Neighborhood Median Income Research Articles

Racial, ethnic and socioeconomic disparities in patients undergoing left atrial appendage closure

ObjectiveThis manuscript aims to explore the impact of race/ethnicity and socioeconomic status on in-hospital complication rates after left atrial appendage closure (LAAC).MethodsThe US National Inpatient Sample was used to identify...

Abstract SS1-09: Medicaid expansion associated with earlier stage and improved reconstruction rates in low income breast cancer patients

Abstract Introduction: Substantial delays in time to initiation of treatment (TTT) following diagnosis of breast cancer (BC) can inflict a toll on quality of life and can decrease cancer-specific survival. Among low-income, non-elderly Ohio women having newly-diagnosed breast cancer with local or regional spread, we examined TTT and other measures where income-related disparities have been documented, comparing 2011-2013 (pre-Medicaid-expansion) vs. 2014-2016 (post-expansion). Our primary hypothesis was that TTT would decrease following 2014 Medicaid expansion.Methods: Using data from the Northeast Ohio Cancer Assessment and Surveillance Engine (NEO-CASE), a multilevel data infrastructure linking Ohio cancer registry data with community data, we identified 30-64 year-old women with new diagnosis of invasive, non-metastatic BC who were uninsured or on Medicaid when diagnosed. TTT was defined as days from diagnosis to first BC treatment with any modality. We excluded women with TTT=0 (likely coding error). The main exposure was pre- or post-Medicaid expansion period defined as 2011-2013 or 2014-2016, respectively. We examined additional key demographic and treatment variables before and after expansion and in multivariate analysis of TTT. We used a previously-described probability-weighting approach based on neighborhood median income to approximate excluding women with incomes above 138% of Federal Poverty Level. As a control analysis, we compared pre- and post-expansion TTT among privately insured women, probability weighted to select for higher income individuals.Results: Our study population included 1177 and 1143 women diagnosed with BC pre- and post-expansion, respectively. Demographic characteristics were similar, though mean age increased by 1.2 years (p<0.01) post-expansion. Mean TTT increased by 2 days post-expansion, from 41.1 to 43.1 (p=0.18). The control analysis showed a similar small post-expansion increase. Though no significant change in TTT was observed, the percent uninsured in the low-income group fell by more than half (from 32.9% to 14.1%; p<0.01), and the percent of women diagnosed with regional stage disease decreased from 38.1% to 30.9% (p<0.01). The percent of women undergoing reconstructive surgery increased from 12.1% to 16.7% (p<0.01) from the pre- to the post-Medicaid expansion period, a change not observed in the privately-insured control group. Cox proportional hazards regression models controlling for the effect on TTT of covariates shown in the table revealed an adjusted hazard rate (AHR) of 0.950 (95% CI 0.855 to 1.056) associated with Medicaid expansion. Stage-stratified Cox models showed a similar lack of effect among women with local and regional disease. Discussion: TTT increased by 2 days post-expansion; however, this increase was neither statistically significant nor clinically meaningful. Despite the lack of improvements in TTT, we note the dramatic drop in the percent uninsured among BC patients post-expansion, as well as a marked decrease in the percent of women diagnosed with regional-stage disease, and an increase in BC patients undergoing reconstruction. Taken together, these trends show an overall positive impact of Medicaid expansion on BC process of care and outcome measures. Pre-expansionPost-expansionpN11771143Mean TTT in days (SD)41.1 (37.1)43.1 (33.7)0.18Mean age at diagnosis (SD)51.6 (8.39)52.8 (8.14)<0.01Non-Hispanic African American (%)269 (22.9)225 (19.7)0.07Married/Partnered (%)408 (34.7)417 (36.5)0.38Uninsured (%)387 (32.9)161 (14.1)<0.01Non-metropolitan census tract (%)285 (24.2)232 (20.3)0.03Area Deprivation Index 9 or 10: most deprived (%)274 (23.3)238 (20.8)0.17Regional disease (%)448 (38.1)353 (30.9)<0.01Reconstructive surgery (%)143 (12.1)191 (16.7)<0.01Breast conserving surgery (%)509 (43.2)590 (51.6)<0.01 Citation Format: Johnie Rose, Weichuan Dong, Uriel Kim, Samilia Obeng-Gyasi, Siran Koroukian. Medicaid expansion associated with earlier stage and improved reconstruction rates in low income breast cancer patients [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SS1-09.

