Reasons For Racial Disparities Research Articles

Provider Care Segregation and Hospital-Region Racial Disparities in the United States for Acute Ischemic Stroke and Endovascular Therapy Outcomes.

Reasons for racial disparities in the use and outcomes of endovascular treatment (ET) are not known. We examined patterns in care segregation for acute ischemic stroke (AIS) in the United States, and outcomes of segregation of care after ET. We used deidentified Medicare data sets to identify AIS admissions between January 1, 2016 and December 31, 2019, using validated International Classification of Diseases, Tenth Revision (ICD-10) codes. For AIS, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for ET cases. Using unadjusted and adjusted multilevel logistic models, we examined associations between measures of segregation and outcomes of discharge home, inpatient mortality, and 30-day mortality. The mean proportional difference in the proportion of White patients comparing hospitalized patients with AIS to the county race distribution was 0.015 (SD, 0.219) at the hospital level. For ET, the mean proportional difference in the proportion of White patients comparing patients receiving ET to the county race distribution was much higher, at 0.146 (SD, 0.374). The dissimilarity index for ET providers was high, with a mean of 0.48 (SD, 0.29) across all hospitals. Black patients with AIS (compared with White patients) had reduced odds of discharge home, inpatient mortality, and 30-day mortality. In this national study with contemporary data in the endovascular era of AIS treatment, we found substantial evidence for segregation of care in the United States, not for only AIS in general but also especially for ET.

Racial Disparity in Placement of Intracranial Pressure Monitoring: A TQIP Analysis.

The Brain Trauma Foundation recommends intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Race is associated with worse outcomes after TBI. The reasons for racial disparities in clinical decision-making around ICP monitor placement remain unclear. We queried the TQIP database from 2017 to 2019 and included patients 16 years or older, with blunt severe TBI, defined as a head abbreviated injury score 3 or greater. Exclusion criteria were missing race, those without signs of life on admission, length of stay 1 day or less, and AIS of 6 in any body region. The primary outcome was ICP monitor placement, which was calculated using a Poisson regression model with robust SEs while adjusting for confounders. A total of 260,814 patients were included: 218,939 White, 29,873 Black, 8,322 Asian, 2,884 American Indian, and 796 Native Hawaiian or Other Pacific Islander. Asian and American Indian patients had the highest rates of midline shift (16.5% and 16.9%). Native Hawaiian or Other Pacific Islanders had the highest rates of neurosurgical intervention (19.3%) and ICP monitor placement (6.5%). Asian patients were found to be 19% more likely to receive ICP monitoring (adjusted incident rate ratio 1.19; 95% CI 1.06 to 1.33; p = 0.003], and American Indian patients were 38% less likely (adjusted incident rate ratio 0.62; 95% CI 0.49 to 0.79; p < 0.001), compared with White patients, respectively. No differences were detected between White and Black patients. ICP monitoring use differs by race. Further work is needed to elucidate modifiable causes of this difference in the management of severe TBI.

Trends over Time in Overall Survival of Patients with Multiple Myeloma By Race/Ethnicity and By Comorbidity Status: A Surveillance, Epidemiology, and End Results (SEER)-Medicare Analysis

