Proxy For Socioeconomic Status Research Articles

Provider Referral Patterns and Surgical Utilization Among New Patients Seen in Spine Clinic.

Retrospective chart review. The objective of this study was to elucidate the demographics of patient referrals from different sources and identify factors that affect a patient's likelihood of undergoing surgery. Despite baseline factors for surgical consideration, such as attempting conservative management, surgeons encounter many patients who are not surgically indicated. Overreferrals, that is, a patient referred to a surgeon that does not need surgery, can result in long wait times, delayed care, worse outcomes, and resource waste. All new patients at a single academic institution seen in the clinic by eight spine surgeons between January 1, 2018, and January 1, 2022, were analyzed. Referral types included self-referral, musculoskeletal (MSK), and non-MSK provider referral. Patient demographics included age, body mass index (BMI), zip code as a proxy for socioeconomic status, sex, insurance type, and surgical procedures undergone within 1.5 years postclinic visit. Analysis of variance and a Kruskal-Wallis test was used to compare means among normally and non-normally disturbed referral groups, respectively. Multivariable logistic regressions were run to assess demographic variables associated with undergoing surgery. From 9356 patients, 84% (7834) were self-referred, 3% (319) were non-MSK, and 13% (1203) were MSK. A statistically significant association with ultimately undergoing surgery was observed with MSK referral type compared with non-MSK referral [odds ratio (OR)=1.37, CI: 1.04-1.82, P =0.0246]. Additional independent variables observed to be associated with patients undergoing surgery included older age (OR=1.004, CI: 1.002-1.007, P =0.0018), higher BMI (OR=1.02, CI: 1.011-1.029, P <0.0001), high-income quartile (OR=1.343, CI: 1.177-1.533, P <0.0001), and male sex (OR=1.189, CI: 1.085-1.302, P =0.0002). A statistically significant association with undergoing surgery was observed with a referral by an MSK provider, older age, male sex, high BMI, and a high-income quartile home zip code. Understanding these factors and patterns is critical for optimizing practice efficiency and reducing the burdens of inappropriate referrals.

The association between educational status and colorectal neoplasia: results from a screening cohort

IntroductionEducational status is used as a proxy for socioeconomic status. While lower levels of education are generally associated with poorer health, the data on the relationship between educational status and colorectal neoplasia is heterogenous. The aim of our study was to examine this relationship and to adjust the association between educational status and colorectal neoplasia for other health parameters.MethodsWe included 5977 participants undergoing a screening colonoscopy in Austria. We split the cohort into patients with lower (n = 2156), medium (n = 2933), and higher (n = 459) educational status. Multivariable multilevel logistic regression models were fitted to evaluate the association between educational status and the occurrence of any or advanced colorectal neoplasia. We adjusted for age, sex, metabolic syndrome, family history, physical activity, alcohol consumption, and smoking status.ResultsWe found that the rates of any neoplasia (32%) were similar between the educational strata. However, patients with higher (10%) educational status evidenced significantly higher rates of advanced colorectal neoplasia compared to medium (8%) and lower (7%) education. This association remained statistically significant after multivariable adjustment. The difference was entirely driven by neoplasia in the proximal colon.ConclusionOur study found that higher educational status was associated with a higher prevalence of advanced colorectal neoplasia compared to medium and lower educational status. This finding remained significant even after adjusting for other health parameters. Further research is needed to understand the underlying reasons for the observed difference, especially with regard to the specific anatomical distribution of the observed difference.

Abstract 1950: Socioeconomic status and lung cancer incidence: An analysis of data from 15 countries in the Lung Cancer Cohort Consortium

