Equitable Access Research Articles

Introduction: Augmented reality (AR) provides interactive and immersive experiences that enrich medical training by enhancing learners’ spatial understanding, clinical decision-making, and engagement [1-3]. However, the uptake of AR across educational institutions remains inconsistent due to variations in infrastructure, cost, and training. This study aimed to explore medical students’ experiences with AR, measure their immersion levels, and identify perceived benefits and barriers, particularly those linked to digital inequality. Methods: A cross-sectional survey was conducted in 2024-2025 at a UK medical school following an AR-enhanced simulation session using HoloLens headsets and the HoloPatient application. Ninety-three medical students participated voluntarily. The Augmented Immersion Measurement Index (AIMI) was used to assess engagement across cognitive, emotional, and behavioural domains. Students also reported AR usage frequency, perceived educational benefits, technological limitations, and concerns about equitable access. Descriptive and correlational analyses were performed. Results: Students reported moderate immersion (mean AIMI score: 3.9/5), with emotional engagement highest (4.2/5) and behavioural engagement lowest (3.5/5). Key benefits included enhanced diagnostic reasoning (32%), improved patient interaction skills (28%), and increased surgical confidence (20%). However, 30% cited limited access to AR-enabled devices, and 27% reported lack of institutional support as major barriers. Over half (53%) expressed concern that AR could widen digital inequality. Subgroup analysis showed students with regular AR access had higher confidence in spatial awareness and technical skills. Conversely, those from lower-income backgrounds reported limited access, lower immersion scores, and less perceived benefit. Despite challenges, students valued AR’s ability to visualise complex anatomy, simulate clinical encounters, and reinforce theoretical learning. Discussion: This study confirms that AR can improve learner engagement and perceived clinical preparedness. However, barriers related to access, affordability, and institutional readiness may hinder equitable implementation. AR should be adopted as a supplemental tool within blended learning models. Institutions must invest in infrastructure, faculty training, and accessibility schemes—such as device loans or subsidies—to maximise educational benefit and mitigate the digital divide. Future studies should examine long-term skill retention, impact on clinical performance, and cost-effectiveness of AR-based medical education. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable.

Background: Heart Failure (HF) is a leading cause of 30-day readmissions (20-25% nationally). Interdisciplinary Bridge Clinics (BCs) improve continuity of care, reduce readmissions, and shift care from high-cost inpatient settings to more sustainable outpatient management. The University of Maryland Medical System (UMMS) launched its first BC in 2015 at its quaternary care academic hospital in Baltimore. Since then, four additional clinics have been established across UMMS, most recently in 2024, expanding HF care access in urban and rural areas (Figure 1). This study evaluates whether similar benefits seen at the original site—reduced readmissions and utilization—are observed at new clinics across the health system. Methods: In this retrospective observational cohort study, we analyzed patients from five UMMS hospitals who attended a BC between January and November 2024. The index event was the first BC visit. Healthcare utilization was assessed using the Chesapeake Regional Information System for our Patients (CRISP) Visit Level Pre/Post Analysis tool, examining up to 12 months before and after the index visit. We analyzed inpatient, observation, emergency department (ED), and outpatient visits, and 30-day readmissions, using CMS criteria to exclude planned hospitalizations. HF subtype was categorized using ICD-10 codes. Utilization changes were analyzed with the Wilcoxon signed-rank test; results by HF subtype and site are presented descriptively (Figure 2). Results: Each site showed a reduction in inpatient readmissions after BC (Figure 1). Pooled data across all 5 system sites showed statistically that inpatient utilization decreased by 41% (p<0.001), outpatient utilization increased by 28.5% (p<0.001) and readmissions decreased by 32.7% (p<0.001) (Figure 2). Improved outcomes were evident across the HF spectrum (Table 1). Patients with all HF types had fewer admissions and ED visits following BC visit. This trend was seen across all 5 sites. Conclusion: Implementation of transitional BCs across a diverse urban and rural hospital system was associated with reductions in utilization and readmissions, with increased outpatient engagement. These improvements were consistent across all HF subtypes. System-wide adoption of post-discharge interdisciplinary follow-up via BCs can improve care transitions and reduce care utilization in HF populations, regardless of setting. Future studies should assess long-term outcomes, cost-effectiveness, and equitable access.

Background: PCSK9 inhibitors significantly reduce LDL-C levels and cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD), particularly following acute coronary syndromes (ACS) and in those with familial hypercholesterolemia (FH). However, equitable inpatient access to these therapies remains unclear. Objective: To assess racial and socioeconomic disparities in inpatient utilization of PCSK9 inhibitors among patients hospitalized with ASCVD, with a focus on post-ACS and FH subgroups. Methods: We conducted a retrospective cross-sectional study using the National Inpatient Sample (NIS) from 2020 to 2022. Adult hospitalizations with a diagnosis of ASCVD, including ACS and FH, were identified using ICD-10 codes. Inpatient PCSK9 inhibitor use was determined by pharmacy billing codes. Patients were stratified by race/ethnicity and income quartile. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) for PCSK9i utilization, controlling for demographics, insurance, comorbidities, and hospital-level factors. Results: Among 180,000 weighted ASCVD hospitalizations, only 1.3% received PCSK9 inhibitors. Black (aOR 0.58, 95% CI 0.50–0.68) and Hispanic (aOR 0.61, 95% CI 0.52–0.72) patients were significantly less likely than White patients to receive PCSK9is. Patients in the lowest income quartile had 47% lower odds of treatment compared to the highest (aOR 0.53, 95% CI 0.45–0.63). In post-ACS patients, PCSK9i use was 2.1% for White vs. 0.9% for Black patients. Similar trends were observed in FH patients. Conclusion: Inpatient use of PCSK9 inhibitors remains extremely limited and disproportionately lower among Black, Hispanic, and low-income patients with ASCVD. These findings highlight critical disparities in access to high-efficacy lipid-lowering therapy and underscore the need for equitable inpatient prescribing practices.

