Non-black Populations Research Articles

Bias and Accuracy of Glomerular Filtration Rate Estimating Equations in the US

There is increasing concern that continued use of a glomerular filtration rate (GFR) estimating equation adjusted for a single racial group could exacerbate chronic kidney disease-related disparities and inequalities. To assess the performance of GFR estimating equations across varied patient populations. PubMed, Embase, Web of Science, ClinicalTrials.gov, and Scopus databases were systematically searched from January 2012 to February 2023. Inclusion criteria were studies that compared measured GFR with estimated GFR in adults using established reference standards and methods. A total of 6663 studies were initially identified for screening and review. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 authors independently extracted data on studies that examined the bias and accuracy of GFR estimating equations. For each outcome, a random-effects model was used to calculate pooled estimates. Data analysis was conducted from March to December 2023. The primary outcomes were bias and accuracy of estimated GFRs in Black vs non-Black patients, as well as in individuals with chronic conditions. Bias was defined as the median difference between the measured GFR and the estimated GFR. Accuracy was assessed with P30 (the proportion of persons in a data set whose estimated GFR values were within 30% of measured GFR values) and measures of heterogeneity. A total of 12 studies with a combined 44 721 patients were included. Significant heterogeneity was found in the bias of various GFR estimation equations. Race-corrected equations and creatinine-based equations tended to overestimate GFR in Black populations and showed mixed results in non-Black populations. For creatinine-based equations, the mean bias in subgroup analysis was 2.1 mL/min/1.73 m2 (95% CI, -0.2 mL/min/1.73 m2 to 4.4 mL/min/1.73 m2) in Black persons and 1.3 mL/min/1.73 m2 (95% CI, 0.0 mL/min/1.73 m2 to 2.5 mL/min/1.73 m2) in non-Black persons. Equations using only cystatin C had small biases. Regarding accuracy, heterogeneity was high in both groups. The overall P30 was 84.5% in Black persons and 87.8% in non-Black persons. Creatinine-based equations were more accurate in non-Black persons than in Black persons. For creatinine-cystatin C equations, the P30 was higher in non-Black persons. There was no significant P30 difference in cystatin C-only equations between the 2 groups. In patients with chronic conditions, P30 values were generally less than 85%, and the biases varied widely. This systematic review and meta-analysis of GFR estimating equations suggests that there is bias in race-based GFR estimating equations, which exacerbates kidney disease disparities. Development of a GFR equation independent of race is a crucial starting point, but not the sole solution. Addressing the disproportionate burden of kidney failure on Black individuals in the US requires an enduring, multifaceted approach that should include improving diagnostics, tackling social determinants of health, confronting systemic racism, and using effective disease prevention and management strategies.

Societal Cost of Racial Pneumococcal Disease Disparities in US Adults Aged 50 Years or Older.

This study aimed to estimate the societal cost of racial disparities in pneumococcal disease among US adults aged ≥ 50 years. In a model-based analysis, societal costs of invasive pneumococcal disease (IPD) and hospitalized nonbacteremic pneumococcal pneumonia (NBP) were estimated using (1) direct medical costs plus indirect costs of acute illness; (2) indirect costs of pneumococcal mortality; and (3) direct and indirect costs of related disability. Disparities costs were calculated as differences in average per-person pneumococcal disease cost between Black and non-Black adults aged ≥ 50 years multiplied by the Black population aged ≥ 50 years. Costs were in 2019 US dollars (US$), with future costs discounted at 3% per year. Total direct and indirect costs per IPD case were US$186,791 in Black populations and US$182,689 in non-Black populations; total hospitalized NBP costs per case were US$100,632 (Black) and US$96,781 (non-Black). The difference in population per-person total pneumococcal disease costs between Black and non-Black adults was US$47.85. Combined societal costs of disparities for IPD and hospitalized NBP totaled US$673.2 million for Black adults aged ≥ 50 years. Disease and disability risks, life expectancy, and case-fatality rates were influential in one-way sensitivity analyses, but the lowest cost across all analyses was US$194 million. The 95% probability range of racial disparity costs were US$227.2-US$1156.9 million in a probabilistic sensitivity analysis. US societal cost of racial pneumococcal disease disparities in persons aged ≥ 50years is substantial. Successful pneumococcal vaccination policy and programmatic interventions to mitigate these disparities could decrease costs and improve health.

Real-World Safety and Effectiveness After 5 Years of Dimethyl Fumarate Treatment in Black and Hispanic Patients with Multiple Sclerosis in ESTEEM.

