Lowest Socioeconomic Status Quartile Research Articles

Impact of socioeconomic status on chronic control and complications of type 1 diabetes mellitus in users of glucose flash systems: a follow-up study

BackgroundThis study investigates the association between socioeconomic status (SES) and glycemic control in individuals with type 1 diabetes (T1D) using flash glucose monitoring (FGM) devices within a public health system where these technologies are freely available and utilized according to recommended guidelines.MethodsA follow-up study of 1060 adults (mean age 47.4 ± 15.0 years, 49.0% women) with T1D, receiving care at three Spanish university hospitals that regularly employ the FGM system. SES was assessed using the Spanish Deprivation Index and the average annual net income per person. Glycemic data were collected over a 14-day follow-up period, including baseline glycated hemoglobin (HbA1c) levels prior to sensor placement, the last available HbA1c levels, and FGM-derived glucose metrics. Individuals with sensor usage time < 70% were excluded. Chronic micro and macrovascular complications related to diabetes were documented. Regression models, adjusted for clinical variables, were employed to determine the impact of SES on optimal sensor control (defined as time in range (TIR) ≥ 70% with time below range < 4%) and disease complications.ResultsThe average follow-up was of 2 years. The mean TIR and the percentage of individuals with optimal control were higher in individuals in the highest SES quartile (64.9% ± 17.8% and 27.9%, respectively) compared to those in the lowest SES quartile (57.8 ± 17.4% and 12.1%) (p < 0.001). Regression models showed a higher risk of suboptimal control (OR 2.27, p < 0.001) and ischemic heart disease and/or stroke (OR 3.59, p = 0.005) in the lowest SES quartile. No association was observed between SES and the risk of diabetic nephropathy and retinopathy. FGM system improved HbA1c levels across all SES quartiles. Although individuals in the highest SES quartile still achieved a significantly lower value at the end of the follow-up 55 mmol/mol (7.2%) compared to those in the lowest SES quartile 60 mmol/mol (7.6%) (p < 0.001), the significant disparities in this parameter between the various SES groups were significantly reduced after FGM technology use.ConclusionsSocioeconomic status plays a significant role in glycemic control and complications in individuals with T1D, extending beyond access to technology and its proper utilization. The free utilization of FGM technology helps alleviate the impact of social inequalities on glycemic control.

Abstract EP36: Socioeconomic Status And Spontaneous Coronary Artery Dissection Outcomes

Introduction: Spontaneous coronary artery dissection (SCAD) is an emerging cause of myocardial infarction. The epidemiology of SCAD is elucidated with recent investigations and analyses. However, the association between socioeconomic status (SES) and SCAD remains to be studied. We performed this study to identify the effects of SES on SCAD. Methods: We conducted a retrospective analysis of the 2016 to 2018 National Inpatient Sample database and the 2018 to 2019 Nationwide Readmission Database (NRD). Study populations were selected using ICD-10 diagnosis code and ICD-10 procedure code for MCS. Socioeconomic status was evaluated using median household income of patient’s ZIP code and dived into quarter. Discharge-level weight analysis was used to produce a national estimate. We conducted univariate and multivariable hierarchical regression analysis to calculate odds ratio (OR) with STATA 17. Results: During the study period, total 106,970,745 patients were hospitalized of which 30.17% were from 1 st (lowest), 26.26% from 2 nd , 23.76% from 3 rd and 19.82 from 4 th (highest) quartile. 0.02 % (24,560 of 106,970,745) patients were diagnosed with spontaneous coronary artery dissection. When lowest SES was compared to the highest SES quartile, the patients from the lowest SES tended to be diabetic (34.17 % v 18.39%) and younger (48.39 ± 0.01 v 50.16 ± 0.01) and less prevalence of hyperlipidemia (2.79% v 3.86%). The prevalence of hypertension (29.78% v 28.31%) and proportion of male (43.59% v 43.33%) were similar. After adjusting for age, sex and comorbid burden, the lowest SES quartile was associated with lower risk of SCAD when it was compared to highest quartile (OR 0.70; 95% CI 0.65-0.76; p&lt;0.0001). However, the lowest SES quartile was associated with higher in-hospital mortality (OR 1.51; 95%CI 1.07-2.15; p=0.02) and 30-day readmission rate (OR 1.56; 95%CI 1.39 -1.88; p&lt;0.0001) with SCAD when it compared to the highest quartile. Discussion: In this study, the lowest SES was associated with lower risk of SCAD. Individuals with low SES carry substantial burden of cardiovascular diseases. It is possible that SCAD is underdiagnosed in low SES population due to the presence of traditional cardiovascular risk factors. The unfavorable effects of low SES on SCAD can be identified with in-hospital mortality and rate of 30-day readmission. Further research is required to better understand the impact of SES on the outcomes of SCAD.

