Lowest Socioeconomic Status Quintile Research Articles

Public funding for private for-profit centres and access to cataract surgery by patient socioeconomic status: an Ontario population-based study.

Public funding of cataract surgery provided in private, for-profit surgical centres increased to help mitigate surgical backlogs during the COVID-19 pandemic in Ontario, Canada. We sought to compare the socioeconomic status of patients who underwent cataract surgery in not-for-profit public hospitals with those who underwent this surgery in private for-profit surgical centres and to evaluate whether differences in access by socioeconomic status decreased after the infusion of public funding for private, for-profit centres. We conducted a population-based study of all cataract operations in Ontario, Canada, between January 2017 and March 2022. We analyzed differences in socioeconomic status among patients who accessed surgery at not-for-profit public hospitals versus those who accessed it at private for-profit surgical centres before and during the period of expanded public funding for private for-profit centres. Overall, 935 729 cataract surgeries occurred during the study period. Within private for-profit surgical centres, the rate of cataract surgeries rose 22.0% during the funding change period for patients in the highest socioeconomic status quintile, whereas, for patients in the lowest socioeconomic status quintile, the rate fell 8.5%. In contrast, within public hospitals, the rate of surgery decreased similarly among patients of all quintiles of socioeconomic status. During the funding change period, 92 809 fewer cataract operations were performed than expected. This trend was associated with socioeconomic status, particularly within private for-profit surgical centres, where patients with the highest socioeconomic status were the only group to have an increase in cataract operations. After increased public funding for private, for-profit surgical centres, patient socioeconomic status was associated with access to cataract surgery in these centres, but not in public hospitals. Addressing the factors underlying this incongruity is vital to ensure access to surgery and maintain public confidence in the cataract surgery system.

Are community oncology practices with or without clinical research programs different? A comparison of patient and practice characteristics.

Expanding access to clinical trials in community settings is a potential approach to addressing disparities in accrual of historically underrepresented populations. However, little is known about the characteristics of practices that do not participate in research. We investigated differences in patient and practice characteristics of US community oncology practices with high vs low engagement in clinical research. We included patients from a real-world, nationwide electronic health record-derived, de-identified database who received active treatment for cancer at community oncology practices between November 1, 2017, and October 31, 2022. We assessed patient and practice characteristics and their associations with high vs low research engagement using descriptive analyses and logistic regression models. Of the 178 practices, 70 (39.3%) events had high research engagement, treated 57.8% of the overall 568 540 patient cohort, and enrolled 3.25% of their patients on cancer treatment trials during the 5-year observation period (vs 0.27% enrollment among low engagement practices). Practices with low vs high research engagement treated higher proportions of the following patient groups: ages 75 years and older (24.2% vs 21.8%), non-Latinx Black (12.6% vs 10.3%) or Latinx (11.6% vs 6.1%), were within the lowest socioeconomic status quintile (21.9% vs16.5%), and were uninsured or had no documented insurance (22.2% vs 13.6%). Patient groups historically underrepresented in oncology clinical trials are more likely to be treated at community practices with limited or no access to trials. These results suggest that investments to expand the clinical research footprint among practices with low research engagement could help address persistent inequities in trial representation.

Towards closing socio-economic status disparities in COVID-19 premature mortality: a nationwide and trend analysis in Chile.

Socio-economic status (SES) disparities in coronavirus disease 2019 (COVID-19) mortality have been reported but complete information and time trends are scarce. In this study, we analysed the years of life lost (YLL) due to COVID-19 premature mortality during the pandemic in Chile and its evolution according to SES and sex compared with a counterfactual scenario [cerebrovascular accidents (stroke)]. We used Chile's national mortality databases from 2020 to 2022. YLL and age-standardized YLL and mortality rates by sex and by epidemic waves were determined. The 346 communes were stratified into SES groups according to their poverty index quintile. Negative binomial regression models were used to test trends. In >2 years of the pandemic, the COVID-19 YLL was 975 937, corresponding to 61 174 deaths. The YLL rate per 100 000 inhabitants was 1027 for males and 594 for females. There was a heterogeneous distribution of YLL rates and the regional level. Communes in the most advantaged SES quintile (Q5) had the highest YLL during the first wave compared with those in the lowest SES quintile (Q1) (P < 0.001) but the opposite was true during the second wave. COVID-19 YLL trends declined and differences between Q1 and Q2 vs Q5 converged from the second to the fourth waves (0.33 and 0.15, Ptrend < 0.001 and Ptrend = 0.024). YLL declined but differences persisted in stroke (-0.002, Ptrend = 0.979). COVID-19 deaths resulted in a higher impact on premature death in Chile, especially in men, with a heterogeneous geographic distribution along the territory. SES and sex disparities in COVID-19 premature mortality had narrowed by the end of the pandemic.

