Diagnostic Disparities Research Articles

Meta-analysis of Black vs. White racial disparity in schizophrenia diagnosis in the United States: Do structured assessments attenuate racial disparities?

Researchers have repeatedly observed that clinicians diagnose Black individuals with schizophrenia at greater rates than White individuals. We conducted a meta-analytic review to quantify the extent of racial diagnostic disparities in schizophrenia, examine whether structured-interview assessments attenuate these disparities, and assess for moderating factors. Studies were included that presented original probability-sample data and reported data sufficient to derive odds ratios and 95% confidence intervals (CIs) for schizophrenia diagnosis by race. In total, 14 studies using structured-interview diagnostic assessments and 41 studies using unstructured assessments met our inclusion criteria. Substantial heterogeneity was observed, but there was little evidence of publication bias. Inverse heterogeneity models showed that Black individuals were diagnosed with schizophrenia at greater rates than White individuals across all studies (OR = 2.42, 95% CI [1.59, 3.66]) as well as in studies using unstructured (OR = 2.43, 95% CI [1.59, 3.72]) and structured-instrument (OR = 1.77, 95% CI [1.31, 2.38]) diagnostic assessments. Studies using structured-instrument diagnostic assessments did not show statistically attenuated odds ratios compared with studies using unstructured assessments. Metaregression analyses indicated higher disparities in studies with higher proportions of White patients or lower average patient age; evidence was equivocal as to the effect of study setting (e.g., hospital vs. community clinic) and geographic region on racial disparities. Overall, racial diagnostic disparity in schizophrenia represents a robust albeit heterogeneous clinical phenomenon that has been stable over the past 3 decades; structured-instrument assessments do not fully mitigate these disparities, but power analysis suggests they may have a small effect. (PsycINFO Database Record

Racial Disparities in the Diagnosis and Treatment of Pancreatic Cancer

Introduction: Pancreatic cancer (PC) is the 4th leading cause of cancer death in the United States with very poor overall survival. African Americans (AA) belong to a subset of the population with the highest incidence of pancreatic cancer with incidence of 14.8 per 100,000 among AA men and 8.8 per 100,000 persons in the general population. Many population studies have found that AA and those with low socioeconomic status have an independent risk factor for pancreatic cancer mortality. This study aimed to investigate the degree of disparity in the diagnosis and treatment of pancreatic cancer among our urban minority patient population. Methods: This was an observational retrospective chart review of pancreatic cancer patients at the Brooklyn Hospital Center from 01/01/1990 to 11/30/2016, who were all of low socioeconomic status and predominantly African American ethnicity. Exclusion criteria were subjects less than 18 years of age, and those with incomplete medical documentation. Patients diagnosed with pancreatic cancer were assessed for race, stage of diagnosis, and treatment option received. Results: 103 patients were analyzed in which 76% (78/103) were AA and 24% (25/103) were non-AA. 45% (35/78) AA patients were diagnosed with pancreatic cancer at stage 4 with distant metastases. All other pancreatic cancers were found at earlier stages in a loco-regional area of the pancreas. Among non-AA, 48% (12/25) were detected at stage 4 with distant metastases. Patients were also analyzed for treatment disparity. AA diagnosed with pancreatic cancer received treatment 62% (48/78) of the time compared to non-AA who received treatment 70% (18/25) of the time with either surgery, chemotherapy, radiation, or surgery with adjuvant chemotherapy. Conclusion: Our study showed no major difference in the late stage detection of pancreatic cancer amongst AA and those of other races. In fact, AA patients had a slightly lower rate of late stage diagnosis. This data did not show much of a diagnostic disparity, which is different from documented studies in the literature. Our data however suggests a relative treatment disparity of about 8% between the two groups. Studies have shown that AA patients often refuse treatment for unknown reasons. Various socioeconomic or lifestyle causes could be reasons for treatment refusal. Our study showed that if low socioeconomic status populations have accessible quality healthcare, pancreatic cancer treatment disparities can be improved.

