Greater Socioeconomic Disadvantage Research Articles

The future of AVS, dizziness, and vertigo in emergency departments Part iii: A tyranny of distance – the persistence of rural health inequity

The future of AVS, dizziness, and vertigo in emergency departments Part iii: A tyranny of distance – the persistence of rural health inequity In the third article of this five-part series, Dr Millie Nakatsuka discusses the impact of isolation on health equity and the medical decision-making for emergency presentations of acute vestibular syndrome (AVS). People in rural and remote areas bear a significantly higher burden of disease and have poorer health outcomes. They have greater socio-economic disadvantage with lower levels of educational attainment, lower rates of employment, lower income and exhibit more health risk factors with markedly increased rates of obesity, tobacco smoking and alcohol consumption.

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services.

Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC. Retrospective cohort study, including older individuals with dementia who accessed HCPs (n=50,257) or PRAC (n=250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n=2367) and PRAC (n=15,597) using the cumulative incidence function. Between 2011-12 and 2015-16, antipsychotic use for >90days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively. While small decreases in antipsychotic use >90days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Sociodemographic patterns in biomarkers of aging in the Add Health cohort

ABSTRACT Biomarkers in population health research serve as indicators of incremental physiological deterioration and contribute to our understanding of mechanisms through which social disparities in health unfold over time. Yet, few population-based studies incorporate biomarkers of aging in early midlife, when disease risks may emerge and progress across the life course. We describe the distributions of several biomarkers of inflammation and neurodegeneration and their variation by sociodemographic characteristics using blood samples collected during Wave V of the National Longitudinal Study of Adolescent to Adult Health (ages 33–44 years). Higher mean levels of inflammatory and neurodegenerative biomarkers were associated with greater socioeconomic disadvantage. For example, the neurodegenerative markers, Neurofilament Light Chain and total Tau proteins were higher among lower income groups, though the relationship was not statistically significant. Similarly, proinflammatory marker Tumor Necrosis Factor-α (TNF-α) levels were higher among those with lower education. Significant differences in the mean levels of other proinflammatory markers were observed by race/ethnicity, sex, census region, BMI, and smoking status. These descriptive findings indicate that disparities in biomarkers associated with aging are already evident among young adults in their 30s and attention should focus on age-related disease risk earlier in the life course.

PATIENT PRIORITIES CARE FOR VETERANS

Abstract People receiving care in the Veterans Affairs (VA) health system are older, have greater socioeconomic disadvantage, and more chronic conditions than those receiving healthcare outside of VA. PPC is well-suited for older adults with multiple chronic conditions and aligns with the VA’s Whole Health movement. A small VA PPC pilot study demonstrated that those receiving PPC compared to usual care had fewer medications added and more home and community services aligned with priorities. VA primary care is a cornerstone and hub for veteran care utilizing a team-based approach. A two-site randomized controlled trial exploring the implementation of PPC in VA primary care is currently recruiting veterans. The early phase of the project involved semi-structured formative assessment interviews with key stakeholders to obtain feedback and perspectives on PPC implementation in VA primary care. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis. Concerns elicited were time constraints, follow up and documentation of changes in priorities over time, managing patient expectation, communication between primary care and specialty care, as well as how PPC would impact quality metrics. In response to these findings, the patient priorities note template was shortened and streamlined, and the study communications workflow was adapted to align with clinician preferences. Succinct templated language for care alignment was crafted and shared with study providers. Education for clinicians highlighted ways in which priorities could be used to optimize communication. Study procedures were added to identify quality metric exclusions. The study will explore how PPC impacts veteran care and experience.