Impact of Race and Socioeconomic Status on Outcomes in Patients Hospitalized with COVID-19

BackgroundThe impact of race and socioeconomic status on clinical outcomes has not been quantified in patients hospitalized with coronavirus disease 2019 (COVID-19).ObjectiveTo evaluate the association between patient sociodemographics and neighborhood disadvantage with frequencies of death, invasive mechanical ventilation (IMV), and intensive care unit (ICU) admission in patients hospitalized with COVID-19.DesignRetrospective cohort study.SettingFour hospitals in an integrated health system serving southeast Michigan.ParticipantsAdult patients admitted to the hospital with a COVID-19 diagnosis confirmed by polymerase chain reaction.Main MeasuresPatient sociodemographics, comorbidities, and clinical outcomes were collected. Neighborhood socioeconomic variables were obtained at the census tract level from the 2018 American Community Survey. Relationships between neighborhood median income and clinical outcomes were evaluated using multivariate logistic regression models, controlling for patient age, sex, race, Charlson Comorbidity Index, obesity, smoking status, and living environment.Key ResultsBlack patients lived in significantly poorer neighborhoods than White patients (median income: $34,758 (24,531–56,095) vs. $63,317 (49,850–85,776), p < 0.001) and were more likely to have Medicaid insurance (19.4% vs. 11.2%, p < 0.001). Patients from neighborhoods with lower median income were significantly more likely to require IMV (lowest quartile: 25.4%, highest quartile: 16.0%, p < 0.001) and ICU admission (35.2%, 19.9%, p < 0.001). After adjusting for age, sex, race, and comorbidities, higher neighborhood income ($10,000 increase) remained a significant negative predictor for IMV (OR: 0.95 (95% CI 0.91, 0.99), p = 0.02) and ICU admission (OR: 0.92 (95% CI 0.89, 0.96), p < 0.001).ConclusionsNeighborhood disadvantage, which is closely associated with race, is a predictor of poor clinical outcomes in COVID-19. Measures of neighborhood disadvantage should be used to inform policies that aim to reduce COVID-19 disparities in the Black community.

Global and localized neighborhood effects on public transit ridership in Baton Rouge, Louisiana

This study examines what socio-demographic and spatial factors explain the variation of public transit ridership in a medium-size city in southern U.S. – Baton Rouge, Louisiana. In order to gain a sharper spatial resolution in the analysis, the ecological inference method is used to disaggregate socio-demographic data from the census block group level to the census block level. Monte Carlo simulation and transit schedule data are used to improve the estimation of travel time by private vehicle and public transit, respectively, also at the census block level. The semi-parametric geographically-weighted regression (SGWR) is used to identify, among significant variables, what are global factors and what are local factors. The results indicate that neighborhoods with higher concentrations of non-White minorities, recent immigrants and carless households have positive global effects on public transit ridership. The effects by neighborhood median income, public transit to private vehicle commuting time ratio, and accessibility to employment via public transit are localized or vary across the study area, and some of these variables even show opposite effects in specific pockets in contrast to their area-wide average effects.

117 Using composite area-level measures as a proxy for self-report family income

Abstract Background Socioeconomic status (SES) is a well-established social determinant of child health. When reliable self-report family income is unavailable, area-level measures, such as median neighbourhood income, are commonly used as a proxy. However, median neighbourhood income is not a good proxy for self-report family income. Newer area-level measures, such as the Neighbourhood Equity Score (NES) and the Child and Family Inequities Score (CFIS) are composite scores comprised of indicators of well-being such as income, parental education and physical surroundings. Objectives The primary objective was to evaluate the agreement between self-report family income and three area-level measures: median neighbourhood income, NES, and CFIS. The secondary objective was to examine the association between self-report family income, NES, and CFIS with two health indicators associated with SES: overweight/obesity (BMI z-score&amp;gt;1) and short breastfeeding duration (&amp;lt;6 months). Design/Methods We conducted a cross-sectional study using data from a healthy urban Canadian cohort of young children (0-5 years) attending a scheduled health supervision visit in primary care. Parents completed a questionnaire including family income, postal code and breastfeeding duration. Research assistants measured height and weight (to calculate body mass index). Postal code was used to determine each area-level measure. Agreement between self-report family income and area-level measures was evaluated using kappa coefficients. The percentage of families accurately classified by area-level measures compared with self-report family income was calculated. Multivariable logistic regression was used to evaluate the association between self-report family income, NES, and CFIS (quintiles) with the two health indicators (present/absent). Results 5149 children were included (mean age 21 months). Agreement between self-report family income and both NES and CFIS was ‘fair’ (weighted k=0.29 for both), and agreement with median neighbourhood income was ‘poor’ (weighted k=0.09). Accurate classification between self-report family income and the three measures were: median neighbourhood income (5.6%), NES (32.2%), CFIS (32.4%). For children in the lowest vs. highest quintile, the odds (95% CI) of overweight/obesity were: self-report family income OR=2.75 (1.60-4.72), NES OR=2.02 (1.23-3.30), CFIS OR=2.04 (1.25-3.33); and having short breastfeeding duration: self-report family income OR=1.61 (1.32-1.97), NES OR=1.84 (1.50-2.25), CFIS OR=1.84 (1.46-2.31). Conclusion Agreement and accurate classification between self-report family income was strongest for composite area-level measures (NES and CFIS), compared with median neighbourhood income. Both self-report family income and composite area-level measures supported the same conclusion that lower SES was associated with poorer health outcomes. These newer measures may be more appropriate than median neighbourhood income when self-report family income is unavailable.

