Implications For Health Equity Research Articles

Abstract PO5-09-05: Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery

Abstract Introduction: Despite the increased awareness and advocacy for health equity, racial and socioeconomic disparities remain prevalent among breast cancer patients. Since lack of access to care is a major barrier, safety-net systems that provide services for the uninsured/underinsured play a significant role in promoting health equity and eliminating disparities. Understanding the patient population treated within these systems, which are often resource-limited, can help develop strategies to improve care delivery and outcomes. Here, we describe characteristics of breast cancer patients treated at a large safety-net system. Methods: Parkland Health (PH) is the safety-net system for Dallas County, and is affiliated with the University of Texas Southwestern Harold C. Simmons Comprehensive Cancer Center (NCI-CCC). Electronic medical records of patients with a new invasive breast cancer diagnosis between 2018 to 2020 at PH were reviewed and data on demographics and clinical presentation were collected. Categorical data was summarized with counts and percentages and continuous data was summarized with median and interquartile range. Statistical comparisons used Chi-square test for categorical data and rank sum test for continuous data with a significance level of 0.05. Data from the National Cancer Database (NCDB) for the same period was used for comparison. Results: A total of 657 patients at PH were included in the analysis (50.2% Hispanic; 32.3% Black). Median age at diagnosis was 53 years (range 46-61), with 39.1% of patients < 50 (12.3% < 40). The majority of patients were uninsured at the time of diagnosis (67.0%). Hispanic patients were younger than others (median age 49 years (range 43-57) vs 57 (range 48-63), p < 0.01), with 51.2% < 50. Late-stage diagnosis was observed in 30.6% of patients (stage III 16.4%, stage IV 14.2%), and triple negative breast cancer (TNBC) accounted for 22.8% of cases. While the stage distribution was not statistically different between racial and ethnic subgroups (p=0.66), black patients were diagnosed with TNBC at a significantly higher rate compared to others (30.2% vs 19.3%, p < 0.01). Although a trend towards higher rate of HER2(+) disease was noted among Hispanics, this difference did not reach the level of statistical significance (22.7% vs 16.5%, p=0.06). One hundred eighty-nine patients (28.8%) were diagnosed outside PH. Compared to Black patients, Hispanic patients were more often diagnosed in the community (22.2% vs 32.4%, p=0.01). Of the 564 patients with stage I-III, 340 (60.3%) had T2-4 and 203 (36.0%) had node positive disease at diagnosis. Median time to treatment initiation (TTI) was 51 days (range 35-76) and was significantly longer in patients who were diagnosed in the community compared to those diagnosed at PH, median 63 days (range 44-96) vs 48 (range 34-70), p < 0.01. Compared to the NCDB, PH patients were younger (39.1% vs 18.4% < 50 years, p < 0.01), presented at a higher rate with late-stage disease (30.6% vs 13.2%, p < 0.01) and TNBC (22.8% vs 10.7%, p < 0.01), and had a longer median time from diagnosis to treatment initiation - 51 days (range 35-76) vs 33 (range 21-49), p < 0.01. Conclusion: Breast cancer patients at PH were significantly different from the national average, with over a third below the USPSTF recommended breast cancer screening age. The rate of late-stage diagnosis at PH was more than two-fold the national average. Lowering the screening age to 40, expansion of outreach mammography programs, improving patient navigation, and simplifying access to indigent care programs are among strategies to promote health equity. Considering the high disease burden among safety-net patients, a systematic effort to increase resources at safety-net health systems is warranted. Citation Format: Sarah Kashanian, Shifa Kanjwal, L. Steven Brown, Andrea Semlow, Mary Hodges, Robyn Cobb, Brad Walsh, Umber Dickerson, Navid Sadeghi. Characteristics of newly diagnosed breast cancer patients at a large safety-net system: Implications for health equity and care delivery [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-09-05.

Addressing Health Equity in the Context of Carbon Capture, Utilization, and Sequestration Technologies.