Abstract Background: Lung cancer is the leading cause of cancer death worldwide. We explored the relationship between socioeconomic status and lung cancer incidence across world regions, using educational level as a proxy for socioeconomic status. Methods: We analyzed the harmonized database of the Lung Cancer Cohort Consortium (LC3). The current study included data from 18 prospective cohorts from 15 countries in the US, Europe, Asia, and Australia. Separately for participants who never or currently/formerly smoked, we estimated the association between educational level and incident lung cancer using Cox proportional hazards models. Information on education was harmonized using the International Standard Classification of Education and then modeled as an ordinal variable in 4 categories. Models were adjusted for age, sex, and for participants who currently/formerly smoked, smoking duration, cigarettes per day, and time since cessation. Results: Among 2.6 million participants from 15 countries, 62,645 developed lung cancer during follow-up (median follow-up = 12.6 years). Among current/former smokers, increased educational level was associated with decreased lung cancer incidence in most cohorts after adjustment for age, sex, and detailed smoking information, with HRs ranging from 0.77 (95%CI: 0.42-1.41) per 1-unit increase in educational level in the Iranian Golestan Cohort Study to 1.02 (95%CI: 0.95-1.09) in the Australian Melbourne Collaborative Cohort Study. When grouping by world region, the association between education and lung cancer incidence among currently/formerly smoking participants was similar for the US (HRpooled=0.88, 95%CI: 0.87-0.89), Europe (HRpooled=0.89, 95%CI: 0.88-0.91), and Asia (HRpooled=0.91, 95%CI: 0.86-0.96), but attenuated in the Australian cohort (HR=1.02, 95%CI: 0.95-1.09). Among never smokers, after adjustment for age and sex, there was no statistically significant association between educational level and lung cancer incidence (p-trend&amp;gt;0.05 in all cohorts), with the exception of the US Southern Community Cohort Study, which comprises primarily African-Americans and showed a HR of 0.75 (95%CI: 0.62-0.90). Conclusion: Among currently and formerly smoking individuals, higher educational level showed a strikingly consistent decreased risk of incident lung cancer across cohorts from 4 continents, after detailed adjustment for smoking. In contrast, among people who never smoked, there was no association between education and lung cancer incidence in any cohort, with the exception of the Southern Community Cohort Study. Further research is needed to clarify the mechanisms, either related or unrelated to smoking, that contribute to the association between education and lung cancer risk. Citation Format: Justina U. Onwuka, Hana Zahed, Xiaoshuang Feng, Karine Alcala, Mattias Johansson, Hilary A. Robbins, Lung Cancer Cohort Consortium. Socioeconomic status and lung cancer incidence: An analysis of data from 15 countries in the Lung Cancer Cohort Consortium [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1950.

Maternal education, classroom emotions, and literacy outcomes among grade 3/4 EFL learners

ABSTRACT Against the backdrop of rapidly growing attention to FL learners’ emotions, the present study investigated learners’ classroom emotions (anxiety, boredom, and enjoyment), literacy outcomes (reading and writing proficiency), and a largely neglected factor in FL emotions research to date – maternal education as a proxy for socio-economic status. One hundred and ninety-one Grade-three/four EFL learners from Hong Kong participated in this study. These learners completed a questionnaire about their classroom emotions, and reading and writing tests. Their parents/guardians attended individual interviews in which the highest level of maternal education was elicited. Overall, the results showed that maternal education and enjoyment were significantly associated with reading and writing proficiency. The contribution of maternal education to literacy outcomes was partially mediated by enjoyment, but not anxiety and boredom. The importance of maternal education and enjoyment are highlighted and discussed.

Does the place of residence influence your risk of being hypertensive? A study-based on Nepal Demographic and Health Survey

Even though several studies have examined various risk factors for hypertension, residential influence is poorly explored especially in the low-income countries. We aim to investigate the association between residential characteristics and hypertension in resource limited and transitional settings like Nepal. A total of 14,652 individuals aged 15 and above were selected from 2016-Nepal Demographic and Health Survey. Individuals with blood pressure ≥140/90 mmHg or a history of hypertension (as identified by physicians/health professionals) or under antihypertensive medication were defined as hypertensive. Residential characteristics were represented by area level deprivation index, with a higher score representing higher level of deprivation. Association was explored using a two-level logistic regression. We also assessed if residential area modifies the association between individual socio-economic status and hypertension. Area deprivation had a significant inverse association with the risk of hypertension. Individuals from the least deprived areas had higher odds of hypertension compared to highly deprived areas 1.59 (95% CI 1.30, 1.89). Additionally, the association between literacy a proxy of socio-economic status and hypertension varied with a place of residence. Literate individuals from highly deprived areas were likely to have a higher odds of hypertension compared to those with no formal education. In contrast, literate from the least deprived areas had lower odds of hypertension. These results identify counterintuitive patterns of associations between residential characteristics and hypertension in Nepal, as compared with most of the epidemiological data from high-income countries. Differential stages of demographic and nutritional transitions between and within the countries might explain these associations.

Abstract P3-03-08: Depression and breast cancer recurrence among female veterans in the United States: a retrospective cohort study

