Computational analyses reduced estimation error by 71.94% (approximately 8 years) and produced vocal age estimates that were correlated with both age and predicted time until death when age was held constant. Paralinguistic analyses augment other assessments for individuals when oral patient histories are recorded.
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Affiliation(s)
- Yunting Yin
- Department of Computer Science, Stony Brook University, Stony Brook, New York, USA
| | - Douglas William Hanes
- Program in Public Health, Department of Family, Population, and Preventive Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Steven Skiena
- Department of Computer Science, Stony Brook University, Stony Brook, New York, USA
| | - Sean A P Clouston
- Program in Public Health, Department of Family, Population, and Preventive Medicine, Stony Brook University, Stony Brook, New York, USA
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12
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Vassy JL, Brunette CA, Lebo MS, MacIsaac K, Yi T, Danowski ME, Alexander NVJ, Cardellino MP, Christensen KD, Gala M, Green RC, Harris E, Jones NE, Kerman BJ, Kraft P, Kulkarni P, Lewis ACF, Lubitz SA, Natarajan P, Antwi AA. The GenoVA study: Equitable implementation of a pragmatic randomized trial of polygenic-risk scoring in primary care. Am J Hum Genet 2023; 110:1841-1852. [PMID: 37922883 PMCID: PMC10645559 DOI: 10.1016/j.ajhg.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
Polygenic risk scores (PRSs) hold promise for disease risk assessment and prevention. The Genomic Medicine at Veterans Affairs (GenoVA) Study is addressing three main challenges to the clinical implementation of PRSs in preventive care: defining and determining their clinical utility, implementing them in time-constrained primary care settings, and countering their potential to exacerbate healthcare disparities. The study processes used to test patients, report their PRS results to them and their primary care providers (PCPs), and promote the use of those results in clinical decision-making are modeled on common practices in primary care. The following diseases were chosen for their prevalence and familiarity to PCPs: coronary artery disease; type 2 diabetes; atrial fibrillation; and breast, colorectal, and prostate cancers. A randomized clinical trial (RCT) design and primary outcome of time-to-new-diagnosis of a target disease bring methodological rigor to the question of the clinical utility of PRS implementation. The study's pragmatic RCT design enhances its relevance to how PRS might reasonably be implemented in primary care. Steps the study has taken to promote health equity include the thoughtful handling of genetic ancestry in PRS construction and reporting and enhanced recruitment strategies to address underrepresentation in research participation. To date, enhanced recruitment efforts have been both necessary and successful: participants of underrepresented race and ethnicity groups have been less likely to enroll in the study than expected but ultimately achieved proportional representation through targeted efforts. The GenoVA Study experience to date offers insights for evaluating the clinical utility of equitable PRS implementation in adult primary care.
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Affiliation(s)
- Jason L Vassy
- VA Boston Healthcare System, Boston, MA, USA; Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Ariadne Labs, Boston, MA, USA.
| | - Charles A Brunette
- VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Matthew S Lebo
- Harvard Medical School, Boston, MA, USA; Laboratory for Molecular Medicine, Mass General Brigham, Boston, MA, USA; Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Thomas Yi
- VA Boston Healthcare System, Boston, MA, USA
| | | | - Nicholas V J Alexander
- VA Boston Healthcare System, Boston, MA, USA; Bucharest University Emergency Hospital, Bucharest, Romania; Bucharest University of Economic Studies, Bucharest, Romania
| | | | - Kurt D Christensen
- Harvard Medical School, Boston, MA, USA; Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Manish Gala
- Harvard Medical School, Boston, MA, USA; Division of Gastroenterology and Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Robert C Green
- Harvard Medical School, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Ariadne Labs, Boston, MA, USA; Department of Medicine (Genetics), Mass General Brigham, Boston, MA, USA
| | | | - Natalie E Jones
- VA Boston Healthcare System, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Benjamin J Kerman
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Peter Kraft
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | | | - Anna C F Lewis
- Department of Medicine (Genetics), Mass General Brigham, Boston, MA, USA; Edmond and Lily Safra Center for Ethics, Harvard University, Boston, MA, USA
| | - Steven A Lubitz
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA; Novartis Institutes for BioMedical Research, Novartis, Basel, Basel-Stadt, Switzerland
| | - Pradeep Natarajan
- Harvard Medical School, Boston, MA, USA; Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA; Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
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13
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Filipas DK, Beatrici E, Nolazco JI, Qian Z, Marks P, Labban M, Stone BV, Pierorazio PM, Lipsitz SR, Trinh QD, Chang SL, Cole AP. The national utilization of nonoperative management for small renal masses over 10 years. JNCI Cancer Spectr 2023; 7:pkad084. [PMID: 37802923 PMCID: PMC10640883 DOI: 10.1093/jncics/pkad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/14/2023] [Accepted: 10/04/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Management of small renal masses often involves a nonoperative approach, but there is a paucity of information about the use and associated predictors of such approaches. This study aimed to determine the trends in and predictors of use of nonoperative management of small renal masses. METHODS Using data from the National Cancer Database for localized small renal masses (N0/M0, cT1a) diagnosed between 2010 and 2020, we conducted a cross-sectional study. Nonoperative management was defined as expectant management (active surveillance or watchful waiting) or focal ablation. Adjusted odds ratios (AORs) were calculated using multivariable logistic regression models. RESULTS Of the 156 734 patients included, 10.5% underwent expectant management, and 13.9% underwent focal ablation. Later year of diagnosis was associated with a higher likelihood of nonoperative management. In 2020, the odds of receiving expectant management and focal ablation were 90% (AOR = 1.90, 95% confidence interval [CI] = 1.71 to 2.11) and 44% (AOR = 1.44, 95% CI = 1.31 to 1.57) higher, respectively, than in 2010. Black patients had increased odds of expectant management (AOR = 1.47, 95% CI = 1.39 to 1.55) but decreased odds of focal ablation (AOR = 0.93, 95% CI = 0.88 to 0.99). CONCLUSION Over the decade, the use nonoperative management of small renal masses increased, with expectant management more frequently used than focal ablation among Black patients. Possible explanations include race-based differences in physicians' risk assessments and resource allocation. Adjusting for Black race in calculations for glomerular filtration rate could influence the differential uptake of these techniques through deflated glomerular filtration rate calculations. These findings highlight the need for research and policies to ensure equitable use of less invasive treatments in small renal masses.
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Affiliation(s)
- Dejan K Filipas
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Edoardo Beatrici
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jose I Nolazco
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Zhiyu Qian
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Phillip Marks
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Muhieddine Labban
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Benjamin V Stone
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Stuart R Lipsitz
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Quoc-Dien Trinh
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven L Chang
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Alexander P Cole
- Department of Urology and Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
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14
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Rasmussen KM, Patil V, Li C, Yong C, Appukkutan S, Grossman JP, Jhaveri J, Halwani AS. Survival Outcomes by Race and Ethnicity in Veterans With Nonmetastatic Castration-Resistant Prostate Cancer. JAMA Netw Open 2023; 6:e2337272. [PMID: 37819658 PMCID: PMC10568364 DOI: 10.1001/jamanetworkopen.2023.37272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/28/2023] [Indexed: 10/13/2023] Open
Abstract
Importance Racial and ethnic disparities in prostate cancer are poorly understood. A given disparity-related factor may affect outcomes differently at each point along the highly variable trajectory of the disease. Objective To examine clinical outcomes by race and ethnicity in patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) within the US Veterans Health Administration. Design, Setting, and Participants A retrospective, observational cohort study using electronic health care records (January 1, 2006, to December 31, 2021) in a nationwide equal-access health care system was conducted. Mean (SD) follow-up time was 4.3 (3.3) years. Patients included in the analysis were diagnosed with prostate cancer from January 1, 2006, to December 30, 2020, that progressed to nmCRPC defined by (1) increasing prostate-specific antigen levels, (2) ongoing androgen deprivation, and (3) no evidence of metastatic disease. Patients with metastatic disease or death within the landmark period (3 months after the first nmCRPC evidence) were excluded. Main Outcomes and Measures The primary outcome was time from the landmark period to death or metastasis; the secondary outcome was overall survival. A multivariate Cox proportional hazards model, Kaplan-Meier estimates, and adjusted survival curves were used to evaluate outcome differences by race and ethnicity. Results Of 12 992 patients in the cohort, 826 patients identified as Hispanic (6%), 3671 as non-Hispanic Black (28%; henceforth Black), 7323 as non-Hispanic White (56%; henceforth White), and 1172 of other race and ethnicity (9%; henceforth other, including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown by patient, and patient declined to answer). Median time elapsed from nmCRPC to metastasis or death was 5.96 (95% CI, 5.58-6.34) years for Black patients, 5.62 (95% CI, 5.11-6.67) years for Hispanic patients, 4.11 (95% CI, 3.96-4.25) years for White patients, and 3.59 (95% CI, 3.23-3.97) years for other patients. Median unadjusted overall survival was 6.26 (95% CI, 6.03-6.46) years among all patients, 8.36 (95% CI, 8.0-8.8) years for Black patients, 8.56 (95% CI, 7.3-9.7) years for Hispanic patients, 5.48 (95% CI, 5.2-5.7) years for White patients, and 4.48 (95% CI, 4.1-5.0) years for other patients. Conclusions and Relevance The findings of this cohort study of patients with nmCRPC suggest that differences in outcomes by race and ethnicity exist; in addition, Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting.
