Code Level Median Household Income Research Articles

Abstract 797: Area deprivation, rurality, healthcare utilization, quality of life, and health status among cancer patients

Abstract Background: Living in deprived or rural neighborhoods can negatively influence individual health through various mechanisms, including limited access to care due to scarce resources, medical facilities, or health professionals. Prior ecological studies have shown an association between living in rural or disadvantaged areas and higher cancer morbidity or mortality, but research on the association between neighborhood of residence and cancer patients’ healthcare utilization, health status, or quality of life has been limited. Method: We used survey and electronic health records data on cancer patients aged ≥18 years (N=16,606) from All of US Controlled Tier Dataset v7 (summer 2017-July 1, 2022). Area deprivation index (ADI) was based on six items, including 3-digit zip code-level median household income, proportions of high school graduation, vacant housing, recipients of public assistance income, and individual without health insurance or with incomes below the poverty level. Rural-urban status was defined at the 3-digit zip code-level as urban (100% urban), mostly urban (≥50%-<100% urban), and rural (>50% rural). Logistic regression models were used to estimate the association between ADI or rurality and health care utilization (general doctor, specialist, mental health, or nurse practitioner/physical assistant [NP/PA] visits) or health outcome (fair/poor physical and mental health status, quality of life), controlling for various covariates. Results: Cancer patients living in the most deprived areas (ADI 5th quintile) were less likely to have general doctor visits (OR=0.73; 95% CI=0.54-0.85), NA/PA visits (OR=0.87; 95% CI=0.77-0.99), or mental health professional visits (OR=0.85; 95% CI=0.74-0.98), and more likely to have fair or poor quality of life (OR=1.31; 95% CI=1.06-1.62), compared to those living in the least deprived areas (ADI 1st quintile), controlling for all covariates. Similarly, rural cancer patients were less likely to have general doctor visits (OR=0.58; 95% CI=0.42-0.79) or mental health professional visits (OR=0.53; 95% CI=0.41-0.67), and more likely to have fair/poor physical health (OR=1.27; 95% CI=1.03-1.57), compared with urban cancer patients. However, rural cancer patients were more likely to have NA/PA visits (OR=1.29; 95% CI=1.04-1.58) and less likely to have fair/poor mental health (OR=0.66; 95% CI=0.48-0.92). Cancer patients in mostly urban areas showed similar patterns to those in rural areas but the magnitudes of associations were smaller. Conclusions: In this study, cancer patients living in deprived or rural areas were less likely to have general doctor or mental health professional visits and more likely to have poor physical health compared to patients in the least deprived or urban area. Community-level interventions in deprived or rural areas are required to mitigate disparities in healthcare and health among cancer patients. Citation Format: Hyunjung Lee, Dongjun Lee, Ding Quan Ng, Daniel Wiese, Ahmedin Jemal, Farhad Islami. Area deprivation, rurality, healthcare utilization, quality of life, and health status among cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 797.

Associations of Greenness, Parks, and Blue Space With Neurodegenerative Disease Hospitalizations Among Older US Adults

Exposure to natural environments has been associated with health outcomes related to neurological diseases. However, the few studies that have examined associations of natural environments with neurological diseases report mixed findings. To evaluate associations of natural environments with hospital admissions for Alzheimer disease and related dementias (ADRD) and Parkinson disease (PD) among older adults in the US. This open cohort study included fee-for-service Medicare beneficiaries aged 65 years or older who lived in the contiguous US from January 1, 2000, to December 31, 2016. Beneficiaries entered the cohort on January 1, 2000, or January 1 of the year after enrollment. Data from US Medicare enrollment and Medicare Provider Analysis and Review files, which contain information about individual-level covariates and all hospital admissions for Medicare fee-for-service beneficiaries, were analyzed between January 2021 and September 2022. Differences in IQRs for zip code-level greenness (normalized difference vegetation index [NDVI]), percentage park cover, and percentage blue space cover (surface water; ≥1.0% vs <1.0%). The main outcome was first hospitalizations with a primary or secondary discharge diagnosis of ADRD or PD. To examine associations of exposures to natural environments with ADRD and PD hospitalization, we used Cox-equivalent Poisson models. We included 61 662 472 and 61 673 367 Medicare beneficiaries in the ADRD and PD cohorts, respectively. For both cohorts, 55.2% of beneficiaries were women. Most beneficiaries in both cohorts were White (84.4%), were not eligible for Medicaid (87.6%), and were aged 65 to 74 years (76.6%) at study entry. We observed 7 737 609 and 1 168 940 first ADRD and PD hospitalizations, respectively. After adjustment for potential individual- and area-level confounders (eg, Medicaid eligibility and zip code-level median household income), NDVI was negatively associated with ADRD hospitalization (hazard ratio [HR], 0.95 [95% CI, 0.94-0.96], per IQR increase). We found no evidence of an association of percentage park and blue space cover with ADRD hospitalization. In contrast, NDVI (HR, 0.94 [95% CI, 0.93-0.95], per IQR increase), percentage park cover (HR, 0.97 [95% CI, 0.97-0.98], per IQR increase), and blue space cover (HR, 0.97 [95% CI, 0.96-0.98], ≥1.0% vs <1.0%) were associated with a decrease in PD hospitalizations. Patterns of effect modification by demographics differed between exposures. The findings of this cohort study suggest that some natural environments are associated with a decreased risk of ADRD and PD hospitalization.

