Race differences in cardiac testing rates for patients with chest pain in a multisite cohort

BACKGROUND

Identifying and eliminating racial health care disparities is a public health priority. However, data evaluating race differences in emergency department (ED) chest pain care are limited.

METHODS

We conducted a secondary analysis of the High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP) cohort, which prospectively enrolled adults with symptoms suggestive of acute coronary syndrome without ST-elevation from eight EDs in the United States from 2017 to 2018. Race was self-reported by patients and abstracted from health records. Rates of 30-day noninvasive testing (NIT), cardiac catheterization, revascularization, and adjudicated cardiac death or myocardial infarction (MI) were determined. Logistic regression was used to evaluate the association between race and 30-day outcomes with and without adjustment for potential confounders.

RESULTS

Among 1454 participants, 42.3% (615/1454) were non-White. At 30 days NIT occurred in 31.4% (457/1454), cardiac catheterization in 13.5% (197/1454), revascularization in 6.0% (87/1454), and cardiac death or MI in 13.1% (190/1454). Among Whites versus non-Whites, NIT occurred in 33.8% (284/839) versus 28.1% (173/615; odds ratio [OR] 0.76, 95% confidence interval [CI] 0.61-0.96) and catheterization in 15.9% (133/839) versus 10.4% (64/615; OR 0.62, 95% CI 0.45-0.84). After covariates were adjusted for, non-White race remained associated with decreased 30-day NIT (adjusted OR [aOR] 0.71, 95% CI 0.56-0.90) and cardiac catheterization (aOR 0.62, 95% CI 0.43-0.88). Revascularization occurred in 6.9% (58/839) of Whites versus 4.7% (29/615) of non-Whites (OR 0.67, 95% CI 0.42-1.04). Cardiac death or MI at 30 days occurred in 14.2% of Whites (119/839) versus 11.5% (71/615) of non-Whites (OR 0.79 95% CI 0.57-1.08). After adjustment there was still no association between race and 30-day revascularization (aOR 0.74, 95% CI 0.45-1.20) or cardiac death or MI (aOR 0.74, 95% CI 0.50-1.09).

CONCLUSIONS

In this U.S. cohort, non-White patients were less likely to receive NIT and cardiac catheterization compared to Whites but had similar rates of revascularization and cardiac death or MI.

Program Evaluation: exploring health disparities that impact chronic pain referrals within a VA Health Care System

Introduction

The present Program Evaluation study examines sociodemographic characteristics of Veterans in the Phoenix VA Health Care System who have back pain, and specifically the likelihood of those characteristics being associated with a referral to the Chronic Pain Wellness Center (CPWC) in the year 2021. We examined the following characteristics: Race/ethnicity, gender, age, mental health diagnosis, substance use disorder diagnosis, and service-connected diagnosis.

Methods

Our study used cross sectional data from the Corporate Data Warehouse for 2021. 13624 records had complete data for the variables of interest. Univariate and multivariate logistic regression was used to determine the likelihood of patients' being referred to the Chronic Pain Wellness Center.

Results

The multivariate model found under-referral to be significant for younger adults and for patients who identified as Hispanic/Latinx, Black/African American, or Native American/Alaskan. Those with depressive disorders and opioid use disorders, on the other hand, were found to be more likely to be referred to the pain clinic. Other sociodemographic characteristics were not found to be significant.

Discussion

Study limitations include the use of cross-sectional data, which cannot determine causality, and the inclusion of patients only if the ICD-10 codes of interest were recorded for an encounter in 2021 (i.e., a prior history of a particular diagnosis was not captured). In future efforts, we plan to examine, implement, and track the impact of interventions designed to mitigate these identified disparities in access to chronic pain specialty care.

