Low Socioeconomic Status Patients Research Articles

Clinical effectiveness of cardiac rehabilitation and barriers to completion in patients of low socioeconomic status in rural areas: A mixed-methods study.

To investigate cardiac rehabilitation utilisation and effectiveness, factors, needs and barriers associated with non-completion. We used the mixed-methods design with concurrent triangulation of a retrospective cohort and a qualitative study. Economically disadvantaged areas in rural Australia. Patients (≥18 years) referred to cardiac rehabilitation through a central referral system and living in rural areas of low socioeconomic status. A Cox survival model balanced by inverse probability weighting was used to assess the association between cardiac rehabilitation utilization and 12-month mortality/cardiovascular readmissions. Associations with non-completion were tested by logistic regression. Barriers and needs to cardiac rehabilitation completion were investigated through a thematic analysis of semi-structured interviews and focus groups (n = 28). Among 16,159 eligible separations, 44.3% were referred, and 11.2% completed cardiac rehabilitation. Completing programme (HR 0.65; 95%CI 0.57-0.74; p < 0.001) led to a lower risk of cardiovascular readmission/death. Living alone (OR 1.38; 95%CI 1.00-1.89; p = 0.048), having diabetes (OR 1.48; 95%CI 1.02-2.13; p = 0.037), or having depression (OR 1.54; 95%CI 1.14-2.08; p = 0.005), were associated with a higher risk of non-completion whereas enrolment in a telehealth programme was associated with a lower risk of non-completion (OR 0.26; 95%CI 0.18-0.38; p < 0.001). Themes related to logistic issues, social support, transition of care challenges, lack of care integration, and of person-centeredness emerged as barriers to completion. Cardiac rehabilitation completion was low but effective in reducing mortality/cardiovascular readmissions. Understanding and addressing barriers and needs through mixed methods can help tailor cardiac rehabilitation programmes to vulnerable populations and improve completion and outcomes.

Chiropractors in Multidisciplinary Teams: Enablers of Colocation Integration in GP-Led Primary Healthcare.

The aim of this study was to explore and document the enablers and barriers of chiropractic care colocation in general practice at a large-scale private primary care centre in Australia. This study focused on the perceptions of healthcare professionals regarding this integration. The research setting was a large integrated primary care centre located in an outer metro, low-socioeconomic area in the City of Moreton Bay, Queensland, Australia. Participant inclusion criteria included general medical practitioners, practice nurses, and medical managers who self-reported interactions with the physically collocated and integrated chiropractic practice. Data was collected from 22 participants using face-to-face, qualitative, semi-structured interviews with an average duration of 32 min. The data collected included perceptions of chiropractic treatment, enablers to patient referral pathways, and views of the integrated chiropractic care model. A reflexive thematic analysis was conducted on the data set. All participants reported that this was their first exposure to the colocation of a chiropractor within a general medical practice. Four key enablers of chiropractic care integration were identified: (1) the practitioner [chiropractor], (2) the organisation [general practice], (3) consumer flow, and (4) the environment [shared spaces and tenant ecosystem]. The chiropractic integration enhanced knowledge sharing and interprofessional trust among healthcare providers. The formal reporting of patient outcomes and understanding of the chiropractor's scope of practice further enabled referrals to the service. Shared administrative and business processes, including patient records, booking systems, and clinical meetings, facilitated relationship development between the chiropractor and referring health providers. Colocation as part of a larger primary care centre created proximity and convenience for health providers in terms of interprofessional communication, and for patients, in terms of access to chiropractic services. Existing governance structures supported communication, professional education, and shared values related to the delivery of patient-centred care. Identified barriers included limited public funding for chiropractic services resulting in reduced access for patients of low-socioeconomic status. Additionally, scepticism or negativity towards the discipline of chiropractic care was identified as an initial barrier to refer patients. In most cases, this view towards the chiropractor was overcome by regular patient reporting of positive treatment outcomes to their GP, the delivery of education sessions by the chiropractor for the health providers, and the development of interprofessional trust between the chiropractor and referring health providers. This study provides preliminary evidence and a conceptual framework of factors influencing the successful integration of chiropractic care within an Australian large primary care centre. The data collected indicated that integration of chiropractic care into a primary care centre serving a low-socioeconomic region can be achieved with a high degree of health provider satisfaction.

