Racial and Ethnic Differences in Long-Term Adverse Radiation Therapy Effects Among Breast Cancer Survivors

PURPOSE

Breast and skin changes are underrecognized side effects of radiation therapy for breast cancer, which may have long-term implications for quality of life (QOL). Racial and ethnic disparities in breast cancer outcomes, including long-term QOL differences after breast radiation therapy, are poorly understood.

METHODS AND MATERIALS

We conducted a cross-sectional survey study of patients from the Texas Cancer Registry who received diagnoses of stage 0-II breast cancer from 2009 to 2014 and treated with lumpectomy and radiation therapy; 2770 patients were sampled and 631 responded (23%). The BREAST-Q Adverse Effects of Radiation overall score and subindices measured the effect of radiation therapy on breast tissue. Multivariable logistic regression evaluated associations of demographic and treatment characteristics with outcomes.

RESULTS

The median age was 57 years (IQR, 48-65), median time from diagnosis to survey response 9 years (IQR, 7-10), and the cohort included 62 Asian American or Pacific Islander (9.8%), 11 American Indian or Alaskan Native (AIAN) (1.7%), 161 Black (25.5%), 144 Hispanic (22.8%), and 253 White (40.1%) patients. Mean BREAST-Q Adverse Effects of Radiation score was worse for AIAN patients (-22.2; 95% CI, -39.9 to -4.6; P = .01), Black patients (-10.8; 95% CI, -16.1 to -5.5; P < .001), and Hispanic patients (-7.8; 95% CI, -13.0 to -2.5; P = .004) compared with White patients, age <50 compared with ≥65 (effect size -8.6; 95% CI, -14.0 to -3.2; P = .002), less than a college education (-5.8; 95% CI, -10.0 to -1.6; P = .01), bra cup size of D/E versus A/B (-5.3; 95% CI, -9.9 to -0.65; P = .03), and current smokers (-11.3; 95% CI, -18.3 to -4.2; P = .002). AIAN, Black, and Hispanic patients reported worse changes in skin pigmentation, telangiectasias, dryness, soreness, and/or irritation compared with White patients.

CONCLUSIONS

AIAN, Black, and Hispanic patients reported substantially worse long-term breast and skin QOL outcomes after radiation therapy. Additional work is needed to understand these differences and how to alleviate them.

Racial Inequities in Mortality Rate in Hospitalized Children

BACKGROUND AND OBJECTIVES

Racial/ethnic inequities for inpatient mortality in children at a national level in the U.S. have not been explored. The objective of this study was to evaluate differences in inpatient mortality rate among different racial/ethnic groups, using the Kids' Inpatient Database.

METHODS

A cross-sectional study of children of ages greater than 28 days and less than 21 years discharged during 2012 and 2016. Racial/ethnic groups - White, Black, Hispanic, Asian and Pacific Islander and Native Americans were analyzed in two cohorts, Cohort A (all discharges) and Cohort B (ventilated children).

RESULTS

A total of 4,247,604 and 79,116 discharges were included in cohorts A and B, respectively. Univariate analysis showed that the inpatient mortality rate was highest among Asian and Pacific Islander children for both cohorts: A (0.47% [0.42-0.51]), B (10.9% [9.8-12.1]). Regression analysis showed that Asian and Pacific Islander and Black children had increased odds of inpatient mortality compared to White children: A (1.319 [1.162-1.496], 1.178 [1.105-1.257], respectively) and B (1.391 [1.199-1.613], 1.163 [1.079-1.255], respectively). Population-based hospital mortality was highest in Black children (1.17 per 10,000 children).

CONCLUSIONS

Inpatient mortality rates are significantly higher in U.S. children of Asian and Pacific Islander and Black races compared to White children. U.S. population-based metrics such as hospitalization rate, ventilation rate, and hospital mortality rate are highest in Black children. Our data suggest that lower median household income alone may not account for a higher inpatient mortality rate. The causes and prevention of racial and ethnic inequities in hospitalized children need to be explored further.

The Impact of Medicaid Expansion Under the Affordable Care Act on the Gap Between American Indians and Whites in Breast Cancer Management and Prognosis

BACKGROUND

Breast cancer (BC) death rates in the USA have not significantly declined for American Indians (AIs) in comparison to Whites. Our objective was to determine whether Medicaid Expansion as part of the Affordable Care Act led to improved BC outcomes for AIs relative to Whites.

PATIENTS AND METHODS

Using the National Cancer Database, we conducted a retrospective cohort study. Included were BC patients who were AI and White; 40 to 64 years of age; diagnosed in 2009 to 2016; lived in states that expanded Medicaid in January 2014, and states that did not expand Medicaid. Our outcomes were stage at diagnosis, insurance status, timely treatment, and 3-year mortality.

RESULTS

There were 359,484 newly diagnosed BC patients, 99.49% White, 0.51% AI. Uninsured rates declined more in the expansion states than in the nonexpansion states (OR = 0.44, 95% CI: 0.15-0.97, P < 0.001). Lower rates of Stage I BC diagnosis was found in AIs compared to Whites (46.58% vs. 55.33%, P < .001); these differential rates did not change after Medicaid expansion. Rates of definitive treatment initiation within 30 days of diagnosis declined after Medicaid expansion (P < .001); there was a smaller decline in the expansion states (OR 1.118, 95% CI: 1.09, 1.15, P < .001). Three year mortality was not different between expansion and nonexpansion states post Medicaid expansion.

CONCLUSIONS

In newly diagnosed BCs, uninsured rates declined more in the states that expanded Medicaid in January 2014. Timely treatment post Medicaid expansion declined less in states that expanded Medicaid. There was no differential benefit of Medicaid expansion in the 2 races.

Racial and Ethnic Disparities in Excess All-Cause Mortality in the First Year of the COVID-19 Pandemic

Research on the COVID-19 pandemic in the United States has consistently found disproportionately high mortality among ethnoracial minorities, but reports differ with respect to the magnitude of mortality disparities and reach different conclusions regarding which groups were most impacted. We suggest that these variations stem from differences in the temporal scope of the mortality data used and difficulties inherent in measuring race and ethnicity. To circumvent these issues, we link Social Security Administration death records for 2010 through 2021 to decennial census and American Community Survey race and ethnicity responses. We use these linked data to estimate excess all-cause mortality for age-, sex-, race-, and ethnicity-specific subgroups and examine ethnoracial variation in excess mortality across states and over the course of the pandemic's first year. Results show that non-Hispanic American Indians and Alaska Natives experienced the highest excess mortality of any ethnoracial group in the first year of the pandemic, followed by Hispanics and non-Hispanic Blacks. Spatiotemporal and age-specific ethnoracial disparities suggest that the socioeconomic determinants driving health disparities prior to the pandemic were amplified and expressed in new ways in the pandemic's first year to disproportionately concentrate excess mortality among racial and ethnic minorities.

Racial disparities in the selection of chief resident: A cross-sectional analysis of a national sample of senior residents in the United States

INTRODUCTION

Part of the difficulty in recruiting and retaining a diverse physician workforce, as well as within medical leadership, is due to racial disparities in medical education. We investigated whether self-identified race-ethnicity is associated with the likelihood of selection as chief resident (CR).

MATERIALS AND METHODS

We performed a cross sectional analysis using de-identified person-level data from the GME Track, a national resident database and tracking system, from 2015 through 2018. The exposure variable, self-identified race-ethnicity, was categorized as African American or Black, American Indian or Alaskan Native, Asian, Hispanic, Latino or of Spanish Origin, Native Hawaiian or Pacific Islander, White, and Multi-racial. The primary study outcome was CR selection among respondents in their final program year. Logistic regression was used to estimate the adjusted odds ratios (aOR) and 95% confidence intervals (CI) of CR selection for each racial group, as compared to the White referent group.

RESULTS

Among the study population (N=121,247), Black, Asian and Hispanic race-ethnicity was associated with a significantly decreased odds of being selected as CR in unadjusted and adjusted analyses. Black, Asian and Hispanic residents had a 26% (aOR=0.74, 95% CI 0.66-0.83), 29% (aOR=0.71, 95% CI 0.66-0.76) and 28% (aOR=0.72, 95% CI 0.66-0.94) decreased likelihood of becoming CR, respectively. Multi-racial residents also had a decreased likelihood, but to a lesser degree (aOR=0.92, 95% CI 0.89-0.95).

CONCLUSIONS

In as much as CR is an honor that sets one up for future opportunity, our findings suggest that residents of color are disproportionately disadvantaged compared to their White peers.

Cancer Diagnoses After Recent Weight Loss

Importance

Weight loss is common in primary care. Among individuals with recent weight loss, the rates of cancer during the subsequent 12 months are unclear compared with those without recent weight loss.

Objective

To determine the rates of subsequent cancer diagnoses over 12 months among health professionals with weight loss during the prior 2 years compared with those without recent weight loss.

Design, Setting, and Participants

Prospective cohort analysis of females aged 40 years or older from the Nurses' Health Study who were followed up from June 1978 until June 30, 2016, and males aged 40 years or older from the Health Professionals Follow-Up Study who were followed up from January 1988 until January 31, 2016.

Exposure

Recent weight change was calculated from the participant weights that were reported biennially. The intentionality of weight loss was categorized as high if both physical activity and diet quality increased, medium if only 1 increased, and low if neither increased.

Main Outcome and Measures

Rates of cancer diagnosis during the 12 months after weight loss.

