Lower Average Household Income Research Articles

Predictors of fuel poverty and the equity of local fuel poverty support: secondary analysis of data from Bradford, England.

Addressing fuel poverty is a critical public health issue given its recent rise in prevalence across Europe. Although previous research identifies national risk markers of fuel poverty, evidence is lacking on whether these are consistent across local geographies, and the equity of local interventions. In the UK's current economic climate, it is more crucial than ever that services benefit households in greatest need. This study aimed to determine significant predictors of fuel poverty among households in Bradford, England, comparing them to national-level predictors, and evaluate if households possessing significant fuel poverty predictors were equitably referred to a local fuel poverty service (Warm Homes Healthy People, WHHP). A multivariate logistic regression model determined significant fuel poverty predictors in Bradford using household-level data from the Energy Saving Trust and the Low Income High Costs fuel poverty definition. Statistical testing highlighted significant differences in predictors of fuel poverty between households referred to WHHP and all Bradford households. Significant (p < .05) predictors of fuel poverty included: living in an area with lower average household incomes and higher proportion of ethnic minority individuals, and living in a property with a lower energy efficiency rating. Households living in a detached or older property, and homeowners were more likely to be fuel poor. Differences in the direction of the relationship with fuel poverty were identified between some national and local predictors. Most predictors were significantly (p < .05) overrepresented among WHHP households, suggesting equitable service reach. Ethnic minorities, younger people, and multiperson households were underrepresented. Local fuel poverty predictors were similar to many national-level predictors, but identified differences in the direction of the relationship between some national and local predictors reaffirm the value of locally focused research. WHHP successfully targeted households possessing key predictors, but should ensure that ethnic minorities, younger people, and multiperson households are equitably referred.

A Saliva-Based Serological and Behavioral Analysis of SARS-CoV-2 Antibody Prevalence in Howard County, Maryland.

The objective of the study was to estimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence in the Howard County, Maryland, general population and demographic subpopulations attributable to natural infection or coronavirus disease 2019 (COVID-19) vaccination and to identify self-reported social behaviors that may affect the likelihood of recent or past SARS-CoV-2 infection. A cross-sectional, saliva-based serological study of 2,880 residents of Howard County, Maryland, was carried out from July through September 2021. Natural SARS-CoV-2 infection prevalence was estimated by inferring infections among individuals according to anti-nucleocapsid immunoglobin G levels and calculating averages weighted by sample proportions of various demographics. Antibody levels between BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) recipients were compared. Antibody decay rate was calculated by fitting exponential decay curves to cross-sectional indirect immunoassay data. Regression analysis was carried out to identify demographic factors, social behaviors, and attitudes that may be linked to an increased likelihood of natural infection. The estimated overall prevalence of natural infection in Howard County, Maryland, was 11.9% (95% confidence interval, 9.2% to 15.1%), compared with 7% reported COVID-19 cases. Antibody prevalence indicating natural infection was highest among Hispanic and non-Hispanic Black participants and lowest among non-Hispanic White and non-Hispanic Asian participants. Participants from census tracts with lower average household income also had higher natural infection rates. After accounting for multiple comparisons and correlations between participants, none of the behavior or attitude factors had significant effects on natural infection. At the same time, recipients of the mRNA-1273 vaccine had higher antibody levels than those of BNT162b2 vaccine recipients. Older study participants had overall lower antibody levels compared with younger study participants. The true prevalence of SARS-CoV-2 infection is higher than the number of reported COVID-19 cases in Howard County, Maryland. A disproportionate impact of infection-induced SARS-CoV-2 positivity was observed across different ethnic/racial subpopulations and incomes, and differences in antibody levels across different demographics were identified. Taken together, this information may inform public health policy to protect vulnerable populations. IMPORTANCE We employed a highly innovative noninvasive multiplex oral fluid SARS-CoV-2 IgG assay to ascertain our seroprevalence estimates. This laboratory-developed test has been applied in NCI's SeroNet consortium, possesses high sensitivity and specificity according to FDA Emergency Use Authorization guidelines, correlates strongly with SARS-CoV-2 neutralizing antibody responses, and is Clinical Laboratory Improvement Amendments-approved by the Johns Hopkins Hospital Department of Pathology. It represents a broadly scalable public health tool to improve understanding of recent and past SARS-CoV-2 exposure and infection without drawing any blood. To our knowledge, this is the first application of a high-performance salivary SARS-CoV-2 IgG assay to estimate population-level seroprevalence, including identifying COVID-19 disparities. We also are the first to report differences in SARS-CoV-2 IgG responses by COVID-19 vaccine manufacturers (BNT162b2 [Pfizer-BioNTech] and mRNA-1273 [Moderna]). Our findings demonstrate remarkable consistency with those of blood-based SARS-CoV-2 IgG assays in terms of differences in the magnitude of SARS-CoV-2 IgG responses between COVID-19 vaccines.