The influence of income on medical school admissions in Canada: a retrospective cohort study

BackgroundThe socioeconomic status of applicants to Canadian medical schools has been understudied in the past two decades. Institutional efforts have been made to address the lack of socioeconomic diversity across Canada during this time. We investigated the income characteristics of medical school applicants, as well as the relationship between applicant income and offer of admission, to characterize the current state of socioeconomic diversity in medical admissions.MethodsWe conducted a retrospective cohort study on 26,120 applicants at one Ontario medical school from 2013 to 2018. Characteristics of applicants who were offered admission were compared to the general population and applicants not offered admission. Regression analyses were used to investigate the association between median total neighborhood income and successful admission.ResultsThe median total neighborhood income for medical school applicants was $98,816, which was approximately $28,480 higher than the Canadian general population. Those not admitted to the medical school had a median total neighborhood income of $98,304 compared to $105,984 for those offered admission (p < 0.001). This trend was seen in every province and territory in Canada. Median total neighborhood income was a predictor of an offer of admission; applicants in the >75th percentile income group had 54% increased odds of being offered admission when compared to applicants in the <25th percentile in our unadjusted model. Income was not significant in our adjusted models but showed that the income medians drastically shifted between pre-interview and post-interview periods, from $98,816 to $104,960 (p < 0.001).ConclusionMedical school applicants are from higher economic strata compared to the general population. Despite already representing a high economic stratum, a higher median total neighborhood income relative to other applicants was associated with an offer of admission.

Pancreatic cancer: Do disparities in mortality rates exist with respect to socioeconomic status?

e19007 Background: Pancreatic cancer continues to have one of the highest mortality rates among major cancer diagnoses with rates greater than 90 percent for all stages and with five year survival rates below 10 percent. With access to treatment modalities such as chemo-radiation, staged surgical interventions and targeted therapies, survival times have increased but due to the costs of these procedures, they may not be accessible to all members of society. Recent studies have shown that lower socioeconomic status is associated with higher mortality rates and lower survival times. With this study we aim to investigate if disparities exist among socioeconomic classes, based on zip code location, in a major multi-ethnic metropolitan city using census data. Methods: Malignant neoplasm mortality data at the ZIP code level was gathered from the New York City Department of Health Vital Statistics Mortality Data from years 2009-2011. NYC population data was gathered from the U.S. Census Bureau 2010 decennial census. We used ordinary least squares regression to assess the independent association between neighborhood median income and neighborhood mortality from malignant neoplasms arising from the pancreas. Results: In 2009-2011, 2,527 deaths from malignant neoplasms arising from the pancreas were recorded across NYC. There is no statistically significant correlation between neighborhood median income and age-adjusted mortality from malignant neoplasms arising from the pancreas for males and for females. For males, there was an R-squared of 0.001721 ( P-value &gt; 0.05). For females, there was an adjusted adjusted R-squared of 9.818e-05 ( P-value &gt; 0.05). Conclusions: Neighborhood median income is not associated with an increase in mortality rate with respect to neoplasms arising from the pancreas.

Association between neighborhood socioeconomic status, tobacco store density and smoking status in pregnant women in an urban area

Smoking during pregnancy can lead to serious health consequences. Given such health risks, an understanding of factors that influence maternal smoking behaviors during pregnancy is critical. The objective of this study is to assess the relationship between tobacco store density, neighborhood socioeconomic status, and neighborhood rates of maternal smoking during pregnancy. Fifty-five community areas in Baltimore City were summarized using data from the Neighborhood Health Profiles. Associations between tobacco store density and smoking while pregnant in a community were determined using Moran's I and spatial regression analyses to account for autocorrelation. The fully adjusted model took into account the following community-level socioeconomic variables as covariates: neighborhood median income, percentage of those living in poverty, percentage of uninsured, and percentage of persons with at least a college degree. In regards to the findings, the percentage of women by community area who identified as actively smoking while pregnant was 10.4% ± 5.8%. The tobacco store density was 21.0 ± 12.7 per 10,000 persons (range 0.0–49.1 tobacco store density per 10,000 persons). In the adjusted model, an increase in density of 1 tobacco store per 10,000 persons was associated with a 10% increase in women who reported smoking during pregnancy (β = 0.10, p = 0.04). In conclusion, tobacco store density and neighborhood socioeconomic factors were associated with prevalence of maternal smoking while pregnant. These findings support the need to further assess and develop interventions to reduce the impact of tobacco store density on smoking behaviors and health risks in communities.

