non-Hispanic Black Patients Research Articles

Racial and elderly disparities in receipt of guideline-concordant care in stage I-III breast cancer.

e13688 Background: Elderly and non-Hispanic Black (NHB) patients have worse breast cancer specific survival outcomes. We evaluated whether guideline concordant care (GCC) and all-cause mortality in stage I-III breast cancer differed by race among patients ≥ 65 years old. Methods: We used the National Cancer Database (NCDB), to identify a cohort of 25174 NHB and 233357 non-Hispanic White patients (NHW), ≥65 years old, diagnosed with stage I-III breast cancer between 2010 and 2019. We used the National Comprehensive Cancer Network guidelines to define GCC, including surgery, radiation and systemic therapy. Specific systemic therapies and cause of death were unavailable. We used logistic regression models to assess the association between race and GCC. We used Cox proportional hazards models to estimate associations between race and all-cause mortality after adjusting for GCC. Both models adjusted for disease, demographics, income and educational attainment. We assessed the odds of not receiving timely GCC within 30, 60 and 90 days from diagnosis for NHB vs. NHW patients using logistic regression. Results: Overall, 15% of patients did not receive GCC. Being NHB compared to NHW was associated with increased odds of not receiving GCC in univariate (OR=1.24 95%CI: 1.20-1.28) and multivariate analysis (aOR=1.13, 95%CI: 1.08-1.17). Being NHB was associated with 26% increased risk of all-cause mortality in the univariate analysis (HR=1.26, p<0.001), which decreased to 4% increased risk, after adjusting for GCC, age, clinical and sociodemographic factors (aHR=1.04, p=0.027). Non-receipt of GCC (aHR=1.75, p<0.001) and lower educational attainment (aHR 1.18, p <0.001) were independently associated with higher risk of all-cause mortality. Higher median income (aHR 0.91, p<0.001) was independently associated with a decreased risk of mortality. Being NHW compared to NHB was associated with increased odds of initiating treatment within 30 (OR=1.65, 95% CI 1.6-1.69), 60 (OR=2.11, 95% CI 2.04-2.18), and 90 days of breast cancer diagnosis (OR=2.39, 95% CI 2.27-2.51). Conclusions: Among elderly patients with stage I-III BC, being NHB was associated with increased odds of not receiving GCC and less timely treatment initiation. Being NHB was associated with increased all-cause mortality, which was attenuated after adjusting for GCC. Optimizing timely receipt of GCC may reduce inferior survival outcomes among elderly NHB breast cancer patients. Identifying area-level determinants may help design targeted interventions. Limitations include lack of granular systemic therapy data, likely overestimating GCC receipt, biasing the analysis towards the null, and lack of cause-specific death among elderly patients with competing risks of death.

Investigating disparities in enrollment of patients in lung cancer clinical trials that led to FDA approval for immunotherapies between 2015 and 2023: A comparison with the US population.

e23104 Background: Registrational clinical trials have led to the FDA approval of numerous immunotherapy (IO) agents in the treatment of non-small cell lung cancer (NSCLC) since 2015. Given the historical lack of adequate representation of the US population with cancer in clinical trials, we aimed to analyze disparities in race and ethnicity reporting and enrollment in lung cancer clinical trials that led to FDA-approved immunotherapies between 2015-2023. Methods: The FDA archives and database were queried to review all FDA drug approvals for IO approved to treat NSCLC between 2015 to 2023. Enrollment data were obtained from FDA labels, ClinicalTrials.gov, and corresponding journal manuscripts. The enrollment incidence ratio (EIR) and enrollment mortality ratio (EMR) were calculated as the proportion of patients of a particular race among clinical trial participants in approval studies divided by the estimated proportion of patients of that particular race diagnosed or dying of lung cancer, respectively, among the US population. Results: Among 27 trials with a total of 15,878 subjects, distribution by race shows that 77.5% were White, 16.7% Asian, 8.8% Hispanic, 1.63% Black, 0.33% American Indian Alaska Native (AIAN), and 0.07% were Native Hawaiian and Other Pacific Islander (NHOPI). 67.4% were males while 32.6% were females. The EIR for Non-Hispanic White, Non-Hispanic Black, Asian, and Hispanic patients was 0.99, 0.13, 3.56, and 0.85 respectively. The EMR for Non-Hispanic White, Non-Hispanic Black, Asian, and Hispanic patients was 0.99, 0.12, 4.23, and 0.96 respectively. Racial demographics were reported in 65% of journal manuscripts, 65% of ClinicalTrials.gov pages, and 92% of FDA labels while ethnicity demographics were reported in 0% of journal manuscripts, 42% of ClinicalTrials.gov pages, and 15% of FDA labels. Conclusions: Black, AIAN and female patients are severely underrepresented in lung cancer trials that lead to approval for IO based therapy. Asian patients were overrepresented. Less than half of the trials reported data on ethnicity. Further research is needed to see if regulatory initiatives to increase clinical trial diversity result in more equitable clinical trial enrollment in pivotal trials.