Demographic and Socioeconomic Trends of Patients Undergoing Total Knee Arthroplasty From 2013 to 2022—An Analysis From an Urban Orthopaedic Hospital

BackgroundAs worldwide utilization of total knee arthroplasty (TKA) broadens, demographic trends can help make projections to inform access to care. This study aimed to assess the temporal trends in the socioeconomic and medical demographics of patients undergoing TKA. MethodsA retrospective review of 15,848 patients who underwent primary, elective TKA at an urban, New York City-based academic medical center between January 2013 and September 2022 was performed. Trends in patients’ age, body mass index (BMI), socioeconomic status (SES) (based on median income by patients’ ZIP code), race, and Charlson comorbidity index were evaluated using the Mann-Kendall test. ResultsIn the last decade, mean patient age (65 to 68 years, P < .001) and Charlson comorbidity index (1.4 to 2.3, P < .001) increased significantly. The proportion of patients who had a BMI ≥ 30 and < 40 increased (43.8 to 51.2%, P = .002), while the proportion of patients who had a BMI ≥ 40 (13.7 to 12.1%, P = .015) and BMI < 30 (42.5 to 36.8%, P = .020) decreased. The distribution of patients’ race and SES did not change from 2013 to 2022; Black (18.1 to 16.8%, P = .211) and low SES (12.9 to 11.3%, P = .283) patients consistently represented a minority of TKA patients. ConclusionsOver the last decade, the average age and comorbidity burden of TKA patients at our institution have increased. This portends the need for higher levels of preoperative optimization and postoperative management for TKA patients. A decreased prevalence of BMI ≥40 could reflect optimization efforts. However, the consistently low prevalence of Black and low-SES patients suggests that recent payment models did not improve access to care for these populations. Level of EvidenceIV.

Hispanic/Latino Ethnicity and Loss of Post-Surgery Independent Living: A Retrospective Cohort Study from a Bronx Hospital Network.

Black race is associated with postoperative adverse discharge to a nursing facility, but the effects of Hispanic/Latino ethnicity are unclear. We explored the Hispanic paradox, described as improved health outcomes among Hispanic/Latino patients on postoperative adverse discharge to nursing facility. A total of 93,356 adults who underwent surgery and were admitted from home to Montefiore Medical Center in the Bronx, New York, between January 2016 and June 2021 were included. The association between self-identified Hispanic/Latino ethnicity and the primary outcome, postoperative adverse discharge to a nursing home or skilled nursing facility, was investigated. Interaction analysis was used to examine the impact of socioeconomic status, determined by estimated median household income and insurance status, on the primary association. Mixed-effects models were used to evaluate the proportion of variance attributed to the patient's residential area defined by zip code and self-identified ethnicity. Approximately 45.9% (42,832) of patients identified as Hispanic/Latino ethnicity and 9.7% (9074) patients experienced postoperative adverse discharge. Hispanic/Latino ethnicity was associated with lower risk of adverse discharge (relative risk [RRadj] 0.88; 95% confidence interval [CI], 00.82-0.94; P < .001), indicating a Hispanic Paradox. This effect was modified by the patient's socioeconomic status (P-for-interaction <.001). Among patients with a high socioeconomic status, the Hispanic paradox was abolished (RRadj 1.10; 95% CI, 11.00-1.20; P = .035). Furthermore, within patients of low socioeconomic status, Hispanic/Latino ethnicity was associated with a higher likelihood of postoperative discharge home with health services compared to non-Hispanic/Latino patients (RRadj 1.06; 95% CI, 11.01-1.12; P = .017). Hispanic/Latino ethnicity is a protective factor for postoperative adverse discharge, but this association is modified by socioeconomic status. Future studies should focus on postoperative discharge disposition and socioeconomic barriers in patients with Hispanic/Latino ethnicity.

Impact of socioeconomic status on biologics utilization in rheumatoid arthritis: revealing inequalities and healthcare efficiency.

