Socioeconomic Disparities In Outcomes Research Articles

Language diversity, gender inequality, and aggregate productivity in Canada

AbstractIdentifying sources of barriers to occupational mobility is central to evaluating the efficiency of the labor market. In this paper, we present an augmented Roy model in which workers self‐select into occupations, subject to labor market barriers that are specific to their socio‐linguistic group. Our findings provide evidence of differences in labor market outcomes across gender and linguistic groups in Canada. We argue that these differences could be attributed to barriers to labor mobility and that the reduction of these disparities would result in higher aggregate productivity in the country. In the augmented Roy model, the frictions result in inefficient allocation of labor across occupations. The study quantifies the change in aggregate productivity that would result from reducing the friction. The elimination of the frictions increased aggregate output on average by 6.2% and 4.4% in 1991 and 2011, respectively. This finding highlights the importance of reducing language barriers and gender inequality in the labor market. We provide policy recommendations for mitigating the disparities in socioeconomic outcomes between gender and linguistic groups.

Pediatric Cataract: Disparately Blinding Globally and in the United States

ABSTRACT Childhood cataract is a complex condition requiring longitudinal care, including early diagnosis, timely referral to a specialist, early surgical intervention, and dedicated postoperative care. Adherence to refractive correction and amblyopia therapy are critical for visual rehabilitation, even months to years after the cataract is removed. We review the impact of the social determinants of health on each step in the visual rehabilitation pathway for children with congenital and infantile cataracts. Children from socioeconomically marginalized backgrounds are more likely to experience delays in access to care and utilization of surgical services. They are also less likely to adhere to amblyopia therapy, with corresponding decrements in visual outcomes. Additional sociocultural factors, including parental stress, self-efficacy, and health literacy, pose barriers for these children. Standardizing clinical roles, improving health communication, managing parental stress, and implementing systemic policy changes may alleviate socioeconomic disparities in outcomes for children with cataracts.

The Impact of Neighborhood Socioeconomic Disadvantage on Operative Outcomes after Single-Level Lumbar Fusion

The relationship between socioeconomic status and neurosurgical outcomes has been investigated with respect to insurance status or median household income, but few studies have considered more comprehensive measures of socioeconomic status. This study examines the relationship between Area Deprivation Index (ADI), a comprehensive measure of neighborhood socioeconomic disadvantage, and short-term postoperative outcomes after lumbar fusion surgery. 1861 adult patients undergoing single-level, posterior-only lumbar fusion at a single, multihospital academic medical center were retrospectively enrolled. An ADI matching protocol was used to identify each patient's 9-digit zip code and the zip code-associated ADI data. Primary outcomes included 30- and 90-day readmission, emergency department visits, reoperation, and surgical complication. Coarsened exact matching was used to match patients on key demographic and baseline characteristics known to independently affect neurosurgical outcomes. Odds ratios (ORs) were computed to compare patients in the top 10% of ADI versus lowest 40% of ADI. After matching (n= 212), patients in the highest 10% of ADI (compared to the lowest 40% of ADI) had significantly increased odds of 30- and 90-day readmission (OR=5.00, P < 0.001 and OR=4.50, P < 0.001), ED visits (OR=3.00, P= 0.027 and OR=2.88, P= 0.007), and reoperation (OR=4.50, P= 0.039 and OR=5.50, P= 0.013). There was no significant association with surgical complication (OR=0.50, P= 0.63). Among otherwise similar patients, neighborhood socioeconomic disadvantage (measured by ADI) was associated with worse short-term outcomes after single-level, posterior-only lumbar fusion. There was no significant association between ADI and surgical complications, suggesting that perioperative complications do not explain the socioeconomic disparities in outcomes.

Letter to Editor Regarding "Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses".

Letter to Editor Regarding "Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses".

Identifying the origin of socioeconomic disparities in outcomes of major elective operations

BackgroundWhile the impact of socioeconomic status (SES) on surgical outcomes has been examined in limited series, it remains a significant determinant of healthcare outcomes at the national level. Therefore, the current study aims to determine SES disparities at three time-points: hospital accessibility, in-hospital outcomes, and post-discharge consequences. MethodsThe Nationwide Readmissions Database 2010–2018 was used to isolate major elective operations. SES was assigned using previously coded median income quartiles as defined by patient zip-code, with low SES defined as the lowest quartile and high SES as the highest. ResultsOf an estimated 4,816,837 patients undergoing major elective operations, 1,037,689 (21.3 %) were categorized as low SES and 1,288,618 (26.5 %) as high. On univariate analysis and compared to those of low SES, high SES patients were more frequently treated at high-volume centers (70.9 vs 55.6 %, p < 0.001), had lower rates of in-hospital complications (24.0 vs 29.0 %, p < 0.001) and mortality (0.4 vs 0.9 %, p < 0.001) as well as less frequent urgent readmissions at 30- (5.7 vs 7.1 %, p < 0.001) and 90-day timepoints (9.4 vs 10.7 %, p < 0.001). On multivariable analysis, high SES patients had higher odds of treatment at high-volume centers (Odds: 1.87, 95 % CI: 1.71–2.06), and lower odds of perioperative complications (Odds: 0.98, 95 % CI: 0.96–0.99), mortality (Odds: 0.70, 95 % CI: 0.65–0.75), and urgent readmissions at 90-days (Odds: 0.95, 95 % CI: 0.92–0.98). ConclusionThis study fills a much-needed gap in the current literature by establishing that all of the aforementioned timepoints include significant disadvantages for those of low socioeconomic status. Therefore, a multidisciplinary approach may be required for intervention to improve equity for surgical patients.

Socioeconomic Disparities in Outcomes Following Conservative Treatment of Spinal Epidural Abscesses.

Primary spinal epidural abscess (SEA) is a rare but serious pathology that may result in severe neurologic injury. While certain literature has identified medical risk factors for failure of conservative therapy, no current evidence has been published regarding socioeconomic risk factors associated with failure of medical therapy. A retrospective review was conducted of patients presenting with SEA from primary spinal infections. Patients presenting with magnetic resonance imaging evidence of SEA treated conservatively in the absence of neurologic deficits were included. Baseline clinical and socioeconomic characteristics were collected. Failure of medical management was defined as requiring surgical intervention despite maximal medical therapy due to the development of neurologic deficits or clinically significant deformity. A total of 150 patients were identified as presenting with magnetic resonance imaging evidence of SEAs without evidence of neurologic deficit. Of these patients, 42 required surgical intervention compared with 108 whose infection was successfully treated with medical therapy alone. Estimated average annual income was $64,746 vs $62,615 in those who successfully cleared their infection with medical management without requiring surgery, which was not statistically significant (P = 0.5). Insured patients were 5 times more likely to be successfully treated with antibiotics alone compared with uninsured patients (OR = 5.83, P = 0.008). Payer type, employment status, and incarceration status were not associated with failure of conservative therapy. In the treatment of primary SEA, absence of medical insurance is associated with failure of medical management. Payer status, employment status, average salary, and incarceration are not significant risk factors for failure of conservative management.