Multiple sclerosis(MS) clinical trials have included low numbers of patients from racial and ethnic minority populations; therefore, it is uncertain whether differences exist in response to disease-modifying therapies. We evaluated the real-world safety and effectiveness of dimethyl fumarate (DMF) treatment over 5years in four patient cohorts: Black, non-Black, Hispanic, and non-Hispanic people with relapsing-remitting MS. ESTEEM is an ongoing, 5-year, multinational, prospective study evaluating the long-term safety and effectiveness of DMF in people with MS. The analysis included patients newly prescribed DMF in routine practice at 393 sites globally. Overall, 5251 patients were analyzed (220 Black, 5031 non-Black; 105 Hispanic, 5146 non-Hispanic). Median (min-max) months of follow-up was 32 (0-72) for Black, 29 (1-77) for Hispanic, and 41 (0-85) for both the non-Black and non-Hispanic populations. In total, 39 (18%) Black and 29 (28%) Hispanic patients reported adverse events leading to treatment discontinuation versus 1126 (22%) non-Black and 1136 (22%) non-Hispanic patients; gastrointestinal disorders were the most common in all subgroups. Median lymphocyte counts decreased by 37% in Black, 40% in non-Black, 10% in Hispanic, and 39% in non-Hispanic patients in the first year, then remained stable and above the lower limit of normal in most patients. Annualized relapse rates (ARRs) (95% confidence intervals) up to 5years were 0.054 (0.038-0.078) for Black, 0.077 (0.072-0.081) for non-Black, 0.069 (0.043-0.112) for Hispanic, and 0.076 (0.072-0.081) for non-Hispanic populations, representing reductions of 91-92% compared with ARR 12months before study entry (all p < 0.0001). The safety profile of DMF in these subgroups was consistent with the overall ESTEEM population. Relapse rates remained low in Black and Hispanic patients, and consistent with non-Black and non-Hispanic patients. These data demonstrate a comparable real-world treatment benefit of DMF in Black and Hispanic patients. ClinicalTrials.gov identifier NCT02047097.

Cost-effectiveness of an in-development adult-formulated pneumococcal vaccine in older US adults

IntroductionCDC pneumococcal vaccination recommendations for older adults now include either 15- or 20-valent pneumococcal conjugate vaccine (PCV15/PCV20). However, an in-development 21-valent vaccine (PCV21), formulated based on adult pneumococcal disease epidemiology, could substantially increase coverage of disease-causing pneumococcal serotypes, particularly in Black older adults, who are at greater risk. The potential public health impact and cost-effectiveness of PCV21 compared to currently recommended vaccines in older adults is unclear. MethodsA Markov decision model compared current pneumococcal vaccination recommendations to PCV21 use in Black and non-Black 65-year-old cohorts. CDC Active Bacterial Core surveillance data informed population and serotype-specific pneumococcal disease risk. Vaccine effectiveness was estimated using Delphi panel estimates and clinical trial data, with variation in sensitivity analyses. Potential indirect effects on adult disease from PCV15 childhood vaccination were examined. All model parameters were varied individually and collectively in sensitivity analyses. Scenarios with decreased PCV21 effectiveness and potential COVID-19 pandemic effects were also examined. ResultsIn the Black cohort, the PCV21 strategy cost $88,478 per quality adjusted life-year (QALY) gained without and $97,952/QALY with childhood PCV15 indirect effects. PCV21 in the non-Black cohort cost $127,436/QALY gained without and $141,358/QALY with childhood PCV15 effects. Current recommendation strategies were economically unfavorable, regardless of population or indirect childhood vaccination effects. Results favoring PCV21 use were robust in sensitivity analyses and alternative scenarios. ConclusionAn in-development PCV21 vaccine would likely be economically and clinically favorable compared to currently recommended pneumococcal vaccines in older adults. While PCV21 was more favorable in Black cohort analyses, results for both Black and non-Black populations were economically reasonable, highlighting the potential importance of adult-specific pneumococcal vaccine formulations and, pending further investigation, potentially justifying a future general population recommendation for PCV21 use in older adults.

Association between sociodemographic characteristics and HIV disclosure among people living with HIV in South Carolina: a structural equation modeling approach

ABSTRACT HIV disclosure continues to be a key consideration among people living with HIV (PLWH). However, there is a lack of studies assessing factors associated with HIV disclosure among PLWH in the Southern U.S. Therefore, the aim of this study was to assess the association between sociodemographic risk factors and HIV disclosure using a structural equation modeling approach among PLWH in South Carolina. Exploratory factor analysis was used to operationalize HIV disclosure. Structural equation models were used to determine the associations between sociodemographic factors and HIV disclosure among PLWH. Two latent variables were obtained for HIV disclosure: partners (stable partners, spouses, casual partners), and family/friends (parents, grandparents, siblings, children, adult children, friends, and coworkers). After adjusting for confounders, Black populations were less likely to disclose their HIV status to both partners (β = −0.250, p = 0.006) and family/friends (β = −0.246, p < 0.001) compared to non-Black populations. As yearly income increased, the likelihood of HIV disclosure to family/friends decreased (β = −0.300, p = <0.001). As time since diagnosis increased, the likelihood of HIV disclosure to family/friends increased (β = 0.266, p = 0.001). Future research can assess the feasibility of implementing disclosure interventions that are geared towards Black, high income and newly diagnosed PLWH and the associations of psychosocial factors and HIV disclosure.