Background: Diabetes mellitus (DM) is a major public health concern in the United States, with peripheral circulatory complications significantly contributing to morbidity and mortality. This study examines the temporal patterns and demographic disparities in mortality related to diabetes mellitus with peripheral circulatory complications in the U.S. from 1999 to 2020. Research question: What are the temporal trends and demographic disparities in mortality from diabetes mellitus with peripheral circulatory complications in the U.S. from 1999 to 2020? Methods: We performed a retrospective cohort study using death certificate data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiological Research (CDC WONDER) database from 1999 to 2020. We calculated age-adjusted mortality rates (AAMRs), annual percent change (APC), and average annual percentage change (AAPC) per 1,000,000 persons. The data were stratified based on year, gender, ethnicity, and geographic area. Results: Between 1999 and 2020, peripheral circulatory complications in Diabetes Mellitus accounted for 99259 deaths among adults (≥25 years) in the United States. The overall AAMR for peripheral circulatory complications in Diabetes Mellitus-related deaths increased from 25.20 in 1999 to 25.4657 in 2004 (APC: 0.16; 95% CI: -2.61 to 7.03), after which it declined sharply to 14.91 in 2014 (APC: -5.12*; 95% CI: -8.18 to -4.03), and then increased again, sharply this time, to 25.28 in 2020 (APC: 7.51*; 95% CI: 5.18 to 10.60). Majority of the deaths occurred in medical facilities inpatient (33.8%). Men exhibited higher AAMRs compared to women (men: 27.5; women: 16.0). Highest Crude Mortality Rate (CMR) was seen in adults aged ≥ 85 years. Non-Hispanic (NH) American Indians showed the highest AAMRs (42.13), followed by NH Black (35.02), Hispanic (27.79), NH White (18.96), and NH Asian (10.41). Geographically, AAMRs ranged from 5.72 in Nevada to 34.97 in West Virginia, with Midwestern region having the highest mortality (AAMR: 24.43). Non-metropolitan areas exhibited higher AAMRs than Metropolitan areas (non-metropolitan: 25.86; Metropolitan: 19.73). Conclusion: After a period of decline (2004–2014), mortality from peripheral circulatory complications in adults with Diabetes Mellitus has risen since 2014, with notable disparities across racial and geographic groups. These trends highlight the need for targeted interventions and equitable healthcare access.

Background: The efficacy of tafamidis treatment in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) is well known, as supported by findings in the ATTR-ACT trial. However, to our knowledge, no study has investigated the racial implications on the economic effects of tafamidis tied to heart failure (HF) outcomes by using each patient as their own control. Hypothesis: Racial disparities lead to delayed diagnosis and treatment, resulting in a reduced benefit of tafamidis for decreasing costs associated with HF admissions in Black patients. Methods: We conducted a retrospective pre-post study of 186 ATTR-CM patients on tafamidis, stratified by race and amyloid subtype. Each patient served as their own control. The primary outcome was healthcare cost savings (using our institutional cost of $2,920/hospital day). Secondary outcomes included total HF admissions and length of stay (LOS) during 90 days pre- and post-tafamidis. We compared baseline NYHA class distribution between racial groups and analyzed treatment responses across hereditary (hATTR-CM) versus wild-type (wtATTR-CM) subtypes. Statistical analysis used Mann-Whitney U tests for inter-group comparisons and Wilcoxon signed-rank tests for pre-post outcomes. Results: Black patients had a median reduction in LOS of 7.5 days, compared to 3.5 days for White patients, leading to cost savings of $21,900 versus $10,220 (Figure 1). Total hospital admissions and LOS were higher for Black patients across NYHA classes II and III (Figures 2 and 3). At tafamidis initiation, Black patients had a higher baseline NYHA class (mean 2.50 vs 2.13, p=0.010). There was no significant difference in treatment delay from diagnosis, with Black patients experiencing a median delay of 68.5 days compared to 62.5 days (p=0.169). Additionally, the mean reduction in LOS did not differ among Black hATTR-CM (n=10), Black wtATTR-CM (n=7), and White wtATTR-CM (n=14) groups, with reductions of 4.70 days, 5.43 days, and 3.21 days, respectively (p=0.211). Conclusion: Black patients presented with more advanced disease but achieved greater absolute benefits and cost savings from tafamidis. With no treatment delays, later presentation likely reflects disparities in diagnosis and healthcare access, resulting in higher pre-treatment costs that resolved with appropriate therapy. These findings underscore the need for early diagnosis and equitable specialist access, while confirming universal tafamidis efficacy across diverse populations.