Inequities in Autologous Stem Cell Transplantation, Chimeric Antigen Receptor T-Cell Therapy and Clinical Trial Participation in Patients Receiving Second-Line and Later Multiple Myeloma Treatment

Introduction: Despite improvements in care and novel therapies for the treatment of multiple myeloma (MM), nearly all patients experience relapse. However, few real-world studies have focused on treatment inequities that occur later in the MM patient journey with subsequent lines of therapy - the setting of particular interest for salvage treatment and novel drug development. The objectives of this study were to measure receipt of autologous stem cell transplantation (ASCT), chimeric antigen receptor T-cell therapy (CAR-T) and participation in clinical trials following initiation of second-line (2L) MM treatment and to describe inequities by race/ethnicity and area-level sociodemographic factors. Methods: This was a retrospective cohort study using the nationwide, electronic health record-derived Flatiron Health de-identified database. We included patients that previously received therapy for newly diagnosed MM and were initiating 2L between 2011 and 2023. The exposures of interest were race/ethnicity and area-level (census block group) socioeconomic status (SES) measured by the Yost index. Outcomes of interest were receipt of ASCT, CAR-T and clinical trial participation. Patients were followed from the date of 2L initiation until the first of the outcome of interest, death or end of the study period. Multivariable cause-specific hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations with receipt of ASCT, CAR-T and clinical trial participation separately and as a single outcome. Informed by the Institute of Medicine's framework for healthcare disparities, models were adjusted for clinical factors, specifically, age, sex, and Eastern Cooperative Oncology Group (ECOG) performance status. Results: In a cohort of 2,017 patients with MM that were ASCT and CAR-T naïve with a median age of 72 years (interquartile range [IQR] 63-79), 52% were male, 52% had ECOG scores of 0 or 1, and 59% were treated in community oncology practices. Prior to 2L, 73% received fluorescence in situ hybridization testing for cytogenetic abnormalities and most patients received either doublet (34%) or triplet (51%) therapy. The majority of patients included were non-Latinx (NL)-White (61%), 21% were NL-Black and 4% were Latinx. Compared to NL-White patients, fewer NL-Black patients received FISH testing (70% versus 73%) and either doublet or triplet therapy (81% versus 86%) for newly diagnosed MM. A higher proportion of Black and Latinx patients resided in areas in the lowest quintile of SES (42% and 40% respectively) compared to NL-White patients (8%). Overall, 12.7% received ASCT, 0.8% received CAR-T and 1.3% participated in a clinical trial following the start of 2L. Compared with NL-White patients, Black and Latinx patients had lower rates of treatment with ASCT and CAR-T; and clinical trial participation was also lower among Latinx patients relative to NL-White patients (see Figure). Patients living in the highest quintile of SES had higher rates of ASCT (19.2%), CAR-T (0.8%) and clinical trial participation (2.3%) compared to those living in the lowest quintile of SES (10.1%, 0.3% and 1.5% respectively). In multivariable models, NL-Black (HR 0.57, 95% CI 0.42-0.76) and Latinx (HR 0.41, 95% CI 0.25-0.76) patients had a lower likelihood of receiving these treatments or participating in a clinical trial compared to NL-White patients; similarly, living in the lowest SES quintile (HR 0.38, 95% CI 0.26-0.56) was also associated with lower likelihood of these outcomes. Other area-level factors associated with inequities in ASCT, CAR-T and trial participation included living in segregated Black neighborhoods and areas with greater concentration of non-citizen residence and no vehicle ownership. Conclusion: We observed lower receipt of ASCT, CAR-T, and participation in clinical trials among Black and Latinx patients initiating 2L or later MM therapy, as well as patients living in areas of low SES. Persistent inequities in MM span the entirety of the patient journey, including the limited uptake and availability of novel therapies at later stages of the disease and a lack of representation in trials investigating new MM therapies.

Low Socioeconomic Status Confers Poorer Real-World Overall Survival for Patients with Acute Myeloid Leukemia Treated in the Modern Era

