non-Hispanic Black Patients Research Articles

Abstract 4137107: The Impact of Race in the Evaluation Process for Advanced Heart Failure Therapies

Introduction: Racial and socioeconomic disparities in heart failure therapy and heart transplantation have been well described. Potential racial disparities during the evaluation process for advanced heart failure (AHF) therapies is not well understood. We examined whether there were differences by race in the evaluation process for heart transplantation or left ventricular assist device (LVAD) implantation. Methods: Adult patients who underwent heart transplant or LVAD evaluation between May 1, 2014 – Dec 31, 2022 at the University of North Carolina Medical Center were included. Logistic regression models assessed whether approval for heart transplant listing or LVAD implantation differed by race. The multivariate model adjusted for demographic and clinical characteristics, LVEF, RV function, and substance use. Secondary outcomes assessed included the time between critical points in the evaluation process: first clinical encounter with an AHF specialist, evaluation initiation, and final decision. Results: The study cohort included 611 patients (304 non-Hispanic Black patients, 307 non-Hispanic White patients). Black patients were younger than White patients (52.4 vs. 60.7 years), less male-predominant (65.5% vs. 81.4%), with less ischemic cardiomyopathy (16.8% vs. 58.3%, all p<0.05). There was no significant difference in approval for advanced therapies between Black and White patients (unadjusted OR [95% CI]: 1.24 [0.90-1.72]; adjusted OR 0.98 [0.64-1.48]). Male sex was associated with a higher likelihood of approval for AHF therapies (adjusted OR 1.55 [1.02-2.36]). Age (OR 0.98 [0.96-0.99]) and creatinine (OR 0.66 [0.53-0.82]) were associated with a lower likelihood of approval for AHF therapies. Black patients had a significantly longer time interval from the first AHF specialist encounter to the initiation of evaluation for AHF therapies (median 45.5 vs. 14 days, p <0.01), and from the initiation of the evaluation process to the final decision (25.5 vs. 14 days, p <0.01). Conclusions: Male patients had a greater approval rate for advanced heart failure therapies. Black and white patients did not have significantly different approval rates for LVAD implantation or listing for heart transplantation. However, the evaluation process was longer for black patients. Further work is needed to investigate which factors contribute to these racial and sex differences in the evaluation and approval process for advanced heart failure therapies.

EPID-31. IMPACT OF THE COVID-19 PANDEMIC ON THE UTILIZATION OF STEREOTACTIC RADIOSURGERY AMONG RACIAL MINORITIES DIAGNOSED WITH BRAIN METASTASES

Abstract OBJECTIVES Brain metastases (BM) is the most common form of adult brain tumors and one of the devastating consequences of cancer. Stereotactic radiosurgery (SRS) is an established and effective treatment for oligometastatic BMs. We examined how COVID-19 pandemic impacted clinical utilization of SRS in BM treatment and generalize such impact to outpatient care for patients with all cancer types. METHODS Three national-scale datasets were used: National Cancer Database (NCDB,N=5,238), the National COVID Cohort Collaborative database (N3C, N=13,106 for BM, N=203,706 for all cancer types), and SEER. Multivariable logistic regression models were performed to determine whether the pandemic affected clinical utilization of SRS in BM treatment and chemotherapy initiation for all cancer types. RESULTS Prior to 2019 (pre-pandemic), we observed no racial disparity in the odds of receiving SRS between non-Hispanic white (NHWs) and non-Hispanic black (NHBs) BMs in both NCDB and N3C. Between 2020 and 2021 (pandemic), however, NHBs were significantly less likely to receive SRS comparing to NHWs in both NCDB (NHB:aOR-0.77,p=0.002) and N3C (NHB:aOR-0.78,p<0.001). In SEER, the age-adjusted incidence rate of BM remained unchanged when comparing pre- and post-pandemic periods. Further substantiating the impact of COVID-pandemic on racial disparity in outpatient care for all cancer patients, we showed that NHB patients were more likely to receive delayed chemotherapy (>60 days since diagnosis of cancer) compared to NHWs during the pandemic (aOR-1.10, p<0.001), but such association was not detected before pandemic. Ratio of odds ratio (ROR) analysis confirmed that NHB patients comparing to NHWs during pandemic experienced 1.11-fold difference in the odds of delayed chemotherapy between NHBs and NHWs before pandemic [ROR=1.11, p<0.001]. CONCLUSION Racial disparity in SRS-receipt for BM patients has been exacerbated during COVID-19 pandemic and such impact could be generalized to outpatient care for all cancer types. Understanding the determinants giving rise to this disparity should augment the readiness of our cancer care infrastructure in anticipation of future pandemics or other public health crises.