Abstract 1784: Disparities in pediatric leukemia incidence and survival: a population-based cancer registry analysis comparing Thailand and the United States

Abstract Background: Pediatric leukemia incidence and survival varies worldwide. This variability may be due to differences in genetics, environmental factors, and access to treatment and diagnosis. However, more work is needed to elucidate patterns of pediatric leukemia in developing countries including Thailand. Therefore, we analyzed pediatric leukemia incidence and survival trends in children age 0-19 years from 1990-2011 in Thailand and compared these results to United States (US) data. We evaluated the following pediatric leukemia subtypes: acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). Methods: We extracted pediatric leukemia cases from five provincial population-based cancer registries in Thailand (n = 1,245). Cases from the US were obtained from the Surveillance, Epidemiology, and End Results program (n = 6,738). We computed age-standardized incidence rates (ASIR) using the WHO 2000 standard population and relative survival using the Ederer II method and estimated survival functions using the Kaplan-Meier method. We evaluated temporal changes in incidence and survival by year of diagnosis and estimated annual percent changes using joinpoint regression. Results: While the ASIR of ALL was lower in Thailand compared to the US (21.1 vs. 31.2 cases per million), the ASIR of AML was similar between Thailand and the US (7.7 vs. 7.7 cases per million). The proportion of ALL and AML diagnosed in Thailand was 60% (n = 746) and 23% (n = 284), respectively, vs. 75% (n = 5,080) and 19% (n = 1,267) in the US (p<0.001). The mean age at diagnosis was significantly older in Thailand compared to the US for both ALL (7.2 vs. 6.5 years, p <0.001) and AML (9.9 vs. 9.0 years, p = 0.047). ALL incidence increased by 1.5% per year in Thailand (p = 0.015) while it increased by 0.9% per year in the US (p = 0.003). AML incidence increased by 2.3% per year in Thailand (p = 0.047) while it remained constant in the US. Five-year survival significantly improved in Thailand between the first (1990-2000) and second half (2001-2011) of our study period for both AML (19% to 29%, p = 0.009) and ALL (45% to 55%, p = 0.001). ALL and AML five-year survival was 86% and 54% in the US. ALL survival increased by 1.5% per year in Thailand (p = 0.022) while it increased by 0.7% per year in the US (p <0.001). AML survival increased by 1.8% per year in the US (p <0.001). Due to variability in survival by year, no trend was identified in Thailand. Conclusion: The incidence of both ALL and AML increased more rapidly in Thailand than in the US from 1990-2011. While five-year survival for pediatric leukemia improved in Thailand, it was much lower than in the US. These disparities in incidence and survival warrant: 1) investigating novel population risk factors for pediatric leukemia, especially AML, in Thailand and 2) identifying diagnostic and treatment disparities to address the survival gap between Thailand and the US. Citation Format: Kathryn Demanelis, Hutcha Sriplung, Rafael Meza, Surapon Wiangnon, Laura S. Rozek, Michael E. Scheurer, Philip J. Lupo. Disparities in pediatric leukemia incidence and survival: a population-based cancer registry analysis comparing Thailand and the United States. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1784.

Factors that Influence Autism Knowledge in Hispanic Cultures: a Pilot Study.

Although the diagnosis of autism spectrum disorder (ASD) is rising, Hispanic children are diagnosed at a disproportionately lower rate compared to other ethnic and racial groups. Lack of ASD knowledge in the Hispanic community may contribute to this disparity. The study objective was to determine whether sociocultural and environmental factors linked to ASD diagnostic disparities were related to Hispanic parents' ASD knowledge. A 60-item survey assessing demographic information, acculturation, religiosity, social support, and ASD knowledge was administered to 64 Hispanic patients (84% female; 76% uninsured; 82% Catholic) visiting a southwest clinic. Socioeconomic status (SES), social support, language of questionnaire, spiritual attribution of child diagnosis, and religious importance predicted ASD knowledge, accounting for 43% of variance. Results contribute to understanding how sociocultural and environmental factors influence ASD knowledge within at-risk Hispanic individuals, which can be used to improve information dissemination and ultimately reduce disparity in ASD services.