Community-level social determinants of health and pregestational and gestational diabetes

Individual adverse social determinants of health are associated with increased risk of diabetes in pregnancy, but the relative influence of neighborhood or community-level social determinants of health is unknown. This study aimed to determine whether living in neighborhoods with greater socioeconomic disadvantage, food deserts, or less walkability was associated with having pregestational diabetes and developing gestational diabetes. We conducted a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be. Home addresses in the first trimester were geocoded at the census tract level. The exposures (modeled separately) were the following 3 neighborhood-level measures of adverse social determinants of health: (1) socioeconomic disadvantage, defined by the Area Deprivation Index and measured in tertiles from the lowest tertile (ie, least disadvantage [T1]) to the highest (ie, most disadvantage [T3]); (2) food desert, defined by the United States Department of Agriculture Food Access Research Atlas (yes/no by low income and low access criteria); and (3) less walkability, defined by the Environmental Protection Agency National Walkability Index (most walkable score [15.26-20.0] vs less walkable score [<15.26]). Multinomial logistic regression was used to model the odds of gestational diabetes or pregestational diabetes relative to no diabetes as the reference, adjusted for age at delivery, chronic hypertension, Medicaid insurance status, and low household income (<130% of the US poverty level). Among the 9155 assessed individuals, the mean Area Deprivation Index score was 39.0 (interquartile range, 19.0-71.0), 37.0% lived in a food desert, and 41.0% lived in a less walkable neighborhood. The frequency of pregestational and gestational diabetes diagnosis was 1.5% and 4.2%, respectively. Individuals living in a community in the highest tertile of socioeconomic disadvantage had increased odds of entering pregnancy with pregestational diabetes compared with those in the lowest tertile (T3 vs T1: 2.6% vs 0.8%; adjusted odds ratio, 2.52; 95% confidence interval, 1.41-4.48). Individuals living in a food desert (4.8% vs 4.0%; adjusted odds ratio, 1.37; 95% confidence interval, 1.06-1.77) and in a less walkable neighborhood (4.4% vs 3.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.04-1.71) had increased odds of gestational diabetes. There was no significant association between living in a food desert or a less walkable neighborhood and pregestational diabetes, or between socioeconomic disadvantage and gestational diabetes. Nulliparous individuals living in a neighborhood with higher socioeconomic disadvantage were at increased odds of entering pregnancy with pregestational diabetes, and those living in a food desert or a less walkable neighborhood were at increased odds of developing gestational diabetes, after controlling for known covariates.

Impact of the Exercise Right for Active Ageing program on physical function in older adults: a quasi-experimental pre-post study

BackgroundThe Exercise Right for Active Ageing (ERAA) program was established to improve access to exercise classes for community-dwelling older Australians. The aims of this study were to determine whether older adults, who participated in ERAA exercise classes experienced a change in physical function, and identify factors associated with this change.MethodsParticipants included community-dwelling older adults, aged ≥ 65 years, from every state and territory of Australia. The ERAA program included 12 subsidised, weekly, low- to moderate-intensity exercise classes, delivered by accredited exercise scientists or physiologists (AESs/AEPs). Primary outcomes included the 30 s Sit-to-Stand (STS) and the 3-metre Timed Up and Go (TUG) tests. Secondary outcomes included grip strength, the Chair Sit and Reach test, and waist circumference. Linear mixed-effects regression models were used to evaluate the change in outcomes following program completion, and to determine factors associated with changes in the primary outcomes.Results3,582 older adults (77% female) with a median (IQR) age of 72 (69–77) years completed follow-up testing. For all primary and secondary outcomes, there was a statistically significant improvement after program completion (p < 0.001). The STS increased by 2.2 repetitions (95% CI: 2.1, 2.3), the TUG decreased by 0.9 s (95% CI: -1.0, -0.8), right and left grip strength increased by 1.3 kg (95% CI: 1.2, 1.5) and 1.5 kg (95% CI: 1.3, 1.6), respectively, right and left reach increased by 1.7 cm (95% CI: 1.4, 2.0), and waist circumference decreased by 1.2 cm (95% CI: -1.4, -1.1). Greater improvements in STS were observed for participants aged 65–69 years, females, and those with greater socio-economic disadvantage. For the TUG, greater improvements were observed in participants reporting 2 + comorbidities, and residing in outer regional areas and areas with greater socio-economic disadvantage.ConclusionsParticipation of older Australians in the ERAA program, led to statistically significant improvements in physical function. The program reached a large number of older Australians from every state and territory, including those from regional and remote parts of Australia, aged over 85 years, and with high levels of comorbidity, which supports the feasibility and acceptability of AES- and AEP-led exercise classes amongst community-dwelling older Australians.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12623000483651). Registered 12 May 2023 - Retrospectively registered, https://www.anzctr.org.au/ACTRN12623000483651.aspx.