Evaluating machine learning model bias and racial disparities in non-small cell lung cancer using SEER registry data.

Despite decades of pursuing health equity, racial and ethnic disparities persist in healthcare in America. For cancer specifically, one of the leading observed disparities is worse mortality among non-Hispanic Black patients compared to non-Hispanic White patients across the cancer care continuum. These real-world disparities are reflected in the data used to inform the decisions made to alleviate such inequities. Failing to account for inherently biased data underlying these observations could intensify racial cancer disparities and lead to misguided efforts that fail to appropriately address the real causes of health inequity. Estimate the racial/ethnic bias of machine learning models in predicting two-year survival and surgery treatment recommendation for non-small cell lung cancer (NSCLC) patients. A Cox survival model, and a LOGIT model as well as three other machine learning models for predicting surgery recommendation were trained using SEER data from NSCLC patients diagnosed from 2000-2018. Models were trained with a 70/30 train/test split (both including and excluding race/ethnicity) and evaluated using performance and fairness metrics. The effects of oversampling the training data were also evaluated. The survival models show disparate impact towards non-Hispanic Black patients regardless of whether race/ethnicity is used as a predictor. The models including race/ethnicity amplified the disparities observed in the data. The exclusion of race/ethnicity as a predictor in the survival and surgery recommendation models improved fairness metrics without degrading model performance. Stratified oversampling strategies reduced disparate impact while reducing the accuracy of the model. NSCLC disparities are complex and multifaceted. Yet, even when accounting for age and stage at diagnosis, non-Hispanic Black patients with NSCLC are less often recommended to have surgery than non-Hispanic White patients. Machine learning models amplified the racial/ethnic disparities across the cancer care continuum (which are reflected in the data used to make model decisions). Excluding race/ethnicity lowered the bias of the models but did not affect disparate impact. Developing analytical strategies to improve fairness would in turn improve the utility of machine learning approaches analyzing population-based cancer data.

County-level racial disparities in prostate cancer specific mortality from 2005 to 2020.

Local conditions where people live continue to influence prostate cancer outcomes. By examining local characteristics associated with trends in Black-White differences in prostate cancer specific mortality (PCSM) over time, we aim to identify factors driving county-level PCSM disparities over a 15-year period. We linked county-level data (Area Health Resource File) with clinicodemographic data of men with prostate cancer (Surveillance, Epidemiology, and End Results registry) from 2005 to 2020. Generalized linear mixed models evaluated associations between race and county-level age-standardized PCSM, adjusting for age, year of death, rurality, and county-level education, income, uninsured rates, and densities of urologists, radiologists, primary care providers, and hospital beds. 185,390 patients in 1085 counties were identified, of which 15.8% were non-Hispanic Black. Racial disparities in PCSM narrowed from 2005 to 2020 (25.4 per 100,000 to 19.2 per 100,000 overall; 57.9 per 100,000 to 38 per 100,000 for Non-Hispanic Black patients and 23.4 per 100,000 to 18.3 per 100,000 for Non-Hispanic White patients). For both Non-Hispanic Black and Non-Hispanic White patients, county PCSM changes varied greatly (-65% to + 77% and -61% to + 112%, respectively). From 2016 to 2020, Non-Hispanic Black harbored greater PCSM risk (RR 2.09, 95% CI 2.01-2.18); higher radiation oncologist density was significantly associated with lower mortality risk (RR 0.93, 95% CI 0.89-0.98) while other provider densities were not. Although overall rates improved, specific counties experienced worsening race-based disparities over time. Identifying locations of highest (and lowest) mortality disparities remains critical to development of location-specific solutions to racial disparities in prostate cancer outcomes.

Racial disparities in presenting stage and surgical management among octogenarians with breast cancer: a national cancer database analysis.

As the US faces a diverse aging population, racial disparities in breast cancer outcomes among elderly patients remain poorly understood. We evaluate the association of race with presenting stage, treatment, and survival of invasive breast cancer among octogenarians. Women (≥ 80years) with invasive breast cancer were identified in 2004-2020 NCDB. To facilitate comparison, only non-Hispanic Black and non-Hispanic White patients were included; patients of Hispanic ethnicity were excluded. Demographics, tumor characteristics, and treatments were assessed by race. Overall survival was compared using the logrank test. Multivariable logistic and Cox proportional hazard regression models were developed to evaluate the independent association of race with outcomes of interest. Of 222,897 patients, 19,059 (8.6%) were Black. Most patients had stage I ER + HER2- invasive ductal carcinoma. Black patients more frequently had greater comorbidities, low income and education, and advanced stage (p < 0.001 each; ref: White). Following adjustment, Black women had increased likelihood of Stage III/IV over time, as well as increased odds of chemotherapy (AOR 1.22, 95% CI 1.15 - 1.29) and non-operative management (AOR 1.82, 95% CI 1.72 - 1.92; ref: White). Although Black patients had lower survival rates compared to White, race was not associated with 5-year mortality following adjustment for stage, receipt of surgery, and adjuvant treatments (p = 0.34). Inferior survival among elderly Black patients appears be driven by advanced stage at presentation. While such disparities are narrowing in the present era, future work must consider upstream interventions to ensure equitable outcomes for all races.