Lung cancer screening use and implications of varying eligibility criteria by race and ethnicity: 2019 Behavioral Risk Factor Surveillance System data

BACKGROUND

In 2021, the US Preventive Services Task Force (USPSTF) expanded the eligibility criteria for low-dose computed tomographic lung cancer screening (LCS) to reduce racial disparities that resulted from the 2013 USPSTF criteria. The annual LCS rate has risen slowly since the 2013 USPSTF screening recommendations. Using the 2019 Behavioral Risk Factor Surveillance System (BRFSS), this study 1) describes LCS use in 2019, 2) compares the percent eligible for LCS using the 2013 versus 2021 USPSTF criteria, and 3) determines the percent eligible using the more detailed PLCOm2012_Race3L risk-prediction model.

METHODS

The analysis included 41,544 individuals with a smoking history from states participating in the BRFSS LCS module who were ≥50 years old.

RESULTS

Using the 2013 USPSTF criteria, 20.7% (95% confidence interval [CI], 19.0-22.4) of eligible individuals underwent LCS in 2019. The 2013 USPSTF criteria was compared to the 2021 USPSTF criteria, and the overall proportion eligible increased from 21.0% (95% CI, 20.2-21.8) to 34.7% (95 CI, 33.8-35.6). Applying the 2021 criteria, the proportion eligible by race was 35.8% (95% CI, 34.8-36.7) among Whites, 28.5% (95% CI, 25.2-31.9) among Blacks, and 18.0% (95% CI, 12.4-23.7) among Hispanics. Using the 1.0% 6-year threshold that is comparable to the 2021 USPSTF criteria, the PLCOm2012_Race3L model selected more individuals overall and by race.

CONCLUSIONS

Using data from 20 states and using multiple imputation, higher LCS rates have been reported compared to prior BRFSS data. The 2021 expanded criteria will result in a greater number of screen-eligible individuals. However, risk-based screening that uses additional risk factors may be more inclusive overall and across subgroups.

LAY SUMMARY

In 2013, lung cancer screening (lung screening) was recommended for high risk individuals. The annual rate of lung screening has risen slowly, particularly among Black individuals. In part, this racial disparity resulted in expanded 2021 criteria. Survey data was used to: 1) describe the number of people screened in 2019, 2) compare the percent eligible for lung screening using the 2013 versus 2021 guidelines, and 3) determine the percent eligible using more detailed criteria. Lung screening rates increased in 2019, and the 2021 criteria will result in more individuals eligible for screening. Using additional criteria may identify more individuals eligible for lung screening.

What's race got to do with it? Informant rating discrepancies in neuropsychological evaluations for children with ADHD

OBJECTIVE

To evaluate race-based discrepancies in informant ratings and in rates of Attention-Deficit/Hyperactivity Disorder (ADHD) diagnosis among a clinically referred sample of Black and White children.

METHOD

Demographic information and ratings of inattention, hyperactivity/impulsivity, and conduct were collected from caregivers and teachers as part of neuropsychological evaluations at an outpatient clinic. The final sample included 3,943 children (6-18 years), of which 70% were White and 30% were Black.

RESULTS

Teachers, but not caregivers, endorsed more inattentive symptoms and conduct problems for Black than for White children, irrespective of ADHD diagnostic status and socioeconomic status (SES), and after controlling for child sex, child age, and learning difficulties. Teachers endorsed more hyperactive/impulsive symptoms for Black children with ADHD of lower SES than for White children with these characteristics. Caregivers of Black children of higher SES reported fewer hyperactive/impulsive symptoms than caregivers of White children of higher SES. Despite differences in teachers' ratings by race, diagnostic rates of ADHD in the context of neuropsychological evaluations were comparable for Black and White children.

CONCLUSIONS

Consistent with previous literature, teachers endorsed more ADHD and conduct problems in Black children. Within our clinically referred sample, this may reflect teacher bias rather than actual prevalence differences by rafce, given that Black caregivers endorsed fewer or similar numbers of symptoms relative to White caregivers. This lack of racial disparities in rates of ADHD diagnosis is inconsistent with findings in community- and population-based samples, and reflectspossible benefit of the use of neuropsychological evaluations in diagnostic decision-making for ADHD.

