Black-white Disparities Research Articles

Evaluating depth of disparities in relation to relative survival rates: Analysis of SEER data.

6602 Background: Prior studies have identified widening survival disparities between Black vs White patients (pts) in solid tumors with higher 5-year relative survival rates (RSR), a surrogate for higher amenability to treatment (Tehranifar et al., 2009). Given major advancements in treatment for hematologic malignancies leading to higher RSR, we sought to evaluate whether disparities worsened with higher RSR, especially among Black pts compared to White pts, in the modern era of therapy. We hypothesized that racial disparities would be larger in malignancies with higher amenability, as measured by 5-year RSR. Methods: We identified first hematologic malignancies among pts ages ≥18 years diagnosed between 2009-2019 in a collection of 17 Surveillance, Epidemiology and End Results (SEER) Program registries. We treated RSR as a continuous variable. Cox proportional-hazards model was used to correlate RSR and race with overall survival (OS) controlling for other pt characteristics. The interaction between RSR and race was included in the model to test if the racial effect on OS differed at various RSR levels. Results: We identified 363,340 pts who met inclusion criteria. Median age was 66 years and 55% were male. 82% were White and 10% Black. With a median follow-up of 48 months (mos), median RSR was 68.2% and median OS was 101 mos (95% CI 100-102 mos). Black pts had a lower median RSR than White pts, 63.8% vs 68.9%, and lower median OS, 90 mos (95% CI 87-93 mos) vs 99 mos (95% CI 98-100 mos). On univariable analysis, all variables were statistically significant given the large sample size. On multivariable analysis (MVA), Black pts had a higher risk of death than White pts. The interaction between 5-year RSR and race was highly significant (p=<0.01, not shown in Table), as indicated by slightly increasing hazard ratios (HRs) reflecting Black-White survival differences with increasing RSR level (i.e., as RSR increased, Black pts had slightly worse OS than White pts) (Table). Conclusions: We hypothesized that with increasing RSR, Black-White disparities might increase, as all effective therapies which contribute to improved RSR might not be equitably available to all populations. We observed that statistically significant disparities were present across RSR levels and increased only minimally for those with hematologic malignancies with higher RSR. In conclusion, disparities are prevalent in hematologic malignancies despite the degree of amenability to treatment. [Table: see text]

Geographic differences in the magnitude of black-white disparities in having obesity.

Obesity disparities in the United States are well documented, but the limited body of research suggests that geographic factors may alter the magnitude of these disparities. A growing body of evidence has identified a "rural mortality penalty" where morbidity and mortality rates are higher in rural than urban areas, even after controlling for other factors. Black-White differences in health and mortality are more pronounced in rural areas than in urban areas. Therefore, the purpose of this study was to explore how rural-urban status and region moderate Black-White health disparities in obesity. Data were abstracted from the 2012 Behavioral Risk Factor Surveillance System, with the sample being restricted to Black and White respondents (n = 403,231). Respondents' county of residence was linked to US Census information to obtain the county-level Index of Relative Rurality (IRR) and Census division. Crude and adjusted logistic regression models were utilized to assess the magnitude of Black-White disparities in having obesity (yes/no) by IRR quartile and by Census division. Overall, Black-White differences in obesity were wider in rural than in urban counties, with a significant linear trend (p < 0.001). Furthermore, when stratified by US Census division, results revealed that disparities were significantly wider in rural than urban areas for respondents living in the Middle Atlantic and South Atlantic divisions. In contrast, the association was reversed for the remaining divisions (New England, East North Central, West North Central, Mountain, and Pacific), where the magnitude of the Black-White difference was the largest in urban areas. Findings highlight the need to understand and account for critical place-based factors that exacerbate racial obesity disparities to develop and maximize the effectiveness of policies and programs designed to reduce racial inequalities and improve population health.

State Minimum Wage Increases As a Potential Policy Lever to Reduce Black-White Disparities in Hypertension.