Impact of switching from the 2009 to the 2021 CKD-EPI Equation for eGFR

Abstract Recent national and international guidelines have recommended implementing the 2021 CKD-EPI equation for estimating glomerular filtration rate (eGFR). Relative to the 2009 CKD-EPI equation, the 2021 equation eliminates race-based modifiers in the calculation of eGFR based on a remodeling of the original CKD-EPI dataset. Further, updated guidelines now recommend integrating Cystatin C as a confirmatory test in all patients with an eGFR between 45-59 mL/min/1.73m2. Here we assess the impact of switching from the 2009 CKD-EPI creatinine-based equation to the 2021 CKD-EPI creatinine-based equation on both non-black and black populations and assess the feasibility of implementing a reflex for Cystatin C on all patients with an eGFR between 45-59 mL/min/1.73m2. The laboratory information system was queried retrospectively from 11/01/2021 to 12/31/2021 for age, sex, self-identified ethnicity, and serum creatinine concentrations from basic/comprehensive metabolic panels and renal panels. Slope and linearity of the reported eGFR with the 2009 and 2021 equations were compared using Deming regression and Fisher’s exact test was used to assess the proportion of eGFR results &amp;lt;30 ml/min/1.73m2 and between 45-59 ml/min/1.73m2. Of the 64,657 serum creatinine values, 37,589 were from self-identifying non-black patients and 27,068 were from self-identifying black patients. Deming regression revealed a slope of 0.997 (95% CI; 0.997-0.998) and intercept of 2.69 (2.65-2.74) for the non-black population and a slope of 0.863 (0.862-0.864) and intercept of 2.451 (2.39-2.51) for the black population. The number of non-black individuals with an eGFR &amp;lt;30 mL/min/1.73m2 decreased 5622 to 5060 (p&amp;lt;0.001) and black patients increased from 4018 to 4387 (p&amp;lt;0.001). The number of non-black individuals with an eGFR in the range of 45-59 ml/min/1.73m2 increased marginally from 4,410 (11.7%) to 4,525(12.0%, p=0.19) and the number of black individuals increased from 2,501 (9.2%) to 3,299 (12.2%, p&amp;lt;0.001). If a Cystatin C reflex test was performed on all patients with an eGFR between 45-59 mL/min/1.73m2, 2325 assays would have been performed on out-patients and 5499 on in-patients. These results, in the context of recently updated guidelines imply that the changing from the 2009 CKD-EPI equation to the 2021 CKD-EPI equation is likely to increase the proportion of black individuals diagnosed with moderate to severe and severe loss of kidney function more so than the non-black populations. Implementation of a Cystatin C reflex on all patients with an eGFR between 45-59 mL/min/1.73m2 is likely to lead to considerable overuse and should be limited to out-patients and physician ordered tests.

Cost-Effectiveness of Newly Recommended Pneumococcal Vaccination Strategies in Older Underserved Minority Adults in the USA.

IntroductionUS pneumococcal vaccination recommendations for adults aged 65 years or older recently changed, with options for either 20-valent pneumococcal conjugate vaccine (PCV20) or the combination of 15-valent conjugate vaccine (PCV15) followed by 23-valent polysaccharide vaccine (PPSV23) 1 year later. Underserved minority adults are at higher risk for pneumococcal disease.MethodsA Markov decision analysis model estimated the incremental cost-effectiveness of the newly adopted general population pneumococcal vaccination strategies in older underserved minority adults. The model examined hypothetical 65-year-old US Black cohorts (serving as a proxy for underserved minorities) and non-Black cohorts receiving PCV20 or PCV15/PPSV23, or no vaccination. Main outcome measures included incremental cost-effectiveness per quality-adjusted life year (QALY) gained and pneumococcal disease public health outcomes.ResultsBlack cohorts had a greater risk of pneumococcal disease hospitalization compared to non-Black cohorts. In Black cohorts, total per person PCV20 strategy costs, compared to no vaccination, were $124 higher while gaining 0.00073 QALY, or $169,540/QALY gained. PCV15/PPSV23 cost $535,797/QALY compared to PCV20. In the non-Black cohort, PCV20 cost $210,529/QALY gained compared to no vaccination and PCV15/PPSV23 cost $728,423/QALY. Plausible variation of vaccine effectiveness minimally affected PCV20 strategy results and made PCV15/PPSV23 more unfavorable. In scenarios where the simpler one-vaccine PCV20 strategy increased absolute vaccine uptake by 10%, PCV20 cost-effectiveness changed minimally while PCV15/PPSV23 cost in excess of $6 million/QALY in the Black cohort. In probabilistic sensitivity analyses that varied all parameters simultaneously, PCV15/PPSV23 was unlikely to be favored at thresholds less than $500,000/QALY gained.ConclusionGeneral population recommendations for PCV20 use are substantially more economically reasonable in Black and non-Black older adult populations than PCV15/PPSV23. If using a single vaccine increases uptake, which is potentially more likely in the underserved, then PCV20 use becomes even more favorable.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-022-00669-x.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