Socioeconomic disparity trends in diagnostic imaging, treatments, and survival for non-small cell lung cancer 2007-2016.

Socioeconomic status (SES) has led to treatment and survival disparities; however, limited data exist for non‐small cell lung cancer (NSCLC). This study investigates the impact of SES on NSCLC diagnostic imaging, treatment, and overall survival (OS), and describes temporal disparity trends. The Ontario Cancer Registry was used to identify NSCLC patients diagnosed between 2007 and 2016. Through linkage to administrative datasets, patients’ demographics, imaging, treatment, and survival were obtained. Based on median household neighborhood income, the Ontario population was divided into five income quintiles (Q1‐Q5; Q1 = lowest income). Multivariable regressions assessed SES association with OS, imaging, treatment receipt, and treatment delay, and their interaction with year of diagnosis to understand temporal trends. Endpoints were adjusted for demographics, stage and comorbidities, along with treatments and imaging for OS. A total of 50 542 patients were identified. Higher SES patients (Q5 vs. Q1) showed improved 5‐year OS (hazard ratio, 0.89; 95% confidence interval [CI], 0.87‐0.92; P < .0001) and underwent greater magnetic resonance imaging head (stages IA‐IV; odds ratio [OR], 1.24; 95% CI, 1.16‐1.32; P < .0001), lung resection (IA‐IIIA; OR, 1.58; 95% CI, 1.43‐1.74; P < .0001), platinum‐based vinorelbine adjuvant chemotherapy (IB‐IIIA; OR, 1.63; 95% CI, 1.39‐1.92; P < .0001), palliative radiation (IV; OR, 1.14; 95% CI, 1.05‐1.25; P = .023), and intravenous chemotherapy (IV; OR, 1.45; 95% CI, 1.32‐1.60; P < .0001). Lower SES patients underwent greater thoracic radiation (IA‐IIIB; OR, 0.86; 95% CI, 0.79‐0.94; P = .0003). Across 2007‐2016, socioeconomic disparities remain largely unchanged (interaction P > .05) despite widening income inequality.

Immigrant and ethnic neighbourhood concentration and reduced child developmental vulnerability: A Canadian cohort study.

IntroductionStudies have consistently demonstrated a gradient between median neighbourhood income and child developmental outcomes. By investigating statistical outliers—neighbourhoods with children exhibiting less or more developmental vulnerability than that predicted by median neighbourhood income—there is an opportunity to identify other neighbourhood characteristics that may be enhancing or impeding early childhood development.ObjectiveTesting a variety of neighbourhood factors, including immigrant or ethnic concentration and characteristics of structural disadvantage (proportion of social assistance recipients, homes in need of major repair, residents with high school education only, lone parent families, and residents moving in the last year) we sought to identify factors associated with more or less developmental vulnerability than that predicted by median neighbourhood income, for young children.MethodsFor this cross-sectional study we used validated Early Development Instrument (EDI) data (2003-2013) linked to demographic and socioeconomic Census and Tax Filer data for 98.3% of Canadian neighbourhoods (n=2,023). The purpose of the instrument is to report, at a population-level, children’s school readiness. Children’s developmental vulnerability was assessed in five domains (physical health and well-being, emotional maturity, social competence, language and cognitive development, and communication and general knowledge) in relation to the 10th percentile from a national normative sample. Levels of children’s neighbourhood vulnerability were determined per domain, as percent of children vulnerable at a given domain. Neighbourhoods were grouped into three cohorts, those having lower than predicted, as predicted, or higher than predicted children’s vulnerability according to neighbourhood median income. Using multivariable binary logistic regression we modelled the association between select neighbourhood characteristics and neighbourhoods with lower or higher than predicted vulnerability per domain, compared to neighbourhoods with predicted vulnerability. This allowed us to determine neighbourhood characteristics associated with better or worse child developmental outcomes, at a neighbourhood-level, than that predicted by income.ResultsIn neighbourhoods with less child developmental vulnerability than that predicted by income, high or low immigrant concentration and ethnic homogeneity was associated with less vulnerability in physical (adjusted odds ratio (aOR) 1.66, 95% CI: 1.43, 1.94), social (aOR 1.30, 95% CI: 1.11, 1.51), and communication domains (aOR 1.24, 95% CI: 1.03, 1.47) compared to neighbourhoods with vulnerability concordant with income. Neighbourhood ethnic homogeneity was consistently associated with less developmental vulnerability than predicted by income across all developmental domains. Neighbourhood-level structural disadvantage was strongly associated with child developmental vulnerability beyond that predicted by median neighbourhood income. ConclusionCanadian neighbourhoods demonstrating less child developmental vulnerability than that predicted by income have greater ethnic and ethnic-immigrant homogeneity than neighbourhoods with child developmental vulnerability concordant with income. Neighbourhood social cohesion and cultural identity may be contributing factors. Neighbourhood structural disadvantage is associated with poorer early childhood development, over and above that predicted by neighbourhood income. Neighbourhood-level policy and programming should address income and non-income related barriers to healthy child development