Black adults are disproportionately burdened by hypertension. Income inequality is associated with elevated risk of hypertension. Minimum wage increases have been explored as a potential policy lever to address the disparate impact of hypertension on this population. However, these increases may have no significant impact on health among Black adults due to structural racism and "diminished gain" of health effects from socioeconomic resources. This study assesses the relationship between state minimum wage increases and Black-White disparities in hypertension. We merged state-level minimum wage data with survey data from the Behavioral Risk Factor Surveillance System (2001-2019). Odd survey years included questions about hypertension. Separate difference-in-difference models estimated the odds of hypertension among Black and White adults in states with and without minimum wage increases. Difference-in-difference-in-difference models estimated the impact of minimum wage increases on hypertension among Black adults relative to White adults. As state wage limits increase, the odds of hypertension significantly decreased among Black adults overall. This relationship is largely driven by the impact of these policies on Black women. However, the Black-White disparity in hypertension worsened as state minimum wage limits increased, and the magnitude of this disparity was larger among women. States having a minimum wage above the federal wage limit are not sufficient to combat structural racism and reduce the disparities in hypertension among Black adults. Rather, future research should explore livable wages as a policy lever to reduce disparities in hypertension among Black adults.

The dynamic nature of student discipline and discipline disparities

Researchers have long used end-of-year discipline rates to identify punitive schools, explore sources of inequitable treatment, and evaluate interventions designed to stem both discipline and racial disparities in discipline. Yet, this approach leaves us with a "static view"-with no sense of how disciplinary responses fluctuate throughout the year. What if daily discipline rates, and daily discipline disparities, shift over the school year in ways that could inform when and where to intervene? This research takes a "dynamic view" of discipline. It leverages 4 years of atypically detailed data regarding the daily disciplinary experiences of 46,964 students from 61 middle schools in one of the nation's largest school districts. Reviewing these data, we find that discipline rates are indeed dynamic. For all student groups, the daily discipline rate grows from the beginning of the school year to the weeks leading up to the Thanksgiving break, falls before major breaks, and grows following major breaks. During periods of escalation, the daily discipline rate for Black students grows significantly faster than the rate for White students-widening racial disparities. Given this, districts hoping to stem discipline and disparities may benefit from timing interventions to precede these disciplinary spikes. In addition, early-year Black-White disparities can be used to identify the schools in which Black-White disparities are most likely to emerge by the end of the school year. Thus, the results reported here provide insights regarding not only when to intervene, but where to intervene to reduce discipline rates and disparities.

Racial and Ethnic Differences in Barriers Faced by Medical College Admission Test Examinees and Their Association With Medical School Application and Matriculation

There has been disappointing progress in enrollment of medical students from racial and ethnic groups underrepresented in medicine, including American Indian or Alaska Native, Black, and Hispanic students. Barriers that may influence students interested in medicine are understudied. To examine racial and ethnic differences in barriers faced by students taking the Medical College Admission Test (MCAT). This cross-sectional study used survey data (surveys administered between January 1, 2015, to December 31, 2018) from MCAT examinees linked with application and matriculation data from the Association of American Medical Colleges. Data analyses were performed from November 1, 2021, to January 31, 2023. Main outcomes were medical school application and matriculation. Key independent variables reflected parental educational level, financial and educational barriers, extracurricular opportunities, and interpersonal discrimination. The sample included 81 755 MCAT examinees (0.3% American Indian or Alaska Native, 21.3% Asian, 10.1% Black, 8.0% Hispanic, and 60.4% White; 56.9% female). There were racial and ethnic differences in reported barriers. For example, after adjustment for demographic characteristics and examination year, 39.0% (95% CI, 32.3%-45.8%) of American Indian or Alaska Native examinees, 35.1% (95% CI, 34.0%-36.2%) of Black examinees, and 46.6% (95% CI, 45.4%-47.9%) of Hispanic examinees reported having no parent with a college degree compared with 20.4% (95% CI, 20.0%-20.8%) of White examinees. After adjustment for demographic characteristics and examination year, Black examinees (77.8%; 95% CI, 76.9%-78.7%) and Hispanic examinees (71.3%; 95% CI, 70.2%-72.4%) were less likely than White examinees (80.2%; 95% CI, 79.8%-80.5%) to apply to medical school. Black examinees (40.6%; 95% CI, 39.5%-41.7%) and Hispanic examinees (40.2%; 95% CI, 39.0%-41.4%) were also less likely than White examinees (45.0%; 95% CI, 44.6%-45.5%) to matriculate at medical school. Examined barriers were associated with a lower likelihood of medical school application and matriculation (eg, examinees having no parent with a college degree had lower odds of applying [odds ratio, 0.65; 95% CI, 0.61-0.69] and matriculating [odds ratio, 0.63; 95% CI, 0.59-0.66]). Black-White and Hispanic-White disparities in application and matriculation were largely accounted for by differences in these barriers. In this cross-sectional study of MCAT examinees, American Indian or Alaska Native, Black, and Hispanic students reported lower parental educational levels, greater educational and financial barriers, and greater discouragement from prehealth advisers than White students. These barriers may deter groups underrepresented in medicine from applying to and matriculating at medical school.