A Call to Action to Fight for Equity and End Necrotizing Enterocolitis Disparities.

Homicides of black people in Brazil: A study of different regions, using generalized additive regression models-with a geo-spatial component.

The number of homicides in Brazil has reached record numbers, and when the race/colour of the victims is considered-an extreme inequality is evident- with a particularly high number of deaths in black and brown populations. The goal of this work was to analyse homicide rates of black people in Brazil from the years 2000 to 2016, using generalized additive regression models, with a geo-spatial component. The statistics were applied to understand the social reasons for homicide risks in the black population in Brazil's 26 states and Federal District with reference to the human development index and its components (education, longevity and income) as well as social inequality indices (Gini and Theil). This socioecological, epidemiological study to estimate the risk of homicide in the black population with a time series component, shows that this risk has increased linearly over time. Less longevity and low income correlated with a greater risk of homicide-while the Gini and Theil indices showed that in places where there are greater inequalities, there is also a higher risk of homicide in both black and non-black populations. The results - regarding the possibility of relating social indicators to homicide risk in the regional units under study, would support implementation of interventional public policy measures.

Time- and Race-Specific Haematological Reference Intervals for Healthy Volunteer Trials: A Retrospective Analysis of Pooled Data From Multiple Phase I Trials.

Most UK hospitals, laboratories, and research institutions use uniform reference intervals (RI) that do not take into account known diurnal and racial variation in total white blood cells (WBC) count and its constituent parameters. These risks of excluding potentially suitable ethnic minority volunteers from participating in phase I clinical trials could call into question the validity of a trial’s findings or limit its scientific applications and ability to accurately observe drug effects upon WBC parameters. This study pools data from multiple phase I trials, assesses the effects of race and time of day on WBC count, and compares it to the existing literature to establish race and time-specific RIs. A total 13,332 venous blood samples obtained from 7,157 healthy male and female volunteers at the time of screening or admission (predosing) who took part in 35 phase I trials over a period of seven years were pooled and the data were analyzed using generalised estimating equation models. Adjusted RI of total WBC count and its individual parameters were then calculated according to time of day (morning vs. evening) for both black and nonblack populations. This study indicates that black individuals on average had lower total WBC, neutrophil, monocyte, eosinophil, and basophil counts than individuals from nonblack racial groups. Black volunteers had higher mean lymphocyte counts relative to their nonblack counterparts. These differences were deemed statistically significant. Statistically significant increases in total WBC, neutrophil, lymphocyte, and monocyte counts were also observed over the course of daily sampling. Eosinophil counts decreased during this time period, but this finding was only statistically significant in the nonblack population. Despite an observed mild diurnal increase in basophil count in both populations, this was not considered statistically significant. This high-powered study adds significant weight to the known evidence for diurnal and racial variation in WBC parameters. Importantly, it proposes specific RIs that more precisely reflect race and time of day. These could ensure increased participation of black volunteers in clinical trials for improved population representation. Furthermore, the proposed RIs allow for more accurate postdose safety monitoring and reporting, and ensure improved monitoring of postdose WBC count changes.

Regional, racial, gender, and tumor biology disparities in breast cancer survival rates in Africa: A systematic review and meta-analysis.