Are there differences in overall survival among older breast cancer patients by race and ethnicity?

BackgroundNon-Hispanic Black women have lower breast cancer incidence but twice the mortality of non-Hispanic White women. Recent data suggest that the overall survival difference may not be observed in older women. This study aims to determine overall survival in women aged ≥70 years with operable breast cancer by race and ethnicity and factors contributing to overall survival. MethodsThe National Cancer Database was queried to identify women aged ≥70 years with stage 0–III breast cancer from 2004 to 2018. Patients were separated by race and ethnicity: non-Hispanic White, non-Hispanic Black, Hispanic, and Other. To examine overall survival, a Cox proportional hazards model was created, and overall survival was calculated using the Kaplan-Meier method. ResultsThere were 304,345 eligible patients. The mean age was 76.8 years (standard deviation 5.5 years), and most were non-Hispanic White (85.2%), had Medicare (86.8%), had hormone receptor–positive breast cancer (78.7%), and underwent partial mastectomy (64.5%). Compared with non-Hispanic White women, non-Hispanic Black women had a higher prevalence of stage III disease (10.8% vs 7.5%, P < .001) and triple-negative breast cancer (16.7% vs 8.7% P < .001), and a longer time to treatment initiation (39.2 vs 32.3 days, P < .001). Median follow-up was 5.38 years (interquartile range: 3.83–7.46 years). Non-Hispanic Black women had the lowest median survival time compared with non-Hispanic White women (9.7 vs 10.4 years, P < .001). After adjusting for insurance type, receptor status, stage, comorbidity, time to treatment, and facility type, there was no increased risk of death for non-Hispanic Black patients (hazard ratio: 0.99, 95% confidence interval: 0.96–1.01, P = .29). ConclusionAlthough overall survival was lower in older non-Hispanic Black women, this difference resolved on multivariate modeling, suggesting that other factors likely influence overall survival for this cohort.

Bridging the Gap: Culturally Responsive Strategies for NIH Trial Recruitment

Abstract Objective To enhance recruitment and participation rates of non-Hispanic Black (NHB) and Hispanic adult patients in a NIH-funded clinical trial studying an emerging health technology. Data Sources and Study Setting This study includes primary data collected in Los Angeles, California from November 2020 through November 2023. Study Design To improve the representation of NHB and Hispanic patients in a NIH-funded (NCT04409353) trial on virtual reality for chronic lower back pain (cLBP), we conducted a multi-phase study utilizing a mixed-method approach. First, we conducted focus groups with NHB and Hispanic cohorts aged 18 and older; based on the feedback, we culturally adapted recruitment materials and study correspondences concordantly. Additionally, a cohort builder was used to filter the electronic medical record to isolate non-Hispanic Black (NHB) and Hispanic patients with cLBP for micro-targeted recruitment. These changes were collectively integrated when the parent NIH study had recruited 222 of its 385 final samples (57.7%), creating a pre-post comparison timepoint (May 17, 2022). Quantitative analysis was performed to assess the efficacy of the modified recruitment strategies by comparing the number of recruited and randomized NHB and Hispanic patients pre- and post-intervention. Data Collection/Extraction Methods Semi-structured focus groups were conducted with NHB and Hispanic patients and community members (age 18 and older). The focus groups were conducted online and recorded with participant consent; transcripts of the recording underwent inductive thematic analysis. Emergent themes directed the modification of study materials, including revised language and imagery, targeted outreach, and incorporation of treating physicians, were implemented in the second half of the study. Quantitative analyses were conducted following parent study completion by comparing records added to the screening database following the implementation of new recruiting methods (5/17/2022) to those added before. Principal Findings Thematic analysis of focus groups identified four key themes: mistrust, lack of interest, culture, and communication. Modifications to recruitment methodology resulted in statistically significant increases in the pre- to post-randomization success rate for the overall study population (p &lt; 0.001), the NHB population (p = 0.011), and the Hispanic population (p &lt; 0.015). When looking at each cohort at different points in the recruitment process before and after the intervention, in the Hispanic population, we saw significant increases in the number approached (p &lt; 0.001) and number randomized (p &lt; 0.001) and statistically insignificant increases in the NHB population approached (p = 0.067) and randomized (p = 0.295). Similarly, we saw that the changes in the recruitment letter led to a statistically significant increase in Hispanic recruitment (7.0 to 39.1%, p &lt; 0.001) but not the NHB cohort (19.6 to 35.8%, p &lt; 0.065). Conclusion This study introduces several culturally sensitive considerations and possible approaches for the design of recruitment materials, addressing mistrust, lack of interest, culture, and communication for use in NHB and Hispanic populations. Similarly, the described microtargeting techniques leverage the technological advancements in cohort building to improve the reach and efficiency of the randomization rate of underrepresented groups thereby enhancing clinical trial diversity.