Socioeconomic and Racial and/or Ethnic Disparities in Multisystem Inflammatory Syndrome

To characterize the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C). This multicenter retrospective case-control study was conducted at 3 academic centers from January 1 to September 1, 2020. Children with MIS-C were compared with 5 control groups: children with coronavirus disease 2019, children evaluated for MIS-C who did not meet case patient criteria, children hospitalized with febrile illness, children with Kawasaki disease, and children in Massachusetts based on US census data. Neighborhood socioeconomic status (SES) and social vulnerability index (SVI) were measured via a census-based scoring system. Multivariable logistic regression was used to examine associations between SES, SVI, race and ethnicity, and MIS-C diagnosis and clinical severity as outcomes. Among 43 patients with MIS-C, 19 (44%) were Hispanic, 11 (26%) were Black, and 12 (28%) were white; 22 (51%) were in the lowest quartile SES, and 23 (53%) were in the highest quartile SVI. SES and SVI were similar between patients with MIS-C and coronavirus disease 2019. In multivariable analysis, lowest SES quartile (odds ratio 2.2 [95% confidence interval 1.1-4.4]), highest SVI quartile (odds ratio 2.8 [95% confidence interval 1.5-5.1]), and racial and/or ethnic minority background were associated with MIS-C diagnosis. Neither SES, SVI, race, nor ethnicity were associated with disease severity. Lower SES or higher SVI, Hispanic ethnicity, and Black race independently increased risk for MIS-C. Additional studies are required to target interventions to improve health equity for children.

Transition of Youth With Type 2 Diabetes: Predictors of Health-Care Utilization After Transition to Adult Care From Population-Based Administrative Data

ObjectivesIn this study, we aimed to compare health-care visits pre- and posttransition from pediatric to adult care between youth with type 2 and type 1 diabetes. MethodsWe linked a clinical database with the Manitoba Population Research Data Repository to compare health-care visits 2 years before and after transition, and investigated baseline factors influencing health-care engagement. ResultsYouth with type 2 diabetes (n=196) vs type 1 diabetes (n=456) were more likely to be female (61% vs 44%), older at diagnosis (13.6 vs 10.6 years), live in northern regions and to be in the lowest socioeconomic status quartile (53% vs 5.4%). Seventy-six percent of youth with type 2 diabetes attended a follow-up visit within 2 years of transition compared to 97% of youth with type 1 diabetes. Youth with type 2 diabetes had higher rates of hospitalization pretransition (19.6 vs 11.6 admissions/100 patient years) and posttransition (24.7 vs 11.7 admissions/100 patient years) and fewer medical visits (pretransition: 2.4 vs 3.0 visits/person year [p<0.01]; posttransition: 1.6 vs 2.1 visits/person year [p<0.01]). Accounting for sex, geography, age, education, socioeconomic status and diabetes type, achieving 4 visits in 2 years posttransition was predicted by the number of visits pretransition (odds ratio, 1.35; 95% confidence interval, 1.23 to 1.49) and diabetes type (type 2 diabetes: odds ratio, 0.57; 95% confidence interval, 0.34 to 0.98). ConclusionsYouth with type 2 diabetes attend fewer medical follow-up visits pre- and posttransition to adult care compared to youth with type 1 diabetes. Focused, informed, specific transition planning is needed that addresses the unique characteristics of this population.