Results

Among 157 474 participants (median age, 62 years [IQR, 54-70 years]; 111 912 were female [71.1%]; there were 2631 participants [1.7%] who self-identified as Asian, Native American, or Native Hawaiian; 2678 Black participants [1.7%]; and 149 903 White participants [95.2%]) and during 1.64 million person-years of follow-up, 15 809 incident cancer cases were identified (incident rate, 964 cases/100 000 person-years). During the 12 months after reported weight change, there were 1362 cancer cases/100 000 person-years among all participants with recent weight loss of greater than 10.0% of body weight compared with 869 cancer cases/100 000 person-years among those without recent weight loss (between-group difference, 493 cases/100 000 person-years [95% CI, 391-594 cases/100 000 person-years]; P < .001). Among participants categorized with low intentionality for weight loss, there were 2687 cancer cases/100 000 person-years for those with weight loss of greater than 10.0% of body weight compared with 1220 cancer cases/100 000 person-years for those without recent weight loss (between-group difference, 1467 cases/100 000 person-years [95% CI, 799-2135 cases/100 000 person-years]; P < .001). Cancer of the upper gastrointestinal tract (cancer of the esophagus, stomach, liver, biliary tract, or pancreas) was particularly common among participants with recent weight loss; there were 173 cancer cases/100 000 person-years for those with weight loss of greater than 10.0% of body weight compared with 36 cancer cases/100 000 person-years for those without recent weight loss (between-group difference, 137 cases/100 000 person-years [95% CI, 101-172 cases/100 000 person-years]; P < .001).

Conclusions and Relevance

Health professionals with weight loss within the prior 2 years had a significantly higher risk of cancer during the subsequent 12 months compared with those without recent weight loss. Cancer of the upper gastrointestinal tract was particularly common among participants with recent weight loss compared with those without recent weight loss.

A mixed-methods study protocol on factors contributing to suicide clusters among Native American youth in a northern plains reservation

Introduction

Suicide and suicide clusters within Native American Reservation communities are devastating to the entire community and increase individuals' risk for suicide over the lifespan. The objective of this paper is to describe the Indigenous community-based participatory research protocol implemented in partnership with the Fort Belknap Indian Community in Montana, United States. The study protocol was developed to understand suicide risk and protective factors, and community-derived solutions, in a reservation community with history of a suicide cluster and high rates of youth suicide.

Methods

In this mixed-methods study, qualitative data from youth, adults, and service providers and quantitative data from 200 adolescents and young adults (aged 14-24 years) were collected in Fort Belknap, Montana from May - December of 2022. Qualitative data were collected first via in-depth interviews and focus groups. Survey questions included validated and pre-tested measures of factors youth experience across socio-ecological levels. Thematic analysis was applied to the qualitative data; and logistic regression models were used to examine relationships within the quantitative data.

Discussion

This study will add a multi-dimensional perspective to our current understanding of (1) risk and protective factors for suicide, community-derived postvention solutions, and insights on community assets, and (2) the current health and psychosocial status of youth in the Fort Belknap community. This study may serve as an exemplar of co-created, culturally safe solutions designed to address mental health resource gaps. Next steps include development of a suicide crisis response tool kit and a culturally aligned postvention intervention that will enhance individual, family, and community survivance.

Community-Level Factors are Predictors of Severe Maternal Morbidity Among American Indian and Alaska Native Pregnant People in the Pacific Northwest in a Multilevel Logistic Regression

INTRODUCTION

American Indian/Alaska Native (AI/AN) pregnant people face barriers to health and healthcare that put them at risk of pregnancy complications. Rates of severe maternal morbidity (SMM) among Indigenous pregnant people are estimated to be twice that of non-Hispanic White (NHW) pregnant people.

METHODS

Race-corrected Oregon Hospital Discharge and Washington Comprehensive Hospital Abstract Reporting System data were combined to create a joint dataset of births between 2012 and 2016. The analytic sample was composed of 12,535 AI/AN records and 313,046 NHW records. A multilevel logistic regression was used to assess the relationship between community-level, individual and pregnancy risk factors on SMM for AI/AN pregnant people.

RESULTS

At the community level, AI/AN pregnant people were more likely than NHW to live in mostly or completely rural counties with low median household income and high uninsured rates. They were more likely to use Medicaid, be in a high-risk age category, and have diabetes or obesity. During pregnancy, AI/AN pregnant people were more likely to have insufficient prenatal care (PNC), gestational diabetes, and pre-eclampsia. In the multilevel model, county accounted for 6% of model variance. Hypertension pre-eclampsia, and county rurality were significant predictors of SMM among AI/AN pregnant people. High-risk age, insufficient PNC and a low county insured rate were near-significant at p < 0.10.

DISCUSSION

Community-level factors are significant contributors to SMM risk for AI/AN pregnant people in addition to hypertension and pre-eclampsia. These findings demonstrate the need for targeted support in pregnancy to AI/AN pregnant people, particularly those who live in rural and underserved communities.

Mammography Compliance for Arizona and New Mexico Hispanic and American Indian Women 2016-2018

Hispanic and American Indian (AI) women experience lower breast cancer incidence than non-Hispanic White (NHW) women, but later-stage diagnoses and lower survival rates, suggesting issues with screening and healthcare access. Between 1999-2015, NHW breast cancer incidence decreased by 10% but increased by 8% for AI women. This study used 2016 and 2018 Behavioral Risk Factor Surveillance System data for Arizona and New Mexico to explore mammography screening. Analyses included Hispanic, AI, and NHW women aged ≥40 years (n = 12,830) to calculate age-specific compliance by race/ethnicity, logistic regression, and adjusted and sample-weighted evaluated associations between compliance and socio-economic covariates. In total, 75.1% of Hispanic women aged 50-74 reported mammography in the past two years (United States Preventive Services Task Force compliant) compared to 73.9% of NHW and 71.0% of AI women. Women who reported doctor visits in the past 12 months were likelier to comply than those without (AOR = 4.2 for Hispanic, 2.9 for AI, and 3.2 for NHW women). Reporting access to a personal doctor was related to compliance, except for AI women. While screening compliance was over 74%, visiting a healthcare provider in the past 12 months was essential. AI women reported issues that suggest unique challenges when deciding on mammography.

Suicides among American Indian/Alaska Native firefighters: Data from the National Violent Death Reporting System, 2003 - 2017

Suicide is a significant public health problem in the United States and disproportionally affects male American Indian/Alaska Natives (AI/AN). Suicide is particularly problematic among AI/AN firefighters who are more likely to report suicide ideation, planning, attempts, and risk compared to non-Hispanic white (NHW) firefighters. The aim of the current study was to compare non-Hispanic AI/AN firefighter and NHW firefighter suicide decedents by demographics and risk/precipitating factors using National Violent Death Reporting System data for 45 male non-Hispanic AI/AN firefighter and 588 male NHW firefighter decedents who died by suicide. Compared to NHW firefighter decedents, AI/AN firefighter decedents were significantly younger and had significantly higher odds of experiencing alcohol use problems and a recent death/suicide of a family member/friend. AI/AN firefighter decedents had significantly lower odds of documented mental health problems, documented diagnosis of depression/dysthymia, receipt of mental health treatment, or leaving a suicide note compared to NHW firefighter decedents. Results from this study may inform tailored suicide prevention and screening efforts among first responders with the goal of lowering suicide mortality among AI/AN firefighters and fire service as a whole.

The Intersection of Race and Sex: A New Perspective Into Diversity Trends in Orthopaedic Surgery

INTRODUCTION

Studies on diversity in orthopaedic surgery have exclusively examined challenges from a race or sex perspective. This study examines trends in the diversity of entering orthopaedic surgery residents from the intersection of race and sex.

METHODS

The American Association of Medical Colleges was queried for individuals entering orthopaedic surgery residencies in the United States from 2001 to 2020. Deidentified data on self-reported sex and race were collected. Proportions by the intersection of sex and race were calculated for 5-year intervals.

RESULTS

From 2001 to 2020, most of the new female residents identified as White (mean, 71.0%). The average proportion of White female residents was lower in 2016 to 2020 than in 2001 to 2005 (71.0% vs. 73.2%) but higher than that in 2011 to 2015 (66.8%). The 2016 to 2020 average was lower than that of 2001 to 2005 for those who identified as Asian (11.7% vs. 14.9%), Black (4.1% vs. 4.8%), Hispanic (3.0% vs. 4.4%), and American Indian/Alaska Native (0.0% vs. 1.5%). Most of the new male orthopaedic surgery residents from 2001 to 2020 identified as White (mean, 74.1%), but the average decreased across every 5-year interval from 2001 to 2005 (76.1%) to 2016 to 2020 (71.1%). The 2016 to 2020 average was lower than that of 2001 to 2005 for those who identified as Asian (12.2% vs. 13.6%), Black (3.5% vs. 4.2%), Hispanic (3.0% vs. 3.4%), American Indian/Alaska Native (0.0% vs. 0.6%), and Native Hawaiian/Other Pacific Islander (0.1% vs. 0.3%). In 2020, White male residents made up to 54.2% of new residents. White female residents were the second highest group represented (12.1%).

CONCLUSION

Increases in representation were observed for some subgroups of new orthopaedic surgery residents from 2001 to 2020. Although the proportion of both White female and male residents decreased by 11.5% during the 20-year study period, these individuals still made up most of the trainees in 2020. These results underscore the need for conversations and recruitment practices to take into consideration the intersectionality of identities.