Contribution of social, behavioral, and contextual exposures to Black-White disparities in incident obesity: The CARDIA study.

The aim of this study was to quantify the contributions of socioeconomic, psychosocial, behavioral, reproductive, and neighborhood exposures in young adulthood to Black-White differences in incident obesity. In the Coronary Artery Risk Development in Young Adults (CARDIA) study, 4488 Black or White adults aged 18 to 30 years without obesity at baseline (1985-1986) were followed over 30 years. Sex-specific Cox proportional hazard models were used to estimate Black-White differences in incident obesity. Models were adjusted for baseline and time-updated indicators. During follow-up, 1777 participants developed obesity. Black women were 1.87 (95% CI: 1.63-2.13) times more likely and Black men were 1.53 (95% CI: 1.32-1.77) times more likely to develop obesity than their White counterparts after adjusting for age, field center, and baseline BMI. Baseline exposures explained 43% of this difference in women and 52% in men. Time-updated exposures explained more of the racial differencein women but less for men, compared with baseline exposures. Adjusting for these exposures accounted for a substantial but incomplete proportion of racial disparities in incident obesity. Remaining differences may be explained by incomplete capture of the most salient aspects of these exposures or potential variation in the impact of these exposures on obesity by race.

Black-White disparities in maternal vulnerability and adverse pregnancy outcomes: an ecological population study in the United States, 2014–2018

Systematic information on the association between community-level determinants and maternal health outcomes and disparities is needed. We aimed to investigate multi-dimensional place-based contributions to Black-White maternal health disparities in the United States. We constructed the Maternal Vulnerability Index, a geospatial measure of vulnerability to poor maternal health. The index was linked to 13m live births and maternal deaths to mothers aged 10-44 for 2014-2018 in the United States. We quantified racial disparities in exposure to higher risk environments, and used logistic regression to estimate associations between race, vulnerability, and maternal death (n=3633), low birthweight (n=1.1m), and preterm birth (n=1.3m). Black mothers lived in disproportionately higher maternal vulnerability counties, when compared to White mothers (median of 55 vs 36/100 points). Giving birth in the highest-quartile MVI counties was associated with an increase in the odds of poor outcomes when compared to the lowest-quartile (aOR 1.43 [95% CI 1.20-1.71] for mortality, 1.39 [1.37-1.41] for low birthweight and 1.41 [1.39-1.43] for preterm birth, adjusted for age, educational attainment level and race/ethnicity). Racial disparities exist in low- and high-vulnerability counties: Black mothers in the least vulnerable counties remain at higher risk of maternal mortality, preterm birth, and low birthweight as White mothers in the most vulnerable. Exposure to community maternal vulnerability is associated with increased odds of adverse outcomes, but the Black-White gap in outcomes remained under all vulnerability levels. Our findings suggest that locally-informed precision health interventions and further research into racism are needed to achieve maternal health equity. Bill & Melinda Gates Foundation(grant number INV-024583).

The Black-White Disparity in Preterm Birth: Race or Racism?

Policy Points Racism is an upstream determinant of health that influences health through many midstream and downstream factors. This Perspective traces multiple plausible causal pathways from racism to preterm birth. Although the article focuses on the Black-White disparity in preterm birth, a key population health indicator, it has implications for many other health outcomes. It is erroneous to assume by default that underlying biological differences explain racial disparities in health. Appropriate science-based policies are needed to address racial disparities in health; this will require addressing racism.