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Affiliation(s)
- Kelli M. Rasmussen
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | - Vikas Patil
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | - Chunyang Li
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | - Christina Yong
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
| | | | | | | | - Ahmad S. Halwani
- University of Utah School of Medicine, Salt Lake City
- George E. Wahlen Veterans Health Administration, Salt Lake City, Utah
- Huntsman Cancer Institute, Salt Lake City, Utah
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15
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Peltzman T, Forehand JA, Freytes IM, Shiner B. Rural and Urban Hispanic Patients of the Veterans Health Administration. J Racial Ethn Health Disparities 2023; 10:2273-2283. [PMID: 36100811 DOI: 10.1007/s40615-022-01406-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/23/2022] [Accepted: 08/30/2022] [Indexed: 01/05/2023]
Abstract
Hispanic Veterans are the largest growing racial and ethnic minority group in the Veterans Health Administration (VA) system. Though recent research has found increasing suicide rates in this population and a growing rural-urban disparity, literature on core population characteristics remains sparse. We used extensive patient demographic and clinical data from VA's electronic medical record repository to examine geographic and longitudinal variation in Hispanic VA patients from 2001 to 2018. As the first such detailed characterization of this population, this study was largely descriptive in nature, and included heatmaps of Hispanic patient residence across rural and urban US counties, along with descriptive measures of patient characteristics by rurality, and first year of VA use. We found that Hispanic patients (n = 722,893) represented 5.2% of new VA users between 2001 and 2018, a proportion which grew nearly 90% from 4.0% (2001-2006) to 7.5% (2013-2018). Hispanic patients were largely White, male, under age 50, and had minimal illness or disability. The highest prevalence of Hispanic patients was in the Southwest US/Mexico border region, while the Midwest experienced the largest growth of Hispanic patients. Rural Hispanic patients were more likely to be older, male, and to live in areas characterized by small foreign-born populations and high socioeconomic deprivation. Compared with Hispanic patients entering the VA system in 2001-2006, patients in 2013-2018 were younger, more likely to be female, and to live in urban areas. These findings illustrate the wide range of demographic, clinical, and geographic experiences in the growing VA Hispanic population and demonstrate that culturally competent care for Hispanic Veterans must reflect their intra-ethnic diversity.
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Affiliation(s)
- Talya Peltzman
- Mental Health and Behavioral Science Service, Veterans Affairs Medical Center, White River Junction, VT, USA.
| | - Jenna A Forehand
- Mental Health and Behavioral Science Service, Veterans Affairs Medical Center, White River Junction, VT, USA
| | - Ivette M Freytes
- North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Brian Shiner
- Mental Health and Behavioral Science Service, Veterans Affairs Medical Center, White River Junction, VT, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- National Center for Posttraumatic Stress Disorder, Veterans Affairs Medical Center, White River Junction, VT, USA
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16
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Nguyen VH, Le I, Ha A, Le RH, Rouillard NA, Fong A, Gudapati S, Park JE, Maeda M, Barnett S, Cheung R, Nguyen MH. Differences in liver and mortality outcomes of non-alcoholic fatty liver disease by race and ethnicity: A longitudinal real-world study. Clin Mol Hepatol 2023; 29:1002-1012. [PMID: 37691484 PMCID: PMC10577349 DOI: 10.3350/cmh.2023.0205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND/AIMS Understanding of nonalcoholic fatty liver disease (NAFLD) continues to expand, but the relationship between race and ethnicity and NAFLD outside the use of cross-sectional data is lacking. Using longitudinal data, we investigated the role of race and ethnicity in adverse outcomes in NAFLD patients. METHODS Patients with NAFLD confirmed by imaging via manual chart review from any clinics at Stanford University Medical Center (1995-2021) were included. Primary study outcomes were incidence of liver events and mortality (overall and non-liver related). RESULTS The study included 9,340 NAFLD patients: White (44.1%), Black (2.29%), Hispanic (27.9%), and Asian (25.7%) patients. For liver events, the cumulative 5-year incidence was highest among White (19.1%) patients, lowest among Black (7.9%) patients, and similar among Asian and Hispanic patients (~15%). The 5-year and 10-year cumulative overall mortality was highest for Black patients (9.2% and 15.0%, respectively, vs. 2.5-3.5% and 4.3-7.3% in other groups) as well as for non-liver mortality. On multivariable regression analysis, compared to White patients, only Asian group was associated with lower liver-related outcomes (aHR: 0.83, P=0.027), while Black patients were at more than two times higher risk of both non-liver related (aHR: 2.35, P=0.010) and overall mortality (aHR: 2.13, P=0.022) as well as Hispanic patients (overall mortality: aHR: 1.44, P=0.022). CONCLUSION Compared to White patients, Black patients with NAFLD were at the highest risk for overall and non-liver-related mortality, followed by Hispanic patients with Asian patients at the lowest risk for all adverse outcomes. Culturally sensitive and appropriate programs may be needed for more successful interventions.
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Affiliation(s)
- Vy H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Harvard Medical School, Boston, MA, USA
| | - Isaac Le
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Emory University, Atlanta, GA, USA
| | - Audrey Ha
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Richard Hieu Le
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- William Carey University College of Osteopathic Medicine, Hattiesburg, MS, USA
| | - Nicholas Ajit Rouillard
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ashley Fong
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Surya Gudapati
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Washington University, St Louis, MO, USA
| | - Jung Eun Park
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Mayumi Maeda
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Scott Barnett
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Division of Gastroenterology and Hepatology, Palo Alto Veterans Affairs Medical Center, Palo Alto, CA, USA
| | - Mindie H. Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, CA, USA
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Presley CA, Khodneva Y, Juarez LD, Howell CR, Agne AA, Riggs KR, Huang L, Pisu M, Levitan EB, Cherrington AL. Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019. Prev Chronic Dis 2023; 20:E81. [PMID: 37708338 PMCID: PMC10516203 DOI: 10.5888/pcd20.220332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019. METHODS We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds. RESULTS We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model. CONCLUSION Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.
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Affiliation(s)
- Caroline A Presley
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
- Division of Preventive Medicine, University of Alabama at Birmingham, 1717 11th Ave South, MT-616, Birmingham, AL 35205
| | - Yulia Khodneva
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Lucia D Juarez
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Carrie R Howell
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - April A Agne
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Kevin R Riggs
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Lei Huang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Maria Pisu
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Emily B Levitan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Andrea L Cherrington
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
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18
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VoPham T, Cravero A, Feld LD, Green P, Feng Z, Berry K, Kim NJ, Vutien P, Mendoza JA, Ioannou GN. Associations of Race and Ethnicity with Hepatocellular Carcinoma, Decompensation, and Mortality in US Veterans with Cirrhosis. Cancer Epidemiol Biomarkers Prev 2023; 32:1069-1078. [PMID: 37255388 PMCID: PMC10390887 DOI: 10.1158/1055-9965.epi-22-1291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/27/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Among patients with cirrhosis, it remains unclear whether there are racial/ethnic differences in cirrhosis complications and mortality. We examined the associations between race/ethnicity and risk for hepatocellular carcinoma (HCC), cirrhosis decompensation, and all-cause mortality overall and by cirrhosis etiology. METHODS US Veterans diagnosed with cirrhosis from 2001 to 2014 (n = 120,992), due to hepatitis C virus (HCV; n = 55,814), alcohol-associated liver disease (ALD; n = 36,323), hepatitis B virus (HBV; n = 1,972), nonalcoholic fatty liver disease (NAFLD; n = 17,789), or other (n = 9,094), were followed through 2020 for incident HCC (n = 10,242), cirrhosis decompensation (n = 27,887), and mortality (n = 81,441). Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) and 95% confidence intervals (CI). RESULTS Compared with non-Hispanic White patients, Hispanic patients had higher risk for HCC overall (aHR, 1.32; 95% CI, 1.24-1.41) and by cirrhosis etiology, particularly for ALD- (aHR, 1.63; 95% CI, 1.42-1.87) and NAFLD-cirrhosis (aHR, 1.76; 95% CI, 1.41-2.20), whereas non-Hispanic Black patients had lower HCC risk in ALD- (aHR, 0.79; 95% CI, 0.63-0.98) and NAFLD-cirrhosis (aHR, 0.54; 95% CI, 0.33-0.89). Asian patients had higher HCC risk (aHR, 1.70; 95% CI, 1.29-2.23), driven by HCV- and HBV-cirrhosis. Non-Hispanic Black patients had lower risk for cirrhosis decompensation overall (aHR, 0.71; 95% CI, 0.68-0.74) and by cirrhosis etiology. There was lower risk for mortality among all other racial/ethnic groups compared with non-Hispanic White patients. CONCLUSIONS Race/ethnicity is an important predictor for risk of developing HCC, decompensation, and mortality. IMPACT Future research should examine factors underlying these racial/ethnic differences to inform prevention, screening, and treatment for patients with cirrhosis.
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Affiliation(s)
- Trang VoPham
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Anne Cravero
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lauren D. Feld
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ziding Feng
- Biostatistics Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Nicole J. Kim
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Philip Vutien
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Jason A. Mendoza
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics and Nutritional Sciences Program, University of Washington, Seattle, Washington
- Cancer Prevention Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - George N. Ioannou
- Epidemiology Program, Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington
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19
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Lagu T, Schroth SL, Haywood C, Heinemann A, Kessler A, Morse L, Khan SS, Kershaw KN, Nash MS. Diagnosis and Management of Cardiovascular Risk in Individuals With Spinal Cord Injury: A Narrative Review. Circulation 2023; 148:268-277. [PMID: 37459417 PMCID: PMC10403284 DOI: 10.1161/circulationaha.123.064859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/07/2023] [Indexed: 07/20/2023]
Abstract
More than 16 000 Americans experience spinal cord injury (SCI), resulting in chronic disability and other secondary sequelae, each year. Improvements in acute medical management have increased life expectancy. Cardiovascular disease is a leading cause of death in this population, and seems to occur earlier in individuals with SCI compared with the general population. People with SCI experience a high burden of traditional cardiovascular disease risk factors, including dyslipidemia and diabetes, and demonstrate anatomic, metabolic, and physiologic changes alongside stark reductions in physical activity after injury. They also experience multiple, complex barriers to care relating to disability and, in many cases, compounding effects of intersecting racial and socioeconomic health inequities. Given this combination of risk factors, some investigators have proposed that people with SCI are at increased risk for cardiovascular disease, beyond that associated with traditional risk factors, and SCI could be considered a risk-enhancing factor, analogous to other risk-enhancing factors defined by the 2019 American Heart Association/American College of Cardiology Primary Prevention Guidelines. However, more research is needed in this population to clarify the role of traditional risk factors, novel risk factors, health care access, social determinants of health, and intersectionality of disability, race, and socioeconomic status. There is an urgent need for primary care physicians and cardiologists to have awareness of the importance of timely diagnosis and management of cardiac risk factors for people with SCI.