American Indian and Alaska Native Accessibility to Comprehensive Cleft Lip and Palate Treatment

American Indians and Alaska Natives (AI/AN) have the highest incidence of cleft lip and palate (orofacial clefts [OFCs]) when compared to other ethnic groups. We aim to determine the AI/AN populations' proximity and accessibility to American Cleft Palate-Craniofacial Association accredited centers (ACPA centers) for treatment of OFCs. Our hypothesis is an unacceptable proportion of the AI/AN population lacks reasonable accessibility to ACPA centers and comprehensive craniofacial care.

A cross-sectional study of ACPA centers and AI/AN populations were analyzed for possible disparities.

ACPA centers were mapped using Geographic Information Systems (GIS) and compared with 2018 census population data and 2017 Tribal Census Tract data to visually display possible disparities. Total annual potential pediatric cleft care need for selected high-density AI/AN populated lands were estimated.

GIS mapping demonstrates geographical isolation of AI/AN populations from ACPA centers. Two states with high AI/AN populated lands (ND, WY) have no ACPA centers. 47.1% of ACPA centers in high AI/AN populated lands have no craniofacial trained surgeons versus 78.9% craniofacial staffed ACPA centers nationally. The potential unmet cleft and craniofacial care need in selected high-density AI/AN populated lands is 1042 children.

AI/AN populations are likely underserved by ACPA centers and by craniofacial fellowship-trained staffed centers. Not addressing OFCs with comprehensive care can lead to worsened outcomes and further marginalization of these children. With future studies, we will be capable of making data-driven, informed decisions to more effectively ensure AI/AN access to comprehensive cleft and craniofacial care.

County-level barriers in the COVID-19 vaccine coverage index and their associations with willingness to receive the COVID-19 vaccine across racial/ethnic groups in the U.S

Background

County-level vaccination barriers (sociodemographic barriers, limited healthcare system resources, healthcare accessibility barriers, irregular healthcare seeking behaviors, history of low vaccination) may partially explain COVID-19 vaccination intentions among U.S. adults. This study examined whether county-level vaccination barriers varied across racial/ethnic groups in the U.S. and were associated with willingness to receive the COVID-19 vaccine. In addition, this study assessed whether these associations differed across racial/ethnic groups.

Methods

This study used data from the REACH-US study, a large online survey of U.S. adults (N = 5,475) completed from January 2021-March 2021. County-level vaccination barriers were measured using the COVID-19 Vaccine Coverage Index. Ordinal logistic regression estimated associations between race/ethnicity and county-level vaccination barriers and between county-level vaccination barriers and willingness to receive the COVID-19 vaccine. Models adjusted for covariates (age, gender, income, education, political ideology, health insurance, high-risk chronic health condition). Multigroup analysis estimated whether associations between barriers and willingness to receive the COVID-19 vaccine differed across racial/ethnic groups.

Results

American Indian/Alaska Native, Black/African American, Hispanic/Latino ELP [English Language Preference (ELP); Spanish Language Preference (SLP)], and Multiracial adults were more likely than White adults to live in counties with higher overall county-level vaccination barriers [Adjusted Odd Ratios (AORs):1.63-3.81]. Higher county-level vaccination barriers were generally associated with less willingness to receive the COVID-19 vaccine, yet associations were attenuated after adjusting for covariates. Trends differed across barriers and racial/ethnic groups. Higher sociodemographic barriers were associated with less willingness to receive the COVID-19 vaccine (AOR:0.78, 95% CI:0.64-0.94), whereas higher irregular care-seeking behavior was associated with greater willingness to receive the vaccine (AOR:1.20, 95% CI:1.04-1.39). Greater history of low vaccination was associated with less willingness to receive the COVID-19 vaccine among Black/African American adults (AOR:0.55, 95% CI:0.37-0.84), but greater willingness to receive the vaccine among American Indian/Alaska Native and Hispanic/Latino ELP adults (AOR:1.90, 95% CI:1.10-3.28; AOR:1.85, 95% CI:1.14-3.01).

Discussion

Future public health emergency vaccination programs should include planning and coverage efforts that account for structural barriers to preventive healthcare and their intersection with sociodemographic factors. Addressing structural barriers to COVID-19 treatment and preventive services is essential for reducing morbidity and mortality in future infectious disease outbreaks.

Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury

Importance

Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system.

Objective

To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded.

Design, Settings, and Participants

This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023.

Exposures

Acute painful traumatic injuries including burns.

Main Outcomes and Measures

Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine.

Results

The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients.

Conclusions and Relevance

In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.

Survival Outcomes by Race and Ethnicity in Veterans With Nonmetastatic Castration-Resistant Prostate Cancer

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.

Native American ancestry and breast cancer risk in Colombian and Mexican women: ruling out potential confounding through ancestry-informative markers

BACKGROUND

Latin American and Hispanic women are less likely to develop breast cancer (BC) than women of European descent. Observational studies have found an inverse relationship between the individual proportion of Native American ancestry and BC risk. Here, we use ancestry-informative markers to rule out potential confounding of this relationship, estimating the confounder-free effect of Native American ancestry on BC risk.

METHODS AND STUDY POPULATION

We used the informativeness for assignment measure to select robust instrumental variables for the individual proportion of Native American ancestry. We then conducted separate Mendelian randomization (MR) analyses based on 1401 Colombian women, most of them from the central Andean regions of Cundinamarca and Huila, and 1366 Mexican women from Mexico City, Monterrey and Veracruz, supplemented by sensitivity and stratified analyses.

RESULTS

The proportion of Colombian Native American ancestry showed a putatively causal protective effect on BC risk (inverse variance-weighted odds ratio [OR] = 0.974 per 1% increase in ancestry proportion, 95% confidence interval [CI] 0.970-0.978, p = 3.1 × 10-40). The corresponding OR for Mexican Native American ancestry was 0.988 (95% CI 0.987-0.990, p = 1.4 × 10-44). Stratified analyses revealed a stronger association between Native American ancestry and familial BC (Colombian women: OR = 0.958, 95% CI 0.952-0.964; Mexican women: OR = 0.973, 95% CI 0.969-0.978), and stronger protective effects on oestrogen receptor (ER)-positive BC than on ER-negative and triple-negative BC.

CONCLUSIONS

The present results point to an unconfounded protective effect of Native American ancestry on BC risk in both Colombian and Mexican women which appears to be stronger for familial and ER-positive BC. These findings provide a rationale for personalised prevention programmes that take genetic ancestry into account, as well as for future admixture mapping studies.

Lessons learned and future directions: A scoping review of American Indian and Alaska Native participants in the National Drug Abuse Treatment Clinical Trials Network

INTRODUCTION

American Indian and Alaska Native (AI/AN) populations are disproportionately affected by substance use disorders (SUDs) and related health disparities in contrast to other ethnoracial groups in the United States. Over the past 20 years, substantial resources have been allocated to the National Institute on Drug Abuse Clinical Trials Network (CTN) to disseminate and implement effective SUD treatments in communities. However, we know little about how these resources have benefitted AI/AN peoples with SUD who arguably experience the greatest burden of SUDs. This review aims to determine lessons learned about AI/AN substance use and treatment outcomes in the CTN and the role of racism and Tribal identity.

METHOD

We conducted a scoping review informed by the Joanna Briggs framework and PRISMA Extension for Scoping Reviews checklist and explanation. The study team conducted the search strategy within the CTN Dissemination Library and nine additional databases for articles published between 2000 and 2021. The review included studies if they reported results for AI/AN participants. Two reviewers determined study eligibility.

RESULTS

A systematic search yielded 13 empirical articles and six conceptual articles. Themes from the 13 empirical articles included: (1) Tribal Identity: Race, Culture, and Discrimination; (2) Treatment Engagement: Access and Retention; (3) Comorbid Conditions; (4) HIV/Risky Sexual Behaviors; and (5) Dissemination. The most salient theme was Tribal Identity: Race, Culture, and Discrimination, which was present in all articles that included a primary AI/AN sample (k = 8). Themes assessed but not identified for AI/AN peoples were Harm Reduction, Measurement Equivalence, Pharmacotherapy, and Substance Use Outcomes. The conceptual contributions used AI/AN CTN studies as exemplars of community-based and Tribal participatory research (CBPR/TPR).

CONCLUSION

CTN studies conducted with AI/AN communities demonstrate culturally congruent methods, including CBPR/TPR strategies; consideration/assessment of cultural identity, racism, and discrimination; and CBPR/TPR informed dissemination plans. Although important efforts are underway to increase AI/AN participation in the CTN, future research would benefit from strategies to increase participation of this population. Such strategies include reporting AI/AN subgroup data; addressing issues of cultural identity and experiences of racism; and adopting an overall effort for research aimed at understanding barriers to treatment access, engagement, utilization, retention, and outcomes for both treatment and research disparities for AI/AN populations.