Racial/Ethnic Disparities in Physical Therapy Utilization After Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a common orthopaedic procedure, after which many patients benefit from physical therapy (PT). However, such services may not be uniformly accessible and used. To that end, disparities in access to care such as PT after interventions may be a factor for those of varying race/ethnicities. TKAs were abstracted from the 2014 to 2016 Standard Analytic Files PearlDiver data set-a large national health administrative data set containing information on more than 60 million Medicare patients. Occurrences of home or outpatient PT within 90 days after TKA were identified. Patient demographic factors were extracted, including age, sex, Elixhauser Comorbidity Index, estimated average household income of patient based on zip code (low average household income [<75k/year] or high average household income [>75k/year]), and patient race/ethnicity (White, Hispanic, Asian, Native American, Black, or Other). Predictive factors for PT utilization were determined and compared with univariate and multivariate analyses. Of 23,953 TKA patients identified, PT within 90 days after TKA was used by 18,837 (78.8%). Patients self-identified as White (21,824 [91.1%]), Black (1,250 [5.2%]), Hispanic (268 [1.1%]), Asian (241 [1.0%]), Native American (90 [0.4%]), or "Other" (280 [1.2%]) and were of low household income (19,957 [83.3%]) or high household income (3,994 [16.7%]). When controlling for age, sex, and ECI, PT was less likely to be received by those of low household income (relative to high household income OR 0.79) or by those of defined race/ethnicity (relative to White or Black OR 0.81, Native American OR 0.58, Asian OR 0.50, or Hispanic OR 0.44) ( P < 0.05 for each). In a large Medicare data set, disparities in utilization of PT after TKA were identified based on patient's estimated household income and race/ethnicity. Identification of such factors may help facilitate the expansion of care to meet the needs of all groups adequately. Level III.

PSII-6 Factors Affecting Consumer Acceptance of Insects as Livestock Feed

Abstract The Food and Agricultural Organization estimated global meat consumption to increase 102% from 2000 to 2050. Thus, there is a need to identify and implement novel, sustainable feed for livestock to meet food demands for animal-source protein without jeopardizing food availability for future generations. Insects have potential to fill this role as they are protein-rich and can grow on low-quality nutrient sources. However, Western societies traditionally feel disgust and fear towards insects. Thus, while previous in-vivo research suggests insects are suitable feed for cattle, pigs, poultry, and fish, it is unknown if U.S. consumers will accept animal-source products from livestock consuming insects as feed. Our objectives were to determine the demographics of likely consumers of products from livestock consuming insects as feed and identify factors that affect U.S. consumer acceptance of insects as livestock feed. This study was approved by Texas State University IRB (#7722). We developed a quantitative, electronic survey-based questionnaire that was distributed through convenience sampling (e.g., Facebook, Reddit) to adult U.S. consumers. We used a 95 ± 5% confidence level to calculate required sample size. Prior to distribution, we established face, content, and construct validity of the survey instrument using an external expert panel and established reliability (Cronbach’s ɑ=0.77) using 12 consumers representative of our target population. The effects of demographics on consumer attitude were analyzed using a multinomial logit model in R statistical software and factors affecting acceptance of products from insects as livestock feed were analyzed with descriptive statistics. Of respondents (n=361), 34% were accepting of insects as livestock feed, 15% were opposed, and 52% were neutral. U.S. consumers more likely to accept insects as livestock feed were younger versus older (18-24 versus 35-44 years; P=0.05), had a higher average household income ($50,000-$100,000 versus $25,000; P=0.01), and achieved higher educational attainment (master’s degree versus high school diploma; P=0.05). Older consumers (65+ versus 35-44 years; P=0.05) and those with a lower average household income (less than $25,000 versus $50,000-$100,000; P=0.01) were more likely to oppose insects as livestock feed. Respondents reported the top factors that would positively affect their acceptance of insects as livestock feed were: “If I knew the insects were healthy for the livestock” (74%); “If I knew it would not affect the balance of our eco-system” (66%); and “If I knew it would lessen the environmental impact of livestock production” (61%). Ultimately, our data indicate that young, educated U.S. consumers with higher-than-average income are the target market for animal-source protein from livestock fed insects. Our data also indicate that marketing and educational efforts should emphasize environmental benefits of insects as livestock feed to increase adoption by consumers with neutral or negative attitudes.