MP12-19 DISPARITIES IN REFUSAL OF SYSTEMATIC THERAPY IN METASTATIC PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023MP12-19 DISPARITIES IN REFUSAL OF SYSTEMATIC THERAPY IN METASTATIC PROSTATE CANCER Catherine Gu, Muhieddine Labban, Kevin R Melnick, Nicola Frego, Mara Koelker, Edoardo Beatrici, Dejan K. Filipas, Benjamin V. Stone, Alexander P. Cole, and Quoc-Dien Trinh Catherine GuCatherine Gu More articles by this author , Muhieddine LabbanMuhieddine Labban More articles by this author , Kevin R MelnickKevin R Melnick More articles by this author , Nicola FregoNicola Frego More articles by this author , Mara KoelkerMara Koelker More articles by this author , Edoardo BeatriciEdoardo Beatrici More articles by this author , Dejan K. FilipasDejan K. Filipas More articles by this author , Benjamin V. StoneBenjamin V. Stone More articles by this author , Alexander P. ColeAlexander P. Cole More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003227.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is evidence of racial disparities in the refusal of guideline-concordant treatment for localized prostate cancer. However, little is known about racial disparities in treatment refusal among men with metastatic prostate cancer. Therefore, we sought to examine whether Black-White disparities exist in patient refusal of various systematic therapies for metastatic prostate cancer. METHODS: We retrospectively queried the National Cancer Database for men with a clinical diagnosis of metastatic prostate cancer between 2004 – 2020 who were offered first-line systemic therapy using at least one of the following: hormone therapy, chemotherapy, or immunotherapy. Refusal of first-line therapy was recorded if systemic treatment was refused by the patient, the patient’s family member, or their guardian. We compared baseline sociodemographic, and clinical data, and rates of refusal of systemic therapies between Black and White men. Then, for each systemic therapy type, we fitted a multivariable logistic regression to evaluate whether there are Black-White disparities in treatment refusal adjusting for age, insurance coverage, Charlson comorbidity index, census tract median income quartiles, the burden of metastasis at diagnosis, facility type and location where care was sought, and the year of diagnosis. RESULTS: The cohort included 102,411 men with metastatic prostate cancer of which 21,444 (20.9%) men were Black. Black men were more likely to have a lower income, be uninsured, and have a higher burden of metastasis at diagnosis (p<0.001). After adjusting for covariates, NHB were more likely to refuse chemotherapy (aOR 2.18; 95%CI 1.54-3.09; p<0.001) compared to NHW. However, there were no racial disparities in the refusal of hormone therapy (aOR 1.16; 95%CI 0.94-1.43; p=0.16) or immunotherapy (aOR 1.10; 95%CI 0.59-2.07; p=0.76) as a first-line treatment for metastatic prostate cancer. CONCLUSIONS: Among men with metastatic prostate cancer, there are racial disparities in refusal of chemotherapy, but not for hormone therapy or immunotherapy. Cultural differences and economic disparities may play a role in accepting chemotherapy treatment. Further research is needed to elucidate the factors that may be driving this difference and how to address them. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e141 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catherine Gu More articles by this author Muhieddine Labban More articles by this author Kevin R Melnick More articles by this author Nicola Frego More articles by this author Mara Koelker More articles by this author Edoardo Beatrici More articles by this author Dejan K. Filipas More articles by this author Benjamin V. Stone More articles by this author Alexander P. Cole More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement PDF downloadLoading ...

PD20-06 RACE-BASED TRENDS IN THE PROPORTION OF METASTATIC PROSTATE CANCER AT DIAGNOSIS BETWEEN 2005 AND 2020: FINDINGS FROM THE NATIONAL CANCER DATABASE