A survey study evaluating donor gamete utilization rates, patient satisfaction, and fertility treatment outcomes according to desired race and ethnicity

To evaluate donor gamete utilization, patient satisfaction, and fertility treatment outcomes of patients pursuing treatment with donor gametes stratified by the desired race as well as ethnicity of the gamete donor. Survey study. Clinic. Patients planning to undergo treatment using donor sperm and/or donor oocytes at a single academic fertility clinic in the Southeastern United States between 2015 and2020. None. Utilization rates of donor gametes, satisfaction with donor gamete selection, and fertility treatment outcomes stratified by race and ethnicity of patient, as well as that of their gamete donor. Four hundred fifty patients were eligible for inclusion and 170 (38%) responded to the survey. Among the respondents, 59% desired a non-Hispanic White gamete donor and 20% desired a non-Hispanic Black gamete donor. Patients seeking a non-Hispanic Black gamete donor had lower odds of using donor gametes (Odds ratio [OR], 0.13; 95% confidence interval [CI], 0.04-0.40) compared with individuals seeking a non-Hispanic White gamete donor. When evaluating satisfaction with donor gamete selection, patients seeking a non-Hispanic Black gamete donor reported lower satisfaction compared with individuals seeking a non-Hispanic White gamete donor (OR, 0.19; 95% CI, 0.09-0.43). When evaluating fertility outcomes, Non-Hispanic Black patients and those using non-Hispaninc Black gamete donors were found to have lower odds of successful conception compared with non-Hispanic White patients (OR, 0.18; 95% CI, 0.07-0.46) and individuals seeking non-Hispanic White gamete donors (OR, 0.26; 95% CI, 0.09-0.75), respectively. Patients seeking non-Hispanic Black donor gametes have lower utilization rates, less satisfaction with gamete donor selection, and lower odds of conception when compared with those seeking non-Hispanic White gamete donors. These findings highlight the need for more racial diversity within donor gamete banks, as well as within the donor pools available through agencies and fertility clinics.

A hybrid epithelial/mesenchymal state in head and neck cancer: A biomarker for survival with differential prognosis by self-reported race

Head and neck squamous cell carcinoma (HNSCC) is the 6th leading cause of cancer-related mortality, with racial disparities amplifying the challenges in treatment. Although the relationship between hybrid epithelial/mesenchymal (E/M) states and tumor progression is of interest, no studies have characterized the clinical relevance of hybrid E/M states in head and neck cancer outcomes among self-reported racial cohorts. Given the overlap in gene expression between hybrid E/M malignant cells and cancer-associated fibroblasts, we utilized deconvolution of bulk RNA sequencing data from oral cavity and laryngeal squamous cell carcinoma tumors from The Cancer Genome Atlas. We utilized our previously collected single-cell profiles to generate inferred malignant profiles and then scored these for hybrid E/M. We then conducted a survival analysis on overall and disease-free survival among self-reported Black and White Americans. The hybrid E/M state was differentially associated with head and neck cancer survival by self-reported race and ethnicity, with a stronger association in non-Hispanic Black patients. Black patients with a high hybrid E/M score had a higher risk of death or recurrence (hazard ratio [HR]: 4.18 [95% confidence interval (CI): 2.06, 8.49]) than White patients with a high hybrid E/M score (HR: 1.58 [95% CI: 1.11, 2.26]). Our results suggest a complex interplay of social structure, racism, and genetic diversity. We implore researchers to consider the social and biological context contributing to disparities. A.L.M. received support from the National Institute of Minority Health and Health Disparities (K01MD013897 [principal investigator (PI), A.L.M.]). S.V.P. received support from the National Institute of Dental and Craniofacial Research (R01DE032865 [PI, S.V.P.] and R01DE032371 [PI, S.V.P.]).

Association of enrollment in Medicare Advantage plans versus fee-for-service in patients with a late-stage diagnosis of gynecologic cancer.

11140 Background: In the United States, uterine cancer is the most common gynecologic (GYN) cancer; and ovarian cancer causes more deaths each year than any other GYN cancer. There are currently no recommended population-wide screening tests for ovarian or uterine cancer, which are heavily concentrated in older women. Medicare is the primary health insurer for 97% of Americans aged 65 years and older. This study is the first to examine the association between Medicare enrollment plan – Medicare Advantage (MA) versus fee-for-service (FFS) – and stage at diagnosis among older women newly diagnosed with ovarian or uterine cancer. Methods: Using the linked Surveillance, Epidemiology, and End Results (SEER) registries and Medicare enrollment data, we identified 101,193 women aged 65 years and older with newly diagnosed ovarian or uterine cancer between 2007-2019. We categorized patients into two groups: 1) those continuously enrolled in Medicare MA for six months prior to their diagnosis, through the diagnosis month, and the month following diagnosis; 2) those continuously enrolled in Medicare FFS within the same eight-month window. Late-stage was defined as “Distant” stage (with “Local” and “Regional” stages representing an earlier-stage diagnosis) using the SEER Summary Stage variable. The association between Medicare enrollment plan and stage was examined through multivariable logistic regression modeling that adjusted for sociodemographic characteristics. The influence of each predictor on the difference in the probability of late stage was summarized as an adjusted marginal effect (ME). Results: Among uterine cancer patients, 37% had MA insurance. Compared with Medicare FFS enrollees, the adjusted percentage of late-stage diagnosis was 0.6 percentage points (ppt) lower for MA enrollees (95% CI = -1.1-(-0.1); P<0.05). Notably, patients were more likely to have a late-stage uterine diagnosis if they were: non-Hispanic Black or Hispanic (vs. non-Hispanic White); age 75 and older (vs. between 65 -74); and residing in a lower SES neighborhood. Among ovarian cancer patients, 34% had MA insurance. We found no significant difference between Medicare MA and FFS enrollees in ovarian cancer stage at diagnosis. Of note, Non-Hispanic Black patients were significantly more likely to be diagnosed with late-stage disease compared to Non-Hispanic White, and likewise for patients aged 75 and older (vs. between 65-74). Conclusions: Among Medicare beneficiaries (age 65+) diagnosed with uterine cancer, those enrolled in an MA plan were significantly less likely to be diagnosed at a later stage. In similar analyses for ovarian cancer, there was no such MA - FFS difference in the probability of late-stage. As enrollment in Medicare Advantage plans continues to grow, it becomes increasingly important to identify whether there are significant outcome differences between MA and FFS plans.

