Area-level Social Deprivation Research Articles

Cardiovascular Risk Associated With Social Determinants of Health at Individual and Area Levels

The benefit of adding social determinants of health (SDOH) when estimating atherosclerotic cardiovascular disease (ASCVD) risk is unclear. To examine the association of SDOH at both individual and area levels with ASCVD risks, and to assess if adding individual- and area-level SDOH to the pooled cohort equations (PCEs) or the Predicting Risk of CVD Events (PREVENT) equations improves the accuracy of risk estimates. This cohort study included participants data from 4 large US cohort studies. Eligible participants were aged 40 to 79 years without a history of ASCVD. Baseline data were collected from 1995 to 2007; median (IQR) follow-up was 13.0 (9.3-15.0) years. Data were analyzed from September 2023 to February 2024. Individual- and area-level education, income, and employment status. ASCVD was defined as the composite outcome of nonfatal myocardial infarction, death from coronary heart disease, and fatal or nonfatal stroke. A total of 26 316 participants were included (mean [SD] age, 61.0 [9.1] years; 15 494 women [58.9%]; 11 365 Black [43.2%], 703 Chinese American [2.7%], 1278 Hispanic [4.9%], and 12 970 White [49.3%]); 11 764 individuals (44.7%) had at least 1 adverse individual-level SDOH and 10 908 (41.5%) had at least 1 adverse area-level SDOH. A total of 2673 ASCVD events occurred during follow-up. SDOH were associated with increased risk of ASCVD at both the individual and area levels, including for low education (individual: hazard ratio [HR], 1.39 [95% CI, 1.25-1.55]; area: HR, 1.31 [95% CI, 1.20-1.42]), low income (individual: 1.35 [95% CI, 1.25-1.47]; area: HR, 1.28 [95% CI, 1.17-1.40]), and unemployment (individual: HR, 1.61 [95% CI, 1.24-2.10]; area: HR, 1.25 [95% CI, 1.14-1.37]). Adding area-level SDOH alone to the PCEs did not change model discrimination but modestly improved calibration. Furthermore, adding both individual- and area-level SDOH to the PCEs led to a modest improvement in both discrimination and calibration in non-Hispanic Black individuals (change in C index, 0.0051 [95% CI, 0.0011 to 0.0126]; change in scaled integrated Brier score [IBS], 0.396% [95% CI, 0.221% to 0.802%]), and improvement in calibration in White individuals (change in scaled IBS, 0.274% [95% CI, 0.095% to 0.665%]). Adding individual-level SDOH to the PREVENT plus area-level social deprivation index (SDI) equations did not improve discrimination but modestly improved calibration in White participants (change in scaled IBS, 0.182% [95% CI, 0.040% to 0.496%]), Black participants (0.187% [95% CI, 0.039% to 0.501%]), and women (0.289% [95% CI, 0.115% to 0.574%]). In this cohort study, both individual- and area-level SDOH were associated with ASCVD risk; adding both individual- and area-level SDOH to the PCEs modestly improved discrimination and calibration for estimating ASCVD risk for Black individuals, and adding individual-level SDOH to PREVENT plus SDI also modestly improved calibration. These findings suggest that both individual- and area-level SDOH may be considered in future development of ASCVD risk assessment tools, particularly among Black individuals.

Relationship of Social Deprivation Among Living Kidney Donor–Recipient Pairs

Background. Living kidney transplant is the most effective renal replacement therapy for patients with end-stage kidney disease. Community-level factors contribute to pervasive socioeconomic and racial disparities in access to living donor kidney transplantation. Little is known about social and environmental conditions between living donors and recipients. Further understanding of these relationships may enhance opportunities for transplantation. Methods. From 2010 to 2020, 59 575 living kidney donor–recipient pairs (≥18 y old) were identified using the Scientific Registry of Transplant Recipients. Living donors and recipients were geocoded to area-level social deprivation index (SDI). The primary outcome was difference between recipient and donor SDI. We used multivariable logistic regression to examine recipient and donor characteristics association with residence in different SDI communities. Results. Living kidney donation occurs across all strata of social deprivation; including when donors, recipients or both reside in more disadvantaged communities. Donor–recipient race combination and biological relationship are associated with differences in SDI. When compared with White recipients of White donors, Black and Hispanic recipients were more likely to reside in more disadvantaged areas (odds ratio = 2.41 [2.19-2.66] and 1.97 [1.78-2.19]). Recipients in anonymous and paired donations were more likely to reside in areas of more disadvantage than their donors (odds ratio = 1.27 [1.15-1.40] and 1.32 [1.23-1.41] compared with biological); attenuating socioeconomic disparities in access to living donor transplantation. Conclusions. Findings illustrate the social and environmental relationships between living kidney donor–recipient pairs that are important to develop targeted approaches and address barriers to living kidney transplantation. Best practices from areas of high deprivation with successful living kidney transplantation can be shared.