Associations of Race and Ethnicity With Presentation and Outcomes of Hypertrophic Cardiomyopathy: JACC Focus Seminar 6/9

Significant racial and ethnicity-based disparities in clinical presentation, management, and outcome of hypertrophic cardiomyopathy (HCM) are reported. Black patients with HCM are more likely to present with heart failure but are less commonly referred for symptom management, sudden cardiac death stratification, surgical septal myectomy, or for implantable cardioverter-defibrillators, all interventions that increase survival. Prevalence of bystander cardiopulmonary resuscitation is lower for Black patients than for White patients. Black patients with HCM have decreased survival after hospital discharge following out-of-hospital cardiac arrest. Biomedical and social interventions are urgently needed to reduce ethnicity-based disparities, which have an impact on outcomes in HCM and other cardiovascular diseases. There is also a need to focus on implementation science to support durable adoption of evidence-based therapies in Black patients and communities.

Impact of Racial and Ethnic Disparities on Patients With Dilated Cardiomyopathy: JACC Focus Seminar 7/9

Significant race- and ethnicity-based disparities among those diagnosed with dilated cardiomyopathy (DCM) exist and are deeply rooted in the history of many societies. The role of social determinants of racial disparities, including racism and bias, is often overlooked in cardiology. DCM incidence is higher in Black subjects; survival and other outcome measures are worse in Black patients with DCM, with fewer referrals for transplantation. DCM in Black patients is underrecognized and under-referred for effective therapies, a consequence of a complex interplay of social and socioeconomic factors. Strategies to manage social determinants of health must be multifaceted and consider changes in policy to expand access to equitable care; provision of insurance, education, and housing; and addressing racism and bias in health care workers. There is an urgent need to prioritize a social justice approach to health care and the pursuit of health equity to eliminate race and other disparities in the management of cardiovascular disease.

Prostate tumors of native men from West Africa show biologically distinct pathways-A comparative genomic study

BACKGROUND

Native African men (NAM) experience a disproportionate burden of prostate cancer (PCa) and have higher mortality rates compared to European American men (EAM). While socioeconomic status has been implicated as a driver of this disparity, little is known about the genomic mechanisms and distinct biological pathways that are associated with PCa of native men of African origin.

METHODS

To understand biological factors that contribute to this disparity we utilized a total of 406 multi-institutional localized PCa samples, collected by Men of African Descent and Carcinoma of the Prostate biospecimen network and Moffitt Cancer Center/University of Pennsylvania Health science system. We performed comparative genomics and immunohistochemistry to identify the biomarkers that are highly enriched in NAM from west Africa and compared them with African American Men (AAM) and EAM. Quantified messenger RNA expression and Median H scores based on immune reactivity of staining cells, were compared using Mann Whitney test. For gene expression analysis, p values were further adjusted for multiple comparisons using false discovery rates.

RESULTS

Immunohistochemical analysis on selected biomarkers showed a consistent association between ETS related gene (ERG) status and race with 83% of NAM exhibiting tumors that lacked TMPRSS2-ERG translocation (ERG^negative ) as compared to AAM (71%) and EAM (52%). A higher proportion of NAM (29%) were also found to be double negative (ERG^negative and PTEN^Loss ) as compared to AAM (6%) and EAM (7%). NAM tumors had significantly higher immunoreactivity (H-score) for PSMA, and EZH2, whereas they have lower H-score for PTEN, MYC, AR, RB and Racemase, (all p < .05). Comparative genomics revealed that NAM had significant transcriptomic variability in AR-activity score. In pathways enrichment analysis NAM tumors exhibited the enrichment of proinflammatory pathways including cytokine, interleukins, inflammatory response, and nuclear factor kappa B signaling.

CONCLUSIONS

Prostate tumors in NAM are genomically distinct and are characterized by the dysregulation of several biomarkers. Furthermore, these tumors are also highly enriched for the major proinflammatory pathways. These distinct biological features may have implications for diagnosis and response to targeted therapy among Black men, globally.