Abstract Background: The importance of mental health to improve the quality of cancer survivorship and outcomes is gaining increased attention. Major depressive disorder (MDD) has been associated with higher breast cancer (BC) incidence, BC-specific and all-cause mortality. The effect of MDD on BC recurrence remains under-studied. The Veterans Health Administration (VHA) provides a unique opportunity to examine this relationship as it mandates annual MDD screening in the primary care setting and reports national screening rates of 96%. Objective: To examine the relationship between pre-existing MDD and BC recurrence among a diverse cohort of women in the United States. Methods: We established a retrospective cohort of women (age ≥ 18 years) diagnosed with early-stage incident BC from 2010 through 2019 using the VHA’s electronic medical record database. We used a two-year window to identify women with clinically diagnosed MDD prior to their BC diagnosis. Our outcome of interest was BC recurrence (local recurrence/second primary and distant recurrence). We used multivariable proportional hazards regression to examine the association between MDD and BC recurrence, accounting for competing risk of death. Our analyses were adjusted for age, race, ethnicity, marital status, priority group rating (proxy for socioeconomic status), rurality of primary residence, geographical region, cancer stage, year of BC diagnosis, and comorbidity burden. Priority group rating is a metric that incorporates patients’ income, receipt of VHA assistance benefits, capacity for gainful employment, and severity of service-connected conditions. We conducted subgroup analyses by tumor subtype. RESULTS: Our cohort consists of 6,045 women with BC, of whom 1,750 (29.0%) had a pre-existing MDD diagnosis. The median length of follow-up from BC diagnosis was 4.5 years (IQR=4.8 years). The average age at BC diagnosis was 57 years (SD=11 years) overall and 56 years (SD=10 years) among women with MDD. Sixty-one percent of women were white, 29% were black, 27% were married, and 28% were rural dwelling. Forty-four percent of invasive carcinomas were localized and 21% were regional. Thirty-five percent of patients had ductal carcinoma in situ. Women with MDD had a higher average Charlson Comorbidity Index score (mean=0.75, SD=1.13 vs. mean=0.58, SD=1.03) and proportion with a priority group rating between 1-4 (40% vs. 32%). The distribution of other described patient characteristics among women with MDD were similar to the overall cohort. On multivariable analysis, women with MDD had a 31% (95% CI: 1.11, 1.56) higher risk of BC recurrence compared to women without MDD. MDD was associated with a 29% (95% CI: 1.01, 1.66) and 33% (95% CI: 1.05, 1.67) higher risk of local recurrence/second primary and distant recurrence, respectively. The relationship between MDD and BC recurrence remained significant after adjusting for tumor subtype (HR=1.40, 95% CI: 1.07, 1.83). In subgroup analyses stratified by tumor subtype, MDD was associated with a higher risk of BC recurrence among women with estrogen receptor positive versus negative tumors (HR=1.65, 95% CI: 1.27, 2.14 vs. HR=0.71, 95% CI: 0.34, 1.46) and HER2/neu negative versus positive tumors (HR=1.53, 95% CI: 1.16, 2.00 vs. HR=1.24, 95% CI: 0.51, 2.96). The interaction between estrogen receptor status and MDD was statistically significant (p-interaction=0.02). CONCLUSION: Women with incident BC should be screened for MDD early in the cancer care continuum given the prevalence of MDD and association with increased risk of local recurrence/second primary and distant BC recurrence. Further research is needed to understand the interplay between these two diseases and their treatments. Citation Format: Maya Aboumrad, Brian Shiner, Avonne Connor, Bradley V. Watts, Kala Visvanathan. Depression and breast cancer recurrence among female veterans in the United States: a retrospective cohort study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P3-03-08.

Association between socio-economic status and non-communicable disease risk in young adults from Kenya, South Africa, and the United Kingdom

There is a pressing need for global health preventions to curb the escalating burden of non-communicable diseases (NCDs). Utilising multi-country study designs can improve our understanding of how socio-economic context shapes the aetiology of NCDs, and this has great potential to advance global health interventions. We examined the association between socio-economic status (SES) and NCD risk, and the potential confounding effects of smoking and alcohol intake in young adults (18–35-year-olds) from Kenya, South Africa (SA), and the United Kingdom (UK). Our study was a cross-sectional online survey that included 3000 respondents (n = 1000 per country, 50% women) conducted in April 2022. We utilised information on twelve NCDs to classify respondents as having “no condition”, “one condition”, and “multimorbidity” (having two or more conditions). A total household asset score was calculated and used as a proxy of SES, and subsequently categorised into quintiles (Q1–Q5; lowest-highest). Ordered logistic regression was used to test the associations between NCD risk and exposure variables. In the UK sample, we found that those in the second lowest SES quintile (Q2) had lower odds of developing NCDs than their lowest SES counterparts (Q1). In contrast, South African and Kenyan youth with a SES score between middle and highest quintiles (Q3–Q5) were more likely to develop NCDs than the lowest SES quintile group. In all countries, smoking and/or alcohol intake were associated with higher odds of developing NCDs, and showed some confounding effects on the SES-NCD relationships. Specifically, in Kenya, the risk of developing NCD was more than two times higher in those in the middle (Q3) SES group (OR 2.493; 95% CI 1.519–4.091; p < 0.001) compared to their lowest (Q1) SES counterparts. After adjusting for smoking and alcohol, the ORs of middle (Q3) SES group changed from 2.493 to 2.241 (1.360–3.721; p = 0.002). Overall, we found that the strength and direction of SES-NCD associations differed within and between countries. This study highlights how different SES contexts shape the risk of NCDs among young adults residing in countries at different levels of economic development.