BackgroundThe survival rates from breast cancer in Africa are poor and yet the incidence rates are on the rise. In this study, we hypothesized that, in Africa, a continent with great disparities in socio-economic status, race, tumor biology, and cultural characteristics, the survival rates from breast cancer vary greatly based on region, tumor biology (hormone receptor), gender, and race. We aimed to conduct the first comprehensive systematic review and meta-analysis on region, gender, tumor-biology and race-specific 5-year breast cancer survival rates in Africa and compared them to 20-year survival trends in the United States.MethodsWe searched MEDLINE, EMBASE, and Cochrane Library to identify studies on breast cancer survival in African published before October 17, 2018. Pooled 5-year survival rates of breast cancer were estimated by random-effects models. We explored sources of heterogeneity through subgroup meta-analyses and meta-regression. Results were reported as absolute difference (AD) in percentages. We compared the survival rates of breast cancer in Africa and the United States.FindingsThere were 54 studies included, consisting of 18,970 breast cancer cases. There was substantial heterogeneity in the survival rates (mean 52.9%, range 7–91%, I2 = 99.1%; p for heterogeneity <0.0001). Meta-regression analyses suggested that age and gender-adjusted 5-year survival rates were lower in sub-Saharan Africa compared to north Africa (AD: –25.4%; 95% CI: –34.9 - –15.82%), and in predominantly black populations compared to predominantly non-black populations (AD: –25.9%; 95% CI: 35.40 - –16.43%). Survival rates were 10 percentage points higher in the female population compared to male, but the difference was not significant. Progesterone and estrogen receptor-positive breast cancer subtypes were positively associated with survival (r = 0.39, p = 0.08 and r = 0.24, p = 0.29 respectively), but triple-negative breast cancer was negatively associated with survival. Survival rates are increasing over time more in non-black Africans (55% in 2000 versus 65% in 2018) compared to black Africans (33% in 2000 versus 40% in 2018); but, the survival rates for Africans are still significantly lower when compared to black (76% in 2015) and white (90% in 2015) populations in the United States.ConclusionRegional, sub-regional, gender, and racial disparities exist, influencing the survival rates of breast cancer in Africa. Therefore, region and race-specific public health interventions coupled with prospective genetic studies are urgently needed to improve breast cancer survival in this region.

Racial Disparities in Adult Pneumococcal Vaccination Indications and Pneumococcal Hospitalizations in the U.S.

BackgroundRacial disparities in U.S. adult pneumococcal vaccination rates persist despite reduced barriers to access. Consequently, racial and ethnic minorities experience pneumococcal disease at higher rates than whites. This study examined prevalence of high-risk conditions and pneumococcal hospitalizations among U.S. black and non-black populations aged ≥50 years. MethodsNational Health Interview Survey, National Center for Health Statistics and National Inpatient Sample data were used to create black and non-black population cohorts, determine risk factors for pneumococcal disease (pneumococcal vaccine indications) and assess the impact of pneumococcal hospitalization. Each racial cohort was segmented into groups based on the presence of immunocompromising or other pneumococcal high-risk conditions. Persons without those conditions were separated into smokers (also a pneumococcal vaccine indication) and nonsmokers. Mortality was estimated from NCHS life table data. NIS data provided length of stay and costs (calculated from cost to charge ratios) for admissions related to pneumococcal disease including bacteremia, meningitis and nonbacteremic pneumonia. ResultsThere were similar proportions of immunocompromised (<5%) and smokers (14%) in both racial cohorts. Likelihood of non-immunocompromising pneumococcal high-risk conditions was higher for blacks than non-blacks at age 65, but higher for non-blacks than blacks at age 80 years (P < 0.001). Age-specific relative likelihood of mortality was 1.1%–12% higher in blacks than non-blacks (P < 0.001). Length of stay was significantly longer for blacks than non-blacks in all age and discharge status groups for non-bacteremic pneumonia and for blacks discharged alive with invasive pneumococcal disease. Costs were higher for blacks 65 years or older with invasive pneumococcal disease. ConclusionMarked differences exist between U.S. black and non-black populations in likelihood of conditions conferring a high-risk of pneumococcal disease, and for length of stay and costs of pneumococcal disease hospitalizations. Further research is recommended to identify cost-effective policies or interventions to increase vaccine uptake in higher risk populations.

Abstract 136: Enrollment of Black Individuals in Cardiovascular Clinical Trials: A Meta-Analysis