Novel Tool to Monitor Adherence to Oral Oncolytics: A Pilot Study.

Nonadherence is a significant issue in cancer care, especially as more oral therapies become available. Measuring and optimizing adherence to such therapies is challenging. In this study, we tested a novel technology that records real-time medication-taking behavior from a smart prescription bottle and can communicate with patients via text message to intervene in cases of nonadherence. We conducted a 28-patient pilot study to assess the feasibility of this technology in measuring and improving adherence in patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. The study had a preintervention stage, during which patients were monitored, and an intervention stage, during which the text messaging intervention was enabled. During preintervention, patients had an average self-adherence of 89%, and during post intervention, they had an average adherence of 90%. We defined three categories of patients by change in adherence: category 1 (> 8%), category 2 (-8% to 8%), and category 3 (< -8%). Patients in category 1 tended to live in regions with lower average household income (mean = $58,937 in US dollars [USD]) than those in category 2 (mean = $77,482 USD) and category 3 (mean = $90,972 USD). Of poststudy survey respondents, most indicated that they would want to continue using this technology and that they would recommend it to others. This novel technology is able to monitor, measure, and intervene for patients taking capecitabine in real time. Adherence overall was high, and some patients appeared to benefit more from text-message interventions. Future work should focus on patients deemed high risk for nonadherence.

Evaluating the unevaluated: a secondary analysis of the National Survey for Family Growth (NSFG) examining infertile women who did not access care.

To characterize the demographic differences between infertile/sub-fertile women who utilized infertility services vs. those that do not. A retrospective analysis of cross-sectional data obtained during the 2011-2013, 2013-2015, and 2015-2017 cycles of National Survey for Family Growth from interviews administered in home for randomly selected participants by a National Center of Health Statistics (NCHS) surveyor was used to analyze married, divorced, or women with long-term partners who reported difficulty having biological children (sub-fertile/infertile women). Demographic differences such as formal marital status, education, race, and religion were compared between women who presented for infertility care vs. those that did not. The primary outcome measure was presenting for infertility evaluation and subsequently utilizing infertility services. Healthcare utilization trends such as having a usual place of care and insurance status were also included as exposures of interest in the analysis. Of the 12,456 women included in the analysis 1770 (15.3%) had used infertility services and 1011 (8.3%) said it would be difficult for them to have a child but had not accessed infertility services. On univariate analysis, compared to women who used infertility services, untreated women had lower average household incomes (295.3 vs. 229.8% of the federal poverty line respectively). Untreated women also had lower levels of education and were more likely to be divorced or never have married. In terms of health status, unevaluated women were less likely to have a usual place for healthcare (87.3%) as compared to women presenting for fertility care (91.9%) (p = 0.004). When examining insurance status, 23.3% of unevaluated women were uninsured as compared to 8.3% of evaluated women. On multivariate analysis, infertile women without insurance were at 0.37 odds of utilizing infertility care compared to women with insurance. Demographic factors are associated with the utilization of infertility care. Insurance status is a significant predictor of whether or not infertile women will access treatment. Data from the three most recent NSFG surveys along with prior analyses demonstrate the need for expanded insurance coverage in order to address the socioeconomic disparities between infertile women who are accessing services vs. those that are not.

Vitamin D levels and pain outcomes in adolescent idiopathic scoliosis patients undergoing spine fusion.

