Racial Disparities In Mortality Research Articles

Where Does the Black–White Life Expectancy Gap Come From? The Deadly Consequences of Residential Segregation

AbstractThe disparity in life expectancy between white and black Americans exceeds five years for men and three years for women. While prior research has investigated the roles of healthcare, health behaviors, biological risk, socioeconomic status, and life course effects on black mortality, the literature on the geographic origins of the gap is more limited. This study examines how the black–white life expectancy gap varies across counties and how much of the national gap is attributable to within‐county racial inequality versus differences between counties. The estimates suggest that over 90 percent of the national gap can be attributed to within‐county factors. Using a quasi‐experimental research design, I find that black–white residential segregation increases the gap by approximately 16 years for men and five years for women. The segregation effect loads heavily on causes of death associated with access to and quality of healthcare; safety and violence; and public health measures. Residential segregation does not appear to operate through health behaviors or individual‐level factors but instead acts primarily through institutional mechanisms. Efforts to address racial disparities in mortality should focus on reducing racial residential segregation or reducing inequalities in the mechanisms through which residential segregation acts: public services, employment opportunities, and community resources.

BEHAVIORAL HEALTH PREDICTORS OF PREMATURE MORTALITY IN A BLACK AMERICAN LONGITUDINAL COHORT

Abstract Life expectancy among Americans is now the lowest it has been in 15 years. While startling, more alarming are the persistent racial disparities in mortality. Black Americans continue to die at significantly younger ages with Black men living, on average, 7.0 fewer years and Black women living 4.4 fewer years than their White counterparts. To inform intervention strategies and resource allocation, we need a complete understanding of the role that malleable factors, such as substance use and depression early in the life course, play in premature mortality for aging Black Americans. This study illuminates behavioral health factors that can be targeted to eliminate mortality disparities among a longitudinal cohort followed from childhood into their 60s. Utilizing data from the Woodlawn Study, a well-defined neighborhood cohort study of 1,242 Black Americans that began in 1966 (age 6), we examined the predictive value of family history of substance use, adolescent substance use and depression, and young adult substance use and depression. Through 2021 (modal age 61), based on National Death Index reports, 21.6% of the original cohort (n=268) has passed away. The poster will present cause and timing of death by gender and adjusted logistic regression findings showing that depression symptoms as early as adolescence (age 16) predict midlife mortality occurring between ages 32 and 60 (p=.003) and that those diagnosed with depression or a substance use disorder in young adulthood are 61% (p=.025) and 85% (p=.001) more likely to die by age 60. Policy and prevention implications will be presented.

RACIAL DIFFERENCES IN THE RELATIONSHIP BETWEEN LONELINESS AND COGNITION AMONG OLDER ADULTS IN THE MIDWEST

Abstract Findings from various studies have revealed a relationship between loneliness and negative health outcomes, including cognitive decline and dementia. The strength and direction of this relationship has been contested as there is wide variability in definitions and testing criteria for loneliness. If loneliness is risk factor for cognitive decline, it may represent a cost-effective site for interventional design. We used data from the Precision Health Initiative’s Person to Person Health Interview Study (P2P), a cross-sectional survey conducted in Indiana from 2020-2021, to investigate the relationship between loneliness (UCLA 3-item loneliness scale) and cognition (The Montreal Cognitive Assessment; MoCA) among older adults and to determine if the strength of the relationship varies for black and white adults. Among our subsample of adults 55 and older, over one quarter (26.7%) reported loneliness, with white respondents reporting more loneliness than black respondents (26.8 and 22.0%, respectively). Being lonely was associated with lower cognition, as was being older, male, black, and having no college education. However, we found that loneliness was associated with worse cognition, for white adults only. Although black respondents in our sample reported more loneliness than older white adults after age 70, we did not have adequate power to determine if advanced age moderated the relationship. Our findings highlight the role of loneliness in cognition for older, white adults and the need for more research to assess this relationship for the “mid-“ and “oldest-old” black adults who may be more susceptible to loneliness due, in part, to racial disparities in mortality.