To describe the role of health equity in the context of carbon capture, utilization, and sequestration (CCUS) technologies. CCUS technologies have the potential to both improve and worsen health equity. They could help reduce greenhouse gas emissions, a major contributor to climate change, but they could also have negative health impacts like air and noise pollution. More research is needed to fully understand the health equity implications of CCUS technologies. CCUS technologies have both health equity risks and benefits. Implementing misguided CCUS projects in vulnerable communities could exacerbate environmental injustice and health disparities and have the potential to increase carbon emissions. However, well-conceived projects could benefit communities through economic development. Governments, industry, and society should prioritize and expedite the reduction of CO2 emissions before considering carbon reductions via CCUS. Furthermore, CCUS projects must be thoroughly evaluated and should only proceed if they have demonstrated a net reduction in CO2 emissions and provide more benefits than risks to local communities. This underscores the importance of prioritizing health equity in the planning of CCUS projects.

Legislative Health Notes: Preliminary Learnings From Piloting a New Policy Analysis Tool.

In 2018, the Health Impact Project (the Project) developed and tested a new health in all policies (HiAP) tool called "legislative health notes" to provide state and local legislators with peer-reviewed evidence, public health data, and local data that illustrate potential positive and negative health and equity effects of proposed bills. The Project sought to refine the health note methodology while piloting the tool in the Colorado and Indiana General Assemblies, and with the Council of the District of Columbia, and worked with affiliates to introduce them in North Carolina, Ohio, and California. External partners solicited feedback on health notes via semistructured interviews and surveys from legislators, legislative staff, and expert reviewers who were familiar with health notes in each of these jurisdictions. Respondents shared that health notes were nonpartisan, were easy for nonexperts to understand, and would be more effective if delivered earlier in the legislative process. In response to informant feedback, practitioners can explore adding high-level summaries, increasing focus on health equity implications and the potential to work with legislators during the policy formulation phase. Data from this pilot suggest that legislative health notes are a promising nonpartisan and standardized tool to better understand the health and equity implications of proposed legislation.

Assessing the implementation of a multi-component hypertension program in a Guatemalan under-resourced dynamic context: an application of the RE-AIM/PRISM extension for sustainability and health equity

BackgroundThe COVID-19 pandemic necessitated rapid changes in healthcare delivery in Guatemala’s public primary care settings. A new hypertension program, implemented as part of a type 2 hybrid trial since 2019, exemplifies an implementation effort amidst a changing context in an under-resourced setting. We assessed the implementation of an evidence-based intervention (EBI; protocol-based hypertension treatment) and one of its main implementation strategies (team-based collaborative care), raising implications for health equity and sustainability. We present innovative application of systems thinking visuals.MethodsConducting a convergent mixed methods analysis, we assessed implementation in response to contextual changes across five Ministry of Health (MoH) districts at the pandemic’s onset. Utilizing quantitative programmatic data and qualitative interviews with stakeholders (n=18; health providers, administrators, study staff), we evaluated dimensions of “Reach, Effectiveness, Adoption, Implementation and Maintenance,” RE-AIM (Reach, Implementation delivery + adaptations), and “Practical Robust Implementation and Sustainability Model,” PRISM (Organizational perspective on the EBI, Fit, Implementation and sustainability infrastructure) frameworks. We assessed representativeness by comparing participants to census data. To assess implementation delivery, we built behavior-over-time (BOT) graphs with quantitative programmatic data (July 2019–July 2021). To assess adaptations and contextual changes, we performed matrix-based thematic qualitative analysis. We converged quantitative implementation delivery data + qualitative adaptations data in joint displays. Finally, we analyzed qualitative and quantitative results across RE-AIM/PRISM and health districts to identify equity and sustainability considerations.ResultsContextual factors that facilitated program delivery included the perception that the EBI was beneficial, program champions, and staff communication. Key barriers to implementation delivery included competition with other primary care activities and limited implementation infrastructure (e.g., equipment, medications). Contextual changes related to COVID-19 hindered implementation delivery, threatened sustainability, and may have exacerbated inequities. However, adaptations that were planned enhanced implementation delivery and may have supported improved equity and sustainability.ConclusionsRecognition of an EBI’s benefits and program champions are important for supporting initial uptake. The ability to plan adaptations amid rapid contextual changes has potential advantages for sustainability and equitable delivery. Systems thinking tools and mixed methods approaches may shed light on the relations between context, adaptations, and equitable and sustainable implementation.Trial registrationNCT03504124

Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial

BackgroundAntibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy (“ROAD Home”) on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection.MethodsThis 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a “stewardship as usual” control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment.DiscussionReducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives.Trial registrationClinicaltrials.gov NCT06106204 on 10/30/23

Gaps In Quality Of Care Not Consistent Between Traditional Medicare, Medicare Advantage For Racial And Ethnic Groups.