Abstract P452: Impact of Socioeconomic Status in Intracerebral Hemorrhage

Background: Socioeconomic status (SES) has been associated with intracerebral hemorrhage (ICH) incidence, but its impact on ICH-related features and outcomes is unclear. Methods: We performed a single-center cohort study on consecutive ICH patients admitted over 2 years. Demographics, ICH characteristics, and outcomes were prospectively collected, while SES-related data were retrospectively abstracted. We classified SES quartiles using census estimates of median household incomes corresponding to patients’ home ZIP codes, then categorized patients as “lower SES” if their ZIP code was in the lowest SES quartile, if they were uninsured, or had Medicaid as their source of insurance. We compared ICH characteristics between patients with lower vs. higher SES, then determined associations between lower SES and unfavorable 3-month outcome (modified Rankin Scale 4-6) using multivariable logistic regression. Results: Of 665 patients, 31% (n=207) were categorized as lower SES. Patients with lower SES were significantly younger (mean [SD] 64.7 [16.1] vs. 73.1 [14.2] years, p&lt;0.001), more often non-white (38% vs. 8%, p&lt;0.001), and had a higher prevalence of multiple vascular risk factors. There were no significant differences in ICH volume or prevalence of infratentorial or intraventricular hemorrhage. However, patients with lower SES had a shorter time-to-presentation (median [IQR] 4.5 [1.3-15.2] vs. 7.4 [1.4-21.7]), hours from last known well, p=0.01), and had fewer ICH due to cerebral amyloid angiopathy (13% vs. 30%, p&lt;0.001). Despite these differences, patients with lower SES did not have a significantly higher likelihood of unfavorable 3-month outcomes (OR 1.2 [95% CI 0.7-1.8]). Conclusions: Differences in ICH features may be driven by pre-morbid healthcare disparities in lower SES patients. Although their younger age and shorter time to presentation may have mitigated the deleterious effects of comorbidities on long-term outcomes, these factors may also belie a greater loss of quality-adjusted life years from ICH-related disability.

High rate of stroke and low rate of atrial fibrillation in low socioeconomic strata and blacks: the atrial fibrillation paradox

Abstract Background and introduction Persons living in areas of low socioeconomic status (SES) usually have higher rates of adverse cardiovascular events (CVE) including stroke. Also, atrial fibrillation (AF) is associated with higher rate of CVEs. One would expect that both the rate of stroke and the occurrence of AF would be higher in areas of low SES. Purpose and methods Using MIDAS, a validated statewide data base of all hospitalizations for cardiovascular disease in NJ with follow up of more than 25 years, we examined the rate of hospitalization for AF by SES in patients with history of myocardial infarction for the years 1995 to 2015 (n=258,339). Zip codes in New Jersey were aggregated into 4 categories representing quarters of the distribution of SES areas. Results At one-year follow-up, patients in the lowest SES (lowest 25th percentile) and Blacks were more likely to suffer a stroke (p&amp;lt;0.0001). During one-year follow-up, patients in the lowest 25th percentile (Figure) were significantly less likely (p&amp;lt;0.0001) to be readmitted with a diagnosis of AF. Blacks had lower rate of admission with a diagnosis AF compared to Whites (p&amp;lt;0.0001) (Figure). Cox proportional hazards regression adjusting for demographics and co-morbidities confirmed the validity of these differences. In this analysis patients in the lowest SES quartile and Blacks were less likely to be admitted with AF than those in the highest quartile (HR 0.95, 95% CI 0.92–0.99). Also, Blacks were less likely to be admitted with AF than Whites (HR 0.76, 95% CI 0.71–0.82). This phenomenon (AF paradox) of lower incidence of AF in low SES and in Blacks has been attributed to under-ascertainment of AF in these groups, that may lead to underuse of anticoagulation and result in the occurrence of stroke. Conclusion Atrial fibrillation is underdiagnosed in patients at low socioeconomic strata and in Blacks and may lead to underuse of anticoagulation and the occurrence of stroke. Special efforts are warranted in detecting AF in these groups. Funding Acknowledgement Type of funding source: None