A Retrospective Review of Social Deprivation Index and Maternal Outcomes with Placenta Accreta Spectrum from a Single Referral Center.

Little is known about how community characteristics influence placenta accreta spectrum (PAS) outcomes. Our objective was to evaluate whether adverse maternal outcomes among pregnant people (gravidae) with PAS delivering at a single referral center differ by community-level measures of social deprivation. We conducted a retrospective cohort study of singleton gravidae with histopathology confirmed PAS delivering from January 2011 to June 2021 at a referral center. Data abstraction collected relevant patient information, including resident zip code, which was linked to Social Deprivation Index (SDI) score (a measure of area-level social deprivation). SDI scores were divided into quartiles for analysis. Primary outcome was a composite of maternal adverse outcomes. Bivariate analyses and multivariable logistic regression were performed. Among our cohort (n = 264), those in the lowest (least deprived) SDI quartile were older, had lower body mass index, and were more likely to identify as non-Hispanic white. Composite maternal adverse outcome occurred in 81 (30.7%), and did not differ significantly by SDI quartile. Intraoperative transfusion of ≥4 red blood cell units occurred more often among those living in deprived areas (31.2% in the highest [most deprived] vs. 22.7% in the lowest [least deprived] SDI quartile, p = 0.04). No other outcomes differed by SDI quartile. In multivariable logistic regression, a quartile increase in SDI was associated with 32% increased odds of transfusion of ≥4 red blood cell units (adjusted odds ratio: 1.32, 95% confidence interval: 1.01-1.75). Within a cohort of gravidae with PAS delivered at a single referral center, we found that those living in more socially deprived communities were more likely to receive transfusion of ≥4 red blood cell units, but other maternal adverse outcomes did not differ. Our findings highlight the importance of considering how characteristics of the surrounding community can impact PAS outcomes and may assist with risk stratification and resource deployment. · Little is known about how community characteristics influence PAS outcomes.. · In a referral center, transfusion was more common in gravidae living in socially deprived areas.. · Future research should consider how community characteristics can impact PAS outcomes..

The role of area level social deprivation on childhood and adolescent consultation rate in primary care: a population based, cohort study

BackgroundStudies show that children and adolescents in the most socially deprived areas (SDA) consult their general practitioner (GP) more often than those in the least socially deprived areas (Non-SDA). Given that GPs see a wide range of diseases, it is important to know which clinical diagnoses are shaped by socioeconomic factors. The primary objective was to determine the association between area level social deprivation and consultation rates in a pediatric population. The secondary objective was to explore this association across a wide range of clinical diagnoses.MethodsA cohort study using the Rijnmond Primary Care Database (RPCD) was conducted. Between 2013 and 2020, a total of 69,861 patients aged 0 to 17 years registered with a GP were analysed. A consultation was defined as patient contact and entry of a diagnosis using the International Classification of Primary Care (ICPC-1) code. Associations between consultation rates, ICPC-1 codes and area level social deprivation were explored using a Poisson regression model. The incidence risk ratio (IRR) and 95% confidence interval (CI) were reported.ResultsOver the 7-year study period the consultation rate of the study population was 3.8 per person-years. The top 5 reasons for children and adolescents to consult their GP was related to skin, respiratory, general unspecified, musculoskeletal and digestive symptoms or diagnoses. Consultation rate was higher in SDA group compared to Non-SDA group (IRR 1.20, 95% CI 1.19–1.20). Consultation rate for ICPC-1 code related to pregnancy and family planning was significantly lower in SDA group compared to Non-SDA group. Upon further exploration of this code, SDA group were less likely to consult for oral contraception and more likely to contact a GP for induced termination of pregnancy compared to Non-SDA group (IRR 0.36; 95% CI 0.33–0.44 and IRR 2.94; 95% CI 1.58–5.46 respectively).ConclusionsOverall, SDA group had higher GP consultation rates for the majority of clinical diagnoses except for pregnancy and family planning. In this latter category, adolescent females in SDA consulted less frequently for oral contraception. This study illustrates the need to understand the underlying health seeking behaviors of children and adolescents at different development phases of their lives.