Introduction: There has been considerable growth in the treatment armamentarium of acute myeloid leukemia (AML) in the last decade. However, there is a lack of recent real-world evidence examining trends in survival amidst this rapidly changing treatment landscape. Further, prior literature has demonstrated significant heterogeneity in outcomes across different demographic groups, with scant data to understand how newer therapies have impacted survival outcomes across demographic groups in a real-world setting. The objective of this study is to describe recent trends in overall survival (rwOS) among patients with AML and to examine associations between race, ethnicity, and socioeconomic status (SES) with rwOS over time. Methods: We conducted a retrospective cohort study with data from the nationwide Flatiron health (FH) electronic health record-derived de-identified database, which is comprised of predominantly community oncology-based sites. We included patients with ≥2 visits in the FH network with a confirmed diagnosis of AML between Jan 1, 2014 and Dec 31, 2022, with potential follow-up through May 31, 2023. Our exposures included year of diagnosis in 3-year periods (2014-2016, 2017-2019, 2020-2022), race, ethnicity, and area-level SES, as measured using the Yost Index at census block group level. Patient characteristics and treatment patterns were described overall and by time periods of AML diagnosis. The Kaplan-Meier method was used to estimate median rwOS and 95% confidence intervals (CIs) from the time of initial AML diagnosis; overall and stratified by time period of AML diagnosis. Cox proportional hazards models were used to estimate unadjusted and minimally-adjusted (for age and sex) hazard ratios (HR) and 95% CIs for associations between race, ethnicity, and SES (modeled separately) with rwOS overall and by year of AML diagnosis.. Results: A total of 10,062 patients were included in the analysis. The median (IQR) age at diagnosis was 70 years (58, 78) and 57% of patients were male. Three-fourths of the study population was White, and 70% of the cohort received care at the community oncology clinic. We identified more patients ≥75 years at diagnosis in 2020-2022 versus 2014-2016 (38% vs 31%) and an overall decrease in patients who underwent hematopoietic stem cell transplant (15% vs 21%). Although the overall proportion of patients receiving any first-line treatment was similar across time periods, fewer patients received induction chemotherapy-based regimens (29%) compared to less intensive therapies (e.g., venetoclax + hypomethylating agent; 34%) in later years. There were 6,132 deaths and an overall median rwOS was 14.2 months (95% CI 13.7-14.7). Age and sex-adjusted Cox models indicated no evidence of decreased risk of death for diagnoses in 2020-2022 (HR 0.98, 95% CI 0.92-1.05) or 2017-2019 (HR 0.95, 95% CI 0.90, 1.02) compared to diagnoses in 2014-2016. Adjusted Cox models showed no statistically significant associations between race or ethnicity with survival overall and across strata of AML diagnosis time periods. Consistent associations between the lowest SES and increased risk of overall mortality among patients with AML were observed across all time periods. Patients residing in areas in the lowest quintile of SES had increased risks of death across all three time periods (2014-2016: HR 1.18, 95% CI 1.00-1.38; 2017-2019: HR 1.28, 95% CI 1.09-1.50; 2020-2022: HR 1.21, 95% CI 1.02-1.43). Conclusion: Results of this real-world study indicate that persons with AML who are in the lowest SES group are associated with increased mortality risk, and this association persists across recent time periods. Race and ethnicity were not associated with survival in this study, although sample size was limited for some groups. Despite introduction of new therapeutic options and an increased utilization of less intensive therapies, we did not observe an increase in the overall proportion of patients with AML receiving first-line treatment. Additionally, we observed no improvement in survival outcomes across these time periods in a predominantly community-based setting. Our study adds to the growing evidence on the complex health inequities in AML and supports the persistent need for tolerable and accessible therapy to improve OS in AML. Future strategies and policies are urgently needed to offset the adverse effects of low SES to further improve outcomes for all patients with AML.

Lower Socioeconomic Status is Associated with an Increased Incidence and Spectrum of Major Congenital Heart Disease and Associated Extracardiac Pathology.

Several studies have suggested an inverse relationship between lower socioeconomic status (SES) and the incidence of congenital heart disease (CHD) among live births. We sought to examine this relationship further in a Canada-wide population study, exploring CHD subtypes, trends, and associated noncardiac abnormalities. Infants born in Canada (less Quebec) from 2008 to 2018 with CHD requiring intervention in the first year were identified using ICD-10 codes through the Canadian Institute for Health Information Discharge Abstract Database. Births of CHD patients were stratified by SES (census-based income quintiles) and compared against national birth proportions using X2 tests. Proportions with extracardiac defects (ED) and nonlethal genetic syndromes (GS) were also explored. From 2008 to 2018, 7711 infants born with CHD were included. The proportions of major CHD distributed across SES quintiles were 27.1%, 20.1%, 19.2%, 18.6%, and 15.0% from lowest to highest, with significant differences relative to national birth proportions (22.0%, 20.0%, 20.6%, 20.7%, and 16.7% from lowest (1) to highest (5)) (p < 0.0001). No temporal trends in the CHD proportions across SES categories were observed over the study period. The distribution across SES quintiles was different only for specific CHD subtypes (double-outlet right ventricle (n = 485, p = 0.03), hypoplastic left heart syndrome (n = 547, p = 0.006), heterotaxy (n = 224, p = 0.03), tetralogy of Fallot (n = 1007, p = 0.008), truncus arteriosus (n = 126, p < 0.0001), and ventricular septal defect (n = 1916, p < 0.0001)), with highest proportions observed in the lowest quintile. The proportion of the total population with ED but not GS was highest in lower SES quintiles (< 0.0001) commensurate with increased proportion of CHD. Our study suggests a negative association between SES and certain CHD lesions and ED.

Racial Disparities in Survival of Patients with High-Risk LA SCCHN in the U.S.