The quality of care experienced by members of racial and ethnic minority groups in Medicare Advantage, which is an increasingly important source of Medicare coverage for these groups, has critical implications for health equity. Comparing gaps in Medicare Advantage and traditional Medicare for three quality-of-care outcomes, measured by adverse health events, between minority and non-Hispanic White populations, we found that the relative magnitude of the gaps varied both by racial and ethnic minority group and by quality measure. Hispanic versus non-Hispanic White gaps were smaller in Medicare Advantage than in traditional Medicare for all outcomes: avoidable emergency department use, preventable hospitalizations, and thirty-day hospital readmissions. The gap between non-Hispanic Black and non-Hispanic White populations was larger in Medicare Advantage than in traditional Medicare for avoidable emergency department use but was no different for hospital readmissions and was smaller for preventable hospitalizations. The Asian versus non-Hispanic White gap was similar in Medicare Advantage and traditional Medicare for avoidable emergency department use and preventable hospitalizations but was larger in Medicare Advantage for hospital readmissions. As Medicare Advantage enrollment expands, monitoring the quality of care for enrollees who are members of racial and ethnic minority groups will remain important.

AUDIO: A Mnemonic for Best Practice Considerations in Audio-Only Telehealth

Audio-only telehealth is essential for equitable access to care for all populations. The expiration of the public health emergency on May 11, 2023, affects audio-only telehealth sustainability. Although recent legislation temporarily extended the continued use and reimbursement parity for audio-only telehealth, these flexibilities expire on December 31, 2024. There are negative implications for health equity in the absence of permanent legislation. This article presents the AUDIO mnemonic as a suggested tool for best practice considerations to guide the development of metrics that can inform policy. Collaborative efforts between policymakers and telehealth stakeholders are essential for achieving equitable access to telehealth.

Mapping Cumulative Risk in Delaware: Approach and Implications for Health Equity.

Addressing health equity requires attention to upstream determinants of health, including environmental and social factors that act in tandem to increase communities' exposure to and vulnerability to toxicants. Cumulative risk assessment, which evaluates combined risks from environmental and social factors, is a useful approach for estimating potential drivers of health disparities. We developed a cumulative risk score of multiple indices of environmental and social conditions and assessed block group-level differences in New Castle County, Delaware. This cross-sectional study used choropleth maps to visualize the distribution of environmental, social, and cumulative risks and Moran's I statistics to assess spatial clustering of cumulative risk across the county and among individual block groups. Findings indicate that environmental risk rarely occurs without social risk and that environmental and social risks co-occur in distinct areas, resulting in large-scale clustering of cumulative risk. Areas of higher cumulative risk had more Black residents and people of lower socioeconomic status. Replicable measures of cumulative risk can show how environmental and social risks are inequitably distributed by race and socioeconomic status, as seen here in New Castle County. Such measures can support upstream approaches to reduce health disparities resulting from histories of environmental racism.

Use of machine learning tools to predict health risks from climate-sensitive extreme weather events: A scoping review