Race as a factor in donor selection and survival of children with hematologic malignancies undergoing hematopoietic stem cell transplant in Florida

BACKGROUND

Previous studies have explored posthematopoietic cell transplant (HCT) outcomes by race in adults; however, pediatric data addressing this topic are scarce.

PROCEDURE

This retrospective registry study included 238 White (W) and 57 Black (B) children with hematologic malignancies (HM) receiving first allogeneic HCT between 2010 and 2019 at one of the five Florida pediatric HCT centers.

RESULTS

We found no differences between W and B children in transplant characteristics, other than donor type. There was a significant difference in use of human leukocyte antigen (HLA)-mismatched donors (HLA-MMD) (53% W, 71% B, p = .01). When comparing HLA-MMD use to fully HLA-matched donors, B had relative risk (RR) of 1.47 (95% CI 0.7-3) of receiving a mismatched unrelated donor (MMUD), RR of 2.34 (95% CI 1.2-4.4) of receiving a mismatched related donor (MMRD), and RR of 1.9 (95% CI 0.99-3.6) of receiving a mismatched cord blood donor (MMCBD) HCT, respectively. There was no significant difference in the incidence of aGVHD (48% W, 35% B), p = .1, or cGVHD (19% W, 28% B, p = .1), or primary cause of death. Overall 24-month survival was 61% (95% CI 55%-68%) for W, and 60% (95% CI 48-75) for B children, log-rank p = .7. While HLA matching improved survival in W children, the number of B children receiving HLA-matched HCT was too small to identify the impact of HLA matching on survival.

CONCLUSIONS

In this contemporary cohort of children with HM, we found that B children were more likely to receive HLA-MMD transplants, but this did not adversely affect survival or GVHD rates.

Kidney-Related Research in the United States: A Position Statement From the National Kidney Foundation and the American Society of Nephrology

Kidney disease is an important US public health problem because it affects over 37 million Americans, and Medicare expenditures for patients with chronic kidney disease now alone exceed $130 billion annually. Kidney disease is characterized by strong racial, ethnic, and socioeconomic disparities, and reducing kidney disease incidence will positively impact US health disparities. Due to the aging of the US population and an unabated obesity epidemic, the number of patients receiving treatment for kidney failure is anticipated to increase, which will escalate kidney disease health expenditures. The historical and current investment in kidney-related research via the National Institute of Diabetes and Digestive and Kidney Diseases has severely lagged behind ongoing expenditures for kidney disease care. Increasing research investment will identify, develop, and increase implementation of interventions to slow kidney disease progression, reduce incidence of kidney failure, enhance survival, and improve quality of life. This perspective states the urgent reasons why increasing investment in kidney-related research is important for US public health. The National Kidney Foundation and the American Society of Nephrology are working together to advocate for increased funding for the National Institute of Diabetes and Digestive and Kidney Diseases. The long-term goal is to reduce the burden of kidney disease in the US population and improve the quality of life of patients living with kidney disease.

Distinguishing Characteristics and Disparities in Child Protective Services-Investigated Maltreatment by Fathers

This study examines distinguishing characteristics of father-perpetrated maltreatment and disparities in Child Protective Services (CPS) investigation outcomes based on perpetrator gender and race. A sample of children (N = 2,017) reported to CPS for maltreatment attributed to their mother and/or father was drawn from the second National Survey of Child and Adolescent Well-being (NSCAW II). Measures included perpetrator(s) relationship to the child (mother alone, father alone, mother and father) and race (Black, White, Other), caseworker-reported maltreatment characteristics and co-occurring risk factors, and CPS investigation outcomes (services, substantiation, out-of-home placement, criminal investigation, and criminal charges). Bivariate analyses revealed no clear pattern of higher risk for maltreatment involving fathers. In regression, father-alone perpetration predicted less out-of-home placement but more criminal investigations and charges. A significant interaction indicated the greatest risk for criminal charges when a Black father co-perpetrated maltreatment with mother. Findings imply needs for anti-bias training, specialized services for fathers, and coordinated diversion between child welfare and criminal justice systems.