You have accessJournal of UrologyCME1 Apr 2023PD20-06 RACE-BASED TRENDS IN THE PROPORTION OF METASTATIC PROSTATE CANCER AT DIAGNOSIS BETWEEN 2005 AND 2020: FINDINGS FROM THE NATIONAL CANCER DATABASE Muhieddine Labban, Brittany D. Berk, Benjamin V. Stone, David-Dan Nguyen, Dejan K. Filipas, Edoardo Beatrici, Sandeep S. Voleti, Firas Abdollah, Adam S. Kibel, and Quoc-Dien Trinh Muhieddine LabbanMuhieddine Labban More articles by this author , Brittany D. BerkBrittany D. Berk More articles by this author , Benjamin V. StoneBenjamin V. Stone More articles by this author , David-Dan NguyenDavid-Dan Nguyen More articles by this author , Dejan K. FilipasDejan K. Filipas More articles by this author , Edoardo BeatriciEdoardo Beatrici More articles by this author , Sandeep S. VoletiSandeep S. Voleti More articles by this author , Firas AbdollahFiras Abdollah More articles by this author , Adam S. KibelAdam S. Kibel More articles by this author , and Quoc-Dien TrinhQuoc-Dien Trinh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003286.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inequity in access to prostate cancer screening, diagnosis, and definitive treatment is widely described. Herein, we sought to evaluate the Black-White differences in the proportion of metastatic status at diagnosis between 2005 and 2020. METHODS: We retrospectively queried the National Cancer Database between 2005 and 2020 to identify non-Hispanic Black (NHB) and non-Hispanic White (NHW) men who received a clinical or pathologic diagnosis of metastatic prostatic cancer across four time periods (2005-2008; 2009-2012; 2013-2016; and 2017-2020). For NHB and NHW men, we compared patient sociodemographics, rural/urban residence, and the region and type of facility where care was sought. Then, we fitted a logistic regression adjusting for covariates to predict metastatic status at diagnosis with an interaction term for race and period of diagnosis. Interaction analysis was used to predict the odds of metastatic status at diagnosis for NHB compared to NHW men across periods. RESULTS: The cohort included 1,838,368 men of which 287,395 (15.6%) were NHB. NHB men were more likely to have Medicaid insurance or to be uninsured and to seek care at non-academic institutions (p<0.001). After adjusting for covariates, NHB men had a higher proportion of metastatic prostate cancer at diagnosis (aOR 1.37; 95%CI 1.34-1.40). We found an interaction between race and time periods (p<0.001) suggesting a statistically significant difference in trends over time by race. In margin analysis, the odds in the proportion of metastatic status at diagnosis among NHB compared to NHW were highest for the 2005-2008 period, narrowed for the 2009-2012 period, and were stable over the last decade (Figure 1). CONCLUSIONS: Although Black-White disparities in the proportion of metastatic prostate cancer at diagnosis narrowed between 2005-2012, they remained stable between 2013-2020. Since the dataset is not a population-based registry, these results cannot be used to determine the incidence or prevalence of metastatic disease. In addition, trends in the proportion of metastatic disease might also be influenced by changes in the definition of low-risk disease. Nevertheless, our findings suggest that there remain significant structural barriers to achieving equity. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e585 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Muhieddine Labban More articles by this author Brittany D. Berk More articles by this author Benjamin V. Stone More articles by this author David-Dan Nguyen More articles by this author Dejan K. Filipas More articles by this author Edoardo Beatrici More articles by this author Sandeep S. Voleti More articles by this author Firas Abdollah More articles by this author Adam S. Kibel More articles by this author Quoc-Dien Trinh More articles by this author Expand All Advertisement PDF downloadLoading ...

Racial/Ethnic Differences in Child Protective Services Reporting, Substantiation and Placement, With Comparison to Non-CPS Risks and Outcomes: 2005-2019.

We used National Child Abuse and Neglect Data System and Census data to examine Black-White and Hispanic-White disparities in reporting, substantiation, and out-of-home placement both descriptively from 2005-2019 and in multivariate models from 2007-2017. We also tracked contemporaneous social risk (e.g., child poverty) and child harm (e.g., infant mortality) disparities using non-child protective services (CPS) sources and compared them to CPS reporting rate disparities. Black-White CPS reporting disparities were lower than found in non-CPS risk and harm benchmarks. Consistent with the Hispanic paradox, Hispanic-White CPS reporting disparities were lower than risk disparities but similar to harm disparities. Descriptive and multivariate analyses of data from the past several years indicated that Black children were less likely to be substantiated or placed into out-of-home care following a report than White children. Hispanic children were slightly more likely to be substantiated or placed in out-of-home care than White children overall, but this difference disappeared in multivariate models. Available data provide no evidence that Black children were overreported relative to observed risks and harms reflected in non-CPS data. Reducing reporting rates among Black children will require addressing broader conditions associated with maltreatment.

Testing the Differential Access Hypothesis That Black Kidney Transplant Candidates Perceive Social Network Access to Fewer Potential Living Donors Than White Candidates.