Approximately 50-67% of patients with squamous cell carcinomas of the head and neck (SCCHN) present with locally advanced (LA) disease. Human papillomavirus (HPV) associated SCCHN has improved survival compared to non-HPV SCCHN. Studies have analyzed racial disparities in LA SCCHN but few have adjusted for HPV status and socio-economic status (SES). Our objective was to characterize disparities in LA SCCHN. We identified high-risk patients from 2010-2017 with AJCC v8 Stage IVA/IVB SCCHN of the oral cavity, oropharynx (OP), larynx or hypopharynx, or Stage III SCCHN of the OP in the Surveillance, Epidemiology, and End Results (SEER) with HPV Status and Census Tract-level SES/Rurality Combined Database. We excluded OP patients with missing HPV data. SEER-reported treatment was used to classify initial treatment as definitive therapy (DT) categories: surgical DT, non-surgical DT or non-DT. The Kaplan Meier method was used to estimate overall survival (OS) with 95% confidence intervals (CI). Multivariable cox proportional hazard models were used for associations between covariates and hazard ratio (HR) of death, adjusted for age, sex, race, ethnicity, DT category, marital status, rurality, tumor size, cancer stage, and HPV status. We explored the impact of additionally adjusting for Yost SES index quintiles. We identified 17,818 eligible patients: 79.3% White, 14.4% Black, 5.8% Asian/Pacific Islander (A/PI), and 0.6% American Indian/Alaska Native (AI/AN). Primary tumor sites were oral cavity (36.8%), larynx (29.0%), OP (24.4%), and hypopharynx (9.9%). 10.4% were HPV-associated. Race and SES quintiles were related (chi-squared, p<0.001) and the majority (56.5%) of black patients were in the lowest SES quintile. mOS was shorter and risk of death was significantly higher for black vs white patients in both the all-site and OP-only cohorts. When we added SES to multivariable analyses, Black race was no longer associated with increased risk of death in the all-site or OP-only cohorts. (Table 1) CONCLUSION: We found that when adjusting for sociodemographic and clinical factors, Black race was independently associated with a higher risk of death compared to white patients. When we adjusted for SES in multivariable analysis the association between Black race and risk of death was no longer significant, consistent with previously published analyses and indicative of a complex relationship between race and SES. Further research is needed to identify and address the causative factors of disparities in LA HNSCC.

Do Physician Patient Sharing Networks Impact Disparities in Access to Multidisciplinary Cancer Consultation for Early-Stage Lung Cancer? A SEER-Medicare Network Analysis

To examine early-stage non-small cell lung cancer (NSCLC) patient and physician network characteristics associated with receipt of multidisciplinary cancer consultations (MDCCs), defined as an encounter with both a surgeon and a radiation oncologist after diagnosis. We tested the hypothesis that physician roles in patient-sharing networks can modify disparities in access to surgical and radiotherapy care. Specifically, we investigated the role of "linchpin physicians" using a novel network measure that assesses the extent to which a physician is the sole type of specialist in their physician patient sharing network, and the association of these physicians on patterns of care. The study cohort included patients diagnosed with stage I/IIA NSCLC in 2016-17 using Surveillance, Epidemiology and End Results (SEER)-Medicare data. We assembled a physician patient-sharing network using all NSCLC patient encounters between 3 months prior to and 12 months following diagnosis. We weighted physicians' patient-sharing ties by the number of shared patients and calculated physician's linchpin scores as a continuous variable measuring the extent to which a physicians' peers in the network lack ties to others of the same specialty as the focal physician. Physicians in the top 15%ile were considered a linchpin specialist. We then derived the proportion of linchpin surgeons or radiation oncologists per hospital referral region (HRR). We assessed patient characteristics including age, sex, race, ethnicity, cancer stage, comorbidity index, rurality, and socioeconomic status (SES). The study outcome was a surgical, radiation oncology, or MDCC in the 2 months following diagnosis. We then performed multivariable logistic regressions (MLR) to assess whether linchpins modified disparities in MDCC. Of 6,148 patients in the study, 12% received a MDCC, 28% only saw a radiation oncologist, 33% only saw a surgeon, and 27% saw neither for 2 months after diagnosis. On MLR, Hispanic patients were significantly less likely than White patients to receive consultations with a radiation oncologist, while patients in lowest SES quintile were significantly less likely to receive a surgical consultation than those in the highest SES. The proportion of linchpin surgeons and radiation oncologists per HRR was negatively associated with receipt of MDCC (OR low vs high [95% CI] = 0.75 [0.66 to 0.86]; 0.70 [0.61 to 0.80, respectively), but our regressions did not show that any demographic or SES disparities were modified by linchpin specialists. Linchpin specialists do not impact known disparities in access to cancer consultations. Identifying additional system-level factors that contribute to disparities in cancer consultations may lead to policy insights aimed at reducing unwarranted variation in care.

Racial and ethnic and socioeconomic disparities in childhood cancer incidence trends in the United States, 2000-2019.

Population-based surveillance of pediatric cancer incidence trends is critical to determine high-risk populations, drive hypothesis generation, and uncover etiologic heterogeneity. We provide a comprehensive update to the current understanding of pediatric cancer incidence trends by sex, race and ethnicity, and socioeconomic status (SES). The Surveillance, Epidemiology, and End Results 22 data (2000-2019) was used to summarize age-adjusted incidence rates for children and adolescents aged 0-19 years at diagnosis. The annual percentage change (APC) and 95% confidence interval (CI) were estimated to evaluate incidence trends by sex, race and ethnicity, and SES overall and for cancer subtypes. Tests of statistical significance were 2-sided. Substantial variation was observed overall and for several histologic types in race and ethnicity- and SES-specific rates. Overall, we observed a statistically significant increase in incidence rates (APC = 0.8%, 95% CI = 0.6% to 1.1%). All race and ethnic groups saw an increase in incidence rates, with the largest occurring among non-Hispanic American Indian and Alaska Native children and adolescents (APC = 1.7%, 95% CI = 0.5% to 2.8%) and the smallest increase occurring among non-Hispanic White children and adolescents (APC = 0.7%, 95% CI = 0.5% to 1.0%). The lowest SES quintiles saw statistically significant increasing trends, while the highest quintile remained relatively stable (quintile 1 [Q1] APC = 1.6%, 95% CI = 0.6% to 2.6%; quintile 5 [Q5] APC = 0.3%, 95% CI = -0.1% to 0.7%). Childhood cancer incidence is increasing overall and among every race and ethnic group. Variation by race and ethnicity and SES may enable hypothesis generation on drivers of disparities observed.