Introduction: New advances in multiple myeloma (MM) treatments have improved overall survival (OS), though there is uncertainty regarding the benefits of these treatments for all patients (pts) with MM. This study assessed OS trends over time in subgroups of pts with MM defined by race/ethnicity and comorbidity status. Methods: Newly diagnosed pts with MM (2007-16) in the US were identified from the SEER-Medicare database. Medicare enrollment on initial diagnosis date was required and pts with other cancers were excluded. Pt characteristics at initial diagnosis and comorbidities during the 6-month baseline period were described for pts with continuous enrollment in the baseline period. OS was described using Kaplan-Meier analysis from initial MM diagnosis to death. Trends in OS over time were evaluated by creating cohorts based on year of diagnosis (2007-09, 2010-12, and 2013-16), and log-rank tests compared OS between the cohorts. All outcomes were described separately for the following race/ethnicity subgroups: non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic (HIS) and for subgroups defined by the presence of diabetes mellitus (DM) or hypertension (HTN), two of the most common comorbidities in pts with MM, in the baseline period. Results: The study included 21,757 pts with MM. Median age at diagnosis was 75 years (range 27-101), 51% of pts were male, and mean Charlson Comorbidity Index (CCI) was 1.2. Overall, 14,077 (64.7%) were NHW, 4078 (18.7%) were NHB, and 2371 (10.9%) were HIS. At baseline, HTN (44.9%), DM (20.4%), renal disease (14.0%), lung disease (13.6%), and heart failure (11.4%) were common comorbidities not related to MM. Monoclonal gammopathy of undetermined significance was identified in 10.0% of pts overall, and in 7.6%, 9.8%, and 11.2% of the NHW, NHB, and HIS cohorts, respectively; 5.5% of pts overall were obese. Median OS was 3.26 years, OS improved significantly over time (P < 0.001 for 2007-09 vs 2010-12, 2007-09 vs 2013-16, 2010-12 vs 2013-16), and median OS increased with each time period (2007-09, 2.78 years; 2010-12, 3.16 years; 2013-16, 3.64 years) (Table 1). The NHW subgroup had a median age of 75 years, 53% male pts, and a mean CCI of 1.1. Trends over time in OS were similar to the overall sample, with P < 0.001 for all-year cohort comparisons and increasing median OS over time. The NHB subgroup had a median age of 73 years, 43% male pts, and a mean CCI of 1.5. Improvements in OS were observed relative to the oldest subgroup (2007-09 vs 2010-12, P < 0.05; 2007-09 vs 2013-16, P < 0.001), but not in the most recent year subgroups (2010-12 vs 2013-16, P = 0.125). The HIS subgroup had a median age of 74 years, 50% male pts, and a mean CCI of 1.4. There was no significant improvement in OS across year cohorts (2007-09 vs 2010-12, P = 0.163; 2007-09 vs 2013-16, P = 0.053; 2010-12 vs 2013-16, P = 0.850), although median OS increased over time (2007-09, 2.92 years; 2010-12, 3.48 years; 2013-16, 3.53 years). Among pts with MM and DM (N = 4410, 20.3%), OS improved over time relative to the oldest cohort (2007-09 vs 2010-12 and 2007-09 vs 2013-16, P < 0.01). No improvement was observed between the most recent cohorts (2010-12 vs 2013-16, P = 0.844) (Table 2). Median OS showed a similar trend (2007-09, 2.44 years; 2010-12, 2.90 years; 2013-16, 2.80 years) and was shorter than the overall population. In the HTN cohort (N = 9646, 44.3%), median OS increased over time (2007-09, 2.58 years; 2010-12: 2.79 years; 2013-16: 3.07 years), but OS showed statistically significant improvements only when comparing the oldest to the most recent cohort (2007-09 vs 2010-12, P = 0.058; 2007-09 vs 2013-16, P < 0.001; 2010-12 vs 2013-16, P = 0.081). Conclusions: Variation in OS trends over time in pts with MM was observed across subgroups. While OS improved significantly across cohorts for NHW and NHB pts, significant improvement was not seen for HIS pts. Comorbidities were common and for pts with HTN and DM, no significant improvement in OS was observed in recent years. Median OS was lower in both comorbidity cohorts compared with the total MM population. Reasons for racial disparities need to be explored further; these differences in outcomes confirm the need for equitable access to effective treatments and tailored treatments for pts with comorbidities. Additional analyses are underway assessing trends over time in gaps in survival between pts with MM and the general population for these subgroups. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Exploring racial differences in patient centeredness of care (PCC) during breast cancer (BC) chemotherapy clinic visits.

49 Background: Racial disparity in breast cancer survival may be attributed to racial differences in BC treatment dose intensity (dose received/dose prescribed within specific time frame). Poor dose intensity is associated with symptom distress among Black women. Chemotherapy associated symptoms and distress are traditionally assessed by the clinician and reported by the patient during the clinical visit. Poor communication patterns between clinician and patient that do not reflect care that is patient centered may be an important etiology of poor symptom reporting and management influencing BC racial treatment disparity. The purpose of this prospective, comparative pilot study was to qualitatively explore and code for the PCC during the chemotherapy clinical visit of women undergoing BC chemotherapy and compare by race. Methods: Dyads consisting of age-matched Black and White women were recruited. Audio recordings of clinical visits conducted prior to any chemotherapy cycle (except first) infusion were obtained and transcribed. The transcripts were reviewed blindly by two independent coders assigning scores using the Four Habits Coding Scheme, a measure of PCC which includes 23 items coded on five-point scale; lower scores indicate better PCC. Mean scores were tabulated from both coders’ scores and then compared by racial groups using t-test. Results: Matched dyads consisting of 6 Black and 5 White patients undergoing breast cancer chemotherapy were recruited from 1/15/2014 to 12/4/2014 at a 90% recruitment rate. Attrition of one black patient left groups of 5 White (mean age 45) and 5 Black (mean age 47) patients. A total of 15 recordings were analyzed for White and 14 for Black participants. All of the 23 PCC scores were better for White vs. Black women. Black women had worse scores (p &lt; .05) for 6/22 or (27%) of the PCC scores. Conclusions: Qualitatively exploring the PCC during the chemotherapy clinical visits may elucidate reasons for racial disparity in symptom assessment, reporting, management and subsequent distress. These preliminary findings inform future research exploring racial disparity in symptom communication as an etiology of disparity in cancer treatment intensity.