Differential patient travel distance and time to psoriasis clinical trial sites

Considering the known disparities in racial representation in psoriasis clinical trials, this study sought to characterize travel distance and time to reach a psoriasis clinical trial site as a potential barrier to trial participation for multiple demographic and geographic variables. We determined travel distance and time from every census tract population center in the United States to the nearest psoriasis clinical trial site using ArcGIS and linked travel estimates to demographic characteristics in each census tract based on 2020 American Community Survey. The average distance and time traveled to reach a psoriasis clinical trial site nationally were 45.6 miles and 51.8 min, respectively. Urban residence and Northeast location had significantly lower travel distance and time relative to their geographic counterparts. Travel burden was significantly greater among Native American and Black races, individuals without college education and Veterans Affairs beneficiaries relative to their counterparts. These findings reveal disparate access regarding rurality, race, education and insurance type, which may encourage investigators to increase travel funding for underrepresented groups and diversity recruitment efforts to promote access to psoriasis clinical trials.

Racial/Ethnic disparities in the chains of morbid events leading to death: network analysis of US multiple cause of death data

Multiple-cause-of-death data have not yet been applied to the study of racial/ethnic differences in causal chains of events leading to death, nor they have been used to examine racial/ethnic disparities in cause-of-death certification. We use publicly available 2019 US death certificate data to reassemble chains of morbid events leading to death. From them, we construct and analyze directed multiple cause of death networks by race and sex of deaths aged 60+. Three perspectives to measure disparities are employed: (i) relative prevalence of cause-of-death-pairs, (ii) strength of associations between diseases, (iii) similarities in transition matrices. Non-Hispanic Blacks (NHB) had overall lower prevalence of cause of death pairs, Hispanics (HIS) were burdened more by alcohol-related mortality and Asian and Pacific Islanders (API) exceeded in transitions to cerebrovascular diseases. Lower similarity was observed in transitions to external causes of death, dementia and Alzheimer's disease, pulmonary heart diseases, interstitial respiratory diseases, and diseases of the liver. After excluding rare diseases, the similarity further decreased for ill-defined conditions, diabetes mellitus, other cardiovascular diseases, diseases of the pleura, and anemia. To sum up, races/ethnicities not only vary in structure and timing of death but they differ in morbid processes leading to death as well.

Overdose deaths involving synthetic opioids: Racial/ethnic and educational disparities in the eastern and western US

BACKGROUND

This study examined racial/ethnic and educational disparities in US synthetic opioid overdose mortality East and West of the Mississippi River.

METHODS

Using restricted-access 2018-2021 mortality data from the Centers for Disease Control and Prevention and population estimates from the American Community Survey, age-standardized rate ratios (SRRs) and 95% Confidence Intervals (CIs) were used to compare rates of synthetic opioid mortality by race/ethnicity and educational attainment level in the regions East and West of the Mississippi River.

RESULTS

Racial/ethnic disparities in synthetic opioid mortality rates, relative to the Non-Hispanic (NH) White population, were observed in the NH Black (SRR, 1.5 [95% CI, 1.5-1.6]) and NH American Indian/Alaska Native (SRR, 2.1 [95% CI, 1.9-2.2]) populations in the West, and the Puerto Rican (SRR, 1.3 [95% CI, 1.3-1.3]) and NH American Indian/Alaska Native (SRR, 1.5 [95% CI, 1.4-1.6]) populations in the East. Relative to those with a Bachelor's degree or higher: in the West, the synthetic opioid mortality rate was more than seven times as high for those with a high school diploma only (SRR 7.7 [95% CI, 7.4-8.0]), and in the East, approximately thirteen times as high for those with a high school diploma only (SRR, 13.0 [95% CI, 12.7-13.3]) or less than a high school diploma (SRR, 13.3 [95% CI, 13.0-13.7]).

CONCLUSION

Disparities in rates of synthetic opioid mortality differ in the eastern and western US, supporting tailored responses within each region.

Cardiovascular Disease Burden and Outcomes Among American Indian and Alaska Native Medicare Beneficiaries

Importance

American Indian and Alaska Native persons face significant health disparities; however, data regarding the burden of cardiovascular disease in the current era is limited.

Objective

To determine the incidence and prevalence of cardiovascular disease, the burden of comorbid conditions, including cardiovascular disease risk factors, and associated mortality among American Indian and Alaska Native patients with Medicare insurance.

Design, Setting, and Participants

This was a population-based cohort study conducted from January 2015 to December 2019 using Medicare administrative data. Participants included American Indian and Alaska Native Medicare beneficiaries 65 years and older enrolled in both Medicare part A and B fee-for-service Medicare. Statistical analyses were performed from November 2022 to April 2023.

Main Outcomes and Measures

The annual incidence, prevalence, and mortality associated with coronary artery disease (CAD), heart failure (HF), atrial fibrillation/flutter (AF), and cerebrovascular disease (stroke or transient ischemic attack [TIA]).

Results

Among 220 598 American Indian and Alaska Native Medicare beneficiaries, the median (IQR) age was 72.5 (68.5-79.0) years, 127 402 were female (57.8%), 78 438 (38.8%) came from communities in the most economically distressed quintile in the Distressed Communities Index. In the cohort, 44.8% of patients (98 833) were diagnosed with diabetes, 61.3% (135 124) were diagnosed with hyperlipidemia, and 72.2% (159 365) were diagnosed with hypertension during the study period. The prevalence of CAD was 38.6% (61 125 patients) in 2015 and 36.7% (68 130 patients) in 2019 (P < .001). The incidence of acute myocardial infarction increased from 6.9 per 1000 person-years in 2015 to 7.7 per 1000 patient-years in 2019 (percentage change, 4.79%; P < .001). The prevalence of HF was 22.9% (36 288 patients) in 2015 and 21.4% (39 857 patients) in 2019 (P < .001). The incidence of HF increased from 26.1 per 1000 person-years in 2015 to 27.0 per 1000 person-years in 2019 (percentage change, 4.08%; P < .001). AF had a stable prevalence of 9% during the study period (2015: 9.4% [14 899 patients] vs 2019: 9.3% [25 175 patients]). The incidence of stroke or TIA decreased slightly throughout the study period (12.7 per 1000 person-years in 2015 and 12.1 per 1000 person-years in 2019; percentage change, 5.08; P = .004). Fifty percent of patients (110 244) had at least 1 severe cardiovascular condition (CAD, HF, AF, or cerebrovascular disease), and the overall mortality rate for the cohort was 19.8% (43 589 patients).

Conclusions and Relevance

In this large cohort study of American Indian and Alaska Native patients with Medicare insurance in the US, results suggest a significant burden of cardiovascular disease and cardiometabolic risk factors. These results highlight the critical need for future efforts to prioritize the cardiovascular health of this population.

Barriers Faced by American Indian Women in Urban Wisconsin in Seeking Help Following an Experience of Intimate Partner Violence

American Indian1 (AI) women experience high rates of intimate partner violence (IPV) and face many barriers when help-seeking. This study aims to understand better the context of IPV and help-seeking behaviors for urban AI women after experiences with IPV. Postcolonial and Indigenous feminist frameworks framed this critical ethnography study. Semistructured interviews with 34 AI IPV survivors2 living in Wisconsin urban areas were conducted. Our findings highlight context-specific structural barriers to help-seeking after experiences of IPV heightened by the COVID-19 pandemic. Context-specific and survivor-led interventions are necessary to address and reduce barriers that urban AI women face.

Facilitating the Urgent Public Health Need to Improve Data Sharing With Tribal Epidemiology Centers

Tribal Epidemiology Centers (TECs) are an essential and unique part of the public health system and an important part of federal efforts to improve the health status of American Indian and Alaska Native people. Pursuant to federal statute, TECs serve the 574 federally recognized Tribes (hereinafter, "Tribes") and their members across the United States, as well as American Indian and Alaska Native people in general. The COVID-19 pandemic has highlighted the need for timely, complete, and accurate public health data, particularly for American Indian and Alaska Native communities and others who may have been disproportionately impacted by COVID-19. This article reviews the history and importance of TECs and federal statutes governing TECs' ability to access and use protected health information for public health purposes. TECs and Tribes often encounter difficulty receiving public health data from state and federal agencies despite their designation as "public health authorities" under the Health Insurance Portability and Accountability Act and associated regulations. Limited access to this information hinders the statutory mission of TECs as well as Tribal monitoring of and response to public health threats such as SARS-CoV-2. Agency acknowledgment and compliance with current federal law regarding data sharing with TECs are essential to improve data access and the fragile public health of Tribal communities.

The Association Between Resiliency Factors and Suicide Indicators Among American Indian/Alaska Native Middle School Students in New Mexico: A Strength-Based Analysis

OBJECTIVE

Suicide is a leading cause of death among American Indian/Alaska Native (AI/AN) young people aged 10-19 years in the United States, but data collection and reporting in this population are lacking. We examined results of an oversample project in New Mexico to determine the association between resiliency factors and suicide-related behaviors among AI/AN middle school students.

METHODS

We conducted analyses using data from the 2019 New Mexico Youth Risk and Resiliency Survey for students in grades 6 through 8. An oversampling method was used to increase the sample size of AI/AN students. We used logistic regression to determine the association between resiliency factors and suicide indicators among AI/AN students, stratified by sex.

RESULTS

Among female AI/AN students, community support had the strongest protective effect against having seriously thought about suicide (adjusted odds ratio [aOR] = 0.23; 95% CI, 0.14-0.38), while family support was significantly associated with the lowest odds of having made a suicide plan (aOR = 0.15; 95% CI, 0.08-0.28) and having attempted suicide (aOR = 0.21; 95% CI, 0.13-0.34) (P < .001 for all). Among male AI/AN students, school support had the strongest protective effect against all 3 outcomes: seriously thought about suicide (aOR = 0.34; 95% CI, 0.19-0.62; P < .001), having made a suicide plan (aOR = 0.19; 95% CI, 0.09-0.39; P < .001), and having attempted suicide (aOR = 0.27; 95% CI, 0.12-0.65; P = .003).