Subjective Social Status, Area Deprivation, and Gender Differences in Health among Chinese Older People.

This study examined the gender differences in the main and interactive effects of subjective social status and area deprivation on health among older adults in Hong Kong. Data for this study came from the baseline of MrOs and MsOs studies, including 4000 Chinese men and women ≥ 65 in Hong Kong. Subjective social status was assessed using the MacArthur Scale of subjective social status scale. Our results reaffirm that subjective social status is an independent indicator of health after adjusting for objective SES measures (e.g., education and income). Perceived rank on the community ladder was more closely related to health among older people than was the society ladder, particularly for women. Although area-level social deprivation was not significantly associated with the health of older people, it may moderate the effect of subjective social status on health. Women with a lower perceived status in the community were more likely to experience depressive symptoms but better grip strength when living in more deprived neighborhoods. The findings suggested that subjective social status provides important information for the physical and mental health of the older population. Policymakers may implement interventions to enhance the subjective social status of older adults. Given the greater contribution of relative status in the community to the health of women, these policies and interventions should target to improve women’s perceived status in the community.

A national population-based study of patients, bystanders and contextual factors associated with resuscitation in witnessed cardiac arrest: insight from the french R\xe9AC registry

BackgroundIn out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA.Methods We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR.ResultsWe included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75).ConclusionsThe level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients.

Racial/Ethnic Disparities in Childhood Cancer Survival in the United States.

Non-white patients with childhood cancer have worse survival than Non-Hispanic (NH) White patients for many childhood cancers in the United States. We examined the contribution of socioeconomic status (SES) and health insurance on racial/ethnic disparities in childhood cancer survival. We used the National Cancer Database to identify NH White, NH Black, Hispanic, and children of other race/ethnicities (<18 years) diagnosed with cancer between 2004 and 2015. SES was measured by the area-level social deprivation index (SDI) at patient residence and categorized into tertiles. Health insurance coverage at diagnosis was categorized as private, Medicaid, and uninsured. Cox proportional hazard models were used to compare survival by race/ethnicity. We examined the contribution of health insurance and SES by sequentially adjusting for demographic and clinical characteristics (age group, sex, region, metropolitan statistical area, year of diagnosis, and number of conditions other than cancer), health insurance, and SDI. Compared with NH Whites, NH Blacks and Hispanics had worse survival for all cancers combined, leukemias and lymphomas, brain tumors, and solid tumors (all P < 0.05). Survival differences were attenuated after adjusting for health insurance and SDI separately; and further attenuated after adjusting for insurance and SDI together. Both SES and health insurance contributed to racial/ethnic disparities in childhood cancer survival. Improving health insurance coverage and access to care for children, especially those with low SES, may mitigate racial/ethnic survival disparities.

Exploring the association of social determinants of health and clinical quality measures and performance in HRSA-funded health centres

ObjectiveThis paper explores the impact of service area-level social deprivation on health centre clinical quality measures.DesignCross-sectional data analysis of Health Resources and Services Administration (HRSA)-funded health centres. We created a...

Association between community-based self-reported COVID-19 symptoms and social deprivation explored using symptom tracker apps: a repeated cross-sectional study in Northern Ireland

ObjectivesThe aim of the study was to investigate the spatial and temporal relationships between the prevalence of COVID-19 symptoms in the community-level and area-level social deprivation.DesignSpatial mapping, generalised linear models,...

Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey

The population of older adults (ie, those aged ≥55 years) in England is becoming increasingly ethnically diverse. Previous reports indicate that ethnic inequalities in health exist among older adults, but information is limited by the paucity of data from small minority ethnic groups. This study aimed to analyse inequalities in health-related quality of life (HRQoL) and five determinants of health in older adults across all ethnic groups in England. In this cross-sectional study, we analysed data from five waves (July 1, 2014, to April 7, 2017) of the nationally representative English General Practice Patient Survey (GPPS). Study participants were adults aged 55 years or older who were registered with general practices in England. We used regression models (age-adjusted and stratified by gender) to estimate the association between ethnicity and HRQoL, measured by use of the EQ-5D-5L index and its domains (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression). We also estimated associations between ethnicity and five determinants of health (presence of long-term conditions or multimorbidity, experience of primary care, degree of support from local services, patient self-confidence in managing own health, and degree of area-level social deprivation). We examined robustness to differential handling of missing data, alternative EQ-5D-5L value sets, and differences in area-level social deprivation. There were 1 416 793 GPPS respondents aged 55 years and older. 1 394 361 (98·4%) respondents had complete data on ethnicity and gender and were included in our analysis. Of these, 152 710 (11·0%) self-identified as belonging to minority ethnic groups. HRQoL was worse for men or women, or both, in 15 (88·2%) of 17 minority ethnic groups than the White British ethnic group. In both men and women, inequalities were widest for Gypsy or Irish Traveller (linear regression coefficient -0·192 [95% CI -0·318 to -0·066] in men; -0·264 [-0·354 to -0·173] in women), Bangladeshi (-0·111 [-0·136 to -0·087] in men; -0·209 [-0·235 to -0·184] in women), Pakistani (-0·084 [-0·096 to -0·073] in men; -0·206 [-0·219 to -0·193] in women), and Arab (-0·061 [-0·086 to -0·035] in men; -0·145 [-0·180 to -0·110] in women) ethnic groups, with magnitudes generally greater for women than men. Differentials tended to be widest for the self-care EQ-5D-5L domain. Ethnic inequalities in HRQoL were accompanied by increased prevalence of long-term conditions or multimorbidity, poor experiences of primary care, insufficient support from local services, low patient self-confidence in managing their own health, and high area-level social deprivation, compared with the White British group. We found evidence of wide ethnic inequalities in HRQoL and five determinants of health for older adults in England. Outcomes varied between minority ethnic groups, highlighting heterogeneity in the direction and magnitude of associations. We recommend further research to understand the drivers of inequalities, together with policy changes to improve equity of socioeconomic opportunity and access to services for older adults from minority ethnic groups. University of Manchester and National Institute for Health Research.

Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England

Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England. We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission. We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2-5). Similarly, at 365days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001). Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined.

Abstract PO-167: Area-level social deprivation and stage at diagnosis among breast cancer patients in South Carolina

Abstract Background: Cancer incidence, staging and mortality rates differ across geographic areas; however, there is a need for a better understanding of how neighborhood level socioeconomic and access to care factors impact cancer burden to tailor cancer control interventions in ways that appropriately target geographic determinants of cancer health disparities. The purpose of this study was to characterize the distribution of neighborhood deprivation in a cohort of breast cancer patients and examine the effect of social deprivation, healthcare professional shortage Area (HPSA) designation, and individual-level characteristics on breast cancer staging. Methods: We established a retrospective cohort of breast cancer patients diagnosed from 1996 to 2015 using the South Carolina Central Cancer Registry. Sociodemographic (e.g., race, age) and clinical variables were abstracted from the registry. We linked registry data to county-level variables to determine levels of social deprivation and residence in a health care professional shortage area using the Robert Graham Center’s Social Deprivation Index (SDI) and the Health Resources and Services Administration primary care HPSA designation. Bivariate analyses and multivariate regression analyses were used to examine associations. Results: The sample included 54,501 female breast cancer patients. Overall, the mean for SDI was 54.2 (+18.1) and the range was 76 (19-95). Approximately 44.4% of women lived in areas with high levels of social deprivation (e.g., SDI score of 52 to 95). In the logistic regression model, living in a geographic area with high social deprivation was significantly associated with African American race (OR=2.3, 95% C.I. 2.2-2.4), being unmarried (OR=1.2, 95% C.I. 1.1-1.3), and HPSA designation (OR=14.0, 95% C.I. 13.5- 14.6). Higher tumor grade (OR=1.2; 95% CI.1.2-1.3) and later stage (OR=1.1, 95% C.I. 1.1-1.2) were also significantly associated with neighborhood deprivation. Conclusion: This study shows that SDI differs by race and clinical characteristics among breast cancer patients. The SDI could be integrated into tumor registries and cancer research to understand the effects of neighborhood level variables on cancer health disparities to improve the precision of cancer control interventions that are developed to address geographic determinants. Citation Format: Andrew B. Lawson, Chanita Hughes-Halbert, Oluwole A. Babatunde, Whitney E. Zahnd, Jan M. Eberth. Area-level social deprivation and stage at diagnosis among breast cancer patients in South Carolina [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-167.