The Effect of Social Deprivation on Patient Satisfaction in Otolaryngology Clinics.

Multiple factors have been associated with lower satisfaction scores. We hypothesize that patients with a more deprived socioeconomic status will have different patient satisfaction scores than patients of higher socioeconomic status. We reviewed Press Ganey satisfaction scores for new, outpatient visits between January 1, 2014, and December 31, 2018. Due to the high ceiling effects of the survey, "satisfaction" was defined as achieving a perfect score of 100. We determined social deprivation using the 2015 Area Deprivation Index (ADI) which serves as a proxy for socioeconomic status derived from zip codes. Patient satisfaction was defined as a binary variable. Univariate and multivariate binary logistic regression analyses were used to identify factors correlated with patient satisfaction. There were 3239 unique new patients with completed surveys. Univariate analysis demonstrated decreased odds of achieving satisfaction for both the Total Score and Provider Sub-Score for each decile increase in ADI (OR 0.94; CI = 0.908-0.981; P = .003 and OR 0.94; CI = 0.91-0.98; P = .002 respectively). Multivariate analysis revealed the odds for reporting satisfaction for each decile increase in ADI were 0.96 for Total Score (CI = 0.921-0.998; P = .038) and 0.96 for Provider Sub-Score (CI = 0.92-0.993; P = .019). Patients in the most deprived quartile, compared to the least deprived, were significantly less likely to be satisfied with their care for both Total Score (OR 0.70; CI = 0.564-0.865; P = .001) and Provider Sub-Score (OR 0.69; CI = 0.558-0.852; P = .001). Increased social deprivation was an independent predictor of lower patient satisfaction in otolaryngology outpatients using the Press Ganey survey. This non-modifiable outcome should be taken into consideration when evaluating patient satisfaction scores and offers further support to the need of addressing and improving healthcare discrepancies in the field of otolaryngology. Level 3.

Race- and Neighborhood-Related Disparities Spanning the COVID-19 Pandemic: Trajectories of Combined Glycemic Control and BMI in Youth With Diabetes.

To use combined glycemic (HbA1c) and BMI z-score (BMIZ) trajectories spanning the coronavirus disease 2019 (COVID-19) pandemic to identify high-risk subgroups of adolescents with diabetes. Retrospective cohort of adolescents 10-19 years old with type 1 and type 2 diabetes with one or more visits at a large pediatric hospital from January 2018 through February 2020 (prepandemic) and April 2020 through August 2021 (pandemic). Group-based trajectory models were used to identify latent classes of combined BMIZ and HbA1c trajectories. Multinomial logistic regression was used to evaluate predictors of class membership, including Area Deprivation Index (ADI) (socioeconomic status proxy). The cohort included 1,322 youth with type 1 diabetes (93% White and 7% Black) and 59 with type 2 diabetes (53% Black and 47% White). For type 1 diabetes, six trajectory classes emerged. Black youth were more likely to be in the class with worsening glycemic control and concurrent BMIZ decrease at pandemic onset (relative risk ratio [RRR] vs. White: 3.0 [95% CI 1.3-6.8]) or in the class with progressively worsening glycemic control and obesity (RRR 3.0 [95% CI 1.3-6.8]), while those from the most deprived neighborhoods (RRR ADI tertile 3 vs. 1: 1.9 [95% CI 1.2-2.9]) were more likely to be in the class with stable obesity and glycemic control. For type 2 diabetes, three distinct trajectories emerged, two of which experienced worsening glycemic control with concurrent BMIZ decline at pandemic onset. Race and neighborhood deprivation were independently associated with distinct glycemic and BMIZ trajectory classes in youth with diabetes, highlighting persistent and widening disparities associated with the COVID-19 pandemic.

Factors that influence morningness-eveningness and daytime sleepiness: A cross-cultural comparison of Iranian and Brazilian adolescents

ABSTRACT As adolescents get older, they become more evening oriented and, because they are usually expected to wake early to attend school, they often present daytime sleepiness, which is associated with negative outcomes. It is still unclear if this is similar cross-culturally. Here, we studied morningness-eveningness and daytime sleepiness in early adolescence from two different developing nations (Brazil and Iran). A total sample of 697 Iranian and Brazilian early adolescents (9- to 15-year-old; 358 boys) from Tehran, Iran, and São Paulo, Brazil, varying in age and parental schooling (a proxy of socioeconomic status: SES) completed the Morningness–Eveningness Scale for Children (MESC) and the Pediatric Daytime Sleepiness Scale (PDSS) and reported their total sleep time on school nights. They also filled in the Pubertal Developmental Scale to determine their pubertal status. A negligible cross-cultural difference in morningness-eveningness was found, indicating that Brazilians showed a slight circadian-phase delay compared with Iranians throughout all tested ages. There was also seen a very slight increase in phase delay as early adolescents aged, indicative of more eveningness. However, there were no country differences in daytime sleepiness once total sleep time during school nights was controlled for, which was the only factor that affects PDSS scores.

Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic.

COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System. We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status. During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care. We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

Inequalities in the quality and proximity of green space exposure are more pronounced than in quantity aspect: Evidence from a rapidly urbanizing Chinese city

Substantial studies have revealed that exposure to green spaces (GSs) yields a variety of health benefits. However, daily GS exposure scenarios are multidimensional, and relevant analyses require a comprehensive framework that assesses GS exposure from overhead- to eye-level perspectives, focusing on GS attributes from quantity and proximity to quality. Moreover, GSs are often unevenly distributed across cities, resulting in green distribution injustice. To this end, this study aimed to systematically evaluate multiple GS exposures considering two-dimensional (2D) spatial exposures (i.e., quantity-based availability, distance-based accessibility, and quality-based attractiveness) and three-dimensional (3D) visual exposures (quantity-based street GS visibility and quality-based street GS perceivability). It then examined the inequalities in GS exposure among socioeconomically disadvantaged groups. Housing prices were employed as proxies for socioeconomic status. Local indicators of spatial association(LISA) were employed to examine the existence of bivariate statistically significant spatial clusters of housing prices and multiple GS exposure. Furthermore, the spatial lag regression model was used to determine inequities in GS exposure among urban residents living in communities with different housing prices. The Nanjing metropolitan area, one of the most densely populated cities in China, was selected as the study case. Residential exposure to GS was comprehensively assessed using a 15-min walkable zone lens. The results suggest that: 1) the spatial cluster of ‘low GS exposure – low housing price’ occupied the largest proportion; 2) all five types of GS exposure were positively associated with housing prices, indicating that the affluent groups are more likely to have access to various GSs; and 3) GS exposure inequalities are more pronounced in measurements of quality(and proximity) than quantity in both spatial and visual exposure metrics. These findings can inform the development of environmental planning and policy strategies for more effective, efficient, and equitable GS provisions that address health issues and green injustice in rapidly urbanizing cities.

Multi‐ethnic differences in brain and biopsychosocial risk factors for ADRD in UK immigrants from the Middle East and North Africa (MENA)

AbstractBackgroundThe populations of the Middle East and North Africa countries (MENA) are predicted to contribute to the world’s sharpest increases in rates of Alzheimer’s disease and related dementias (ADRD) in the coming years (GBD 2022), yet this group is underrepresented in health studies. The UK Biobank provides one of the largest and well‐characterized datasets on aging immigrants in the UK. We compare risk factors for ADRDs between UK immigrants from MENA countries to those of immigrants from other countries.MethodImmigrants from MENA countries (N = 3557), India (N = 2959), Germany (N = 1103), and genetically‐determined British individuals (N = 1929) born outside of the UK in any of the three areas of interest were included in the study. There are multiple definitions of MENA: here, MENA was defined broadly to include the union of all included countries; Figure 1 highlights the distribution in this sample. We focused on variables associated with suboptimal brain aging and ADRD risk: APOE genotypes; education; an algorithmically defined diet quality score (Zhuang, 2021); BMI; incidence of parental death before 65 years; and the Townsend deprivation index (TDI) as a proxy of socioeconomic status (SES). Chi‐squared or Mann‐Whitney tests provided statistics on distribution discrepancies for categorical or continuous data, respectively. We also charted hippocampal volumes with age for the subset of each ethnic group who underwent neuroimaging.ResultFigure 2 highlights group demographics and distributions. Compared to all other groups (Figure 3), MENA groups had higher TDI (lower SES), lowest diet quality, and highest BMIs; these differences remained even in college educated individuals. MENA also reported a greater incidence of maternal deaths before age 65. German immigrants were more highly educated than all other groups. ApoE4 alleles were significantly less prevalent in MENA and Indian countries than groups of European ancestry (Figure 4). Hippocampal volumes, adjusted for intracranial volume, had similar age‐trends across groups.ConclusionMany ADRD risk factors differ substantially across different ethnic groups, even when the proportion with a college education is not different. It is imperative to understand underlying lifestyle and sociological factors associated with immigration, to provide adequate healthcare for all aging individuals.