Impact of race and ethnicity on financial toxicity in patients with genitourinary cancers.

11077 Background: Genitourinary (GU) cancers contribute substantially to the cost of healthcare in the United States (US). While advancements in cancer treatment have improved patient outcomes, disparities in healthcare costs persist, exacerbating the financial burden on vulnerable populations. We sought to investigate the disparities in costs of inpatient hospitalizations among patients with GU cancers in the US. Methods: Eligible adult GU cases from the Medical Expenditure Panel Survey (2019–2021) were included in this study. ICD-10 CM codes were utilized to identify renal cell, prostate, urothelial, testicular, and penile cancers. In addition to the total hospital inpatient (IP) facility expenditure, questions about ability to pay for healthcare were included in the analysis after accounting for the complex survey design and sampling weights. Results: The study included a weighted sample size of 9,061,181 (wt SE = 538,502) GU cases in the US between 2019 and 2021. The mean (95% CI) age of the sample was 71.6 (70.7, 72.5) years. The sample consisted of 7.9% Hispanics, 74.8% non-Hispanic White (NHW), 13.8% non-Hispanic Black (NHB), and 3.5% Asian or other races (NHA). In 2021, NHB participants reported the lowest annual family income of $51742 (18932, 106185), followed by Hispanics with $65233 (24314, 95859), and NHW with 82035 (36298, 158863). A greater proportion of the elderly NHW population was insured compared to NHB and Hispanics (44.9% vs. 32.5% vs. 19.5%), respectively. Of note, NHB patients had worse self-perceived physical and mental health compared to NHW and Hispanics, with 18.1% reporting fair or poor physical and mental health (vs. 8.1% and 14.3%, respectively). NHB participants reported higher rates of familial financial hardship (2019: 10.2% vs. 3.6%; 2020: 6.2% vs. 3.5%; 2021: 7.1% vs. 3.3%) or not being able to afford medical care (2019: 7.2% vs. 2.1%; 2020: 2.5% vs. 0.6%; 2021: 1.9% vs. 1.7%) when compared to NHW. Overall, mean total hospital IP facility expenses were: Hispanics = $2873.30 (1434.49, 4312.12); NHW = $4213.81 (3241.05, 5186.56); and NHB = $5199.99 (2842.93, 7557.05). After accounting for sample weights, gender, family income, age, insurance status, and survey year, Poisson regression analysis showed significant differences between different racial groups. Hispanics were less likely (𝛽=-0.48; p<0.0001), while NHB (𝛽=0.152; p<0.0001) and NHA (𝛽=0.48; p<0.0001) were more likely to spend for an IP hospitalization when compared to NHW (ref.). Conclusions: Our data revealed racial disparities in the costs of inpatient hospitalizations, highlighting potential financial toxicity among patients with GU cancers. Additional investigation is warranted to elucidate factors contributing to these inequities, aiming to optimize cancer management and alleviate financial burdens. Addressing these disparities is crucial to prioritize equitable healthcare access and promote systemic change.

Association of baseline hypertension and hyperlipidemia with the clinical characteristics and outcomes in patients with colorectal cancer: A single institution experience.