Racial disparities in septic shock mortality: a retrospective cohort study

Patients with septic shock have the highest risk of death from sepsis, however, racial disparities in mortality outcomes in this cohort have not been rigorously investigated. Our objective was to describe the association between race/ethnicity and mortality in patients with septic shock. Our study is a retrospective cohort study of adult patients in the OneFlorida Data Trust (Florida, United States of America) admitted with septic shock between January 2012 and July 2018. We identified patients as having septic shock if they received vasopressors during their hospital encounter and had either an explicit International Classification of Disease (ICD) code for sepsis, or had an infection ICD code and received intravenous antibiotics. Our primary outcome was 90-day mortality. Our secondary outcome was in-hospital mortality. Multiple logistic regression with Least Absolute Shrinkage and Selection Operator (LASSO) for variable selection was used to assess associations. There were 13,932 patients with septic shock in our cohort. The mean age was 61 years (SD 16), 68% of the cohort identified as White (n=9419), 28% identified as Black (n=3936), 2% (n=294) identified as Hispanic ethnicity, and 2% as other races not specified in the previous groups (n=283). In our logistic regression model for 90-day mortality, patients identified as Black had 1.57 times the odds of mortality (95% CI 1.07-2.29, p=0.02) compared to White patients. Other significant predictors included mechanical ventilation (OR 3.66, 95% CI 3.35-4.00, p<0.01), liver disease (OR 1.75, 95% CI 1.59-1.93, p<0.01), laboratory components of the Sequential Organ Failure Assessment score (OR 1.18, 95% CI 1.16-1.21, p<0.01), lactate (OR 1.10, 95% CI 1.08-1.12, p<0.01), congestive heart failure (OR 1.19, 95% CI 1.10-1.30, p<0.01), human immunodeficiency virus (OR 1.35, 95% CI 1.04-1.75, p=0.03), age (OR 1.04, 95% CI 1.04-1.04, p<0.01), and the interaction between age and race (OR 0.99, 95% CI 0.99-1.00, p<0.01). Among younger patients (<45 years), patients identified as Black accounted for a higher proportion of the deaths. Results were similar in the in-hospital mortality model. In this retrospective study of septic shock patients, we found that patients identified as Black had higher odds of mortality compared to patients identified as non-Hispanic White. Our findings suggest that the greatest disparities in mortality are among younger Black patients with septic shock. National Institutes of Health National Center for Advancing Translational Sciences (1KL2TR001429); National Institute of Health National Institute of General Medical Sciences (1K23GM144802).

Racial Disparities in Liver Disease Mortality Trends Among Black and White Populations in the United States, 1999-2020: An Analysis of CDC WONDER Database.

Liver disease is a significant public health problem in the United States, with notable racial disparities in mortality. This study examines liver disease mortality trends among Black and White populations during 1999-2020. We used CDC WONDER database to ascertain liver disease age-standardized mortality rates in Black and White Americans. Annual percent change was calculated. Age-standardized absolute rate difference and rate ratios were computed by subtracting and dividing the White population's rate from that of the Black population. Liver diseases accounted for 171,627 Black and 1,314,903 White deaths during 1999-2020. Age-standardized mortality rates for Blacks decreased from 22.5 to 20.1 per 100,000 person-years (annual percentage change -0.4%, -0.6% to -0.2%), whereas an increase was observed for Whites, from 17.9 to 25.3 per 100,000 person-years (annual percentage change 1.4%, 1.4% to 1.7%). The rate ratio decreased from 1.26 (1.22-1.29) in 1999 to 0.79 (0.78-0.81) in 2020. This pattern was evident in all census regions, more pronounced among the younger (age 25-64 years) than older (age 65+ years) population and observed across different urbanization levels. The pattern may be attributable to increasing alcohol-related liver disease and metabolic dysfunction-associated steatotic liver disease-related deaths in Whites and tapering in viral hepatitis and primary liver cancer-related deaths in Blacks. Despite notable improvement, racial disparities persist in primary liver cancer and viral hepatitis among the Black population. The rise in alcohol-related liver disease and metabolic dysfunction-associated steatotic liver disease-related deaths among Whites, and enduring liver cancer and viral hepatitis disparities in the Black population, underscores the urgent need for tailored public health interventions.

Increased Mortality of Black Incarcerated and Hospitalized People: a Single State Cohort Analysis.