Objectives: Lack of racial and ethnic diversity in clinical trials (CT) limits the generalizability of results to individuals who have unique cultural, environmental and physiological factors that affect outcomes. Consequently, the NIH and FDA issued directives to include historically underrepresented racial and ethnic groups in research studies. We sought to determine the enrollment of black relative to non-black populations in cardiovascular clinical trials and whether racial enrollment varied across trial characteristics. Methods: Clinical trials were identified using PubMed, Embase, and Cochrane. Between 2000-2018, studies were included if they were English language, CT of cardiovascular disease or risk factors and race/ethnicity were reported. Trial characteristics were extracted from the primary manuscript or clinical trials.gov and included: study area, funding source, intervention type, location, sample size, and distribution of female participants. Summary statistics for each study included percentage of blacks enrolled with 95% CI. Meta-analysis of the proportion of black enrollment across relevant CT was conducted to analyze overall estimates of the effect compared to non-black enrollment using an inverse variance weighted random effects model. Additional meta-analyses compared candidate variables that could influence the likelihood of black enrollment. All analyses were performed with SAS version 9.4 (SAS Institute Inc., Cary NC). Results: We identified 2501 trials, 85 met inclusion criteria, comprising a total of 159,791 patients: 25,720 black and 134,071 non-black. The percentage of blacks 38.2% (95%CI: 33.0%-43.6%) enrolled was significantly less than non-blacks 61.8% (95%CI: 56.4%-67%). Enrollment differed significantly across study type with peripheral vascular disease enrolling the largest 59.9% (95%CI: 47.3%-71.4%) and cerebrovascular disease the least 25.1% (16.1%-37%). Industry only studies accounted for 41% (35 of 85) of total trials and were less likely 30.3% (95%CI: 22.7%-39.1%), than NIH 40.9% (95%CI: 34%-48.1%), joint NIH/Industry 46.8% (95%CI: 33.3%-60.7%), and non-NIH/Industry 76.6% (95%CI: 38.7%-94.4%) funded studies to enroll black patients. Pharmacotherapy studies 29.3% (23.3%-36.1%) enrolled fewer black patients than behavioral 43.8% (36.9%-51%) and device/other 48.2% (37.5%-59.1%) studies. Black enrollment decreased for non-US based studies, and as a function of decreasing female sex enrollment and increasing sample sizes of studies. Conclusion: CTs of cardiovascular disease and risk factors were significantly less likely to enroll blacks when compared to non-black patients. Trial characteristics such as study area, funding source, intervention type, study site location, sample size, female percentage, and mean age had statistically significant impacts on black patient accrual in cardiovascular CTs.

Outcomes of Black Patients with Multiple Myeloma in the Veterans Health Administration

Background: Multiple myeloma (MM) is the most common hematologic malignancy in blacks with more than twice the incidence of non-black populations in national registry data. Prior studies have shown that blacks present with MM at an earlier age and have improved survival compared to non-blacks, contrary to the pattern in most malignancies. These findings have been theorized due to the effects of obesity, treatment variation, and disparities in care, in addition to alternate disease biology in black patients. In order to understand possible effects of race on outcomes while adjusting for confounders not available in other national datasets such as treatment, comorbidities, and baseline laboratory characteristics, we studied outcomes in a nationwide population of United States veterans with MM in the Veterans Health Administration (VHA).Methods: Patients with MM were identified by the VHA Central Cancer Registry between September 1, 1999 and December 31, 2013 and followed through December 31, 2014. Age, sex, race, body mass index (BMI), Charlson (Romano) comorbidity index, treatment (including transplant), hemoglobin (hgb), albumin, renal function (eGFR), and statin use were included. Cox proportional hazards regression modeling was used to assess the association between black race and overall survival at five years while controlling for known prognostic factors. The study was approved the Saint Louis VA Medical Center institutional review board.Results: 4805 patients were identified with MM, of which 1418 (29.5%) were black. Black patients were younger (66.2 years vs. 69.2, p<0.001) with increased mean comorbidity scores (3.7 vs. 3.0 p<0.001) compared to non-black patients. Black patients had lower mean BMI (27.0 years vs. 27.8, p<0.001) and higher rates of hgb <10 g/dL, 49.1% vs. 35.3%, p<0.001) and albumin below 3 g/dL (35.3% vs. 28.3% p<0.001) with similar rates of decreased renal function of eGFR <30 (22.1% vs. 21.2%, p=0.69) compared to non-black patients. Black patients underwent stem cell transplantation at similar rates (12.3% vs. 14.2%, p=0.09) and there no differences based on race in treatment with lenalidomide (35.1% vs. 36.0%, p=0.52), thalidomide (36.7% vs. 38.7%, p=0.20), or melphalan (32.7% vs. 34.8%, p=0.16). More black patients were treated with bortezomib compared to non-blacks (50.1% vs 44.4%, p<0.001). In unadjusted analyses, black race was associated with reduced risk of death at five years (Hazard Ratio [HR] 0.89, 95% CI 0.83-0.97). After controlling for age, comorbidity score, hgb, albumin, transplant, and treatment; black patients also had improved survival (HR 0.82, 95% CI 0.76-0.89). After adding BMI, year of diagnosis, and statin use to the final Cox model, black patients continued to have improved survival (HR 0.80, 95% CI 0.73-0.86).Conclusions: Survival of black patients with MM was improved compared to non-blacks in the VHA, a national comprehensive care delivery system. Black patients also received similar therapies compared to non-blacks, while presenting at a younger age with more comorbidities. These results are strengthened after adjusting for treatments and patient characteristics not available in other large data studies. Despite increased incidence of MM in the black population, outcomes are improved, similar to other large studies of patients in the United States. Alternate disease biology may be responsible for improved survival and further studies of MM based on race are appropriate. DisclosuresCarson:Flatiron Health: Employment; Washington University in St. Louis: Employment; Roche: Consultancy. Sanfilippo:BMS/Pfizer: Speakers Bureau.