Childhood socioeconomic status and inflammation: Psychological moderators among Black and White Americans

OBJECTIVE

The current study examined race differences in how childhood socioeconomic status (SES) predicted midlife inflammation. It also tested psychological resources (purpose in life, optimism, and conscientiousness) as moderators of the association between childhood SES and inflammation among Black and White adults.

METHOD

Data came from the biomarker subsamples of the Midlife in the United States Core and Refresher studies (n = 1,578 White and n = 395 Black participants). Childhood SES was operationalized as a composite of parental education, perceived financial status, and welfare status. Outcomes included circulating IL-6 and CRP.

RESULTS

Childhood SES did not predict IL-6 or CRP among Black or White adults in fully adjusted models. Among Black adults with low optimism, lower childhood SES predicted higher IL-6 and CRP. Among Black adults with low purpose in life, lower childhood SES predicted higher CRP (but not IL-6). Conscientiousness did not moderate childhood SES-inflammation associations among Black adults. Among White adults with low conscientiousness or low optimism, lower childhood SES predicted higher IL-6 (but not CRP). Purpose in life did not moderate associations among White adults. Effect sizes were small (≤1% variance explained) and comparable to effects of clinical risk factors in this sample (e.g., age, chronic conditions).

CONCLUSIONS

Race differences in the childhood SES and inflammation association were not apparent. Childhood SES was linked to inflammation more strongly among those with fewer psychological resources across both racial groups. Psychological resources may be important moderators of inflammation in the context of early life SES disadvantage. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Reach Out Emergency Department: Partnering With an Economically Disadvantaged Community in the Development of a Text-Messaging Intervention to Address High Blood Pressure

Background. Hypertension affects nearly 30% of the U.S. adult population. Due to the ubiquitous nature of mobile phone usage, text messaging offers a promising platform for interventions to assist in the management of chronic diseases including hypertension, including among populations that are historically underserved. We present the intervention development of Reach Out, a health behavior theory-based, mobile health intervention to reduce blood pressure among hypertensive patients evaluated in a safety net emergency department primarily caring for African Americans. Aims. To describe the process of designing and refining text messages currently being implemented in the Reach Out randomized controlled trial. Method. We used a five-step framework to develop the text messages used in Reach Out. These steps included literature review and community formative research, conception of a community-centered behavioral theoretical framework, draft of evidence-based text messages, community review, and revision based on community feedback and finalization. Results. The Reach Out development process drew from pertinent evidence that, combined with community feedback, guided the development of a community-centered health behavior theory framework that led to development of text messages. A total of 333 generic and segmented messages were created. Messages address dietary choices, physical activity, hypertension medication adherence, and blood pressure monitoring. Discussion. Our five-step framework is intended to inform future text-messaging-based health promotion efforts to address health issues in vulnerable populations. Conclusion. Text message-based health promotion programs should be developed in partnership with the local community to ensure acceptability and relevance.

Home-Based Gait Speed Assessment: Normative Data and Racial/Ethnic Correlates Among Older Adults

OBJECTIVES

To determine home-based gait speed performance and its associations with sociodemographic and health-related factors among older adults.

DESIGN

Cross-sectional analysis of a nationally representative US population sample.

SETTING AND PARTICIPANTS

Homes of Health and Retirement Study (HRS) participants.

METHODS

Walk test data measured at home over 2.5 m were aggregated for 6983 individuals, aged ≥65 years (mean age 74.8 ± 6.9 years, 54.2% women), from the 2006 and 2008 HRS waves. Means for gait speed at normal pace were determined for demographic and clinical groupings; association of gait speed with demographic, socioeconomic status, and health factors were examined. Four-year mortality was predicted from baseline slow gait status defined using demographic-based cutoff scores as well as commonly recommended cutoff scores (100 or 60 cm/s).