Prior research has indicated adolescent idiopathic scoliosis (AIS) patients have lower bone mineral density and lower vitamin D levels than healthy peers. Vitamin D deficiency has been associated with higher levels of pain. This study investigated whether vitamin D-deficient AIS patients had higher pain before or immediately after posterior spine fusion (PSF) surgery. 25-Hydroxy vitamin D levels were tested in all AIS patients at their pre-operative appointment. Patients were grouped by serum 25-hydroxy vitamin D level: deficient, < 20ng/mL; insufficient, 20-29ng/mL; sufficient, ≥ 30ng/mL. Primary outcomes included pre-operative Scoliosis Research Society Health-Related Quality of Life (SRS-30) and numeric rating scale (NRS) scores (0-10) up to 72h post-operatively, and analyzed using ANOVA and linear mixed modeling, respectively. 176 patients undergoing PSF were included. Intra-operative characteristics by vitamin D status were also assessed. The cohort was 82% female and an average of 15.2years (range 10.6-25.3years) at fusion. Average major curve was 60 (range 40-104) degrees pre-operatively. Forty-five (26%) patients were deficient in vitamin D, 75 (43%) were insufficient, and 56 (32%) were sufficient. Patients with vitamin D deficiency had lower average household income by zip code (p < 0.01) and higher secondhand smoke exposure (p < 0.001). There were no differences in pre-operative SRS-30 score, pre- and post-operative major curve angles, or estimated blood loss across vitamin D groups. Trajectories of NRS indicated no differences in pain during the first 72h after surgery. Vitamin D deficiency in this population is associated with potential markers of lower socioeconomic status; however, it does not influence AIS PSF patients' experience of pain before or immediately after spine fusion surgery. II.

Environmental Barriers Experienced by People With Spinal Cord Injury Across 22 Countries: Results From a Cross-Sectional Survey

ObjectivesTo investigate the experience of environmental barriers by people with spinal cord injury (SCI) across 22 countries. Specific aims were to describe and compare the prevalence of environmental barriers experienced across countries, and to analyze determinants of environmental barriers at individual and country level. DesignCross-sectional community survey. ParticipantsIndividuals (N=12,591) living with SCI in the community. InterventionsNot applicable. Main Outcome MeasureNottwil Environmental Factors Inventory–Short Form. ResultsMost barriers were experienced in relation to accessibility, climate, transportation, finances, and state services. More severe barriers were experienced in settings with lower gross domestic product (GDP), which especially refers to medical supplies (gamma=–0.38; P<.001) and finances (gamma=–0.37; P<.001) in this study. However, in a multivariable negative binomial regression using within-between estimation of the number of barriers experienced on the selected predictors, the effect of GDP was reversed when it was adjusted for covariates. On the individual level, the number of experienced barriers decreased with better mental health and greater self-care ability. People with low income, with paraplegia, complete lesions, and more health problems reported more barriers. On the country level, fewer barriers were reported in countries with higher average age, better mental health, and greater self-care ability, as well as in those with a higher percentage of traumatic SCI, paraplegia, and complete lesions. More barriers were reported in countries with a higher percentage of married individuals, lower average household income, higher average time since injury, higher mean vitality scores, and greater income inequality. ConclusionsStudy participants reported a significant number of environmental barriers, many of which are modifiable. Complementary interventions are recommended. Within and between country effects of covariates sometimes pointed in different directions, suggesting that countries with a different composition of SCI population also differed in environmental contexts.

Comparative Analysis of Water Quality Disparities in the United States in Relation to Heavy Metals and Biological Contaminants

Drinking water quality can be compromised by heavy metals, such as copper and lead. If consumed raw, water can pose a health burden to the general population. In this study, the roles of heavy metals and biological contaminants have been explored in determining the quality of drinking water available to consumers of various socioeconomic backgrounds in the United States. In an effort to gain an understanding of possible social disparities in drinking water, a quantitative analysis was conducted to examine whether vulnerable populations are disproportionately impacted by drinking water contaminants. Our data indicated that states with middle-average household incomes were statistically more susceptible to higher levels of lead in drinking water. The states with higher-average household incomes demonstrated lower copper levels compared to those with lower incomes, although a direct correlation was not present. No statistical significance was observed in the total coliform and turbidity levels in correlation to the average household incomes. In general, more violations in water quality were prevalent in middle-income states when compared to the states with lower-average household incomes.

A novel tool to monitor adherence to oral oncolytics: A pilot study.