This cross-sectional study aimed to investigate biologics treatment disparities in rheumatoid arthritis (RA) patients based on socioeconomic status (SES). Data from the KOrean Observational Study Network for Arthritis (KORONA) database were analyzed to assess various factors associated with SES, health behaviors, and biologics use. Logistic regression and structured equation modeling (SEM) were utilized for data analysis. Among 5,077 RA patients included, 393 (7.7%) patients were identified as biologics users. Within the entire cohort, 31.8% of the participants were in the low-income and low-education groups, and 39.3% of the participants were in the high-income and high-education groups. Despite the patients with low income or low education experienced higher disease activity at diagnosis, had more comorbidities, exhibited higher medication compliance, underwent more check-ups, and had more hospital admissions than their counterparts, the odds of patients with low-income receiving biologics were 34% lower (adjusted odds ratio = 0.76, 95% confidence interval: 0.60-0.96, p = 0.021) after adjustment for demographics and comorbidities. SEM and pathway analyses confirmed the negative impact of low SES on biologics use. The findings suggest that SES plays a significant role in biologics use among RA patients, indicating potential healthcare inefficiencies for low SES patients. Moreover, adverse healthcare habits negatively affect biologics use in RA patients. The study highlights the importance of considering socioeconomic factors while discussing biologics use and promoting equitable access to biologics for optimal RA management.

Comorbidity patterns in cardiovascular diseases: the role of life-stage and socioeconomic status.

Cardiovascular diseases stand as a prominent global cause of mortality, their intricate origins often entwined with comorbidities and multimorbid conditions. Acknowledging the pivotal roles of age, sex, and social determinants of health in shaping the onset and progression of these diseases, our study delves into the nuanced interplay between life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Leveraging data from a cross-sectional survey encompassing Mexican adults, we unearth a robust association between these variables and the prevalence of comorbidities linked to cardiovascular conditions. To foster a comprehensive understanding of multimorbidity patterns across diverse life-stages, we scrutinize an extensive dataset comprising 47,377 cases diagnosed with cardiovascular ailments at Mexico's national reference hospital. Extracting sociodemographic details, primary diagnoses prompting hospitalization, and additional conditions identified through ICD-10 codes, we unveil subtle yet significant associations and discuss pertinent specific cases. Our results underscore a noteworthy trend: younger patients of lower socioeconomic status exhibit a heightened likelihood of cardiovascular comorbidities compared to their older counterparts with a higher socioeconomic status. By empowering clinicians to discern non-evident comorbidities, our study aims to refine therapeutic designs. These findings offer profound insights into the intricate interplay among life-stage, socioeconomic status, and comorbidity patterns within cardiovascular diseases. Armed with data-supported approaches that account for these factors, clinical practices stand to be enhanced, and public health policies informed, ultimately advancing the prevention and management of cardiovascular disease in Mexico.

Association of Socioeconomic Status With Worse Overall Survival in Patients With Bone and Joint Cancer.

The effect of socioeconomic status (SES) on the outcomes of patients with metastatic cancer to bone has not been adequately studied. We analyzed the association between the Yost Index, a composite geocoded SES score, and overall survival among patients who underwent nonprimary surgical resection for bone metastases. This population-based study used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010 to 2018). We categorized bone and joint sites using International Classification of Disease-O-3 recodes. The Yost Index was geocoded using a factor analysis and categorized into quintiles using census tract-level American Community Service 5-year estimates and seven measures: median household income, median house value, median rent, percent below 150% of the poverty line, education index, percent working class, and percent unemployed. Multivariate Cox regression models were used to calculate adjusted hazard ratios of overall survival and 95% confidence intervals. A total of 138,158 patients were included. Patients with the lowest SES had 34% higher risk of mortality compared with those with the highest SES (adjusted hazard ratio of 1.34, 95% confidence interval: 1.32 to 1.37, P < 0.001). Among patients who underwent nonprimary surgery of the distant bone tumor (n = 11,984), the age-adjusted mortality rate was 31.3% higher in the lowest SES patients compared with the highest SES patients (9.9 versus 6.8 per 100,000, P < 0.001). Patients in the lowest SES group showed more racial heterogeneity (63.0% White, 33.5% Black, 3.1% AAPI) compared with the highest SES group (83.9% White, 4.0% Black, 11.8% AAPI, P < 0.001). Higher SES patients are more likely to be married (77.5% versus 59.0%, P < 0.0001) and to live in metropolitan areas (99.6% versus 73.6%, P < 0.0001) compared with lower SES patients. Our results may have implications for developing interventions to improve access and quality of care for patients from lower SES backgrounds, ultimately reducing disparities in orthopaedic surgery.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations.

Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations. Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced). Cross-sectional study using ordinary least squares regression controlling for patient and community factors. Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid. Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022. Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001). Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

Racial Disparities in Pelvic Floor Disorders.

To investigate the impact of racial disparities and Socioeconomic Status (SES) on pelvic floor disorder (PFD) care. Racial disparities in colorectal PFD remain uninvestigated, despite prior research in urogynecology. This retrospective study was conducted at Guy's and St. Thomas' Hospital of London in 2023. Patients with colorectal PFD from 2013 to 2018 were evaluated. Patients were classified according to the Index of Multiple Deprivation (IMD) scores and divided into quintiles. The lowest quintile represents the most deprived, whereas the higher quintile represents the least deprived. Assessed variables: patient complaint, symptoms, consultant and biofeedback referrals, investigations, multidisciplinary meeting (MDM) discussions, treatment, and follow-up appointments. 2001 patients were considered. A total of 1126 patients were initially analyzed, and 875 patients were excluded owing to incomplete data. Eight ethnic groups were identified in this study. Constipation was the most common compliant across ethnic groups (P=0,03). Diagnostics, MDM discussions, and conservative treatment did not vary between ethnicities. White British and Asian patients were significantly more likely to be seen by a consultant (P=0.001) and undergo surgery (P=0.002). In the second part of the study, the IMD was calculated for 1992 patients who were categorized into quintiles. Diagnostic tests, discussion in MDM, Consultant review, and surgical treatments were significantly lower in the two lowest quintiles (P<0.001, P<0.001, P=0.02, and P=0.02, respectively). Conservative treatment did not vary between the IMD groups. Disparities in the diagnosis and treatment of colorectal PFD exist among ethnic minorities and patients of low SES. This study allows for the replication of service provision frameworks in other affected areas to minimize inequalities.

Impact of socioeconomic status on presentation, care quality and outcomes of patients attended by emergency medical services for dyspnoea: a population-based cohort study

BackgroundLow socioeconomic status (SES) has been linked to poor outcomes in many conditions. It is unknown whether these disparities extend to individuals presenting with dyspnoea. We aimed to evaluate the...

Delayed Prescribing of Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) in Patients with Low Socioeconomic Status

Background/Objective: Atrial fibrillation (AF) and venous thromboembolism (VTE) are conditions with significant morbidity and mortality when left untreated. American Heart Association guidelines changed in 2019 to make non-vitamin K antagonist oral anticoagulants (NOACs) the preferred method for preventing stroke and systemic embolism in patients with AF or history of VTE. NOACs were first introduced to the United States in 2010 and now include dabigatran, apixaban, rivaroxaban, and edoxaban. There is a dearth of research concerning the speed with which new treatments are prescribed to those in different socioeconomic status (SES) groups. We hypothesized that patients with lower SES were prescribed NOACs later than higher SES counterparts following the introduction of NOACs in 2010.&#x0D; Methods: The IU Cardiovascular Research Consortium/Sidus Dataset was mined for AF and VTE patients prescribed a NOAC between 2010 and 2022. The SES groups were determined using 2020 U.S. Census income data that correlated to patients’ zip codes. The yearly number ofpatients in each SES group were compared to assess for proportional uptake of NOAC prescribing. The primary outcome was the proportion of low SES to high SES prescribing over each year between 2010 and 2022.&#x0D; Results: Low SES patients (n=101,945) were prescribed NOACs at an average of 0.65 times the rate of high SES patients (n= 89,130) from 2010 to 2012, the first three years of NOAC market availability. Prescribing rates equilibrated in 2013 and low SES prescribing has outpaced high SES prescribing since 2021.&#x0D; Conclusion/Impact: Low SES patients experienced a three year delay in receiving NOAC prescriptions at the same rate as their high SES counterparts. Systemic changes, like more frequent prescribing guideline updates and improved evidence-based education amongst providers in low-income areas, could prevent a similar delay when introducing similarly transformative treatments in the future.

Socioeconomic status as a predictor of post-operative mortality and outcomes in carotid artery stenting vs. carotid endarterectomy.