Abstract P3-14-17: Exploring racial disparities in BRCA testing for triple negative breast cancer patients: A real-world data analysis

Abstract Background and Objective: BRCA testing for patients (pts) with triple negative breast cancer (TNBC) is important because it has secondary prevention implications for patients and multigenerational implications allowing for earlier detection of BRCA gene carriers in the family and enabling primary prevention. And with the advent of PARP inhibitors it also has treatment implications. The NCCN guidelines recommended in January 2015 that BRCA testing be performed for all pts with TNBC diagnosed at age 60 or younger regardless of race, ethnicity or family history. To understand disparities in BRCA testing among TNBC pts we analyzed the proportion tested, explored barriers to testing, and made comparisons by race, ethnicity, and socioeconomic status (SES). Methods: Adult pts with TNBC diagnosed at or under age 60 between January 1, 2015 and December 31, 2020 were identified in the Syapse Learning Health Network, a real-world database with clinical and genomic data from community health systems. Study end was June 1, 2021, allowing for a minimum follow up of 5 months. Electronic health records were reviewed to calculate proportion tested and barriers to testing. SES was estimated using zip code level median household income from the 2010 census and stratified based on the national poverty level (low &amp;lt;150%, middle 150-299%, high 300%+). χ;2 statistics were used to assess differences between groups. Results: 577 pts with a median age at TNBC of 50 and median follow up of 18 months were included. 65.2% self-identified as white, 27.9% as Black or African American (AA), 1.4% Asian, 1.4% American Indian or Alaska Native, and 4.2% other. 8% identified as Hispanic/Latino. Due to relative size of racial/ethnic groups, the stratified analyses focused on comparisons between white and AA pts. Overall, 459 (79.5%) pts received a test, but with 83% of white pts receiving tests as compared to 72.7% of AA pts (p=0.009). 71.4% of pts with low SES received a test vs. 81.8% for middle and 79.4% with high SES (p=0.068). Among the 118 pts with no test, 48 (40.7%) did not have documentation of a test referral or evidence of testing offered in clinician notes. This differed by race with white pts less likely to have test offer documented vs. AA pts (53.1% vs. 72.7%, p=0.064). Among the 48 pts with no evidence of test offer, additional details were often not documented. However some clinician notes cited a perceived ineligibility due to lack of family history, transferring out or move to hospice, and pt refusal. Among the 70 (59.3%) pts who were offered a test but did not receive it, reasons included 37.1% choosing not to be tested, 11.4% due to early death, loss to follow up or transferring away, and 7.1% lacked adequate health insurance. These reasons varied by race, with 59.4% of AA pts choosing not to be tested vs. 20.6% of white pts (p=0.003) (Table 1). Conclusions: Real-world data provides insight into BRCA testing patterns in routine clinical practice where racial disparities are well documented and persistent. While the overall proportion of pts who received BRCA testing was high, AA pts experienced more barriers. Despite AA pts having greater evidence of a test offer vs. white pts, there was a significant gap in testing favoring white pts, with the most notable reason for lack of testing being pt choice. The clinical significance of BRCA testing in TNBC indicates a need to create targeted strategies to close gaps in education, confidence and access among patients and providers to improve testing levels. Table 1.BRCA testing barriers among patients who were offered a test but did not receive it (N=70)Total (n=70)White (n=34)Black or African American (n=32)Low SES (n=19)Middle SES (n=43)High SES (n=8)Lack of adequate health insurance, n (%)5 (7.1)3 (8.8)1 (3.1)3 (15.8)1 (2.3)1 (12.5)Patient chose not to be tested, n (%)26 (37.1)7 (20.6)19 (59.4)8 (42.1)14 (32.6)4 (50.0)Deceased before testing occurred, n (%)5 (7.1)3 (8.8)2 (6.3)1 (5.3)4 (9.3)0 (0)LTFU/Transferred, n (%)3 (4.3)2 (5.9)1 (3.1)1 (5.3)1 (2.3)1 (12.5)Other, n (%)7 (10.0)6 (17.6)1 (3.1)1 (5.3)6 (14.0)0 (0)Unknown, n (%)24 (34.3)13 (38.2)8 (25.0)5(26.3)17 (39.5)2 (25.0) Citation Format: Jeanna Wallenta Law, Hanadi BuAli, Sherri Costa, Michael P. Mullane, Mohamed Hendawi, Michael McPhee, Bryanne Collini, Mahder Teka, Francesca Coutinho, Ronda Broome, Frank M. Wolf, Liz Toland, Trista Weber, Anna Berry, Thomas D. Brown, Haythem Ali. Exploring racial disparities in BRCA testing for triple negative breast cancer patients: A real-world data analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-17.