Association of socioeconomic disadvantage with lower patient satisfaction at an academic radiation oncology center.

347 Background: The correlation between socioeconomic status and healthcare outcomes is well-established. Patient satisfaction serves as a crucial indicator of healthcare quality, however, it is unclear if patient satisfaction relates to patient socioeconomic status. To assess socioeconomic status, the Area Deprivation Index (ADI) is utilized, encompassing factors such as income, education, employment, and housing quality to measure the status of a neighborhood. The purpose of this study was to evaluate if there was a correlation between socioeconomic status and the likelihood a patient would recommend the facility or provider. Methods: This is a single-institution study evaluating the responses to a CMS approved patient satisfaction vendor survey of patients seen at an outpatient academic radiation oncology department from May 2021 through March 2023. ADI was collected using the Neighborhood Atlas, including both national percentiles and state deciles, with the higher values indicating greater socioeconomic disadvantage. Univariate (UVA) and multivariate (MVA) logistic regression analyses were conducted using the survey recommendation scores between 0 and 10 as the primary outcome. We used the score ≥9 to represent increased likelihood for recommendation for facility or provider and &lt;9 represented decreased likelihood. Results: There were 5,403 survey results included in our analysis. The mean state and national ADI in our cohort were 3.9 (range 1-10) and 50.35, respectively. Patients with state and national ADI scores below the mean were more likely to recommend the provider than those above the mean, 95.6% versus 93.6% (p=0.002) and 95.8% versus 93.6% (p&lt;0.001), respectively. There was no difference in the likelihood of recommending the facility between the groups. On univariate analysis state ADI &lt;3.9 (OR 1.46, p=0.016) and national ADI &lt;50.35 (OR 1.43, p=0.023) were associated with increased likelihood to recommend the facility or provider. On multivariate analysis, state ADI &lt;3.9 (OR 1.44, p=0.018) and national ADI &lt;50.35 (OR 1.40, p=0.033) remained significant. Conclusions: The findings of this study highlight the significance of socioeconomic status as an independent factor influencing patient satisfaction and their likelihood to recommend a healthcare provider. Providers should consider the unique needs of socioeconomically disadvantaged individuals.