286 Background: Non-adherence is an important issue in cancer care as more oral cytotoxic and targeted agents become available. Although oral therapies may be more convenient for patients, measuring and optimizing adherence is challenging. The Nomi system records real-time medication taking behavior from a "smart" prescription bottle and displays the data on a web-based interface. Nomi can also communicate with patients via text message to intervene in cases of non-adherence. We report the results of a 28-patient pilot study aiming to assess Nomi’s ability to assist patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. Methods: Eligible patients were prescribed capecitabine for breast, colorectal, pancreatic, or biliary cancer. The study had a pre-intervention stage, during which patients were monitored, and an intervention stage, in which the text messaging feature was enabled. Adherence was defined as the number of correct doses (both timing and quantity) over the total number of prescribed doses. Conversions were events in which patients took a dose after receiving a text intervention (from Nomi). We defined three categories of patients by percent change in adherence: category 1 ( &gt; 8%), category 2 (-8% to 8%), and category 3 ( &lt; -8%). Results: We collected data from 28 patients (24 pre/post and 4 pre-only). On average, patients were 84% adherent (N = 28; SD = 11%). During pre-intervention, patients had a self-adherence of 89% (SD = 12%), and afterwards, they had an average adherence of 90% (SD = 6%). Most of the patients in category 1 demonstrated a substantial conversion rate ( &gt; 35%). Patients in category 1 tended to live in regions with lower average household income (Mean = $58,937) than those in category 2 (Mean = $77,482) and category 3 (Mean = $90,972). Of survey respondents, 56% indicated that they would want to continue using Nomi, while 67% indicated that they would recommend it to others. Conclusions: This innovative technology is able to monitor, measure and intervene for patients taking capecitabine in real-time. Adherence overall was high, and some patients appeared to benefit more from text message interventions. Future work should focus on patients deemed high risk for non-adherence.

A novel tool to monitor adherence to oral oncolytics: a pilot study

Background: Non-adherence is an important issue in cancer care as more oral cytotoxic and targeted agents become available. Although oral therapies may be more convenient for patients, measuring and optimizing adherence is challenging. The Nomi system records real-time medication taking behavior from a “smart” prescription bottle and displays the data on a web-based interface. Nomi can also communicate with patients via text message to intervene in cases of non-adherence. Aims: The objective is to report the results of a 28-patient pilot study aiming to assess Nomi’s ability to assist patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. Methods: Eligible patients were prescribed capecitabine for breast, colorectal, pancreatic, or biliary cancer. The study had a pre-intervention stage, during which patients were monitored, and an intervention stage, in which the text messaging feature was enabled. Adherence was defined as the number of correct doses (both timing and quantity) over the total number of prescribed doses. Conversions were events in which patients took a dose after receiving a text intervention (from Nomi). Adherence throughout the study was calculated from the data that the bottles collected – we calculated adherence scores for each patient, during each cycle and study period (pre vs. post-intervention), defined as the number of correct doses (both timing and quantity) over the total number of prescribed doses. We defined three categories of patients by percent change in adherence: category 1 (>8%), category 2 (−8% to 8%), and category 3 (< −8%). Results: We collected data from 28 patients (24 pre/post and 4 pre-only). On average, patients were 84% adherent (N = 28; SD = 11%). During pre-intervention, patients had a self-adherence of 89% (SD = 12%), and afterwards, they had an average adherence of 90% (SD = 6%). Most of the patients in category 1 demonstrated a substantial conversion rate (> 35%). Patients in category 1 tended to live in regions with lower average household income (Mean = $58,937) than those in category 2 (Mean = $77,482) and category 3 (Mean = $90,972). Of survey respondents, 56% indicated that they would want to continue using Nomi, while 67% indicated that they would recommend it to others Conclusions: This innovative technology is able to monitor, measure and intervene for patients taking capecitabine in real-time. Adherence overall was high, and some patients appeared to benefit more from text message interventions. Future work should focus on patients deemed high risk for non-adherence.