To quantify racial disparities in mortality and post-hospitalization outcomes among incarcerated individuals that were hospitalized during their incarceration period. We designed a retrospective cohort study using administrative and hospital data collected from a preferred healthcare referral center for all Massachusetts jails and prisons between January 2011 and December 2018 with linkage to Massachusetts Vital Records and Statistics. We identified 4260 incarcerated individuals with complete data on race/ethnicity that were hospitalized during the study period. The primary study indicators were age, race, ethnicity, length of hospital stay, Elixhauser comorbidity score, incarceration facility type, and number of hospital admissions. The primary outcome was time to death. Of the incarcerated individuals that were hospitalized, 2606 identified as White, 1214 identified as Black, and 411 people who identified as some other race. The hazard of death significantly increased by 3% (OR: 1.03; 95% CI: 1.02-1.03) for each additional yearly increase in age. After adjusting for the interaction between race and age, Black race was significantly associated with 3.01 increased hazard (95% CI: 1.75-5.19) of death for individuals hospitalized while incarcerated compared to White individuals hospitalized while incarcerated. Hispanic ethnicity and being incarcerated in a prison facility was not associated with time to mortality, while increased mean Elixhauser score (HR: 1.07; 95% CI: 1.06-1.08) and ≥ 3 hospital admissions (HR: 2.47; 95% CI: 2.07-2.95) increased the hazard of death. Our findings suggest disparities exist in the mortality outcomes among Black and White individuals who are hospitalized during incarceration, with an increased rate of death among Black individuals.Despite hypothesizedequal access to healthcare within correctional facilities, our findings suggest that incarcerated and hospitalizedBlack individuals may experience worse disparities than their White counterparts, which has not been previouslyexplored or reported in the literature. In addition to decarceration, advocacy, and political efforts, increasedefforts to support research access to datasets of healthcare outcomes, including hospitalization and death, forincarcerated people should be encouraged. Further research is needed to identify and address the implicit and explicit sources of these racial health disparities across the spectrum of healthcare provision.

Racial Disparities, Advanced Ovarian Cancer, and HER2 Expression: 2023 ASCO Annual Meeting Highlights for the Advanced Practitioner

Andrew S. Guinigundo, MSN, RN, CNP, ANP-BC, of Cincinnati Cancer Advisors, discusses the effect of Medicaid expansion on racial disparities in mortality among patients with gastrointestinal malignancies. He also describes the phase III DUO-O trial, which evaluated therapies for patients with advanced ovarian cancer without a BRCA1/2 mutation. Finally, the first tumor-agnostic global study of fam-trastuzumab deruxtecan-nxki showed encouraging results in patients with different cancers.

Racial disparities in cancer mortality in patients with gastrointestinal malignancies following Medicaid expansion.

6546 Background: Racial minorities experience disparities in receipt of cancer treatment and survival. The optional Medicaid expansion provision of the Affordable Care Act provided federal funding to participating states to improve healthcare access for disadvantaged populations by expanding Medicaid eligibility criteria. This study aimed to investigate the effect of Medicaid expansion on racial disparities in mortality among patients with gastrointestinal malignancies. Methods: A cross-sectional cohort study of patients with pancreatic ductal adenocarcinoma (PDAC), colorectal cancer (CRC), and gastric adenocarcinoma (GC) of any stage was conducted using the National Cancer Database (2009-2019). Difference-in-difference analysis (DID) was performed to compare adjusted 2-year mortality separately among Black and White patients residing in Medicaid expansion states (MES) and non-expansion states (non-MES) before (2009-2013) and after (2014-2019) expansion. Differences in receipt of surgery and chemotherapy were also evaluated. Results: A total of 86,052 patients were included for analysis, including 19,188 patients with PDAC, 60,404 with CRC, and 6,460 with GC. Two-year mortality decreased among Black patients with PDAC residing in MES compared to non-MES following expansion (DID -9.4%, p&lt;0.001) (Table). Mortality also decreased among Black and White patients with CRC in MES compared to non-MES following expansion (DID -4.2%, p &lt; 0.001 and -2.9%, p = 0.047). Among patients with GC, Black patients in MES experienced a marked reduction in mortality compared to non-MES (DID -7.7%, p = 0.07). Both Black and White stage 3-4 PDAC patients had an increase in receipt of chemotherapy in MES following expansion (DID 3.7%, p=0.28 and DID 2.7%, p=0.20). Rates of surgery, but not chemotherapy receipt, increased among Black patients with stage 4 CRC in MES following expansion (DID 5.7%, p=0.03 and 1.0%, p=0.66, respectively). A greater increase in receipt of chemotherapy was observed among Black patients with stage 4 GC in MES than in non-MES (DID 11%, p=0.06). Conclusions: Medicaid expansion was associated with a greater reduction in 2-year mortality rates for Black patients residing in MES than for those in non-MES. Existing racial disparities in mortality remained the same or worsened in non-MES but in almost all cases were mitigated in MES following Medicaid expansion. [Table: see text]

Unveiling inequities in palliative care and clinical trial participation among patients with metastatic breast cancer in the state of Florida.