Association between Cumulative Airborne Dioxin Exposure and Chronic Lymphocytic Leukemia/Non-Hodgkin's Lymphoma Risk in a Nested Case-Control Study within the French E3N Cohort

Background: Dioxins are a family of lipophilic, bio-accumulative chemical compounds belonging to persistent organic pollutants groups. The TCDD (2, 3, 7, 8 tetrachlorodibenzo-para-dioxin) which is the most toxic congener of dioxins is classified as carcinogen to humans by the International Agency for Research on Cancer. Airborne dioxins exposure is suspected to increase the risk of Chronic Lymphocytic Leukemia (CLL) and non-Hodgkin's lymphoma (NHL) in some studies. Although dioxins are bio-accumulative in the human body, no epidemiological study had assessed the relationship between cumulative airborne dioxin exposure and CLL/NHL risk. Objective: The relationship between cumulative airborne dioxin exposure and CLL or NHL risk was assessed in a case-control study nested within the French E3N cohort (cohort of 98 995 women covered by the health insurance provider of the national education system). Materials and methods: All incident cases of CLL/NHL diagnosed between 1990 and 2008 were selected. They were identified by self-administered questionnaires as well as through reports from family members and from the national cause of death registries. All cases were validated with medical reports. Subtypes of NHL were classified according to the International Lymphoma Epidemiology Consortium working group classification of lymphoid neoplasms for epidemiologic research. 368 incident cases of CLL and NHL were matched to 368 controls on age (± 1 year) and on the department of residence reported at inclusion in 1990. Cumulative exposure to airborne dioxins was estimated for each participant at the individual address level using a Geographic Information System (GIS) based exposure index including residence-to-source distance, wind direction, annual dioxin emission intensity, length of operation and meteorological parameters (1). Airborne dioxin exposure was summarized into a cumulative exposure index from the latest inclusion date (i.e., the date of return of the first questionnaire) of the case-control pair, to the index date (i.e., the date of diagnosis of the case). Multivariate conditional logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI). The main model was adjusted on education level used as a proxy for socioeconomic status, place of residence, body mass index (kg/m2), physical activity (metabolic equivalent activity task-hour per week (MET-h/w)) and smoking status. Results: The mean follow-up time was 11.7 years ranging from 0.2 to 19.4 years and the cumulative exposure index averaged was 3.6 µg-TEQ/m2. The mean age of women at diagnosis of CLL/NHL was 63.3 years. The subtype distribution was 23% of Diffuse Large B-cell Lymphoma (DLBCL), 19% of Follicular Lymphoma (FL), 27% of CLL & small lymphocytic lymphoma (SLL), 11% of Marginal Zone Lymphoma (MZL) and 20% of other NHL. We observed a statistically significant positive association between the cumulative dioxin exposure index and the CLL/NHL risk (OR and 95% CI: 1.2 (1.0,1.4) for a 4.4 log µg-TEQ/m2 increase corresponding to a standard deviation). Analysis by subtypes showed a significant association between the CLL/SLL subtypes and the cumulative continuous exposure index (OR and 95% CI: 1.6 (1.1,2.3)) (Table 1). Discussion/Conclusion: The present study supports a positive significant association between cumulative airborne dioxin exposure and CLL/NHL risk, and, more specifically, a positive significant association for CLL & SLL. Our findings are consistent with publications that found positive associations between dioxin exposure and CLL/NHL risk. This is the first epidemiological study investigating the relationship between cumulative airborne dioxins exposure and CLL/NHL risk using a GIS-based cumulative exposure index and a multi-source approach. These findings contribute to justify the efforts to decrease the airborne exposition to dioxins. Additional studies evaluating the association between cumulative dioxin exposure and other hematologic malignancies are required. Reference 1. Coudon, T., Danjou, A.M.N., Faure, E. et al. Development and performance evaluation of a GIS-based metric to assess exposure to airborne pollutant emissions from industrial sources. Environ Health18, 8 (2019). https://doi.org/10.1186/s12940-019-0446-x Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The impact of the COVID-19 pandemic on racial disparities in patients undergoing total shoulder arthroplasty in the United States

The purpose of this study was to assess racial disparities in total shoulder arthroplasty (TSA) in the United States and to determine whether these disparities were affected by the COVID-19 pandemic. Centers for Medicare and Medicaid Services (CMS) 100% sample was used to examine primary TSA volume from April to December from 2019 to 2020. Utilization was assessed for White, Black, Hispanic, and Asian populations to determine if COVID-19 affected these groups differently. A regression model adjusted for age, sex, CMS-hierarchical condition categories (HCC) score, dual enrollment (proxy for socioeconomic status), time-fixed effects, and core-based statistical area fixed effects was used to study difference across groups. In 2019, the TSA volume per 1000 beneficiaries was 1.51 for White and 0.57 for non-White, with a 2.6-fold difference. In 2020, the rate of TSA in White patients (1.30/1000) was 2.9 times higher than non-White (0.45/1000) during the COVID-19 pandemic (P<.01). There was an overall 14% decrease in TSA volume per 1000 Medicare beneficiaries in 2020; non-White patients had a larger percentage decrease in TSA volume than White (21% vs. 14%, estimated difference; 8.7%, P=.02). Black patients experienced the most pronounced disparity with estimated difference of 10.1%, P=.05, compared with White patients. Similar disparities were observed when categorizing procedures into anatomic and reverse TSA, but not proximal humerus fracture. During the COVID-19 pandemic, overall TSA utilization decreased by 14% with White patients experiencing a decrease of 14%, and non-White patients experiencing a decrease of 21%. This trend was observed for elective TSA, while disparities were less apparent for proximal humerus fracture.