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Affiliation(s)
- Tara Lagu
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (T.L., S.L.S., C.H., A.H., A.K., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Divisions of Hospital Medicine (T.L.), Northwestern Feinberg School of Medicine, Chicago, IL
- Department of Medicine (T.L., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
| | - Samantha L Schroth
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (T.L., S.L.S., C.H., A.H., A.K., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Cardiology (S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Departments of Pathology (S.L.S.), Northwestern Feinberg School of Medicine, Chicago, IL
| | - Carol Haywood
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (T.L., S.L.S., C.H., A.H., A.K., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Medical Social Sciences (C.H.), Northwestern Feinberg School of Medicine, Chicago, IL
| | - Allen Heinemann
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (T.L., S.L.S., C.H., A.H., A.K., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Physical Medicine and Rehabilitation (A.H., A.K.), Northwestern Feinberg School of Medicine, Chicago, IL
| | - Allison Kessler
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (T.L., S.L.S., C.H., A.H., A.K., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Physical Medicine and Rehabilitation (A.H., A.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Shirley Ryan Ability Lab, Chicago, IL (A.K., A.K.)
| | - Leslie Morse
- Department of Rehabilitation Medicine, University of Minnesota Medical School, Minneapolis (L.M.)
| | - Sadiya S Khan
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine (T.L., S.L.S., C.H., A.H., A.K., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Department of Medicine (T.L., S.S.K.), Northwestern Feinberg School of Medicine, Chicago, IL
- Preventive Medicine (S.S.K., K.N.K.), Northwestern Feinberg School of Medicine, Chicago, IL
| | - Kiarri N Kershaw
- Preventive Medicine (S.S.K., K.N.K.), Northwestern Feinberg School of Medicine, Chicago, IL
| | - Mark S Nash
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, FL (M.S.N.)
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Schexnayder J, Perry KR, Sheahan K, Majette Elliott N, Subramaniam S, Strawbridge E, Webel AR, Bosworth HB, Gierisch JM. Team-Based Qualitative Rapid Analysis: Approach and Considerations for Conducting Developmental Formative Evaluation for Intervention Design. QUALITATIVE HEALTH RESEARCH 2023; 33:778-789. [PMID: 37278662 DOI: 10.1177/10497323231167348] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Qualitative rapid analysis is one of many rapid research approaches that offer a solution to the problem of time constrained health services evaluations and avoids sacrificing the richness of qualitative data that is needed for intervention design. We describe modifications to an established team-based, rapid analysis approach that we used to rapidly collect and analyze semi-structured interview data for a developmental formative evaluation of a cardiovascular disease prevention intervention. Over 18 weeks, we conducted and analyzed 35 semi-structured interviews that were conducted with patients and health care providers in the Veterans Health Administration to identify targets for adapting the intervention in preparation for a clinical trial. We identified 12 key themes describing actionable targets for intervention modification. We highlight important methodological decisions that allowed us to maintain rigor when using qualitative rapid analysis for intervention adaptation and we provide practical guidance on the resources needed to execute similar qualitative studies. We additionally reflect on the benefits and challenges of the described approach when working within a remote research team environment.ClinicalTrials.gov: NCT04545489.
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Affiliation(s)
- Julie Schexnayder
- University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA
| | - Kathleen R Perry
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | | | - Nadya Majette Elliott
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | | | - Elizabeth Strawbridge
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | - Allison R Webel
- University of Washington School of Nursing, Seattle, WA, USA
| | - Hayden B Bosworth
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Veterans Affairs Health Care System, Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
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21
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Zhou J, Chen C, Wang J, Liu S, Li X, Wei Y, Ye L, Ye J, Kraus VB, Lv Y, Shi X. Development and Validation of a Lifespan Prediction Model in Chinese Adults Aged 65 Years or Older. J Am Med Dir Assoc 2023; 24:1068-1073.e6. [PMID: 36965505 PMCID: PMC10335838 DOI: 10.1016/j.jamda.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 03/27/2023]
Abstract
OBJECTIVES Previous studies investigated factors associated with mortality. Nevertheless, evidence is limited regarding the determinants of lifespan. We aimed to develop and validate a lifespan prediction model based on the most important predictors. DESIGN A prospective cohort study. SETTING AND PARTICIPANTS A total of 23,892 community-living adults aged 65 years or older with confirmed death records between 1998 and 2018 from 23 provinces in China. METHODS Information including demographic characteristics, lifestyle, functional health, and prevalence of diseases was collected. The risk prediction model was generated using multivariate linear regression, incorporating the most important predictors identified by the Lasso selection method. We used 1000 bootstrap resampling for the internal validation. The model performance was assessed by adjusted R2, root mean square error (RMSE), mean absolute error (MAE), and intraclass correlation coefficient (ICC). RESULTS Twenty-one predictors were included in the final lifespan prediction model. Older adults with longer lifespans were characterized by older age at baseline, female, minority race, living in rural areas, married, with healthier lifestyles and more leisure engagement, better functional status, and absence of diseases. The predicted lifespans were highly consistent with observed lifespans, with an adjusted R2 of 0.893. RMSE was 2.86 (95% CI 2.84-2.88) and MAE was 2.18 (95% CI 2.16-2.20) years. The ICC between observed and predicted lifespans was 0.971 (95% CI 0.971-0.971). CONCLUSIONS AND IMPLICATIONS The lifespan prediction model was validated with good performance, the web-based prediction tool can be easily applied in practical use as it relies on all easily accessible variables.
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Affiliation(s)
- Jinhui Zhou
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Chen Chen
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jun Wang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Sixin Liu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, China
| | - Xinwei Li
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Yuan Wei
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Lihong Ye
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China; School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaming Ye
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China; Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, China
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Yuebin Lv
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xiaoming Shi
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China; Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
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22
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Ochoa-Allemant P, Tate JP, Williams EC, Gordon KS, Marconi VC, Bensley KM, Rentsch CT, Wang KH, Taddei TH, Justice AC. Enhanced Identification of Hispanic Ethnicity Using Clinical Data: A Study in the Largest Integrated United States Health Care System. Med Care 2023; 61:200-205. [PMID: 36893404 PMCID: PMC10114212 DOI: 10.1097/mlr.0000000000001824] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND Collection of accurate Hispanic ethnicity data is critical to evaluate disparities in health and health care. However, this information is often inconsistently recorded in electronic health record (EHR) data. OBJECTIVE To enhance capture of Hispanic ethnicity in the Veterans Affairs EHR and compare relative disparities in health and health care. METHODS We first developed an algorithm based on surname and country of birth. We then determined sensitivity and specificity using self-reported ethnicity from the 2012 Veterans Aging Cohort Study survey as the reference standard and compared this to the research triangle institute race variable from the Medicare administrative data. Finally, we compared demographic characteristics and age-adjusted and sex-adjusted prevalence of conditions in Hispanic patients among different identification methods in the Veterans Affairs EHR 2018-2019. RESULTS Our algorithm yielded higher sensitivity than either EHR-recorded ethnicity or the research triangle institute race variable. In 2018-2019, Hispanic patients identified by the algorithm were more likely to be older, had a race other than White, and foreign born. The prevalence of conditions was similar between EHR and algorithm ethnicity. Hispanic patients had higher prevalence of diabetes, gastric cancer, chronic liver disease, hepatocellular carcinoma, and human immunodeficiency virus than non-Hispanic White patients. Our approach evidenced significant differences in burden of disease among Hispanic subgroups by nativity status and country of birth. CONCLUSIONS We developed and validated an algorithm to supplement Hispanic ethnicity information using clinical data in the largest integrated US health care system. Our approach enabled clearer understanding of demographic characteristics and burden of disease in the Hispanic Veteran population.
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Affiliation(s)
| | - Janet P. Tate
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, CT, USA
| | - Emily C. Williams
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Services Research & Development, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Kirsha S. Gordon
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, CT, USA
| | - Vincent C. Marconi
- Emory University, Atlanta, GA, USA
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA
| | | | - Christopher T. Rentsch
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, CT, USA
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Karen H. Wang
- Equity Research and Innovation Center, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Medical Informatics, Yale School of Medicine, New Haven, CT, USA
| | - Tamar H. Taddei
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, CT, USA
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Amy C. Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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23
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Koköfer A, Mamandipoor B, Flamm M, Rezar R, Wernly S, Datz C, Jung C, Osmani V, Wernly B, Bruno RR. The impact of ethnic background on ICU care and outcome in sepsis and septic shock - A retrospective multicenter analysis on 17,949 patients. BMC Infect Dis 2023; 23:194. [PMID: 37003970 PMCID: PMC10064763 DOI: 10.1186/s12879-023-08170-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Previous studies have been inconclusive about racial disparities in sepsis. This study evaluated the impact of ethnic background on management and outcome in sepsis and septic shock. METHODS This analysis included 17,146 patients suffering from sepsis and septic shock from the multicenter eICU Collaborative Research Database. Generalized estimated equation (GEE) population-averaged models were used to fit three sequential regression models for the binary primary outcome of hospital mortality. RESULTS Non-Hispanic whites were the predominant group (n = 14,124), followed by African Americans (n = 1,852), Hispanics (n = 717), Asian Americans (n = 280), Native Americans (n = 146) and others (n = 830). Overall, the intensive care treatment and hospital mortality were similar between all ethnic groups. This finding was concordant in patients with septic shock and persisted after adjusting for patient-level variables (age, sex, mechanical ventilation, vasopressor use and comorbidities) and hospital variables (teaching hospital status, number of beds in the hospital). CONCLUSION We could not detect ethnic disparities in the management and outcomes of critically ill septic patients and patients suffering from septic shock. Disparate outcomes among critically ill septic patients of different ethnicities are a public health, rather than a critical care challenge.
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Affiliation(s)
- Andreas Koköfer
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Richard Rezar
- Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Sarah Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital, Paracelsus Medical University of Salzburg, Oberndorf, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital, Paracelsus Medical University of Salzburg, Oberndorf, Austria
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, Trento, Italy
| | - Bernhard Wernly
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria.
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital, Paracelsus Medical University of Salzburg, Oberndorf, Austria.
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.
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Bernstein EL, DeRycke EC, Han L, Farmer MM, Bastian LA, Bean-Mayberry B, Bade B, Brandt C, Crothers K, Skanderson M, Ruser C, Spelman J, Bazan IS, Justice AC, Rentsch CT, Akgün KM. Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates. AJPM FOCUS 2023; 2:100094. [PMID: 37362395 PMCID: PMC10038675 DOI: 10.1016/j.focus.2023.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Background Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design Settings Participants Measurements Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results Compared with unvaccinated patients, those vaccinated (n=3,238,532; 55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99]; AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95]; AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination; all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution.