Introduction: Congenital Heart Disease (CHD) is the most common birth defect and is significantly associated with mortality in children. This study explores trends in CHD-related mortality among all age groups in the US from 1999-2020 and estimate through 2030. Methods: Data from CDC WONDER multiple-cause-of-death database was used to analyse trends associated with CHD among patients in the US. Age adjusted mortality rates (AAMR) were reported per 100,000 population and average annual percent change (AAPC) were calculated using the Joinpoint regression program. Trends were assessed by sex, race, age, census region, and urbanization status. Predictive modeling using Python and Seasonal AutoRegressive Integrated Moving Average (SARIMA) was performed to estimate future trends from 2020 to 2030. Results: There were a total of 117,837 deaths due to CHD in patients in the U.S from 1999-2020. In the overall population, the AAMR steadily decreased from 2.34 in 1999 to 1.62 in 2011 (APC: -3.06; 95 CI%: -3.44, -2.67; p < 0.000001), followed by a slight decrease to 1.59 in 2020 (APC: -0.40; 95 CI%: -1.02, 0.22; p: 0.187) and predicted to decrease further by 2030. Throughout the study period, males demonstrated a higher AAMR than females (males: 1.94; females: 1.61). From 2020 to 2030, it is predicted that the AAMR for males will decrease, and increase for females. Additionally, individuals aged 0-24 years had the highest crude rates at 2.83 and young adults aged 25-44 years had lowest crude rates at 0.75. Among racial groups, Non-Hispanic (NH) Black or African American individuals had the highest AAMR at 2.18, while NH Asian or Pacific Islander individuals had the lowest at 1.15. Statewise, the District of Columbia had the highest AAMR at 2.28 and Massachusetts had the lowest AAMR at 1.25. Regionally, the Midwest exhibited the highest AAMR at 1.91 and the Northeast had the lowest AAMR at 1.50. Rural areas demonstrated a higher AAMR (2.03) than urban areas (1.72) from 1999 to 2020. It is forecasted that rural areas will face a drastic decrease in mortality, whereas mortality in urban areas will increase till 2030. Conclusion: This study highlights significant disparities in CHD-related mortality in individuals in the U.S. The differences among the demographic factors and geographic regions highlights the need for equitable healthcare access. Addressing disparities in healthcare access, and improving early detection and management of CHD is crucial.

Introduction: Underrepresentation in clinical trials remains a significant obstacle to achieving equitable healthcare outcomes. In an effort to promote transparency and inclusivity, Congress enacted the Final Rule for Clinical Trials Registration and Results Information Submission (42 CFR Part 11) in January 2017, mandating the reporting of race and ethnicity data on ClinicalTrials.gov. This study examines demographic trends in enrollment for transthyretin amyloid cardiomyopathy (ATTR-CM) clinical trials. Hypothesis: We hypothesize that a significant difference exists between the demographic composition of patients diagnosed with ATTR-CM and those enrolled in U.S.-based clinical trials. Methods: A systematic review of ClinicalTrials.gov was conducted using the search terms “Transthyretin Amyloid Cardiomyopathy,” “Cardiac Amyloidosis,” and “Amyloidosis Cardiac.” Inclusion criteria were U.S.-based studies completed since 2018 with publicly available results. Extracted demographic data included sex, age, and race/ethnicity. An enrollment fraction (EF), the ratio of clinical trial participants to the estimated U.S. disease prevalence, was calculated for gender and race using data from the Cardiac Amyloidosis Registry Study (CARS). Due to limited data, EF calculations were only feasible for participants identifying as White or Black. Statistical analyses were performed using Python. Results: Of 264 identified trials, 17 met the inclusion criteria, 11,786 participants (8,578 males and 3,208 females; male-to-female ratio approximately 3:1). The average participant age was 61 years. Racial and ethnic composition was as follows: White 54%, Black 6.2%, Asian 5.2%, Latino 2.1%, Native Hawaiian or Pacific Islander 0.01%, Native American 0.02%, and Unknown 27.4%. Chi-squared analysis revealed that the EF for White participants was significantly higher than for Black participants (5.85 vs. 0.62; p < 0.05). Male participants also had a higher EF than females (0.12 vs. 0.05; p < 0.05). Conclusion: Despite the 2017 Final Rule, ATTR-CM clinical trials continue to show significant racial and gender disparities. This limits the generalizability of findings and equitable treatment access. Future strategies should prioritize culturally sensitive recruitment, community engagement, and stronger policy enforcement to promote inclusive trial designs.

Background: Maternal hypertensive disorders (MHD), a leading cause of maternal and perinatal morbidity and mortality, remain a critical public health issue even in high-income countries (HIC) with advanced obstetric care. Despite progress in healthcare systems, the evolving trends in MHD burden across HIC remain poorly characterized. Methods: We employed the Global Burden of Disease Study 2021 analytical framework to estimate the burden of MHD across HIC. Case definitions were standardized using ICD-10 codes, and estimates were generated through DisMod-MR 2.1, a Bayesian meta-regression tool. Mortality was modeled using cause-of-death ensemble modeling, while years lived with disability (YLDs) were computed by applying disability weights to prevalence estimates. Temporal trends in age-standardized rates were evaluated using log-linear regression to calculate annual percentage changes (APCs). Results: Between 1990 and 2021, the total number of prevalent cases of maternal hypertensive disorders increased in High-income North America (HINA) from 124,114 (95% UI: 77,999–192,941) to 131,063 (85,937–185,149), in Southern Latin America from 24,774 (15,450–37,690) to 31,021 (20,449–45,050), and in Western Europe from 82,654 (51,187–127,529) to 85,625 (53,336–127,823). Conversely, declines were observed in High-income Asia Pacific (from 31,578 [19,282–48,836] to 18,741 [12,085–27,289]) and Australasia (from 8,037 [5,348–11,685] to 7,408 [4,516–10,924]). The highest annual increase in age-standardized incidence was seen in Germany (0.97%), followed by France (0.86%), Denmark (0.66%), and Israel (0.58%), while the USA exhibited a slight decline (−0.13%). In terms of mortality, Canada was the only high-income country to report an increasing APC (0.19%), whereas all others, including the USA, showed declines, with the USA decreasing by −0.67%. Across all time points, the burden was greatest in women aged 20–29 years, with HINA consistently exhibiting the highest incidence, mortality, and YLDs, despite declining death rates elsewhere and persistently elevated disability burden. Conclusion: Despite declining mortality, MHD remain a persistent challenge in HIC , with rising incidence in parts of Europe and substantial disability burden in HINA. The disproportionate burden among women aged 20–29 years underscores the need for region-specific maternal health strategies focused on early detection, long-term management, and equitable care access.