Assessment of poor cardiovascular health metrics and related disparities among cancer patients in the United States: a nationwide analysis of over 1.5 million individuals

Abstract Background Cancer, a major health challenge and a leading cause of mortality in the United States, significantly impacts cardiovascular health (CVH). The American Heart Association (AHA) emphasizes several CVH metrics to improve health outcomes, yet disparities in CVH persist nationwide. The specific impact of these disparities on the CVH of individuals with cancer, however, has yet to be fully explored. Purpose This study aims to utilize a detailed and nationally representative dataset from the U.S. to assess the prevalence of poor CVH among adults with a cancer diagnosis, focusing on uncovering sociodemographic disparities. Methods We utilized self-reported data from the Behavioral Risk Factor Surveillance System (2011 to 2019). This system, a state-based telephone survey, gathering data on cancer diagnoses, CVH metrics, and sociodemographic characteristics. We measured CVH through a composite score (0-7) based on the AHA’s seven CVH indicators: hypertension, high cholesterol, smoking, body mass index, diabetes, physical activity, and fruits and vegetables consumption. Individuals scoring between 0 and 2 were defined as having poor CVH. Multivariable generalized linear models within a binomial framework was applied to estimate adjusted prevalence ratios (aPRs) for poor CVH among cancer patients. Results Of 1,575,187 U.S. adults (representing an estimated 154.5 million; 50.7% female, 10.9% non-Hispanic black), 7.8% reported a cancer diagnosis between 2011 and 2019. Adjusted* findings show that having cancer (vs without) associated with a 16% higher prevalence of poor CVH (aPR=1.16; 95% CI [1.12-1.19]). Age-specific analysis revealed increased prevalence of poor CVH in middle-aged (45-64; aPR=3.55) and elderly (≥65; aPR=3.58) cancer patients, indicating a 255% and 358% rise, respectively, with p_interaction &amp;lt;0.001. Female cancer patients experienced a 22% lower prevalence of poor CVH than males (aPR=0.78; p_interaction &amp;lt;0.001). Non-Hispanic black cancer patients faced a 42% higher prevalence of poor CVH than their non-Hispanic white counterparts (aPR=1.42; p_interaction=0.001). Higher-income and education levels associated with 52% and 53% reduced prevalence of poor CVH, respectively (p_interaction &amp;lt;0.001; Table). Conclusions Our research identifies a strong correlation between cancer and deteriorating CVH metrics across U.S. adults, with pronounced variations based on sociodemographic factors. Specifically, the prevalence of poor CVH is substantially higher among cancer patients who are middle-aged, elderly, or identify as non-Hispanic Black, compared to other groups. Conversely, female cancer patients and those with a higher socioeconomic status appear to have a reduced risk of poor CVH. These outcomes stress the critical need for targeted, equitable public health initiatives that address both the cardiovascular and broader health needs of cancer patients, particularly among those most vulnerable.Table1

Evaluating bias of child maltreatment referrals in encounters for unintentional ingestions