Eight-Year Incidence of Open-Angle Glaucoma in the Tema Eye Survey

To determine the incidence of open-angle glaucoma (OAG) and its risk factors in the Tema Eye Survey in Ghana, West Africa. Longitudinal, observational population-based study. One thousand two hundred five of 1500 participants 40 years of age or older selected randomly from 5603 participants originally drawn from the population and who had undergone a baseline examination. All participants underwent baseline and follow-up ophthalmologic examinations 8 years apart. Glaucoma diagnosis was determined based on the International Society for Geographical and Epidemiologic Ophthalmology criteria. Incidence and odds ratio (OR). The response rate was 80.3%. Of 1101 nonglaucomatous participants at baseline who had complete follow-up data, 4.6% (95% confidence interval [CI], 3.7%-5.2%) demonstrated OAG over the 8-year period, or 0.58% (95% CI, 0.4%-0.8%) per year. The 8-year incidence increased with age from 3.1% in those 40 to 49 years old to 7.0% in those 60 to 69 years old. Baseline risk factors for incident OAG were male gender (OR, 2.1; 95% CI, 1.1-4.0; P= 0.025), older age relative to those 40 to 49 years old (those 50-50 years old: OR, 2.6; 95% CI, 1.2-5.7; those 60-69 years old: OR, 4.3; 95% CI, 2.0-8.8; and for those 70 years of age andolder: OR, 6.3; 95% CI, 2.6-15.4; all P < 0.001), higher intraocular pressure (IOP; OR, 1.4; 95% CI, 1.1-1.8; P< 0.001), larger vertical cup-to-disc ratio (OR, 5.8; 95% CI, 5.2-6.6; P < 0.001), and thinner central cornea (OR, 1.2; 95% CI, 1.03-1.5; P= 0.013). A separate analysis performed with central corneal thickness-based IOP correction did not change the outcome of the associative model of incident glaucoma. The incidence of OAG is higher in this population than reported in nonblack populations outside Africa. This is important not only in Ghana and probably other West African countries but also wherever people of the West African diaspora reside. These data enhance our understanding of the epidemiologic factors of OAG in this setting and may serve as reference for public health policy and planning.

Relationship between race and community water and sewer service in North Carolina, USA.

Previous evidence has identified potential racial disparities in access to community water and sewer service in peri-urban areas adjacent to North Carolina municipalities. We performed the first quantitative, multi-county analysis of these disparities. Using publicly available data, we identified areas bordering municipalities and lacking community water and/or sewer service in 75 North Carolina counties. Logistic regression was performed to evaluate the relationship between race and access to service in peri-urban areas, controlling for population density, median home value, urban status, and percent white in the adjacent municipality. In the peri-urban areas analyzed, 67% of the population lacked community sewer service, and 33% lacked community water service. In areas other than those with no black residents, odds of having community water service (p<0.01) or at least one of the two services (p<0.05) were highest for census blocks with a small proportion of black residents and lowest in 100% black census blocks, though this trend did not hold for access to community sewer service alone. For example, odds of community water service were 85% higher in areas that were greater than 0% but less than 22% black than in 100% black areas (p<0.001). Peri-urban census blocks without black populations had the lowest odds of community water service, community sewer service, and at least one of the two services, but this difference was only statistically significant for sewer. Peri-urban areas lacking service with no black residents were wealthier than 100% black areas and areas with any percent black greater than 0%. Findings suggest two unserved groups of differing racial and socioeconomic status: (1) lower-income black populations potentially excluded from municipal services during the era of legal racial segregation and (2) higher-income non-black populations. Findings also suggest greater racial disparities in community water than community sewer services statewide.

Transcutaneous bilirubin nomograms in African neonates.

BackgroundThe use of transcutaneous bilirubin (TcB) as a screening tool, based on relevant population-specific nomogram, or proxy for total serum bilirubin (TSB) levels in assessing the risk of subsequent hyperbilirubinemia is supported by several clinical guidelines on the management of neonatal hyperbilirubinemia. However, while TcB has been found to significantly over-estimate TSB in neonates of African-American ancestry, with variations across TcB devices, no nomogram has been specifically reported for this racial group. This study therefore set out to develop TcB nomograms for healthy late pre-term and term black African neonates derived from two widely used bilirubinometers.MethodsA retrospective analysis of 12,377 TcB measurements obtained from 6,373 neonates in the first postnatal week, over a period of 48 months using Bilichek and JM-103 bilirubinometers. TcB percentiles were computed from hour-specific TcB values and nomograms developed for each of the screening devices. Predictive ability of the 75th and 95th percentiles to detect significant hyperbilirubinemia was evaluated between 24–96 hours of age. The 95th percentile curve was compared with those from other populations.ResultsThe velocity of TcB rise at 75th and 95th percentiles was generally higher with JM-103 than Bilichek. Both percentiles also peaked at higher TcB levels with JM-103. The 95th percentile for both instruments showed a downward trend as from approximately 114 hours. Both instruments had high negative predictive values across the selected time-epochs and lower discriminatory ability than reported in non-black populations.ConclusionsThe predictive utility of TcB as a potential screening tool varies across devices in black African neonates with or without risk of significant hyperbilirubinemia, and lower than levels reported in non-black populations. Equipment-specific nomograms should be considered for TcB monitoring in this racial population where TSB is not routinely available.