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Affiliation(s)
- Ethan L. Bernstein
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Section of Pulmonary, Critical Care, and Sleep Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Eric C. DeRycke
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Ling Han
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Melissa M. Farmer
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Lori A. Bastian
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of General Internal Medicine, School of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Bevanne Bean-Mayberry
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Brett Bade
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Section of Pulmonary, Critical Care, and Sleep Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Cynthia Brandt
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kristina Crothers
- VA Puget Sound Health Care, Seattle, Washington
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
| | - Melissa Skanderson
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Christopher Ruser
- VA Connecticut Healthcare System, West Haven, Connecticut
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Juliette Spelman
- VA Connecticut Healthcare System, West Haven, Connecticut
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Isabel S. Bazan
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven, Connecticut
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of General Internal Medicine, School of Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Christopher T. Rentsch
- VA Connecticut Healthcare System, West Haven, Connecticut
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kathleen M. Akgün
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
- Pain Research, Informatics, Multi-morbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Section of Pulmonary, Critical Care, and Sleep Medicine, VA Connecticut Healthcare System, West Haven, Connecticut
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York JA, Valvano M, Hughes F, Sternke LM, Lauerer JA, Baker JA, Edlund B, Reich K, Pope C. Nursing leadership and influence in practice domains at a Veterans Affairs Health Care System. Nurs Outlook 2023; 71:101937. [PMID: 36965357 DOI: 10.1016/j.outlook.2023.101937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 02/04/2023] [Accepted: 02/04/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Studies in Veteran populations have examined disparities in health service use, care quality, outcomes and increased demands for behavioral health. PURPOSE The purpose is to describe the development of nursing leadership roles that influenced practice improvements and demonstrated outcomes related to health disparities in a Veterans Affairs (VA) population over a 12-year period. METHODS The Sundean and colleagues' concept analysis of nurse leadership influence was applied to frame the initiative process and impacts. DISCUSSION Antecedents and processes that facilitated leadership development included mentorship, disparities expertise, partnerships, consultation, scholarship, dissemination, advocacy, education, and strong coauthor collaboration. Improvements and outcomes included access to services, improved health indicators, tools, workforce, funding, innovations, and nurse investigator studies, consistent with VA priorities and policy related to disparities and equity. Limitations and barriers were addressed. CONCLUSION This initiative models' strategies to increase nurse leadership in health equity and care transformation in health systems and community practices.
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Affiliation(s)
- Janet A York
- Ralph H. Johnson VAHCS, Charleston, SC; College of Nursing, Medical University of South Carolina, Charleston, SC; Even Health, Baltimore, Maryland.
| | - Mary Valvano
- Ralph H. Johnson VAHCS, Charleston, SC; Lyons VAHCS, Lyons, NJ
| | - Frederica Hughes
- Ralph H. Johnson VAHCS, Charleston, SC; College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Lisa Marie Sternke
- Ralph H. Johnson VAHCS, Charleston, SC; College of Nursing, Medical University of South Carolina, Charleston, SC
| | - Joy A Lauerer
- College of Nursing, Medical University of South Carolina, Charleston, SC
| | | | - Barbara Edlund
- College of Nursing, Medical University of South Carolina, Charleston, SC; College of Nursing, Auburn University at Montgomery, Montgomery, AL
| | | | - Charlene Pope
- Ralph H. Johnson VAHCS, Charleston, SC; College of Nursing, Medical University of South Carolina, Charleston, SC; College of Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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Patient Perspectives on Artificial Intelligence in Healthcare Decision Making: A Multi-Center Comparative Study. Indian J Orthop 2023; 57:653-665. [PMID: 37122674 PMCID: PMC9979110 DOI: 10.1007/s43465-023-00845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023]
Abstract
Objective Investigate the patient opinion on the use of Artificial Intelligence (AI) in Orthopaedics. Methods 397 orthopaedic patients from a large urban academic center and a rural health system completed a 37-component survey querying patient demographics and perspectives on clinical scenarios involving AI. An average comfort score was calculated from thirteen Likert-scale questions (1, not comfortable; 10, very comfortable). Secondary outcomes requested a binary opinion on whether it is acceptable for patient healthcare data to be used to create AI (yes/no) and the impact of AI on: orthopaedic care (positive/negative); healthcare cost (increase/decrease); and their decision to refuse healthcare if cost increased (yes/no). Bivariate and multivariable analyses were employed to identify characteristics that impacted patient perspectives. Results The average comfort score across the population was 6.4, with significant bivariate differences between age (p = 0.0086), gender (p = 0.0001), education (p = 0.0029), experience with AI/ML (p < 0.0001), survey format (p < 0.0001), and four binary outcomes (p < 0.05). When controlling for age and education, multivariable regression identified significant relationships between comfort score and experience with AI/ML (p = 0.0018) and each of the four binary outcomes (p < 0.05). In the final multivariable model gender, survey format, perceived impact of AI on orthopaedic care, and the decision to refuse care if it were to increase cost remained significantly associated with the average AI comfort score (p < 0.05). Additionally, patients were not comfortable undergoing surgery entirely by a robot with distant physician supervision compared to close supervision. Conclusion The orthopaedic patient appears comfortable with AI joining the care team.
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Washington V, Franklin JB, Huang ES, Mega JL, Abernethy AP. Diversity, Equity, and Inclusion in Clinical Research: A Path Toward Precision Health for Everyone. Clin Pharmacol Ther 2023; 113:575-584. [PMID: 36423203 DOI: 10.1002/cpt.2804] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
Abstract
Healthcare disparities are a persistent societal problem. One of the contributing factors to this status quo is the lack of diversity and representativeness of research efforts, which result in nongeneralizable evidence that, in turn, provides suboptimal means to enable the best possible outcomes at the individual level. There are several strategies that research teams can adopt to improve the diversity, equity, and inclusion (DEI) of their efforts; these strategies span the totality of the research path, from initial design to the shepherding of clinical data through a potential regulatory process. These strategies include more intentionality and DEI-based goal-setting, more diverse research and leadership teams, better community engagement to set study goals and approaches, better tailored outreach interventions, decentralization of study procedures and incorporation of innovative technology for more flexible data collection, and self-surveillance to identify and prevent biases. Within their remit of overlooking research efforts, regulatory authorities, as stakeholders, also have the potential for a positive effect on the DEI of emerging clinical evidence. All these are implementable tools and mechanisms that can make study participation more approachable to diverse communities, and ultimately generate evidence that is more generalizable and a conduit for better outcomes. The research community has an imperative to make DEI principles key foundational aspects in study conduct in order to pursue better personalized medicine for diverse patient populations.
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Affiliation(s)
| | | | - Erich S Huang
- Verily Life Sciences, South San Francisco, California, USA
| | - Jessica L Mega
- Verily Life Sciences, South San Francisco, California, USA
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Liou-Johnson V, Merced K, Klyce DW, Agtarap S, Finn JA, Chung JS, Campbell T, Harris OA, Perrin PB. Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A veterans affairs model systems study. NeuroRehabilitation 2023; 52:451-462. [PMID: 36806517 DOI: 10.3233/nre-220225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI). OBJECTIVE This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five VA TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). METHODS Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89) and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling. RESULTS Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories. CONCLUSION The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.
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Affiliation(s)
- Victoria Liou-Johnson
- Polytrauma Department, VA Palo Alto Healthcare Center, Palo Alto, CA, USA.,Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Kritzia Merced
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA
| | - Daniel W Klyce
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA.,Department of Physical Medicine and Rehabilitation, Virginia Common wealth University, Richmond, VA, USA.,Sheltering Arms Institute, Richmond, VA, USA
| | | | - Jacob A Finn
- Rehabilitation and Extended Care, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA
| | - Joyce S Chung
- Rehabilitation Department, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Thomas Campbell
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA
| | - Odette A Harris
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.,Rehabilitation Department, Traumatic Brain Injury Center of Excellence, VA Palo Alto Health Care System, PaloAlto, CA, USA
| | - Paul B Perrin
- Central Virginia Veterans Affairs Health Care System, Richmond, VA, USA.,Department of Psychology, School of Data Science, University of Virginia, Charlottesville, VA, USA
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Carrington SJ, Romero-Alvarez D, Coral-Almeida M, Vela A, Henríquez-Trujillo AR, Mascialino G. Ethnodemographic characterization of stroke incidence and burden of disease in hospital discharge records in Ecuador. Front Neurol 2023; 14:1059169. [PMID: 36846135 PMCID: PMC9945224 DOI: 10.3389/fneur.2023.1059169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/16/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction Stroke is the second most common cause of death and disability-adjusted life years (DALYs) globally. However, the incidence and impact of stroke by ethnicity and gender is frequently distinct. This is particularly the case in Ecuador where geographic and economic marginalization are often correlated with ethnic marginalization and the extent to which females lack the same opportunities as their male counterparts. The aim of this paper is to investigate the differential impacts in terms of stroke diagnosis and burden of disease by ethnicity and gender, using hospital discharge records over the years 2015-2020. Methods This paper calculates stroke incidence, and fatality rates using hospital discharge and death records over the years 2015-2020. The DALY package in R was employed to calculate the Disability Adjusted Life Years lost due to stroke in Ecuador. Results The results show that while the incidence rate of stroke in males (64.96 per 100,000 persons-year) is higher than that for females on average (57.84 per 100,000 persons-year), males accounted for 52.41% of all stroke cases and 53% of all surviving cases. Thus, hospital data suggests that females had a higher death rate when compared to males. Case fatality rates also differed significantly by ethnicity. The highest fatality rate corresponded to the Montubio ethnic group (87.65%), followed by Afrodescendants (67.21%). The estimated burden of disease of stroke calculated using Ecuadorian hospital records (2015-2020) varied from 1,468 to 2,991 DALY per 1,000 population on average. Discussion Differences in the burden of disease by ethnic group are likely to reflect differential access to care by region and socio-economic group, both of which are frequently correlated with ethnic composition in Ecuador. Equitable access to health services remains an important challenge in the country. The gender discrepancy in fatality rates suggests that there is a need for targeted educational campaigns to identify stroke signs early, especially in the female population.