Introduction: Virtual reality (VR) immersive technologies are an emerging area in healthcare education involving a digital representation of a 3D environment and a head-set to “block out the real world” [1]. They allow for controlled, standardised and repeatable interactions [2] promoting equitable access to high-fidelity learning. Successful implementation necessitates collaboration with learners, to inform development of the product. The session aim was to create a platform for Occupational Therapy (OT) students to develop skills and knowledge with people experiencing suicidal ideation. This module was new for the OT programme. Methods: A half-day session was designed for 53 OT 2nd year prequalifying students at Brookes University Oxford. The VR module was entitled “The mental health practitioner” developed by Bodyswaps™, A preceding on-boarding session had been organised to familiarise students with the Bodyswaps™ platform. Students rotated in groups into a skills lab set up with the VR headsets but joined together in a classroom for a pre-briefing on ground rules, using VR headsets and psychological safety. Students interacted with a virtual patient experiencing suicidal thoughts, choosing responses to her statements and receiving feedback. The experience allowed for self-reflection, students assuming the role of the patient, listening to their own responses embodied by a chosen ‘avatar’. A debrief session was followed by a theory-based seminar on suicide. Results: Students completed an evaluation with Likert scales and free text questions. The session was overall well rated. 20/26 (77%) scored the session at least 7 out of 10. 65% indicated 7 or more out of 10 (10 being strongly agree) that the session helped them improve skills in relation to mental health practice. Some students preferred VR to live simulation while some felt it was artificial. There was a prominent theme around more time, privacy and space. Discussion: The session allowed students to practice difficult conversations in a low-risk immersive environment, through reviewing their own responses and appreciating the patient’s perspective, increasing preparedness for placement and future practice. Faculty staff could use the feedback to develop the module as an alternative to more familiar live-actor simulation. The debrief and theory session supported reflection and theoretical understanding. Feedback indicates a demand for more VR-based mental health training in the future and scope to develop this further for OT teaching. Ethics Statement: As the submitting author, I can confirm that all relevant ethical standards of research and dissemination have been met. Additionally, I can confirm that the necessary ethical approval has been obtained, where applicable.

Background: Ventricular Septal Defects (VSDs) are the most common congenital heart defect in children, affecting about 1 in 500 newborns in the United States, and are the second most prevalent cardiac defect in adults. However, limited data is available on demographic disparities in VSD-related mortality within the US. Aims: We assessed the trends in VSD-related mortality among the US population with an emphasis on age-related, racial, and geographic differences. Methods: The CDC WONDER multiple-cause of death database was analyzed from 1999 to 2023 for VSD-related mortality across all age categories, using the ICD-10 code Q21.0 (Ventricular Septal Defect). Crude mortality rates (CMRs) and age-adjusted mortality rates (AAMRs) with 95% confidence intervals (CIs) were calculated per 1,000,000 for age, year, sex, race, region, state, and urbanization status. Annual percentage change (APC) was determined by Joinpoint regression. Results: From 1999 to 2023, 8,601 deaths in the US were attributed to VSDs, with nearly two-thirds occurring in individuals <45 years. The AAMR declined from 1.8 in 1999 to 0.9 in 2012 (APC: -4.8; 95% CI: -8.2, -3.7), then stabilized through 2023 (APC: 0.8, 95% CI: -1.6, 7.2). Infants less than a year old accounted for the most deaths (38.4%) and the highest overall CMRs (33.6) which declined from 46.1 in 1999 to 25.6 in 2013 (APC: -3.2; 95% CI: -6.9, -1.9), then increased to 36.1 in 2023 (APC: 2.8; 95% CI: 0.2, 11.4). CMRs in other age groups either declined or remained stable. Female deaths (53.3%) exceeded male deaths (46.7%), though similar AAMRs were seen (1999: 1.7 vs 1.8; 2023: 0.9 vs 0.9). By race, the highest AAMRs were noted among the non-Hispanic (NH) Blacks (1.2), followed by NH Whites (1.1) and Hispanics/Latinos (0.9). Regionally, the West and Midwest had the highest AAMRs (1.2). Rural areas had higher mortality rates (1.3) than urban areas (1.1). Moreover, states in the top 90th percentile of VSD-related mortality included Iowa, the District of Columbia, West Virginia, Maine, and New Mexico. Conclusion: After declining until 2012, VSD-related mortality rates have stabilized through 2023, although a concerning rise in infant deaths has emerged since 2013. Higher death rates, noted among infants, NH Blacks, Western, Midwestern, and rural residents, highlight the need for targeted surveillance, timely diagnosis, equitable access to specialized care and further research into the factors driving these patterns.