Household Income as a Predictor for Surgical Outcomes and Opioid Use After Spine Surgery in the United States.

Cross-Sectional Study. Socioeconomic status (SES) is a fundamental root of health disparities, however, its effect on surgical outcomes is often difficult to capture in clinical research, especially in spine surgery. Here, we present a large single-center study assessing whether SES is associated with cause-specific surgical outcomes. Patients undergoing spine surgery between 2015 and 2019 were assigned income in accordance with the national distribution and divided into quartiles based on the ZIP code-level median household income. We performed univariate, chi-square, and Analysis of Variance (ANOVA) analysis assessing the independent association of SES, quantified by household income, to operative outcomes, and multiple metrics of opioid consumption. 1199 patients were enrolled, and 1138 patients were included in the analysis. Low household income was associated with the greatest rates of 3-month opioid script renewal (OR:1.65, 95% CI:1.14-2.40). In addition, low-income was associated with higher rates of perioperative opioid consumption compared to higher income including increased mean total morphine milligram equivalent (MME) 252.25 (SD 901.32) vs 131.57 (SD 197.46) (P < .046), and inpatient IV patient-controlled analgesia (PCA) MME 121.11 (SD 142.14) vs 87.60 (SD 86.33) (P < .023). In addition, household income was independently associated with length of stay (LOS), and emergency room (ER) revisits with low-income patients demonstrating significantly longer postop LOS and increasing postoperative ER visits. Considering the comparable surgical management provided by the single institution, the associated differences in postoperative outcomes as defined by increased morbidities and opioid consumption can potentially be attributed to health disparities caused by SES.

Primary Site and Other Prognostic Factors for Fibrosarcoma: An Analysis of the National Cancer Database.

Purpose: Fibrosarcoma (FS) is a rare and malignant tumor that can occur in a variety of anatomic sites. The goal of this study is to use the National Cancer Database (NCDB) to analyze various factors affecting overall survival in FS and to be one of the rare studies to characterize the significance of the primary anatomic sites.Methods: The study cohort included 2,278 patients diagnosed with fibrosarcoma who received surgery from the NCDB. Kaplan-Meier curves, log-rank tests, and a multivariable Cox proportional hazard model were used to analyze the significance of factors affecting overall survival.Results: The head, face, and neck (HR = 1.44; 95% CI: 1.01-2.05; P = 0.046) and thorax anatomical sites (HR = 1.33; 95% CI: 1.02-1.73; P = 0.035) had a higher increased risk of death in comparison to the lower limb and hip. Compared to patients with private insurance, patients without insurance (HR = 1.99; 95% CI: 1.22 to 3.25; P = 0.006) and patients with Medicaid (HR = 1.99; 95% CI: 1.37 to 2.90; P < 0.001) had decreased overall survival. Patients associated with a zip code-level median household income ≥ $63,000 had a decreased risk of mortality when compared to lower income groups.Conclusion: In general, older patients with comorbidities, advanced-stage disease, and larger tumors who did not have private insurance and were from areas associated with lower income levels had poorer overall survival. No significant difference in overall survival was associated with receipt of neoadjuvant chemotherapy or neoadjuvant radiation.

Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System

Rationale & ObjectiveHealth-impeding social determinants of health—including reduced access to care—contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care.Study DesignCross-sectional study.Setting & ParticipantsMHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018.PredictorsRace, sponsor’s rank (a proxy for socioeconomic status and social class), median household income by sponsor’s zip code, and marital status.OutcomeCKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype.Analytical ApproachMultivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor’s service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index).ResultsOf 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators.LimitationsThe cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code–level median household income data.ConclusionsRacial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.

The Association of Socioeconomic Status and Discharge Destination with 30-Day Readmission after Ischemic Stroke

ObjectivesThis study aimed to explore the association of socioeconomic status and discharge destination with 30-day readmission after ischemic stroke. Materials and MethodsWe examined 30-day all-cause readmission among patients hospitalized for ischemic stroke in states of Arkansas, Iowa, and Wisconsin in 2016 and 2017 and New York in 2016 using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. ResultsAmong the 52301 patients included, 51.1% were female. The 30-day readmission rates were 10.2%, 8.2%, 9.3%, 10.4%, 11.6%, and 11.2% for age group 18-34, 35-44, 45-54, 55-64, 65-74, and ≥75 years, respectively (p<0.001). In Generalized Estimating Equation analysis, patients with Medicare and Medicaid insurance were more likely to be readmitted, compared with private insurance, (adjusted Odds Ratio [aOR] 1.37, 95% CI 1.23-1.53; and aOR 1.26, 95% CI 1.09-1.45, respectively). Patients in the bottom quartile of zip code level median household income had higher 30-day readmission rate (12.4%) than those in the 2nd, 3rd and 4th quartile (10.3%, 10.1%, and 10.7%, respectively, p<0.001). Compared with those discharged home with self-care which had the lowest readmission rate (8.4%), patients who left against medical advice had the highest readmission rate (18.6%; aOR 2.23, 95% CI 1.75-2.83), followed by rehabilitation and skilled nursing facilities (13.2%; aOR 1.33, 95% CI 1.22-1.46), and home with home health care (11.3%, aOR 1.18, 95% CI 1.08-1.28). ConclusionsSocioeconomic status and discharged destination affect readmission after stroke. These results provide evidence to inform vulnerable patient population as targets for readmission prevention.

Associations of Race, Insurance, and Zip Code-Level Income with Nonadherence Diagnoses in Primary and Specialty Diabetes Care.

Evidence suggests that clinicians may view or label patients as nonadherent in a biased manner. Therefore, we performed a retrospective cohort analysis exploring associations between patient demographics and zip code-level income with the International Classification of Diseases, Tenth Version (ICD-10) diagnoses for nonadherence among type 2 diabetes mellitus (T2DM) patients, comparing primary and specialty care settings. Providers in the primary care group included internal medicine and family medicine physicians. In the specialty care group, providers included endocrinologists and diabetologists only. Participants were identified from 5 primary care and 4 endocrinology sites in the University of Pennsylvania Health System between January 1, 2015, and January 1, 2019. Demographics, hemoglobin A1c (HbA1c), and ICD-10 codes for T2DM and nonadherence were extracted from the electronic health record and analyzed in October 2019. Log-binomial regression models were used to estimate patients' risk of nonadherence labeling by race, insurance, and zip code-level median household income, controlling for patient characteristics and HbA1c as a proxy for diabetes self-management. Results were compared between primary and specialty care sites. A total of 6072 patients aged 18-70 years were included in this study. Black race, Medicare, and Medicaid were associated with increased nonadherence labeling while controlling for patient characteristics ([ARR = 2.48, 95% CI: 2.01, 3.04], [ARR = 1.82, 95% CI: 1.50, 2.18], [ARR = 1.61, 95% CI: 1.32, 1.93], respectively). The results remained significant on adjustment with zip code-level income and showed no differences between primary and specialty sites. Lower-income zip codes showed a significant association with increased rates of nonadherence labeling. Black race, non-private insurance, and lower-income zip codes were associated with disproportionately high rates of nonadherence labeling in both primary and specialty management of T2DM, possibly suggestive of racial or class bias.