The contribution of prognostic factors to socio-demographic inequalities in breast cancer survival in Victoria, Australia.

Breast cancer survival in Australia varies according to socio-economic status (SES) and between rural and urban places of residence. Part of this disparity may be due to differences in prognostic factors at the time of diagnosis. Women with invasive breast cancer diagnosed from 2008 until 2012 (n = 14,165) were identified from the Victorian Cancer Registry and followed up for 5 years, with death from breast cancer or other causes recorded. A prognostic score, based on stage at diagnosis, cancer grade, whether the cancer was detected via screening, reported comorbidities and age at diagnosis, was constructed for use in a mediation analysis. Five-year breast cancer mortality for women with breast cancer who were in the lowest quintile of SES (10.3%) was almost double that of those in the highest quintile (5.7%). There was a small survival advantage (1.7% on average, within each socio-economic quintile) of living in inner-regional areas compared with major cities. About half of the socio-economic disparity was mediated by prognostic factors, particularly stage at diagnosis and the presence of comorbidities. The inner-regional survival advantage was not due to differences in prognostic factors. Part of the socio-economic disparity in breast cancer survival could be addressed by earlier detection in, and improved general health for, more disadvantaged women. Further research is required to identify additional causes of socio-economic disparities as well as the observed inner-regional survival advantage.

Community socioeconomic status and rural/racial disparities in HPV−/+ head and neck cancer

Head and Neck Cancer (HNC) is a major cause of cancer morbidity and mortality in the United States, but the burden is not evenly distributed. Rural and racial disparities are obvious across the HNC continuum. Most HNC disparities research have emphasized individual factors perpetuating rural and racial disparities, ignoring the role of community-level factors. We analyzed data from the Surveillance Epidemiology and End Results (SEER) program's "Specialized HNC-Human Papillomavirus (HPV) Census-Tract SES" datafile (2010-2016). In addition to cancer patient characteristics, this data includes a socioeconomic status (SES) quintile based on the patient's census-tract. Our outcome variables included whether the HNC patient 1) was diagnosed at a distant stage, 2) received initial treatment two or more months after diagnosis, 3) received radiation therapy, 4) survived two years after diagnosis. We tested for differences across SES quintiles, in the full sample and then within rural/racial categories. We then tested for differences between each rural/racial category conditional on SES quintile. For both HPV(-) and HPV+HNCs, patients in higher SES census-tracts have 8-10% lower rates of distant stage diagnoses and delayed treatment initiation, and 12.0-14.5% higher survival rates than patients in lower SES census-tracts. Radiation treatment only varied across SES quintiles in HPV+HNC patients. We find little evidence of rural-urban differences within each socioeconomic quintile. However, within lower SES quintiles, we found significant racial disparities in delayed detection and treatment. These differences were largest in the lowest SES quintile, as non-Hispanic Black patients reported 10-11% higher rates of delayed detection and treatment initiation than non-Hispanic White patients. Our research illustrates the value and constraints in leveraging community-level factors in health disparities research that can ultimately assist in designing effective policies that address and achieve rural and racial cancer equity.

Association of socioeconomic status in the incidence, quality-of-care metrics, and outcomes for patients with cardiogenic shock in a pre-hospital setting.

The relationship between lower socioeconomic status (SES) and poor cardiovascular outcomes is well described; however, there exists a paucity of data exploring this association in cardiogenic shock (CS). This study aimed to investigate whether any disparities exist between SES and the incidence, quality of care or outcomes of CS patients attended by emergency medical services (EMS). This population-based cohort study included consecutive patients transported by EMS with CS between 1 January 2015 and 30 June 2019 in Victoria, Australia. Data were collected from individually linked ambulance, hospital, and mortality datasets. Patients were stratified into SES quintiles using national census data produced by the Australian Bureau of Statistics.A total of 2628 patients were attended by EMS for CS. The age-standardized incidence of CS amongst all patients was 11.8 [95% confidence interval (95% CI), 11.4-12.3] per 100000 person-years, with a stepwise increase from the highest to lowest SES quintile (lowest quintile 17.0vs. highest quintile 9.7 per 100000 person-years, P-trend<0.001). Patients in lower SES quintiles were less likely to attend metropolitan hospitals and more likely to be received by inner regional and remote centres without revascularization capabilities. A greater proportion of the lower SES groups presented with CS due to non-ST elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UAP), and overall were less likely to undergo coronary angiography. Multivariable analysis demonstrated an increased 30-day all-cause mortality rate in the lowest three SES quintiles when compared with the highest quintile. This population-based study demonstrated discrepancies between SES status in the incidence, care metrics, and mortality rates of patients presenting to EMS with CS. These findings outline the challenges in equitable healthcare delivery within this cohort.