Background: Cardiogenic shock (CS) is a high-acuity condition with in-hospital mortality rates of 30–40%. Over time, the acuity and multimorbidity of patients with CS has increased, along with the number of CS admissions and use of mechanical circulatory support (MCS). In response, professional societies advocate for a three-tiered cardiac intensive care unit (CICU) model based on patient acuity and hospital capabilities. State level and national data outlining availability of CICU care is not available, hampering efforts to develop coordinated care systems. This challenge is pronounced in large states with competing health care systems like California. Objective: The goal of this study is to characterize CS care capabilities across California, map the location and catchment areas of Level 1 and Level 2 CICUs, and identify access disparities within the state's decentralized healthcare system. Methods: We identified cardio-capable hospitals using California HCAI databases, 2021 Census data, and manufacturer information (Getinge, Abiomed). Structured surveys were sent to each hospital to assess staffing and resource availability. Hospitals were categorized by their capability to manage CS as Level 1-3 CICUs based on professional staffing and therapeutic resources. Geospatial analysis was performed to map CICU locations with their estimated geographic reach based on 60-minute travel time and population density. Results: We identified 184 cardio-capable hospitals throughout the state of California. Of these, 16 (8.7%) met the criteria for Level 1 CICU designation. These were concentrated in densely populated urban areas, leaving large rural areas outside of timely access to advanced CS care (Figure 1 and Figure 2). Survey responses were received from 88 institutions (Table 1), most of which were urban (89.7%). Dedicated CICUs were present in 29.5%. CS care resources varied: dedicated shock teams (21.6%), on-site ECMO (44.3%), Impella (69.3%), and intra-aortic balloon pumps (76.1%). Only 19.3% had 24/7 intensivist coverage, and 10.2% reported critical care cardiologist staffing. Most had on-site cath labs (78.4%) and cardiothoracic surgery (64.7%). Conclusion: There is significant variation in hospital capabilities for managing CS across California, with a limited number of Level 1 CICUs that are concentrated in urban areas. These findings highlight the need for regionalized care networks to ensure equitable access to comprehensive care for patients with CS.

Background: Left Atrial Appendage Occlusion (LAAO) is a critical intervention for stroke prevention in patients with atrial fibrillation who are unsuitable for long-term anticoagulation. Despite its efficacy, disparities in referral rates for LAAO based on race and insurance type remain underexplored. This study evaluates the rates of LAAO referrals among atrial fibrillation patients across different racial groups and insurance types using data from the National Inpatient Sample (NIS). Objective: To evaluate disparities in referral rates for left atrial appendage occlusion among patients with atrial fibrillation, specifically examining differences across racial groups and insurance types using data from the National Inpatient Sample. Methods: We conducted a retrospective cohort study using the NIS from 2018 to 2023. Adult patients (≥18 years) with a diagnosis of atrial fibrillation were identified using validated ICD-10 codes. Patients were stratified by race (White, Black, Hispanic, Asian) and primary payer type (Private Insurance vs. Medicaid/Medicare). Referrals for LAAO were identified using procedure-related billing and referral codes. Patients with missing race or insurance data were excluded. Chi-square tests were used to compare referral rates across groups, with statistical significance set at p < 0.05. Results: Among 4,500 atrial fibrillation patients analyzed, 62% were White, 18% Black, 12% Hispanic, and 8% Asian. Overall, referral rates for LAAO were significantly higher among patients with private insurance (68%) compared to those with Medicaid/Medicare (47%) (p < 0.01). Referral disparities were evident across all racial groups. Among White patients, referral rates were 72% (private) vs. 50% (Medicaid/Medicare); for Black patients, 58% vs. 35%; for Hispanic patients, 60% vs. 38%; and for Asian patients, 65% vs. 42%, respectively. Black patients with Medicaid/Medicare had the lowest referral rate of any subgroup. Conclusion: Disparities in LAAO referral rates are evident across racial and insurance groups, with Medicaid/Medicare recipients, particularly Black patients, being significantly less likely to receive referrals for LAAO. Addressing these disparities is crucial to ensure equitable access to stroke prevention strategies in atrial fibrillation care.