CONCLUSIONS

Oversampling AI/AN young people can help accurately quantify and understand health risk behaviors and strengths of this population, leading to improved health and wellness. Family, community, and school-based support should be considered in interventions geared toward suicide prevention among AI/AN young people.

Intimate Partner Violence, Economic Insecurity, and Health Outcomes Among American Indian and Alaska Native Men and Women: Findings From a National Sample

Limited data are available on experiences of intimate partner violence (IPV) and sexual violence (SV) and health outcomes among American Indian and Alaska Native (AIAN) populations. This study explores the relationship between IPV and SV, food insecurity, housing insecurity, healthcare access, and self-reported physical and mental health status in a nationally representative sample of AIAN adults (N = 3,634). IPV and SV were associated with poorer physical and mental health at the bivariate level, but not in multivariate analyses. Economic inequalities are a salient predictor of health and may be compounded by demographic and geographic contexts.

Years of life lost due to deaths of despair and COVID-19 in the United States in 2020: patterns of excess mortality by gender, race and ethnicity

BACKGROUND

In 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen-which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020.

METHODS

This cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation.

RESULTS

In 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes.

CONCLUSIONS

This study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.

Anemia In Pregnancy: Examining Missed Diagnoses and Racial Disparities in the Upper Midwest

Anemia in pregnancy (AIP) is associated with poor maternal/fetal outcomes. The prevalence of AIP globally ranges from 44-53% and varies drastically depending on maternal race/ethnicity and other factors. Screening and treatment of AIP is disputed. This study is a retrospective review of electronic medical records (EMR) of pregnant adults over three years (2018-2020, inclusive) of Sanford Health, a large healthcare system in the upper Midwest. AIP was determined by either diagnosis or lab values (hemoglobin, hematocrit, and ferritin) overlapping with pregnancy. A missed diagnosis was characterized by confirmed anemia through lab values but lacking a diagnosis of anemia within EMR. A total of 35,498 patients were included in this study, 42.9% were determined to have AIP. Of AI/AN (American Indian/Alaska Native) patients, 58.3% were anemic and 55.1% of Black/African American patients were anemic compared to 40.0% of anemic white patients. Of anemic patients, 81.1% did not have an anemia diagnosis listed in EMR. This study identifies racial and ethnic disparities of AIP among patients in the upper Midwest. In addition, this study highlights the need for improved data integrity within EMR.

Prevalence of Dementia in American Indians and Alaska Natives Compared to White, Black, and Hispanic Medicare Beneficiaries: Findings from the National Health and Aging Trends Study

OBJECTIVE

To estimate the prevalence of dementia among American Indian and Alaska Native (AIAN) Medicare beneficiaries and compare the prevalence of dementia in AIANs and other racial and ethnic minority groups-non-Hispanic Blacks (NHBs) and Hispanics-with non-Hispanic Whites (NHWs) Medicare beneficiaries.

METHODS

We used survey data from Round 5 of the National Health and Aging Trends Study (NHATS, 2015) (N = 7,449), a nationally representative study of Medicare beneficiaries ages 65 years and older. We used logistic regression to estimate the age- and sex-adjusted prevalence of dementia with 95% confidence intervals by race/ethnicity as well as prevalence differences between groups.

RESULTS

The majority of participants were between 65 and 74 years old. Approximately half of them were female. NHWs had a prevalence of 5% for dementia, and AIAIs had a prevalence of 9%, four percentage points higher than NHWs (95%CI 1%, 11%). We estimated a similar difference in the prevalence of dementia in AIAN Medicare beneficiaries compared to NHBs.

CONCLUSION

While previous research has reported that AIANs share a similar or lower prevalence of dementia than NHWs, our findings suggest a potentially higher prevalence of dementia among AIAN Medicare beneficiaries. A relatively small number of AIAN resulted in wide confidence intervals for many of our associations. Future research should focus on recruiting a larger sample and on dementia prevalence and unique risk factors within and among AIAN tribes.

Integrating Opioid Use Disorder Treatment Into Primary Care Settings

Importance

Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist.

Objective

To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD.

Design, Setting, and Participants

This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022.

Exposure

Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services.

Measures

Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods.

Results

Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care.

Conclusions and Relevance

The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Comparing American Indian/Alaska Native Adolescent Daughters' and Their Mothers' Awareness, Knowledge, Attitudes, and Behaviors Regarding Risk for Gestational Diabetes: Implications for Mother-Daughter Communication on Reproductive Health

PURPOSE

The purpose of the study was to describe, compare, and examine associations at baseline of reproductive health awareness, knowledge, health beliefs, communication and behaviors related to gestational diabetes (GDM) and GDM risk reduction in a vulnerable population of both American Indian/Alaska Native (AIAN) adolescent girls and their mothers.

METHODS

Descriptive/comparative/correlational analyses examined multitribal baseline data on 149 mother-daughter (M-D) dyads (N = 298; daughter age = 12-24 years) enrolled in a longitudinal study to adapt and evaluate a culturally relevant diabetes preconception counseling (PC) program (Stopping-GDM). The associations between GDM risk reduction awareness, knowledge, health beliefs, and behaviors (eg, daughters' eating, physical activity, reproductive-health [RH] choices/planning, M-D communication, daughters' discussions on PC) were examined. Data collected online from 5 national sites.

RESULTS

Many M-D lacked awareness/knowledge of GDM and risk reduction. Both M-D were unaware of the girl's risk for GDM. Mothers' knowledge and beliefs on GDM prevention/RH were significantly higher than daughters. Younger daughters had greater self-efficacy healthy living. Overall sample reported low to moderate scores for both M-D communication and daughters' GDM and RH risk-reduction behaviors.

CONCLUSIONS

Knowledge, communication, and behaviors to prevent GDM were low in AIAN M-D, especially daughters. More than daughters, mothers perceive greater risk of GDM for daughters. Early culturally responsive dyadic PC programs could help decrease risk of developing GDM. Implications for M-D communication is compelling.

Racial and ethnic disparities in monthly trends in alcohol-induced mortality among US adults from January 2018 through December 2021

Background: Historically, American Indians/Alaska Natives (AIANs), Blacks, and Hispanics have experienced higher alcohol-induced mortality rates. Given a disproportionate surge in unemployment rate and financial strain among racial and ethnic minorities and limited access to alcohol use disorder treatment during the COVID-19 pandemic, it is essential to examine monthly trends in alcohol-induced mortality in the United States during the pandemic.Objectives: This study estimates changes in monthly alcohol-induced mortality among US adults by age, sex, and race/ethnicity.Methods: Using monthly deaths from 2018-2021 national mortality files (N = 178,201 deaths, 71.5% male, 28.5% female) and census-based monthly population estimates, we calculated age-specific monthly alcohol-induced death rates and performed log-linear regression to derive monthly percent increases in mortality rates.Results: Alcohol-induced deaths among adults aged ≥25 years increased by 25.7% between 2019 (38,868 deaths) and 2020 (48,872 deaths). During 2018-2021, the estimated monthly percent change was higher for females (1.1% per month) than males (1.0%), and highest for AIANs (1.4%), followed by Blacks (1.2%), Hispanics (1.0%), non-Hispanic Whites (1.0%), and Asians (0.8%). In particular, between February 2020 and January 2021, alcohol-induced mortality increased by 43% for males, 53% for females, 107% for AIANs, the largest increase, followed by Blacks (58%), Hispanics (56%), Asians (44%), and non-Hispanic Whites (39%).Conclusions: During the peak months of the pandemic, the rising trends in alcohol-induced mortality differed substantially by race and ethnicity. Our findings indicate that behavioral and policy interventions and future investigation on underlying mechanisms should be considered to reduce alcohol-induced mortality among Blacks and AIANs.

Remapping racial and ethnic inequities in severe maternal morbidity: The legacy of redlining in California

BACKGROUND

Historical mortgage redlining, a racially discriminatory policy designed to uphold structural racism, may have played a role in producing the persistently elevated rate of severe maternal morbidity (SMM) among racialised birthing people.

OBJECTIVE

This study examined associations between Home-Owner Loan Corporation (HOLC) redlining grades and SMM in a racially and ethnically diverse birth cohort in California.

METHODS

We leveraged a population-based cohort of all live hospital births at ≥20 weeks of gestation between 1997 and 2017 in California. SMM was defined as having one of 21 procedures and diagnoses, per an index developed by Centers for Disease Control and Prevention. We characterised census tract-level redlining using HOLC's security maps for eight California cities. We assessed bivariate associations between HOLC grades and participant characteristics. Race and ethnicity-stratified mixed effects logistic regression models assessed the risk of SMM associated with HOLC grades within non-Hispanic Black, Asian/Pacific Islander, American Indian/Alaskan Native and Hispanic groups, adjusting for sociodemographic information, pregnancy-related factors, co-morbidities and neighbourhood deprivation index.

RESULTS

The study sample included 2,020,194 births, with 24,579 cases of SMM (1.2%). Living in a census tract that was graded as "Hazardous," compared to census tracts graded "Best" and "Still Desirable," was associated with 1.15 (95% confidence interval [CI] 1.03, 1.29) and 1.17 (95% CI 1.09, 1.25) times the risk of SMM among Black and Hispanic birthing people, respectively, independent of sociodemographic factors. These associations persisted after adjusting for pregnancy-related factors and neighbourhood deprivation index.