e15522 Background: Hypertension (HTN) and hyperlipidemia (HLD) are widely prevalent diseases, but their effect on colorectal cancer (CRC) outcomes is limited. We aimed to study the effects of baseline HTN and HLD on CRC survival. Methods: We identified patients with stage 1-4 colorectal cancer diagnosed between 2011 and 2017 from tumor registry of a large safety-net hospital and NCI-designated Comprehensive Cancer Center. Patients with a diagnosis of HTN (ICD-9/10: I10, 401.9) and HLD (ICD 9/10: E78.0-E78.5, 272.0-272.4) at CRC diagnosis were compared with patients who did not have these comorbidities. Chi-square tests were used to compare categorical differences between groups. Multivariable logistic regression was used to identify factors associated with HTN and HLD. Overall survival (OS) was estimated using the Kaplan-Meier method and Cox proportional hazards model with an index date of tumor diagnosis until death. Patients who did not meet endpoint of interest were censored at the date of last clinical contact. Results: We identified 1,921 patients - 627 (33%) had HTN, 403 (21%) had HLD and 309 (16%) had HTN and HLD. The median age of diagnosis of CRC was 61 (IQR: 54-68) for HTN patients and 61 (IQR: 53-69) for HLD patients. Compared to patients without HTN or HLD, patients with HTN or HLD were more likely to be non-Hispanic Blacks (HTN: 39% vs 19%; HLD: 30% vs 24%), uninsured (HTN: 33% vs 17%; HLD: 36% vs 18%) and treated at safety-net hospital (HTN: 53% vs 24%; HLD: 55% vs 27%). These patients had a higher prevalence of other comorbidities including diabetes mellitus (HTN: 39% vs 7%; HLD: 50% vs 9%), anxiety (HTN:12% vs 3%; HLD: 14% vs 4%), and tobacco use (HTN: 16% vs 5%; HLD: 14% vs 7%). On multivariable analysis, HTN and HLD patients were older (HTN-OR: 1.05, 95CI: 1.04-1.06; HLD-OR: 1.03, 95CI: 1.02-1.05), had concurrent diabetes mellitus (HTN-OR: 4.2, 95CI: 2.9-6.3; HLD-OR: 4.5, 95CI: 3.2 - 6.4), depression (HTN-OR: 2.0, 95CI: 1.3-3.2; HLD-OR: 1.9, 95CI: 1.2-3.0), and cirrhosis (HTN-OR: 2.6, 95CI: 1.3-5.2; HLD-OR: 2.1, 95CI: 1.1-3.9) and treated at safety-net hospital (HTN-OR: 2.7, 95CI: 1.7-4.3; HLD-OR: 1.4, 95CI: 0.9-2.2). Compared to patients without HTN or HLD, OS was improved for HLD alone patients (HR: 0.58; 95CI: 0.38-0.89; P: 0.01), while it was not different for patients with HTN without HLD (HR: 0.99; 95CI: 0.81-1.2; P: 0.55) or HTN and HLD (HR: 0.92; 95CI: 0.75-1.13; P: 0.34). The 5-year yr OS for these groups were 65%, 77%, 66%, and 69% respectively. Conclusions: In this single institution cohort that includes a safety-net hospital, the prevalence of HTN or HLD at CRC diagnosis was higher among older and non-Hispanic Black CRC patients and associated with coexisting diabetes mellitus, anxiety, and tobacco use. CRC patients with HLD alone had a significantly better 5-yr OS compared to those without HTN or HLD, with HTN alone, and with HTN and HLD.

Do Racial and Ethnic Disparities Exist in Intensity of Intracranial Pressure-Directed Therapies and Outcomes Following Pediatric Severe Traumatic Brain Injury?

Studies suggest disparities in outcomes in minoritized children after severe traumatic brain injury. We aimed to evaluate for disparities in intracranial pressure-directed therapies and outcomes after pediatric severe traumatic brain injury. We conducted a secondary analysis of the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial, which enrolled pediatric severe traumatic brain injury patients (Glasgow Coma Scale score ≤8) with an intracranial pressure monitor from 2014 to 2018. Patients admitted outside of the United States were excluded. Patients were categorized by race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, and "Other"). We evaluated outcomes by assessing mortality and 3-month Glasgow Outcome Score-Extended for Pediatrics. Our analysis involved parametric and nonparametric testing. A total of 671 children were analyzed. Significant associations included older age in non-Hispanic White patients (P < .001), more surgical evacuations in "Other" (P < .001), and differences in discharge location (P = .040). The "other" cohort received hyperventilation less frequently (P = .046), although clinical status during Paco2 measurement was not known. There were no other significant differences in intracranial pressure-directed therapies. Hispanic ethnicity was associated with lower mortality (P = .004) but did not differ in unfavorable outcome (P = .810). Glasgow Outcome Score-Extended for Pediatrics was less likely to be collected for non-Hispanic Black patients (69%; P = .011). Our analysis suggests a general lack of disparities in intracranial pressure-directed therapies and outcomes in children after severe traumatic brain injury. Lower mortality in Hispanic patients without a concurrent decrease in unfavorable outcomes, and lower availability of Glasgow Outcome Score-Extended for Pediatrics score for non-Hispanic Black patients merit further investigation.

Does structural racism impact receipt of NCCN guideline-concordant breast cancer treatment?

Disparities in breast cancer survival remain a challenge. We aimed to analyze the effect of structural racism, as measured by the Index of Concentration at the Extremes (ICE), on receipt of National Cancer Center Network (NCCN) guideline-concordant breast cancer treatment. We identified patients treated at two institutions from 2005 to 2017 with stage I-IV breast cancer. Census tracts served as neighborhood proxies. Using 5-year estimates from the American Community Survey, 5 ICE variables were computed to create 5 models, controlling for economic segregation, non-Hispanic Black (NHB) segregation, NHB/economic segregation, Hispanic segregation, and Hispanic/economic segregation. Multi-level logistic regression models were used to determine the association between individual and neighborhood-level characteristics on receipt of NCCN guideline-concordant breast cancer treatment. 5173 patients were included: 55.2% were Hispanic, 27.5% were NHW, and 17.3% were NHB. Regardless of economic or residential segregation, a NHB patient was less likely to receive appropriate treatment [(OR)Model1 0.58 (0.45-0.74); ORModel2 0.59 (0.46-0.78); ORModel3 0.62 (0.47-0.81); ORModel4 0.53 (0.40-0.69); ORModel5 0.59(0.46-0.76); p < 0.05]. To our knowledge, this is the first analysis assessing receipt of NCCN guideline-concordant treatment by ICE, a validated measure for structural racism. While much literature emphasizes neighborhood-level barriers to treatment, our results demonstrate that compared to NHW patients, NHB patients are less likely to receive NCCN guideline-concordant breast cancer treatment, independent of economic or residential segregation. Our study suggests that there are potential unaccounted individual or neighborhood barriers to receipt of appropriate care that go beyond economic or residential segregation.