Background: Heart disease continues to be the leading cause of death in the United States in 2025. Ill-defined descriptions of heart disease may lead to misclassification of deaths by ICD codes, potentially obscuring the growing clinical burden and masking disparities among high-risk populations and regions across the U.S. Research Question: What are the temporal trends in mortality due to complications and ill-defined heart disease from 1999 to 2020 in U.S? Methods: We abstracted data from CDC-WONDER database using ICD-10 code: I51, from 1999-2020. Age-Adjusted Mortality Rate (AAMR) per 100,000 population and Annual Percentage Change (APC) along with 95% confidence intervals (CI) were determined. Joinpoint regression analysis (v 5.4.0.0) was used to examine trends stratified by overall, sex, race/ethnicity, age-group, states, census region and 2013 urbanization. Results: A total of 863,974 deaths related to ill-defined descriptions of heart disease were reported between 1999-2020, with a steady increase in overall AAMR (11.80), and an APC of 1.56 (95% CI 1.29 to 1.82, p <0.000001). Males had overall higher AAMR (15.22) compared to females (8.94). Non-Hispanic (NH) Blacks or African American exhibited overall highest AAMR (16.49), followed by NH-American Indian or Alaska Native (12.49). People aged 85+ years outweighed all age-groups with a strikingly high overall AAMR (211.74). States in top 90 th percentile; Alabama (21.16), Louisiana (21.58), Georgia (23.29), Mississippi (29.99) had a roughly 4-5 times difference in the overall AAMR than states in the lower 10 th percentile; Massachusetts (6.43), Virginia (8.14), New York (8.15). By census region, the South had the overall highest AAMR (14.24) followed by Midwest (11.42). Similar disparities were noted in urban-rural status, with Non-metropolitan displaying overall highest AAMR (15.62). Conclusions: The disproportionately high mortality rates among NH-Blacks or African American, NH-American Indians or Alaska natives and non-metropolitan regions of states in the South (Louisiana, Georgia, Mississippi) underscore the urgent need for improved diagnostic accuracy, standardized cause-of-death certification, and equitable access to quality healthcare. Addressing these gaps is essential for shaping informed and effective health policy across the United States.

Introduction: Atrial fibrillation (AF) has emerged as a critical and escalating public health threat, particularly among individuals with diabetes mellitus, a population already burdened with elevated cardiovascular risk. In 2023, an estimated 1.8 million Americans are living with AF along with diabetes, a dangerous convergence of two chronic conditions that dramatically amplifies the risk of cardiovascular mortality. Diabetic patients face a 1.4–1.6 times greater risk of developing AF, yet national surveillance data on mortality trends in this high-risk group remain limited. This study urgently examines the growing burden and pronounced disparities in atrial fibrillation-related mortality among diabetic patients across the United States to guide targeted interventions and shape equitable health policy responses. Methods: The CDC WONDER database was used to analyze trends in mortality due to atrial fibrillation in patients with diabetes mellitus from 1999 to 2023, calculating mortality rates and a 95% confidence interval to assess national trends. Results: Throughout the study period, males consistently exhibited a higher age-adjusted mortality rate (AAMR) from atrial fibrillation in diabetic patients—148.92 (95% CI: 148.37–149.48)—compared to females, 106.11 (95% CI: 105.73–106.49). The African American population had the highest AAMR, reaching 342.37 in 2023 (95% CI: 335.99–348.74), significantly exceeding rates in White 158.45 (95% CI: 157.66–159.24), Hispanic 96.88 (95% CI: 95.45–98.30), and Asian/Pacific Islander populations 75.21 (95% CI: 73.79–76.72). From 1999 to 2023, the AAMR in non-metropolitan areas rose from 112.47 (95% CI: 110.21–114.73) to 386.21 (APC: 6.30; 95% CI: 377.66–394.76), reflecting a significant and sustained increase. AAMRs also varied by state, ranging from 119.90 (95% CI: 119.20–120.61) in Hawaii to 211.97 (95% CI: 209.39–214.55) in West Virginia. Conclusion: From 1999 to 2023, mortality attributable to atrial fibrillation among diabetic patients rose at an alarming rate, disproportionately affecting males, African American individuals, and those residing in non-metropolitan regions. These stark disparities highlight a growing crisis in cardiovascular health equity. Addressing this alarming trend requires urgent action focused on early screening, improving equitable access to healthcare, and implementing targeted interventions. Without intervention, the rising toll of preventable deaths in vulnerable populations will worsen.

Purpose This study explores how digital exclusion impacts citizen engagement with e-government services in China, particularly among non-local (migrant) populations. Through surveys and interviews, this study will explore migrants' experiences of digital exclusion and its effects on empowerment and service satisfaction. It will also provide empirical insights into whether e-government enhances social belonging or deepens exclusion in China. Design/methodology/approach A mixed-methods approach combined quantitative surveys (N = 450) with qualitative interviews (N = 60). The study integrates the technology acceptance model (TAM), digital divide theory and empowerment theory to examine the hypotheses. Findings Results indicate that the digital divide reinforces social inequality, with older, less-educated and migrant users experiencing greater difficulty accessing digital public services. Perceived ease of use and usefulness significantly influence satisfaction and intention to use e-government services. Government responsiveness and expectation confirmation are critical in fostering psychological, social and political empowerment, particularly for migrants who rely more on digital platforms but do not have access. Originality/value This study contributes to the e-government studies within the public administration discipline by integrating digital empowerment theory with the technology acceptance model into a novel conceptual proposal that is empirically tested by focusing on the lived experiences of the migrants in China. It offers practical recommendations for inclusive digital governance design to ensure equitable access and engagement across diverse user groups.

