non-Hispanic White Patients Research Articles

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.

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 and ethnic disparities in outcomes of diffuse large B cell lymphoma in adolescent and young adults: a SEER database analysis.

Data regarding racial disparities in the incidence, treatment, and outcomes of diffuse large B-cell lymphoma (DLBCL) is limited in the adolescent and young adult (AYA) population. We utilized the surveillance, epidemiology, and end-result (SEER) registry research plus database to evaluate racial/ethnic disparities in 8605 AYA patients with DLBCL. Race/ethnicity was categorized into three main subsets: non-Hispanic Whites (NHW), non-Hispanic Blacks (NHB), and 'other races' that included Hispanics (H), American Indian/Alaskan Native (AI/AN), Asian or Pacific Islander (A/PI). NHB were more likely to present with advanced stage disease (p < 0.001) and B symptoms (p < 0.001) and were less likely to receive chemotherapy(p < 0.001) compared to non-Hispanic white (NHW) patients and other races respectively. NHB patients had inferior 5-year disease specific survival (DSS) (70% vs 85% vs 80%, p < 0.001) and 5-year overall survival (OS) (66% vs 82% vs 77%, p < 0.001) compared to NHW and other races respectively. Black race was independently associated with both inferior DSS (HR 1.55, 95% CI 1.17-2.05, p = 0.002) and OS (HR 1.41, 95% CI 1.10-1.83, p = 0.007) after adjusting for age, gender, stage, presence of B symptoms, receipt of chemotherapy and radiation. NHB-DLBCL patients also had a lower 1-year relative survival rate (RSR) compared to NHW and other races. The low RSR in NHB patients persisted up to 5 years from diagnosis unlike NHW and other races. Our study shows that despite significant therapeutic advances in DLBCL over the last two decades, NHB AYA patients with DLBCL continue to have inferior survival outcomes compared to other ethnic and racial groups with disparities arising as early as the first year of diagnosis.

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.

Substance Use among Youth Presenting to the Pediatric Emergency Department.

Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk substance use. We conducted a tablet-based, anonymous, self-administered screening for substance use using a modified version of the Screening to Brief Intervention (S2BI) tool among a convenience sample of 383 patients 12-21 years presenting to an urban, academic PED from February to July 2023. Patients' attitudes toward ED screening and interventions for substance use also were collected. The frequency and type of substance use was analyzed by age group. Ordinal logistic regression was used to identify characteristics associated with higher-risk use (monthly or more substance use) and lower-risk use (past year use), as compared to no past year use. Among 14-17-year-olds (n = 144), 38% reported substance use in the past year; 25% had higher-risk use. Among 18-21-year-olds (n = 172), 67% reported substance use in the past year; 48% had higher-risk use. Alcohol, cannabis, and tobacco were most commonly used. Substance use was rare for 12-13-year-olds. Compared to youth 14-17 years, youth 18-21 years were more likely to have either higher-risk use (aOR 3.81, 95% CI (2.24-6.47)) or lower-risk use (aOR 2.74 (1.41-5.35)), rather than no use. Compared to Asian patients, Non-Hispanic White patients (aOR 5.23 (1.07-25.66)) and Hispanic patients (aOR 3.18 (1.06-9.58)) were more likely to have higher-risk use than no use. Most patients reported that it was important for youth to be asked about substance use in the ED and to be offered help for substance use. Youth substance use was common in this urban, academic PED, and many patients reported higher-risk use. These findings support future research to determine the best practices for ED substance use screening and ED-based interventions for youth.

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.

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.

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.

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.