Impact of Socio-demographic Characteristics on Time in Outpatient Cardiology Clinics: A Retrospective Analysis.

Inequitable access to health services influences health outcomes. Some studies have found patients of lower socio-economic status (SES) wait longer for surgery, but little data exist on access to outpatient services. This study analyzed patient-level data from outpatient public cardiology clinics and assessed whether low SES patients spend longer accessing ambulatory services. Retrospective analysis of cardiology clinic encounters across 3 public hospitals between 2014 and 2019 was undertaken. Data were linked to age, gender, Indigenous status, country of birth, language spoken at home, number of comorbidities, and postcode. A cox proportional hazards model was applied adjusting for visit type (new/follow up), clinic, and referral source. Higher hazard ratio (HR) indicates shorter clinic time. Overall, 22 367 patients were included (mean [SD] age 61.4 [15.2], 14 925 (66.7%) male). Only 7823 (35.0%) were born in Australia and 8452 (37.8%) were in the lowest SES quintile. Median total clinic time was 84 min (IQR 58-130). Visit type, clinic, and referral source were associated with clinic time (R2 = 0.23, 0.35, 0.20). After adjusting for these variables, older patients spent longer in clinic (HR 0.94 [0.90-0.97]), though there was no difference according to SES (HR 1.02 [0.99-1.06]) or other variables of interest. Time spent attending an outpatient clinic is substantial, amplifying an already significant time burden faced by patients with chronic health conditions. SES was not associated with longer clinic time in our analysis. Time spent in clinics could be used more productively to optimize care, improve health outcomes and patient experience.

Low socioeconomic status was associated with a higher mortality risk in multiple sclerosis

Background: The relationship between socioeconomic status (SES) and mortality among persons with multiple sclerosis (PwMS) is poorly understood. Objective: To investigate the association between SES and mortality risk in PwMS. Methods: From health-administrative data, we identified 12,126 incident MS cases with a first demyelinating event (MS ‘onset’) occurring between 1994 and 2017. Cox proportional hazard model assessed the association between socioeconomic status quintiles (SES-Qs) at MS onset and all-cause mortality. Results: Lower SES-Qs were associated with higher mortality risk; adjusted hazard ratios: SES-Q1 (most deprived) =1.61 (95% confidence interval (CI) = 1.36–1.91); SES-Q2 = 1.26 (95% CI = 1.05–1.50); SES-Q3 = 1.22 (95% CI = 1.02–1.46); SES-Q4 = 1.13 (95% CI = 0.94–1.35) versus SES-Q5 (least deprived). Conclusion: A lower SES was associated with higher mortality risk in PwMS.

Understanding the association between neighbourhood socioeconomic status and grocery store alcohol sales following market liberalization in Ontario, Canada.

In 2015, Ontario partially deregulated alcohol sales by allowing grocery stores to sell alcohol. The purpose of this study was to evaluate (1) whether neighbourhood-level socioeconomic status (SES) impacted the likelihood that a grocery store began selling alcohol, and (2) whether increases in alcohol retail availability following deregulation differed between neighbourhoods based on SES. This was a repeated cross-sectional analysis of 1062 grocery stores in 17,096 neighbourhoods in urban Ontario. The association between neighbourhood-level SES and whether a grocery store began selling alcohol was modeled using mixed effect logistic regression. The annual change in drive-distance from a neighbourhood to the closest off-premise alcohol outlet between 2015 and 2020 was modeled using mixed effect linear regression. An interaction between time and SES was included to evaluate whether this change differed between neighbourhoods based on SES. Grocery stores in neighbourhoods in the lowest SES quintile were 39% less likely to start selling alcohol than grocery stores in neighbourhoods in the highest SES quintile (odds ratio (OR): 0.61, 95% confidence interval (CI): 0.39-0.94). As grocery store sales expanded, the distance to the closest off-premise alcohol outlet decreased by 51.8 m annually (95% CI: 48.8-54.9, p < 0.01). A significant interaction between year and SES was observed whereby this trend was more pronounced in high- versus low-SES neighbourhoods. The expansion of grocery store alcohol sales increased alcohol availability, but this increase was proportionately larger in high- versus low-SES neighbourhoods. This reduced historic disparities in alcohol availability between low- and high-SES neighbourhoods.

Impact of rural residence and low socioeconomic status on rate and timing of prenatal detection of major congenital heart disease in a jurisdiction of universal health coverage.