The Effect of Trihalomethanes in Contaminating the Major Watersheds of Middle Tennessee

We have analyzed the contamination of the three major watersheds in Middle Tennessee (Middle Cumberland River Watershed, Stones River Watershed, and Harpeth River Watershed) by trihalomethanes, such as chloroform, bromodichloromethane, dibromochloromethane, and bromoform. These chemicals play an important role in the develop-ment of cancer and adverse reproductive outcomes, and were found to be present above the threshold established by the Environmental Protection Agency. Certain portions of each watershed were found to be contaminated by the trihalomethanes, and deemed un-healthy. The household incomes in the major areas in the three watershed regions were also examined to determine a possible relationship with the level of water contamination. We concluded that income did not necessarily relate to water quality. Specific areas within each watershed that had lower average household incomes were found to have a higher concentration of the trihalomethanes in their drinking water, while other high-income areas were also affected by unhealthy water. However, these effects were random, and the level of contamination remained below the guidelines regulated by the State of Tennessee.

The interactive role of income (material position) and income rank (psychosocial position) in psychological distress: a 9-year longitudinal study of 30,000 UK parents.

Parents face an increased risk of psychological distress compared with adults without children, and families with children also have lower average household incomes. Past research suggests that absolute income (material position) and income status (psychosocial position) influence psychological distress, but their combined effects on changes in psychological distress have not been examined. Whether absolute income interacts with income status to influence psychological distress are also key questions. We used fixed-effects panel models to examine longitudinal associations between psychological distress (measured on the Kessler scale) and absolute income, distance from the regional mean income, and regional income rank (a proxy for status) using data from 29,107 parents included in the UK Millennium Cohort Study (2003-2012). Psychological distress was determined by an interaction between absolute income and income rank: higher absolute income was associated with lower psychological distress across the income spectrum, while the benefits of higher income rank were evident only in the highest income parents. Parents' psychological distress was, therefore, determined by a combination of income-related material and psychosocial factors. Both material and psychosocial factors contribute to well-being. Higher absolute incomes were associated with lower psychological distress across the income spectrum, demonstrating the importance of material factors. Conversely, income status was associated with psychological distress only at higher absolute incomes, suggesting that psychosocial factors are more relevant to distress in more advantaged, higher income parents. Clinical interventions could, therefore, consider both the material and psychosocial impacts of income on psychological distress.

Household Healthcare Expenditure (Out-of-Pocket) Distribution Pattern in Kenya

Background: This is a retrospective study that examines the household healthcare expenditure (Out-of-pocket) in an African countries-Kenya. Generally, there is a limited body of knowledge in this area of focus in Africa, therefore, this study serves to impact on the available knowledge and inform health policy and program implementation. Methodology: The study was carried out using raw data from 2004/2005 household survey obtained from the Kenyan Bureau of statistics. In all, 1340 households representing a household per cluster of ten out of a total of 13,340 households selected were analyzed. Descriptive data analysis was done. Further results were achieved by analyzing average household income and average household healthcare expenditure. Comparative analysis was done based on settlements and across the eight districts. Result: The study of Out of Pocket (OOP) Household Healthcare Expenditure Distribution Pattern in Kenya shows that lower income groups were found to be having highest household healthcare (OOP) expenditure while the highest income groups have the lowest out of pocket healthcare expenditure. Generally, the urban settlement with higher income has lower Household Healthcare Expenditure and vice versa. Overall, the rural settlement accounts for 58% of the total out-of-pocket household healthcare expenditure with the urban settlement accounting for the remaining 42%. Further analysis show varying percentage of household expenditure by district with the North/Eastern Province with low average household income at 332.9Kshs having the highest average Household out of pocket healthcare expenditure at 71.7%.

A population-based analysis of leaving the hospital against medical advice: incidence and associated variables

BackgroundPrior studies of patients leaving hospital against medical advice (AMA) have been limited by not being population-based or assessing only one type of patient.MethodsWe used administrative data at the Manitoba Centre for Health Policy to evaluate all adult residents of Manitoba, Canada discharged alive from acute care hospitals between April 1, 1990 and February 28, 2009. We identified the rate of leaving AMA, and used multivariable logistic regression to identify socio-demographic and diagnostic variables associated with leaving AMA.ResultsOf 1 916 104 live hospital discharges, 21 417 (1.11%) ended with the patient leaving AMA. The cohort contained 610 187 individuals, of whom 12 588 (2.06%) left AMA once and another 2 986 (0.49%) left AMA more than once. The proportion of AMA discharges did not change over time. Alcohol and drug abuse was the diagnostic group with the highest proportion of AMA discharges, at 11.71%. Having left AMA previously had the strongest association with leaving AMA (odds ratio 170, 95% confidence interval 156–185). Leaving AMA was more common among men, those with lower average household incomes, histories of alcohol or drug abuse or HIV/AIDS. Major surgical procedures were associated with a much lower chance of leaving the hospital AMA.ConclusionsThe rate of leaving hospital AMA did not systematically change over time, but did vary based on patient and illness characteristics. Having left AMA in the past was highly predictive of subsequent AMA events.