4 Neurophenotypes and recovery trajectories following laboratory-confirmed SARS-CoV-2 infection

Objective:Cognitive sequelae are reported in 20-25% of patients following SARS-CoV-2 infection. It remains unclear whether post-infection sequelae cluster into a uniform cognitive syndrome. In this cohort study, we characterized post-COVID neuropsychological outcome clusters, identified factors associated with cluster membership, and examined 6-month recovery trajectories by cluster.Participants and Methods:The Mayo Clinic Institutional Review Board approved study protocols. Informed consent was obtained from all participants. Participants (&gt; 18 years old) were recruited from a hospital-wide registry of Mayo Clinic Florida patients who tested positive for SARS-CoV-2 infection from July 2020 to Feb 2022. We abstracted participant health history and COVID-19 disease severity (NIAID score) from the electronic health record and retrieved Area Deprivation Index (ADI) scores as a measure of neighborhood socioeconomic disadvantage. We assessed objective cognitive performance with the CNS Vital-Signs (CNSVS) and subjective neuropsychological symptoms with the Neuropsych Questionnaire-45 (NPQ-45). Results were used as input features in a K-means clustering analysis to derive neurophenotypes. Chi-square and analysis of variance (AnOvA) tests were used to identify clinical and sociodemographic factors associated with cluster membership. Participants repeated the CNS Vital Signs, NPQ-45, as well as the Medical Outcomes Survey (MOS SF-36) and a posttraumatic stress disorder (PTSD) checklist (PCL-C 17) 6 months following initial testing. Repeated-measures ANOVA was used to assess change in neurocognitive performance over time by cluster. Significance was set at P &lt; 0.05.Results:Our cohort consisted of 205 participants (171 ambulatory, 34 hospitalized) who completed post-acute outcome assessment a mean of 5.7 (± 3.8) weeks following testing positive for SARS-CoV-2. K-means clustering with elbow method fitting identified three subgroups (see figure). The first cluster (N = 31) is characterized by executive dysfunction, greater socioeconomic disadvantage, and higher rates of obesity. The second cluster (N = 32) is characterized by memory and speed impairment, higher COVID severity, prevalent anosmia (70%), and greater severity of memory complaints, depression, anxiety, and fatigue. The third and largest cluster (N = 142) is absent cognitive impairment. Approximately 39% of participants completed the 6-month outcome assessment (N=79). Regardless of cluster membership, verbal memory, psychomotor speed, and reaction time scores improved over time. Regardless of timepoint, cluster 1 (dysexecutive) showed lower scores on cognitive flexibility and complex attention and cluster 2 (memory-speed impaired) showed lower scores on verbal memory, psychomotor speed, and reaction time. Modeling of cluster by timepoint interactions showed a steeper slope of improvement in complex attention and cognitive flexibility in cluster 1 (dysexecutive). Cluster 3 (normal) showed significant improvement in fatigue while cluster 2 (memory-speed impaired) continued to report moderate-severe fatigue, worse medical outcomes, and higher PTSD symptom severity scores at six months.Conclusions:Most participants were cognitively normal or experienced cognitive recovery following SARS-CoV-2 infection. The 25-30% of participants who showed cognitive impairment cluster into two different neurophenotypes. The dysexecutive phenotype was associated with socioeconomic factors and medical comorbidities that are non-specific to COVID-19, while the amnestic phenotype was associated with COVID-19 severity and anosmia. These results suggest that cognitive sequelae following SARS-CoV-2 infection are not uniform. Deficits may be influenced by distinct patient- and disease-specific factors, necessitating differentiated treatment approaches.

Greater Socioeconomic Disadvantage as Measured by the Area Deprivation Index Is Associated With Failure of Healing Following Arthroscopic Repair of Massive Rotator Cuff Tears but Not With Clinical Outcomes

To analyze the relationship between Area Deprivation Index (ADI) and preoperative status and short-term postoperative clinical outcomes among patients who underwent arthroscopic rotator cuff repair (ARCR) of massive rotator cuff tears (MRCTs). A retrospective review was conducted on prospectively maintained data on patients who underwent ARCR of MRCTs defined as tear size ≥5 cm or complete tear of at least 2 tendons, with a minimum 2-year follow-up and a valid home address between January 2015 and December 2018. Each patient's home address was mapped to the ADI to determine neighborhood disadvantage. This composite index is composed of 17 census-based indicators, including income, education, employment, and housing quality to quantify the level of socioeconomic deprivation. Ratings were recorded and categorized based on the sample's percentile. Patients were then divided into 2 groups: upper quartile (ie, most disadvantaged [≥75th percentile]) and lower 3 quartiles (ie, least disadvantaged [<75th percentile]). Bivariate analysis was performed to associate ADI with patient-reported outcomes (PROs) and range of motion pre- and postoperatively, as well as complications, healing rate, satisfaction, and return to work. Patients reaching or exceeding the minimal clinically important difference for visual analog scale (VAS), American Shoulder and Elbow Surgeons, Veterans Rand 12-Item questionnaire, and subjective shoulder value were recorded for both cohorts. Ninety-nine patients were eligible for study analysis. Preoperative PROs and range of motion were similar, except for a greater VAS for pain (6.3 vs 4.3; P < .01) and lower American Shoulder and Elbow Surgeons score (32.2 vs 45.1; P= .01) in the most disadvantaged group. Both groups showed similar postoperative PROs scores, but greater VAS improvement was seen in the upper quartile group (Δ 4.2 vs Δ 3.0; P= .04). In contrast, only the least-disadvantaged group significantly improved in internal rotation (P= .01) and forward flexion (18°; P < .01) from baseline. Although satisfaction, complications, and return to work were comparable (P > .05), failure of healing occurred more frequently in the most disadvantaged group (21% vs 6%; P= .03). Patients with MRCTs residing in the most disadvantaged neighborhoods as measured by the ADI have more pain and functional limitations before undergoing ARCR but demonstrate similar postoperative functional improvements to patients from other socioeconomic backgrounds. Failure of healing of MRCTs may be more common in disadvantaged groups. Furthermore, both groups reported similar rates of clinically important functional improvement. Level III, retrospective cohort comparison.