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Affiliation(s)
- Sarah J. Carrington
- Department of Economics, Universidad de Las Américas, Quito, Ecuador,*Correspondence: Sarah J. Carrington ✉
| | - Daniel Romero-Alvarez
- Biodiversity Institute and Department of Ecology and Evolutionary Biology, The University of Kansas, Lawrence, KS, United States,One Health Research Group, Faculty of Medicine, Universidad de Las Américas, Quito, Ecuador
| | - Marco Coral-Almeida
- Grupo de bioquimioinformática GBQ, Universidad de Las Américas, Quito, Ecuador
| | - Andrea Vela
- Facultad de Ciencias Pecuarias, Carrera de Medicina Veterinaria, Escuela Superior Politécnica de Chimborazo, Chimborazo, Ecuador
| | | | - Guido Mascialino
- Escuela de Psicología, Universidad de Las Américas, Quito, Ecuador,Guido Mascialino ✉
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Witting C, Zheng J, Tisdale RL, Shannon E, Kohsaka S, Lewis EF, Heidenreich P, Sandhu A. Treatment Differences in Medical Therapy for Heart Failure With Reduced Ejection Fraction Between Sociodemographic Groups. JACC. HEART FAILURE 2023; 11:161-172. [PMID: 36647925 PMCID: PMC10069379 DOI: 10.1016/j.jchf.2022.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are sociodemographic disparities in outcomes of heart failure with reduced ejection fraction (HFrEF), but disparities in guideline-directed medical therapy (GDMT) remain poorly characterized. OBJECTIVES This study aimed to analyze GDMT treatment rates in eligible patients with recently diagnosed HFrEF, and to determine how rates vary by sociodemographic characteristics. METHODS This retrospective cohort study included patients diagnosed with HFrEF at Veterans Affairs (VA) hospitals from 2013 to 2019. The authors analyzed GDMT treatment rates and doses, excluding patients with contraindications. Therapies of interest were evidence-based beta-blockers (BBs), renin-angiotensin system inhibitors (RASIs), angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid antagonists (MRAs). The authors compared adjusted treatment rates by race and ethnicity, neighborhood social vulnerability, rurality, distance to medical care, and sex. RESULTS The cohort comprised 126,670 VA patients with recently diagnosed HFrEF. The study found that racial and ethnic minorities had similar or higher treatment rates than White patients. Patients residing in socially vulnerable neighborhoods had 3.4% lower ARNI (95% CI: 1.9%-5.0%) treatment rates. Patients residing farther from specialty care had similar rates of GDMT therapy overall, but were less likely to be taking at least 50% of the target doses of either BBs (4.0% less likely; 95% CI: 3.1%-5.0%) or RASIs (5.0% less likely; 95% CI: 4.1%-6.0%) compared with those closer to care. CONCLUSIONS Among VA patients with recently diagnosed HFrEF, the authors did not find that racial and ethnic minority patients were less likely to receive GDMT. However, appropriate dose up-titration may occur less frequently in more remote patients.
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Affiliation(s)
- Celeste Witting
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Jimmy Zheng
- School of Medicine, Stanford University, Stanford, California, USA
| | - Rebecca L Tisdale
- VA Palo Alto Health Care System, Palo Alto, California, USA; Department of Health Policy, Stanford University, Stanford, California, USA
| | - Evan Shannon
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, California, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Eldrin F Lewis
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Paul Heidenreich
- Department of Medicine, Stanford University, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Alexander Sandhu
- Department of Medicine, Stanford University, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA.
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Hirschfeld W, Corrado R, Banaag A, Korona-Bailey J, Koehlmoos TP. Identifying prescribing differences of direct oral anticoagulants for atrial fibrillation within the Military Health System. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 26:100258. [PMID: 38510183 PMCID: PMC10945905 DOI: 10.1016/j.ahjo.2023.100258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 03/22/2024]
Abstract
Background Direct oral anticoagulants (DOACs) are a first-line anticoagulant therapy for eligible patients with atrial fibrillation. Prescribing differences in the Military Health System have not yet been assessed. Methods We conducted a retrospective cross-sectional study using administrative claims data from the Military Health System Data Repository from fiscal years 2018-2019. We identified TRICARE Prime and Prime Plus patients between the ages of 18 and 64 with a diagnosis of atrial fibrillation and a CHA2DS2-VASc score of ≥2. Descriptive statistics and odds of receiving DOACs by gender, age, race, and socioeconomic status were calculated. Results A total of 5289 TRICARE Prime and Prime Plus patients within the Military Health System who carried a diagnosis of atrial fibrillation and a CHA2DS2-VASc ≥2 were identified. Of all patients, 2373 (40.71 %) were prescribed a DOAC whereas 287 (4.92 %) were prescribed warfarin within 90 days of diagnosis of atrial fibrillation. Black patients were significantly less likely to be prescribed a DOAC compared to White patients (adjusted odds ratio [aOR], 0.82; 95 % CI 0.68-0.99), as were females compared to males (aOR, 0.64; 95 % CI 0.52-0.79). Senior officers were significantly more likely to be prescribed a DOAC compared to senior enlisted service members (aOR, 0.64; 95 % CI 0.52-0.79). Conclusions Our study shows that differences exist within the Military Health System in the prescription of DOACs for atrial fibrillation by race, gender, and socio-economic status. These differences cannot be explained by differences in access to insurance or cost of medications.
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Affiliation(s)
- William Hirschfeld
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Richele Corrado
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Amanda Banaag
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement in Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Jessica Korona-Bailey
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement in Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Tracey Perez Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Bajema KL, Rowneki M, Berry K, Bohnert A, Bowling CB, Boyko EJ, Iwashyna TJ, Maciejewski ML, O’Hare AM, Osborne TF, Viglianti EM, Hynes DM, Ioannou GN. Rates of and Factors Associated With Primary and Booster COVID-19 Vaccine Receipt by US Veterans, December 2020 to June 2022. JAMA Netw Open 2023; 6:e2254387. [PMID: 36729454 PMCID: PMC9896301 DOI: 10.1001/jamanetworkopen.2022.54387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 12/15/2022] [Indexed: 02/03/2023] Open
Abstract
Importance COVID-19 vaccination rates remain suboptimal in the US. Identifying factors associated with vaccination can highlight existing gaps and guide targeted interventions to improve vaccination access and uptake. Objective To describe incidence and patient characteristics associated with primary, first booster, and second booster COVID-19 vaccination in the Veterans Health Administration (VHA). Design, Setting, and Participants This retrospective cohort study assessed US veterans receiving care in VHA medical centers and outpatient clinics as of December 1, 2020. All VHA enrollees with an inpatient, outpatient, or telehealth encounter in VHA as well as a primary care physician appointment in the preceding 24 months were included. Exposures Demographic characteristics, place of residence, prior SARS-CoV-2 infection, and underlying medical conditions. Main Outcomes and Measures Cumulative incidence of primary, first booster, and second booster COVID-19 vaccination through June 2022. Cox proportional hazards regression was used to identify factors independently associated with COVID-19 vaccination. Results Among 5 632 413 veterans included in the study, 5 094 392 (90.4%) were male, the median (IQR) age was 66 (51-74) years, 1 032 334 (18.3%) were Black, 448 714 (8.0%) were Hispanic, and 4 202 173 (74.6%) were White. Through June 2022, cumulative incidences were 69.0% for primary vaccination, 42.9% for first booster, and 9.3% for second booster. Cumulative incidence for primary vaccination increased with increasing age, from 46.9% (95% CI, 46.8%-47.0%) among veterans aged 18 to 49 years to 82.9% (95% CI, 82.8%-83.0%) among veterans aged 80 to 84 years. More Black veterans completed primary vaccination (71.7%; 95% CI, 71.6%-71.8%) compared with White veterans (68.9%; 95% CI, 68.9%-69.0%), and more urban-dwelling veterans completed primary vaccination (70.9%; 95% CI, 70.9%-71.0%) compared with highly rural-dwelling veterans (63.8%; 95% CI, 63.4%-64.1%). Factors independently associated with higher likelihood of both primary and booster vaccination included older age, female sex, Asian or Black race, Hispanic ethnicity, urban residence, and lack of prior SARS-CoV-2 infection. Conclusions and Relevance In this cohort study of US veterans, COVID-19 vaccination coverage through June 2022 was suboptimal. Primary vaccination can be improved among younger, rural-dwelling veterans. Greater uptake of booster vaccination among all veterans is needed.
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Affiliation(s)
- Kristina L. Bajema
- Veterans Affairs Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland
| | - Mazhgan Rowneki
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - Kristin Berry
- Center of Innovation for Veteran Centered Value Driven Care, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington
| | - Amy Bohnert
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Anesthesiology, University of Michigan, Ann Arbor
| | - C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Edward J. Boyko
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Healthcare Seattle, Washington
| | - Theodore J. Iwashyna
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Schools of Medicine and Public Health, Johns Hopkins, Baltimore, Maryland
| | - Matthew L. Maciejewski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Ann M. O’Hare
- Veterans Affairs Puget Sound Healthcare Seattle, Washington
- Department of Medicine, University of Washington, Seattle
| | - Thomas F. Osborne
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Elizabeth M. Viglianti
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Denise M. Hynes
- Center of Innovation to Improve Veteran Involvement in Care, Veterans Affairs Portland Health Care System, Portland, Oregon
- Health Management and Policy, School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Health Data and Informatics Program, Center for Quantitative Life Sciences, Oregon State University, Corvallis
| | - George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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Dickerson F, Dilmore AH, Godoy-Vitorino F, Nguyen TT, Paulus M, Pinto-Tomas AA, Moya-Roman C, Zuniga-Chaves I, Severance EG, Jeste DV. The Microbiome and Mental Health Across the Lifespan. Curr Top Behav Neurosci 2023; 61:119-140. [PMID: 35947353 DOI: 10.1007/7854_2022_384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The combined genetic material of the microorganisms in the human body, known as the microbiome, is being increasingly recognized as a major determinant of human health and disease. Although located predominantly on mucosal surfaces, these microorganisms have profound effects on brain functioning through the gut-brain axis. METHOD The content of the chapter is based on a study group session at the annual meeting of the American College of Neuropsychopharmacology (ACNP). The objective was to discuss the emerging relationship between the human microbiome and mental health as relevant to ACNP's interests in developing and evaluating novel neuropsychiatric treatment strategies. The focus is on specific brain disorders, such as schizophrenia, substance use, and Alzheimer's disease, as well as on broader clinical issues such as suicidality, loneliness and wisdom in old age, and longevity. RESULTS Studies of schizophrenia indicate that the microbiome of individuals with this disorder differs from that of non-psychiatric comparison groups in terms of diversity and composition. Differences are also found in microbial metabolic pathways. An early study in substance use disorders found that individuals with this disorder have lower levels of beta diversity in their oral microbiome than a comparison group. This measure, along with others, was used to distinguish individuals with substance use disorders from controls. In terms of suicidality, there is preliminary evidence that persons who have made a suicide attempt differ from psychiatric and non-psychiatric comparison groups in measures of beta diversity. Exploratory studies in Alzheimer's disease indicate that gut microbes may contribute to disease pathogenesis by regulating innate immunity and neuroinflammation and thus influencing brain function. In another study looking at the microbiome in older adults, positive associations were found between wisdom and alpha diversity and negative associations with subjective loneliness. In other studies of older adults, here with a focus on longevity, individuals with healthy aging and unusually long lives had an abundance of specific microorganisms which distinguished them from other individuals. DISCUSSION Future studies would benefit from standardizing methods of sample collection, processing, and analysis. There is also a need for the standardized collection of relevant demographic and clinical data, including diet, medications, cigarette smoking, and other potentially confounding factors. While still in its infancy, research to date indicates a role for the microbiome in mental health disorders and conditions. Interventions are available which can modulate the microbiome and lead to clinical improvements. These include microbiome-altering medications as well as probiotic microorganisms capable of modulating the inflammation in the brain through the gut-brain axis. This research holds great promise in terms of developing new methods for the prevention and treatment of a range of human brain disorders.