12120 Background: Persistent inequities in the care for patients with metastatic breast cancer (mBC) were recognized by ASCO and, in partnership with Pfizer, awarded our team a grant to understand and address them in people of color. Florida has a higher age-adjusted percentage of breast cancer in females and a higher mortality rate in those under the age of 65 compared to the United States. The racial disparity in mortality is further magnified among female patients with mBC. Therefore, we sought to characterize the prevalence and trends of palliative care utilization and clinical trial participation (CTP) among Floridians with mBC and quantify the associated factors. Methods: Using the OneFlorida+ Data Trust, a repository of patient-level electronic health records of ~17 million Floridians seen in public and private health care systems, including those enrolled in Medicaid, we obtained demographics of mBC patients, including sex, age, race, and ethnicity, insurance type, zip-code based socioeconomic status, Charlson comorbidity index (CCI) and rural/urban residence. CPT codes were obtained for palliative care services between the date of mBC diagnosis and death, including pain management, psychology, psychiatry, nutrition, and advanced care planning. Our analysis included the Cochran-Armitage trend test and bivariate analysis to correlate patient characteristics to palliative care receipt and CTP. Results: In Florida, 25,225 individuals (1.5% men and 98.5% women) were diagnosed with mBC between 2012 and 2021; 49.3% were under age 60. 19.5% of this cohort received palliative care at a median time of 10.1 months (IQR 2.1 – 27.1) from the initial diagnosis of mBC. The median survival was 13.6 months (IQR 3.4 – 31.6). On multivariable analysis, significant variables (p &lt; 0.001) associated with increased palliative care utilization were Non-Hispanic Black, self-pay/uninsured and Medicaid insured, and a CCI of 5+. Only 3% of the study cohort had advanced care planning. There was a declining trend in CTP among patients with mBC, from 13.9% in 2012 to 7.9% in 2021. Among those participating in clinical trials, 80.2% did not receive palliative care. Variables associated with higher CTP (p &lt; 0.001) were younger age (18-49), Asian and Hispanic race/ethnicity, the highest quartile of median household income and education level, private insurance, metropolitan residence, and CCI of 0. Further, there was a trend towards more prolonged survival among those enrolled in clinical trials. Conclusions: This robust statewide assessment highlights that less than 20% of patients with mBC receive palliative care, and its receipt is exclusive of CTP. We identified significant racial and socioeconomic disparities in CTP. Educational interventions with palliative care trained navigators, partnerships with providers on palliative care benefits, and state policy support are needed.

Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia

There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality. Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses. Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (β=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (β=0.01, p=0.002) or with mental health disorders (β= -0.12, p<0.001), despite higher fatal opioid overdoses. There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

(752) Does Age Modify Racial Disparities in Mortality Among Patients with Heart Failure

(752) Does Age Modify Racial Disparities in Mortality Among Patients with Heart Failure

Racial disparities in post-transplant stroke and mortality following stroke in adult cardiac transplant recipients in the United States.

Black heart transplant recipients have a higher mortality rate than white recipients 6-12 months after transplant. Whether there are racial disparities in post-transplant stroke incidence and all-cause mortality following post-transplant stroke among cardiac transplant recipients is unknown. Using a nationwide transplant registry, we assessed the association between race and incident post-transplant stroke using logistic regression and the association between race and mortality among adults who survived a post-transplant stroke using Cox proportional hazards regression. We found no evidence of an association between race and the odds of post-transplant stroke (OR = 1.00, 95% CI: 0.83-1.20). The median survival time of those with a post-transplant stroke in this cohort was 4.1 years (95% CI: 3.0, 5.4). There were 726 deaths among the 1139 patients with post-transplant stroke, including 127 deaths among 203 Black patients and 599 deaths among 936 white patients. Among post-transplant stroke survivors, Black transplant recipients experienced a 23% higher rate of mortality compared to white recipients (HR = 1.23, 95% CI: 1.00-1.52). This disparity is strongest in the period beyond the first 6 months and appears to be mediated by differences in the post-transplant setting of care between Black and white patients. The racial disparity in mortality outcomes was not evident in the past decade. The improved survival of Black patients in the recent decade may reflect overall protocol improvements for heart transplant recipients irrespective of race, such as advancements in surgical techniques and immediate postoperative care as well as increased awareness about reducing racial disparities.