Rural secondary school leaver attainment inequities for students entering medical programmes in Aotearoa New Zealand

ABSTRACT The education literature suggests that there are rural–urban differences in educational achievement. Lower educational achievement in rural schools may impact entry into highly competitive medical programmes and disadvantage rural students. Within this study, the National Certificate of Educational Achievement (NCEA) and University Entrance (UE) attainment rates are compared across Aotearoa New Zealand secondary schools for 2012–2021. High schools were classified as urban or rural according to the two rural admission schemes used in the medical programmes at the University of Otago and the University of Auckland. Descriptive statistics were calculated and regression models created to adjust for a range of variables. The data demonstrates that rural high schools have lower NCEA and UE attainment. Lower Māori student NCEA and UE attainment, greater socioeconomic disadvantage and differing characteristics account for the majority of differences between rural and urban schools. The lower UE attainment rate for rural schools will likely mean that rural students will have greater difficulty in entering medical programmes and that this inequity is worse for rural Māori students. Medical programme admission pathways need to undergo a fundamental shift–from workforce pathways to workforce and equity pathways in order to address rural workforce issues.

Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care?

Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care. A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant. Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90days after surgery ($12,700 vs. $10,462, p < 0.0001). Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care. III.

(312) Area Deprivation Index in Men Undergoing AUS Placement– Community Resource Limitations Do Not Correlate with Poorer Device or Satisfaction Outcomes

Abstract Introduction Outcomes following artificial urinary sphincter (AUS) placement have been associated with non-urologic health metrics including hemoglobin A1c and BMI, as well as with health literacy and frailty. Concerns about these patient factors may lead urologic prosthetic surgeons to alter their recommendations for stress urinary incontinence treatment to avoid poor patient outcomes. The Area Deprivation Index (ADI) is a ranking system to measure socioeconomic disadvantage between neighborhoods and correlates with rates of chronic medical conditions such as diabetes and cardiovascular disease, as well as healthcare service utilization and death. This ranking system includes a composite score of patient income, education level, employment status and housing quality. Evaluating socioeconomic disadvantage may help implanters tailor their patient counseling and improve patient pre- and postoperative education. Objective We sought to characterize variability in functional, subjective, and objective outcomes following AUS placement according to ADI. Methods Patients were identified by CPT codes for AUS insertion, removal/replacement, and revision from 2014 to 2022 at our institution. National percentile ADI was obtained using the Neighborhood Atlas® (Madison, WI) based on patient home address. Higher ADI scores indicate greater socioeconomic disadvantage. Associations of ADI with post-AUS satisfaction, device survival, and complications including (I) any Clavien-Dindo complication and (II) complications requiring surgical intervention. Patient satisfaction was assessed on a 1-5 Likert scale based on telephone interviews. Results 284 patients met inclusion criteria with 232 having data available regarding complications. Median ADI scores in our cohort was 59 (41-75), and we divided the cohort according to high (&amp;gt;58) and low socioeconomic deprivation groups based on this cutoff. Of these, 53 (22.8%) experienced any complication following AUS procedure, over a median of 6.3 months follow up. Device survival at last follow up was similar between low (88.8%) and high ADI groups (92%, P=0.41). Patients with low and high ADI scores had similar overall complication rates (21.6% vs. 24.4%; P=0.64) of any Clavien-Dindo score. Device survival was high at last follow up regardless of ADI score (88.8% vs. 92.0%; P=0.41) with total follow up also being similar between groups (5.64 mo vs. 8.01 mo; P=0.23). Time from prostatectomy to AUS implantation was also similar between high and low ADI groups (4.23 years vs. 4.17 years, P=0.70) Finally, patient satisfaction was very high in both the low and high ADI groups (5 vs. 5; P=0.41). Conclusions ADI was not associated with time to sphincter implantation, postoperative complications, patient satisfaction or device survival. Despite ADI capturing several factors that potentially impact a patient’s ability to optimally access medical care-including income, education and housing quality, we found no evidence that socioeconomic disadvantage by ADI scores was predictive of poorer outcomes, satisfaction, or suboptimal follow up. Disclosure No

Underage Sales of Tobacco in Dollar Stores and Top Grocery Stores, 2015–2020, U.S.