Concurrent and sequential chemoradiation therapy are associated with improved survival among unresected stage III non-small cell lung cancer patients in the United States.

7043 Background: Concurrent chemoradiation therapy (cCRT) has been shown to improve survival outcomes among inoperable stage III non-small cell lung cancer (NSCLC) patients compared to sequential CRT (sCRT) and single-modality therapy in clinical trials. However, many “real world” patients do not receive CRT, and less is known about the survival benefits of concurrent CRT vs other treatment modalities in pragmatic, non-clinical trial settings. Methods: We used the National Cancer Database (2004-2011) to identify unresected stage III NSCLC patients (ages 18-79 years) with Charlson comorbidity score ≤1 and 5-year follow up through the end of 2016. cCRT was defined as the initiations of chemotherapy (CT) and radiation therapy (RT) that were ≤14 days (n = 30,290) apart, whereas sCRT was defined as &gt; 14 days apart (total n = 10,596). The remaining three treatment groups included CT only (n = 11,216), RT only (n = 7,772), and neither CT/RT during first course treatment (n = 10,694). Cox proportional hazard model was used to examine the 5-year survival by treatment modalities, controlling for patient demographics, comorbidity score, health insurance, facility type, area-level social deprivation index (SDI, a composite measure for area-level socio-economic status), driving time to the treatment facility, diagnosis year, and region. Adjusted hazard ratios (HR), and medium survivals were generated by treatment modalities. Results: Among 70,568 unresected stage III NSCLC patients, 61,487 (87.1%) patients died within the 5-year follow-up period. In adjusted analyses, cCRT and sCRT had similar survival (median survivals: 15.3 months), whereas other treatment modalities were associated with worse survival compared to cCRT: CT only (median survival: 10.8 months; HR [95%CI]: 1.46 [1.43-1.50]), RT only (median survival: 6.7 months; HR [95%CI]: 1.93[1.88-1.99]), and no treatment (median survival: 3.2 months; HR [95%CI]: 2.64 [2.58-2.71]), all p &lt; 0.001. Higher comorbidity score (Charlson score 1 vs 0, HR [95%CI]: 1.18 [1.16-1.21]), non-private insurance (Medicaid: 1.16 [1.12-1.20]; Medicare: 1.10 [1.08-1.13]; uninsured: 1.21 [1.16-1.26]) were all associated with worse survival (all p &lt; 0.001). Conclusions: Concurrent CRT and sequential CRT have similar survival outcomes among unresected stage III NSCLC patients with minimum comorbidities, however, single modality and no therapy are associated with much poorer survival among “real world” patients, and should be avoided unless clinically appropriate.