Recent trends in the incidence of early-onset prostate cancer.

Early-onset prostate cancer (EOPC) is relatively uncommon. It is unclear if the incidence of EOPC is evolving. Utilizing data from the SEER database from 2000 to 2020, the study identified prostate cancer cases in men under 55 years, focusing on trends in annual age-adjusted incidence rates (AAIR), stage at presentation, race/ethnicity, and local treatment patterns. The study encompassed 93 071 cases of EOPC, with the median age at diagnosis being 51 years. From 2000 to 2007, the AAIR of EOPC experienced a wave-like increase from 6.9 to 8.3 per 100 000 people. It then sharply declined to 5.4 by 2014, followed by 6 years of stability, and by 2020 it had dropped to its lowest point of 4.5. The trend observed across different racial groups was consistent with the overall pattern, where non-Hispanic Black patients consistently exhibited the highest incidence and the least reduction rate (annual percent change, -1.0; 95% confidence interval, -1.8 to -0.2; P < 0.05). Stage II was the most commonly diagnosed, although its AAIR declined from 4.9 to 1.2 per 100 000 people. From 2010 through 2020, the proportion of receiving prostatectomy decreased from 63.0 to 43.6%. The declining rates of EOPC across diverse racial groups emphasize the critical need for focused research and interventions. Specifically, there is an urgent call to establish a tailored screening protocol for prostate cancer targeting Black youth.

Race has no impact on prostate cancer-specific mortality, when comparing patients with similar risk of other-cause mortality: An analysis of a population-based cohort.

Other-cause mortality (OCM) can serve as a surrogate for access-to-care. The authors sought to compare prostate cancer-specific mortality (PCSM) in Black versus White men matched based on their calculated OCM risk. The Surveillance, Epidemiology, and End Results (SEER) database was queried for Black and White men diagnosed with prostate cancer between 2004 to 2009, to collect long-term follow-up. A Cox regression was used to calculate the OCM risk using all available covariates. This calculated OCM risk was used to construct a 1:1 propensity score matched (PSM) cohort. Then, a competing-risks multivariable tested the impact of race on PCSM. A total of 94,363 patients were identified, with 19,398 Black men and 74,965 White men. The median (IQR) follow-up was 11.3 years (9.8-12.8). In the unmatched-cohort at 10-years, PCSM and OCM were 5.5% versus 3.5% and 13.8% versus 8.4% in non-Hispanic Black (NHB) versus non-Hispanic White (NHW) patients (all p<.0001). The standardized mean difference was <0.15 for all covariates, indicating a good match. In the matched cohort at 10-years, OCM was 13.6% and 10.0% in NHB versus NHW (p<.0001), whereas the PCSM was 5.3% versus 4.7% (p<.01). On competing-risks multivariable analysis on PCSM, Black men had a hazard ratio of 1.08 (95% confidence interval, 0.98-1.20) compared to White men with a p=.13. The results of this study showed similar PCSM in Black and White patients, when matched with their calculated OCM risk. This report is the first to indicate at a population-based level that race has no impact on PCSM. Prostate cancer is a very common cancer among men and it is associated with health disparities that disproportionately impact Black men compared to White men. There is an on-going discussion of whether disparities between these two groups stem from genetic or environmental factors. This study sought to examine if matching based on overall health status, a proxy for the impact of social determinants of health, mitigated significant differences in outcomes. When matched using risk of death from any cause other than prostate cancer, Black and White men had no significant differences in prostate cancer death.

Racial-ethnic differences in liver transplant waitlist outcomes in patients with hepatocellular carcinoma before and after recent changes to allocation policy.

In May 2019, liver transplant (LT) allocation policy changed to limit MELD exception points for hepatocellular carcinoma (HCC) to median MELD at transplant minus three (MMaT-3). We evaluated this policy's impact on waitlist outcomes for HCC candidates, by race and ethnicity, hypothesizing that the introduction of the MMaT-3 reduced inequities in waitlist outcomes. Retrospective cohort study of the Scientific Registry for Transplant Recipients, including all adult LT candidates (N=10751) who received HCC exception points from May 17, 2017 to May 18, 2019 (pre-policy; N=6627) to May 19, 2019 to March 1, 2021 (post-policy; N=4124). We compared incidence of LT and waitlist removal for death or becoming too sick pre- and post-policy for non-Hispanic White, non-Hispanic Black, Hispanic/Latinx, and Asian patients using competing risk regression adjusted for candidate characteristics. One-year cumulative incidence of LT decreased significantly pre-/post-policy among White (77.4%vs. 64.5%; p<.01) and Black (76.2%vs. 63.1%; p<.01) candidates only, while a 1-year incidence of death/non-LT waitlist removal decreased significantly only among Hispanics (13.4%vs. 7.5%; p<.01). After covariate adjustment, the effect of the policy change was a significantly decreased incidence of LT for White (SHR:.63 compared to pre-policy; p<.001), Black (SHR:.62; p<.001), and Asian (SHR:.68; p=.002), but no change for Hispanic patients. Only Hispanic patients had a significant decrease in death/waitlist removal after the policy change (SHR: .69; p=.04). Compared to White patients in the pre-policy era, Hispanic (SHR: .88, p<.007) and Asian candidates (SHR: .72; p<.001) had lower unadjusted incidence of LT. This disparity was mitigated in the post-policy era where Hispanic patients had higher likelihood of LT than Whites (SHR: 1.22; p=.002). For the outcome of death/non-LT waitlist removal, the only significant difference was a 42% lower incidence of waitlist removal for Asian compared to White patients in the post-policy era (SHR: .58; p=.03). Among LT recipients with HCC, racial/ethnic subpopulations were differentially affected by the MMAT-3 policy, resulting in a post-policy reduction of some of the previous disparities.