The Relationship Between Peripheral Arterial Disease Severity and Socioeconomic Status

Although socioeconomic disparities in outcomes of peripheral arterial disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship. Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005 - 2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses. There were 765,175 patients identified; 34% in the 1st MHI quartile and 18% in the 4th MHI quartile. Compared to patients in the 1st quartile, those in the 4th quartile were more likely White (69% vs. 42%, P <0.001), more likely ≥65 years old (75% vs. 62%, P <0.001), and were less likely to undergo amputations (25% vs. 34%, P <0.001). After adjusting for patient characteristics, the 4th quartile was associated with more severe disease [Odds ratio: 1.19, 95% CI: 1.11 - 1.27] compared to the 1st quartile.. While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.

Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease

Cardiovascular disease is the leading cause of pregnancy mortality. Socioeconomic and racial disparities in pregnancy are well established. Despite this, little is known about the impact of social determinants of health in pregnant patients with heart disease. This study aims to determine whether pregnant patients with heart disease living in lower income neighborhoods and managed at cardio-obstetrics programs have higher rates of cardiac events or preterm deliveries compared with those living in higher income neighborhoods. This is a retrospective cohort study of 206 patients between 2010 and 2020 at a quaternary care hospital in Northern California. The exposure was household income level based on neighborhood defined by the US Census data. Patients in lower income neighborhoods (N = 103) were 45% Hispanic, 34% White, and 14% Asian versus upper income neighborhoods (N = 103), which were 48% White, 31% Asian, and 12% Hispanic (p < 0.001). There was no significant difference in the rates of intrapartum cardiac events (10% vs. 4%; p = 0.16), postpartum cardiac events (14% vs. 17%; p = 0.7), and preterm delivery (24% vs. 17%; p = 0.23). The rates of antepartum hospitalization were higher for lower income neighborhoods (42% vs 22%; p = 0.004). While there is no significant difference in cardiac events and preterm delivery rates between patients from low versus high income neighborhoods, patients from lower income neighborhoods have higher antepartum hospitalization rates. Earlier identification of clinical deterioration provided by a cardio-obstetrics team may contribute to increased hospitalizations, which might mitigate socioeconomic disparities in outcomes for these pregnant patients with heart disease.

Mother to Newborn Transmission of SARS-CoV-2 Infection: Evolution of Evidence in 1.5 Years of COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) pandemic caused significant mortality and morbidity in people of all age groups worldwide. Given the uncertainty regarding the mode of transmission and potential effects of COVID-19 on pregnant mothers and their newborns, guidelines for taking care of maternal-newborn dyads have evolved tremendously since the pandemic began. There has been an enormous influx of published materials regarding the outcomes of mothers and newborns. Still, multiple knowledge gaps regarding comprehensive information about risk to the mothers and newborns exist, which need to be addressed. Current evidence suggests that mothers with symptomatic COVID-19 infection are at increased risk of severe illness during pregnancy, with a higher need for respiratory support and premature deliveries. Neonates born to mothers with COVID-19 are at increased risk of needing intensive care; however, most newborns do well after birth. As new mutant variants arise, we need to be cautious while proactively understanding any new evolving patterns. All leading health authorities strongly recommend COVID-19 vaccination before or during pregnancy to reduce the risk of maternal morbidities and benefit from passing antibodies to newborns prenatally and via breastmilk. Additionally, there are racial, ethnic, and socioeconomic disparities in outcomes and vaccination coverage for pregnant women. This article summarizes the rapidly evolving evidence for the last 1.5 years and aims to help health care professionals care for mothers with COVID-19 and their newborns. KEY POINTS: · COVID-19 in pregnancy can cause perinatal morbidities.. · Breastfeeding and breast milk are safe for newborns.. · COVID-19 vaccination reduces the risk for morbidities..

A Review of Thomas Sowell’s Discrimination and Disparities

In Discrimination and Disparities, Thomas Sowell describes how economists think about the causes of disparities in socioeconomic outcomes. He cautions against government intervention to reduce disparities, noting that such interventions often have unintended consequences. In this review, I discuss the role of economic theory and empirical evidence in helping move society toward more equitable outcomes. I find far more reason to be hopeful about the role of government than Sowell does, but also argue for more experimentation and rigorous evaluation to be sure that our well-intentioned policies have their intended impacts. (JEL D63, J15, J16, J71, J78)

Structural Racism and COVID-19 in the USA: a County-Level Empirical Analysis.

Substantial health disparities exist across race/ethnicity in the USA, with Black Americans often most affected. The current COVID-19 pandemic is no different. While there have been ample studies describing racial disparities in COVID-19 outcomes, relatively few have established an empirical link between these disparities and structural racism. Such empirical analyses are critically important to help defuse “victim-blaming” narratives about why minority communities have been badly hit by COVID-19. In this paper, we explore the empirical link between structural racism and disparities in county-level COVID-19 outcomes by county racial composition. Using negative binomial regression models, we examine how five measures of county-level residential segregation and racial disparities in socioeconomic outcomes as well as incarceration rates are associated with county-level COVID-19 outcomes. We find significant associations between higher levels of measured structural racism and higher rates of COVID-19 cases and deaths, even after adjusting for county-level population sociodemographic characteristics, measures of population health, access to healthcare, population density, and duration of the COVID-19 outbreak. One percentage point more Black residents predicted a 1.1% increase in county case rate. This association decreased to 0.4% when structural racism indicators were included in our model. Similarly, one percentage point more Black residents predicted a 1.8% increase in county death rates, which became non-significant after adjustment for structural racism. Our findings lend empirical support to the hypothesis that structural racism is an important driver of racial disparities in COVID-19 outcomes, and reinforce existing calls for action to address structural racism as a fundamental cause of health disparities.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40615-020-00948-8.

Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association

The American Pediatric Surgical Association (APSA) is a professional organization composed of over 1500 members dedicated to providing high-quality surgical care to infants and children. The organization was founded in 1969 with the mission to “ensure optimal pediatric surgical care of patients and their families, to promote excellence in the field, and to foster a vibrant and viable community of pediatric surgeons.” In collaboration with other national and international organizations, APSA creates educational guidelines and standard of care policies for the surgical care of pediatric patients that influence public policy and set best practices.[1]American Pediatric Surgery Association. https://eapsa.org/apsa-info/about-us/, Accessed 21 July 2019.Google Scholar APSA recognizes the broad diversity of the United States population and that the membership and leadership of our organization is not reflective of this diversity. The APSA Board of Governors (BOG) has recently committed to advance diversity, equity, and inclusion (DEI) in all aspects of pediatric surgery. APSA's strategic prioritization of DEI is presented in this paper. (Table 1)Table 1Position statements endorsed by the American Pediatric Surgical Association.Position statements on diversity, equity, and inclusion supported by APSAAPSA acknowledges the potential for enhanced productivity, creativity, and innovation within diverse organizations.APSA recognizes the positive impact a diverse cadre of pediatric surgeons may have on healthcare outcomes, patient satisfaction, and patient compliance.APSA adopts “Equity and social justice” as the fifth pillar of its organizational mission statement and “Inclusion, representation, and participation for all” as the foundation of its pillars.APSA endorses the activities of a member committee dedicated to the study and promotion of diversity, equity, and inclusion in pediatric surgery.APSA supports implicit bias assessment to enhance awareness and generate discussion and reflection regarding existing disparities in the care of pediatric surgery patients.APSA urges medical schools, general surgery residency programs, and pediatric surgery training programs to enact measures targeted at increasing the diversity of learners who will become pediatric surgeons.APSA encourages transparency and intentional hiring and promotion practices that are inclusive, fair, and open for women, underrepresented minority groups, surgeons with disabilities, and for all.APSA champions the establishment of mentorship and sponsorship programs specifically aimed at increasing the retention and recruitment of women and underrepresented pediatric surgeons.APSA uniformly condemns discrimination, racism, verbal and physical abuse, and sexual harassment.APSA promotes the importance of wellness, mental health, and work-life balance to the well-being of its membership and to the positive health outcomes of pediatric surgery patients.APSA advocates for efforts to create workplaces that are conducive to new parents at all levels of surgical training and practice.APSA pledges to engage in initiatives and strategies to address differential healthcare outcomes related to social determinants of health.APSA commits to achieving organizational benchmarks in the quest for increased diversity and inclusion among its membership and leadership. Open table in a new tab All pediatric health care providers are challenged to address the urgent public health crisis of childhood and adolescent healthcare disparities in the United States.2Keppel K.G. Ten largest racial and ethnic health disparities in the United States based on Healthy People 2010 Objectives.Am J Epidemiol. 2007; 166: 97-103https://doi.org/10.1093/aje/kwm044Crossref PubMed Scopus (110) Google Scholar, 3Oberg C. Colianni S. King-Schultz L Child Health Disparities in the 21st Century.Curr Probl Pediatr Adolesc Health Care. 2016; 46: 291-312https://doi.org/10.1016/j.cppeds.2016.07.001Crossref PubMed Scopus (11) Google Scholar, 4Haider A.H. Dankwa-Mullan I. Maragh-Bass A.C. et al.Setting a National Agenda for Surgical Disparities Research: recommendations From the National Institutes of Health and American College of Surgeons Summit.JAMA Surg. 2016; 151: 554-563https://doi.org/10.1001/jamasurg.2016.0014Crossref PubMed Scopus (68) Google Scholar Underrepresented minority and low-income children experience poorer outcomes in our healthcare system. (Box 1) Healthcare disparities have been reported in multiple surgical specialties including general surgery,[5]Akbilgic O. Langham Jr, M.R. Davis R.L Race, Preoperative Risk Factors, and Death After Surgery.Pediatrics. 2018; 141e20172221https://doi.org/10.1542/peds.2017-2221Crossref PubMed Scopus (13) Google Scholar trauma,[6]LaPlant M.B. Hess D.J. A review of racial/ethnic disparities in pediatric trauma care, treatment, and outcomes.J Trauma Acute Care Surg. 2019; 86: 540-550https://doi.org/10.1097/TA.0000000000002160Crossref PubMed Scopus (9) Google Scholar urology,[7]Chu D.I. Canning D.A. Tasian G.E Race and 30-day morbidity in pediatric urologic surgery.Pediatrics. 2016; 138e20154574https://doi.org/10.1542/peds.2015-4574Crossref PubMed Scopus (19) Google Scholar otolaryngology,[8]Jabbour J. Robey T. Cunningham M.J Healthcare disparities in pediatric otolaryngology: a systematic review.Laryngoscope. 2018; 128: 1699-1713https://doi.org/10.1002/lary.26995Crossref PubMed Scopus (24) Google Scholar kidney transplantation,[9]Laster M. Soohoo M. Hall C. et al.Racial-ethnic disparities in mortality and kidney transplant outcomes among pediatric dialysis patients.Pediatr Nephrol. 2017; 32: 685-695https://doi.org/10.1007/s00467-016-3530-2Crossref PubMed Scopus (12) Google Scholar bariatric surgery,[10]Nunez Lopez O. Jupiter D.C. Bohanon F.J. et al.Health disparities in adolescent bariatric surgery: nationwide outcomes and utilization.J Adolesc Health. 2017; 61: 649-656https://doi.org/10.1016/j.jadohealth.2017.05.028Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar neurosurgery,11Siegel D.A. Li J. Ding H. et al.Racial and ethnic differences in survival of pediatric patients with brain and central nervous system cancer in the United States.Pediatr Blood Cancer. 2019; 66: e27501https://doi.org/10.1002/pbc.27501Crossref PubMed Scopus (14) Google Scholar, 12Austin M.T. Hamilton E. Zebda D. et al.Health disparities and impact on outcomes in children with primary central nervous system solid tumors.J Neurosurg Pediatr. 2016; 18: 585-593https://doi.org/10.3171/2016.5.PEDS15704Crossref PubMed Scopus (34) Google Scholar, 13Attenello F.J. Ng A. Wen T. et al.Racial and socioeconomic disparities in outcomes following pediatric cerebrospinal fluid shunt procedures.J Neurosurg Pediatr. 2015; 15: 560-566https://doi.org/10.3171/2014.11.PEDS14451Crossref PubMed Scopus (33) Google Scholar surgical oncology,[14]Jacobs A.J. Lindholm E.B. Levy C.F. et al.Racial and ethnic disparities in treatment and survival of pediatric sarcoma.J Surg Res. 2017; 219: 43-49https://doi.org/10.1016/j.jss.2017.05.031Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and anesthesia.[15]Rosenbloom J.M. Mekonnen J. Tron L.E. et al.Racial and Ethnic Health Services Disparities in Pediatric Anesthesia Practice: a Scoping Review [published online ahead of print, 2020 Jun 12].J Racial Ethn Health Disparities. 2020; (10.1007/s40615-020-00792-w)https://doi.org/10.1007/s40615-020-00792-wCrossref Scopus (2) Google Scholar,[16]Baetzel A.E. Holman A. Dobija N. et al.Racial disparities in pediatric anesthesia.Anesthesiol Clin. 2020; 38: 327-339https://doi.org/10.1016/j.anclin.2020.01.010Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar A large proportion of children are vulnerable and affected by health inequities in the United States. Fewer than 40% of children in the United States were non-Hispanic White in 2019.[17]A More diverse nation. United States Census Bureau. https://www.census.gov/library/visualizations/2019/comm/age-race-distribution.html Accessed 10 January 2020.Google Scholar Twenty-three percent of American children do not use English as their primary language at home.[18]Characteristics of children under 18 years, by age, for the United States, regions, states, and Puerto Rico: 2000. United States Census Bureau. https://www.census.gov/data/tables/2000/dec/phc-t-30.html. Accessed 13 August 2020.Google Scholar Nearly 20% of youth ages 12–17 have special health care needs.[19]Trends in prevalence of disabilities among youth. US Department of Health and Human Services. https://www.hhs.gov/ash/oah/adolescent-development/physical-health-and-nutrition/chronic-conditions-and-disabilities/trends.html#:~:text=The%20National%20Survey%20of%20Children,16%2D20%20have%20a%20disability. Accessed 08/09/2020.Google Scholar Discrepant healthcare outcomes for underrepresented and lower socioeconomic status populations may be influenced by the demographic incongruity between providers and patients. Race and ethnicity concordance between patients and providers has been found to significantly increase the likelihood that Hispanic, Black, and Asian patients will seek preventive care.[20]Ma A. Sanchez A. Ma M The impact of patient-provider race/ethnicity concordance on provider visits: updated evidence from the medical expenditure panel survey.J Racial Ethn Health Disparities. 2019; 6: 1011-1020https://doi.org/10.1007/s40615-019-00602-yCrossref PubMed Scopus (28) Google Scholar Patients in race-discordant relationships with their physician have shorter office visits,[21]Cooper L.A. Roter D.L. Johnson R.L. Ford D.E. Steinwachs D.M. Powe N.R Patient-centered communication, ratings of care, and concordance of patient and physician race.Ann Intern Med. 2003; 139: 907-915https://doi.org/10.7326/0003-4819-139-11-200312020-00009Crossref PubMed Scopus (826) Google Scholar rate their healthcare visits as significantly less participatory,[22]Cooper-Patrick L. Gallo J.J. Gonzales J.J. Vu H.T. et al.Race, gender, and partnership in the patient-physician relationship.JAMA. 1999 Aug 11; 282: 583-589https://doi.org/10.1001/jama.282.6.583Crossref PubMed Scopus (1452) Google Scholar and have a less positive perception of care received.