Disentangling individual and neighborhood differences in the intention to quit smoking in Asian American male smokers.

Numerous studies have assessed individual-level factors associated with intention to quit smoking. However, fewer studies have assessed how neighborhood and built environment also contribute towards individual-level behavior. We used baseline data of 340 Chinese and Vietnamese male daily smokers from August 2015 to November 2017 living in the San Francisco Bay Area, who enrolled in a lifestyle intervention trial. The outcome variable was intention to quit in 30 days. To understand the role of contextual factors participants’ residential addresses were geocoded, and neighborhood median income, ethnic composition, and tobacco retail density were computed. Individual level analysis suggested that Vietnamese American men had greater intention to quit smoking (OR = 2.90 CI = 1.59, 5.26) in comparison to Chinese Americans. However, after adding neighborhood level factors to the model, no ethnic group difference was observed. Neighborhood household median income (OR = 0.74, CI = 0.64, 0.86) and tobacco retail counts (OR = 0.79, CI = 0.67, 0.94) were negatively associated with intention to quit. Years lived in the U.S. was the only individual level factor associated with intention to quit. By comparing two Asian American groups that live in heterogeneous neighborhoods, we identify key environmental and policy drivers that are associated with quit intention. Future studies aimed at influencing individual-level behavior should take into consideration the neighborhood context and built environment characteristics.

Changing Trends in Adjuvant Treatment Post-Lumpectomy (L) in Older Women with Early-Stage, Estrogen Receptor-Positive (ER+) Breast Cancer (BC) and Its Impact on Clinical Outcomes

Several seminal randomized trials established the standard of L+ radiation therapy (RT) in the treatment of early stage BC. More recently, interpretation of results from trials on older women suggests that breast RT may be omitted in ER+, stage T1N0 BC patients >70 years of age who receive adjuvant endocrine therapy (ET). The purpose of this study is to examine the practice trends of adjuvant ET+RT dual therapy (DT), RT alone, and ET alone after L in older women with ER+ BC, and further evaluate clinical outcomes by type of adjuvant therapy administered. In the 2003 to 2014 National Cancer Database, we identified 81,907 women age ≥70 years with T1N0, ER+BC who underwent L and had a minimum one year follow-up. Women who received no adjuvant therapy and those receiving any chemotherapy were excluded. We performed Chi-square tests to compare frequency of the 3 different adjuvant treatments administered, and the NCI Joinpoint Regression Program (Ver. 4.6.0.0) to estimate average annual percentage change in the utilization rates of the 3 different adjuvant treatments. Patients were stratified by Charlson-Deyo Comorbidity (CDC) score to be healthy (score 0) vs. with co-morbid status (CDC ≥1). Kaplan-Meier statistics and a Cox proportional hazards model adjusted for age, CDC score, and demographic variables (race/ethnicity, insurance, facility type, median neighborhood income, residence, and distance from hospital) were used to compare overall survival (OS) between patients receiving adjuvant DT, RT alone, and ET alone. Trending the utilization rates of the 3 different adjuvant treatments from 2003 to 2014, we observed the practice of adjuvant DT increase from 59.8% to 63.2%, RT alone decrease from 28.8% to 11.8%, and ET alone increase from 11.4% to 25% (p<0.0001). On Joinpoint regression analysis, the rate of RT alone declined by 8.2% annually (95% CI 7.1-9.4%, p<0.0001), whereas ET alone increased by an average of 8.0% per year (95% CI 6.1-10.0%, p<0.0001). Stratification by healthy and comorbid status noted a similar change in practice trends within each cohort. The overall median age of our study population is 76 years (IQR 72-80). Median follow-up is 57.5 months. The 5-year overall survival is 89.8%, 84.9%, and 79.2% for adjuvant DT, RT alone, and ET alone, respectively (p<0.0001). After adjusting for age, comorbidities, and demographic variables we note that compared to adjuvant DT, the hazard of death with RT alone is 20.3% (p<0.0001), and with ET alone is 44.3% (p<0.0001). In this study we observed a steady decline in the utilization of adjuvant RT alone and an increase in ET alone. Compared to adjuvant DT, the hazard of death was higher in patients receiving ET alone compared to RT alone. When considering de-escalation of therapy in older patients, our data suggests that older women derive benefit from adjuvant RT. These observations warrant further comparative study of RT alone vs. ET alone for defining the optimal adjuvant monotherapy in older women.