The association between low socioeconomic status (SES) and worse surgical outcomes has become an emerging area of interest. Literature has demonstrated that carotid artery stenting (CAS) poses greater risk of postoperative complications, particularly stroke, than carotid endarterectomy (CEA). This study aims to compare the impact of low SES on patients undergoing CAS vs. CEA. The National Inpatient Sample (NIS) was queried for patients undergoing CAS and CEA from 2010 to 2015. Patients were stratified by highest and lowest median income quartiles by zip code and compared through demographics, hospital characteristics, and comorbidities defined by the Charlson Comorbidity Index (CCI). Primary outcome was in-hospital mortality. Secondary outcomes included acute kidney injury (AKI), post-operative stroke, sepsis, and bleeding requiring reoperation.Multivariable logistic regression was used to determine the effect of SES on outcomes. Five thousand four hundred twenty-five patients underwent CAS (Low SES: 3,516 (64.8%); High SES: 1,909 (35.2%) and 38,399 patients underwent CEA (Low SES: 22,852 (59.5%); High SES: 15,547 (40.5%). Low SES was a significant independent predictor of mortality [OR = 2.07 (1.25-3.53); p = 0.005] for CEA patients, but not for CAS patients [OR = 1.21 (CI 0.51-2.30); p = 0.68]. Stroke was strongly associated with low SES, CEA patients (Low SES = 1.5% vs. High SES = 1.2%; p = 0.03), while bleeding was with high SES, CAS patients (Low SES = 5.3% vs. High SES = 7.1%; p = 0.01). CCI was a strong predictor of mortality for both procedures [CAS: OR1.45 (1.17-1.80); p < 0.001. CEA: OR1.60 (1.45-1.77); p < 0.001]. Advanced age was a predictor of mortality post-CEA [OR = 1.03 (1.01-1.06); p = 0.01]. While not statistically significant, advanced age and increased mortality trended towards a positive association in CAS [OR = 1.05 (1.00-1.10); p = 0.05]. Low SES is a significant independent predictor of post-operative mortality in patients who underwent CEA, but not CAS. CEA is also associated with higher incidence of stroke in low SES patients. Findings demonstrate the impact of SES on outcomes for patients undergoing carotid revascularization procedures. Prospective studies are warranted to further evaluate this disparity.

Advancing equity in challenging times: A qualitative study of telehealth expansion and changing patient-provider relationships in primary care settings during the COVID-19 pandemic.

The patient-provider relationship is critical for achieving high-quality care and better health outcomes. During the COVID-19 pandemic, primary care practices rapidly transitioned to telehealth. While telehealth provided critical access to services for many, not all patients could optimally utilize it, raising concerns about its potential to exacerbate inequities in patient-provider relationships. We investigated technical and workforce-related barriers to accessing telehealth and the impacts on patient-provider relationships for vulnerable populations. Qualitative, semi-structured interviews from May 2021 to August 2021 with 31 individuals (medical directors, physicians, and medical assistants) working at 20 primary care practices in Massachusetts, North Carolina, and Texas. Thematic analysis to better understand how barriers to using telehealth complicated patient-provider relationships. Interviewees shared challenges for providers and patients that had a negative effect on patient-provider relationships, particularly for vulnerable patients, including older adults, lower socio-economic status patients, and those with limited English proficiency. Providers faced logistical challenges and disruptions in team-based care, reducing care coordination. Patients experienced technological challenges that made accessing and engaging in telehealth difficult. Interviewees shared challenges for patient-provider relationships as commonly used telephone-only telehealth reduced channels for non-verbal communication. This study indicates that barriers to virtual interaction with patients compared to in-person care likely led to weaker personal relationships that may have longer-term effects on engagement with and trust in the healthcare system, particularly among vulnerable patient groups. Additional support and resources should be available to primary care providers to optimize telehealth utilization.

Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System.

Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

Neighborhood Disadvantage Increases Risk of Adverse Clinical Events in Children with Sickle Cell Disease

Background: Hydroxyurea is the most widely used pharmacologic agent to treat patients with sickle cell disease (SCD). Hydroxyurea treatment has well established effects of inducing expression of fetal hemoglobin (HbF) and a beneficial impact on clinical outcomes such as reduced number of vaso-occlusive (VOC) events, transfusions, and hospitalizations. In non-SCD populations, living in socio-economic disadvantage is a well-established factor for poor health outcomes. However, there is a paucity of data to describe how social stressors impact children with SCD. We hypothesized that socio-economic disadvantage impacts risk of adverse clinical outcomes in pediatric SCD patients even while on hydroxyurea therapy. Methods: We performed a retrospective chart review on 121 pediatric patients with severe SCD genotypes (homozygous HbS and sickle-beta 0 thalassemia) seen at Texas Children's Hospital (TCH) between 2010-2021. All patients were treated with hydroxyurea for a minimum of five years. Adherence to hydroxyurea was assessed through lab markers including absolute neutrophil count and reticulocyte counts. Patients not adherent were excluded from analysis. We examined the incidence of all clinical events for a total of 1026 patient years, including the number of office visits, ER visits, hospitalizations, transfusions, VOC, acute chest syndrome episodes (ACS), acute splenic sequestration (ASS), and febrile illness. We collected laboratory data including absolute neutrophil count, hemoglobin level, and HbF levels for each patient per year they were on hydroxyurea. We used the area deprivation index (ADI) to determine a score of neighborhood disadvantage amongst our cohort of patients. The ADI is a factor-based index which uses 17 US Census variables including poverty, education, and employment. We used individual residential addresses during our observation period to assign a geocode specific to each individual and obtain an ADI score. The ADI scores are ranked from 1-10, with higher ADI rankings reflecting a higher level of disadvantage. Results: All individuals with SCD had a robust response to hydroxyurea within their first year of initiating the drug (&amp;gt;20% HbF). We stratified our cohort based on their ADI scores into low ADI (1-3; n=42); medium ADI (4-6; n=42); and high ADI groups (7-10; n=37), where high ADI is the group with highest levels of disadvantage. All three groups had a similar average duration of hydroxyurea treatment. There were no significant differences in age, sex, or reason given for starting hydroxyurea between the ADI groups. When we examined hydroxyurea response, there was no significant difference in HbF levels at 1 year (23.8 vs. 24.06 %HbF in the low vs. high ADI groups) or after 5 years (19.6 vs. 18.6 % HbF in the low and high ADI groups). Individuals with high ADI did started hydroxyurea at a younger age (2.9 years vs. 4.9 years, p=0.02). We found that any individual living in an area with higher ADI had an increased incidence of adverse clinical events. We calculated the incidence of each clinical event per 100 patient years in our 3 ADI groups and used a conditional maximum likelihood estimate of rate ratio method to compare incidences (Table 1). We found that among individuals living in an area with a higher ADI (more deprived region), there was increased frequency of ER visits, hospitalizations, transfusions, VOC, and ASS. In particular, patients with the highest ADI had a 3 and 5 times higher rate of VOC and ASS, respectively (Table 1). Discussion: While we did not observe an association between ADI and HbF expression, our results show that higher neighborhood disadvantage is associated with poorer clinical outcomes among hydroxyurea-adherent pediatric patients with SCD who maintained a robust response to the drug (&amp;gt;20% HbF). All individuals in our study had a similar number of routine office visits at our clinic but any patient living in an area of high ADI had significantly more ER visits and hospitalizations for VOC and ASS events. While hydroxyurea is shown to reduce hospitalizations and VOC events in pediatric sickle cell patients, we show that neighborhood disadvantage can influence clinical outcomes even among patients who respond to hydroxyurea. More analysis remains in order to better characterize this association, and to understand additional strategies that can be used to reduce clinical events in pediatric patients of lower socioeconomic status.

1477. Do Federal Risk Assessment Criteria Adequately Classify Patients for Surgical Site Infections Following Colon Surgery?