Youth access to tobacco in retail settings remains a pressing public health concern and may vary across retail corporations. This study compares underage sales violation rates in tobacco-selling dollar store corporations-a rapidly growing retail segment where cheaper tobacco prices may appeal to youth-with rates in other major grocery corporations. In 2021, U.S. Food and Drug Administration data (N=64,059 inspections) from January 2015 to March 2020 were used to compare underage tobacco sales in the two major tobacco-selling dollar store corporations, Dollar General and Family Dollar, with sales in major grocery corporations: Albertsons, Delhaize, Kroger, Publix, and Walmart. Generalized linear mixed models controlled for neighborhood characteristics. Post hoc analyses examined whether the corporation with the highest violation rate was more likely to be in neighborhoods with higher proportions of racially minoritized residents, socioeconomic disadvantage, or rural status. Family Dollar failed 12.1% of underage sales inspections. All other corporations had a significantly lower likelihood of selling tobacco to an underage buyer than Family Dollar. This significant association persisted after controlling for neighborhood characteristics. Family Dollar locations were associated with being in neighborhoods with higher proportions of racially minoritized residents and greater socioeconomic disadvantage. Regulating corporate behavior is necessary to reduce underage access to tobacco in dollar stores and address place-based inequities in youth tobacco access. Increasing the use of U.S. Food and Drug Administration no-tobacco-sale orders and Assurances of Voluntary Compliance, which provide a mechanism for state attorneys general to engage with tobacco retailers regarding enforcement of minimum legal sales age laws, may help to reduce youth tobacco access in retail settings.

THE RELATIONSHIP BETWEEN SOCIOECONOMIC DISADVANTAGE AND DEMENTIA CAREGIVER BURDEN

Abstract More than 16 million people provide unpaid care to someone with Alzheimer’s disease or a related dementia (ADRD) in the United States. These caregivers frequently report experiencing psychological and physical burden. Prior research shows that socioeconomic disadvantaged neighborhoods have higher rates of ADRD, but little is known about caregiver burden. We hypothesized more socioeconomic disadvantage is associated with higher caregiver burden. We performed a secondary analysis using baseline data on dementia caregivers (n=132) enrolled in the Indiana University Telephone Acceptance and Commitment Therapy for Caregivers (TACTICs) pilot trials. Mean (SD) caregiver age was 61.6 (11.6) years; 83.3% women; 78.8% white; 19.7% black. Seventy-two percent of the caregivers lived with the care recipient and 50.8% reported moderate dementia severity. A linear regression model examined the relationship between caregiver’s national Area Deprivation Index (ADI) score (ranging from 1–100 with higher scores indicating greater socioeconomic disadvantage) and caregiver burden. The following covariates were included: age, sex, race, education, shared residence with care-recipient, health status, anxiety, depression, and dementia severity of care recipient. Higher ADI was associated with lower caregiver burden (β=-0.222, p &amp;lt; 0.001). Caregiver burden has a significant negative relationship with ADI and dementia severity (p&amp;lt;-.001 and 0.046, respectively) and positive relationship with anxiety (p=0.014) controlling other covariates in the model. Although we found no support for the hypothesis, further research should examine these factors with how caregiver’s ADI may impact other psychosocial wellbeing outcomes. Discussion will highlight the need for caregivers to have access to resources that can aid them through their experience.

COVID-19 Vaccination and Diabetes Mellitus: How Much Has It Made a Difference to Outcomes Following Confirmed COVID-19 Infection?