[23]Thornton R.L. Powe N.R. Roter D. Cooper L.A Patient-physician social concordance, medical visit communication and patients' perceptions of health care quality.Patient Educ Couns. 2011; 85: e201-e208https://doi.org/10.1016/j.pec.2011.07.015Crossref PubMed Scopus (99) Google Scholar In pediatric medicine, one study found that the mortality of Black infants is halved if cared for by Black physicians.[24]Greenwood B.N. Hardeman R.R. Huang L. Sojourner A Physician-patient racial concordance and disparities in birthing mortality for newborns.Proc Natl Acad Sci U S A. 2020; 117: 21194-21200https://doi.org/10.1073/pnas.1913405117Crossref PubMed Scopus (101) Google Scholar Black and Hispanic physicians are more likely to practice in communities with higher proportions of Black and Hispanic residents.[25]Komaromy M. Grumbach K. Drake M. et al.The role of black and Hispanic physicians in providing health care for underserved populations.N Engl J Med. 1996; 334: 1305-1310https://doi.org/10.1056/NEJM199605163342006Crossref PubMed Scopus (593) Google Scholar Higher practitioner cultural competence has been shown to result in better patient adherence to treatment and improved health outcomes.[26]Henderson S. Horne M. Hills R. Kendall E Cultural competence in healthcare in the community: a concept analysis.Health Soc Care Commun. 2018; 26: 590-603https://doi.org/10.1111/hsc.12556Crossref PubMed Scopus (47) Google Scholar Language-concordant care has been shown to improve patient satisfaction and understanding for Hispanic families of pediatric surgery patients.[27]Dunlap J.L. Jaramillo J.D. Koppolu R. Wright R. Mendoza F. Bruzoni M The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients.J Pediatr Surg. 2015; 50: 1586-1589https://doi.org/10.1016/j.jpedsurg.2014.12.020Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar A diverse and culturally-competent healthcare workforce is necessary to mitigate healthcare disadvantages presented to these children. Groups strategically rich in identity and cognitive diversity produce results-oriented bonuses with greater regularity than homogenous groups.28Page S. The diversity bonus: how great teams pay off in the knowledge economy. Princeton University Press, 2017Crossref Google Scholar, 29Hunt V. Prince S. Dixon-Fyle S. Yee L Delivering through diversity. McKinsey & Company, 2018Google Scholar, 30Kersley R., Klerk E., Boussie A., et al. Gender diversity is good for business. The CS Gender 3000 report 2019. https://www.credit-suisse.com/about-us-news/en/articles/news-and-expertise/cs-gender-3000-report-2019-201910.html; 2019 [accessed Jan 10, 2020].Google Scholar (Box 2) In part, this is because groups with greater diversity have access to a wider range of information, knowledge, mental models, frameworks, and heuristics. Diverse cognitive repertoires produce differences in thinking that result in greater creativity, innovation, and profit. [31]Hewlett S. Marshall M. Sherbin L How diversity can drive innovation.Harvard Bus Rev. 2013; ([accessed 10 January 2020])https://static1.squarespace.com/static/5ae89190aa49a17d6e450047/t/5b0d92c4aa4a99c9a42ddd3c/1527616197302/How+Diversity+Can+Drive+Innovation+_HBR.pdfGoogle Scholar,[32]Florida R. The economic geography of talent.Ann Am Assoc Geographers. 2003; ([accessed 10 January 2020])https://onlinelibrary.wiley.com/doi/abs/10.1111/1467-8306.00314Google Scholar Diverse teams also have a higher tendency to focus on facts, a greater expectation and acceptance of differing opinions, and an increased awareness of individual biases.[33]Rock D. Why diverse teams are smarter.Psychology Today. 2017; (Mar 9 Aug) ([accessed 10 January 2020])https://www.psychologytoday.com/us/blog/your-brain-work/201703/why-diverse-teams-are-smarterGoogle Scholar In the healthcare field specifically, diversity bonuses have been found on a range of topics. Diverse medical school student bodies enrich the educational experience for all students.[34]Whitla D.K. Orfield G. Silen W. et al.Educational benefits of diversity in medical school: a survey of students.Acad Med. 2003; 78: 460-466https://doi.org/10.1097/00001888-200305000-00007Crossref PubMed Scopus (145) Google Scholar An additional example of the diversity bonus is the finding that higher NIH funding rankings is found in surgical departments with more women professors.[35]Valsangkar N. Fecher A. Rozycki G.S. et al.Understanding the barriers to hiring and promoting women in surgical subspecialties.J Am Coll Surg. 2016; 223: 387-398Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar APSA membership in 2019 was 72% male and 70% White surgeons.[36]Newman E.A. “Advancing organizational excellence: leveraging differences as our strengths.” APSA Annual Meeting. 21 May 2019. Boston, MA.Google Scholar From 1937–2019, 26 (11.5%) Pediatric surgery fellowship directors were women, and in APSA's first 50 years, six (12.8%) APSA BOG members and four APSA presidents (8.0%) were women.[37]Glick P.L., Chen M.K., Escobar M.A., et al. A Genealogy of North American Pediatric Surgery: from Ladd Until Now, Ed 2.0. APSA Annual Meeting. 19 May 2019. Boston, MA.Google Scholar The first Black President of APSA presided from 2017 to 2018.[38]APSA Past Presidents, APSA website. https://eapsa.org/apsa-info/about-us/our-heritage/apsa-past-presidents/ [accessed 31 December 2019].Google Scholar This problem of demographic underrepresentation is not exclusive to pediatric surgery and in fact remains prevalent throughout most medical specialties.39Aziz H.A. Ducoin C. Welsh D. et al.2018 ACS Governors survey: gender inequality and harassment remain a challenge in surgery.Bull Am Coll Surg. 2019; ([accessed 4 September 2019])http://bulletin.facs.org/2019/09/2018-acs-governors-survey-gender-inequality-and-harassment-remain-a-challenge-in-surgery/Google Scholar, 40Association of American Medical Colleges. Women were majority of US medical school applicants in 2018, https://news.aamc.org/press-releases/article/applicant-data-2018/; 2018 [accessed 4 September 2019].Google Scholar, 41Abelson J.S. Symer M.M. Yeo H.L. Butler P.D. et al.Surgical time out: our counts are still short on racial diversity in academic surgery.Am J Surg. 2018; 215: 542-548https://doi.org/10.1016/j.amjsurg.2017.06.028Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 42Deville C. Chapman C.H. Burgos R. Hwang W.T. Both S. Jr Thomas CR Diversity by race, Hispanic ethnicity, and sex of the United States medical oncology physician workforce over the past quarter century.J Oncol Pract. 2014; 10: e328-e334https://doi.org/10.1200/JOP.2014.001464Crossref PubMed Scopus (21) Google Scholar, 43Kane K. Rosero E.B. Clagett G.P. Adams-Huet B. Timaran C.H Trends in workforce diversity in vascular surgery programs in the United States.J Vasc Surg. 2009; 49: 1514-1519https://doi.org/10.1016/j.jvs.2009.02.003Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 44Lane-Fall M.B. Miano T.A. Aysola J. Augoustides J.G.T Diversity in the emerging critical care workforce: analysis of demographic trends in critical care fellows from 2004 to 2014.Crit Care Med. 2017; 45: 822-827https://doi.org/10.1097/CCM.0000000000002322Crossref PubMed Scopus (15) Google Scholar, 45Lett L.A. Orji W.U. Sebro R Declining racial and ethnic representation in clinical academic medicine: a longitudinal study of 16 US medical specialties.PLoS ONE. 2018; 13 (Published 2018 Nov 16)e0207274https://doi.org/10.1371/journal.pone.0207274Crossref PubMed Scopus (74) Google Scholar These data highlight a fundamental challenge relevant to the current delivery of pediatric surgical care in the United States. It seems likely that the current lack of diversity in practicing pediatric surgeons in the United States may negatively affect pediatric surgical outcomes and limit innovation. Now more than ever before, access to diverse perspectives and creative solutions are required for APSA to fulfill its missions of ensuring optimal patient care and promoting excellence in the field. In extending these ideas to the realm of pediatric surgery, we assert that the complex mission of APSA is best served by an active, engaged membership rich in identity diversity, cognitive repertoires, and socioeconomic and cultural backgrounds. APSA seeks to engage talents from a diverse group of learners and surgeons as the surest way to achieve the highest quality clinical care and create solutions to the next generation of challenges in pediatric surgery. This task requires a multi-faceted approach designed to improve our organization's performance, better support all our members, and position us strategically to accomplish the aspirational goal of a work force reflective of those we serve. To comprehensively build strategies that address these factors, the APSA BOG created a fifth organizational strategic pillar termed “Equity and Social Justice” and modified the foundation of APSA's strategic pillars to read “Inclusion, representation, and participation for all.” (Fig. 1) The Diversity, Equity, and Inclusion Committee (DEI Committee) was established in the summer of 2018 to guide the organization in this arena, and committee members were selected from APSA membership. Through a process of iterative group revision, the following mission statement was created:Diversity, equity, and inclusion are core values for APSA that drive excellence and innovation in clinical care, research, education, advocacy, and leadership. We will broaden organizational diversity across cultural, demographic, cognitive, and practice style domains. Our environment