The Influence of Demographic Factors on the Identification of Autism Spectrum Disorder: A Review and Call for Research

Autism spectrum disorder (ASD) diagnoses are made based on a pattern of behavioral symptoms, yet a growing body of research indicates that when, and indeed whether, an individual receives a diagnosis of ASD is influenced by myriad demographic factors including race, ethnicity, socioeconomic status (SES), and parental education level. The current manuscript provides a focused review of a subset of existing literature chosen to demonstrate how demographic factors may be related to the identification of individuals with ASD within the United States. Several possible explanations for existing disparities are discussed, along with clinical implications for professionals working with children from diverse backgrounds who are suspected of having ASD. Additional research in this area is needed to facilitate development of effective means to eliminate the diagnostic disparities.

Abstract P5-02-10: Factors influencing agreement of Ki67 labeling index between core needle biopsy and surgical resection specimens

Abstract Reliable determination of Ki67 labeling index (Ki67 LI) on core needle biopsy specimens (CNB) is essential for determining breast cancer intrinsic subtype (IST), preoperative treatment decisions and short-term treatment response during neoadjuvant therapy. However, analyses investigating robustness of Ki67 LI assessment upon repeated tumor biopsies are scarce and results of studies investigating agreement of KI67 LI between CNB and surgical resection (SR) specimens are conflicting. In the present study, we analysed the role of clinical and pathological factors in influencing concordance of Ki67 LI between CNB and SR specimens. 502 matched pairs of CNB and SR specimens of patients with invasive ER-positive, HER2-negative breast cancer were included in our study. Ki67 LI was determined according to recent recommendations. Luminal B disease was defined by Ki67 LI > 20% according to SR. Ki67 LI values were considered concordant by a divergence of 10% points. Agreement was calculated by Cohen's kappa. Associations with clinicopathological factors were analyzed by Chi square test and logistic regression. Factors investigated included age, menopausal status, CNB method, BIRADS assessment category of imaging abnormality, time between CNB and SR, extent of surgery, histological grade (including individual grading score components according to Elston and Ellis), tumor size, lymph node stage, estrogen- (ER), progesterone- (PR) and HER2-receptor status. A cutoff value of 20% for KI67 LI in SR demonstrated a sensitivity of 90% and a specificity of 60% for identifying luminal B breast cancer in CNB. Upon investigating measurement agreement, we found substantial agreement of Ki67 LI between CNB and SR specimens with a weighted kappa value of 0.837. IST assesment in CNB and SR showed only moderate concordance with a kappa value of 0.587. Concordant diagnosis of IST in CNB and SR was significantly associated with PR expression and histological grade (p>0.05). Agreement of Ki67 LI was higher in tumors expressing low and high levels of PR compared to tumors with intermediate PR score. 27% and 22% of low and intermediate grade breast cancers showed discordant IST in CNB and SR, respectively. In contrast, only 3% of high grade breast cancers differed regarding IST upon repeated measurements. Interestingly, concordance of IST was significantly associated with all separate grading score components in CNB samples such as extent of glandular differentiation (p=0.015), nuclear polymorphism (p=0.005) and number of mitotic figures (p>0.001). We conclude that agreement of breast cancer IST according to Ki67 LI between CNB and SR specimens is significantly influenced by histological tumor grade and PR status. These factors, including all three grading score components are likely to mirror tumor heterogeneity that might compromise obtaining a CNB sample representative of the entire tumor. Our results cast a doubt upon robustness of single CNB-driven measurements of prognostic indicators and outcome predictors in estrogen-receptor positive breast cancer of low or intermediate histological grade. Whether molecular testing of CNB specimens improves classification of luminal breast cancer and helps resolve diagnostic disparities remains to be determined. Citation Format: Zsuzsanna Bago-Horvath, Fabian Roessler, Philipp Wimmer, Martina Mittlboeck, Nicolas Kozakowski, Katja Pinker-Domenig, Rupert Bartsch, Peter Dubsky, Martin Filipits, Margaretha Rudas. Factors influencing agreement of Ki67 labeling index between core needle biopsy and surgical resection specimens [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-02-10.