Since early 2020 the whole world has been challenged by the SARS-CoV-2 virus (COVID-19), its successive variants and the associated pandemic caused. We have previously shown that for people living with type 2 diabetes (T2DM), the risk of being admitted to hospital or dying following a COVID-19 infection progressively decreased through the first months of 2021. In this subsequent analysis we have examined how the UK COVID-19 vaccination programme impacted differentially on COVID-19 outcomes in people with T1DM or T2DM compared to appropriate controls. T1DM and T2DM affected individuals were compared with their matched controls on 3:1 ratio basis. A 28-day hospital admission or mortality was used as the binary outcome variable with diabetes status and vaccination for COVID-19 as the main exposure variables. A higher proportion of T1DM individuals vs their controls was found to be vaccinated at the point of their first recorded positive COVID-19 test when compared to T2DM individuals vs their controls. Regarding the 28-day hospital admission rate, there was a greater and increasing protective effect of subsequent vaccination dosage (one, two or three) in mitigating the effects of COVID-19 infection versus no vaccination in T1DM than in T2DM individuals when compared with matched controls. Similar effects were observed in T2DM for death. Across both diabetes and non-diabetes individuals, those at greater socio-economic disadvantage were more likely to test positive for COVID-19 in the early phase of the pandemic. For T2DM individuals socio-economic disadvantage was associated with a greater likelihood of hospital admission and death, independent of vaccination status. Age and male sex were also independently associated with 28-day hospital admission in T2DM and to 28-day mortality, independent of vaccination status. African ethnicity was also an additional factor for hospital admission in people with T2DM. A beneficial effect of COVID-19 vaccination was seen in mitigating the harmful effects of COVID-19 infection; this was manifest in reduced hospital admission rate in T1DM individuals with a lesser effect in T2DM when compared with matched controls, regarding both hospital admission and mortality. Socio-economic disadvantage influenced likelihood of COVID-19 confirmed infection and the likelihood of hospital admission/death independent of the number of vaccinations given in T2DM.

USING AREA DEPRIVATION INDEX TO ASSESS RACIAL DISPARITIES IN ASTHMA AMONG CHILDREN WITH FOOD ALLERGY

<h3>Introduction</h3> Previous studies have shown significant racial disparities in food allergy (FA) phenotype and outcomes. Our study sought to understand if higher rates of asthma in African American (AA) children with FA were driven by differences in individual and community-level socioeconomic status (SES), regardless of race. <h3>Methods</h3> We analyzed data from FORWARD, which is a prospective, multicenter cohort study investigating the natural history of pediatric atopy. A validated, multi-component area deprivation index (ADI) was used to estimate patient exposure to low SES at the local census block group level. Higher ADI is associated with greater socioeconomic disadvantage. <h3>Results</h3> Of the 700 children in this study, 51% were non-Hispanic White, 37% AA, and 12% Hispanic. The mean ADI across the analytic sample was 37.7 (95% CI: 35.6-39.7). The highest mean ADI (51.5) was seen among AA patients when compared to non-Hispanic White (mean ADI of 24.2) and Hispanic (mean ADI of 41) patients (p < .0001). The mean ADI was 43.3 in children with asthma as opposed to 31.8 in those without asthma (p < .0001). Asthma was more common among AA children [OR = 2.76 (95% CI: 1.77-4.29)] after adjusting for household income, respondent educational attainment, child gender, and recruitment site. <h3>Conclusion</h3> Our data shows that higher ADI is independently associated with higher odds of asthma among children with FA. These findings demonstrate the role of socioeconomic deprivation in the development of asthma among children with FA. This is especially important considering the obstacles associated with socioeconomic deprivation that hinder appropriate management of asthma.

Key predictors and burden of meticillin-resistant Staphylococcus aureus infection in comparison with meticillin-susceptible S. aureus infection in an Australian hospital setting