Racial, ethnic, and socioeconomic diversity and outcomes of patients with graft-versus-host disease: a CIBMTR analysis

AbstractSocioeconomic status (SES) and race/ethnicity have been associated with the outcomes of allogeneic hematopoietic stem cell transplantation (allo-HCT). Certain aspects of graft-versus-host disease (GVHD) management, such as the need for long-term care, prolonged immunosuppressive treatment, and close follow-up for complications, may exacerbate disparities. Adults (≥18 years) reported to the Center for International Blood and Marrow Transplant Research who underwent a first allo-HCT for acute leukemia, myelodysplastic syndrome, or myeloproliferative neoplasm between 2008 and 2018 were included. End points for those developing GVHD included overall survival (OS), transplant-related mortality (TRM), and disease relapse. Models were adjusted for patient- and transplant-related variables. A 2-sided P value < .01 was considered significant. Among the 14 825 allo-HCT recipients, 6259 (42.2%) and 6675 (45.0%) patients developed acute GVHD (aGVHD) and chronic GVHD (cGVHD), respectively. Among patients with aGVHD, non-Hispanic Black patients had increased TRM and overall mortality compared with non-Hispanic White patients; this association disappeared when severity of aGVHD was included in the model. Lower SES was associated with increased risk of disease relapse but not OS or TRM. In patients who developed cGVHD, race and ethnicity were not associated with OS, TRM, or disease relapse. However, the highest quartile of annual household income (≥$80 000) had improved OS and reduced TRM compared with the lowest quartile, after adjusting for race and ethnicity. In summary, race/ethnicity and SES are associated with outcomes after GVHD. Optimizing the health care resources available to low SES patients and strategies to minimize the risk of severe GVHD in non-Hispanic Black patients may improve long-term outcomes.

Examining Linguistic Differences in Electronic Health Records for Diverse Patients With Diabetes: Natural Language Processing Analysis.

Individuals from minoritized racial and ethnic backgrounds experience pernicious and pervasive health disparities that have emerged, in part, from clinician bias. We used a natural language processing approach to examine whether linguistic markers in electronic health record (EHR) notes differ based on the race and ethnicity of the patient. To validate this methodological approach, we also assessed the extent to which clinicians perceive linguistic markers to be indicative of bias. In this cross-sectional study, we extracted EHR notes for patients who were aged 18 years or older; had more than 5 years of diabetes diagnosis codes; and received care between 2006 and 2014 from family physicians, general internists, or endocrinologists practicing in an urban, academic network of clinics. The race and ethnicity of patients were defined as White non-Hispanic, Black non-Hispanic, or Hispanic or Latino. We hypothesized that Sentiment Analysis and Social Cognition Engine (SEANCE) components (ie, negative adjectives, positive adjectives, joy words, fear and disgust words, politics words, respect words, trust verbs, and well-being words) and mean word count would be indicators of bias if racial differences emerged. We performed linear mixed effects analyses to examine the relationship between the outcomes of interest (the SEANCE components and word count) and patient race and ethnicity, controlling for patient age. To validate this approach, we asked clinicians to indicate the extent to which they thought variation in the use of SEANCE language domains for different racial and ethnic groups was reflective of bias in EHR notes. We examined EHR notes (n=12,905) of Black non-Hispanic, White non-Hispanic, and Hispanic or Latino patients (n=1562), who were seen by 281 physicians. A total of 27 clinicians participated in the validation study. In terms of bias, participants rated negative adjectives as 8.63 (SD 2.06), fear and disgust words as 8.11 (SD 2.15), and positive adjectives as 7.93 (SD 2.46) on a scale of 1 to 10, with 10 being extremely indicative of bias. Notes for Black non-Hispanic patients contained significantly more negative adjectives (coefficient 0.07, SE 0.02) and significantly more fear and disgust words (coefficient 0.007, SE 0.002) than those for White non-Hispanic patients. The notes for Hispanic or Latino patients included significantly fewer positive adjectives (coefficient -0.02, SE 0.007), trust verbs (coefficient -0.009, SE 0.004), and joy words (coefficient -0.03, SE 0.01) than those for White non-Hispanic patients. This approach may enable physicians and researchers to identify and mitigate bias in medical interactions, with the goal of reducing health disparities stemming from bias.