The Relationship Between Socioeconomic Status and Clinical Outcomes in African Americans with Chronic Lymphocytic Leukemia

Abstract 3912 Background:Epidemiologic data compiled by the Survey Epidemiology and End Results (SEER) identifies important differences in incidence and survival for African Americans with chronic lymphocytic leukemia (CLL). Although the incidence of CLL is lower among African Americans (AA) than Caucasians (Cauc) (4.4 and 6.1 per 100,000 men, respectively), age adjusted survival is inferior. The overall 5-year relative survival for 1999–2006 from 17 SEER geographic areas by race and sex was: 77.0% for Cauc men, 81.1% for Cauc women, 62.4% for AA men, and 68.3% for AA women; hence, AA CLL patients have an approximate 15% greater absolute risk of CLL-related death in the first 5 years after diagnosis. We have undertaken biologic and genetic investigations to identify factors that contribute to poorer outcomes among AA patients with CLL. A central unanswered question is whether the differences in biology and genetics are the primary cause of inferior overall survival, or whether differences in socioeconomic status (SES) also play a significant role in clinical outcomes. Methods:The Duke University CLL database contains information on greater than 550 CLL patients at Duke University Hospital and the Durham Veterans Affairs Medical Center. We performed a detailed retrospective analysis of this cohort, using average income by ZIP code as a surrogate marker for SES. This was compared with survival data abstracted from the Social Security Outcomes Database. The primary outcome measure was overall survival, and secondary outcome measure was time to treatment (TTT). These outcome measures were compared against average income by ZIP code in addition to other standard validated clinical risk parameters such as race, gender, age, and Rai stage. Statistical analyses were performed using JMP software, version 9.0.1 (SAS, Cary, NC). Average income by ZIP code is publicly available information via IRS tax returns; we used the average adjusted gross income from 2007. Results:Mean household income, as estimated by ZIP code, was $43,255/year for AA (n= 37) and $55,353/year for Cauc (n= 363) (p<0.0001). For univariate analyses, Kaplan-Meier survival curves were generated for age, race, gender, and average income by ZIP code. Mean survival was 8.5 years for AA, and 17.9 years for Cauc (p<0.0001, Log-Rank). Mean survival was 18.5 years for those under the age of 60, and 14.8 years for those 60 and above (p<0.0001, Log-Rank). Mean survival was 18.6 years for females, and 15.9 years for males (p= 0.25, Log-Rank). For univariate analysis, average income by ZIP code was divided into quintiles, and mean survival was 16.0, 13.4, 16.2, 18.0, and 13.9 years, in order of ascending incomes (p= 0.73, Log-Rank). Mean TTT was 2.7 years for AA, and 4.5 years for Cauc (p= 0.0004, t-test). A multivariable analysis using a Cox proportional hazards model showed that the following prognostic variables (followed by respective hazard ratios (HR) and p value) were independent predictors of shorter overall survival: AA race (versus Cauc race; HR= 3.6, p= 0.0005), age (examined as a continuous variable; HR= 1.07, per unit change in regressor, HR= 41.1 per change in regressor over entire range, p= <0.0001), Rai stage (HR varies depending on stages under comparison, p= 0.003), and male gender (versus female; HR= 1.9, p= 0.015). Mean income by ZIP code was not an independent predictor of shorter overall survival (examined as a continuous variable; HR= 0.99, per unit change in regressor, HR= 0.53 per change in regressor over entire range, p= 0.39). Conclusions:AA patients with CLL have poorer overall survival than Cauc. We have examined whether SES plays a role in these inferior outcomes. While the AA patients in our cohort have lower average household incomes, this was not an independent predictor of survival in a multivariable model. We conclude that clinical and biologic, rather than socioeconomic, factors are primary determinants of inferior clinical outcomes. However, SES is intrinsically a difficult construct to measure, and it is possible that using average incomes by ZIP code does not accurately approximate socioeconomic status. Disclosures:No relevant conflicts of interest to declare.