Exposure to multiple air pollutants and the incidence of coronary heart disease: A fine-scale geographic analysis

Geographical variations in cardiovascular disease rates have been linked to individual air pollutants. Investigating the relation between cardiovascular disease and exposure to a complex mixture of air pollutants requires holistic approaches. We assessed the relationship between exposure to multiple air pollutants and the incidence of coronary heart disease (CHD) in a general population sample. We collected data in the Lille MONICA registry (2008–2011) on 3268 incident cases (age range: 35–74). Based on 20 indicators, we derived a composite environmental score (SEnv) for cumulative exposure to air pollution. Poisson regression models were used to analyse associations between CHD rates on one hand and SEnv and each single indicator on the other (considered in tertiles, where T3 is the most contaminated). We adjusted models for age, sex, area-level social deprivation, and neighbourhood spatial structure. The incidence of CHD was a spatially heterogeneous (p=0.006). There was a significant positive association between SEnv and CHD incidence (trend p=0.0151). The relative risks [95%CI] of CHD were 1.08 [0.98–1.18] and 1.16 [1.04–1.29] for the 2nd and 3rd tertile of SEnv exposure. In the single pollutant analysis, PM10, NO2, cadmium, copper, nickel, and palladium were significantly associated with CHD rates. Multiple air pollution was associated with an increased risk of CHD. Single pollutants reflecting road traffic pollution were the most strongly associated with CHD. Our present results are consistent with the literature data on the impact of road traffic on the CHD risk in urban areas.

Racial/ethnic disparities in childhood cancer survival in the United States: Mediation effects of health insurance coverage and area-level social deprivation.

143 Background: Childhood cancer survival varies by race/ethnicity in the United States. This study evaluated the impact of potentially modifiable characteristics - health insurance and area-level social deprivation - on racial/ethnic disparities in childhood cancer survival nationwide. Methods: We identified 65,113 childhood cancer patients aged &lt; 18 years newly diagnosed with any of 10 common cancer types (e.g. central nervous system (CNS) neoplasms, acute lymphoblastic leukemia (ALL), Hodgkin lymphoma) from the 2004-2014 National Cancer Database. Cox proportional hazard models were used to compare survival probabilities by race and ethnicity (non-Hispanic white (NHW) vs non-Hispanic black (NHB), Hispanic, and non-Hispanic other (NH other)) for each cancer type. We conducted mediation analyses by the mma R package to evaluate the racial/ethnic survival disparities mediated by health insurance (private, Medicaid, and uninsured) and social deprivation index (SDI) quartile. SDI is a composite measure of deprivation based on seven characteristics (e.g. income, education, employment). Results: Compared to NHW, worse survival were observed for NHB (HR (hazard ratio): 1.4, 95% CI: 1.3-1.5), Hispanic (HR: 1.2, 95% CI: 1.1-1.2), and NH other (HR: 1.2, 95% CI: 1.1-1.3) for all cancer sites combined after adjusting for sociodemographic characteristics other than health insurance and SDI. Health insurance explained 20% of the survival disparities and SDI explained 19% of the disparity between NHB vs NHW; health insurance explained 48% of the survival disparities and SDI explained 45% of the disparity between Hispanic vs NHW. For ALL, health insurance significantly explained 15% and 18% of the survival disparities between NHB and Hispanic vs NHW, respectively. SDI significantly explained 19% and 31% of the disparities, respectively. Conclusions: Health insurance and SDI mediated racial/ethnic survival disparities for several childhood cancers. Expanding insurance coverage and improving healthcare access in disadvantaged areas may effectively reduce disparities for these cancer sites.

Individual and area-level determinants associated with C-reactive protein as a marker of cardiometabolic risk among adults: Results from the German National Health Interview and Examination Survey 2008-2011.