Muslim-Non-Muslim Locational Attainment in Philadelphia: A New Fault Line in Residential Inequality?

This study examines Muslim-non-Muslim disparities in locational attainment. We pool data from the 2004, 2006, and 2008 waves of the Public Health Management Corporation's Southeastern Pennsylvania Household Survey. These data contain respondents' religious identities and are geocoded at the census-tract level, allowing us to merge American Community Survey data and examine neighborhood-level outcomes to gauge respondents' locational attainment. Net of controls, our multivariate analyses reveal that among blacks and nonblacks, Muslims live in neighborhoods that have significantly lower shares of whites and greater representations of blacks. Among blacks, Muslims are significantly less likely than non-Muslims to reside in suburbs. The Muslim disadvantages for blacks and nonblacks in neighborhood poverty and neighborhood median income, however, become insignificant. Our results provide support for the tenets of the spatial assimilation and place stratification models and suggest that Muslim-non-Muslim disparities in locational attainment define a new fault line in residential stratification.

Neighborhood Racial Diversity, Socioeconomic Status, and Perceptions of HIV-Related Discrimination and Internalized HIV Stigma Among Women Living with HIV in the United States.

Relationships that traverse sociodemographic categories may improve community attitudes toward marginalized groups and potentially protect members of those groups from stigma and discrimination. The present study evaluated whether internalized HIV stigma and perceived HIV-related discrimination in health care settings differ based on individual- and neighborhood-level characteristics of women living with HIV (WLHIV). We also sought to extend previous conceptual and empirical work to explore whether perceived HIV-related discrimination mediated the association between neighborhood racial diversity and internalized HIV stigma. A total of 1256 WLHIV in the Women's Interagency HIV Study (WIHS) attending 10 sites in metropolitan areas across the United States completed measures of internalized HIV stigma and perceived HIV-related discrimination in health care settings. Participants also provided residential information that was geocoded into Federal Information Processing Standard (FIPS) codes and linked with census-tract level indicators. In cross-sectional analyses, greater neighborhood racial diversity was associated with less internalized HIV stigma and less perceived HIV-related discrimination regardless of individual race. Neighborhood median income was positively associated with internalized HIV stigma and perceived discrimination, while individual income was negatively associated with perceptions of stigma and discrimination. In an exploratory mediation analysis, neighborhood racial diversity had a significant indirect effect on internalized HIV stigma through perceived HIV-related discrimination. An indirect effect between neighborhood income and internalized stigma was not supported. These findings suggest that greater neighborhood racial diversity may lessen HIV stigma processes at the individual level and that HIV stigma-reduction interventions may be most needed in communities that lack racial diversity.

Cigarette Smoke Exposure and Radiographic Pulmonary Vascular Morphology in the Framingham Heart Study.

Rationale: Cigarette smoke exposure is a risk factor for many lung diseases, and histologic studies suggest that tobacco-related vasoconstriction and vessel loss plays a role in the development of emphysema. However, it remains unclear how tobacco affects the pulmonary vasculature in general populations with a typical range of tobacco exposure, and whether these changes are detectable by radiographic methods. Objectives: To determine whether tobacco exposure in a generally healthy population manifests as lower pulmonary blood vessel volumes and vascular pruning on imaging. Methods: A total of 2,410 Framingham Heart Study participants with demographic data and smoking history underwent volumetric whole-lung computed tomography from 2008 to 2011. Automated algorithms calculated the total blood volume of all intrapulmonary vessels (TBV), smaller peripheral vessels (defined as cross-sectional area <5 mm2 [BV5]), and the relative fraction of small vessels (BV5/TBV). Tobacco exposure was assessed as smoking status, cumulative pack-years, and second-hand exposure. We constructed multivariable linear regression models to evaluate associations of cigarette exposure and pulmonary blood vessel volume measures, adjusting for demographic covariates, including age, sex, height, weight, education, occupation, and median neighborhood income. Results: All metrics of tobacco exposure (including smoking status, pack-years, and second-hand exposure) were consistently associated with higher absolute pulmonary blood vessel volume, higher small vessel volume, and/or higher small vessel fraction. For example, ever-smokers had a 4.6 ml higher TBV (95% confidence interval [CI] = 2.9-6.3, P < 0.001), 2.1 ml higher BV5 (95% CI = 1.3-2.9, P < 0.001), and 0.28 percentage-point-higher BV5/TBV (95% CI = 0.03-0.52, P = 0.03) compared with never-smokers. These associations remained significant after adjustment for percent predicted forced expiratory volume in 1 second, cardiovascular comorbidities, and did not differ based on presence or absence of airflow obstruction. Conclusions: Using computed tomographic imaging, we found that cigarette exposure was associated with higher pulmonary blood vessel volumes, especially in the smaller peripheral vessels. Although, histologically, tobacco-related vasculopathy is characterized by vessel narrowing and loss, our results suggest that radiographic vascular pruning may not be a surrogate of these pathologic changes.