Socioeconomic barriers to prenatal diagnosis of critical congenital heart disease.

The study was designed to assess the impact of socioeconomic barriers on the rate of prenatal diagnosis of critical congenital heart disease (CCHD). This was a retrospective review of the Medicaid analytic extract (MAX) dataset, a national Medicaid administrative claims database with linked maternal-infant claims, from 2007 to 2012. Infants with CCHD were identified by searching for International Classification of Diseases (ICD) 9 codes and Procedural Coding System (PCS) codes for CCHD within the first 6 months after the delivery date. Multivariate logistic regression was used to evaluate the effect of maternal and socioeconomic factors on the prenatal diagnosis rate. There were 4702 mother-infant dyads included in the analysis. The prenatal diagnosis rate of CCHD was 27.9%. Factors independently associated with odds of prenatal diagnosis of CCHD were presence of maternal diabetes (OR, 2.055; P < .001), ZIP code level median household income (OR, 1.005; P = .015), sonographer labor quotient (OR, 1.804; P = .047), the year of the delivery (OR, 1.155; P < .001), and needing a view other than a 4 chamber or outflow tract view to obtain the diagnosis (OR, 0.383; P < .001). Maternal health, diabetes, socioeconomic factors, and access to sonographers impacts prenatal diagnosis of CCHD.

What Are the Risk Factors for 48 or More–Hour Stay and Nonhome Discharge After Total Knee Arthroplasty? Results From 151 Illinois Hospitals, 2016-2018

BackgroundBundled payment programs and the Centers for Medicare and Medicaid Services removal of total knee arthroplasty (TKA) from the inpatient-only list potentially incentivize avoiding patients with extended length of stay (eLOS) and nonhome discharge (NHD). We aimed to describe which patients are most at risk of eLOS (>2 days), very eLOS (veLOS; >4 days), and NHD. MethodsAdmissions for unilateral TKAs at 151 Illinois nonfederal hospitals from January 2016 to June 2018 were selected from the Illinois Hospital and Health Systems Association COMPdata administrative hospital discharge database. Records included patient age, race and ethnicity, Illinois region, insurance status, principal diagnosis, and date of procedure. Zip code level median household income, Charlson comorbidity index, and obesity status were computed. Hospitals were characterized through their bundled payment participation status, academic status, and annual knee replacement volume. Poisson regression was used to test the associations between patient and hospital characteristics and the likelihood of eLOS, veLOS, and NHD. ResultsOf the 72,359 admissions included, 25.0% had an NHD, 41.1% had eLOS, and 4.0% veLOS. Female patients, those 75 years old or more as compared to those 65-74 years old, non-Hispanic blacks, Hispanics and Asians versus non-Hispanic whites, Medicaid/uninsured patients versus those privately insured, obese patients, those with nonzero Charlson comorbidity index, and those treated at low-volume hospitals (<200 TKAs/year vs >600 TKAs/year) were more likely to have eLOS, veLOS, and/or NHD (P < .05). ConclusionArthroplasty surgeons may be incentivized to avoid the abovementioned patient groups due to bundled payment programs and recent Centers for Medicare and Medicaid Services legislation.

Incidence and Risk Factors of Second Malignancies Among Medicare Beneficiaries with Newly-Diagnosed Philadelphia Chromosome-Negative Classical Myeloproliferative Neoplasms Receiving Cytoreductive Therapy with Hydroxyurea

Incidence and Risk Factors of Second Malignancies Among Medicare Beneficiaries with Newly-Diagnosed Philadelphia Chromosome-Negative Classical Myeloproliferative Neoplasms Receiving Cytoreductive Therapy with Hydroxyurea

Association of Race and Poverty With Mortality Among Nursing Home Residents on Maintenance Dialysis