Occupational class and risk of hepatitis B and C viral infections: A case-control study-based data from a nationwide hospital group in Japan

BackgroundOccupational class, a proxy for socio-economic status, is a known factor for health disparities. However, no study has reported the association between occupational class and the risk of viral hepatitis B and C (HBV/HCV) infections. We investigated the effects of occupational class on the prevalence of HBV/HCV infections. MethodsThis is an unmatched hospital-based case-control study that included 12,101 patients who were diagnosed with HBV infection (ICD–10, B16.0, B16.1, B16.2, B16.9, B17.0, B18.0, B18.1) or HCV infection (ICD–10, B17.1, B18.2) and 698,168 controls (those with non-HBV/HCV-related diseases) aged ≥ 20 years who were initially hospitalized between 2005 and 2019. Patients were categorized according to occupational class (blue-collar, service, professional, and manager) and industrial sector (blue-collar, service, and white-collar). Managers in the blue-collar industry were set as the reference group, and the odds ratios (ORs) for the risk of HBV and HCV infections were calculated. ResultsOccupational class was significantly associated with only HCV infection risk. Professionals in all industrial sectors showed the lowest risk for HCV (OR (95% confidence intervals [CIs]) = 0.69 [0.58–0.82] in the blue-collar industry, 0.52 [0.38–0.73] in the service industry, and 0.60 [0.52–0.70] in the white-collar industry). Further, after adjusting for sex, age, and region of admitting hospital, all occupational classes in the white-collar industry showed lower risks of HCV than those in the other industries (ORs= 0.58 [0.47–0.71] in blue-collar workers, 0.74 [0.64–0.84] in service workers, 0.60 [0.52–0.70] in professionals, and 0.81 [0.64–1.02] in managers in white-collar industry). ConclusionsOccupational class was closely associated with HCV infection risk only. Considering that blue-collar workers in the white-collar industry also showed a low risk, adequate measures should be taken against hepatitis, possibly because of the screening tests and cure implemented in that population.

Chromosomal Abnormality, fetal/neonatal Death and Socioeconomic Status: A Prospective Cohort Study.

To assess the risk gradient of chromosomal abnormalities and fetal or neonatal death across a socioeconomic spectrum of pregnant women. We used the data from the Korean Prenatal Diagnosis Study (KPDS), which included singleton pregnancies who were candidates for fetal aneuploidy screening enrolled from the Seoul Capital Area from December 2016 to April 2018. We analyzed chromosomal abnormalities which were diagnosed pre- or postnatally, and fetal or neonatal death. The highest level of education among the women and the average monthly household income were used as proxies for socioeconomic status. Among the 6,715 women, the majority of were 30-39 years old and university graduates, with a reported household income higher than the national median. Chromosomal abnormalities occurred in 45 women (6.7 per 1,000). Fetal or neonatal death occurred in 70 (11.3 per 1,000), excluding pregnancies affected by chromosomal abnormality diagnosis. The adjusted odds ratio for chromosomal abnormalities was higher when household income was < 4,484 USD per month. For fetal or neonatal death, the risk estimates for lower education and lower household income were generally positive but remained imprecise. We observed some evidence of an inverse association between the risk of fetal chromosomal abnormality and level of household income in a prospective cohort of pregnant women. Interventions to reduce socioeconomic disparities in perinatal health should focus on those with a low household income.

Abstract 14071: Sleep as a Contributor to Socioeconomic Disparities in Hypertension: The Midlife in the United States (MIDUS) II Study