The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes

AimsWhile several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease. MethodsWe used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables. ResultsOur calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes. ConclusionsThere is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.

Impact of COVID-19 on Patients Hospitalized with ST-Segment Elevation Myocardial Infarction in the United States during the Early Pandemic: An Analysis of Outcomes, Care Delivery, and Racial Disparities in Mortality.

The COVID-19 pandemic has impacted healthcare delivery to patients with ST-segment elevation myocardial infarction (STEMI). The aim of our retrospective study was to determine the effect of COVID-19 on inpatient STEMI outcomes and to investigate changes in cardiac care delivery during 2020. We utilized the National Inpatient Sample database to examine inpatient mortality and cardiac procedures among STEMI patients with and without COVID-19. In our study, STEMI patients with COVID-19 had higher inpatient mortality (47.4% vs. 11.2%, aOR: 3.8, 95% CI: 3.2−4.6, p < 0.001), increased length of stay (9.0 days vs. 4.3 days, p < 0.001) and higher cost of hospitalization (USD 172,518 vs. USD 131,841, p = 0.004) when compared to STEMI patients without COVID-19. STEMI patients with COVID-19 also received significantly less invasive cardiac procedures (coronary angiograms: 30.4% vs. 50.8%, p < 0.001; PCI: 32.9% vs. 70.1%, p < 0.001; CABG: 0.9% vs. 4.1%, p < 0.001) and were more likely to receive systemic thrombolytic therapy (4.2% vs. 1.1%, p < 0.001) when compared to STEMI patients without COVID-19. Our findings are the result of complications of SARS-CoV2 infection as well as alterations in healthcare delivery due to the burden of the COVID-19 pandemic.

Abstract C124: Identifying cancer disparities in the University of Chicago catchment area

Abstract (a) Cancer statistics are vital for helping doctors and researchers track cancer cases and use the data to find trends in various populations and patterns of occurrences, and make important public health decisions on where to direct funding, screening programs, and other steps to take in high-rate areas. This data can also tell doctors and researchers how effective some treatments are, based on the rise or fall in incidence and mortality rates, and can also help them pinpoint areas that need more attention. (b) Disparities in cancer incidence and mortality have not been described for the University of Chicago Comprehensive Cancer Center’s (UCCCC) patient catchment area (CA), the region from which the center draws its patients. This research aimed to describe incidence and mortality rates (2013-2017) for leading cancers in the CA, which consists of Cook County, IL; DuPage County, IL; Lake County, IL; Will County, IL; and Lake County, IN. Age-adjusted rates (per 100,000) were calculated for leading cancers by sex for each county, the CA, U.S., and IL. Racial disparities were also examined by comparing Black rates to White rates. (c) Incidence rates were higher in the CA compared to the U.S for all cancers data was available for: all sites combined, breast, and prostate. For males, mortality rates of prostate, colorectal, pancreatic, and stomach cancers were higher in the CA compared to the U.S. For females, mortality rates of breast, colorectal, myeloma, uterine, stomach, and bladder cancers, as well as all sites combined were higher in the CA compared to the U.S. By county, males experienced incidence rates of 8% to nearly 2.5 times higher and mortality rates 3% to over 1.5 times higher compared to the U.S. for various cancers. By county, females experienced incidence rates 5% to over 4 times higher and mortality rates 4% to over 1.5 times higher compared to the U.S. for various cancers. Lake County, IN generally had the highest incidence and mortality rates. Racial disparities in incidence and mortality were present for most cancers in the CA overall and by county. For males, racial disparities in mortality for prostate, stomach, and larynx are of greatest concern. For females, racial disparities in mortality for myeloma, cervical, and uterine are of greatest concern. (d) This research highlights important health inequities and priorities for the UCCC to reduce these disparities in the areas of cancer risk, prevention, and treatment. Citation Format: Joel Ssepuuya, Stephanie Zhang, Kelsey Meador, Lizeth Tamayo, Brandon Pierce. Identifying cancer disparities in the University of Chicago catchment area [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C124.