Background: Although catheter ablation (CA) has become a cornerstone in rhythm control for atrial fibrillation (AF), real-world practice continues to lean heavily on antiarrhythmic drug (AAD) therapy, particularly in older, underserved, and racially diverse populations. While clinical trials demonstrated that ablation improves quality of life, symptom control, and long-term cardiovascular outcomes, these findings may not fully translate into routine care. This study examines nationwide patterns in the use of ablation and AADs, assess associated outcomes, and evaluate socio-demographic disparities in the treatment of AF. Methods: A retrospective cohort study was done using the National Inpatient Sample (2016–2020), identifying adult hospitalizations with a primary diagnosis of AF. Treatment groups were defined as patients undergoing CA (ICD-10-PCS codes) and those receiving AADs. Outcomes included in-hospital mortality, length of stay, cardioversion rates, and major adverse events (stroke, cardiac arrest, bradyarrhythmia). Stratified analyses were performed by age, sex, race, insurance, and hospital type. Logistic regression models adjusted for clinical and demographic variables were used to identify predictors of treatment type and adverse outcomes. Results: Out of 287,450 weighted AF hospitalizations, only 6.7% underwent CA, while nearly 1/3 (32.8%) received AAD therapy. Ablation recipients were younger (mean age 61 vs. 72), more often male (63% vs. 52%), and White (76% vs. 59%). Patients from racial and ethnic minority groups, especially Black and Hispanic patients, were significantly less likely to receive ablation even after controlling for comorbidities and hospital characteristics. In-hospital mortality was markedly lower in the ablation group (0.3% vs. 1.9%), with fewer adverse events and shorter stays (median 2.1 vs. 4.3 days). Notably, adverse drug reactions and bradycardia were more frequent in the AAD group, particularly among women and older adults. Conclusion: Despite compelling evidence in favor of CA, real-world treatment for AF continues to favor pharmacologic rhythm control which affects women, racial minorities, and patients treated at small setups. Our findings suggest that rhythm control decisions are shaped not just by clinical factors, but also by systemic inequities in access and referral patterns. Reducing overreliance on AADs and expanding equitable access to ablation may improve patient outcomes and better align practice with evidence.

Background: Stroke is the fifth leading cause of mortality in the United States (US), with diverse etiologies. Evidence suggests that cancer is a significant predisposing factor, with studies demonstrating an elevated risk of stroke in cancer patients. However, mortality trends due to concomitant stroke and cancer remain underexplored. Therefore, our study aims to investigate mortality trends attributable to stroke and cancer in the US across demographics and regions. Methods: The CDC WONDER multiple cause of death database was used to extract death certificate data for adults aged ≥ 25 years. Age-adjusted mortality rates (AAMR) per 100,000 persons were calculated, and annual trends were determined by calculating annual percent change (APC) and the average APC (AAPC) in AAMR using Joinpoint regression analysis. Results: From 1999 to 2023, a total of 538,858 stroke and cancer-related deaths were recorded in the US. The AAMR decreased from 1999 to 2009 (APC: -3.76, 95% CI: -4.90 to -3.06) and then till 2014 (APC: -2.36, 95% CI: -3.98 to -0.97), followed by a stable trend till 2018 (APC: 0.85, 95% CI: -1.36 to 2.21). Subsequently, the AAMR surged between 2018 and 2021 (APC: 7.86, 6.29 to 9.10) and then a stable disease period was observed till 2023 (APC:0.72, 95% CI: -1.20 to 2.60). Males had higher AAMRs than females. Non-Hispanic (NH) Black or African Americans displayed the highest AAMR, followed by NH White, other NH populations, and Hispanic or Latino group. Midwest region reported the highest AAMR while Northeast reported the lowest. Rural areas exhibited a higher AAMR (11.09, 95% CI: 11.01 to 11.16) than urban areas (AAMR: 9.2, 95% CI: 9.17 to 9.23). When stratified by cancer types, gastrointestinal and lung cancer experienced the highest AAMRs. Upon stratification by stroke subtype, intracerebral hemorrhage had the highest AAMRs during early years of study period; however, ischemic stroke-related AAMR showed the highest increase between 2017 and 2023 (APC: 11.89, 95% CI: 8.14 to 13.82). Conclusions: While the overall stroke and cancer-related mortality is decreasing, ischemic stroke-related cancer deaths are on the rise. Highest mortality rates were found in men, NH Black or African Americans, residents of the Midwest region, and rural areas. Our findings underscore the critical need for early cardiovascular care for cancer patients. Furthermore, efforts are needed to improve equitable access to healthcare for socioeconomically disadvantaged populations.

Background: Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide. Ventricular arrhythmias (VAs), including ventricular tachycardia and ventricular fibrillation, are often life-threatening in setting of AMI. While advances in revascularization have improved outcomes, the burden of AMI and VA-related mortality across U.S. subpopulations remains unclear. We aimed to assess trends and demographic disparities in AMI and VA-related deaths in the United States. Methods: We analyzed national mortality data from the CDC WONDER database between 1999 and 2020. Deaths attributed to AMI and VAs were identified using ICD codes. Age-adjusted mortality rates (AAMRs) per 100,000 population and 95% confidence intervals (CIs) were calculated and stratified by sex, race/ethnicity, age group, and geographic region. Results: A total of 71,036 deaths were attributed to AMI and VAs over the study period. The AAMR declined sharply from 2.41 in 1999 to 1.08 in 2007 (APC: -9.91; 95% CI: -10.7 to -9.02). From 2007 to 2020, a gradual decline in mortality was observed (1.08 to 1.01) (APC: -0.83; 95% CI: -1.47 to -0.19). Men had consistently higher AAMR than women from 1999 (4.39 vs 1.88) to 2020 (1.84 v s0.68); moreover, since 2008, no significant decline in mortality was observed for males. Whites had the highest number of deaths (n=62,157; AAMR: 1.51 [95% CI: 1.50–1.52]), followed by Blacks or African Americans (1.43 [95% CI: 1.39–1.46]), American Indians (1.10 [95% CI: 0.98–1.22]), Hispanics (1.04 [95% CI: 1.00–1.07]), and Asian or Pacific Islanders (0.89 [95% CI: 0.85–0.94]). All races had a significant decline in mortality across years; however, Hispanics had a rise in mortality from 2011-2020 (APC: 3.06; 95% CI: 0.82 to 5.36). Mortality increased markedly with age: older adults (≥65 years) had a 49-fold higher AAMR (5.38 vs 0.11) compared to younger adults. There was also a significant state-wide difference in mortality as shown in Figure 1. Conclusion: AMI and VA-related mortality in the US from 1999–2020 remained substantial, with significant disparities by age, sex, race, and region. Older adults, males, and those residing in the South experienced the highest mortality burden. Hispanic had a increase in mortality since 2011. These findings underscore the continued need for targeted prevention, early recognition of electrical complications of AMI, improved post-AMI surveillance, and equitable access to life-saving interventions like ICDs.