BackgroundHigh-sensitivity C-reactive protein (hsCRP) is a sensitive biomarker of systemic inflammation and is related to the development and progression of cardiometabolic diseases. Beyond individual-level determinants, characteristics of the residential physical and social environment are increasingly recognized as contextual determinants of systemic inflammation and cardiometabolic risks. Based on a large nationwide sample of adults in Germany, we analyzed the cross-sectional association of hsCRP with residential environment characteristics. We specifically asked whether these associations are observed independent of determinants at the individual level.MethodsData on serum hsCRP levels and individual sociodemographic, behavioral, and anthropometric characteristics were available from the German Health Interview and Examination Survey for Adults (2008–2011). Area-level variables included, firstly, the predefined German Index of Socioeconomic Deprivation (GISD) derived from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database and, secondly, population-weighted annual average concentration of particulate matter (PM10) in ambient air provided by the German Environment Agency. Associations with log-transformed hsCRP levels were analyzed using random-intercept multi-level linear regression models including 6,768 participants aged 18–79 years nested in 162 municipalities.ResultsNo statistically significant association of PM10 exposure with hsCRP was observed. However, adults residing in municipalities with high compared to those with low social deprivation showed significantly elevated hsCRP levels (change in geometric mean 13.5%, 95%CI 3.2%-24.7%) after adjusting for age and sex. The observed relationship was independent of individual-level educational status. Further adjustment for smoking, sports activity, and abdominal obesity appeared to markedly reduce the association between area-level social deprivation and hsCRP, whereas all individual-level variables contributed significantly to the model.ConclusionsArea-level social deprivation is associated with higher systemic inflammation and the potentially mediating role of modifiable risk factors needs further elucidation. Identifying and assessing the source-specific harmful components of ambient air pollution in population-based studies remains challenging.

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The influence of area level social deprivation on preoperative disease severity and postoperative outcomes following unicompartmental knee joint replacement

BackgroundThis study investigated the effect of socioeconomic deprivation on preoperative disease and outcome following unicompartmental knee replacement (UKR). Methods307 Oxford UKRs implanted between 2008 and 2013 under the care of one surgeon using the same surgical technique were analysed. Deprivation was quantified using the Northern Ireland Multiple Deprivation Measure. Preoperative disease severity and postoperative outcome were measured using the Oxford Knee Score (OKS). ResultsThere was no difference in preoperative OKS between deprivation groups. Preoperative knee range of motion (ROM) was significantly reduced in more deprived patients with 10° less ROM than least deprived patients. Postoperatively there was no difference in OKS improvement between deprivation groups (p=0.46), with improvements of 19.5 and 21.0 units in the most and least deprived groups respectively. There was no significant association between deprivation and OKS improvement on unadjusted or adjusted analysis. Preoperative OKS, Short Form 12 mental component score and length of stay were significant independent predictors of OKS improvement. A significantly lower proportion of the most deprived group (15%) reported being able to walk an unlimited distance compared to the least deprived group (41%) one year postoperatively. ConclusionMore deprived patients can achieve similar improvements in OKS to less deprived patients following UKR. Level of evidence2b — retrospective cohort study of prognosis.

Do family physicians choose self-assessment activities based on what they know or don't know?

Maintenance of Certification (MOC) for Family Physicians (MC-FP) includes clinical Self-Assessment Modules (SAMs). Whether family physicians choose SAMs that reflect their aptitudes or knowledge gaps has not been studied. Secondary analysis of demographic data, 2009 certification examination scores, and 2009-2012 SAM participation data. We computed disease-specific scores for asthma, diabetes, and hypertension from the examination. We ran unadjusted logistic and adjusted conditional logistic regression models of score quintiles, matched on the number of SAMs completed and controlling for physician demographics and area-level social deprivation. In 2009, 9,610 physicians passed the exam. Mean scores were 591.4 (SD ± 308.5) for asthma, 558.6 (SD ± 216.1) for diabetes, and 533.3 (± 226.7) for hypertension. Average scores on hypertension and diabetes were higher for physicians who subsequently completed related SAMs but not for those who completed the asthma SAM. The percentage of physicians in each quintile of scaled score who completed each SAM increased for diabetes (32.3%-40.9%) and hypertension (33.0%-36.9%). For asthma, logistic regression analyses found no statistically significant associations. For diabetes, there was a consistent association in both models between higher score quintile and likelihood of taking the SAM. For hypertension, an association of higher score and higher likelihood of taking the SAM was significant only in the third quintile (OR = 1.20 (1.03, 1.39)). We found inconsistent relationships between physician knowledge and SAM selection. For MOC to better impact quality, boards should consider directing physicians toward MOC activities that fill knowledge gaps rather than areas of strength.

Differences in atherosclerosis according to area level socioeconomic deprivation: cross sectional, population based study

Objectives To examine the relation between area level social deprivation and ultrasound markers of atherosclerosis (common carotid intima-media thickness and plaque score), and to determine whether any differences can be...