Socioeconomic Status and Kidney Transplant Outcomes in a Universal Healthcare System: A Population-based Cohort Study.

Conflicting evidence exists regarding the relationship between socioeconomic status (SES) and outcomes after kidney transplantation. We conducted a population-based cohort study in a publicly funded healthcare system using linked administrative healthcare databases from Ontario, Canada to assess the relationship between SES and total graft failure (ie, return to chronic dialysis, preemptive retransplantation, or death) in individuals who received their first kidney transplant between 2004 and 2014. Secondary outcomes included death-censored graft failure, death with a functioning graft, all-cause mortality, and all-cause hospitalization (post hoc outcome). Four thousand four hundred-fourteen kidney transplant recipients were included (median age, 53 years; 36.5% female), and the median (25th, 75th percentile) follow-up was 4.3 (2.1-7.1) years. In an unadjusted Cox proportional hazards model, each CAD $10000 increase in neighborhood median income was associated with an 8% decline in the rate of total graft failure (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.87-0.97). After adjusting for recipient, donor, and transplant characteristics, SES was not significantly associated with total or death-censored graft failure. However, each CAD $10000 increase in neighborhood median income remained associated with a decline in the rate of death with a functioning graft (adjusted (a)HR, 0.91; 95% CI, 0.83-0.98), all-cause mortality (aHR, 0.92; 95% CI, 0.86-0.99), and all-cause hospitalization (aHR, 0.95; 95% CI, 0.92-0.98). In conclusion, in a universal healthcare system, SES may not adversely influence graft health, but SES gradients may negatively impact other kidney transplant outcomes and could be used to identify patients at increased risk of death or hospitalization.

Factors contributing to racial disparities in influenza vaccinations.

BackgroundRacial/ethnic disparities in rates of influenza vaccinations in the US remain an issue even among those with access, no out-of-pocket costs, and after adjusting for confounders. We used an approach called the Oaxaca-Blinder (OB) decomposition method to ascertain the contribution of covariates individually and in aggregate to the racial disparity in influenza vaccination.MethodsWe included members > = 18 years of age as of 05/01/2014 with continuous enrollment through 04/30/2015. Influenza vaccination was defined by diagnosis, procedure, or medication codes, or documentation in the immunization table. Characteristics were reported by race. Logistic regression models estimated the odds of vaccination associated with: (1) race; and (2) covariates stratified by race. The Oaxaca-Blinder (OB) method calculated the contribution of covariates to the difference or disparity in vaccination between Blacks and Whites.ResultsWe found that among adults, 44% were vaccinated; 55% were Black; and 45% were White. Black members have 42% lower odds of vaccination than White members. The contribution of the differences in the average value of the study covariates between Black and White members (the OB covariate effect) accounted for 29% of the racial disparity. The contributions to the total White-Black disparity in vaccination included: age (16%), neighborhood median income (11%), and registration on the online patient portal (13%). The contribution of the differences in how the covariates impact vaccination (OB coefficient effect) accounted for 71% of the disparity in vaccination between Blacks and Whites.ConclusionIn conclusion, equalizing average covariate values in Blacks and Whites could reduce the racial disparity in influenza vaccination by 29%. For health system vaccine campaigns, improving registration on the patient portal may be a target component of an effective system-level strategy to reduce racial disparities in vaccination. Additional information on patient-centered factors could further improve the value of the OB approach.