Comparing the U.S. Decennial Census Coverage Estimates for Children from Demographic Analysis and Coverage Measurement Surveys

Following every U.S. decennial census since 1960, the U.S. Census Bureau has evaluated the completeness of coverage using two different methods. Demographic analysis (DA) compares the census counts to a set of independent population estimates to infer coverage differences by age, sex, and race. The survey-based approach (also called dual system estimation or DSE) provides coverage estimates based on matching data from a post-enumeration survey to census records. This paper reviews the fundamentals of the two methodological approaches and then initially examines the results of these two methods for the 2010 decennial census in terms of consistency and inconsistency for age groups. The authors find that the two methods produce relatively consistent results for all age groups, except for young children. Consequently, the paper focuses on the results for children. Results of the 1990, 2000, and 2010 decennial censuses are shown for the overall population in this age group and by demographic detail (age, race, and Hispanic origin). Among children, the DA and DSE results are most inconsistent for the population aged 0–4 and most consistent for ages 10–17. Results also show that DA and DSE are more consistent for Black than non-Black populations. The authors discuss possible explanations for the differences in the two methods for young children and conclude that the DSE approach may underestimate the net undercount of young children due to correlation bias.

Racial Differences in the Association Between Preoperative Serum Cholesterol and Prostate Cancer Recurrence: Results from the SEARCH Database.

Black men are disproportionately affected by both cardiovascular disease and prostate cancer. Epidemiologic evidence linking dyslipidemia, an established cardiovascular risk factor, and prostate cancer progression is mixed. As existing studies were conducted in predominantly non-black populations, research on black men is lacking. We identified 628 black and 1,020 non-black men who underwent radical prostatectomy and never used statins before surgery in the Shared Equal Access Regional Cancer Hospital (SEARCH) database. Median follow-up was 2.9 years. The impact of preoperative hypercholesterolemia on risk of biochemical recurrence was examined using multivariable, race-stratified proportional hazards. In secondary analysis, we examined associations with low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides, overall and among men with dyslipidemia. High cholesterol was associated with increased risk of recurrence in black [HR(per10 mg/dL) 1.06; 95% confidence interval (CI), 1.02-1.11] but not non-black men (HR(per10 mg/dL) 0.99; 95% CI, 0.95-1.03; P(interaction) = 0.011). Elevated triglycerides were associated with increased risk in both black and non-black men (HR(per10 mg/dL) 1.02; 95% CI, 1.00-1.03 and 1.02; 95% CI, 1.00-1.02, respectively; P(interaction) = 0.458). There were no significant associations between LDL or HDL and recurrence risk in either race. Associations with cholesterol, LDL, and triglycerides were similar among men with dyslipidemia, but low HDL was associated with increased risk of recurrence in black, but not non-black men with dyslipidemia (P(interaction) = 0.047). Elevated cholesterol was a risk factor for recurrence in black but not non-black men, whereas high triglycerides were associated with increased risk regardless of race. Significantly contrasting associations by race may provide insight into prostate cancer racial disparities.

A Systems Framework for Modeling Health Disparities in the Prevalence in Chronic Conditions following a Natural Disaster Event

Natural disaster events impact both the short- and long-term health of a region’s population. Due to variation in the vulnerability among population segments, a severe storm event can be expected over time to have a greater public health impact upon traditionally underserved and medically fragile populations. This research illustrates the causal relationships leading to a change over time in the prevalence of chronic conditions among black and non-black populations within U.S. Hampton Roads. Using a system dynamics approach, the authors develop and integrate a macro model that captures change in regional economic and demographic profiles with a micro model that focuses on access to health services and the ability to respond within the context of the changing regional environment. The authors’ study finds that: (1) the disparity in the prevalence of chronic conditions increases over time following the event, (2) the growth in health disparity may be slowed by regional resiliency intervention policies, and (3) mitigation efforts result in greater reductions in growth of chronic conditions among the black population relative the non-black general population. Knowledge of the disparate impact that such an event will have on the long-term health of underserved and medically fragile populations may be used to inform mitigation investments.