Cancer statistics, 2023

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence and outcomes using incidence data collected by central cancer registries and mortality data collected by the National Center for Health Statistics. In 2023, 1,958,310 new cancer cases and 609,820 cancer deaths are projected to occur in the United States. Cancer incidence increased for prostate cancer by 3% annually from 2014 through 2019 after two decades of decline, translating to an additional 99,000 new cases; otherwise, however, incidence trends were more favorable in men compared to women. For example, lung cancer in women decreased at one half the pace of men (1.1% vs. 2.6% annually) from 2015 through 2019, and breast and uterine corpus cancers continued to increase, as did liver cancer and melanoma, both of which stabilized in men aged 50years and older and declined in younger men. However, a 65% drop in cervical cancer incidence during 2012 through 2019 among women in their early 20s, the first cohort to receive the human papillomavirus vaccine, foreshadows steep reductions in the burden of human papillomavirus-associated cancers, the majority of which occur in women. Despite the pandemic, and in contrast with other leading causes of death, the cancer death rate continued to decline from 2019 to 2020 (by 1.5%), contributing to a 33% overall reduction since 1991 and an estimated 3.8 million deaths averted. This progress increasingly reflects advances in treatment, which are particularly evident in the rapid declines in mortality (approximately 2% annually during 2016 through 2020) for leukemia, melanoma, and kidney cancer, despite stable/increasing incidence, and accelerated declines for lung cancer. In summary, although cancer mortality rates continue to decline, future progress may be attenuated by rising incidence for breast, prostate, and uterine corpus cancers, which also happen to have the largest racial disparities in mortality.

257: GEOGRAPHY AND AGE DRIVE RACIAL AND ETHNIC DISPARITIES IN PEDIATRIC PNEUMONIA MORTALITY

Introduction: Racial disparities in adult community acquired pneumonia (CAP) outcomes are described. Disparities in pediatric CAP and potential mechanisms underlying disparities remain unclear. Literature shows that demographics including race, socioeconomic status, education level, and geographic region intersect in their associations with health outcomes. Given disparities in outcomes related to age and geography in sepsis, a related diagnosis, we aimed to determine whether age and geography modified the association between race and mortality in CAP. We hypothesized that Black and Hispanic patients would have higher mortality and that geographic region and age would clarify potential contributing mechanisms. Methods: This is a retrospective cohort study of children age < 18 years with a diagnosis of CAP admitted between 2016 and 2021 in the Public Health Information System (n=44 children’s hospitals). We investigated the intersection of race, age, and regional effects by creating a joint exposure variable incorporating 4 racial/ethnic groups (White, Black, Hispanic, and Other), 2 age categories (≤1 and >1 year), and 4 geographic regions (Northeast, South, Midwest, West) into 1 categorical exposure. We performed mixed-effect multivariable logistic regression, clustering by the hospital as a random effect. We used the joint exposure variable to quantify the relationship between race, age, and geographic region with mortality for CAP. Joint exposure modeling shows the combined effect of multiple exposures as a single variable with an outcome. Mixed effect analyses adjusted for rurality, income, sex, insurance type, and complex chronic conditions. Results: Among 783,744 patients (median age 4 years, IQR 1-9; 46% female) with CAP, the overall mortality rate was 0.9%. Joint analysis revealed region and age ≤1 year conferring increased mortality risk. Black patients ≤1 year in the South (aOR 2.35, 95% CI 1.52-3.63, p< 0.001) and West (aOR 2.47, 95% CI 1.35-4.49, p=0.003) and Hispanic patients ≤1 year in the Northeast (aOR 2.36, 95% CI 1.46-3.66, p = 0.031) had the highest adjusted mortality odds. Conclusions: We found evidence of racial disparities in mortality for children diagnosed with CAP. Joint associations of age and geographic region may partially explain mechanisms underlying these racial disparities.

COVID-19 and NSTEMI Outcomes among Hospitalized Patients in the United States and Racial Disparities in Mortality: Insight from National Inpatient Sample Database.