Machine learning (ML) algorithms may play a role in predicting the adverse health impacts of climate-sensitive extreme weather events because accurate prediction of such effects can guide proactive clinical and policy decisions. To systematically review the literature that describe ML algorithms that predict health outcomes from climate-sensitive extreme weather events. A comprehensive literature search was performed in the following databases from inception–October 2022: Ovid MEDLINE, Ovid EMBASE, The Cochrane Library, Web of Science, bioRxiv, medRxiv, Institute of Electrical and Electronic Engineers, Google Scholar, and Engineering Village. The retrieved studies were then screened for eligibility against predefined inclusion/exclusion criteria. The studies were then qualitatively synthesized based on the type of extreme weather event. Gaps in the literature were identified based on this synthesis. Of the 6096 records screened, seven studies met the inclusion criteria. Six of the studies predicted health outcomes from heat waves, and one for flooding. Health outcomes described included 1) all-cause non-age standardized mortality rates, 2) heat-related conditions and 3) post-traumatic stress disorder. Prediction models were developed using six validated ML techniques including non-linear exponential regression, logistic regression, spatiotemporal Integrated Laplace Approximation (INLA), random forest and decision tree methods (DT), and support vector machines (SVM). Use of ML algorithms to assess adverse health impacts from climate-sensitive extreme weather events is possible. However, to fully utilize these ML techniques, better quality data suitable for use is desirable. Development of data standards for climate change and health may help ensure model robustness and comparison across space and time. Future research should also consider health equity implications.

The health equity implications of the Health Resources and Services Administration's Ryan White HIV/AIDS Program.

Investigate the role of the Ryan White HIV/AIDS Program (RWHAP) - which funds services for vulnerable and historically disadvantaged populations with HIV - in reducing health inequities among people with HIV over a 10-year horizon. We use an agent-based microsimulation model to incorporate the complexity of the program and long-time horizon. We use a composite measure (the Theil index) to evaluate the health equity implications of the RWHAP for each of four subgroups (based on race and ethnicity, age, gender, and HIV transmission category) and two outcomes (probability of being in care and treatment and probability of being virally suppressed). We compare results with the RWHAP fully funded versus a counterfactual scenario, in which the medical and support services funded by the RWHAP are not available. The model indicates the RWHAP will improve health equity across all demographic subgroups and outcomes over a 10-year horizon. In Year 10, the Theil index for race and ethnicity is 99% lower for both outcomes under the RWHAP compared to the non-RWHAP scenario; 71-93% lower across HIV transmission categories; 31-44% lower for age; and 73-75% lower for gender. Given the large number of people served by the RWHAP and our findings on its impact on equity, the RWHAP represents an important vehicle for achieving the health equity goals of the National HIV/AIDS Strategy (2022-2025) and the Ending the HIV Epidemic Initiative goal of reducing new infections by 90% by 2030.

DOES RURAL LIVING INCREASE RISK FOR MORTALITY? FINDINGS FROM TWO LONGITUDINAL STUDIES

Abstract Most prior work on rural-urban health disparities has been conducted with population-level data, which is limited in its capacity for causal inferences about individuals and lifespan health. The present study leverages individual-level longitudinal data, spanning up to 29 years, to understand how rurality-urbanicity predicts individuals’ risk for all-cause mortality; whether these effects hold above and beyond socioeconomic status; and whether the association between rurality-urbanicity and mortality risk varies by sex, socioeconomic status, race, and partner status. The present pre-registered study uses data from two large longitudinal studies of U.S. Americans (HRS and MIDUS; total N = ~55,000), who reported on their socio-demographic characteristics, had their addresses linked to geographical indicators (i.e., rural-urban continuum codes), and have data from the National Death Index regarding vital status and survival time. Using a series of cox proportional hazards regression models, findings showed that suburban and rural residents were at a 12% and 18% greater risk for earlier all-cause mortality compared to urban residents in HRS, but the effects of rurality-urbanicity on mortality risk were non-significant in MIDUS. The longitudinal effects of rurality-urbanicity on mortality risk were largely independent of the effects of socioeconomic status. Finally, the three statistically significant interaction effects suggest that the strength and direction of the association between rurality-urbanicity and mortality risk differed by race (HRS, MIDUS) and partner status (HRS). The discussion elaborates on the theoretical implications for our understanding of social determinants of health, as well as practical implications for health equity in rural areas.

Video versus telephone for telehealth delivery: a cross-sectional study of Australian general practice trainees.