Many studies of Black-White disparities in living donor kidney transplantation hypothesize that they were partially due to Black-White differences in candidate social network access to healthy, willing donors. This differential access hypothesis has not been tested using directly measured social network data. Do black kidney transplant candidates have perceived lower social network access to health and/or willing living donors than white candidates? A cross-sectional survey that measured the social network members was collected in 2015. Black-White differences in patient counts of perceived healthy and/or willing potential donors in social networks, and individual network members' probability of being perceived healthy and/or willing, were compared using logistic and negative binomial regression models. The survey included 66 kidney transplant candidates reporting on 1474 social network members at a large Southeastern US transplant center in 2015. Black and White patients had similar access to perceived healthy, likely potential donors (86% vs 87% had 1 or more, P = .92; 5.91 vs 4.13 mean counts, P = .20) and perceived healthy, agreed potential donors (56% vs 48%, P = .54; 1.77 vs 1.74, P = .97). Black patients' network members were individually more likely to be perceived healthy and likely potential donors (26% vs 21%, P = .04), and White patients' network members were more likely to have agreed (13% vs 9%, P = .03), but these differences were statistically insignificant in demographically adjusted models. Black and White transplant candidates perceived access to similar numbers of potential donors in their social networks. This result does not support the differential access hypothesis.

The Cumulative Effects of Colorism: Race, Wealth, and Skin Tone

Abstract Researchers have long documented a persistent Black–White gap in wealth. These studies, however, often treat race as a discrete category, eluding its socially constructed nature. As a result, these studies assume that the “effect of race” is consistent across all individuals racialized as Black. Studies that make this assumption potentially obscure heterogeneity in the size of the Black–White wealth gap. Research on skin color stratification suggests that it is possible that the Black–White wealth gap varies by the extent to which a racial subgroup is deemed to fit the broader racial umbrella. In turn, I adopt a more complex operationalization of race that is based on both racial and skin tone appraisals. Drawing on data from the National Longitudinal Survey of Youth 1997, I find that the Black–White wealth gap does vary by the Black skin tone subgroup. Generally, the Black–White gap in assets is smallest when focusing on lighter-skin Black people and largest when focusing on darker-skin Black people. These differences are not only the result of initial disadvantage but also cumulative disadvantage in the rate of wealth accumulation. Lastly, the findings suggest that the Black–White wealth gaps grow at a faster rate than the skin tone wealth gaps. I found that differences were robust to adjustments for parental socioeconomic status, childhood background, and interviewer characteristics. I conclude by discussing the theoretical implications for our understanding of the mechanisms undergirding Black–White disparities in wealth attainment.

Effects of Part D Star Ratings on racial and ethnic disparities in health care costs

BackgroundRacial/ethnic minorities are less likely than non-Hispanic White (White) patients to be included in the Medicare Part D Star Ratings measure assessment due to the restrictive inclusion criteria for the measures. ObjectiveThis paper examined the effects of racial/ethnic disparities in the measure assessment in Part D Star Ratings on disparities in healthcare costs among patients with Alzheimer's disease and related dementias (ADRD). MethodsThis cross-sectional study analyzed 2017 Medicare data. Proportions of Beneficiaries with ADRD were categorized into the included and excluded groups based on the inclusion criteria for the calculation of medication adherence measures in Star Ratings. Outcomes included costs for medications, physician visits, emergency room (ER) visits, and total costs. A generalized linear model was employed to compare costs across racial/ethnic groups. To explore the differential disparities in healthcare costs between the 2 groups, interaction terms between dummy variables for being excluded from the measure calculation and racial/ethnic minorities were included in the models. ResultsThe patterns of racial/ethnic disparities in healthcare costs found in this study were generally consistent with expectations, with some exceptions. For example, compared with White patients, in the hyperlipidemia cohort, the physician visit cost for Black patients among the included group was 31% lower (cost ratio or CR = 0.69, 95% CI = 0.67–0.72); in the hypertension cohort, the hospitalization cost for Blacks among the excluded group was 15% higher (CR = 1.15, 95% CI = 1.12–1.19). More importantly, exclusion from measurement assessments was associated with differential cost disparities. For example, compared with individuals included in the measure assessment for hypertension, the Black-White disparities in costs for hospitalization and total healthcare were 30% higher (CR = 1.30, 95% CI = 1.26–1.34), and 10% higher (CR = 1.10; 95% CI = 1.08–1.12), respectively, among the excluded group. ConclusionsMedicare Part D Star Ratings may be associated with aggravated racial/ethnic disparities in healthcare costs in the Medicare Part D population.