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Affiliation(s)
- Faith Dickerson
- Sheppard Pratt, Baltimore, MD, USA.
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Amanda Hazel Dilmore
- Biomedical Sciences Graduate Program, University of California, San Diego, CA, USA
- Sam and Rose Stein Institute for Research on Aging, University of California, San Diego, CA, USA
| | - Filipa Godoy-Vitorino
- Department of Microbiology and Medical Zoology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Tanya T Nguyen
- Sam and Rose Stein Institute for Research on Aging, University of California, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Martin Paulus
- Laureate Institute for Brain Research, Tulsa, OK, USA
| | | | | | - Ibrahim Zuniga-Chaves
- Department of Bacteriology, Microbial Doctoral Training Program, University of Wisconsin-Madison, Madison, WI, USA
| | - Emily G Severance
- Stanley Neurovirology Laboratory, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dilip V Jeste
- Sam and Rose Stein Institute for Research on Aging, University of California, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, CA, USA
- Department of Neurosciences, University of California, San Diego, CA, USA
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Umeres-Francia GE, Rojas-Fernández MV, Herrera-Añazco P, Benites-Zapata VA. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as risk factors for mortality in Peruvian adults with chronic kidney disease. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00420-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Objective
To assess the association between the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) with all-cause mortality in Peruvian patients with chronic kidney disease (CKD) attending a tertiary hospital.
Methods
We conducted a retrospective cohort study in adults with CKD in stages 1–5. The outcome variable was mortality and as variables of exposure to NLR and PLR. Both ratios were categorized as high with a cutoff point of 3.5 and 232.5, respectively. We carried out a Cox regression model and calculated crude and adjusted hazard ratios (HR) with their 95% confidence interval (95% CI).
Results
We analyzed 343 participants with a mean age of 78.3 (± 11.9) years and 62.9% (n = 216) men. The median follow-up time was 2.45 years (2.08–3.08), and the frequency of deaths was 17.5% (n = 60). The mortality of patients with high NLR was 28% compared to 15.7% of the group with normal NLR, and the mortality was 35.7% in those with high PLR and 15.6% in those with normal PLR. In the crude analysis, the high NLR and PLR were significantly associated with all-cause mortality (HR = 2.01; 95% CI 1.11–3.66) and (HR = 2.58; 95% CI 1.31–5.20). In the multivariate model, after adjusting for age, sex, serum creatinine, albumin and hemoglobin, the high NLR and PLR remained as independent risk factors for all-cause mortality (aHR = 1.97; 95% CI 1.05–3.69) and (aHR = 2.62; 95% CI 1.25–5.51), respectively.
Conclusion
Our study suggests the relationship between high NLR and PLR with all-cause mortality in patients with CKD.
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Shukla VV, Carlo WA, Niermeyer S, Guinsburg R. Neonatal resuscitation from a global perspective. Semin Perinatol 2022; 46:151630. [PMID: 35725655 DOI: 10.1016/j.semperi.2022.151630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.
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Affiliation(s)
- Vivek V Shukla
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Susan Niermeyer
- University of Colorado School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Ruth Guinsburg
- Universidade Federal de São Paulo/Escola Paulista de Medicina, São Paulo, SP, Brazil.
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Gaffney A, Himmelstein DU, Dickman S, McCormick D, Woolhandler S. Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020. J Gen Intern Med 2022; 38:1152-1159. [PMID: 36163527 PMCID: PMC9512990 DOI: 10.1007/s11606-022-07797-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN Cross-sectional. PARTICIPANTS Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. CONCLUSIONS VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.
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Affiliation(s)
- Adam Gaffney
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - David U Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
| | | | - Danny McCormick
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Stephanie Woolhandler
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Hunter College, City University of New York, New York, NY, USA.,Public Citizen Health Research Group, Washington, DC, USA
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Kolarcik CL, Bledsoe MJ, O'Leary TJ. Returning Individual Research Results to Vulnerable Individuals. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:1218-1229. [PMID: 35750259 DOI: 10.1016/j.ajpath.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Abstract
Although issues associated with returning individual research results to study participants have been well explored, these issues have been less thoroughly investigated in vulnerable individuals and populations. Considerations regarding return of research results to these individuals and populations, including how best to ensure truly informed consent, how to minimize the risks and benefits of the return of research results, and how best to ensure justice may differ from those of the population at large. This article discusses the issues and challenges associated with the return of individual research results (such as genomic, proteomic, or other biomarker data) to potentially vulnerable individuals and populations, including those who may be vulnerable for cognitive, communicative, institutional, social, deferential, medical, economic, or social reasons. It explores factors that should be considered in the design, conduct, and oversight of ethically responsible research involving the return of research results to vulnerable individuals and populations and discuss recommendations for those engaged in this work.
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Affiliation(s)
- Christi L Kolarcik
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Timothy J O'Leary
- Office of Research and Development, Veterans Health Administration, Washington, District of Columbia; Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland.
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Enogela EM, Buchanan T, Carter CS, Elk R, Gazaway SB, Goodin BR, Jackson EA, Jones R, Kennedy RE, Perez-Costas E, Zubkoff L, Zumbro EL, Markland AD, Buford TW. Preserving independence among under-resourced older adults in the Southeastern United States: existing barriers and potential strategies for research. Int J Equity Health 2022; 21:119. [PMID: 36030252 PMCID: PMC9419141 DOI: 10.1186/s12939-022-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Disability prevention and preservation of independence is crucial for successful aging of older adults. To date, relatively little is known regarding disparities in independent aging in a disadvantaged older adult population despite widely recognized health disparities reported in other populations and disciplines. In the U.S., the Southeastern region also known as “the Deep South”, is an economically and culturally unique region ravaged by pervasive health disparities – thus it is critical to evaluate barriers to independent aging in this region along with strategies to overcome these barriers. The objective of this narrative review is to highlight unique barriers to independent aging in the Deep South and to acknowledge gaps and potential strategies and opportunities to fill these gaps. We have synthesized findings of literature retrieved from searches of computerized databases and authoritative texts. Ultimately, this review aims to facilitate discussion and future research that will help to address the unique challenges to the preservation of independence among older adults in the Deep South region.
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Affiliation(s)
- Ene M Enogela
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Taylor Buchanan
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Christy S Carter
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Ronit Elk
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Shena B Gazaway
- Department of Family, Community, and Health Systems, School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Jackson
- Department of Medicine - Division of Cardiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Raymond Jones
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Richard E Kennedy
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Emma Perez-Costas
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Lisa Zubkoff
- Department of Medicine - Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA
| | - Emily L Zumbro
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Alayne D Markland
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA
| | - Thomas W Buford
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA. .,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA.
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Zhong P, Yang B, Pan F, Hu F. Temporal trends in Black-White disparities in cancer surgery and cancer-specific survival in the United States between 2007 and 2015. Cancer Med 2022; 12:3509-3519. [PMID: 35968573 PMCID: PMC9939184 DOI: 10.1002/cam4.5141] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/16/2022] [Accepted: 08/02/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The American Society of Clinical Oncology (ASCO) has strived to address racial/ethnic disparities in cancer care since 2009. Surgery plays a pivotal role in cancer care; however, it is unclear whether and how racial/ethnic disparities in cancer surgery have changed over time. METHODS This cohort study included 1,113,256 White and Black cancer patients across 9 years (2007-2015) using patient data extracted from the Surveillance, Epidemiology, and End Results (SEER)-18 registries. Patient data were included from 2007 to adjust insurance status and by 2015 to obtain at least a 3-year survival follow-up (until 2018). The primary outcome was a surgical intervention. The secondary outcomes were the use of (neo)adjuvant chemotherapy and cancer-specific survival (CSS). Adjusted associations of the race (Black/White) with the outcomes were measured in each cancer type and year. RESULTS The gap between surgery rates for Black and White patients narrowed overall, from an adjusted odds ratio (aOR) of 0.621 (0.592-0.652) in 2007 to 0.734 (0.702-0.768) in 2015. However, the racial gap persisted in the surgery rates for lung, breast, prostate, esophageal, and ovarian cancers. In surgically treated patients with lymph node metastasis, Black patients with colorectal cancer (CRC) were less likely to receive (neo)adjuvant chemotherapy than White patients. Black patients undergoing surgery were more likely to have a worse CSS rate than White patients undergoing surgery. In breast cancer patients, the overall trend was narrow, but continuously present, with an adjusted hazard ratio (aHR) of 1.224 (1.278-1.173) in 2007 and 1.042 (1.132-0.96) in 2015. CONCLUSIONS Overall, progress has been made toward narrowing the Black-White gap in cancer surgical opportunity and survival. Future efforts should be directed toward those specific cancers for which the Black-White gap continues. Additionally, it is worth addressing the Black-White gap regarding the use of (neo)adjuvant chemotherapy for CRC treatment.