RESULTS

Home-based gait speed (cm/s) means were lower for female than male (9.6% difference), older than younger (18.0% difference), African American than white (20.5% difference), and Hispanic than Non-Hispanic (10.3% difference) participants. Differences by age group, race, and ethnicity remained significant within sexes (P < .001). Lower speed was associated with African American race and all health problems; higher speed was associated with higher socioeconomic status and alcohol consumption. Four-year mortality was predicted by slow gait status. Predictive validity was, in general, higher for slow gait cutoff scores defined by demographic characteristics.

CONCLUSIONS AND IMPLICATIONS

Mean gait speed measured at home differs among older (aged ≥65 years) US resident population groups defined by sex, age, race, ethnicity, health status, and combinations of these factors, and predicts 4-year mortality when substantially slower than group-based norms. These findings may assist researchers and clinicians in determining normal and abnormal gait performance in older adults in community settings.

Racial Disparities in Hospice Outcomes: A Race or Hospice-Level Effect?

OBJECTIVES

To determine whether there is racial variation in hospice enrollees in rates of hospitalization and hospice disenrollment and, if so, whether systematic differences in hospice provider patterns explain the variation.

DESIGN

Longitudinal cohort study.

SETTING

Hospice.

PARTICIPANTS

Medicare beneficiaries (N = 145,038) enrolled in a national random sample of hospices (N = 577) from the National Hospice Survey and followed until death (2009-10).

MEASUREMENTS

We used Medicare claims data to identify hospital admissions, emergency department (ED) visits, and hospice disenrollment after hospice enrollment. We used a series of hierarchical models including hospice-level random effects to compare outcomes of blacks and whites.

RESULTS

In unadjusted models, black hospice enrollees were significantly more likely than white enrollees to be admitted to the hospital (14.9% vs 8.7%, odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.74-1.95), visit the ED (19.8% vs 13.5%, OR = 1.58, 95% CI = 1.50-1.66), and disenroll from hospice (18.1% vs 13.0%, OR = 1.48, 95% CI = 1.40-1.56). These results were largely unchanged after accounting for participant clinical and demographic covariates and hospice-level random effects. In adjusted models, blacks were at higher risk of hospital admission (OR = 1.75, 95% CI = 1.64-1.86), ED visits (OR = 1.61, 95% CI = 1.52-1.70), and hospice disenrollment (OR = 1.54, 95% CI = 1.45-1.63).

CONCLUSION

Racial differences in intensity of care at the end of life are not attributable to hospice-level variation in intensity of care. Differences in patterns of care between black and white hospice enrollees persist within the same hospice.

Race disparities in pubertal timing: Implications for cardiovascular disease risk among African American women

Compared to white girls, sexual maturation is accelerated in African American girls as measured by indicators of pubertal development, including age at first menses. Increasing epidemiological evidence suggests that the timing of pubertal development may have strong implications for cardio-metabolic health in adolescence and adulthood. In fact, younger menarcheal age has been related prospectively to poorer cardiovascular risk factor profiles, a worsening of these profiles over time, and an increase in risk for cardiovascular events, including non-fatal incident cardiovascular disease and cardiovascular-specific and all-cause mortality. Yet, because this literature has been limited almost exclusively to white girls/women, whether this same association is present among African American girls/women has not been clarified. In the current narrative review, the well-established vulnerability of African American girls to experience earlier pubertal onset is discussed as are findings from literatures examining the health outcomes of earlier pubertal timing and its antecedents, including early life adversity exposures often experienced disproportionately in African American girls. Gaps in these literatures are highlighted especially with respect to the paucity of research among minority girls/women, and a conceptual framework is posited suggesting disparities in pubertal timing between African American and white girls may partially contribute to well-established disparities in adulthood risk for cardio-metabolic disease between African American and white women. Future research in these areas may point to novel areas for intervention in preventing or lessening the heightened cardio-metabolic risk among African American women, an important public health objective.