BackgroundUnintentional ingestions commonly result in presentation to the pediatric emergency department (PED). No standardized recommendations exist regarding when to call Child Protective Services (CPS) for unintentional ingestions, which allows for the possibility of biased decision-making. ObjectiveIdentify patient and visit level characteristics associated with CPS referral status in unintentional ingestion encounters. Participants and SettingRetrospective cross-sectional study of children ≤6 years old presenting with unintentional ingestion to a metropolitan PED from 2015 to 2021. MethodsICD-10-CM codes were used to identify unintentional ingestion visits in the electronic health record. CPS referral was determined by manual chart review. Bivariable and multivariable logistic regression models identified patient and visit level characteristics associated with CPS referral. Socioeconomic status (SES) was classified based on zip code, the Child Opportunity Index data, and insurance. ResultsOf 3,836 charts reviewed, 808 met inclusion criteria. CPS referrals were made in 109 (13.5%) visits. Compared to non-Hispanic white patients, non-Hispanic Black patients had 7.37 (95% CI:1.38, 39.26) higher adjusted odds of being referred to CPS after adjusting for triage level, age, and ingestion type. Patients in the Lowest SES group had a 3.01 (95% CI:1.42, 6.40) higher adjusted odds when compared to the Middle/Highest SES group. ConclusionThis study found that CPS referrals in unintentional ingestions occur more often in those identifying as non-Hispanic Black and in those in the Lowest SES group, suggesting clinician bias may impact the decision regarding referrals. To mitigate subjective decision-making, we propose creating standardized, objective CPS referral criteria for unintentional ingestions.

Demystifying delays: Factors associated with timely treatment of adrenocortical carcinoma

BackgroundDelays in management of adrenocortical carcinoma (ACC) may lead to worse outcomes. We assessed for delays in ACC treatment according to sociodemographic factors. MethodsWe performed a retrospective cohort study of patients treated for ACC (2010–2019) utilizing the National Cancer Database. Cox proportional hazards modeling was used to evaluate the associations between sociodemographic, geographic, and clinical factors and time to intervention from diagnosis. ResultsAcross 1399 subjects treated for ACC, the median time to treatment was 27 days (IQR 15–47). Non-Hispanic Black patients (HR 0.798, p ​= ​0.033) and patients aged 40–64 years (HR 0.800, p ​= ​0.008) were at greater risk of delays in care, whereas female patients (HR 1.169, p ​= ​0.011) and those with metastatic disease (HR 1.176, p ​= ​0.010) received more timely care. ConclusionsOlder age, male sex, and Black race were associated with delays in care for ACC though these delays did not translate to worsened overall survival.

Association of race and ethnicity with genomic testing at a comprehensive cancer center in North Carolina.

Genomic testing, which analyzes tumor cells or circulating tumor DNA to guide cancer treatment, is increasingly used in precision oncology. However, data on racial and ethnic disparities in its use are limited. This retrospective cohort study included patients diagnosed with stage IV breast, colorectal, non-small cell lung, or prostate cancer in 2014-2019. Patients were identified from an institutional multilevel data warehouse and their data was linked to an institutional genomics database and electronic health records. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the receipt of tumor-specific genomic testing among non-Hispanic (NH) Black and NH White patients, stratified by cancer type. The linked dataset included 3,461 patients, 44.5% of whom received genomic testing. NH Black patients with prostate cancer were less likely to use genomic testing vs. NH White patients across the study period (fully adjusted OR: 0.55, 95% CI: 0.32, 0.95), as were NH Black patients diagnosed with breast cancer in 2014-2016 (OR adjusted for patient-level covariates: 0.34, 95% CI: 0.11, 0.99). No differences in testing were observed between NH Black and NH White patients with colorectal or non-small cell lung cancer, or breast cancer diagnosed in 2017-2019. Lower documented use of tumor-specific genomic testing among NH Black patients with prostate cancer across the study period underscores the need to monitor trends and address disparities in the use of emerging precision oncology technologies. Future work targeting multilevel barriers to genomic testing is a crucial next step forward.

Ventral hernia repair with permanent mesh for non-Hispanic black versus white patients: access and post-operative outcomes in the era of robotic surgery.

Robotic ventral hernia surgery may provide better patient outcomes. Whether it is provided equitably based on race remains unknown. We examined whether patients from the Abdominal Core Health Quality Collaborative who were Black had equitable access to robotic surgery for ventral hernia repair with permanent mesh compared to white counterparts from 2013 to 2023. We performed propensity-score matching to address confounding and then chi-squared testing to examine access to robotic, laparoscopic, and open approaches. Secondary outcomes included 30-day readmissions, complications, and death and 1- and 2-year hernia recurrence and quality of life measured by HerQLes Summary and PROMIS Pain T-Scores analyzed with chi-squared, Fisher exact, and Wilcoxon testing. 2397 patients identified as Black, and 21,900 identified as white. Our propensity-score matched cohort included 2374 Black patients and 7122 white. Black and white groups had the same rates of laparoscopy (15% vs 15%). Patients who identified as Black were more likely to undergo robotic surgery (36% vs 32%). Open approach was 49% for Black and 53% for white (p = 0.005). For 30-day complications, we found Black patients were more likely to experience reoperation (2% vs 1%, p = 0.005) and less likely surgical site infection (1% vs 2%, p < 0.001). Hernia recurrence scores and perceived abdominal health based on HerQLes were not statistically significantly different. At 2years, absolute reported T-Scores were higher for Black patients (median 40 (IQR 31-49) vs 36 (31-46), p = 0.031). This is the first large-scale study examining access to robotic surgery, complications, and quality of life measures. We found patients who identified as Black were more likely than white counterparts to undergo robotic surgery, but they were more likely to require reoperation and had higher pain scores. Our data suggest equitable access still may not translate to equitable patient outcomes.