Abstract Background Infections related to colon surgery are associated with adverse outcomes. Colon SSIs are reportable to National Healthcare Safety Network (NSHN) and Centers for Medicare and Medicaid Services (CMS). Rates of SSIs are factored into federal reimbursement programs; financial penalty may exist for “low-performing” hospitals. CMS employs a risk assessment tool to calculate the number of expected colon SSIs for each center. Methods The NYC H+H consist of hospitals that serve patients of low socioeconomic status. Five of the eleven are designated as level 1 trauma centers. Data regarding patients that underwent colon surgery from 2015-2022, including those that developed SSIs, were obtained from NHSN. Propensity score matching was done to match patients with colon SSIs to those without SSIs. Covariates included the CMS risk factors: gender, diabetes, age, BMI, ASA score, surgical closure type. Results A total of 5217 patients underwent colon surgery from 2015-2022. There were 276 patients with a colon SSI. A propensity matched cohort (n=276), using the CMS risk assessment variables, was matched with the 276 patients with SSIs (Table 1). Other features involving the colon surgery were examined for the two cohorts (Table 2). Compared to the matched controls, there was a disproportionate distribution of wound class groups among the SSI cohort. Significantly more patients had dirty wounds in the SSI group. Surgery was more often emergent, and had a significantly longer duration in the SSI cohort. Of the patients with SSIs, more were trauma cases, and a significantly greater percentage had surgery performed in a trauma center compared to the other hospitals. Conclusion Colon SSI preventive measures are not applicable for emergent and trauma cases. The current risk assessment model used by CMS does not fully adjust for the complexity of various colon surgeries. As such, hospital performance as judged by federal SSI assessments does not correlate with the quality of care provided. Financial penalties imposed by CMS may be devastating, particularly for safety net hospitals serving patients primarily of low socioeconomic status. Until appropriate risk assessment models are developed, the use of colon surgery SSIs as a quality measure should be re-evaluated. Disclosures All Authors: No reported disclosures

Financial toxicity among adult cancer survivors in Singapore: does it exist?

Abstract Introduction: Cancer survivors may experience financial toxicity (FT) arising from diagnosis, treatment and potential employment loss. The prevalence of FT in the context of Singapore healthcare model is unknown. We investigate whether higher out-of-pocket (OOP) expenditure correlates positively with FT, and whether higher FT correlates with a worse quality of life (QoL). Methods: In this pilot study, a cross-sectional survey was conducted on survivors of nasopharyngeal or breast cancer at the National University Hospital Singapore. Patients’ FT and QoL were measured using the COmprehensive Score on financial Toxicity (COST) and Functional Assessment of Cancer Therapy-General (FACT-G) questionnaires. Two multivariate regression models estimated (a) the association between FT and a range of variables, and (b) the association between FT and QoL. Results: Sixty-three percent of our cohort of 76 patients experienced mild–moderate FT. Overall, the mean COST and FACT-G scores were 18.0 (out of 44) and 68.3 (out of 108), respectively. There was a positive correlation between COST and FACT-G scores (r = 0.45). We did not find any significant association between OOP expenditure and FT. Predictors for FT included government-subsidised housing, lower education levels, hire of a formal caregiver and the need for household members to take on extra employment. Conclusion: Greater FT correlated with a decline in QoL. Patients of lower socioeconomic status were at higher risk of FT. OOP expenditure was not directed related to FT, likely in view of the effective means-tested subsidies. Additional resources should be considered for this at-risk population. Based on this pilot study, our methodology to quantify FT and OOP expenditure can be scaled up to other cancer primaries.

Mediation Analyses of the Mechanisms by Which Socioeconomic Status, Comorbidity, Stroke Severity, and Acute Care Influence Stroke Outcome.

Low socioeconomic status (SES) is associated with increased risk of death and disability after stroke, but interventional targets to minimize disparities remain unclear. We aim to assess the extent to which SES-based disparities in the association between low SES and death and dependency at 3 months after stroke could be eliminated by offsetting differences in comorbidity, stroke severity, and acute care. This nationwide register-based cohort study included all 72 hospitals caring for patients with acute stroke in Sweden. All patients registered with an acute ischemic stroke in the Swedish Stroke Register in 2015-2016 who were independent in activities of daily living (ADL) during stroke were included. Data on survival and SES the year before stroke were retrieved by cross-linkage with other national registers. SES was defined by education and income and categorized into low, mid, and high. Causal mediation analysis was used to study the absolute risk of death and ADL dependency at 3 months depending on SES and to what extent hypothetical interventions on comorbidities, stroke severity, and acute care would equalize outcomes. Of the 25,846 patients in the study, 6,798 (26.3%) were dead or ADL dependent 3 months after stroke. Adjusted for sex and age, low SES was associated with an increased absolute risk of 5.4% (95% CI 3.9%-6.9%; p < 0.001) compared with mid SES and 10.1% (95% CI 8.1%-12.2%; p < 0.001) compared with high SES. Intervening to shift the distribution of all mediators among patients with low SES to those of the more privileged groups would result in absolute reductions of these effects by 2.2% (95% CI 1.2%-3.2%; p < 0.001) and 4.0% (95% CI 2.6%-5.5%; p < 0.001), respectively, with the largest reduction accomplished by equalizing stroke severity. Low SES patients have substantially increased risks of death and ADL dependency 3 months after stroke compared with more privileged patient groups. This study suggests that if we could intervene to equalize SES-related differences in the distributions of comorbidity, acute care, and stroke severity, up to 40 of every 1,000 patients with low SES could be prevented from dying or becoming ADL dependent.