Private expenditure and the role of private health insurance in Greece: status quo and future trends

The health care system in Greece is financed in almost equal proportions by public and private sources. Private expenditure, consists mostly of out-of-pocket and under-the-table payments. Such payments strongly suggest dissatisfaction with the public system, due to under financing during the last 25 years. This gap has been filled rapidly by the private sector. From this point of view, one might suggest that the flourishing development of private provision may lead in turn to a corresponding growth in private health insurance (PHI). This paper aims to examine the role of PHI in Greece, to identify the factors influencing its development, and to make some suggestions about future policies and trends. In the decade of 1985-1995 PHI show increasing activity, reflecting the intention of some citizens to seek health insurance solutions in the form of supplementary cover in order to ensure faster access, better quality of services, and increased consumer choice. The benefits include programs covering hospital expenses, cash benefits, outpatient care expenses, disability income insurance, as well as limited managed care programs. However, despite recent interest, PHI coverage remains low in Greece compared to other EU countries. Economic, social and cultural factors such as low average household income, high unemployment, obligatory and full coverage by social insurance, lead to reluctance to pay for second-tier insurance. Instead, there is a preference to pay a doctor or hospital directly even in the form of under-the-table payments (which are remarkably high in Greece), when the need arises. There are also factors endogenous to the PHI industry, related to market policies, low organisational capacity, cream skimming, and the absence of insurance products meeting consumer requirements, which explain the relatively low state of development of PHI in Greece.

Die Krebsfrüherkennungsuntersuchung für Frauen wird in Regionen mit niedrigerem Haushaltseinkommen seltener in Anspruch genommen – Analyse von Daten der Kassenärztlichen Vereinigung Bayerns

Differences in health care in Germany have rarely been analysed. Recent research, however, indicates that subjects of the lower social class participate in cancer screening less frequently. Participation in screening for cervical cancer among women older than 20 years has been analysed using billing information of the KVB (Kassenärztlichen Vereinigung Bayern) for the period from 2002-2005. Women were assigned to one of the 96 Bavarian districts based on their postal code. The following variables were used: Participation rate in cervical cancer screening; age; average household income; gynaecologists per 10,000 women. Multivariate analyses were based on age-stratified linear regressions. There are considerable regional differences in participation in screening for cancer among older women. Participation rates are lower in districts with lower average household income. The correlation between participation rates and average household income shows an almost linear dependence on the level of districts. This association could not be explained by the variable "gynaecologists per 10,000 women". In order to provide social equality in health care, regional differences in cancer screening participation should be targeted. This is especially important in districts with lower average household incomes.

Average household income, crime, and smoking behaviour in a local area: The Finnish 10-Town study

Social environments, like neighbourhoods, are increasingly recognised as determinants of health. While several studies have reported an association of low neighbourhood socio-economic status with morbidity, mortality and health risk behaviour, little is known of the health effects of neighbourhood crime rates. Using the ongoing 10-Town study in Finland, we examined the relations of average household income and crime rate measured at the local area level, with smoking status and intensity by linking census data of local area characteristics from 181 postal zip codes to survey responses to smoking behaviour in a cohort of 23,008 municipal employees. Gender-stratified multilevel analyses adjusted for age and individual occupational status revealed an association between low local area income rate and current smoking. High local area crime rate was also associated with current smoking. Both local area characteristics were strongly associated with smoking intensity. Among ever-smokers, being an ex-smoker was less likely among residents in areas with low average household income and a high crime rate. In the fully adjusted model, the association between local area income and smoking behaviour among women was substantially explained by the area-level crime rate. This study extends our knowledge of potential pathways through which social environmental factors may affect health.

Neither Fish nor Fowl: Feminism, Desire, and the Lesbian Consumer Market

This article addresses gay marketers’ tardy and ambivalent attempts to imagine and organize lesbians as a viable target marketing niche. Practical considerations make lesbians less attractive as a market: They have a lower average household income than gay male and heterosexual couples and they are hard to reach for market research purposes and with advertising. But the lesbian market is also dogged by the popular image of lesbians as lacking both erotic and acquisitive desire, embodied in the stereotype of anti-consumption, parsimonious, unsexy feminists who resist marketers’ interest in them as consumers.