Diagnostic disparity of previous and revised American Thoracic Society guidelines for idiopathic pulmonary fibrosis.

A revised guideline for the diagnosis of idiopathic pulmonary fibrosis (IPF) was formulated by the American Thoracic Society (ATS) in 2011 to improve disease diagnosis and provide a simplified algorithm for clinicians. The impact of these revisions on patient classification, however, remain unclear. To examine the concordance between diagnostic guidelines to understand how revisions impact patient classification. A cohort of 54 patients with either suspected IPF or a working diagnosis of IPF was evaluated in a retrospective chart review, in which patient data were examined according to previous and revised ATS guidelines. Patient characteristics influencing the fulfillment of diagnostic criteria were compared using one-way ANOVA and χ(2) tests. Revised and previous guideline criteria for IPF were met in 78% and 83% of patients, respectively. Revised guidelines modified a classification based on previous guidelines in 28% of cases. Fifteen percent of patients meeting previous ATS guidelines failed to meet revised criteria due to a lack of honeycombing on high-resolution computed tomography and the absence of a surgical lung biopsy. Patients failing to meet previous and revised diagnostic criteria for IPF were younger. The revised guidelines for the diagnosis of IPF classify a substantial proportion of patients differently than the previous guidelines.

Age at first autism spectrum disorder diagnosis: the role of birth cohort, demographic factors, and clinical features.

This study sought to identify factors that may be associated with delays in autism spectrum disorder (ASD) diagnosis, including birth cohort, sociodemographic characteristics, and clinical features. Participants included 1716 children and adolescents with ASD enrolled in the Autism Speaks Autism Treatment Network (AS-ATN) between the years 2008 and 2011. Data were collected at enrollment using AS-ATN parent- and clinician-report forms and standardized measures of I.Q., ASD symptoms, adaptive function, and psychiatric symptoms. Age at first ASD diagnosis was positively correlated with current age, suggesting a birth cohort effect. Sociodemographic and clinical features were also associated with age at diagnosis, even after controlling for current age. Hierarchical linear regression results showed that older current age, lower socioeconomic status (SES), higher I.Q. score, and lower levels of autism symptoms were associated with later age at initial diagnosis. There was also a significant interaction between current age and I.Q., with higher functioning children being diagnosed at younger ages than in previous years. Early diagnosis of ASD is critically important for improving access to interventions; however, many children experience diagnostic delays. In this sample, children from the most recent birth cohorts were diagnosed earlier, suggesting that early signs of ASD are being increasingly recognized. However, socioeconomic barriers to diagnosis still seem to exist. Children with less severe ASD symptoms and with higher I.Q. are also diagnosed at later ages. Efforts are still needed to reduce diagnostic disparities for families of low SES and to improve early recognition of more subtle symptoms.

Disparities in counseling female cancer patients for fertility preservation: adding insult to injury?

Disparities in counseling female cancer patients for fertility preservation: adding insult to injury?

Barriers to palliative care research for emergency department patients with advanced cancer.