CONCLUSIONS

Historical redlining, a tool of structural racism that influenced the trajectory of neighbourhood social and material conditions, is associated with increased risk of experiencing SMM among Black and Hispanic birthing people in California. These findings demonstrate that addressing the enduring impact of macro-level and systemic mechanisms that uphold structural racism is a vital step in achieving racial and ethnic equity in birthing people's health.

Temporal Location of Changes in the US Suicide Rate by Age, Ethnicity, and Race: A Joinpoint Analysis 1999-2020

ABSTRACT

Suicide rates differ over time. Our objective was to determine when significant changes occurred by age, race, and ethnicity in the United States between 1999 and 2020. National Center for Health Statistics WONDER data were used in joinpoint regression. The annual percent change in suicide rate increased for all race, ethnic, and age groups, except for those 65 years and older. For American Indian/Alaska Natives, the largest increase occurred between 2010 and 2020 for those with ages 25 to 34 years. For Asian/Pacific Islander, the largest increase occurred among those 15 to 24 years old between 2011 and 2016. For Black/African-Americans, the largest increases occurred between 2010 and 2020 among 15- to 34-year-olds. For Whites, the largest increase occurred between 2014 and 2017 among 15- to 24-year-olds. Between 2018 and 2020, suicide rates significantly declined among Whites 45 to 64 years of age. Among Hispanics, significant increases in suicide rate occurred between 2012 and 2020 among those with ages 15 to 44 years. Between 1999 and 2020, the contour of suicide burden varied by age groups, race, and ethnicity.

The relationship between depressed affect, parental monitoring, and sex on cannabis use among American Indian youth

BACKGROUND AND OBJECTIVES

American Indian (AI) adolescents report higher rates of cannabis use than national US adolescents. Previous study examined interactive relationships between depressed affect and family factors on AI adolescent alcohol use. These factors have not been investigated for cannabis use. We examined whether parental monitoring dampened risk for cannabis use due to depressed affect, and potential moderation by sex.

METHODS

We measured cannabis use, depressed affect, parental monitoring, and sex among reservation area AI youth among students in grades 7-12 attending 45 schools. We used censor-inflated regression models to identify parental monitoring as a moderator of the relationship between depressed affect and cannabis use.

RESULTS

In the logistic portion of censor-inflated models, level of depressed affect and parental monitoring significantly related to last 30-day cannabis use. Higher levels of parental monitoring at lower levels of depressed affect related to lower likelihood of cannabis use. Female students had greater likelihood of endorsing cannabis use at higher levels of depressed affect. In the linear portion of the censor-inflated regression models, sex and level of parental monitoring significantly related to cannabis use frequency. Male students endorsed more frequent cannabis use while higher levels of parental monitoring related to lower frequency of use.

DISCUSSION AND CONCLUSIONS

Parental monitoring may dampen the effect of depressed affect on cannabis use among AI youth on reservations.

SCIENTIFIC SIGNIFICANCE

Future interventions should foster skill-building prevention efforts directed at coping with depression, along with parental training for effective monitoring. Special attention to AI female adolescents may be indicated.

The Economic Burden of Racial, Ethnic, and Educational Health Inequities in the US

Importance

Health inequities exist for racial and ethnic minorities and persons with lower educational attainment due to differential exposure to economic, social, structural, and environmental health risks and limited access to health care.

Objective

To estimate the economic burden of health inequities for racial and ethnic minority populations (American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander) and adults 25 years and older with less than a 4-year college degree in the US. Outcomes include the sum of excess medical care expenditures, lost labor market productivity, and the value of excess premature death (younger than 78 years) by race and ethnicity and the highest level of educational attainment compared with health equity goals.

Evidence Review

Analysis of 2016-2019 data from the Medical Expenditure Panel Survey (MEPS) and state-level Behavioral Risk Factor Surveillance System (BRFSS) and 2016-2018 mortality data from the National Vital Statistics System and 2018 IPUMS American Community Survey. There were 87 855 survey respondents to MEPS, 1 792 023 survey respondents to the BRFSS, and 8 416 203 death records from the National Vital Statistics System.

Findings

In 2018, the estimated economic burden of racial and ethnic health inequities was $421 billion (using MEPS) or $451 billion (using BRFSS data) and the estimated burden of education-related health inequities was $940 billion (using MEPS) or $978 billion (using BRFSS). Most of the economic burden was attributable to the poor health of the Black population; however, the burden attributable to American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander populations was disproportionately greater than their share of the population. Most of the education-related economic burden was incurred by adults with a high school diploma or General Educational Development equivalency credential. However, adults with less than a high school diploma accounted for a disproportionate share of the burden. Although they make up only 9% of the population, they bore 26% of the costs.

Conclusions and Relevance

The economic burden of racial and ethnic and educational health inequities is unacceptably high. Federal, state, and local policy makers should continue to invest resources to develop research, policies, and practices to eliminate health inequities in the US.

Urbanicity, Income, and Mammography-Use Disparities Among American Indian Women

INTRODUCTION

Reported breast cancer screening among American Indian women is consistently below that of White women. The last claims-based trends were from 1991 to 2001. This study updates mammography trends for American Indian women and examines the impact of race, urbanicity, and income on long-term mammography use.

METHODS

This was a multi-year (2005-2019), retrospective study of women aged 40-89 years using a 5% sample of Medicare fee-for-service beneficiaries residing in Arizona, California, New Mexico, Oklahoma, and Washington. This study used multivariable logistic regression to examine the impact of urbanicity and income on receiving mammography for American Indian women compared with that for White women. Analyses were conducted in 2022.

RESULTS

Overall, annual age-adjusted mammography use declined from 205 per 1,000 in 2005 to 165 per 1,000 in 2019. The slope of these declines was significantly steeper (difference = -2.41, p<0.001) for White women (-3.06) than for American Indian women (-0.65). Mammography-use odds across all urbanicity categories were less for American Indian women than for White women compared with those of their respective metropolitan counterparts (e.g., rural: 0.96, 95% CI=0.77, 1.20 for American Indian women and 1.47, 99% CI=1.39, 1.57 for White women). Although residing in higher-income communities was not associated with mammography use for American Indian women, it was 31% higher for White women (OR=1.31, 99% CI=1.28, 1.34).

CONCLUSIONS

The disparity in annual age-adjusted mammography use between American Indian and White women narrowed between 2005 and 2019. However, the association of urbanicity and community income on mammography use differs substantially between American Indian and White women. Policies to reduce disparities need to consider these differences.

Smoking Behaviors Among Indigenous Pregnant People Compared to a Matched Regional Cohort

INTRODUCTION

Smoking commercial tobacco products is highly prevalent in American Indian and Alaska Native (Indigenous) pregnancies. This disparity directly contributes to maternal and fetal mortality. Our objective was to describe cigarette smoking prevalence, cessation intervention uptake, and cessation behaviors of pregnant Indigenous people compared to sex and age-matched regional cohort.

AIMS AND METHODS

Pregnancies from an Indigenous cohort in Olmsted County, Minnesota, identified in the Rochester Epidemiology Project, were compared to pregnancies identified in a sex and age-matched non-Indigenous cohort from 2006 to 2019. Smoking status was defined as current, former, or never. All pregnancies were reviewed to identify cessation interventions and cessation events. The primary outcome was smoking prevalence during pregnancy, with secondary outcomes measuring uptake of smoking cessation interventions and cessation.

RESULTS

The Indigenous cohort included 57 people with 81 pregnancies, compared to 226 non-Indigenous people with 358 pregnancies. Smoking was identified during 45.7% of Indigenous pregnancies versus 11.2% of non-Indigenous pregnancies (RR: 3.25, 95% CI = 1.98-5.31, p ≤ .0001). Although there was no difference in uptake of cessation interventions between cohorts, smoking cessation was significantly less likely during Indigenous pregnancies compared to non-Indigenous pregnancies (OR: 0.23, 95% CI = 0.07-0.72, p = .012).

CONCLUSIONS

Indigenous pregnant people in Olmsted County, Minnesota were more than three times as likely to smoke cigarettes during pregnancy compared to the non-indigenous cohort. Despite equivalent uptake of cessation interventions, Indigenous people were less likely to quit than non-Indigenous people. Understanding why conventional smoking cessation interventions were ineffective at promoting cessation during pregnancy among Indigenous women warrants further study.

IMPLICATIONS

Indigenous pregnant people in Olmsted County, Minnesota, were greater than three times more likely to smoke during pregnancy compared to a regional age matched non-Indigenous cohort. Although Indigenous and non-Indigenous pregnant people had equivalent uptake of cessation interventions offered during pregnancy, Indigenous people were significantly less likely to quit smoking before fetal delivery. This disparity in the effectiveness of standard of care interventions highlights the need for further study to understand barriers to cessation in pregnant Indigenous people.

Blood cadmium, lead, manganese, mercury, and selenium levels in American Indian populations: The Strong Heart Study

BACKGROUND

Many American Indian (AI) communities are in areas affected by environmental contamination, such as toxic metals. However, studies assessing exposures in AI communities are limited. We measured blood metals in AI communities to assess historical exposure and identify participant characteristics associated with these levels in the Strong Heart Study (SHS) cohort.