Impact of Socioeconomic Status on Outcomes of Patients with Kawasaki Disease

To evaluate the association of neighborhood socioeconomic status (SES) with time to intravenous immunoglobulin treatment, length of stay (LOS), and coronary artery aneurysms (CAAs) in patients with Kawasaki disease. We examined the relationship of SES in 915 patients treated at a large academic center between 2000 and 2017. Neighborhood SES was measured using a US census-based score derived from 6 measures related to income, education, and occupation. Linear and logistic regression were used to examine the association of SES with number of days of fever at time of treatment, LOS, and CAA. Patients in the lowest SES quartile were treated later than patients with greater SES (7 [IQR 5, 9] vs 6 [IQR 5, 8] days, P=.01). Patients in the lowest SES quartile were more likely to be treated after 10days of illness, with an OR 1.9 (95% CI 1.3-2.8). In multivariable analysis, SES remained an independent predictor of the number of days of fever at time of treatment (P=.01). Patients in the lowest SES quartile had longer LOS than patients with greater SES (3 [IQR 2, 5] vs 3 [IQR 2, 4], P=.007). In subgroup analysis of white children, those in the lowest SES quartile vs quartiles 2-4 were more likely to develop large/giant CAA 17 (12%) vs 30 (6%), P=.03. Lower SES is associated with delayed treatment, prolonged LOS, and increased risk of large/giant CAA. Novel approaches to diagnosis and education are needed for children living in low-SES neighborhoods.

Socioeconomic Status, Race/Ethnicity, and Health Disparities in Children and Adolescents in a Mixed Rural-Urban Community—Olmsted County, Minnesota

ObjectiveTo characterize disparities in childhood health outcomes by socioeconomic status (SES) and race/ethnicity in a mixed rural-urban US community. MethodsThis was a retrospective population-based study of children 18 years and younger residing in Olmsted County, Minnesota, in 2009. The prevalence rates of childhood health outcomes were determined using International Classification of Diseases, Ninth Revision codes. Socioeconomic status was measured using the HOUsing-based SocioEconomic Status index (HOUSES), derived from real property data. Adjusting for age and sex, logistic regression models were used to examine the relationships among HOUSES, race/ethnicity, and prevalence of childhood health outcomes considering an interaction between HOUSES and race/ethnicity. Odds ratios were calculated using the lowest SES quartile and non-Hispanic white participants as the reference groups. ResultsOf 31,523 eligible children, 51% were male and 86% were of non-Hispanic white race/ethnicity. Overall, lower SES was associated with higher prevalence of bronchiolitis, urinary tract infection, asthma, mood disorder, and accidents/adverse childhood experiences (physical and sexual abuse) in a dose-response manner (P<.04). Prevalence rates of all childhood conditions considered except for epilepsy were significantly different across races/ethnicities (P<.002). Racial/ethnic disparities for asthma and mood disorder were greater with higher SES. ConclusionSignificant health disparities are present in a predominantly affluent, non-Hispanic white, mixed rural-urban community. Socioeconomic status modifies disparities by race/ethnicity in clinically less overt conditions. Interpretation of future health disparity research should account for the nature of disease.

Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant

There is mixed evidence of racial and socioeconomic disparities in heart transplant outcomes. Their underlying cause-and whether individual- or community-level traits are most influential-remains unclear. The current study aimed to characterize socioeconomic disparities in outcomes and identify time trends and mediators of these disparities. We used United Network for Organ Sharing registry data and included 33 893 adult heart transplant recipients between 1994 and 2014. Socioeconomic status (SES) indicators included insurance, education, and neighborhood SES measured using a composite index. Black race and multiple indicators of low SES were associated with the primary outcome of death or retransplant, independent of baseline clinical characteristics. Blacks had lower HLA and race matching, but further adjustment for these and other graft characteristics only slightly attenuated the association with black race (HR, 1.25 after adjustment). This and the associations with neighborhood SES (HR, 1.19 for lowest versus highest decile), Medicare (HR, 1.17), Medicaid (HR, 1.29), and college education (HR, 0.90) remained significant after full adjustment. When comparing early (1994-2000) and late (2001-2014) cohorts, the disparities associated with the middle (second and third) quartiles significantly decreased over time, but those associated with lowest SES quartile and black race persisted. Low neighborhood SES was also associated with higher risks of noncompliance (HR, 1.76), rejection (HR, 1.28), hospitalization (HR, 1.13), and infection (HR, 1.10). Racial and socioeconomic disparities exist in heart transplant outcomes, but the latter may be narrowing over time. These disparities are not explained by differences in clinical or graft characteristics.