Introduction: Advanced heart failure in incarcerated individuals presents unique clinical, ethical, and logistical challenges. Mechanical circulatory support (MCS), including left ventricular assist devices (LVAD), offers life-saving therapy for patients ineligible for heart transplant. However, access remains limited in the prison system due to systemic healthcare disparities. This case highlights the complexity of managing cardiogenic shock in incarcerated patients and barriers to equitable advanced heart failure care with MCS. Case Presentation: A 57-year-old incarcerated male with non-ischemic cardiomyopathy presented with abdominal pain, dyspnea, and atrial fibrillation with rapid ventricular response. Exam revealed hypotension, cold extremities, and elevated jugular venous pressure. Workup showed a renal infarct (presumed cardioembolic), EF 8%, biventricular dysfunction, and cardiogenic shock despite cardioversion and rhythm control requiring norepinephrine (0.5 mcg/kg/min), epinephrine (0.1 mcg/kg/min), and dobutamine (2.5 mcg/kg/min). Though initially ineligible for transplant or LVAD due to incarceration and prior substance use, he was temporarily stabilized with an Impella 5.5. He was transitioned to milrinone with clinical improvement and discharged to his correctional facility with plans for reassessment for advanced options following expected imminent prison release. Unfortunately, he was readmitted with recurrent cardiogenic shock and MRSE bacteremia. Following stabilization with dual inotropes and aggressive afterload reduction as well as completion of antibiotic therapy, he underwent successful LVAD placement. Discussion: This case underscores the barriers in providing durable LVAD therapy to incarcerated patients. Coordination of care is limited by the constraints of the correctional health system, including staff education, restricted access to specialized centers, and difficulty with device maintenance such as hygiene, battery care, and emergency care in case of device malfunction. Incarceration also limits social support, impacts adherence, and contributes to psychological stress. Infection risk and security concerns further complicate care. Addressing these challenges are essential to ensure that incarcerated individuals receive equitable access to advanced heart failure therapies and thus facilitate optimal outcomes.

Introduction: Substance abuse disorder (SUD) combined with atrial fibrillation (AF) results in dire patient outcomes and accelerated mortality. Research on the combined mortality trends and disparities, stratified by different demographic and geographical classifications related to substance use disorders (SUD) and alcohol-related fatalities (AF), is limited. This study examines mortality trends in adults aged 25 years and older with SUD and AF from 1999 to 2020. Methods: The CDC WONDER Multiple Cause-of-Death dataset from 1999 to 2020 was used to analyze mortality trends among adults aged 25 years and older, using ICD-10 codes F10-F19 for SUD and I48 for AF. Age-adjusted mortality rates (AAMR) were quantified per 100,000 (95% CI). Ten-year age groups were used in the data extraction. Average annual percent change (AAPC) in terms of AAMR was analyzed using the Joinpoint regression model, and statistical significance was set at p<0.05. Results: Between 1999 and 2020, 253,949 SUD- and AF-related deaths occurred, mostly in nursing homes/long-term care facilities (41.6%). Overall, AAMR rose from 0.5 in 1999 to 10.5 in 2020 (AAPC: 17.1; 95% CI: 16.0 to 20.0). Men had a higher AAMR compared to women (men: 8.1 vs. women: 3.4), though both sexes had similar rates of increase (AAPC men: 16.8; 95% CI: 15.8 to 20.1 vs. women: 16.8; 95% CI: 15.7 to 18.9). AAMR increased with age, as adults aged ≥ 75 years had the highest AAMR (38.6) compared to 55-74-year-olds (6.8) and 25-54-year-olds (0.2). Adults aged ≥ 75 years also had the highest rate of increase (AAPC: 18.2; 95% CI: 17.1 to 21.3). Non-Hispanic (NH) Whites had a higher AAMR (6.1) compared to NH Black/African Americans (3.0), along with a higher rate of increase (AAPC: 17.6; 95% CI: 16.6 to 20.4). Regionally, the Midwest had the highest AAMR (6.8), along with the highest rate of increase (AAPC: 18.1; 95% CI: 17.2 to 20.2). State-wise, AAMR extended from 1.0 in California to 16.1 in Vermont. Non-metropolitan areas had a higher AAMR (7.2) versus metropolitan areas (5.0), along with a higher rate of increase (AAPC: 18.8; 95% CI: 17.8 to 20.9). Conclusion: SUD- and AF-related mortality in adults ≥ 25 years old increased from 1999 to 2020, along with significant disparities among demographic and regional stratifications. These disparities emphasize the need for targeted prevention and support strategies for at-risk communities to achieve equitable access to health care so that mortality rates can decrease in the future.