Reach Out Churches: A Community-Based Participatory Research Pilot Trial to Assess the Feasibility of a Mobile Health Technology Intervention to Reduce Blood Pressure Among African Americans

Innovative strategies are needed to reduce the hypertension epidemic among African Americans. Reach Out was a faith-collaborative, mobile health, randomized, pilot intervention trial of four mobile health components to reduce high blood pressure (BP) compared to usual care. It was designed and tested within a community-based participatory research framework among African Americans recruited and randomized from churches in Flint, Michigan. The purpose of this pilot study was to assess the feasibility of the Reach Out processes. Feasibility was assessed by willingness to consent (acceptance of randomization), proportion of weeks participants texted their BP readings (intervention use), number lost to follow-up (retention), and responses to postintervention surveys and focus groups (acceptance of intervention). Of the 425 church members who underwent BP screening, 94 enrolled in the study and 73 (78%) completed the 6-month outcome assessment. Median age was 58 years, and 79% were women. Participants responded with their BPs on an average of 13.7 (SD = 10.7) weeks out of 26 weeks that the BP prompts were sent. All participants reported satisfaction with the intervention. Reach Out, a faith-collaborative, mobile health intervention was feasible. Further study of the efficacy of the intervention and additional mobile health strategies should be considered.

Racial variation in the clinical and economic burden of skeletal-related events among elderly men with stage IV metastatic prostate cancer

Prostate cancer (PCa) outcomes vary widely among African American (AA) and non-Hispanic White (NHW) men. The authors investigated racial variation in the incidence of skeletal-related events (SREs) and SRE-related healthcare costs among AA and NHW men, a topic that has received limited attention in the literature. AA and NHW men diagnosed with metastatic PCa were identified from the linked Surveillance, Epidemiology and End Results-Medicare dataset. The sample included 6455 men with metastatic PCa, including 5420 NHW men and 1035 AA men. Approximately 16% experienced SREs during follow-up. AA men were less likely to experience SREs compared with NHW men, controlling for individual characteristics (adjusted odds ratio: 0.79; 95% CI: 0.66- 0.94). The SRE-specific costs were US$35,725 (US$22,190-US$49,260) among AA men and US$25,896 (US$21,669-US$30,123) among NHW men. Although AA men were less likely to experience SREs, there were substantial costs attributable to the treatment of SREs among AA men.

THE RELATIONSHIPS AMONG VIGILANT COPING STYLE, RACE, AND DEPRESSION

Although Black-white differences in depression are well documented, vigilant coping style as an explanation for the observed inequalities in depression is less understood. Using data from 718 adults in the Exploring Health Disparities in Integrated Communities (EHDIC) Study, we estimated logistic regression models to examine the cross sectional relationship between race, vigilant coping style, and depression. After controlling for demographic variables, white adults were more likely to report depression than Black adults. Moreover, when accounting for coping style, the Black-white difference in depression widened. This association persisted even with the addition of the covariates. While high rates of depression among whites compared with Blacks are well documented, the degree of the differences appears to be greater than previously reported once vigilance is accounted for. This finding suggests that if it were not for the high prevalence of vigilant coping in blacks, the well-documented black advantage regarding depression compared to whites would likely be even greater.

Examination of race disparities in physical inactivity among adults of similar social context

OBJECTIVE

The objective of the study was to determine whether race disparities in physical inactivity are present among urban low-income Blacks and Whites living in similar social context.

DESIGN

This analysis included Black and White respondents ( > or = 18 years) from the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB; N=1350) Study and the National Health Interview Survey (NHIS; N = 67790). Respondents who reported no levels of moderate or vigorous physical activity, during leisure time, over a usual week were considered physically inactive.

RESULTS

After controlling for confounders, Blacks had higher adjusted odds of physical inactivity compared to Whites in the national sample (odds ratio [OR] = 1.40; 95% confidence interval [CI] =1.30-1.51). In EHDIC-SWB, Blacks and Whites had a similar odds of physical inactivity (OR = 1.09; 95% CI .86-1.40).