Introduction: Hypertension is highly prevalent among adults in the United States and is a major risk factor for cardiovascular disease (CVD). Previous research has found that hypertension is distributed inequitably, with a higher burden of hypertension among individuals of lower socioeconomic status (SES). However, limited studies have investigated the role of sleep quality, a risk factor for CVD, in understanding socioeconomic disparities in hypertension. Methods: We used cross-sectional data from the Midlife in the United States (MIDUS) II. Participants underwent seven days of actigraphy and completed biological assessments, including blood pressure measurements. Sleep quality was measured as actigraphy-defined wakefulness after sleep onset (WASO) and sleep efficiency. Our analysis consisted of participants with complete data on educational attainment, our proxy for SES (n=426). Poisson and linear regression models were fit to examine associations between SES, sleep quality, and hypertension or blood pressure (continuous). We controlled for age, gender, race, body mass index, and perceived stress. Sensitivity analyses measuring SES with the Socioeconomic Index Score were also conducted (n=274). Results: Participants had a mean age of 53.5 years (SD=12.4), were 59.6% female, and were 42.5% Black American. The prevalence of poor WASO (&gt; 30 minutes), low SE (&lt;85%), and hypertension was 77.7%, 67.1%, and 61.0%, respectively. Low SES was associated with a higher prevalence of hypertension but was attenuated after adjustment for race. SES was not associated with sleep or hypertension after adjustment for covariates. Individuals with high (vs. low) sleep efficiency had 19% lower prevalence of hypertension (PR=0.81, 95% CI: 0.66, 0.98), lower systolic blood pressure (β= -4.69, 95% CI: -8.63, -0.75), and lower diastolic blood pressure (β= -2.59, 95% CI: -5.00, 0.18) after adjustment for covariates. There was no evidence of sleep mediating the SES-hypertension relation. Conclusions: Effective interventions to lower the prevalence of hypertension should consider strategies that target sleep efficiency. Future research should explore the intersectionality of SES and race, as race may modify the association between SES and hypertension.

Abstract 14644: The Association Between Neighborhood Distress and Outcomes Following Peripheral Vascular Intervention

Introduction: Peripheral arterial disease (PAD) is associated with an elevated risk of mortality. Low socioeconomic status (SES) is associated with increased prevalence and severity of PAD, and low SES has been associated with poor post procedural outcomes in cardiovascular disease. The Distressed Communities Index (DCI) uses seven common proxies of SES, such as educational attainment, housing stability, median income, and employment rate, to generate an aggregate score at a zip code level. Hypothesis: We hypothesized that increased levels of neighborhood distress, as measured by the DCI, is associated with an increased risk of mortality and amputation after PVI. Methods : We queried the Vascular Quality Initiatives (VQI) database, linked with Medicare claims data for patients who had undergone PVI. A total of 16,980 patients with PVI were found and 53 Excluded because ≥ 1 missing data for covariate used in modelling and 381 because DCI Missing. Patient 5-digit zip codes were used to obtain a DCI score (range 1-100, with higher scores indicating greater distress) from the Economic Innovation group. We examined the association between DCI and 2-year mortality and major amputation. Results: At 24 months, 2 964 (17.5%) had died 1 669 (9.9%) and had a major amputation DCI score was positively associated 2-year mortality risk. A 10-point higher DCI score was associated with increased mortality risk (unadjusted HR=1.02; 95%CI [1.01,1.03]) and a higher risk of amputation (unadjusted HR=1.05; 95%CI [1.04,1.07]). Fig. Conclusions: Higher level of community deprivation was associated with increased risk of short-and long-term mortality and amputation outcomes following PVI. PAD care pathways should integrate improved risk assessments and integrated care models for patients from distressed communities to help address health disparities.

Gender differences in social environmental factors of psychological distress among Indonesian adolescents: Findings from the 2015 Global School-based Student Health Survey.

This study aimed to investigate gender differences in social environmental factors of psychological distress among Indonesian adolescents. This was a cross-sectional study using the data from the 2015 Indonesia Global School-based Student Health Survey. Binary logistic regression was used to assess the influences of main independent variables - social environmental factors (i.e., peer support, having close friends, bullying victimisation, physical fight, physical attack, parental supervision, connectedness, bonding), demographic characteristics, and health-related behaviours on the measures of psychological distress (loneliness, anxiety-induced sleep disturbance, and a combination of both measures as psychological distress). The prevalence of psychological distress measured as loneliness, anxiety-induced sleep disturbance, and combined psychological distress was 6.12%, 4.52%, and 8.04%, respectively. Findings from multivariate analyses indicated that bullying victimisation, physical attack, experience of hunger (a proxy of socioeconomic status), and sedentary behaviour were associated with all measures of psychological distress. Meanwhile, age, gender, drug use, parental connectedness and bonding, and having no close friends were correlates of one or two measures of psychological distress. Based on gender-stratified analyses, experience of hunger, sedentary behaviour, bullying victimisation, and having no close friends were consistently associated with measures of psychological distress among both girls and boys. In addition, the influence of some social environmental factors, such as parental connectedness, peer support, and physical attack, were more salient among girls. The findings suggest that social environmental factors, demographic characteristics, and health-related behaviours were associated with psychological distress, and the associations appeared to differ by gender. Interventions that include improving positive social environmental factors (e.g., reducing interpersonal violence, encouraging positive relationships with parents and peers) and promoting healthy behaviours (e.g., less sedentary behaviour, preventing substance use) might help reduce the risk of psychological distress among Indonesian adolescents.