Community socioeconomic status and public access defibrillators: A multilevel analysis

BackgroundAlthough current guidelines recommend that distribution of public-access defibrillators (PADs) should take into account area-level risk of out-of-hospital cardiac arrest (OHCA), community socioeconomic status (SES) can unduly influence policy implementation in positioning PADs. Using recent, complete data from Seoul Metropolitan City, Korea, this study aims to examine whether community SES is associated with distribution of PADs, in terms of per capita count and risk-grid coverage. MethodsA cross-sectional, observational study was conducted using three sources of administrative data: (1) PAD registry data (2007–2015), (2) OHCA database (2010–2014), and (3) community socioeconomic characteristics of two sub-city levels (neighborhoods nested in districts). We examined the relationship between neighborhood per capita tax, an SES proxy, with each of the two outcome variables. After examining per capita number of PADs and risk-grid coverage by neighborhood tax quartile, multilevel linear regression analysis was conducted to account for the nested nature of data and also to control for OHCA risk in the model. ResultsA total of 6609 PADs in 405 neighborhoods were included in the analysis. The average number of positioned PADs per 10,000 persons was 7.45, showing a gradient by neighborhood SES (4.92 in the lowest SES quartile vs 12.66 in the highest). Risk-grid coverage was around 10% across all neighborhood SES quartiles. These findings remained valid in the multilevel analysis: per capita number of PADs was still positively associated with neighborhood SES, while risk-grid coverage of PADs was not. ConclusionsMore affluent neighborhoods in Seoul exhibit higher per capita PADs, even accounting for OHCA risk, while risk-grid coverage is generally low regardless of community SES. Seoul’s ongoing program aimed to increase PAD coverage should also pay attention to improving community-level inequality as well as distributional efficiency.

Impact of Socioeconomic Status on Patients Supported With a Left Ventricular Assist Device: An Analysis of the UNOS Database (United Network for Organ Sharing).

Low socioeconomic status (SES) is a known risk factor for heart failure, mortality among those with heart failure, and poor post heart transplant (HT) outcomes. This study sought to determine whether SES is associated with decreased waitlist survival while on left ventricular assist device (LVADs) support and after HT. A total of 3361 adult patients bridged to primary HT with an LVAD between May 2004 and April 2014 were identified in the UNOS database (United Network for Organ Sharing). SES was measured using the Agency for Healthcare Research and Quality SES index using data from the 2014 American Community Survey. In the study cohort, SES did not have an association with the combined end point of death or delisting on LVAD support (P=0.30). In a cause-specific unadjusted model, those in the top (hazard ratio, 1.55; 95% confidence interval, 1.14-2.11; P=0.005) and second greatest SES quartile (hazard ratio 1.50; 95% confidence interval, 1.10-2.04; P=0.01) had an increased risk of death on device support compared with the lowest SES quartile. Adjusting for clinical risk factors mitigated the increased risk. There was no association between SES and complications. Post-HT survival, both crude and adjusted, was decreased for patients in the lowest quartile of SES index compared with all other SES quartiles. Freedom from waitlist death or delisting was not affected by SES. Patients with a higher SES had an increased unadjusted risk of waitlist mortality during LVAD support, which was mitigated by adjusting for increased comorbid conditions. Low SES was associated with worse post-HT outcomes. Further study is needed to confirm and understand a differential effect of SES on post-transplant outcomes that was not seen during LVAD support before HT.

Health disparities and impact on outcomes in children with primary central nervous system solid tumors

OBJECTIVE Health disparities in access to care, early detection, and survival exist among adult patients with cancer. However, there have been few reports assessing how health disparities impact pediatric patients with malignancies. The objective in this study was to examine the impact of racial/ethnic and social factors on disease presentation and outcome for children with primary CNS solid tumors. METHODS The authors examined all children (age ≤ 18 years) in whom CNS solid tumors were diagnosed and who were enrolled in the Texas Cancer Registry between 1995 and 2009 (n = 2421). Geocoded information was used to calculate the driving distance between a patient's home and the nearest pediatric cancer treatment center. Socioeconomic status (SES) was determined using the Agency for Healthcare Research and Quality formula and 2007-2011 US Census block group data. Logistic regression was used to determine factors associated with advanced-stage disease. Survival probability and hazard ratios were calculated using life table methods and Cox regression. RESULTS Children with advanced-stage CNS solid tumors were more likely to be < 1 year old, Hispanic, and in the lowest SES quartile (all p < 0.05). The adjusted odds ratios of presenting with advanced-stage disease were higher in children < 1 year old compared with children > 10 years old (OR 1.71, 95% CI 1.06-2.75), and in Hispanic patients compared with non-Hispanic white patients (OR 1.56, 95% CI 1.19-2.04). Distance to treatment and SES did not impact disease stage at presentation in the adjusted analysis. Furthermore, 1- and 5-year survival probability were worst in children 1-10 years old, Hispanic patients, non-Hispanic black patients, and those in the lowest SES quartile (p < 0.05). In the adjusted survival model, only advanced disease and malignant behavior were predictive of mortality. CONCLUSIONS Racial/ethnic disparities are associated with advanced-stage disease presentation for children with CNS solid tumors. Disease stage at presentation and tumor behavior are the most important predictors of survival.