Neighbourhood poverty and psychological distress in adolescents aged 11–15 in China: a multilevel study of 507 local communities

BackgroundNeuropsychiatric conditions have become the leading cause of disability in adolescents aged 11–24 globally. Higher neighbourhood economic status was found to be associated with lower incidence of neuropsychiatric conditions in children and adolescents in developed countries, but there is a lack of evidence in China. This study aims to examine the associations between neighbourhood poverty and psychological distress among adolescents in China. MethodsWe applied multilevel logistic regression to data from the 2014 China Family Panel Studies. 281 villages and 226 cities were randomly selected, and 1790 adolescents aged 11–15 were surveyed from 2178 households selected randomly. Severe psychological distress was defined as a score of 16 or over out of 24 in the K6 psychological disorder scale. Neighbourhood economic status was measured in two ways: using the log of median household monthly income within the community; and the percentage of residents receiving governmental subsistence allowance. Neighbourhood poverty was defined as more than 15% of residents receiving governmental subsistence allowance. We controlled for family-level economic conditions by ranking the households within each community by income. We also controlled for family structure and individual demographics. Rural and urban neighbourhoods were analysed separately. FindingsOf the surveyed adolescents, 2·3% (41 of 1790) were at high risk of severe distress (a score of >16 out of 24). The percentages were substantially higher in villages (2·6%, 29 of 1107) than in cities (1·8%, 12 of 683). Multilevel regression demonstrated diverse risk factors of psychological distress between adolescents in rural and urban areas. In villages, neighbourhood poverty was a significant and positive predictor of psychological distress in adolescents (adjusted odds ratio [AOR] 3·54, 95% CI 1·05–11·88, p=0·04), net of family-level and individual-level features. In cities, neighbourhood poverty had no significant effect on adolescents' mental health, but adolescents in families with higher income rankings within the community had a lower risk of psychological distress (0·81, 0·67–0·97, p=0·02). Median neighbourhood income and total household income were insignificant to adolescents' psychological distress in both rural and urban China. InterpretationOur findings highlight the serious issue of psychological distress in adolescents, and its influencing factors, in rural and urban China. The study focused on neighbourhood poverty. Further studies may consider other ecological characteristics. FundingNo funding.

Myopia prevalence and risk factors in children.

PurposeTo evaluate the prevalence and risk factors for pediatric myopia in a contemporary American cohort.MethodsA cross-sectional study of pediatric patients enrolled in the Kaiser Permanente Southern California health plan was done. Eligible patients were 5- to 19-years old between January 1, 2008, through December 31, 2013, and received an ophthalmologic or optometric refraction. Electronic medical records were reviewed for demographic data, refraction results, and exercise data. Prevalence and relative risks of myopia (defined as ≤−1.0 diopter) were characterized. Age, sex, race/ethnicity, median neighborhood income, and minutes of exercise per day were examined as risk factors.ResultsThere were 60,789 patients who met the inclusion criteria, of which 41.9% had myopia. Myopia was more common in older children (14.8% in 5- to 7-year olds, 59.0% in 17- to 19-year olds). Asian/Pacific Islander patients (OR 1.64, CI 1.58–1.70) had an increased rate of myopia compared to White patients as did African Americans to a lesser extent (OR 1.08, CI 1.03–1.13). Median neighborhood household income of $25,000–40,000 was associated with lower rates of myopia (OR 0.90, CI 0.83–0.97) compared to median neighborhood household incomes less than $25,000. Having at least 60 min of daily exercise was associated with lower prevalence of myopia (OR 0.87, CI 0.85–0.89).DiscussionMyopia was common in this large and diverse Southern Californian pediatric cohort. The prevalence of myopia increases with age. Asian children are at highest risk for myopia. Exercise is associated with a lower rate of myopia and represents an important potentially modifiable risk factor that may be a target for future public health efforts.

Impact of cost on use of non-vitamin K antagonists in atrial fibrillation patients in Ontario, Canada.

Canadian guidelines recommend non vitamin K antagonists (NOACs) in preference to vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation (AF), but NOACs are more expensive than VKAs. Canada has a universal healthcare system that covers the cost of NOACs for select patient groups. Ability to pay for NOACs may influence their use. We reviewed medical charts of Hamilton General Hospital outpatients under the age of 65 with a new diagnosis of AF who were referred for initiation of OAC therapy. We contacted these patients by phone and asked them to complete a questionnaire regarding their OAC choice, economic factors that may have influenced this choice (income, insurance) and the financial burden of OAC therapy. We included 110 patients, mean age 56years, and 26.4% females. NOAC users had a higher median neighborhood income than VKA users (p = 0.0144, n = 110). 73 patients responded to the questionnaire. NOAC users reported higher annual household income (p = 0.0038, n = 73). Patients with private insurance were more likely to use NOACs than those without insurance (p = 0.0496, n = 73). The cost of NOACs and ability to pay is a determinant of their use Ontario patients under the age of 65. This two tiered provision of care appears to contradict the values of Canada's universal healthcare system.