Remunerated telehealth consultations were introduced in Australia in 2020 in response to the COVID-19 pandemic. Videoconferencing has advantages over telephone-consulting, including improved diagnostic and decision-making accuracy. However, videoconferencing uptake in Australia has been low. This study aimed to establish prevalence and associations of video versus telephone consultations in Australian general practice (GP) registrars' practice. A cross-sectional analysis of data from 2020 to 2021 (three 6-monthly data-collection rounds) from the Registrars Clinical Encounters in Training (ReCEnT) study. GP registrars record details of 60 consecutive consultations every 6-month term, for a total of 3 terms. Univariable and multivariable logistic regression were performed within the Generalized Estimating Equations framework with the outcome video versus telephone. 102,286 consultations were recorded by 1,168 registrars, with 21.4% of consultations performed via telehealth. Of these, telephone accounted for 96.6% (95% CI: 96.3-96.8%) and videoconferencing for 3.4% (95% CI: 3.2-3.7%). Statistically significant associations of using videoconferencing, compared to telephone, included longer consultation duration (OR 1.02, 95% CI: 1.01-1.03 per minute; and mean 14.9 versus 12.8 min), patients aged 0-14 years old (OR 1.29, 95% CI: 1.03-1.62, compared to age 15-34), patients new to the registrar (OR 1.19, 95% CI: 1.04-1.35), part-time registrars (OR 1.84, 95% CI: 1.08-3.15), and areas of less socioeconomic disadvantage (OR 1.27, 95% CI: 1.00-1.62 per decile). Registrars' telehealth consultations were mostly performed via telephone. Telephone use being associated with socioeconomic disadvantage has health equity implications. Future research should explore barriers to videoconferencing use and strategies to increase its uptake.

"Cancer's a demon": a qualitative study of fear and multilevel factors contributing to cancer treatment delays.

Delays initiating cancer therapy are increasingly common, impact outcomes, and have implications for health equity. However, it remains unclear (1) whether patients' beliefs regarding acceptable diagnostic to treatment intervals align with current guidelines, and (2) to what degree psychological factors contribute to longer intervals. We conducted a qualitative study with patients and cancer care team members ("providers"). We interviewed patients with several common solid tumors as well as providers. Interviews were analyzed using an interpretive approach, guided by modified grounded theory. Twenty-two patients and 12 providers participated. Half of patients had breast cancer; 27% waited >60 days between diagnosis and treatment. Several themes emerged. (1) Patients felt treatment should begin immediately following diagnosis, while providers' opinion on the goal timeframe to start treatment varied. (2) Patients experienced psychological distress while waiting for treatment. (3) Participants identified logistical, social, and psychological sources of delay. Fear related to multiple aspects of cancer care was common. Emotion-driven barriers could manifest as not taking steps to move ahead, or as actions that delayed care. (4) Besides addressing logistical challenges, patients believed that education and anticipatory guidance, from their care team and from peers, may help overcome psychological barriers to treatment and facilitate the start of therapy. Patients feel an urgency to start cancer therapy, desiring time frames shorter than those included in guidelines. Psychological distress is frequently both a contributor to, and a consequence of, treatment delays. Addressing multilevel barriers, including psychological ones, may facilitate timely treatment and reduce distress.

Abstract B148: Colorectal cancer screening uptake and test use for individuals with diabetes in the U.S.: Implications for health equity