Socioeconomic status (SES) and distance of residence from tertiary care may impact fetal detection of congenital heart disease (CHD), partly through reduced access to and quality of obstetric ultrasound screening. It is unknown whether SES and remoteness of residence (RoR) affect prenatal detection of CHD in jurisdictions with universal health coverage. We examined the impact of SES and RoR on the rate and timing of prenatal diagnosis of major CHD within the province of Alberta in Canada. In this retrospective study, we identified all fetuses and infants diagnosed with major CHD in Alberta, from 2008 to 2018, that underwent cardiac surgical intervention within the first year after birth, died preoperatively, were stillborn or underwent termination. Using maternal residence postal code and geocoding, Chan SES index quintile, geographic distance from a tertiary-care fetal cardiology center and the Canadian Index of Remoteness (IoR) were calculated. Outcome measures included rates of prenatal diagnosis and diagnosis after 22 weeks' gestation. Risk ratios (RR) were calculated using log-binomial regression and stratified by rural (≥ 100 km from tertiary care) or metropolitan (< 100 km from tertiary care) residence, adjusting for year of birth and the obstetric ultrasound screening view in which CHD would most likely be detected (four-chamber view; outflow-tract view; three-vessel or three-vessels-and-trachea or non-standard view; septal view). Of 1405 fetuses/infants with major CHD, prenatal diagnosis occurred in 814 (57.9%). Residence ≥ 100 km from tertiary care (adjusted RR, 1.19; 95% CI, 1.05-1.34) and higher IoR (adjusted RR, 1.9; 95% CI, 1.1-3.3) were associated with missed prenatal diagnosis of major CHD. Similarly, residence ≥ 100 km from tertiary care (adjusted RR, 1.41; 95% CI, 1.22-1.62) and higher IoR (adjusted RR, 3.6; 95% CI, 2.2-8.2) were associated with prenatal diagnosis after 22 weeks. Although adjusted and unadjusted analyses showed no association between Chan SES index quintile and prenatal-diagnosis rate overall nor for residence in rural areas, in metropolitan regions, lower SES quintiles were associated with missed prenatal diagnosis (quintile 1: RR, 1.24; 95% CI, 1.02-1.50) and higher risk of diagnosis after 22 weeks' gestation (quintile 1: RR, 1.46; 95% CI, 1.10-1.93; quintile 2: RR, 1.66; 95% CI, 1.24-2.23). Despite universal healthcare, rural residence in Alberta is associated with lower rate of prenatal diagnosis of major CHD and higher risk of late prenatal diagnosis (≥ 22 weeks). Within metropolitan regions, lower SES impacts negatively prenatal-diagnosis rate and timing. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Association Between Socioeconomic and Insurance Status and Delayed Diagnosis of Gastrointestinal Cancers

IntroductionAssociation between socioeconomic status (SES) and stage at diagnosis in gastrointestinal (GI) cancers is poorly described. Relationship between low SES and stage at diagnosis as well as the mediating role of insurance status (IS) was examined. MethodsThe Surveillance, Epidemiology, and End Results database was queried for esophageal, gastric, liver, biliary, pancreatic, colon, and rectal cancers diagnosed in 2012-2016. Relationship between census-tract SES index quintiles and late diagnosis (distant disease at diagnosis) was examined. Uni and multivariable logistic regressions were performed. Mediation analyses were conducted to determine the degree to which IS (private/Medicare versus Medicaid/uninsured) mediates the relationship between SES and late diagnosis of cancer. ResultsAnalysis included 236,713 adult patients from 18 Surveillance, Epidemiology, and End Results areas. In univariable analysis, lowest SES quintile was significantly associated with late diagnosis for all cancers except gastric and biliary cancers. In multivariable analysis controlling for age, gender, marital status and race, this association remained significant for liver (odds ratio (OR) 1.41 [95% confidence interval (CI) 1.25-1.58]), pancreatic (OR 1.13 [95% CI 1.06-1.21]), and rectal (OR 1.31 [95% CI 1.20-1.42]) cancers. Further controlling for IS showed the largest effect size reduction for rectal cancer (OR 1.18 [95% CI 1.09-1.29]), with IS mediating 36.5% (P < 0.0001) of SES effect. ConclusionsLow SES is an independent risk factor for late diagnosis in liver, pancreas, and rectal cancers. Insurance is not a critical mediator of difference by SES for most GI cancers, with the exception of rectal cancer. Further research is needed to understand factors beyond IS that can account for SES differences in late diagnosis for GI cancers. Insurance related differences for rectal cancer deserves further attention.

Association of Socioeconomic Status With Outcomes and Care Quality in Patients Presenting With Undifferentiated Chest Pain in the Setting of Universal Health Care Coverage.

BACKGROUNDThis study aimed to assess whether there are disparities in incidence rates, care, and outcomes for patients with chest pain attended by emergency medical services according to socioeconomic status (SES) in a universal health coverage setting.METHODS AND RESULTSThis was a population‐based cohort study of individually linked ambulance, emergency, hospital admission, and mortality data in the state of Victoria, Australia, from January 2015 to June 2019 that included 183 232 consecutive emergency medical services attendances for adults with nontraumatic chest pain (mean age 62 [SD 18] years; 51% women) and excluded out‐of‐hospital cardiac arrest and ST‐segment–elevation myocardial infarction. Age‐standardized incidence of chest pain was higher for patients residing in lower SES areas (lowest SES quintile 1595 versus highest SES quintile 760 per 100 000 person‐years; P<0.001). Patients of lower SES were less likely to attend metropolitan, private, or revascularization‐capable hospitals and had greater comorbidities. In multivariable models adjusted for clinical characteristics and final diagnosis, lower SES quintiles were associated with increased risks of 30‐day and long‐term mortality, readmission for chest pain and acute coronary syndrome, lower acuity emergency department triage categorization, emergency department length of stay >4 hours, and emergency department or emergency medical services discharge without hospital admission and were inversely associated with use of prehospital ECGs and transfer to a revascularization‐capable hospital for patients presenting to non‐percutaneous coronary intervention centers.CONCLUSIONSIn this study, lower SES was associated with a higher incidence of chest pain presentations to emergency medical services and differences in care and outcomes. These findings suggest that substantial disparities for socioeconomically disadvantaged chest pain cohorts exist, even in the setting of universal health care access.