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Affiliation(s)
- Peijie Zhong
- Clinical Medical CollegeSouthwest Medical UniversityLuzhouChina
- Department of Gastroenterology and HepatologyHuaihe Hospital of Henan UniversityKaifengChina
| | - Bo Yang
- Department of Interventional MedicineThe Affiliated hospital of Southwest Medical UniversityLuzhouChina
| | - Feng Pan
- Department of Interventional MedicineThe Affiliated hospital of Southwest Medical UniversityLuzhouChina
| | - Fang Hu
- Department of Interventional MedicineThe Affiliated hospital of Southwest Medical UniversityLuzhouChina
- College of nursingSouthwest Medical UniversityLuzhouChina
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Carrasco-Aguilar A, Galán JJ, Carrasco RA. Obamacare: A bibliometric perspective. Front Public Health 2022; 10:979064. [PMID: 36033824 PMCID: PMC9416003 DOI: 10.3389/fpubh.2022.979064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 01/25/2023] Open
Abstract
Obamacare is the colloquial name given to the Affordable Care Act (ACA) signed into law by President Obama in the USA, which ultimately aims to provide universal access to health care services for US citizens. The aim of this paper is to provide an overview of the political-legal, economic, social, management (or administrative), and medical (or health) repercussions of this law, using a bibliometric methodology as a basis. In addition, the main contributors to research on ACA issues have been identified in terms of authors, organizations, journals, and countries. The downward trend in scientific production on this law has been noted, and it has been concluded that a balance has not yet been reached between the coexistence of private and public health care that guarantees broad social coverage without economic or other types of barriers. The law requires political consensus to be implemented in a definitive and global manner for the whole of the United States.
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Liu B, Ornstein KA, Frydman JL, Kelley AS, Benn EKT, Siu AL. Use of hospitals in the New York City Metropolitan Region, by race: how separate? How equal in resources and quality? BMC Health Serv Res 2022; 22:1021. [PMID: 35948923 PMCID: PMC9365444 DOI: 10.1186/s12913-022-08414-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/27/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Although racial and ethnic minorities disproportionately use some hospitals, hospital-based racial and ethnic composition relative to geographic region and its association with quality indicators has not been systematically analyzed. METHODS We used four race and ethnicity categories: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander/Alaskan Native/American Indian (API/AIAN), as well as a combined non-NHW category, from the 2010 (latest year publicly available) Medicare Institutional Provider & Beneficiary Summary public use file for 84 hospitals in the New York City region. We assessed the relative distribution of race and ethnicity across hospitals grouped at different geographic levels (region, county, hospital referral region [HRR], or hospital service areas [HSA]) using the dissimilarity index. Hospital characteristics included quality star ratings, essential professional services and diagnostic/treatment equipment, bed size, total expenses, and patients with dual Medicare and Medicaid enrollment. We assessed Spearman's rank correlation between hospital-based racial and ethnic composition and quality/structural measures. RESULTS Dissimilarity Index decreases from region (range 30.3-40.1%) to county (range 13.7-23.5%), HRR (range 10.5-27.5%), and HSA (range 12.0-16.9%) levels. Hospitals with larger non-NHW patients tended to have lower hospital ratings and higher proportions of dually-enrolled patients. They were also more likely to be safety net hospitals and non-federal governmental hospitals. CONCLUSIONS In the NYC metropolitan region, there is considerable hospital-based racial and ethnic segregation of Medicare patients among non-NHW populations, extending previous research limited to NHB. Availability of data on racial and ethnic composition of hospitals should be made publicly available for researchers and consumers.
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Affiliation(s)
- Bian Liu
- grid.59734.3c0000 0001 0670 2351Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Katherine A. Ornstein
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA
| | - Julia L. Frydman
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA
| | - Amy S. Kelley
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA ,grid.274295.f0000 0004 0420 1184Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, NY USA
| | - Emma K. T. Benn
- grid.59734.3c0000 0001 0670 2351Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Albert L. Siu
- grid.59734.3c0000 0001 0670 2351Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1640, New York, NY 10029 USA ,grid.274295.f0000 0004 0420 1184Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, NY USA
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Carpenter DJ, Natesan D, Floyd RW, Oyekunle T, Niedzwiecki D, Waters L, Godfrey D, Moravan MJ, Bitting RL, Gingrich JR, Lee WR, Salama JK. Impact of Race on Outcomes of High-Risk Patients With Prostate Cancer Treated With Moderately Hypofractionated Radiotherapy in an Equal Access Setting. Fed Pract 2022; 39:S35-S41. [PMID: 36426110 PMCID: PMC9662313 DOI: 10.12788/fp.0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Moderately hypofractionated radiotherapy (MHRT) is an accepted treatment for localized prostate cancer; however, limited MHRT data address high-risk prostate cancer (HRPC) and/or African American patients. We report clinical outcomes and toxicity profiles for individuals with HRPC treated in an equal access system. METHODS We identified patients with HRPC treated with MHRT at a US Department of Veterans Affairs referral center. Exclusion criteria included < 12 months follow-up and elective nodal irradiation. MHRT included 70 Gy over 28 fractions or 60 Gy over 20 fractions. Acute and late gastrointestinal (GI) and genitourinary (GU) toxicities were graded using Common Terminology Criteria for Adverse Events, version 5.0. Clinical endpoints, including biochemical recurrence-free survival (BRFS), distant metastases-free survival (DMFS), overall survival (OS), and prostate cancer-specific survival (PCSS) were estimated using Kaplan-Meier methods. Clinical outcomes, acute toxicity, and late toxicity-free survival were compared between African American and White patients with logistic regression and log-rank testing. RESULTS Between November 2008 and August 2018, 143 patients with HRPC were treated with MHRT and followed for a median of 38.5 months; 82 (57%) were African American and 61 were White patients. Concurrent androgen deprivation therapy (ADT) was provided for 138 (97%) patients for a median duration of 24 months. No significant differences between African American and White patients were observed for 5-year OS (73% [95% CI, 58%-83%] vs 77% [95% CI, 60%-97%]; P = .55), PCSS (90% [95% CI, 79%-95%] vs 87% [95 % CI, 70%-95%]; P = .57), DMFS (91% [95% CI, 80%-96%] vs 81% [95% CI, 62%-91%]; P = .55), or BRFS (83% [95% CI, 70%-91%] vs 71% [95% CI, 53%-82%]; P = .57), respectively. Rates of acute grade 3+ GU and GI were low overall (4% and 1%, respectively). Late toxicities were similarly favorable with no significant differences by race. CONCLUSIONS Individuals with HRPC treated with MHRT in an equal access setting demonstrated favorable clinical outcomes that did not differ by race, alongside acceptable rates of acute and late toxicities.
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Affiliation(s)
| | - Divya Natesan
- Duke University School of Medicine, Durham, North Carolina
| | - R Warren Floyd
- Duke University School of Medicine, Durham, North Carolina
| | - Taofik Oyekunle
- Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Health Care System, North Carolina
| | | | - Laura Waters
- Durham Veterans Affairs Health Care System, North Carolina
| | - Devon Godfrey
- Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Health Care System, North Carolina
| | | | - Rhonda L Bitting
- Durham Veterans Affairs Health Care System, North Carolina
- Duke Cancer Institute, Center for Prostate & Urologic Cancers, Duke University, Durham, North Carolina
| | - Jeffrey R Gingrich
- Durham Veterans Affairs Health Care System, North Carolina
- Duke Cancer Institute, Center for Prostate & Urologic Cancers, Duke University, Durham, North Carolina
| | - W Robert Lee
- Duke University School of Medicine, Durham, North Carolina
| | - Joseph K Salama
- Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Health Care System, North Carolina
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Peltzman T, Rice K, Jones KT, Washington DL, Shiner B. Optimizing Data on Race and Ethnicity for Veterans Affairs Patients. Mil Med 2022; 187:e955-e962. [PMID: 35323934 DOI: 10.1093/milmed/usac066] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Maintaining accurate race and ethnicity data among patients of the Veterans Affairs (VA) healthcare system has historically been a challenge. This work expands on previous efforts to optimize race and ethnicity values by combining multiple VA data sources and exploring race- and ethnicity-specific collation algorithms. MATERIALS AND METHODS We linked VA patient data from 2000 to 2018 with race and ethnicity data from four administrative and electronic health record sources: VA Medical SAS files (MedSAS), Corporate Data Warehouse (CDW), VA Centers for Medicare extracts (CMS), and VA Defense Identity Repository Data (VADIR). To assess the accuracy of each data source, we compared race and ethnicity values to self-reported data from the Survey of Health Experiences of Patients (SHEP). We used Cohen's Kappa to assess overall (holistic) source agreement and positive predictive values (PPV) to determine the accuracy of sources for each race and ethnicity separately. RESULTS Holistic agreement with SHEP data was excellent (K > 0.80 for all sources), while race- and ethnicity-specific agreement varied. All sources were best at identifying White and Black users (average PPV = 0.94, 0.93, respectively). When applied to the full VA user population, both holistic and race-specific algorithms substantially reduced unknown values, as compared to single-source methods. CONCLUSIONS Combining multiple sources to generate race and ethnicity values improves data accuracy among VA patients. Based on the overall agreement with self-reported data, we recommend using non-missing values from sources in the following order to fill in race values-SHEP, CMS, CDW, MedSAS, and VADIR-and in the following order to fill in ethnicity values-SHEP, CDW, MedSAS, VADIR, and CMS.
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Affiliation(s)
- Talya Peltzman
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
| | - Korie Rice
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
| | | | - Donna L Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
- Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA 90024, USA
| | - Brian Shiner
- White River Junction VA Medical Center, White River Junction, VT 05009, USA
- Geisel School of Medicine at Dartmouth College, Hanover, NH 03755, USA
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Provider reported challenges with completing death certificates: A focus group study demonstrating potential sources of error. PLoS One 2022; 17:e0268566. [PMID: 35594279 PMCID: PMC9122187 DOI: 10.1371/journal.pone.0268566] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/03/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives To characterize the experiences of providers in completing the cause of death section on death certificates, with particular reference to deaths in people who have cancer. Methods Focus groups were conducted until thematic saturation was reached, resulting in four groups over three months. Participants were from a variety of specialties and levels and types of training. Focus groups were recorded and transcribed verbatim and analyzed using constant comparison analysis. Results Three types of challenges to case classification were identified. 1) Infrastructural and procedural challenges encountered when completing death certificates, including the rigid structure of the form, lack of training in its completion, and lack of real-time feedback. 2) Clinical uncertainty and the varied approaches providers take to determine the cause of death based on their perception of the purpose of the death certificate. 3) Choosing cause of death in decedents with a history of cancer. Conclusions There are specific and substantial challenges in the death certification process that lead to errors in documenting the cause of death, but many of these challenges could be addressed with structural change to the forms or mechanism of training. Using these data to inform change could improve the death certification process and reliability of this data.