METHOD

Archived blood specimens collected from participants (n = 2014, all participants were 50 years of age and older) in Arizona, Oklahoma, and North and South Dakota during SHS Phase-III (1998-1999) were analyzed for cadmium, lead, manganese, mercury, and selenium using inductively coupled plasma triple quadrupole mass spectrometry. We conducted descriptive analyses for the entire cohort and stratified by selected subgroups, including selected demographics, health behaviors, income, waist circumference, and body mass index. Bivariate associations were conducted to examine associations between blood metal levels and selected socio-demographic and behavioral covariates. Finally, multivariate regression models were used to assess the best model fit that predicted blood metal levels.

FINDINGS

All elements were detected in 100% of study participants, with the exception of mercury (detected in 73% of participants). The SHS population had higher levels of blood cadmium and manganese than the general U.S. population 50 years and older. The median blood mercury in the SHS cohort was at about 30% of the U.S. reference population, potentially due to low fish consumption. Participants in North Dakota and South Dakota had the highest blood cadmium, lead, manganese, and selenium, and the lowest total mercury levels, even after adjusting for covariates. In addition, each of the blood metals was associated with selected demographic, behavioral, income, and/or weight-related factors in multivariate models. These findings will help guide the tribes to develop education, outreach, and strategies to reduce harmful exposures and increase beneficial nutrient intake in these AI communities.

Homicides Involving American Indian and Alaska Native Individuals

This Viewpoint discusses homicide rates among American Indian and Alaska Native individuals and the importance of utilizing existing strategies tailored to the needs of American Indian and Alaska Native communities to prevent violence and reduce these rates.

Diversity, Equity, and Inclusion: A Current Analysis of General Surgery Residency Programs

BACKGROUND

Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally.

MATERIALS AND METHODS

General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses.

RESULTS

A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05).

DISCUSSION

In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.

Representation of American Indian and Alaska Native Individuals in Academic Medical Training

IMPORTANCE

Identifying gaps in inclusivity of Indigenous individuals is key to diversifying academic medical programs, increasing American Indian and Alaska Native representation, and improving disparate morbidity and mortality outcomes in American Indian and Alaska Native populations.

OBJECTIVE

To examine representation of American Indian and Alaska Native individuals at different stages in the 2018-2019 academic medical training continuum and trends (2011-2020) of American Indian and Alaska Native representation in residency specialties.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, population-based analysis was conducted using self-reported race and ethnicity data on trainees from the Association of American Medical Colleges (2018), the Accreditation Council for Graduate Medical Education (2011-2018), and the US Census (2018). Data were analyzed between February 18, 2020, and March 4, 2021.

EXPOSURES

Enrolled trainees at specific stages of medical training.

MAIN OUTCOMES AND MEASURES

The primary outcome was the odds of representation of American Indian and Alaska Native individuals at successive academic medical stages in 2018-2019 compared with White individuals. Secondary outcomes comprised specialty-specific proportions of American Indian and Alaska Native residents from 2011 to 2020 and medical specialty-specific proportions of American Indian and Alaska Native physicians in 2018. Fisher exact tests were performed to calculate the odds of American Indian and Alaska Native representation at successive stages of medical training. Simple linear regressions were performed to assess trends across residency specialties.

RESULTS

The study data contained a total of 238 974 607 White and American Indian and Alaska Native US citizens, 24 795 US medical school applicants, 11 242 US medical school acceptees, 10 822 US medical school matriculants, 10 917 US medical school graduates, 59 635 residents, 518 874 active physicians, and 113 168 US medical school faculty. American Indian and Alaska Native individuals had a 63% lower odds of applying to medical school (odds ratio [OR], 0.37; 95% CI, 0.31-0.45) and 48% lower odds of holding a full-time faculty position (OR, 0.52; 95% CI, 0.44-0.62) compared with their White counterparts, yet had 54% higher odds of working in a residency specialty deemed as a priority by the Indian Health Service (OR, 1.54; 95% CI, 1.09-2.16). Of the 33 physician specialties analyzed, family medicine (0.55%) and pain medicine (0.46%) had more than an average proportion (0.41%) of American Indian and Alaska Native physicians compared with their representation across all specialties.

CONCLUSIONS AND RELEVANCE

This cross-sectional study noted 2 distinct stages in medical training with significantly lower representation of American Indian and Alaska Native compared with White individuals. An actionable framework to guide academic medical institutions on their Indigenous diversification and inclusivity efforts is proposed.

Vaginal microbiota of American Indian women and associations with measures of psychosocial stress

Molecular-bacterial vaginosis (BV) is characterized by low levels of vaginal Lactobacillus species and is associated with higher risk of sexually transmitted infections (STI). Perceived psychosocial stress is associated with increased severity and persistence of infections, including STIs. American Indians have the highest rates of stress and high rates of STIs. The prevalence of molecular-BV among American Indian women is unknown. We sought to evaluate measures of psychosocial stress, such as historic loss (a multigenerational factor involving slavery, forced removal from one's land, legally ratified race-based segregation, and contemporary discrimination) and their association with the vaginal microbiota and specific metabolites associated with BV, in 70 Northwestern Plains American Indian women. Demographics, perceived psychosocial stressors, sexual practices, and known BV risk factors were assessed using a modified version of the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project survey. Self-collected mid-vaginal swabs were profiled for bacterial composition by 16S rRNA gene amplicon sequencing and metabolites quantified by targeted liquid-chromatography mass spectrometry. Sixty-six percent of the participants were classified as having molecular-BV, with the rest being either dominated by L. crispatus (10%) or L. iners (24%). High levels of lifetime trauma were associated with higher odds of having molecular-BV (adjusted Odds Ratio (aOR): 2.5, 95% Credible Interval (CrI): 1.1-5.3). Measures of psychosocial stress, including historic loss and historic loss associated symptoms, were significantly associated with lifestyle and behavioral practices. Higher scores of lifetime trauma were associated with increased concentrations of spermine (aFC: 3.3, 95% CrI: 1.2-9.2). Historic loss associated symptoms and biogenic amines were the major correlates of molecular-BV. Historical loss associated symptoms and lifetime trauma are potentially important underlying factors associated with BV.

The Alaska Native/American Indian experience of hepatitis C treatment with sofosbuvir-based direct-acting antivirals

BACKGROUND

Direct-acting antiviral (DAA) drugs have been effective in the treatment of chronic hepatitis C virus (HCV) infection. Limited data are available on safety, tolerability, and efficacy in American Indian or Alaska Native people. We aim to evaluate the treatment outcomes of sofosbuvir- based regimens for treatment of HCV in a real life setting in Alaska Native/American Indian (AN/AI) people.

METHODS

AN/AI patients within the Alaska Tribal Health System with confirmed positive anti-HCV and HCV RNA, who were 18 years of age and older were included in the study. Pretreatment baseline patient characteristics, treatment efficacy based on sustained virologic response (SVR) 12 weeks after treatment completion, and adverse effects were assessed. The following treatments were given according to the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) HCV Guidance: ledipasvir/sofosbuvir, sofosbuvir plus weight-based ribavirin, and sofosbuvir/velpatasvir.

RESULTS

We included 501 patients with a mean age of 54.3 (range 21.3-78.3) in the study. Overall SVR was achieved in 95.2% of patients who received one of the three DAA regimens. For those with cirrhosis, overall SVR was 92.8% and for those with genotype 3 91.1% achieved SVR. The most common symptom experienced during treatment was headache. Joint pain was found to decrease during treatment. One person discontinued sofosbuvir plus ribavirin due to myocardial infarction and one discontinued sofosbuvir/velpatasvir due to urticaria.

CONCLUSIONS

In the real-world setting, sofosbuvir-based treatment is safe, effective, and well tolerated in AN/AI patients. Sustained virologic response was high regardless of HCV genotype or cirrhosis status.

Homicides of American Indians/Alaska Natives - National Violent Death Reporting System, United States, 2003-2018

PROBLEM/CONDITION

Homicide is a leading cause of death for American Indians/Alaska Natives (AI/ANs). Intimate partner violence (IPV) contributes to many homicides, particularly among AI/AN females. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on AI/AN homicides. Results include victim and suspect sex, age group, and race/ethnicity; method of injury; type of location where the homicide occurred; precipitating circumstances (i.e., events that contributed to the homicide); and other selected characteristics.

PERIOD COVERED

2003-2018.

DESCRIPTION OF SYSTEM

NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, and law enforcement reports and links related deaths (e.g., multiple homicides and homicide followed by suicide) into a single incident. This report includes data on AI/AN homicides that were collected from 34 states (Alabama, Alaska, Arizona, California, Colorado, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Virginia, Washington, and Wisconsin) and the District of Columbia.