The Co-occurrence of Specialty Vape Shops, Social Disadvantage, and Poor Air Quality in the United States: An Assessment of Cumulative Risks to Youth.

Introduction: We conducted a cumulative environmental health risk assessment of whether specialty vape shops and poor air quality are more likely to co-occur in socially disadvantaged neighborhoods where racial/ethnic minority youth live.Methods: We examined the population-adjusted incidence of specialty vape shops in relation to youth race/ethnicity, neighborhood socioeconomic status (SES), and air quality (nitrogen dioxide [NO2]) at the census tract level across the conterminous United States for 2018.Results: We did not find disparity in vape shop incidence related to minority youth race/ethnicity. Vape shop incidence was significantly negatively associated with all the youth race/ethnicities examined. The two lowest SES quintiles had nearly double the rate of specialty vape shop incidence compared with the highest SES quintile. Specialty vape shop incidence increased with NO2 concentration, with more vape shops in poor air quality neighborhoods.Conclusions: Specialty vape shops are disproportionately present in neighborhoods with poor air quality and where socially disadvantaged youth live. The increased incidence of vape shops in poor air quality neighborhoods, particularly in an urban context with increased traffic emissions, further points to potentially disproportionate impacts on disadvantaged populations due to cumulative social and environmental risks. This raises environmental justice and health equity concerns. Retailer-focused strategies aimed at limiting youth exposure to electronic cigarettes' labeling and advertising, preventing sales to minors, and limiting the number of retailers in low-SES neighborhoods may reduce initiation and help prevent tobacco-related health disparities among youth.

Incidence and Outcomes of Nontraumatic Shock in Adults Using Emergency Medical Services in Victoria, Australia

Nontraumatic shock is a challenging clinical condition, presenting urgent and unique demands in the prehospital setting. There is a paucity of data assessing its incidence, etiology, and clinical outcomes. To assess the incidence, etiology, and clinical outcomes of patients treated by emergency medical services (EMS) with nontraumatic shock using a large population-based sample. This population-based cohort study included consecutive adult patients with shock not related to trauma who received care by EMS between January 1, 2015, and June 30, 2019, in Victoria, Australia. Data were obtained from individually linked ambulance, hospital, and state death index data sets. During the study period there were 2 485 311 cases attended by EMS, of which 16 827 met the study's inclusion criteria for shock. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital stay, emergency department discharge disposition, rates of coronary angiography and revascularization procedures, and the use of mechanical circulatory support. A total of 12 695 patients were successfully linked, with a mean (SD) age of 65.7 (19.1) years; 6411 (50.5%) were men. The overall population-wide incidence of EMS-treated prehospital shock was 76 (95% CI, 75-77) per 100 000 person-years. An increased incidence was observed in men (79 [77-81] per 100 000 person-years), older patients (eg, aged 70-79 years: 177 [171-183] per 100 000 person-years), regional locations (outer regional or remote: 100 [94-107] per 100 000 person-years), and in areas with increased socioeconomic disadvantage (lowest socioeconomic status quintile: 92 [89-95] per 100 000 person-years). Patients with hospital outcome data were stratified into shock etiologies; 3615 (28.5%) had cardiogenic shock: 3998 (31.5%), septic shock; 1457 (11.5%), hypovolemic shock; and 3625 (28.6%), other causes of shock. Nearly one-third of patients (4158 [32.8%]) were deceased at 30 days. In multivariable analyses, increased age (all etiologies: hazard ratio [HR], 1.04; 95% CI, 1.03-1.04), female sex (cardiogenic shock: HR, 1.26; 95% CI, 1.12-1.42), increased initial heart rate (all etiologies: 1.01; 95% CI, 1.00-1.01), prehospital intubation (all etiologies: HR, 3.93; 95% CI, 3.48-4.44), and preexisting comorbidities (eg, chronic kidney disease, all etiologies: HR, 1.25; 95% CI, 1.10-1.42) were independently associated with 30-day mortality, while higher socioeconomic status (all etiologies: HR, 0.96; 95% CI, 0.94-0.98) and increased initial systolic blood pressure (all etiologies: HR, 0.99; 95% CI, 0.99-0.99) were associated with lower risk. This population-level cohort study found that EMS-treated nontraumatic shock was a common condition, with a high risk of morbidity and mortality regardless of etiology. It disproportionately affected men, older patients, patients in regional areas, and those with social disadvantage. Further studies are required to assess how current systems of care can be optimized to improve outcomes.