The COVID-19 pandemic has impacted healthcare delivery to patients with non-ST-segment elevation myocardial infraction (NSTEMI). The aim of our retrospective study is to determine the effect of COVID-19 on inpatient NSTEMI outcomes and to investigate whether changes in cardiac care contributed to the observed outcomes. After multivariate adjustment, we found that NSTEMI patients with COVID-19 had a higher rate of inpatient mortality (37.3% vs. 7.3%, adjusted odds ratio: 4.96, 95% CI: 4.6-5.4, p &lt; 0.001), increased length of stay (9.9 days vs. 5.4 days, adjusted LOS: 3.6 days longer, p &lt; 0.001), and a higher cost of hospitalization (150,000 USD vs. 110,000 USD, inflation-adjusted cost of hospitalization: 36,000 USD higher, p &lt; 0.001) in comparison to NSTEMI patients without COVID-19, despite a lower burden of pre-existing cardiac comorbidity. NSTEMI patients with COVID-19 also received less invasive cardiac procedures (coronary angiography: 8.7% vs. 50.3%, p &lt; 0.001; PCI: 4.8% vs. 29%, p &lt; 0.001; and CABG: 0.7% vs. 6.2%, p &lt; 0.001). In our study, we observed increased mortality and in-hospital complications to be a combined effect of COVID-19 infection and myocardial inflammation as a result of cytokine storm, prothrombic state, oxygen supply/demand imbalance and alterations in healthcare delivery from January to December 2020.

Racial and neighborhood disparities in mortality among hospitalized COVID-19 patients in the United States: An analysis of the CDC case surveillance database.

Black and Hispanic populations have higher overall COVID-19 infection and mortality odds compared to Whites. Some state-wide studies conducted in the early months of the pandemic found no in-hospital racial disparities in mortality. We performed chi-square and logistic regression analyses on the CDC COVID-19 Case Surveillance Restricted Database. The primary outcome of the study was all-cause in-hospital mortality. The primary exposures were racial group (White, Black, Hispanic and Others) and neighborhood type (low vulnerability, moderate vulnerability, high vulnerability, very high vulnerability). The overall unadjusted mortality rate was 33% and was lowest among Hispanics. In the fully adjusted models, Blacks and Hispanics had higher overall odds of dying [OR of 1.20 (95% CI 1.15, 1.25) and 1.23 (95% CI 1.17, 1.28) respectively] compared with White patients, and patients from neighborhoods with very high vulnerability had the highest mortality odds in the Northeast, Midwest and overall [Adjusted OR 2.08 (95% CI 1.91, 2.26)]. In the Midwest, Blacks and Hispanics had higher odds of mortality compared with Whites, but this was not observed in other regions. Among hospitalized COVID-19 patients, Blacks and Hispanics were more likely to die compared to Whites in the Midwest. Patients from highly vulnerable neighborhoods also had the highest likelihood of death in the Northeast and Midwest. These results raise important questions on our efforts to curb healthcare disparities and structural racism in the healthcare setting.

Impact of the Affordable Care Act on Disparities in Access to and Outcomes After Coronary Artery Bypass Grafting

ObjectivesThe aim of this study was to examine the effect of implementation of the Affordable Care Act’s Medicaid expansion on access to and outcomes after coronary artery bypass grafting (CABG) surgery.MethodsRetrospective observational study utilizing the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2011 to 2016. The southern region of the USA was used as a control and the western region as the implementation group. Univariate regression models and interrupted time series models were created to evaluate and assess the impact of the Affordable Care Act’s Medicaid expansion on mortality after CABG with respect to patient race.ResultsFrom 2011 to 2016, a total of 117,819 isolated CABG operations were identified in the specified regions using the HCUP NIS. Of these, 89,918 were performed in the southern region, and the remainder were performed in the western region. The proportion of African American patients with Medicaid increased significantly in the western region after the ACA Medicaid expansion, from 13.1 to 17.6%, p = 0.034. There was no significant increase seen in the number of African American patients with Medicaid in the southern region. We found that overall, Black patients had higher mortality after CABG as compared to white patients (OR 1.15, p = 0.02); however, when broken down by region we found higher mortality among African American patients in the southern region only, with no statistically significant difference in mortality between white and Black patients in the western region.ConclusionsImplementation of the Affordable Care Act increased access to Medicaid among Black Americans but did not necessarily decrease the disparity in access to CABG or mortality after CABG between Black and white patients. When it comes to racial disparities in mortality after CABG, there are significant regional and geographic variations which have not been previously described. This finding has important implications for the development of policy and other strategies that aim to reduce these disparities.