Health Disparities Influence Childhood Melanoma Stage at Diagnosis and Outcome

To identify health disparities in pediatric patients with melanoma that affect disease presentation and outcome. This was a retrospective cohort study of all persons aged ≤18years diagnosed with melanoma and enrolled in the Texas Cancer Registry between 1995 and 2009. Socioeconomic status (SES) and driving distance to the nearest pediatric cancer treatment center were calculated for each patient. Logistic regression was used to determine factors associated with advanced-stage disease. Life table methods and Cox regression were used to estimate survival probability and hazard ratios. A total of 185 adolescents (age >10years) and 50 young children (age ≤10years) were identified. Hispanics (n=27; 12%) were 3 times more likely than non-Hispanic whites (n=177; 75%) to present with advanced disease (OR, 3.8; 95% CI, 1.7-8.8). Young children were twice as likely as adolescents to present with advanced disease (OR, 2.2; 95% CI, 1.1-4.3). Distance to treatment center and SES did not affect stage of disease at presentation. Hispanics and those in the lowest SES quartile had a significantly higher mortality risk (hazard ratios, 3.0 [95% CI, 1.2-7.8] and 4.3 [95% CI, 1.4-13.9], respectively). In the adjusted survival model, only advanced disease was predictive of mortality (P<.001). Hispanics and young children with melanoma are more likely to present with advanced disease, and advanced disease is the single most important predictor of survival. Heightened awareness among physicians is needed to facilitate early detection of melanoma within these groups.

Abstract 13850: Outcomes and Resource Utilization in ST Elevation Myocardial Infarction in the United States: Evidence for socioeconomic disparities

Background: Socioeconomic status (SES) as reflected by residential zip code status may detrimentally influence a number of pre-hospital clinical, access-related and transport variables that influence outcome for patients with ST-elevation myocardial infarction (STEMI) undergoing reperfusion. We sought to analyze the relationship between SES and in-hospital mortality following STEMI. Methods: We used the 2003-2011 US Nationwide Inpatient Sample for this study. All admissions with a principal diagnosis of STEMI were identified using standard ICD codes. SES was classified based on median household income of the residential zip code of every patient. In-hospital death and timely reperfusion within day 0 of presentation were the primary outcomes for the study. Results: A total of 372984 admissions with STEMI were analyzed. There was a significantly higher mortality among the lowest SES quartile as compared to the highest quartile [OR (95% CI): 1.11(1.06-1.17)] (Fig). There was a highly significant trend indicating a progressively reduced timely reperfusion among patients from lower quartiles [OR (95% CI): 0.80 (0.74-0.88)] (Fig). In addition, there was a greater utilization of circulatory support devices and Swan Ganz catheterization among patients from higher as compared to lower quartiles (Fig). Furthermore, the mean adjusted cost of hospitalization among quartiles 2,3, and 4, as compared to quartile 1 was significantly higher by $913, $2140 and $4070 respectively. Conclusions: Patients residing in zip codes with lower SES had increased mortality and decreased timely reperfusion following STEMI as compared to patients residing in higher SES zip codes. Despite higher mortality, the utilization of circulatory support devices and Swan Ganz catheterization was paradoxically lower among patients from lower SES zip codes. In addition, cost of hospitalization of patients from higher SES quartiles was significantly higher than those from lower quartiles.