Abstract Purpose: Individuals with diabetes mellitus have an estimated 27% elevated risk of developing colorectal cancer (CRC) and are disproportionately from health disparities populations. This study examined associations of race and ethnicity and CRC screening uptake and CRC test type used among individuals with diabetes to identify factors to consider in targeting CRC screening efforts to promote health equity. Methods: Merged Medical Expenditures Panel Survey Household Component (2012-2018) and National Health Interview Survey data sets were used to identify individuals with diabetes (non-Hispanic White (NHW) n=223,046; Hispanic n=54,791; Non-Hispanic Black (NHB) n=54,791). The main outcomes were self-reported up-to-date CRC screening based on United States Preventive Services Taskforce guidelines and screening test used (i.e., blood-stool test or direct visualization). The main independent variable of interest was race and ethnicity. Logistic regression models included socio-demographic and health-related co-variates. Results: Among individuals with diabetes 62.6% reported being up-to-date (UTD) with CRC screening, among the screened 5.8% used blood stool tests only and 56.8% used direct visualization tests.  In the final logistic model comparing relative risk of UTD screening to being unscreened, NHBs were more likely to be UTD for CRC screening [RR: 1.3, 95% CI: 1.13-1.53, p=0.001] compared to NHWs. Individuals with no high school degree [RR: 0.8, 95% CI: 0.65-0.99, p=0.3] were less likely to be UTD compared to college educated individuals. Individuals receiving recommended diabetes care were less likely to be unscreened [RR: 0.84, 95% CI: 0.76-0.94, p=0.002]. Among screened individuals, race and ethnicity were insignificant in final models. Low-income individuals were less likely to be screened with direct visualization [RR: 0.73, 95% CI: 0.55-0.97, p=0.03] compared to high-income individuals. Overweight individuals (BMI 26-29) were less likely to be screened with direct visualization [RR:0.75, 95% CI:0.57-0.99, p=0.41] compared to individuals with BMI ≤25. Individuals with five or more comorbidities were more likely to be screened using direct visualization [RR: 3.45, 95% CI: 1.86, 6.43, p<0.001] compared to individuals with 1-2 comorbidities. Conclusions: Among individuals with diabetes, social determinants and health factors associated with UTD and testing type differed. Race, education, and diabetes care quality were determinants of receipt of any UTD CRC testing.  Among those screened, lower income and overweight individuals were more likely to use stool-based testing and those with greater comorbidity burdens were more likely to be screened with direct visualization. Efforts to improve CRC screening for patients with diabetes, specifically those in the primary care safety-net, should consider these factors when tailoring CRC prevention and early detection efforts.   Citation Format: Denalee M. O'Malley, Pamela Ohman-Strickland, Tracy Andrews, Cilgy Abraham, Benjamin F. Crabtree, Shawna V. Hudson, Anita Y. Kinney. Colorectal cancer screening uptake and test use for individuals with diabetes in the U.S.: Implications for health equity [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B148.

Understanding over- and under-screening of cervical cancer among a national sample of commercially insured women: Implications for health equity.

451 Background: Cervical cancer screening guidelines have changed frequently in recent years. Different adherence patterns by screening modalities (e.g., cytology-only, HPV testing-only, co-testing) could lead to overuse and underuse of care. It is unclear if receipt of guideline adherent screening varies among racial/ethnic minorities and those with low socioeconomic status (SES), which can exacerbate existing disparities. Methods: Optum Clinformatics Data Mart from 2013-2021 was used to identify women aged 30-65 to examine over- and under-screening to understand national patterns of guideline adherence. Average-risk women with continuous enrollment for 6 years for years starting in 2012-2016 and at least one claim were included. Those with history of hysterectomy and cervical cancer were excluded. According to the 2012 U.S. Preventive Services Task Force guideline, adherence was defined as screening interval of 4.5-5.5 years for co-testing/HPV testing as the index screening modality and 2.5-3.5 years for cytology-only, and over-screening as <4.5 years and <2.5 years, and under-screening as > 5.5 years and > 3.5 years including lack of subsequent screening, respectively. We compared distribution of screening adherence by screening modality, race, education level, and household net worth using chi-squared test. Results: A total of 1,422,258 individuals ages 30-65 were included. Among the eligible sample, 1,016,067 women received at least one cervical cancer screening from 2013-2017. Of these, 830,549 (81.7%) were considered average-risk. About half (48.4%) received an index screening with cytology-only, 51.0% with co-testing and 0.6% with HPV testing. Overall, 7.4% were guideline adherent, 62.1% were over-screened and 30.5% were under-screened. 12.7% of the women screened with cytology-only were adherent compared to 2.5% of those screened with co-testing, 59.2% vs. 64.9% were over-screened, and 28.1% vs. 32.6% were under-screened, respectively. Unadjusted differences in the distribution of adherence were statistically significant by race, education level, and household net worth (p < 0.01). Conclusions: The study identified high rates of over-screening and under-screening among a national cohort of commercially insured women, signaling the need for interventions to improve guideline adherent screening. Furthermore, over- and under-screening varied by screening modalities, race and SES factors, which highlights the need to study specific patterns of adherence among subpopulations to address cervical cancer inequities.