A Statement on Abortion by 170 Obstetricians/Gynecologists after the Reversal of Roe v Wade.

In a recent American Journal of Obstetrics and Gynecology, 900 professors submitted a Special Report calling for reinstating federal protection for abortion. Here, we provide an alternative consensus statement. Induced abortion is not a constitutional right. We, too, value patient autonomy, but autonomy does not allow for causing harm to another human being, in this case, the human fetus. We share concern about maternal mortality in the United States, but evidence shows that induced abortion increases, not decreases, maternal mortality. We share the authors' concern for the effect of induced abortion on minority populations and mourn the fact that the abortion rate in non-Hispanic black patients is three times that of non-Hispanic white patients and twice that of Hispanic patients. Many obstetricians/gynecologists, like ourselves, do not support abortion, and most obstetricians/gynecologists do not perform abortions. Induced abortion is not necessary to provide evidence-based care. We also have seen tragic situations and misinformation and want to work toward addressing these issues. We support the highest level of clinical practice, bodily autonomy, reproductive freedom, and evidence-based care for both our patients-the pregnant woman and the human being in utero-whom we have dedicated our lives to serving.

Racial and ethnic differences in healthcare access and utilization among U.S. adults with melanoma and keratinocyte carcinomas in the NIH All of Us Research Program.

There is a paucity of information on racial and ethnic disparities relating to barriers to care in healthcare access and utilization in patients with cutaneous malignancies. We conducted a cross-sectional analysis of adults with melanoma, basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) in the National Institutes of Health (NIH) All of Us Research Program collected between May 2018 and July 2022. Participants included adults (aged 18 or older) with cutaneous malignancy who completed the Health Care Access and Utilization survey. We identified 5,817 adults who were diagnosed with BCC (67%), cSCC (28.9%), and melanoma (23.9%). Non-Hispanic Black (NHB) and Hispanic patients were more likely than non-Hispanic White (NHW) patients to delay a primary care visit due to cost (p = 0.005 and p = 0.015, respectively). NHB patients were also more likely to delay care due to lack of transportation (p < 0.001). NHB and Hispanic patients were more likely to place importance on seeing a provider from the same background (NHB p < 0.002; Hispanic p = 0.002) and also were more likely to report never being able to see such a provider (NHB p < 0.001; Hispanic p = 0.002). Medicaid/Medicare patients, non-college graduates, and those with lower incomes also faced increased barriers to care, including delays due to cost and transportation issues. People of color with cutaneous malignancies are more likely to delay care in seeing primary care providers due to cost or transportation issues. This study provides important insights on disproportionate healthcare usage among racial/ethnic groups that may help mitigate healthcare disparities.

Race and Ethnicity and Clinician Linguistic Expressions of Doubt in Hospital Admission Notes

Stigmatizing language in electronic health records (EHRs) can generate or reinforce negative stereotypes about patients from minoritized groups and erode their trust and experience. However, less is known about the use of such language to cast doubt on patient clinical history in hospital settings. To compare the prevalence of language expressing doubt about patient clinical history (eg, experiences and symptoms) in hospital admission notes by patient race and ethnicity. In this cohort study, natural language processing tools were applied to analyze 54 936 admission notes from 1249 clinicians about patients aged 18 years or older at admission and hospitalized at an academic health system in the Northeast US between January 1, 2018, and February 28, 2023. Data were analyzed from September 1, 2022, to July 31, 2023. Patient race and ethnicity (non-Hispanic Black, non-Hispanic White, and racial and ethnic minoritized groups excluding non-Hispanic Black [includes multiple racial and ethnic groups, such as Hispanic and Asian]) as recorded in the EHR based on self-report or registrar determination. Binary indicator for at least 1 term casting doubt on patient clinical history was defined using epistemic stance, a linguistic construct expressing a writer's degree of certainty in information. Terms were manually validated via iterative review of notes by the study team. Among 56 325 admission notes (mean [SD] age of patients, 55.9 [19.0] years; 30 913 notes among female patients [54.9%]; 25 649 notes among non-Hispanic Black patients [45.5%], 26 442 notes among non-Hispanic White patients [46.9%], and 2985 notes among members of racial and ethnic minoritized groups excluding non-Hispanic Black patients [5.3%]), we analyzed 54 936 admission notes that had no missing data. Among all analyzed admission notes, 39 023 notes (71.0%) contained doubt language. Notes written about non-Hispanic Black patients had increased odds of containing at least 1 word or phrase of doubt (adjusted odds ratio, 1.21; 95% CI, 1.14-1.28; P < .001) compared with notes among non-Hispanic White patients. Compared with notes among non-Hispanic White patients, notes written about members of racial and ethnic minoritized groups excluding non-Hispanic Black patients had similar odds of containing at least 1 term of doubt. In this study, language casting doubt on patient clinical history was more likely to be found in notes of non-Hispanic Black patients. These results suggest that with the implementation of policies allowing patients full access to their health records, examining clinical documentation standards may be associated with improved patient experience.