Patients with advanced cancer often visit the emergency department (ED). Little is known about their willingness or ability to engage in palliative care research, although enrollment in clinical trials of other seriously ill ED patients—those with stroke, for example—has been shown to be feasible. To identify barriers to the enrollment of ED patients with advanced cancer in palliative care research. We prospectively tracked factors that affected patient accrual into a trial of palliative care for adults with metastatic solid tumors at an urban, academic ED. Research staff screened the electronic medical records for patients admitted to the hospital with metastatic solid tumors 8-12 hours a day, Monday through Friday. The ED attending of record and the patient's medical oncologist had to agree before research staff invited the patient to participate. Informed consent was obtained at the bedside in the ED, and patients were offered a $20 incentive to participate. Attempts were made to enroll 150 eligible patients in the study, and 73 were enrolled (49% enrollment rate). Barriers to enrollment for the 77 patients who did not participate were deduced from the field notes and placed into the following categories: patient refusal (n = 38, 49%), diagnostic uncertainty regarding cancer stage (n = 11, 14%), symptom burden (n = 9, 12%), family refusal (n = 7, 9%), physician refusal (n = 7, 9%), and/or patient unaware of illness or stage (n = 5, 7%). The findings are descriptive and do not test predetermined hypotheses. Patient refusal, symptom burden, and diagnostic disparities are common barriers encountered when recruiting ED patients with advanced cancer. Despite the barriers, recruitment was feasible for such ED patients. This study was funded by a Mentored Research Scholar Grant from the American Cancer Society (Dr Grudzen), a Medical Student Training in Aging Research Grant from the American Federation on Aging (Mr Kandarian), and by a Mid- Career Investigator Award in Patient Oriented Research (K24 AG022345) from the National Institute on Aging (Dr Morrison).

Evaluating Teaching Techniques in the Hmong Breast and Cervical Cancer Health Awareness Project

Cancer health disparities are a reality for Hmong women who are often diagnosed at a later stage and have low literacy and experienced care that are not culturally appropriate. Lack of attention to cultural appropriateness and literacy levels of cancer screening materials may contribute to disproportionately low levels of cancer screening among Hmong women. The purposes of this study were to evaluate the Hmong Health Awareness Project (HHAP), a program designed to create awareness and acceptance of breast and cervical cancer screening, and to examine participants' perceptions of the utility of the content of the workshops. Hmong researchers partnered with three Midwestern Hmong community centers to implement six workshops. Three teaching techniques: pictographs, videos, and hands-on activities were utilized to teach Hmong participants about cancer screening. Participants included 150 Hmong (male participants = 30 and female participants = 120). Teach-back method was used to assess the participants' understanding of cancer screening throughout the workshops. Qualitative data were collected in focus groups to assess the feasibility of teaching methods and participants' perceptions of the utility of the content of the workshops. Directed content analysis was used to analyze participants' responses. The three teaching techniques were helpful in increasing the Hmong people's understanding about breast and cervical cancer screening. Nearly, all participants perceived an increased in their understanding, greater acceptance of cancer screening, and increased willingness to be screened. Men expressed support for screening after the workshops. Findings can guide future interventions to improve health communications and screening and reduce diagnostic disparities among Hmong and immigrant populations.

Racial, Ethnic, and Language Disparities in Early Childhood Developmental/Behavioral Evaluations

The U.S. Department of Health and Human Services has proposed “Increasing the proportion of children with mental health problems who receive treatment” as one of its Healthy People 2020 Objectives.(1) With high rates (2) and increasing prevalence of childhood behavioral and developmental (DB) conditions,(3–6) promptly identifying and treating these disorders is important so that children’s functional outcomes can be maximized. In addition, since long-term treatment of childhood DB conditions is expensive,(7–9) intervention in early childhood has the potential to produce large cost savings.(10) However, as with other areas of child health,(11, 12) racial/ethnic and language disparities exist in the diagnosis and treatment of early childhood DB conditions. For instance, compared to other children, African-American and Latino children are less likely to be diagnosed with an autism spectrum disorder (ASD), and are more likely to be diagnosed at older ages and with more severe symptoms.(13–18) Likewise, African-American and Latino children are less likely to be diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), and are less likely to be treated with a stimulant medication once diagnosed.(19–22) Table 1 summarizes recent peer-reviewed studies of diagnostic disparities in ASD and ADHD, two common early childhood developmental conditions. Similar disparities exist in the areas of overall developmental risk,(23) depression and mental health disorders,(24–26) use of psychotropic medications,(27) and use of mental health services.(28) These racial and ethnic disparities deserve increased attention given recent demographic trends: Census estimates suggest that the U.S. population younger than age 5 is nearly 50% racial/ethnic minority,(29) and some states are now “majority minority” for young children (30) Table 1 Racial and Ethnic Differences in Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) Diagnosis Rates