Treatment and Survival Disparities in Asian Americans With Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death in the United States and globally. The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) population has often been studied as one homogenous cohort despite its heterogeneity. We aim to understand differences in treatment modality and mortality among AANHPI patients with early-stage HCC. Methods: The National Cancer Database was queried between 2004 and 2019. Patients with early-stage HCC eligible for liver transplantation (LT) were included. AANHPI patients were further disaggregated into subgroups, and non-Hispanic White (NHW) patients were included as reference. χ2 was used for categorical variables and the Student t test was used for continuous variables. Survival curves were generated using Kaplan-Meier estimates. Results: A total of 3039 (8.5%) AANHPI and 32,845 (91.5%) NHW were included. Among the AANHPI, 1368 (45.0%) were East Asian (EA), 1229 (40.4%) were Southeast Asian (SEA), 302 (9.9%) were South Asian (SA), and 140 (4.6%) were Native Hawaiian and other Pacific Islander (NHPI). Compared with NHW, AANHPI patients were less likely to undergo LT but had lower mortality. When disaggregated, SA patients were more likely to receive LT (HR: 2.70), and SEA (HR: 1.43) and NHPI (HR: 1.90) patients had higher mortality when compared with EA, all P&lt;0.01. Conclusions: AANHPI with early-stage HCC had better survival as a cohort. However, when disaggregated, there were notable disparities among different subgroups. AANHPI represents an incredibly diverse group of individuals, and it is imperative for physicians, researchers, and policy makers to appreciate the true heterogeneity of this population.

Polycystic ovary syndrome underdiagnosis patterns by individual-level and spatial social vulnerability measures.

To use electronic health records (EHR) data at Boston Medical Center (BMC) to identify individual-level and spatial predictors of missed diagnosis, among those who meet diagnostic criteria for PCOS. The BMC Clinical Data Warehouse was used to source patients who presented between October 1, 2003 and September 30, 2015 for any of the following: androgen blood tests, hirsutism, evaluation of menstrual regularity, pelvic ultrasound for any reason, or PCOS. Algorithm PCOS cases were identified as those with International Classification of disease (ICD) codes for irregular menstruation and either an ICD code for hirsutism, elevated testosterone lab, or polycystic ovarian morphology as identified using natural language processing on pelvic ultrasounds. Logistic regression models were used to estimate odds ratios (ORs) of missed PCOS diagnosis by age, race/ethnicity, education, primary language, body mass index (BMI), insurance type and social vulnerability index (SVI) score. In the 2003-2015 BMC-EHR PCOS at-risk cohort (n=23,786), there were 1,199 physician-diagnosed PCOS cases and 730 algorithm PCOS cases. In logistic regression models controlling for age, year, education, and SVI scores, Black/African American patients were more likely to have missed a PCOS diagnosis (OR = 1.69 [95% CI, 1.28, 2.24]) compared to non-Hispanic White patients, and relying on Medicaid or charity for insurance was associated with an increased odds of missed diagnosis when compared to private insurance (OR = 1.90 [95% CI, 1.47, 2.46], OR = 1.90 [95% CI, 1.41, 2.56], respectively). Higher SVI scores were associated with increased odds of missed diagnosis in univariate models. We observed individual-level and spatial disparities within the PCOS diagnosis. Further research should explore drivers of disparities for earlier intervention.

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.

Area-Level Social Deprivation and Cytomegalovirus Seropositivity at the Time of Solid Organ Transplant

Cytomegalovirus (CMV) is associated with significant morbidity and mortality in solid organ transplant (SOT) recipients. The risk factors for CMV seropositivity in SOT recipients, including area-level social deprivation in the US, have not been fully characterized. To (1) evaluate CMV seroprevalence, (2) assess the recipient characteristics associated with CMV seropositivity, and (3) assess the association of area-level social deprivation index (SDI) scores with pretransplant CMV serostatus. This retrospective cross-sectional analysis of the Scientific Registry of Transplant Recipients database included all adult (aged ≥18 years) SOT recipients from January 1, 2008, to May 31, 2022. Data were analyzed from April 10 to October 25, 2023. Recipient characteristics and area-level SDI. Multivariable generalized linear models were used to evaluate the association between (1) patient characteristics and CMV and (2) social deprivation (measured by SDI scores, which were assessed in quintiles, from lowest to highest) and CMV seropositivity. In addition, differences based on patient demographics and the transplanted organ(s) were evaluated. Among the 389 288 SOT recipients included in the analysis, mean (SD) age was 53.3 (13.0) years; 63.0% were male, 21.4% were Black, 15.2% were Hispanic White, 56.2% were non-Hispanic White, and 62.7% were CMV seropositive. The mean (SD) age was higher among CMV seropositive (54.0 [12.7] years) compared with CMV seronegative (52.0 [13.5] years) patients. Seropositivity for CMV was higher among women (69.9%) than men (58.5%) and among Black (74.8%) and Hispanic White (80.2%) patients compared with non-Hispanic White patients (50.4%). Seropositivity for CMV was highest among kidney (64.5%), liver (63.6%), and kidney and liver (66.2%) recipients. Greater SDI scores were associated with greater CMV seropositivity, ranging from 51.7% for the least deprived to 75.5% for the most deprived quintiles (P < .001), independent of age, sex, or race. In this cross-sectional study, an association between SDI and CMV seropositivity was observed among SOT recipients, independent of age, sex, or race and ethnicity. To optimize posttransplant outcomes in CMV seropositive recipients, efforts targeting prevention of CMV reactivation need to be prioritized in these higher-risk populations.