Assessing for race, ethnicity, and socioeconomic disparities in central line-associated bloodstream infection risk in a large academic health system.

To examine the relationship between race and ethnicity and central line-associated bloodstream infections (CLABSI) while accounting for inherent differences in CLABSI risk related to central venous catheter (CVC) type. Retrospective cohort analysis. Acute care facilities within an academic healthcare system. Adult inpatients from January 2012 through December 2017 with CVC present for ≥2 contiguous days. We describe variability in demographics, comorbidities, CVC type/configuration, and CLABSI rate by patient's race and ethnicity. We estimated the unadjusted risk of CLABSI for each demographic and clinical characteristic and then modelled the effect of race on time to CLABSI, adjusting for total parenteral nutrition use and CVC type. We also performed exploratory analysis replacing race and ethnicity with social vulnerability index (SVI) metrics. 32,925 patients with 57,642 CVC episodes met inclusion criteria, most of which (51,348, 89%) were among non-Hispanic White or non-Hispanic Black patients. CVC types differed between race/ethnicity groups. However, after adjusting for CVC type, configuration, and indication in an adjusted cox regression, the risk of CLABSI among non-Hispanic Black patients did not significantly differ from non-Hispanic White patients (adjusted hazard ratio [aHR] 1.19; 95% confidence interval [CI]: 0.94, 1.51). The odds of having a CLABSI among the most vulnerable SVI subset compared to the less vulnerable was no different (odds ratio [OR] 0.95; 95% CI: 0.75-1.2). We did not find a difference in CLABSI risk between non-Hispanic White and non-Hispanic Black patients when adjusting for CLABSI risk inherent in type and configuration of CVC.

Demographic-based disparities in outcomes for adults with central line-associated bloodstream infections in the United States: a National Inpatient Sample database study (2016-2020).

Central line-associated bloodstream infections (CLABSI) are prevalent and preventable hospital-acquired infections associated with high morbidity and costs. Disparities based on race, ethnicity, and hospital factors remain underexplored. This study compares cost, length of stay, and mortality for adults with CLABSI by race-ethnicity, hospital location-teaching status, and geographic region in the United States using data from the National Inpatient Sample (NIS) database from 2016 to 2020. The hospitalization cohort included adults diagnosed with CLABSI, excluding those with primary CLABSI diagnoses, cancer, immunosuppressed states, or neonatal conditions. Primary outcomes were in-hospital mortality, length of stay, and hospital costs, adjusted to mid-year 2020 US dollars. Independent variables included race-ethnicity, hospital location-teaching status, and geographic region. All analyses accounted for NIS sampling design. From 2016 to 2020, there were approximately 19,835 CLABSI hospitalizations. The overall in-hospital mortality rate was 9.1%, with a median hospital stay of 16.9 days and median cost of $44,810. Hispanic patients experienced significantly higher mortality, longer length of stay, and higher costs compared to non-Hispanic Black and White patients. Urban teaching hospitals had longer stays and higher costs than rural and urban non-teaching hospitals. Regionally, the Northeast and West had higher costs and longer stays than the Midwest and South, but mortality rates did not differ significantly. This study highlights significant disparities in CLABSI outcomes based on demographic factors. Addressing these disparities is crucial for improving CLABSI management and healthcare equity. Further research should explore the underlying causes of these differences to inform targeted interventions.

Equity-Focused Evaluation of a Medicaid-Funded Statewide Diabetes Quality Improvement Project Collaborative.