Abstract P422: Diminished Returns: Racial/Ethnic Differences in Diet Quality Vary by Education Level

Introduction: Poor diet is a major modifiable risk factor for cardiovascular disease. Educational attainment is highly correlated with healthy dietary behavior; as education level increases, diet quality also increases. Nevertheless, a recent study reported that Black adults with a high education level consume lower amounts of healthy foods (e.g., fruits, vegetables, whole grains) compared to White adults with a high education level. These findings are concerning because they suggest that certain individual or structural factors may produce diminished returns on educational investment among Black-identifying people. The literature on this topic is scarce. To address this gap, this study examined racial/ethnic differences in diet quality by education level among U.S. adults. Hypothesis: Black adults with ≥ bachelor’s degree will have lower diet quality than White adults with the same education level. Methods: We analyzed cross-sectional data on 19,591 adults (age ≥ 20) who participated in the National Health &amp; Nutrition Examination Survey from 2011-2018. We calculated Healthy Eating Index (HEI)-2015 total scores using the participant’s 24-hour recall data. HEI-2015 (scale: 0-100) reflects how well an individual’s food and beverage intake aligns with the 2015-2020 Dietary Guidelines for Americans . We ran stratified linear regression models to identify racial/ethnic differences in HEI-2015 total score within each category of educational attainment: &lt; high school, high school or equivalent, some college/associate’s degree, ≥ bachelor’s degree. All models were adjusted for age, sex, marital status, poverty level, and household size. Results: Regression models revealed that Asian adults, on average, had significantly higher HEI-2015 total scores compared to White adults at every education level (p&lt;0.0001 in all models). Hispanic adults had significantly higher scores than White adults in every educational category except ≥ bachelor’s degree where there was no difference. There was no difference in HEI-2015 total score between Black and White adults at every education level except ≥ bachelor’s degree. Black adults with a bachelor’s degree, on average, had a lower HEI-2015 total score (β = -1.69; SE: 0.79; p=0.03) compared to White adults with the same education level. Additional sex-specific analyses revealed that this disparity existed mainly between Black and White women with ≥ bachelor’s degree (β = -2.26; SE: 1.11; p=0.04). Conclusion: This study found that racial/ethnic differences in diet quality do vary by education level. As hypothesized, there is a Black-White disparity in diet quality among adults with higher education levels. Additional research is need to explore the individual and structural factors associated with this disparity.

Abstract MP43: The Role of the Physical Environment in Racial Differences in Sleep Duration

Background: Racial and ethnic sleep disparities have been documented; however, the mechanisms are unclear. The physical environment is associated with sleep duration and may explain sleep disparities. We examined the physical environment as a mediator of racial differences in sleep duration using data from the Multi-Ethnic Study of Atherosclerosis (N=2073). Methods: Participants underwent 1-week actigraphy, completed questionnaires on the neighborhood environment, and addresses were geocoded and linked to physical environment features. Actigraphy-measured sleep duration was analyzed as both continuously and categorically (short sleep duration &lt; 6 hours vs. ≥ 6 hours). Physical environment characteristics included availability of healthy foods, aesthetic quality, walking environment, walking destination density, the proportion of land dedicated to retail space and an overall built environment score. Multi-level linear and Poisson regression models with robust variance were fit to examine associations of race, physical environment, and sleep duration with adjustment for covariates. Direct and indirect mediation was tested via path models. Results: The mean age was 68.6 ± 9.2 years. Approximately 46% of participants were male and 37.7% White, 27.7% Black, 23.1% Hispanic, and 11.5% Chinese American. The prevalence of short sleep (6 hours) was highest for racial minorities, ranging from 32.2% to 44.3% compared to 19.2% for White adults. A higher built environment factor score was associated with shorter sleep duration. The physical environment partially mediated racial disparities in sleep duration between Hispanic and White adults. A significant indirect effect of race on sleep duration via aesthetic quality, walking destination density, proportion retail and the built environment factor score was detected, explaining 4.0%, 27.2%, 7.6%, and 37.8%, respectively of the association between race and sleep duration for Hispanic individuals, compared to White individuals. The physical environment did not explain the Black-White or Chinese-White disparity in sleep duration. Conclusion: Black, Hispanic, and Chinese individuals had shorter sleep duration than White individuals. The Hispanic-White disparity in sleep duration was partially explained by the physical environment. These findings suggest that the physical environment may be an important mechanism in which racial disparities in sleep exist and a likely a target for intervention.