Moderating effects of organizational minority representation on racial and ethnic differences in early palliative care receipt among patients diagnosed with advanced cancers in 2010-2019 in the US.

52 Background: Early palliative care (PC) is recommended for advanced cancers, but differential use has been documented by race and ethnicity. We examined whether racial and ethnic differences in early PC use were moderated by organization-level proportions of minority patients served. Methods: We identified patients aged ≥65.5 years diagnosed with advanced-stage breast, colorectal, non-small cell lung (NSCL), small cell lung (SCL), pancreas, and prostate cancers in 2010-2019 with ≥6 months survival and continuous fee-for-service coverage from the SEER-Medicare data. Early PC was identified by PC encounter diagnosis codes or hospice and palliative medicine (HPM) specialty codes within 90 days post-diagnosis or up to first hospice admission date. Treating physicians and organizations were assigned based on the plurality of visits within 180 days surrounding diagnosis. Using patient race and ethnicity information, organizations were classified based on the percent of racial and ethnic minorities patients (Low&lt;10%, Medium 10-19%, and High Minority-Serving ≥20%). Multivariable logistic models assessed interacting effects of organizations’ minority representation and individual race and ethnicity on early PC receipt, adjusting for patient characteristics. Results: Among 102,060 patients treated at 8,039 organizations, the percent receiving early PC increased from 1.44% in 2010 to 10.30% in 2019. High Minority-Serving organizations were larger size and more likely to employ a HPM specialist and to treat a higher proportion of patients in metropolitan but lower socioeconomic areas, and were dually Medicare-Medicaid eligible. After adjusting for patient characteristics, Hispanic patients were 1.6 percentage points (ppts, 95%CI=-3.1, -0.1) less likely to receive early PC than Non-Hispanic (NH) White patients in Low Minority-Serving organizations. In High Minority-Serving organizations, Hispanic and NH Black patients were 0.8 ppts (95%CI=0.1, 1.6) and 1.6 ppts (95%CI=1.0, 2.3) more likely to receive early PC than NH White patients. (Table). Conclusions: Racial and ethnic minorities were more likely to receive early PC than NH White at High Minority-Serving organizations but not Medium/Low Minority-Serving organizations. System-level factors may be modified to narrow racial and ethnic differences in early PC use. Adjusted difference in early palliative care by race and ethnicity. Organization Minority Representation Individual Adjusted Probability Difference (95% CI) Low NH White Ref Hispanic -1.6 (-3.1, -0.1) NH Black 0.01 (-1.7, 1.7) Other/Unknown 1.1 (-1.2, 3.4) Medium NH White Ref Hispanic -0.6 (-1.7, 0.5) NH Black -0.8 (-1.7, 0.2) Other/Unknown 0.4 (-0.9, 1.7) High Non-Hispanic White Ref Hispanic 0.8 (0.1, 1.6) NH Black 1.6 (1.0, 2.3) Other/Unknown -0.3 (-1.1, 0.4)

The impact of the COVID-19 pandemic on racial disparities in postoperative outcomes after bariatric surgery