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Zhao Y, Ma Y, Zhao C, Lu J, Jiang H, Cao Y, Xu Y. The effect of integrated health care in patients with hypertension and diabetes: a systematic review and meta-analysis. BMC Health Serv Res 2022; 22:603. [PMID: 35513809 PMCID: PMC9074341 DOI: 10.1186/s12913-022-07838-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 03/23/2022] [Indexed: 11/18/2022] Open
Abstract
Background A growing number of studies show that integrated health care provides comprehensive and continuous care to patients with hypertension or diabetes. However, there is still no consensus about the effect of integrated health care on patients with hypertension or diabetes. The objective of this study was to verify the effectiveness of integrated health care for patients with hypertension or diabetes by using a systematic review and meta-analysis. Methods The study searched multiple English and Chinese electronic databases. The search period was from database inception to 31 October 2020. Systematic reviews and meta-analyses were conducted after assessing the risk of bias of each study. Results Sixteen studies that involved 5231 patients were included in this study. The results of the systematic review revealed that systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI) and glycosylated haemoglobin (HbA1c) are commonly used indicators for patients with hypertension or diabetes. Individual models and group- and disease-specific models are the most commonly used models of integrated health care. All the studies were from high-income and middle-income countries. Meta-analysis showed that integrated health care significantly improved SBP, DBP and HbA1c but not BMI. A comparison of interventions lasting 6 and 12 months for diabetes was conducted, and HbA1c was decreased after 12 months. The changes in SBP and DBP were statistically significant after using group- and disease-specific model but not individual models. HbA1c was significantly improved after using group- and disease-specific models and individual models. Conclusion Integrated health care is a useful tool for disease management, and individual models and group- and disease-specific models are the most commonly used models in integrated health care. Group- and disease-specific models are more effective than individual models in the disease management of hypertension patients. The duration of intervention should be considered in the disease management of patients with diabetes, and interventions longer than 12 months are recommended. The income level may affect the model of integrated health care in selecting which disease to intervene, but this point still needs support from more studies.
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Affiliation(s)
- Yan Zhao
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Yue Ma
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jiahong Lu
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong Jiang
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China
| | - Yanpei Cao
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China.
| | - Yafang Xu
- Department of Nursing, Huashan Hospital, Fudan University, 12 Middle Urumqi Road, Shanghai, China. .,School of Nursing, Fudan University, Shanghai, China.
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Del Valle JP, Fillmore NR, Molina G, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol 2022; 29:3194-3202. [PMID: 35006509 DOI: 10.1245/s10434-021-11250-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). METHODS Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. RESULTS In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. CONCLUSIONS Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - George Molina
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Fairweather
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiping Wang
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas E Clancy
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanley W Ashley
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward E Whang
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason S Gold
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Seal KH, Bertenthal D, Carey E, Grunfeld C, Bikle DD, Lu CM. Association of Vitamin D Status and COVID-19-Related Hospitalization and Mortality. J Gen Intern Med 2022; 37:853-861. [PMID: 34981368 PMCID: PMC8723909 DOI: 10.1007/s11606-021-07170-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/24/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND The relationship between vitamin D status and COVID-19-related clinical outcomes is controversial. Prior studies have been conducted in smaller, single-site, or homogeneous populations limiting adjustments for social determinants of health (race/ethnicity and poverty) common to both vitamin D deficiency and COVID-19 outcomes. OBJECTIVE To evaluate the dose-response relationship between continuous 25(OH)D and risk for COVID-19-related hospitalization and mortality after adjusting for covariates associated with both vitamin D deficiency and COVID-19 outcomes. DESIGN Retrospective cohort study. PATIENTS Veteran patients receiving care in US Department of Veteran Affairs (VA) health care facilities with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test and a blood 25(OH)D test between February 20, 2020, and November 8, 2020, followed for up to 60 days. MAIN MEASURES Exposure was blood 25(OH)D concentration ascertained closest to and within 15 to 90 days preceding an index positive SARS-CoV-2 test. Co-primary study outcomes were COVID-19-related inpatient hospitalization requiring airborne, droplet, contact, or other isolation and mortality ascertained within 60 days of an index positive SARS-CoV-2 test. KEY RESULTS Of 4,599 veterans with a positive SARS-CoV-2 test, vitamin D deficiency (< 20 ng/mL) was identified in 665 (14.5%); 964 (21.0%) were hospitalized; and 340 (7.4%) died. After adjusting for all covariates, including race/ethnicity and poverty, there was a significant independent inverse dose-response relationship between increasing continuous 25(OH)D concentrations (from 15 to 60 ng/mL) and decreasing probability of COVID-19-related hospitalization (from 24.1 to 18.7%, p=0.009) and mortality (from 10.4 to 5.7%, p=0.001). In modeling 25(OH)D as a log-transformed continuous variable, the greatest risk for hospitalization and death was observed at lower 25(OH)D concentrations. CONCLUSIONS Continuous blood 25(OH)D concentrations are independently associated with COVID-19-related hospitalization and mortality in an inverse dose-response relationship in this large racially and ethnically diverse cohort of VA patients. Randomized controlled trials are needed to evaluate the impact of vitamin D supplementation on COVID-19-related outcomes.
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Affiliation(s)
- Karen H Seal
- San Francisco Veterans Affairs Health Care System, Integrative Health Service, San Francisco, CA, USA. .,Departments of Medicine and Psychiatry, University of California San Francisco, San Francisco, CA, USA.
| | - Daniel Bertenthal
- San Francisco Veterans Affairs Health Care System, Integrative Health Service, San Francisco, CA, USA
| | - Evan Carey
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Denver, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Carl Grunfeld
- San Francisco Veterans Affairs Health Care System, Research Service and Division of Endocrinology and Metabolism, San Francisco, CA, USA.,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Daniel D Bikle
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,San Francisco Veterans Affairs Health Care System, Division of Endocrinology and Metabolism and Dermatology, San Francisco, CA, USA
| | - Chuanyi M Lu
- Department of Laboratory Medicine, University of California San Francisco and San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
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Florez HJ, Ghosh A, Pop-Busui R, Hox SH, Underkofler C, McKee MD, Park J, Rhee MK, Killean T, Krause-Steinrauf H, Aroda VR, Wexler DJ. Differences in complications, cardiovascular risk factor, and diabetes management among participants enrolled at veterans affairs (VA) and non-VA medical centers in the glycemia reduction approaches in diabetes: A comparative effectiveness study (GRADE). Diabetes Res Clin Pract 2022; 184:109188. [PMID: 34971663 PMCID: PMC8917078 DOI: 10.1016/j.diabres.2021.109188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/14/2021] [Accepted: 12/23/2021] [Indexed: 02/03/2023]
Abstract
AIMS We evaluated differences in participants with type 2 diabetes (T2DM) enrolled in the GRADE study at VA vs non-VA sites, focusing on cardiovascular risk factors and rates of diabetes care target achievements. METHODS We compared baseline characteristics between participants at VA (n = 1216) and non-VA (n = 3831) sites, stratifying analyses by cardiovascular disease (CVD) history. RESULTS VA and non-VA participants had similar diabetes duration (4.0 years), HbA1c (7.5%), and BMI (34 kg/m2); however, VA participants had more individuals ≥ 65 years (37.3% vs 19.8%, p < 0.001), men (90.0% vs 55.2%, p < 0.001), hypertension (75.8% vs 63.6%, p < 0.001), hyperlipidemia (76.6% vs 64.6%, p < 0.001), current smokers (19.0% vs 12.1%, p < 0.001), nephropathy (20.4% vs 17.0%, p < 0.05), albuminuria (18.4% vs 15.1%, p < 0.05), and CVD (10.4% vs 5.2%, p < 0.001). In those without CVD, more VA participants were treated with lipid (70.8% vs 59.5%, p < 0.001) and blood pressure (74.9% vs 65.4%, p < 0.001) lowering medications, and had LDL-C < 70 mg/dl (32.9% vs 24.2%, p < 0.05). Among those with CVD, more VA participants had BP < 140/90 (80.2% vs 70.1%, p < 0.05) after adjusting for demographics. CONCLUSION GRADE participants at VA sites had more T2DM complications, greater CVD risk and were more likely to be treated with medications to reduce it, leading to more LDL-C at goal than non-VA participants, highlighting differences in diabetes populations and care.
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Affiliation(s)
- Hermes J Florez
- Medical University of South Carolina and Department of Veterans Affairs, Charleston, SC, United States
| | - Alokananda Ghosh
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, United States
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Sophia H Hox
- Department of Veterans Affairs Pacific Islands Health Care System, Honolulu, HI, United States
| | - Chantal Underkofler
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - M Diane McKee
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Jean Park
- MedStar Health Research Institute, Hyattsville and Baltimore MD, United States
| | - Mary K Rhee
- Emory University School of Medicine, Department of Medicine, Division of Endocrinology, Metabolism and Lipids, and the Atlanta VA Health Care System, Decatur, GA, United States
| | - Tina Killean
- Obesity and Diabetes Clinical Research Section, NIDDK-Phoenix, Phoenix, AZ, United States
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, United States
| | - Vanita R Aroda
- MedStar Health Research Institute, Hyattsville and Baltimore MD, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA, United States.
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Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System. Kidney Med 2022; 4:100381. [PMID: 35072045 PMCID: PMC8767122 DOI: 10.1016/j.xkme.2021.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rationale & Objective Health-impeding social determinants of health—including reduced access to care—contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care. Study Design Cross-sectional study. Setting & Participants MHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018. Predictors Race, sponsor’s rank (a proxy for socioeconomic status and social class), median household income by sponsor’s zip code, and marital status. Outcome CKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype. Analytical Approach Multivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor’s service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index). Results Of 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators. Limitations The cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code–level median household income data. Conclusions Racial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.
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Koehlmoos TP, Korona-Bailey J, Janvrin ML, Madsen C. Racial Disparities in the Military Health System: A Framework Synthesis. Mil Med 2021; 187:e1114-e1121. [PMID: 34910808 DOI: 10.1093/milmed/usab506] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/25/2021] [Accepted: 12/11/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). MATERIALS AND METHODS We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. RESULTS We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women's health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women's health procedures. CONCLUSION Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.
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Affiliation(s)
- Tracey Pérez Koehlmoos
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA
| | - Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Bethesda, MD 20817, USA
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