Health disparities are important determinants of outcome for children with solid tumor malignancies

PurposeThe purpose of this study was to identify health disparities in children with non-CNS solid tumor malignancies and examine their impact on disease presentation and outcome. MethodsWe examined the records of all children (age≤18years) diagnosed with a non-CNS solid tumor malignancy and enrolled in the Texas Cancer Registry between 1995 and 2009 (n=4603). The primary outcome measures were disease stage and overall survival (OS). Covariates included gender, age, race/ethnicity, year of diagnosis, socioeconomic status (SES), and driving distance to the nearest pediatric cancer treatment facility. Statistical analyses included life table methods, logistic, and Cox regression. Statistical significance was defined as p<0.05. ResultsChildren with advanced-stage disease were more likely to be male, <10years old, and Hispanic or non-Hispanic Blacks (all p<0.05). Distance to treatment and SES did not impact stage of disease at presentation. However, Hispanic and non-Hispanic Blacks and patients in the lowest SES quartile had the worst 1- and 5-year survival (all p<0.05). The adjusted OS differed by age, race, and stage, but not SES or distance to the nearest treatment facility. ConclusionsRace/ethnicity plays an important role in survival for children with non-CNS solid tumor malignancies. Future work should better define these differences to establish mechanisms to decrease their impact.

Association of race and socioeconomic status with the use of endovascular repair to treat thoracic aortic diseases

Descending thoracic aortic diseases may be treated with either open thoracic aortic repair or thoracic endovascular aortic repair (TEVAR). Previous studies have demonstrated that race and socioeconomic status (SES) affect access to care and treatment allocation in vascular surgery. We hypothesized that racial minorities and lower SES patients have decreased propensity to have their thoracic aortic disease treated with TEVAR. Weighted discharge records for patients who underwent either open thoracic aortic repair or TEVAR between 2005 and 2008 were evaluated using the Nationwide Inpatient Sample. Patient records were stratified by therapeutic intervention (open repair vs TEVAR). Differences in baseline comorbidities, race, and SES were compared. To account for the effects of comorbidities and other factors, hierarchical logistic regression modeling was used to determine the likelihood for TEVAR performance based on differences in patients' race and SES. A total of 60,784 thoracic repairs were analyzed, the majority (79.4%) of which were open repairs. The most common race was white (78.2%), followed by black (9.1%), Hispanic (5.7%), Asian or Pacific Islander (2.9%), and Native American (0.7%). Patients were divided into quartiles according to SES with 20.6% of patients in the lowest SES quartile, 24.3% in the second quartile, 26.4% in the third quartile, and 28.8% in the highest SES quartile. Indications for treatment were similar for both treatment groups. After adjusting for multiple patient and hospital factors, race and SES were significantly associated with treatment modality for thoracic aortic disease. Black, Hispanic, and Native American populations had increased adjusted odds ratios of TEVAR performance compared with white patients. Similarly, lower SES correlated with increased use of TEVAR. Contrary to our initial hypothesis, racial minorities (Black, Hispanic, and Native American) and patients with lower median household incomes have a greater association with the performance for TEVAR after accounting for patient comorbid disease, indication for treatment, payer status, and hospital volume. These results indicate that traditional racial disparities do not persist in TEVAR allocation.

Socioeconomic Status and In-Hospital Pediatric Mortality

Socioeconomic status (SES) is inversely related to pediatric mortality in the community. However, it is unknown if this association exists for in-hospital pediatric mortality. Our objective was to determine the association of SES with in-hospital pediatric mortality among children's hospitals and to compare observed mortality with expected mortality generated from national all-hospital inpatient data. This is a retrospective cohort study from 2009 to 2010 of all 1,053,101 hospitalizations at 42 tertiary care, freestanding children's hospitals. The main exposure was SES, determined by the median annual household income for the patient's ZIP code. The main outcome measure was death during the admission. Primary outcomes of interest were stratified by income and diagnosis-based service lines. Observed-to-expected mortality ratios were created, and trends across quartiles of SES were examined. Death occurred in 8950 (0.84%) of the hospitalizations. Overall, mortality rates were associated with SES (P < .0001) and followed an inverse linear association (P < .0001). Similarly, observed-to-expected mortality was associated with SES in an inverse association (P = .014). However, mortality overall was less than expected for all income quartiles (P < .05). The association of SES and mortality varied by service line; only 3 service lines (cardiac, gastrointestinal, and neonatal) demonstrated an inverse association between SES and observed-to-expected mortality. Within children's hospitals, SES is inversely associated with in-hospital mortality, but is lower than expected for even the lowest SES quartile. The association between SES and mortality varies by service line. Multifaceted interventions initiated in the inpatient setting could potentially ameliorate SES disparities in in-hospital pediatric mortality.