Race, substance use, and evaluation for heart transplantation: Insights from a large urban medical center

It is unknown whether racial disparities in access to heart transplantation (HT) are amplified when coupled with substance use. We examined patients evaluated for HT over eight years at an urban transplant center. We evaluated substance use and race/ethnicity as independent and interactive predictors of HT and left ventricular assist device (LVAD) implantation. Of 1148 patients evaluated for HT, substance use was cited as an ineligibility factor in 151 (13%) patients, 16 (11%) of whom ultimately received HT. Significantly more non-Hispanic Black patients were deemed ineligible due to substance use (n=59, 19%) compared to other races/ethnicities (non-Hispanic white: n=68, 12%; other race/ethnicity: n=24, p=0.002). No racial differences were observed in likelihood of HT among patients initially excluded for substances, but more non-Hispanic Black patients ultimately received LVAD than the other racial groups. This study encourages greater awareness of the role of substance use and race in the HT evaluation.

Sociodemographic Disparities and Postoperative Outcomes Following Cranial Vault Remodeling for Craniosynostosis: Analysis of the 2012 to 2021 NSQIP-Pediatric Database.

The objective of this study was to assess whether race and ethnicity are independent predictors of inferior postoperative clinical outcomes, including increased complication rates, extended length of stay (LOS), and unplanned 30-day readmission following cranial vault repair for craniosynostosis. A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database. Pediatric patients under 2 years of age undergoing cranial vault repair for craniosynostosis between 2012 and 2021 were identified using the International Classification of Diseases-9/10 and Current Procedural Terminology codes. Patients were dichotomized into 4 cohorts: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and other. Only patients with available race and ethnicity data were included in this study. Patient demographics, comorbidities, surgical variables, postoperative adverse events, and hospital resource utilization were assessed. Multivariate logistic regression analysis was used to assess the impact of race on complications, extended LOS, and unplanned readmissions. In our cohort of 7764 patients, 72.80% were NHW, 8.44% were NHB, 15.10% were Hispanic, and 3.67% were categorized as "other." Age was significantly different between the 4 cohorts ( P <0.001); NHB patients were the oldest, with an average age of 327.69±174.57 days old. Non-Hispanic White experienced the least adverse events while NHB experienced the most ( P =0.01). Total operative time and hospital LOS were shorter for NHW patients ( P <0.001 and P <0.001, respectively). Rates of unplanned 30-day readmission, unplanned reoperation, and 30-day mortality did not differ significantly between the 4 cohorts. On multivariate analysis, race was found to be an independent predictor of extended LOS [NHB: adjusted odds ratio: 1.30 (1.04-1.62), P=0.021; other: 2.28 (1.69-3.04), P =0.005], but not of complications or readmission. Our study demonstrates that racial and ethnic disparities exist among patients undergoing cranial vault reconstruction for craniosynostosis. These disparities, in part, may be due to delayed age of presentation among non-Hispanic, non-White patients. Further investigations to elucidate the underlying causes of these disparities are necessary to address gaps in access to care and provide equitable health care to at-risk populations.

Disparities in Patient Portal Engagement Among Patients With Hypertension Treated in Primary Care

Patient portals are increasingly used for patient-clinician communication and to introduce interventions aimed at improving blood pressure control. To characterize patient portal use among patients with hypertension managed in primary care. This retrospective cohort study used electronic health records linked with patient portal log file data from a large, diverse Midwestern health care system. Patients with hypertension who had a primary care visit from January 1, 2021, to December 31, 2021, were included. The first visit in 2021 was considered the baseline visit; patient portal engagement was evaluated during the following year. Multivariate logistic regressions, presented as odds ratios (ORs) and 95% CIs, were used to evaluate associations between patient characteristics and patient portal engagement, adjusting for potential confounders. Primary exposures included 4 sociodemographic factors routinely collected in the electronic health record: race and ethnicity, insurance, preferred language, and smoking status. Indicators of patient engagement with the patient portal included accessing the patient portal at least once, accessing the portal within 7 days of at least 50.0% of primary care physician (PCP) visits, frequent logins (<28 vs ≥28), messaging (<2 vs ≥2), and sharing home blood pressure readings. Among 366 871 patients (mean [SD], 63.5 [12.6] years), 52.8% were female, 3.4% were Asian, 7.8% were Hispanic, 19.7% were non-Hispanic Black, 66.9% were non-Hispanic White, and 2.3% were of other race or ethnicity. During the 1-year study period starting in 2021, 70.5% accessed the patient portal at least once, 60.2% accessed around the time of their PCP visits, 35.7% accessed the portal frequently, 28.9% engaged in messaging, and 8.7% shared home blood pressure readings. Compared with White patients, non-Hispanic Black and Hispanic patients had lower odds of any access (Black: OR, 0.53; 95% CI, 0.52-0.54; Hispanic: OR, 0.66; 95% CI, 0.64-0.68), access around PCP visit time (Black: OR, 0.49; 95% CI, 0.48-0.50; Hispanic: OR, 0.62; 95% CI, 0.60-0.64), frequent access (Black: OR, 0.56; 95% CI, 0.55-0.57; Hispanic: OR, 0.71; 95% CI, 0.69-0.73), and messaging (Black: OR, 0.63; 95% CI, 0.61-0.64); Hispanic: OR, 0.71; 95% CI, 0.69-0.73). This cohort study of patients with hypertension found clear sociodemographic disparities in patient portal engagement among those treated in primary care. Without special efforts to engage patients with portals, interventions that use patient portals to target hypertension may exacerbate disparities.