CONCLUSION

Social context contributes to our understanding of racial disparities in physical inactivity.

How does race get "under the skin"?: inflammation, weathering, and metabolic problems in late life

Using nationally representative data from the 2005-2006 U.S. National Social Life, Health, and Aging Project, this study queries the mechanisms underlying worse metabolic outcomes--blood-sugar control and cardiovascular health--among black than white men ages 57-85. Results indicate that contrary to much of the academic literature as well as media accounts-implicitly rooted in a "culture of irresponsibility" model--older black men's social isolation, poor health behaviors, or obesity may not play a major role in their worse metabolic problems. Instead, these outcomes seem to derive more consistently from a factor almost unexamined in the literature--chronic inflammation, arguably a biological "weathering" mechanism induced by these men's cumulative and multi-dimensional stress. These findings highlight the necessity of focusing attention not simply on proximal behavioral interventions, but on broader stress-inducing social inequalities, to reduce men's race disparities in health.

Kidney disease and the cumulative burden of life course socioeconomic conditions: the Atherosclerosis Risk in Communities (ARIC) study

The authors investigated the cumulative effects of life course social class and neighborhood socioeconomic conditions on the prevalence of chronic kidney disease (CKD) in adulthood. Subjects were members of the Atherosclerosis Risk in Communities (ARIC) Study, a longitudinal cohort study of four US communities. CKD was defined by glomerular filtration rate <45 ml/min/1.73 m2 or hospital discharge diagnosis. Working class was defined by workplace roles for subjects and their fathers; area socioeconomic status (SES) was based on census information. Being working class for all life course periods or for some life course periods was associated with increased odds of CKD, compared to being non-working class for all periods (adjusted odds ratio, OR, for all periods (95% confidence interval) 1.4 (0.9, 2.0) in Whites and 1.9 (1.3, 2.9) in African-Americans; OR for some periods 1.3 (1.0, 1.9) in Whites and 1.4 (0.9, 2.2) in African-Americans). Low area SES over the life course was not significantly related to CKD compared to living in a higher SES areas at all life course periods. Adjustment for age, gender, community of residence, cumulative social class (for neighborhood measures), cumulative low-neighborhood SES (for cumulative individual social class), hypertension and diabetes does not account for these associations. Our conclusion is that chronic kidney disease is associated with life course socioeconomic conditions. As such, life course social class and neighborhood conditions deserve further attention in accounting for socioeconomic disparities in kidney disease.

Referral of patients to specialists: factors affecting choice of specialist by primary care physicians

BACKGROUND

We wanted to determine the importance of factors in primary care physicians' choice of specialist when referring patients and to compare importance ratings by physicians' race and sex.

METHODS

Using a cross-sectional study design, we surveyed a stratified national sample of 1,252 primary care physicians serving adults to include equal numbers of black women, white women, black men, and white men. We assessed the percentage of physicians rating each of 17 items to be of major importance in choosing a specialist and compared importance ratings by physicians' race and sex.

RESULTS

The response rate was 59.1%. Medical skill, appointment timeliness, insurance coverage, previous experience with the specialist, quality of specialist communication, specialist efforts to return patient to primary physician for care, and the likelihood of good patient-specialist rapport were of major importance to most respondents. Compared with black physicians, white physicians were more likely to rate previous experience with the specialist (65% vs 55%, P = .05) and board certification (41% vs 29%, P < .05) to be of major importance. White physicians were somewhat less likely than black physicians (17% vs 26%, P = .06) to rate patient convenience to be of major importance. Compared with male physicians, female physicians were more likely to rate the patient's insurance status to be of major importance (60% vs 44%, P < .01).

CONCLUSIONS

Primary care physicians serving adults consider several factors to be of major importance when choosing a specialist. The importance of patient convenience, previous experience with the specialist, specialist board certification, and insurance coverage accepted by specialist varied by physicians' race and sex. A better understanding of factors important to a diverse physician workforce may help to improve the referral process.