Abstract 18368: Management of Incident AF in Hospitalized Patients - Deficient, Delayed, Detrimental

Introduction: Atrial fibrillation (AF) is potentially associated with significant complications including stroke and cardiac decompensation. Early appropriate AF management mitigates this risk. However, intervention is frequently delayed - a median of 1.5 days from AF onset in the ICU to clinical response. We sought to better understand delays in detection and management of AF in patients admitted to a cardiology bed and the consequences of delays. Methods: We undertook a retrospective review of 498 patients admitted to cardiology beds at the University of Virginia Medical Center who had automated algorithmic detection of AF episodes lasting ≥6 min. Time from algorithmic detection to clinical identification, AF burden, AF interventions and complications, medical history, and demographics were identified in each patient’s chart. Results: Of the 498 patients, 171 had an algorithmically detected episode of AF that was not acknowledged medically. These undetected episodes were generally shorter relative to episodes that were acknowledged (median 8 min vs. 52 min). 96 of the 498 patients had initial clinical detection of AF following algorithm detection; of the 96, 21 received early intervention (within 60 min), 51 received late intervention (after 60 min), and 24 received no intervention at all. Patients with early intervention experienced less AF burden compared to late and no intervention groups (median 8.6 hrs vs 21.75 hrs vs 29.35 hrs). Late intervention patients had more AF related complications compared to early intervention patients (9.8% vs. 4.8%). 20.8% of patients with clinical acknowledgement of AF but no intervention suffered a complication. Patients with a history of AF were more likely to have delays in intervention and over twice as likely to suffer an AF complication compared to those with no history (15.6% vs. 7.4%). Patients of lower socioeconomic status (SES) were also more likely to experience a complication. Conclusions: In summary, cardiology inpatients at our hospital commonly experience delays in management of AF that are considerable in duration, resulting in greater AF burden and higher complication rates. Differences in management, and subsequent outcomes, following AF appear to be impacted by prior history of AF and patient SES.

Abstract 13300: Recovery From Acute Cardiac Events in Lower-Socioeconomic Status Patients: Physical and Psychological Outcomes Over Time

Introduction: Participation in cardiac rehabilitation (CR) reduces morbidity, and mortality, while improving quality of life following major cardiovascular events. Patients with lower-socioeconomic status (SES), such as those enrolled in Medicaid, are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events. Methods: A secondary analysis was performed on a randomized controlled trial in which 130 individuals enrolled in Medicaid, with a CR-qualifying cardiac event, were randomized 1:1 to receive financial incentives for completing CR sessions or to usual care. Participants were assessed on clinical and cognitive outcomes soon after discharge as well as at 4 months, and 1 year following entry. The current analyses focused on how outcomes changed over the three timepoints. Outcomes included changes in psychological measurements (depressive/anxious symptoms, quality of life), body composition (waist circumference, body mass index), and fitness (peak VO2/METS). Mixed model repeated measures analyses of variance were used to test for main effects while controlling for sex, smoking status, age, and qualifying diagnosis. Results: Lower-SES patients entering CR had remarkably low levels of fitness and high rates of psychological issues. Fitness improved between intake and 4-months, and gains were maintained through one year (p&lt;0.001) (Table 1) however gains were less in females and those who completed fewer sessions of CR. Body composition measurements significantly worsened between 4-months and 1-year (p&lt;0.03). Psychological measures did not improve in the year following the event. Conclusion: While fitness improved in lower-SES patients, especially among those who completed more sessions of CR, psychological symptoms were elevated and did not improve. Future research should seek to understand how we can better serve this population, especially in the area of psych symptoms.