ObjectivesThe association of race, ethnicity, and socioeconomic factors with survival rates of nursing home (NH) residents with treated end-stage renal disease (ESRD) is unclear. We examined whether race/ethnicity, ZIP code–level, and individual-level indicators of poverty relate to mortality of NH residents on dialysis. DesignRetrospective cohort study. Participants/SettingUsing the United States Renal Data System database, we identified 56,194 nursing home residents initiated on maintenance dialysis from January 1, 2007 through December 31, 2013, followed until May 31, 2014. MeasurementsWe evaluated baseline characteristics of the NH cohort on dialysis, including race and ethnicity. We assessed the Medicare-Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code–level median household income (MHI) data. We conducted Cox regression analyses with all-cause mortality as the outcome variable, adjusted for clinical and sociodemographic factors including end-of-life preferences. ResultsAdjusted Cox analysis showed a significantly lower risk of death among black vs nonblack NH residents [adjusted hazard ratio (AHR) 0.91, 95% confidence interval (CI) 0.89, 0.94]. Dual-eligibility status was significantly associated with lower risk of death compared to those with Medicare alone (AHR 0.80, 95% CI 0.78, 0.82). Compared to those in higher MHI quintile levels, NH ESRD patients in the lowest quintile were significantly associated with higher risk of death (AHR 1.09, 95% CI 1.06, 1.13). Conclusions/ImplicationsBlack and Hispanic NH residents on dialysis had an apparent survival advantage. This “survival paradox” occurs despite well-documented racial/ethnic disparities in ESRD and NH care and warrants further exploration that could generate new insights into means of improving survival of all NH residents on dialysis. Area-level indicator of poverty was independently associated with mortality, whereas dual-eligibility status for Medicare and Medicaid was associated with lower risk of death, which could be partly explained by improved access to care.

Impact of poverty and race on pre-end-stage renal disease care among dialysis patients in the United States.

BackgroundAccess to nephrology care prior to end-stage renal disease (ESRD) is significantly associated with lower rates of morbidity and mortality. We assessed the association of area-level and individual-level indicators of poverty and race/ethnicity on pre-ESRD care provided by nephrologists.MethodsIn this retrospective cohort study using the US Renal Data System database, we identified 739 537 patients initiated on maintenance dialysis from 1 January 2007 through 31 December 2012. We assessed the Medicare–Medicaid dual eligibility status as an indicator of individual-level poverty and ZIP code–level median household income (MHI) data obtained from the 2010 US census. We conducted multivariable logistic regression of pre-ESRD nephrology care as the outcome variable.ResultsAmong patients in the lowest area-level MHI quintile, 61.28% received pre-ESRD nephrology care versus 67.68% among those in higher quintiles (P < 0.001). Similarly, the proportions of dual-eligible and nondual-eligible patients who had pre-ESRD nephrology care were 61.49 and 69.84%, respectively (P < 0.001). Patients in the lowest area-level MHI quintile were associated with significantly lower likelihood of pre-ESRD nephrology care (adjusted odds ratio [aOR] 0.86 [95% confidence interval (CI) 0.85–0.87]) compared with those in higher quintiles. Both African American (AA) and Hispanic patients were significantly less likely to have received pre-ESRD nephrology care [aOR 0.85 (95% CI 0.84–0.86) and aOR 0.72 (95% CI 0.71–0.74), respectively].ConclusionsIndividual- and area-level measures of poverty, AA race and Hispanic ethnicity were independently associated with a lower likelihood of pre-ESRD nephrology care. Efforts to improve pre-ESRD nephrology care may require focusing on the poor and minority groups.

Predictors and Outcomes of Pediatric Firearm Injuries Treated in the Emergency Department: Differences by Mechanism of Intent.

Firearm injuries among children are a major clinical and public health concern and one of the leading causes of pediatric fatalities. Our objective was to investigate differences in predictors and clinical outcomes between self-inflicted, violent, and unintentional pediatric firearm injuries for patients who present to pediatric emergency departments (EDs). We conducted a retrospective study of patients 0 to 21 years old treated in 37 pediatric academic EDs from 2004 to 2014. Patients were classified into the injury intent categories of self-inflicted, violent, and unintentional firearm injury using the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnoses and external causes of injury codes. Multivariable multinomial regression models compared groups. We identified 9,628 firearm injuries from 2004 to 2014: 109 (1%) self-inflicted, 2,394 (25%) violent, and 7,125 (74%) unintentional. Male sex, increasing age, nonwhite race, public insurance, residing in an urban zip code, and lower zip code-level median household income were all independently associated with violent firearm injuries, relative to self-inflicted and unintentional injuries. Self-inflicted injuries were at the highest risk for hospital admission, death, intensive care unit services, surgical services, and increased length of stay, followed by violent injuries with intermediate risk and unintentional injuries at the lowest risk Self-inflicted, violent, and unintentional firearm injuries in children had distinct demographic risk factors and clinical and utilization outcomes. Targeted prevention and intervention efforts should be developed to reduce the incidence and severity of these injuries.

Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients

Background: The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD. Methods: In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 2012. We assessed the Medicare-Medicaid dual-eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable. Results: The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p < 0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage. Conclusions: Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.

Population income and longitudinal trends in living kidney donation in the United States.

Living kidney donation is declining in the United States. We examined longitudinal trends in living donation as a function of median household income and donor relation to assess the effect of financial barriers on donation in a changing economic environment. The zip code-level median household income of all 71,882 living donors was determined by linkage to the 2000 US Census. Longitudinal changes in the rate of donation were determined in income quintiles between 1999 and 2004, when donations were increasing, and between 2005 and 2010, when donations were declining. Rates were adjusted for population differences in age, sex, race, and ESRD rate using multilevel linear regression models. Between 1999 and 2004, the rate of growth in living donation per million population was directly related to income, increasing progressively from the lowest to highest income quintile, with annualized changes of 0.55 (95% confidence interval [95% CI], 0.14 to 1.05) for Q1 and 1.77 (95% CI, 0.66 to 2.77) for Q5 (P<0.05). Between 2005 and 2010, donation declined in Q1, Q2, and Q3; was stable in Q4; and continued to grow in Q5. Longitudinal changes varied by donor relationship, and the association of income with longitudinal changes also varied by donor relationship. In conclusion, changes in living donation in the past decade varied by median household income, resulting in increased disparities in donation between low- and high-income populations. These findings may inform public policies to support living donation during periods of economic volatility.

Disparities in Access to Lung Transplantation for Patients with Cystic Fibrosis by Socioeconomic Status

Although previous studies suggest that access to care for patients with cystic fibrosis (CF) does not vary appreciably by socioeconomic status (SES), disparities with respect to access to lung transplantation for patients with CF are largely unknown. To determine whether access to lung transplantation for patients with CF differs according to SES. Observational study involving 2,167 adult patients with CF from the CF Foundation Patient registry who underwent their first lung transplant evaluation between 2001 and 2009. The primary outcome was acceptance for lung transplant after initial evaluation. The main SES indicator was Medicaid status. Alternate SES indicators included race, educational attainment, ZIP code-level median household income, and driving time from residence to closest lung transplant center. The odds that Medicaid recipients were not accepted for lung transplant were 1.56-fold higher (95% confidence interval [CI], 1.27-1.92) than patients without Medicaid, after multivariate adjustment for demographic characteristics, disease severity, and potential contraindications to lung transplant, and before or after use of the lung allocation score. This association was independent of other SES indicators, including race, educational attainment, ZIP code-level median household income, and driving time to closest transplant center (odds ratio [OR] = 1.37; 95% CI, 1.10-1.72). Patients not completing high school (OR = 2.37; 95% CI, 1.49-3.79) and those residing in the lowest (vs. highest) ZIP code median household income category (OR = 1.39; 95% CI, 1.01-1.93) also experienced a higher odds of not being accepted for lung transplant in multivariate analysis. In this nationally representative study of adult patients with CF, multiple indicators of low SES were associated with higher odds of not being accepted for lung transplant.