BackgroundThe COVID-19 pandemic has affected the outcomes and access to elective surgery across the United States. This study hypothesized that preexisting racial and ethnic disparities were exacerbated by the pandemic for bariatric surgery. MethodsThis retrospective cohort study evaluated the outcome disparities in 1,046,578 patients who underwent bariatric surgery from 2016–2019 (before the COVID-19 pandemic) to 2020–2021 (during the COVID-19 pandemic) using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. The primary outcomes of interest, Clavien-Dindo (CD) scores (0−5) and extended length of stay (eLOS; >90th percentile), were compared between non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, and non-Hispanic Asian/American Indian/Pacific Islander (A/AI/PI) patients using ordinal and binomial logistic regression models, respectively. In addition, the modifying effect of COVID-19 on racial disparities in these outcomes was assessed. ResultsOverall, patients during the COVID-19 pandemic had higher odds of a higher CD score (odds ratio [OR], 1.05; 95% CI, 1.04–1.06; P < .001) than patients before the COVID-19 pandemic on adjusted multivariate analysis. NHB patients were more likely to experience postoperative complications as characterized by higher CD scores (OR, 1.37; 95% CI, 1.35–1.39; P < .001) than NHW patients, and COVID-19 was a contributory factor (ratio of ORs, 1.07; 95% CI, 1.05–1.10). There was no significant difference in CD scores in Hispanic (OR, 1.00; 95% CI, 0.98–1.03; P = .800) and A/AI/PI (OR, 0.98; 95% CI, 0.92–1.06; P = .651) patients compared with NHW patients, and COVID-19 did not have a modifying effect on these patients. All non-White patients had a higher likelihood of eLOS before the COVID-19 pandemic, but COVID-19 had a modifying effect of decreased odds of eLOS for all races (ratio of ORs, 0.60–0.69; 95% CI, 0.56–0.80). DiscussionNHB patients had inferior perioperative outcomes than patients of other races after bariatric surgery during the COVID-19 pandemic. In addition, all races/ethnicities had decreased odds of eLOS during the COVID-19 pandemic.

Regional Variation in Deescalated Therapy in Older Adults With Early-Stage Breast Cancer

Although trial data support the omission of axillary surgery and radiation therapy (RT) in women aged 70 years or older with T1N0 hormone receptor-positive (HR+) breast cancer, potential overtreatment in older adults with frailty persists. To determine how much geospatial variation in locoregional therapy may be attributed to region vs patient factors. This retrospective cross-sectional study included women aged 70 years or older who were diagnosed with HR+/ERBB2-negative (ERBB2-) breast cancer from January 1, 2013, to December 31, 2017. Data came from Surveillance, Epidemiology, and End Results-Medicare. Hierarchical multivariable modeling was used to evaluate the variance in deescalated care attributable to 4 domains, ie, (1) random, (2) region (health service area [HSA]), (3) patient factors, and (4) unexplained. Patient factors included age, frailty (validated claims-based measure), Charlson Comorbidity Index (CCI), and socioeconomic status (Yost index). Analyses were performed from January to October 2023. HSA. Deescalated care, defined as omission of axillary surgery, RT, or both. Standard therapy was defined as lumpectomy, axillary surgery, and RT or mastectomy with axillary surgery. Multivariable logistic regression was used to identify factors associated with deescalated care receipt. Of 9173 patients (mean [SD] age, 76.5 [5.2] years), 2363 (25.8%) were aged 80 years or older, 705 (7.7%) had frailty, and 419 (4.6%) had a CCI of 2 or greater. While 4499 (49.1%) underwent standard therapy, 4674 (50.9%) underwent deescalated therapy (1193 [13.0%] of the population omitted axillary surgery and 4342 [55.5%] of patients undergoing lumpectomy omitted RT). Of the total variance, random variation explained 27.3%, region/HSA explained 35.3%, patient factors explained 2.8%, and 34.5% was unexplained. In adjusted models, frailty and increased age were associated with a higher likelihood of undergoing deescalated therapy (frailty: odds ratio [OR], 1.70; 95% CI, 1.43-2.02; age, by 1-year increment: OR, 1.10; 95% CI, 1.09-1.11), but CCI was not. Patients in rural areas compared with those in urban areas (OR, 0.82; 95% CI, 0.68-0.99) and Asian and Pacific Islander patients compared with non-Hispanic White patients (OR, 0.68; 95% CI, 0.54-0.85) had a lower likelihood of undergoing deescalated therapy. In this retrospective cross-sectional study of women aged 70 years or older diagnosed with T1N0 HR+/ERBB2- breast cancer, region/HSA contributed more to the variation in deescalated therapy use than patient factors. Unexplained variation may be attributed to unmeasured characteristics, such as multidisciplinary environment and patient preference. Decision support efforts to address overtreatment should target regions with low rates of evidence-based deescalation.