Association of Social Determinants and Tumor Biology With Racial Disparity in Survival From Early-Stage, Hormone-Dependent Breast Cancer

Black women with hormone receptor-positive breast cancer experience the greatest racial disparity in survival of all breast cancer subtypes. The relative contributions of social determinants of health and tumor biology to this disparity are uncertain. To determine the proportion of the Black-White disparity in breast cancer survival from estrogen receptor (ER)-positive, axillary node-negative breast cancer that is associated with adverse social determinants and high-risk tumor biology. A retrospective mediation analysis of factors associated with the racial disparity in breast cancer death for cases diagnosed between 2004 and 2015 with follow-up through 2016 was carried out using the Surveillance, Epidemiology, and End Results (SEER) Oncotype registry. The study included women in the SEER-18 registry who were aged 18 years or older at diagnosis of a first primary invasive breast cancer tumor that was axillary node-negative and ER-positive, who were Black (Black), non-Hispanic White (White), and for whom the 21-gene breast recurrence score was available. Data analysis took place between March 4, 2021, and November 15, 2022. Census tract socioeconomic disadvantage, insurance status, tumor characteristics including the recurrence score, and treatment variables. Death due to breast cancer. The analysis with 60 137 women (mean [IQR] age 58.1 [50-66] years) included 5648 (9.4%) Black women and 54 489 (90.6%) White women. With a median (IQR) follow-up time of 56 (32-86) months, the age-adjusted hazard ratio (HR) for breast cancer death among Black compared with White women was 1.82 (95% CI, 1.51-2.20). Neighborhood disadvantage and insurance status together mediated 19% of the disparity (mediated HR, 1.62; 95% CI, 1.31-2.00; P < .001) and tumor biological characteristics mediated 20% (mediated HR, 1.56; 95% CI, 1.28-1.90; P < .001). A fully adjusted model that included all covariates accounted for 44% of the racial disparity (mediated HR, 1.38; 95% CI, 1.11-1.71; P < .001). Neighborhood disadvantage mediated 8% of the racial difference in the probability of a high-risk recurrence score (P = .02). In this study, racial differences in social determinants of health and indicators of aggressive tumor biology including a genomic biomarker were equally associated with the survival disparity in early-stage, ER-positive breast cancer among US women. Future research should examine more comprehensive measures of socioecological disadvantage, molecular mechanisms underlying aggressive tumor biology among Black women, and the role of ancestry-related genetic variants.

The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes

AimsWhile several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease. MethodsWe used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables. ResultsOur calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes. ConclusionsThere is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.

Racial disparities in diagnostic evaluation of uterine cancer among Medicaid beneficiaries.

To inform reasons contributing to Black-White disparity in early diagnosis of uterine cancer, we compared the quality of diagnostic evaluation received by Black vs White patients with abnormal uterine bleeding (AUB) ultimately diagnosed with uterine cancer. Using 2008-2019 MarketScan Multi-State Medicaid Database, we identified Black (n = 858) and White (n = 1749) patients with uterine cancer presenting with AUB. Quality of diagnostic evaluation was measured by delayed diagnosis (>1 year after AUB reporting), not receiving guideline-recommended diagnostic procedures, delayed time to first diagnostic procedure (>2 months after AUB reporting), number of diagnostic procedures received, and number of evaluation and management visits for AUB. The association between race and quality indicators was examined by multivariable regressions adjusting for patient characteristics. Black patients were more likely than White patients to experience delayed diagnosis (11.3% vs 8.3%, P = .01; adjusted odds ratio [OR] = 1.71, 95% confidence interval [CI] = 1.27 to 2.29) or to not receive guideline-recommended diagnostic procedures (10.1% vs 5.0%, P < .001; adjusted OR = 1.94, 95% CI = 1.40 to 2.68). Even when they did receive recommended diagnostic procedures, Black patients were more likely than White patients to experience delay in time to the first diagnostic procedure (adjusted OR = 1.46, 95% CI = 1.09 to 1.97). In addition, Black patients underwent more evaluation and management visits for AUB before getting diagnosed compared with White patients (adjusted mean ratio = 1.13, 95% CI = 1.04 to 1.23). Black and White patients with uterine cancer differed in the quality of diagnostic evaluation received. Improving equity in this area may help reduce Black-White disparity in stage at diagnosis.

Black-White disparities in fatigue and comorbidity among breast cancer survivors

Black-White disparities in fatigue and comorbidity among breast cancer survivors