Characterizing "collateral damage" in men and women with metastatic breast cancer (mBC) from diverse racial and ethnic backgrounds in New York City.

Patients from diverse racial, ethnic, and socio-economic backgrounds may be particularly vulnerable to experiencing undue social and financial burdens ("collateral damage") from a metastatic breast cancer (mBC) diagnosis; however, these challenges have not been well explored in diverse populations. From May 2022 to May 2023, English- or Spanish-speaking adults with mBC treated at four New York-Presbyterian (NYP) sites were invited to complete a survey that assessed collateral damage, social determinants of health, physical and psychosocial well-being, and patient-provider communication. Fisher's exact and the Kruskal-Wallis rank-sum tests assessed differences by race and ethnicity. Of 87 respondents, 14% identified as Hispanic, 28% non-Hispanic Black (NHB), 41% non-Hispanic White (NHW), 7% Asian American Pacific Islander (AAPI), and 10% other/multiracial. While 100% of Hispanic, NHW, and AAPI participants reported stable housing, 29% of NHB participants were worried about losing housing (p = 0.002). Forty-two percent of Hispanic and 46% of NHB participants (vs. 8%, NHW and 0%, AAPI, p = 0.005) were food insecure; 18% of Hispanic and 17% of NHB adults indicated lack of reliable transportation in the last year (vs. 0%, NHW/AAPI, p = 0.033). Participants were generally satisfied with the quality of communication that they had with their healthcare providers and overall physical and mental well-being were modestly poorer relative to healthy population norms. In our study, NHB and Hispanic mBC patients reported higher levels of financial concern and were more likely to experience food and transportation insecurity compared to NHW patients. Systematically connecting patients with resources to address unmet needs should be prioritized to identify feasible approaches to support economically vulnerable patients following an mBC diagnosis.

Race/Ethnicity Analysis of Vascular Alterations in Optical Coherence Tomography Angiography in Diabetic Patients

ABSTRACT Purpose Racial and ethnic minorities have a higher prevalence of diabetic retinopathy (DR) and present at advanced stages of disease. In an urban hospital population, we investigated microvascular differences in optical coherence tomography angiography (OCTA) between racial/ethnic groups while adjusting for socioeconomic status (SES). Methods 3 × 3 mm2 macular OCTA scans were obtained for analysis of foveal avascular zone (FAZ) area, FAZ perimeter as well as superficial (SCP) and deep capillary plexus (DCP) vessel density (VD), vessel length density (VLD), and adjusted flow index (AFI). SES was measured using the Area Deprivation Index. Multivariable regression models were used to adjust estimates for relevant confounders. Results 217 non-diabetic and 1,809 diabetic patients were included in the study, consisting of 42.2% Hispanic, 24.9% non-Hispanic (NH) Asian, 6.8% NH Black, 9.7% NH White and 16.3% Other patients. NH White was used as the reference group. Hispanic, NH Asian, and NH Black patients had significantly greater FAZ areas and FAZ perimeters, and lower DCP VD and VLD, among both non-diabetic and diabetic patients (Benjamini-Hochberg adjusted P-values <0.05). The addition of SES scores in the models did not modify any regressions significantly. Conclusions In patients with and without diabetes, racial and ethnic minorities have significant retinal microvasculature differences when compared to NH White patients, regardless of SES. These differences are pronounced in DCP and may predispose racial/ethnic minorities to worse outcomes in DR, thus widening disparities in ophthalmic care.

Evaluating site-of-care-related racial disparities in kidney graft failure using a novel federated learning framework.

Racial disparities in kidney transplant access and posttransplant outcomes exist between non-Hispanic Black (NHB) and non-Hispanic White (NHW) patients in the United States, with the site of care being a key contributor. Using multi-site data to examine the effect of site of care on racial disparities, the key challenge is the dilemma in sharing patient-level data due to regulations for protecting patients' privacy. We developed a federated learning framework, named dGEM-disparity (decentralized algorithm for Generalized linear mixed Effect Model for disparity quantification). Consisting of 2 modules, dGEM-disparity first provides accurately estimated common effects and calibrated hospital-specific effects by requiring only aggregated data from each center and then adopts a counterfactual modeling approach to assess whether the graft failure rates differ if NHB patients had been admitted at transplant centers in the same distribution as NHW patients were admitted. Utilizing United States Renal Data System data from 39043 adult patients across 73 transplant centers over 10 years, we found that if NHB patients had followed the distribution of NHW patients in admissions, there would be 38 fewer deaths or graft failures per 10000 NHB patients (95% CI, 35-40) within 1year of receiving a kidney transplant on average. The proposed framework facilitates efficient collaborations in clinical research networks. Additionally, the framework, by using counterfactual modeling to calculate the event rate, allows us to investigate contributions to racial disparities that may occur at the level of site of care. Our framework is broadly applicable to other decentralized datasets and disparities research related to differential access to care. Ultimately, our proposed framework will advance equity in human health by identifying and addressing hospital-level racial disparities.