Staphylococcus aureus is associated with significant mortality and increased burden on the healthcare system. Relatively few reliable estimates are available regarding the impact of meticillin-resistant S.aureus (MRSA) infection compared with meticillin-susceptible S.aureus (MSSA) infection. To compare patients with MRSA infection and MSSA infection to identify differences in inpatient mortality, length of stay and costs of hospital services, and identify predictors of MRSA as a cause of S.aureus infection. An analytical, retrospective, longitudinal study using non-identifiable linked data on adults admitted to hospitals of a health district in Australia with a diagnosis of S.aureus infection over a 10-year period. The main outcome measure was 30-day inpatient mortality. Secondary endpoints included total overnight stays, all-cause inpatient mortality, and hospitalization costs within 1 year of index admission. Inpatient mortality at 30, 100 and 365 days was estimated to be significantly greater for patients with MRSA infection. The mean additional cost of MRSA infection when controlling for additional factors was $5988 and 4 nights of additional hospital stay per patient within 1 year of index admission. Key predictors of MRSA infection were: date of index admission; higher comorbidity score; greater socio-economic disadvantage; admission to hospital other than via the emergency department; older age; and prior admission to hospital within 28 days of index admission. MRSA infection is associated with increased inpatient mortality, costs and hospital length of stay compared with MSSA infection. Efforts are required to alleviate the additional burden of MRSA infection on patients and healthcare systems.

The socioeconomic gradient in mortality from ovarian, cervical, and endometrial cancer in Australian women, 2001-2018: A population-based study.

Socio-economic (SE) status is closely linked to health status and the mechanisms of this association are complex. One important adverse effect of SE disadvantage is vulnerability to cancer and cancer is a major cause of morbidity and mortality in Australia. We aimed to estimate the effect of SE status on mortality rates from ovarian, cervical, and endometrial cancer. National mortality data were obtained from the Australian Bureau of Statistics (ABS) for the calendar years from 2001 to 2018, inclusive. Individual deaths were grouped by the ABS Index of Relative Socio-economic Advantage and Disadvantage. Population data were obtained to provided denominators allowing calculation of mortality rates (deaths per 100 000 women aged 30-79 years). Statistical analyses performed included tabulating point-estimates of mortality rates and their changes over time and modelling the trends of rates using maximum likelihood method. Age-standardised mortality rates for ovarian and cervical cancer fell over the study period but increased for endometrial cancer. There was clear evidence of a SE gradient in the mortality rate for all three cancers. This SE gradient increased over the study period for ovarian and cervical cancer but remained unchanged for endometrial cancer. Women at greater SE disadvantage have higher rates of death from the commonest gynaecological cancers and this gradient has not reduced over the last two decades. After the COVID-19 pandemic efforts must be redoubled to ensure that Australians already at risk of ill health do not face even greater risks because of their circumstances.

Bike Helmet Usage in the Most Disadvantaged Neighborhoods: A Focused Area for Trauma Prevention

IntroductionThere is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries. MethodsBetween 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage. ResultsAmong 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P < 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage. ConclusionsOutcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Treatment disparities in muscle-invasive bladder cancer: Evidence from a large statewide cancer registry.

To identify patient-level factors that can lead to treatment disparities for muscle invasive bladder cancer, we examine factors associated with receipt of definitive therapy, type of definitive therapy, and neoadjuvant chemotherapy administration in a statewide cohort of muscle-invasive bladder cancer patients. We identified 2,434 patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2010 and 2015 using the Pennsylvania Cancer Registry. We divided the cohort into three subsamples to examine receipt of treatment: definitive therapy among all muscle-invasive bladder cancer patients (n = 1548), cystectomy (n = 1254) vs. trimodal therapy (n = 294), and neoadjuvant chemotherapy among radical cystectomy patients (n = 1156). Multivariable logistic regression models controlling for patient-level covariates, including insurance status, and socioeconomic disadvantage (based on Area Deprivation Index from census tract data) were estimated to examine factors associated with each treatment outcome. Only 64% of muscle-invasive bladder cancer patients underwent definitive therapy. Those receiving trimodal therapy were more likely to be covered by Medicare than those undergoing cystectomy. Uninsured patients were less likely to undergo definitive treatment and Medicare-insured patients were less likely to undergo cystectomy as their definitive therapy. Patients with greater socioeconomic disadvantage were less likely to receive definitive treatment, undergo cystectomy, or receive neoadjuvant chemotherapy. Over the course of the study period, there was increased neoadjuvant chemotherapy use, but a persistent gap by neighborhood socioeconomic status. Socioeconomic disadvantage and insurance status are patient-level factors associated with suboptimal treatment for muscle-invasive bladder cancer.