will advance pediatric surgeons to attain their greatest potential, work in partnership to eliminate health inequities, and provide the highest quality of pediatric surgical care for all. Operationalizing this mission statement and changing the culture of our organization will require: 1) increasing education and raising consciousness among current pediatric surgeons, APSA BOG members, and allied healthcare practitioners on the importance of representation and inclusion; 2) formalizing strategies that lower the impact of implicit bias and racism throughout the organization; 3) career development of underrepresented surgeons needed to support the next generation of children, 4) affirmatively supporting programs that address the needs of potential pediatric surgeons throughout medical school, residency, and fellowship;[46]Butler P.D. Britt L.D. Jr Green ML Longaker M.T. et al.The Diverse Surgeons Initiative: an effective method for increasing the number of under-represented minorities in academic surgery.J Am Coll Surg. 2010; 211: 561-566https://doi.org/10.1016/j.jamcollsurg.2010.06.019Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,[47]Dai J.C. Agochukwu-Mmonu N. Hittelman A.B Strategies for attracting women and underrepresented minorities in urology.Curr Urol Rep. 2019; 20 (Published 2019 Sep 2): 61https://doi.org/10.1007/s11934-019-0921-5Crossref PubMed Scopus (17) Google Scholar and 5) supporting the well-being of current pediatric surgeons who are members of underrepresented groups and championing their growth as mentors and leaders within our organization. The remainder of this paper outlines APSA's strategy on increasing diversity and inclusivity in pediatric surgery. To better understand the composition of APSA membership and the alignment with its patient population, the DEI Committee will distribute a membership survey to gather demographic information such as race / ethnicity, gender, sexual orientation, and religious preferences. The survey results will guide the agenda of the DEI Committee with strategies that increase DEI within APSA's membership and leverage identity and cognitive diversity bonuses. Implicit bias may negatively impact patient-provider interactions, treatment decisions, and patient outcomes. Implicit biases can lead to negative evaluation and treatment of a person based on identity characteristics such as gender, race, sexual orientation, weight status, or disability. Implicit biases have been shown to exist among healthcare providers at similar (typically low or moderate) levels as they exist in the general public.[48]Hall W.J. Chapman M.V. Lee K.M. et al.Implicit racial / ethnic bias among health care processionals and its influence on health care outcomes: a systematic review.Am J Public Health. 2015; 105: e60-e76Crossref PubMed Scopus (640) Google Scholar Several studies have found significant associations between poorer healthcare metrics and healthcare providers with higher levels of racial and ethnic implicit bias.[49]FitzGerald C. Hurst S Implicit bias in healthcare professionals: a systematic review.BMC Med Ethics. 2017; 18 (Mar 1): 19Crossref PubMed Scopus (498) Google Scholar,[50]Maina I.W. Belton T.D. Ginzberg S. Singh A. et al.A decade of studying implicit racial / ethnic bias in healthcare providers using the implicit association test.Soc Sci Med. 2018; 199: 219-229Crossref PubMed Scopus (193) Google Scholar The link between implicit bias and clinical decision-making is less clear.[51]Dehon E. Weiss N. Jones J. Faulconer W. et al.A Systematic review of the impact of physician implicit racial bias on clinical decision making.Acad Emerg Med. 2017; 24: 895-904Crossref PubMed Scopus (109) Google Scholar Many of these studies employ Implicit Association Tests (IATs), which are exercises available to the public through the website of Project Implicit, a research group studying implicit social cognition.[52]Project Implicit. https://www.projectimplicit.net/ Accessed 4 January 2020.Google Scholar Versions of these tests examine implicit biases related to topics including gender, body weight, sexuality, race and skin tone, religion, and age. [53]Greenwald A.G. McGhee D.E. Schwartz J.L Measuring individual differences in implicit cognition: the implicit association test.J Pers Soc Psychol. 1998; 74: 1464-1480Crossref PubMed Scopus (6649) Google Scholar Though there is debate in the literature about the IATs’ ability to meaningfully predict discrimination and disparate clinical practices,54Oswald F.L. Mitchell G. Blanton H. Jaccard J. et al.Predicting ethnic and racial discrimination: a meta-analysis of IAT criterion studies.J Pers Soc Psychol. 2013; 105: 171-192Crossref PubMed Scopus (345) Google Scholar, 55Greenwald A.G. Banaji M.R. Nosek B.A Statistically small effects of the implicit association test can have societally large effects.J Pers Soc Psychol. 2015; 108: 553-561Crossref PubMed Scopus (265) Google Scholar, 56Oswald F.L. Mitchell G. Blanton H. Jaccard J. et al.Using the IAT to predict ethnic and racial discrimination: small effect sizes of unknown societal significance.J Pers Soc Psychol. 2015; 108: 562-571Crossref PubMed Scopus (78) Google Scholar, 57Carlsson R. Agerstrom J A closer look at the discrimination outcomes in the IAT literature.Scand J Psychol. 2016; 57: 278-287Crossref PubMed Scopus (38) Google Scholar the tests are generally regarded as useful tools to promote bias awareness and generate open discussions.[58]Sukhera J. Wodzinski M. Rehman M. Gonzalez C.M The implicit association test in health professions education: a meta-narrative review.Perspect Med Educ. 2019; 8: 267-275Crossref PubMed Scopus (17) Google Scholar As an initial step towards lowering the influence of bias within our organization, the APSA BOG has committed for all current members to take IATs and require future members to do so when on boarding. We encourage committee chairs and members to take these as well to incorporate bias awareness and focus on lowering bias in all aspects of organizational work. The DEI Committee will provide targeted educational opportunities on bias and racism that aim to stimulate self-reflection and open discussion. We will do this by submitting topical articles to the APSA “Articles of Interest” email; writing themed articles for quarterly submission to the Journal of Pediatric Surgery; developing an online toolkit for APSA members and the public; contributing content to the Pediatric Surgery Library (http://www.pedsurglibrary.com); and sponsoring plenary and break-out sessions at the APSA Annual Meeting. We believe that initiatives that provide ongoing awareness and strategies to decrease the influences of bias, paired with broad-based changes that directly address structural and systemic forms of bias and discrimination will ultimately contribute to a more open and representative organization and improved health care for patients.[59]Kang S.K. Kaplan S. Working towards gender diversity and inclusion in medicine: myths and Solutions.Lancet. 2019; 393: 579-586Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar The disproportionate effect the Covid-19 pandemic has had on minority populations[60]Webb Hooper M. Nápoles A.M. Pérez-Stable E COVID-19 and racial / ethnic disparities.JAMA. 2020; https://www.doi.org/1001/jama.2020.8598Crossref PubMed Scopus (752) Google Scholar and the high-profile killings of several Black Americans by police in the spring of 2020 have given APSA cause to again consider the healthcare effects of racism in the United States. In light of these events, the APSA BOG issued a statement to its membership and the public on the organization's commitment to equity and social justice.[61]Waldhausen J. Newman E. Statement on equity and social justice.Am Pediatr Surg Assoc. 2020; ([accessed 26 June 2020])https://eapsa.org/apsa-info/about-us/news/statement-on-equity-and-social-justice/Google Scholar APSA acknowledges ongoing racial injustices that disproportionately affect people of color and those living below the poverty line. APSA members are called on to address and engage in these complex societal issues. The organization pledges to foster an open and inclusive culture, ensure programmatic development that directly addresses structural and systemic barriers to care for marginalized patients, and continuously raise consciousness around challenging issues like implicit bias, generational poverty, and racism. The path to becoming a pediatric surgeon is demanding in rigor and duration. The success rate of matching into a pediatric surgery fellowship position averages 50%, despite applicants pursuing 11–13 years of post-graduate training, having a median of 15 publications, completing additional pediatric subspecialty training, and spending an average of $8000 on fellowship interviews.[62]Savoie K.B. Kulaylat A.N. Huntington J.T. et al.The pediatric surgery match by the numbers: defining the successful application.J Pediatr Surg. 2020; 55: 1053-1057Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,[63]Chandler N.M. Litz C.N. Chang H.L. Danielson P.D Efficacy of videoconference interviews in the pediatric surgery match.J Surg Educ. 2019; 76: 420-426Crossref PubMed Scopus (31) Google Scholar This effort is especially challenging for underrepresented minorities and students from disadvantaged backgrounds. Socioeconomic factors such as poverty or parental education attainment may limit access to high-quality schools, which may prevent a promising student from even beginning this journey.[64]Youmans Q.R. Essien U.R. Capers Q 4th. A test of diversity - what USMLE pass/fail scoring means for medicine.N Engl J Med. 2020; 382: 2393-2395Crossref PubMed Scopus (13) Google Scholar Lack of mentorship and access to courses and study materials for standardized exams further exacerbate leaks in the pipeline. As a result, exam scores are frequently lower among Black, His