Structural Health and the Politics of African American Masculinity

This commentary describes ways in which notions of African American men's "health" attained by individual choice-embedded in the notion that African American men should visit doctors or engage in fewer risky behaviors-are at times in tension with larger cultural, economic, and political notions of "health." It argues that efforts to improve the health of Black men must take structural factors into account, and failure to do so circumvents even well-intentioned efforts to improve health outcomes. Using historical examples, the article shows how attempts to identify and intervene into what are now called social determinants of health are strengthened by addressing on-the-ground diagnostic disparities and also the structural violence and racism embedded within definitions of illness and health. And, that, as such, we need to monitor structural barriers to health that exist in institutions ostensibly set up to incarcerate or contain Black men and in institutions ostensibly set up to help them.

The influence of audit on the diagnosis of occlusal caries.

Audit is widely used to improve the quality of care in both medicine and dentistry but has not always been subject to systematic evaluation. The aim of this study was to assess the effect of an audit exercise on the diagnosis of occlusal caries. Using combined visual and radiographic methods. 11 dentists assessed 60 extracted molars for occlusal caries on two occasions. An audit exercise, in the form of a meeting, was carried out in the intervening period. Inter- and intra-examiner reproducibility were estimated for each of the two examinations. Validation was through a gold standard set up by sectioning the teeth. Wide diagnostic disparity was seen at both examinations, all inter- and intra-examiner kappa values were below 0.73. Intra-examiner kappa values increased significantly on the second occasion. Mean sensitivity and specificity were 0.65 and 0.74, respectively, at the first examination and 0.65 and 0.72 at the second. No changes were seen that could be attributed directly to the audit exercise but practising the diagnostic test appeared to be beneficial to intra-examiner reproducibility of diagnosis.

The Arthrogram in Diagnosis of Meniscal Lesions in the Fourth Decade of Life

Forty-nine patients older than 35 years of age (mean, 45 years) undergoing arthrotomy for clinically diagnosed meniscal tears had preoperative double-contrast arthrograms. Fifty of 53 meniscii were visualized as torn and treated by surgical excision. At the time of operation the incidence of transverse tears was high (34%). In only 72% of cases was there complete correlation between the preoperative arthrographic diagnosis and the definitive surgical diagnosis. This diagnostic disparity was most marked on the lateral side (53% correlation) and unrelated to the high incidence of transverse tears (66% correlation). In this age group, arthrography is not a reliable indicator to the diagnosis of torn meniscii.

Chinese diagnostic interview schedule. I. Agreement with psychiatrist's diagnosis.

NIMH-DIS was translated into Chinese and modified to the Chinese version of DIS (DIS-CM). One hundred clinical patients and 187 community subjects were studied for diagnostic agreement between the DIS-CM and the psychiatrist's clinical diagnosis. In the community sample, DIS-CM overdiagnosed the cases of manic episode, phobic disorder, obsessive-compulsive disorder and alcoholic problem, while it underdiagnosed the cases of tobacco dependence in the community sample and manic episode in the clinical cases. Standard diagnostic criteria, method of symptom detection, and social desirability, were identified as the major factors contributing to the diagnostic disparity. Variables related to life situations, language habit and medical histories were also analysed to test the external validity of the DIS-CM in case identification. The results affirm that the DIS-CM is reliable as a psychiatric epidemiological tool.