Clinical performance and health equity implications of the American Diabetes Association's 2023 screening recommendation for prediabetes and diabetes.

The American Diabetes Association (ADA) recommends screening for prediabetes and diabetes (dysglycemia) starting at age 35, or younger than 35 years among adults with overweight or obesity and other risk factors. Diabetes risk differs by sex, race, and ethnicity, but performance of the recommendation in these sociodemographic subgroups is unknown. Nationally representative data from the National Health and Nutrition Examination Surveys (2015-March 2020) were analyzed from 5,287 nonpregnant US adults without diagnosed diabetes. Screening eligibility was based on age, measured body mass index, and the presence of diabetes risk factors. Dysglycemia was defined by fasting plasma glucose ≥100mg/dL (≥5.6 mmol/L) or haemoglobin A1c ≥5.7% (≥39mmol/mol). The sensitivity, specificity, and predictive values of the ADA screening criteria were examined by sex, race, and ethnicity. An estimated 83.1% (95% CI=81.2-84.7) of US adults were eligible for screening according to the 2023 ADA recommendation. Overall, ADA's screening criteria exhibited high sensitivity [95.0% (95% CI=92.7-96.6)] and low specificity [27.1% (95% CI=24.5-29.9)], which did not differ by race or ethnicity. Sensitivity was higher among women [97.8% (95% CI=96.6-98.6)] than men [92.4% (95% CI=88.3-95.1)]. Racial and ethnic differences in sensitivity and specificity among men were statistically significant (P=0.04 and P=0.02, respectively). Among women, guideline performance did not differ by race and ethnicity. The ADA screening criteria exhibited high sensitivity for all groups and was marginally higher in women than men. Racial and ethnic differences in guideline performance among men were small and unlikely to have a significant impact on health equity. Future research could examine adoption of this recommendation in practice and examine its effects on treatment and clinical outcomes by sex, race, and ethnicity.

Examining differences in opioid deaths by race in North Carolina following the STOP Act, 2010–2019

IntroductionNorth Carolina's 2017 STOP Act implemented several measures to address the increasing opioid overdose death rate. However, due to racial differences prescription opioid use and treatment service access, the STOP Act may exhibit differential impacts by race. This study examined the impact of the STOP Act on opioid overdose deaths by race. MethodsState-level secondary data were compiled for all 50 states. Race-stratified opioid overdose rates were obtained from the Centers for Disease Control and Prevention's WONDER database from 2010 to 2019. The study obtained state-level population characteristics from the Current Population Surveys from 2010 to 2016, the CDC's 2017 Drug Surveillance Report, the National Survey of Substance Abuse Treatment Services from 2011 to 2016, and the National Survey on Drug Use and Health from 2010 to 2016. We obtained outcomes from 2010 to 2019 and state characteristics were obtained for the pre-STOP Act period (2010–2016) as available. Using the synthetic control method, we created two synthetic North Carolinas, one Black/African American and one White, from a weighted average of other states similar to North Carolina in terms of pre-STOP Act race-stratified opioid overdose rates and population characteristics. Change was assessed as the difference in the race-stratified opioid overdose death rate for North Carolina the corresponding synthetic control. ResultsThe opioid overdose death rate among the White population decreased by 7.17 and 8.96 deaths/100 k in 2018 and 2019 following the STOP Act (overall decrease p = .0217); however, the study found no significant change in the opioid overdose death rate among the Black/African American population (overall decrease p = .1053), with decreases 1.68 and 3.2 deaths/100 k in 2018 and 2019, respectively. ConclusionsOur findings suggest that the STOP Act reduced the opioid overdose death rate in North Carolina among the White, but not Black/African American, population. This heterogeneous effect has implications for health equity and can inform the development of future substance use policies.

Screening for Prediabetes and Diabetes in a National Network of Federally Qualified Health Centers: An Observational Study.