Association of Poverty Income Ratio with Physical Functioning in a Cohort of Patients with Systemic Lupus Erythematosus.

To examine the association of income relative to the poverty threshold [poverty income ratio (PIR)] with self-reported physical functioning (PF) in a cohort of patients with systemic lupus erythematosus. We used cross-sectional data on 744 participants from Georgians Organized Against Lupus (GOAL), and secondary analyses used data on 56 participants from a nested pilot study. Primary analyses used multivariable linear regression to estimate the association between PIR (categorized as < 1.00, 1.00-1.99, 2.00-3.99, and ≥ 4.00; lower PIR indicate higher poverty) and PF (scaled subscore from the Medical Outcomes Study Short Form-12 survey; range 0-100, higher scores indicate better functioning). Secondary analyses summarized complementary measures of PF as means or percentages by PIR (categorized as < 1.00, 1.00-1.99, and ≥ 2.00). The mean age of participants was 48.0 years; 6.7% were male; 80.9% were black; and 37.5%, 21.0%, 29.6%, and 12.0% had PIR of < 1.00, 1.00-1.99, 2.00-3.99, and ≥ 4.00, respectively. The overall mean PF score was 45.8 (36.2, 40.7, 55.5, and 61.2 for PIR of < 1.00, 1.00-1.99, 2.00-3.99, and ≥ 4.00). With adjustment, higher PIR remained associated with higher PF scores [2.00-3.99 vs 1.00-1.99: β = 10.9 (95% CI 3.3-18.6); ≥ 4.00 vs 1.00-1.99: β = 16.2 (95% CI 6.4-26.0)]. In secondary analyses, higher PIR was also associated with higher scores for objective physical performance. Our results show that higher income relative to the poverty threshold is associated with better PF across multiple domains, warranting further research into multicomponent functional assessments to develop individual treatment plans and potentially improve socioeconomic disparities in outcomes.