Following the Organ Supply

Disparity in access to liver transplantation (LT) in the United States persists despite directives from the federal government to reduce geographic variation. We assessed the impact of socioeconomic status (SES) and traveling to alternative donation service areas (DSAs) on patient survival. A prospective cohort study integrating transplant registry and U.S. Census data was analyzed using multivariate linear Cox proportional hazards models. A separate matched-pairs analysis was used to assess the benefit of traveling on patient survival and transplantation rate. High SES is associated with increased access to LT (adjusted hazard ratio [aHR], 1.05; 95% confidence interval [95% CI], 1.01-1.08) and reduced mortality after waitlisting (aHR [95% CI], 0.88 [0.85-0.93]). Increased access is mediated, in part, through inter-DSA travel. Travel was associated with high SES, white race, blood group O, private insurance, and residence in regions 1, 5, and 11. Transplant candidates in the highest SES quartile were approximately 70% more likely to travel (aHR [95% CI], 1.67 [1.43-1.97]) than those in the lowest SES quartile. Compared with matched control patients, travelers were 74% more likely to be transplanted (aHR [95% CI], 1.74 [1.56-1.94]) and 20% less likely to die after listing (aHR [95% CI], 0.79 [0.69-0.92]). High SES and inter-DSA travel are strongly associated with increased LT access and reduced mortality. Travelers are more likely to be sociodemographically advantaged and privately insured and to live in regions with reduced access to deceased-donor organs.

High School Music Ensemble Students in the United States

The purpose of this study is to construct a national demographic profile of high school band, choir, and orchestra students in the United States using evidence from the 2004 follow-up wave of the Education Longitudinal Study of 2002. Results indicate that 21% of seniors in the United States’ class of 2004 participated in school music ensembles. Significant associations were found between music ensemble participation and variables including gender, race/ethnicity, socioeconomic status (SES), native language, parents’ education, standardized test scores, and GPA. Certain groups of students, including those who are male, English language learners, Hispanic, children of parents holding a high school diploma or less, and in the lowest SES quartile, were significantly underrepresented in music programs across the United States. In contrast, white students were significantly overrepresented among music students, as were students from higher SES backgrounds, native English speakers, students in the highest standardized test score quartiles, children of parents holding advanced postsecondary degrees, and students with GPAs ranging from 3.01 to 4.0. Findings indicate that music students are not a representative subset of the population of U.S. high school students.

Socioeconomic Status and Transient Ischaemic Attack/Stroke: A Prospective Observational Study

Background: Lower socioeconomic status (SES) is associated with an increased risk of stroke but the mechanisms are unclear. We aimed to determine whether low-SES stroke/transient ischaemic attack (TIA) patients have a greater burden of vascular risk factors/co-morbidity and reduced health care access. Methods: We prospectively studied 467 consecutive stroke and TIA patients from 3 Scottish hospitals (outpatients and inpatients) during 2007/2008. We recorded vascular risk factors, stroke severity, co-morbidity measures, investigations and health service utilisation. SES was derived from postcodes using Scottish Neighbourhood Statistics and analysed in quartiles. Results: TIA/stroke patients in the lowest SES quartile were younger (64 years, SD 14.1) than those in the highest quartile (72 years, SD 12.9; p < 0.0001). They were more likely to be current smokers (42 vs. 22%; p = 0.001) but there was no association with other vascular risk factors/co-morbidity. There was a trend for those with lower SES to have a more severe stroke [modified National Institutes of Health Stroke Scale score and interquartile range: 4 (2–6) vs. 3 (1–5); multivariate p = 0.05]. Lower SES groups were less likely to have neuro-imaging (82 vs. 90%; p = 0.036) or an electrocardiogram (72 vs. 87%; p = 0.003), but differences were no longer significant on multivariate analysis. However, there was equal access to stroke unit care. Conclusions: Low-SES TIA and stroke patients are younger and have a more severe deficit; an increased prevalence of smoking is likely to be a major contributor. We found equal access to stroke unit care for low-SES patients.