Hospital Variation in Readmission After Coronary Artery Bypass Surgery in California

Readmissions are common after coronary artery bypass grafting (CABG) surgery and account for a significant percentage of hospital healthcare costs. Readmission rates also vary widely between hospitals, but the reasons for this variation have not been studied previously. We linked 2009 California CABG clinical registry data to hospital discharge data for 2009 and 2010 to identify 30-day readmissions for all patients undergoing isolated CABG surgery. Both standard and hierarchical logistic models were developed to predict readmission risk and explore sources of hospital readmission variation. Among 11 823 patients discharged alive after isolated CABG in 2009, 1565 (13.2%) patients were readmitted within 30 days of surgery. Heart failure and postoperative infections were the most frequent reasons for readmission (15.3% and 12.9%, respectively). Multiple patient risk factors, including age, sex, and lower zip code-level median household income, were significant predictors of readmission (all adjusted odds ratios >1.0; P<0.05). The readmission rates among the 119 hospitals performing CABG varied from 0% to 26.9%. Compared with hospitals in lower quartiles for readmission, hospitals in higher quartiles had a significantly higher readmission rates due to circulatory diseases, infections, complications for surgical and medical care and digestive diseases (all P<0.05). In a hierarchical model, including several hospital characteristics, hospital-level variables did not predict readmission risk (all P>0.05, with an intraclass correlation of 0.004 for hospitals). California hospitals performing CABG surgery vary widely in 30-day readmission rates. Patient demographic and clinical risk factors, rather than measured hospital characteristics, accounted for most of the observed hospital-level variation in CABG readmissions.

Is socioeconomic status associated with awareness of and receptivity to the truth ® Campaign?

Background The truth ® campaign is credited with preventing approximately 450,000 youth from starting to smoke, from 2000 through 2004 [Farrelly, M.C., Nonnemaker, J., Davis, K.C., Hussin, A., 2009. The Influence of the National truth ® Campaign on Smoking Initiation. Am. J. Prev. Med. February 9 [Epub ahead of print]]. However, no research has been conducted to determine whether lower socioeconomic status (SES) youth benefit equally from the campaign. This study examines whether socioeconomic status is associated with awareness of and receptivity to the truth ® campaign among youth ages 12–17. Methods This study is based on seven waves of Legacy Media Tracking Survey (LMTS) data, collected from September 2000 through January 2004 ( n = 30,512). LMTS is a nationally representative, cross-sectional telephone survey. Median household income and median household education at the zip code level were appended to the LMTS data. Results Females had lower levels of confirmed awareness of the truth ® campaign as compared with males. Youth who lived in lower education zip codes were less likely to have confirmed campaign awareness as compared with those in higher education zip codes. Zip code level median household income was not associated with confirmed awareness. Receptivity to the campaign was not associated with zip code level median household income or education. Conclusions These findings suggest that the effectiveness of the truth ® campaign could be enhanced by developing strategies to increase campaign awareness among females and youth from lower education zip codes. Increased campaign exposure within these populations could result in lower smoking rates and, ultimately, lower rates of tobacco-related disease.

Évaluation de la prise en charge initiale des entorses graves du genou (à propos d’une étude prospective faite aux urgences du CHU de brest)

Bundled payment programs and the Centers for Medicare and Medicaid Services removal of total knee arthroplasty (TKA) from the inpatient-only list potentially incentivize avoiding patients with extended length of stay (eLOS) and nonhome discharge (NHD). We aimed to describe which patients are most at risk of eLOS (>2 days), very eLOS (veLOS; >4 days), and NHD.Admissions for unilateral TKAs at 151 Illinois nonfederal hospitals from January 2016 to June 2018 were selected from the Illinois Hospital and Health Systems Association COMPdata administrative hospital discharge database. Records included patient age, race and ethnicity, Illinois region, insurance status, principal diagnosis, and date of procedure. Zip code level median household income, Charlson comorbidity index, and obesity status were computed. Hospitals were characterized through their bundled payment participation status, academic status, and annual knee replacement volume. Poisson regression was used to test the associations between patient and hospital characteristics and the likelihood of eLOS, veLOS, and NHD.Of the 72,359 admissions included, 25.0% had an NHD, 41.1% had eLOS, and 4.0% veLOS. Female patients, those 75 years old or more as compared to those 65-74 years old, non-Hispanic blacks, Hispanics and Asians versus non-Hispanic whites, Medicaid/uninsured patients versus those privately insured, obese patients, those with nonzero Charlson comorbidity index, and those treated at low-volume hospitals (<200 TKAs/year vs >600 TKAs/year) were more likely to have eLOS, veLOS, and/or NHD (P < .05).Arthroplasty surgeons may be incentivized to avoid the abovementioned patient groups due to bundled payment programs and recent Centers for Medicare and Medicaid Services legislation.