A Review of Thomas Sowell's Discrimination and Disparities

In Discrimination and Disparities, Thomas Sowell describes how economists think about the causes of disparities in socioeconomic outcomes. He cautions against government intervention to reduce disparities, noting that such interventions often have unintended consequences. In this review, I discuss the role of economic theory and empirical evidence in helping move society towards more equitable outcomes. I find far more reason to be hopeful about the role of government than Sowell does, but also argue for more experimentation and rigorous evaluation to be sure that our well-intentioned policies have their intended impacts.

BURDEN, ACCESS, AND DISPARITIES IN KIDNEY DISEASE

Racial/ethnic and socioeconomic disparities in chronic kidney disease (CKD) have been documented for decades, yet little progress has been made in mitigating them. Several recent studies offer new insights into the root causes of these disparities, point to areas where future research is warranted and identify opportunities for changes in policy and clinical practice. Recently published evidence suggests that geographic disparities in CKD prevalence exist and vary by race. CKD progression is more rapid for racial/ethnic minority groups as compared to whites and may be largely, but not completely, explained by genetic factors. Stark socioeconomic disparities in outcomes for dialysis patients exist, and vary by race, place of residence and treatment facility. Disparities in access to living kidney donation may be driven primarily by the socioeconomic status of the donor as opposed to recipient factors. Recent studies highlight opportunities to eliminate disparities in CKD, including efforts to direct resources to areas and populations where disparities are most prevalent, efforts to understand how to best use emerging information on the contribution of genetic factors to disparities, and continued work to identify modifiable environmental, social, and behavioral factors for targeted interventions among high-risk populations.

From Gaming to Justice? A Note on the Effect of American Indian Casinos on Tribal Judicial Systems

From Gaming to Justice?A Note on the Effect of American Indian Casinos on Tribal Judicial Systems Randall Akee (bio), Valentina Dimitrova-Grajzl (bio), Peter Grajzl (bio), and Richard M. Todd (bio) AN EFFICIENT AND IMPARTIAL JUDICIAL SYSTEM is essential to economic development. The judiciary plays a central role in upholding property rights and promoting commerce in large-scale anonymous markets where reputation-based relational contracting loses its efficacy (see, e.g., Dixit 2003; Stephenson 2007). An effective judiciary has been shown to foster investment, entrepreneurship, industrial activity, and credit (see, e.g., Chemin 2009a, 2009b, 2012; Jappelli, Pagano, and Bianco 2005; Visaria 2009). In the context of Indian Country in particular, recent empirical evidence suggests that differences in legislative frameworks that structure the functioning of judicial institutions are an important driver of disparities in socioeconomic outcomes (see, e.g., Goldberg and Champagne 2007; Anderson and Parker 2008; Dimitrova- Grajzl, Grajzl, and Guse 2014; Dimitrova-Grajzl, Guse, and Todd 2015; Wellhausen 2017). This raises the question of what factors impact and facilitate the development of an effective judiciary in Native communities. In Indian Country, access to an effective judiciary has been limited as a consequence of a long history of federal encroachment on tribal sovereignty, inadequate government funding, and a maze of jurisdictional overlaps and limits. To fill the resulting institutional vacuum, tribal communities have striven to expand and enhance their own tribal judicial systems. Given that "tribal justice systems have been underfunded for decades" (US Commission on Civil Rights 2003, 77), financial constraints have been the main obstacle in this regard. In such an environment, characterized by severe resource scarcity, the American Indian gaming industry has emerged as a mechanism capable of relaxing tribal financial constraints (Akee, Spilde, and Taylor 2015). Indeed, a key goal of the 1988 Indian Gaming Regulatory Act (IGRA) was to promote "tribal economic development, self-sufficiency, and strong tribal governments" (Indian Gaming Regulatory Act 1988). The implementing regulations explicitly recognized tribal government spending to enhance the judicial system as "allowable expenditures of gaming revenues" (National Indian [End Page 32] Gaming Commission 2005). In addition, gaming conceivably creates additional demand for tribal judicial services. The socioeconomic impact of gaming in Indian Country has been explored by a handful of previous studies (see, e.g., Evans and Topoleski 2002; Reagan and Gitter 2007; Anderson 2013). However, to date, no contribution has empirically examined the link between gaming and tribal institution building, in particular, the development of tribal judicial systems. We evaluate how the presence of the American Indian gaming industry has impacted one basic yet salient dimension of tribal judicial systems: their extensiveness. Our analysis thereby fills an important gap in the emerging empirical literature that examines the causes and consequences of institutional development in Indigenous communities (see, e.g., Cornell and Kalt 2000; Dippel 2014; Akee and Jorgensen 2014; Akee, Jorgensen, and Sunde 2015; Aragón 2015). Data The source of our data on tribal justice systems is the 2002 Census of Tribal Justice Agencies in American Indian and Alaska Native Jurisdiction. We measure the size of a tribal justice system with the sum of all part-time and fulltime personnel working within the tribal justice system (Tribal Justice System Staff). Personnel is the key input in the administration of justice (see, e.g., Beenstock and Haitovsky 2004; Dimitrova-Grajzl et al. 2012; Dimitrova-Grajzl, Grajzl, and Zajc 2014; Dimitrova-Grajzl et al. 2016; Grajzl and Silwal 2017) and, therefore, an appropriate measure of the extensiveness of a tribal justice system. We concentrate our analysis on reservations with a population of at least five hundred in year 2000. Our dataset covers 106 reservations from twenty-three states; 97 of these 106 reservations have a tribal justice system. Our focal explanatory variable, Gaming, is Conner and Taggart's (2013) and Taylor and Kalt's (2005) dummy equal to 1 if the tribe associated with a specific reservation in year 2000 operates a class II (e.g., bingo facility) or class III (Las Vegas–style casino) gaming facility. Our 1990 reservation-level controls come from Akee and Taylor (2014) and include total population, percent of adults with a college degree, percent unemployed, median household income, and percent...