RESULTS

NVDRS collected data on 2,226 homicides of AI/ANs in 34 states and the District of Columbia during 2003-2018. The age-adjusted AI/AN homicide rate was 8.0 per 100,000 population. The homicide rate was three times higher in AI/AN males than females (12.0 versus 3.9), and the median age of AI/AN victims was 32 years (interquartile range: 23-44 years). Approximately half of AI/AN homicide victims lived or were killed in metropolitan areas (48.2% and 52.7%, respectively). A firearm was used in nearly half (48.4%) of homicides and in a higher percentage of homicides of AI/AN males than females (51.5% versus 39.1%). More AI/AN females than males were killed in a house or apartment (61.8% versus 53.7%) or in their own home (47.7% versus 29.0%). Suspects were identified in 82.8% of AI/AN homicides. Most suspects were male (80.1%), and nearly one third (32.1%) of suspects were AI/ANs. For AI/AN male victims, the suspect was most often an acquaintance or friend (26.3%), a person known to the victim but the exact nature of the relationship was unclear (12.3%), or a relative (excluding intimate partners) (10.5%). For AI/AN female victims, the suspect was most often a current or former intimate partner (38.4%), an acquaintance or friend (11.5%), or a person known to the victim but the exact nature of the relationship was unclear (7.9%). A crime precipitated 24.6% of AI/AN homicides (i.e., the homicide occurred as the result of another serious crime). More AI/AN males were victims of homicides due to an argument or conflict than females (54.7% versus 37.3%), whereas more AI/AN females were victims of homicides due to IPV than males (45.0% versus 12.1%). For homicides related to IPV, 87.2% of AI/AN female victims were killed by a current or former intimate partner, whereas approximately half (51.5%) of AI/AN male victims were corollary victims (i.e., victims killed during an IPV-related incident who were not the intimate partners themselves).

INTERPRETATION

This report provides a detailed summary of NVDRS data on AI/AN homicides during 2003-2018. Interpersonal conflict was a predominant circumstance, with nearly half of all AI/AN homicides precipitated by an argument and for female victims, 45.0% precipitated by IPV.

PUBLIC HEALTH ACTION

NVDRS provides critical and ongoing data on AI/AN homicides that can be used to identify effective and early intervention strategies for preventing these deaths. When possible, violence prevention efforts should include community-developed, culturally relevant, and evidence-based strategies. These efforts should incorporate traditional native knowledge and solutions, implement and possibly adapt evidence-based IPV and other violence prevention strategies, and consider the influence of historical and larger societal factors that increase the likelihood of violence in AI/AN communities.

Intraglomerular Dysfunction Predicts Kidney Failure in Type 2 Diabetes

No longitudinal data link intraglomerular hemodynamic dysfunction with end-stage kidney disease (ESKD) in people with type 2 diabetes (T2D). Afferent (R_A) and efferent (R_E) arteriolar resistance and intraglomerular pressure (P_GLO) are not directly measurable in humans but are estimable from glomerular filtration rate (GFR), renal plasma flow (RPF), blood pressure, hematocrit, and plasma oncotic pressure. We examined the association of the R_A-to-R_E ratio and P_GLO with ESKD incidence in 237 Pima Indian individuals with T2D who underwent serial measures of GFR (iothalamate) and RPF (p-aminohippurate). Their association with kidney structural lesions was also examined in a subset of 111 participants. Of the 237 participants (mean age 42 years, diabetes duration 11 years, and GFR 153 mL/min and median urine albumin-to-creatinine ratio 36 mg/g), 69 progressed to ESKD during a median follow-up of 17.5 years. In latent class analysis, distinct trajectories characterized by increasing R_A-to-R_E ratio (HR 4.60, 95% CI 2.55-8.31) or elevated P_GLO followed by a rapid decline (HR 2.96, 95% CI 1.45-6.02) strongly predicted incident ESKD. P_GLO (R ² = 21%, P < 0.0001) and R_A-to-R_E ratio (R ² = 15%, P < 0.0001) also correlated with mesangial fractional volume, a structural predictor of DKD progression. In conclusion, intraglomerular hemodynamic parameters associated strongly with incident ESKD and correlated with structural lesions of DKD.

COVID-19 Pandemic and Indigenous Representation in Public Health Data

Public Health 3.0 calls for the inclusion of new partners and novel data to bring systemic change to the US public health landscape. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has illuminated significant data gaps influenced by ongoing colonial legacies of racism and erasure. American Indian and Alaska Native (AI/AN) populations and communities have been disproportionately affected by incomplete public health data and by the COVID-19 pandemic itself. Our findings indicate that only 26 US states were able to calculate COVID-19‒related death rates for AI/AN populations. Given that 37 states have Indian Health Service locations, we argue that public health researchers and practitioners should have a far larger data set of aggregated public health information on AI/AN populations. Despite enormous obstacles, local Tribal facilities have created effective community responses to COVID-19 testing, tracking, and vaccine administration. Their knowledge can lead the way to a healthier nation. Federal and state governments and health agencies must learn to responsibly support Tribal efforts, collect data from AI/AN persons in partnership with Indian Health Service and Tribal governments, and communicate effectively with Tribal authorities to ensure Indigenous data sovereignty. (Am J Public Health. 2021;111(S3): S208-S214. https://doi.org/10.2105/AJPH.2021.306415).

Association of Prenatal Exposure to Maternal Drinking and Smoking With the Risk of Stillbirth

IMPORTANCE

Prenatal smoking is a known modifiable risk factor for stillbirth; however, the contribution of prenatal drinking or the combination of smoking and drinking is uncertain.

OBJECTIVE

To examine whether prenatal exposure to alcohol and tobacco cigarettes is associated with the risk of stillbirth.

DESIGN, SETTING, AND PARTICIPANTS

The Safe Passage Study was a longitudinal, prospective cohort study with data collection conducted between August 1, 2007, and January 31, 2015. Pregnant women from Cape Town, South Africa, and the Northern Plains region of the US were recruited and followed up throughout pregnancy. Data analysis was performed from November 1, 2018, to November 20, 2020.

EXPOSURE

Maternal consumption of alcohol and tobacco cigarettes in the prenatal period.

MAIN OUTCOMES AND MEASURES

The main outcomes were stillbirth, defined as fetal death at 20 or more weeks' gestation, and late stillbirth, defined as fetal death at 28 or more weeks' gestation. Self-reported alcohol and tobacco cigarette consumption was captured at the recruitment interview and up to 3 scheduled visits during pregnancy. Participants were followed up during pregnancy to obtain delivery outcome.

RESULTS

Of 11663 pregnancies (mean [SD] gestational age at enrollment, 18.6 [6.6] weeks) in 8506 women for whom the pregnancy outcome was known by 20 weeks' gestation or later and who did not terminate their pregnancies, there were 145 stillbirths (12.4 per 1000 pregnancies) and 82 late stillbirths (7.1 per 1000 pregnancies). A total of 59% of pregnancies were in women from South Africa, 59% were in multiracial women, 23% were in White women, 17% were in American Indian women, and 0.9% were in women of other races. A total of 8% were older than 35 years. In 51% of pregnancies, women reported no alcohol or tobacco cigarette exposure (risk of stillbirth, 4 per 1000 pregnancies). After the first trimester, 18% drank and smoked (risk of stillbirth, 15 per 1000 births), 9% drank only (risk of stillbirth, 10 per 1000 pregnancies), and 22% smoked only (risk of stillbirth, 8 per 1000 pregnancies). Compared with the reference group (pregnancies not prenatally exposed or without any exposure after the first trimester), the adjusted relative risk of late stillbirth was 2.78 (98.3% CI, 1.12-6.67) for pregnancies prenatally exposed to drinking and smoking, 2.22 (98.3% CI, 0.78-6.18) for pregnancies prenatally exposed to drinking only after the first trimester, and 1.60 (98.3% CI, 0.64-3.98) for pregnancies prenatally exposed to smoking only after the first trimester. The adjusted relative risk for all stillbirths was 1.75 (98.3% CI, 0.96-3.18) for dual exposure, 1.26 (98.3% CI, 0.58-2.74) for drinking only, and 1.27 (98.3% CI, 0.69-2.35) for smoking only compared with the reference group.

CONCLUSIONS AND RELEVANCE

These results suggest that combined drinking and smoking after the first trimester of pregnancy, compared with no exposure or quitting before the end of the first trimester, may be associated with a significantly increased risk of late stillbirth.

Sleep disparities during the COVID-19 pandemic: An investigation of AIAN, Asian, Black, Latinx, and White young adults

OBJECTIVES

This study investigates race-related disparities in sleep duration and quality among diverse young adults during the coronavirus 2019 (COVID-19) pandemic.

DESIGN & SETTING

Online cross-sectional study of young adults in the United States in April 2020.

PARTICIPANTS

About 547 American Indian/Alaskan Native (AIAN), Asian, Black, Latinx, and White young adults ages 18-25 years.

MEASUREMENTS

Participants completed measures of sleep duration and quality, coronavirus victimization distress, depression, age, sex/gender, employment status, essential worker status, student status, residential region, socioeconomic status, concerns about contracting coronavirus and CDC health risks.

RESULTS

Black young adults reported the largest disparity in sleep duration and quality. For sleep duration, AIAN, Asian, White, and Latinx young adults reported approximately one additional hour of sleep compared to Black respondents. Mediation analyses suggest that disparities in sleep duration between Asian and Black young adults may be explained by the higher likelihood of Black respondents being essential workers. For sleep quality, Latinx, White, AIAN, and Asian young adults reported higher levels than Black respondents. Including coronavirus victimization distress as an intervening pathway decreased the effect for Asian and White respondents on sleep quality, suggesting that coronavirus victimization distress partially explains Black and Asian, as well as Black and White differences in sleep quality.

CONCLUSIONS

Black young adults reported the shortest sleep duration and lowest levels of sleep quality relative to AIAN, Asian, Latinx and White peers. Interpersonal experiences of coronavirus victimization and structural inequities may partially explain disparities during the COVID-19 pandemic.