To evaluate the Ohio Diabetes Quality Improvement Project (QIP) equity aim to reduce the percentage of Non-Hispanic Black (NHB) and Hispanic patients with A1C >9% by ≥20% over 2 years. The Ohio Department of Medicaid, Ohio Colleges of Medicine Government Resource Center, Ohio Medicaid managed care plans, and seven medical schools in Ohio formed the Diabetes QIP collaborative using the collective impact model to improve diabetes outcomes and equity in 20 practices across 11 health systems. The quality improvement (QI) strategies included data audit and feedback, peer-to-peer learning, QI coaching/practice facilitation, and subject matter expert consultation through coaching calls, monthly webinars, and annual virtual learning sessions. Electronic health record data were collected for preintervention (2019-2020) and intervention (2020-2022) periods. Assessments of improvements in A1C were based on prevalence of A1C >9% from preintervention, year 1, and year 2 with stratification by race and ethnicity. The Diabetes QIP included 7,689 (54% female) sociodemographically diverse patients, self-identifying as non-Hispanic White (NHW) (42%), NHB (43%), Hispanic (8%), non-Hispanic Asian (4%), or other (3%). In year 2 compared with baseline, there were decreases in the proportion of patients with A1C >9% among NHW, NHB, and Hispanic patients (NHW from 19% to 12% [37% reduction], NHB 23% to 18% [22% reduction], and Hispanic 29% to 23% [20% reduction]). The Ohio Diabetes QIP, focused on multisector collaborative approaches, reduced the percentage of patients with A1C >9% by ≥20% among NHW, NHB, and Hispanic populations. Given the persistence of disparities, further equity-focused refinements are warranted to address disparities in diabetes control.

Leaving Against Medical Advice From Children's Hospitals.

Leaving the hospital against medical advice (AMA) reflects a breakdown in the family-clinician relationship and creates ethical dilemmas in inpatient pediatric care. There are no national data on frequency or characteristics of leaving AMA from US children's hospitals. We performed a retrospective cohort study of hospital discharges for children under 18 years old from January 1, 2018 to December 31, 2022 in 43 children's hospitals in the Pediatric Health Information System (PHIS) database. The primary outcome was leaving AMA. Exposures were demographic, geographic, and clinical characteristics. We used multivariable mixed effects logistic regression models to assess independent factors associated with leaving AMA and all-cause 14-day hospital readmission. Among 3 672 243 included inpatient encounters, 2972 (0.08%) ended in leaving AMA. Compared with non-Hispanic white patients, non-Hispanic Black patients had higher odds of leaving AMA (adjusted odds ratio [aOR] 1.31 [95% confidence interval (CI) 1.19-1.44]), whereas Hispanic patients (aOR 0.66 [95% CI 0.59-0.75]) had lower odds of leaving AMA. Hospitalizations for patients with noncommercial insurance were more likely to end in leaving AMA. Leaving AMA was associated with increased odds of 14-day inpatient readmission (aOR 1.41 [95% CI 1.24-1.61]) compared with patients who did not leave AMA. There was substantial interhospital variability in standardized rates of leaving AMA (range 0.18-2.14 discharges per 1000 inpatient encounters). Approximately 1 in 1235 inpatient encounters ended in leaving AMA. Non-Hispanic Black patients had increased odds of leaving AMA. Leaving AMA was associated with increased odds of 14-day readmission.

What explains differences in average wait time in the emergency department among different racial and ethnic populations: A linear decomposition approach.

Non-Hispanic Black (NHB) and Hispanic/Latino (Hispanic) patients wait longer in the emergency department (ED) to see practitioners when compared with non-Hispanic White (NHW) patients. We investigate factors contributing to longer wait times for NHB and Hispanic patients using a linear decomposition approach. This retrospective observational study included patients presenting to one tertiary hospital ED from 2019 to 2021. Median wait times among NHW, NHB, and Hispanic were calculated with multivariable linear regressions. The extent to which demographic, clinical, and hospital factors explained the differences in average wait time among the three groups were analyzed with Blinder‒Oaxaca post-linear decomposition model. There were 310,253 total patients including 34.7% of NHW, 34.7% of NHB, and 30.6% of Hispanic patients. The median wait time in NHW was 9 min (interquartile range [IQR] 4‒47 min), in NHB was 13 min (IQR 4‒59min), and in Hispanic was 19 min (IQR 5‒78 min, p<0.001). The top two contributors of average wait time difference were mode of arrival and triage acuity level. Post-linear decomposition analysis showed that 72.96% of the NHB‒NHW and 87.77% of the Hispanic‒NHW average wait time difference were explained by variables analyzed. Compared to NHW patients, NHB and Hispanic patients typically experience longer ED wait times, primarily influenced by their mode of arrival and triaged acuity levels. Despite these recognized factors, there remains 12%‒27% unexplained factors at work, such as social determinants of health (including implicit bias and systemic racism) and many other unmeasured confounders, yet to be discovered.