Association of Racial and Socioeconomic Disparities With Outcomes Among Patients Hospitalized With Acute Myocardial Infarction, Heart Failure, and Pneumonia

Although studies have described differences in hospital outcomes by patient race and socioeconomic status, it is not clear whether such disparities are driven by hospitals themselves or by broader systemic effects. To determine patterns of racial and socioeconomic disparities in outcomes within and between hospitals for patients with acute myocardial infarction, heart failure, and pneumonia. Retrospective cohort study initiated before February 2013, with additional analyses conducted during the peer-review process. Hospitals in the United States treating at least 25 Medicare fee-for-service beneficiaries aged 65 years or older in each race (ie, black and white) and neighborhood income level (ie, higher income and lower income) for acute myocardial infarction, heart failure, and pneumonia between 2009 and 2011 were included. For within-hospital analyses, risk-standardized mortality rates and risk-standardized readmission rates for race and neighborhood income subgroups were calculated at each hospital. The corresponding ratios using intraclass correlation coefficients were then compared. For between-hospital analyses, risk-standardized rates were assessed according to hospitals' proportion of patients in each subgroup. These analyses were performed for each of the 12 analysis cohorts reflecting the unique combinations of outcomes (mortality and readmission), demographics (race and neighborhood income), and conditions (acute myocardial infarction, heart failure, and pneumonia). Between 74% (3545 of 4810) and 91% (4136 of 4554) of US hospitals lacked sufficient racial and socioeconomic diversity to be included in this analysis, with the number of hospitals eligible for analysis varying among cohorts. The 12 analysis cohorts ranged in size from 418 to 1265 hospitals and from 144 417 to 703 324 patients. Within included hospitals, risk-standardized mortality rates tended to be lower among black patients (mean [SD] difference between risk-standardized mortality rates in black patients compared with white patients for acute myocardial infarction, -0.57 [1.1] [P = .47]; for heart failure, -4.7 [1.3] [P < .001]; and for pneumonia, -1.0 [2.0] [P = .05]). However, risk-standardized readmission rates among black patients were higher (mean [SD] difference between risk-standardized readmission rates in black patients compared with white patients for acute myocardial infarction, 4.3 [1.4] [P < .001]; for heart failure, 2.8 [1.8] [P < .001], and for pneumonia, 3.7 [1.3] [P < .001]). Intraclass correlation coefficients ranged from 0.68 to 0.79, indicating that hospitals generally delivered consistent quality to patients of differing races. While the coefficients in the neighborhood income analysis were slightly lower (0.46-0.60), indicating some heterogeneity in within-hospital performance, differences in mortality rates and readmission rates between the 2 neighborhood income groups were small. There were no strong, consistent associations between risk-standardized outcomes for white or higher-income neighborhood patients and hospitals' proportion of black or lower-income neighborhood patients. Hospital performance according to race and socioeconomic status was generally consistent within and between hospitals, even as there were overall differences in outcomes by race and neighborhood income. This finding indicates that disparities are likely to be systemic, rather than localized to particular hospitals.

Abstract IA22: Financial well-being and health: Definitions and measurement issues

Abstract The cost of cancer care is rising faster than other diseases, and the financial hardship that cancer imposes on families may exacerbate racial/ethnic and socioeconomic disparities in outcomes throughout survivorship. Discussions about the financial burden of cancer care have increased in recent years in the academic literature and popular press, and several terms have been used to describe this burden. Yet, the discussion oftentimes conflates the lack of material resources to cover medical expenses, the potential psychosocial distress accompanying the lack/reduction in financial resources, and the behavioral coping responses to address the lack /reduction in financial resources. Many health care professionals report feeling unprepared to address family financial well-being in the context of health care delivery, and research suggests that most individuals report low levels of financial self-efficacy even outside the context of managing a chronic disease. We currently lack reliable and valid measures to adequately assess the material, psychosocial, and behavioral aspects of household financial well-being prior to, during, and following cancer care. The dearth in assessment tools of financial well-being in the cancer context impedes efforts to identify modifiable intervention targets of the financial burden of cancer care to ensure that families do not succumb to financial ruin as they manage a chronic disease and navigate the health care system. Citation Format: Reginald Tucker-Seeley. Financial well-being and health: Definitions and measurement issues [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr IA22.

Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant

There is mixed evidence of racial and socioeconomic disparities in heart transplant outcomes. Their underlying cause-and whether individual- or community-level traits are most influential-remains unclear. The current study aimed to characterize socioeconomic disparities in outcomes and identify time trends and mediators of these disparities. We used United Network for Organ Sharing registry data and included 33 893 adult heart transplant recipients between 1994 and 2014. Socioeconomic status (SES) indicators included insurance, education, and neighborhood SES measured using a composite index. Black race and multiple indicators of low SES were associated with the primary outcome of death or retransplant, independent of baseline clinical characteristics. Blacks had lower HLA and race matching, but further adjustment for these and other graft characteristics only slightly attenuated the association with black race (HR, 1.25 after adjustment). This and the associations with neighborhood SES (HR, 1.19 for lowest versus highest decile), Medicare (HR, 1.17), Medicaid (HR, 1.29), and college education (HR, 0.90) remained significant after full adjustment. When comparing early (1994-2000) and late (2001-2014) cohorts, the disparities associated with the middle (second and third) quartiles significantly decreased over time, but those associated with lowest SES quartile and black race persisted. Low neighborhood SES was also associated with higher risks of noncompliance (HR, 1.76), rejection (HR, 1.28), hospitalization (HR, 1.13), and infection (HR, 1.10). Racial and socioeconomic disparities exist in heart transplant outcomes, but the latter may be narrowing over time. These disparities are not explained by differences in clinical or graft characteristics.

Regional socioeconomic disparities in outcomes for workers with low back pain in the United States.

BackgroundAlthough regional socioeconomic (SE) factors have been associated with worse health outcomes, prior studies have not addressed important confounders or work disability.MethodsA national sample of 59 360 workers’ compensation (WC) cases to evaluate impact of regional SE factors on medical costs and length of disability (LOD) in occupational low back pain (LBP).ResultsLower neighborhood median household incomes (MHI) and higher state unemployment rates were associated with longer LOD. Medical costs were lower in states with more workers receiving Social Security Disability, and in areas with lower MHI, but this varied in magnitude and direction among neighborhoods. Medical costs were higher in more urban, more racially diverse, and lower education neighborhoods.ConclusionsRegional SE disparities in medical costs and LOD occur even when health insurance, health care availability, and indemnity benefits are similar. Results suggest opportunities to improve care and disability outcomes through targeted health care and disability interventions.