In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended screening for prediabetes and diabetes among adults aged 35-70years with overweight or obesity. Studying dysglycemia screening in federally qualified health centers (FQHCs) that serve vulnerable patient populations is needed to understand health equity implications of this recommendation. To investigate screening practices among FQHC patients who would be eligible according to the 2021 USPSTF recommendation. Retrospective cohort study analyzing electronic health records from a national network of 282 FQHC sites. We included 183,329 patients without prior evidence of prediabetes or diabetes, who had ≥ 1 office visit from 2018-2020. Screening eligibility was based on age and measured body mass index (BMI). The primary outcome, screening completion, was ascertained using hemoglobin A1c or fasting plasma glucose results from 2018-2020. Among 89,543 patients who would be eligible according to the 2021 USPSTF recommendation, 53,263 (59.5%) were screened. Those who completed screening had higher BMI values than patients who did not (33.0 ± 6.7kg/m2 vs. 31.9 ± 6.2kg/m2, p < 0.001). Adults aged 50-64years had greater odds of screening completion relative to younger patients (OR 1.13, 95% CI: 1.10-1.17). Patients from racial and ethnic minority groups, as well as those without health insurance, were more likely to complete screening than White patients and insured patients, respectively. Clinical risk factors for diabetes were also associated with dysglycemia screening. Among patients who completed screening, 23,588 (44.3%) had values consistent with prediabetes or diabetes. Over half of FQHC patients who would be eligible according to the 2021 USPSTF recommendation were screened. Screening completion was higher among middle-aged patients, those with greater BMI values, as well as vulnerable groups with a high risk of developing diabetes. Future research should examine adoption of the 2021 USPSTF screening recommendation and its impact on health equity.

Examining spatial variation for immunisation coverage in pregnant women: A nationwide and geospatial retrospective cohort study in Aotearoa New Zealand

BackgroundMaternal influenza and pertussis immunisation is crucial for protecting mothers during pregnancy and their babies in the first weeks of life against severe disease. We examined geospatial variation in maternal immunisation coverage among pregnant women in Aotearoa New Zealand and its health equity implications. MethodWe constructed a retrospective cohort including all pregnant women who delivered between 01 January 2013 and 31 December 2020 using administrative health datasets. Our outcomes were receipt of influenza or pertussis vaccine in any one of three relevant national databases (e.g. National Immunisation Register, Proclaims, or Pharmaceutical collection) during the eligible pregnancy. ResultsData from our retrospective cohort study show significant regional variation in maternal immunisation coverage for both influenza and pertussis from 2013 to 2020. Maximal coverage was around 50% in the best performing regions, which means that half of the women who were pregnant (183,737 women) were not protected. In addition, we found significant spatio-temporal variation and clustering of immunisation coverage. Our findings are interactively available to explore here: https://geohealthlab.shinyapps.io/hapumama/ ConclusionOur study is one of the first to examine spatial variation in maternal vaccination coverage in pregnant women at a national level over space and time. This provides powerful tools to measure the impact of interventions to improve coverage at national and regional levels, with specific reference to inequities between ethnic groups, likely applicable to similar settings internationally.

A Whole School, Whole Community, Whole Child Approach to Support Student Physical Activity and Nutrition: Introduction/Methods.

We introduce the Whole School, Whole Community, Whole Child approach to supporting student and school staff physical activity and nutrition and describe the methods used to generate the evidence synthesized across the special issue articles. A 2-phase literature review search included a search of systematic reviews (2010-2018) for individual qualifying articles (Phase 1) and a search for individual articles on topics not addressed by a review (2010-2020) or that needed an update because they were in a review that was older (2010-2016) or showed insufficient evidence (Phase 2). Research librarians developed search strategies. In each phase, pairs of subject matter experts applied criteria to review abstracts and full-text articles and extracted data using standardized forms. We included 314 articles, describing 293 studies. Most of the included studies looked at elementary or secondary school level interventions; 51% were rated poor quality, and few took place in a rural setting. Most of the identified studies engaged majority minority or racially/ethnically diverse schools, suggesting that these interventions are feasible in a variety of settings. This collection of 10 articles identifies evidence-based interventions, gaps in research, and implications for health equity.