Prostate cancer outcomes for African American and caucasian patients undergoing radical prostatectomy.

40 Background: A disproportionate burden of prostate cancer (CaP) incidence and mortality is observed for African American (AA) versus Caucasian (CA) patients in the US. Potential underlying reasons for racial disparity include biology, comorbidity profiles, access to health care, adherence to follow-up care and/or treatment aggressiveness. This study examined CaP progression and overall survival (OS) among AA and CA patients undergoing radical prostatectomy (RP). Methods: This retrospective cohort study examined men enrolled in the Center for Prostate Disease Research (CPDR) Multi-Center National Database between January 1, 1990 and December 31, 2014. Patients with biopsy-detected CaP without metastasis and treated with RP within 12 months of CaP diagnosis were eligible. Biochemical recurrence (BCR) was defined as a PSA value of &gt; = 0.4 ng/mL followed by a subsequent increase. PSADT was categorized as &lt; 3, 3-8.99, 9-14.99, and &gt; = 15 months. Kaplan-Meier estimation curves and multivariable Cox proportional hazards analysis were used to examine BCR and OS. Results: A total of 6,785 patients were eligible; 21.5% self-reported as AA and 78.5% self-reported as CA. Median follow-up time was 6.1 years. Comparable distributions of pathologic features at RP and adjuvant treatment over time were observed across race but several comorbid conditions were more common in AA patients including cardiovascular disease, hypertension, diabetes, and other cancer types. In race-specific unadjusted Kaplan Meier analyses, PSADT was an important predictor of BCR and OS for both AA and CA patients (Log rank p &lt; 0.0001 for all KM models). In multivariable analysis, a greater odds of BCR over time was observed for AA versus CA patients (HR = 1.28, CI = 1.11, 1.48, p = 0.0009) after adjustment for D’Amico risk stratum, comorbidity, pathological features, and PSADT. PSADT was a critical predictor of BCR, with worst outcomes at extreme comparison of PSADT categories: HR &lt; 3 vs. &gt; = 15 months= 41.5, CI = 33.6, 51.3, p &lt; 0.0001). Conclusions: In a large racially diverse, longitudinal cohort with equal health care access, there was a striking relationship between PSADT and time to BCR for each racial group and poorer outcomes for AA versus CA patients.

Racial Disparity in Receiving a Physician Recommendation for Human Papillomavirus Vaccine among US Adolescent Girls: Trend from 2008 to 2012

Abstract To examine the trend of racial disparity in receiving a physician recommendation for human papillomavirus (HPV) vaccine among US adolescent girls. Methods: We analyzed National Immunization Survey of Teens (NIS-Teen) 2008–2012 data and examined the trend of racial disparity in receiving a physician recommendation for HPV vaccine among 13–17 year old US adolescent girls. Results: Overall, the weighted proportion of girls who received a physician recommendation was 49.2%, 57.0%, 54.9%, 58.8% and 65.3% in 2008, 2009, 2010, 2011 and 2012, respectively (p for trend &amp;lt;0.001). The respective weighted proportion for non-Hispanic white, non-Hispanic black and Hispanic girls were: 53.6%, 60.7%, 59.0%, 63.4% and 70.2%; 42.7%, 50.0%, 46.3%, 52.5% and 62.8%; and 40.0%, 50.8%, 48.0%, 51.4% and 56.5% (P &amp;lt; 0.001 for all 5 years). After adjusting for demographic characteristics, separate weighted analysis for each year of data showed that non-Hispanic black and Hispanic girls were less likely to receive a physician recommendation than non-Hispanic white girls (P &amp;lt; 0.01 for all 5 years). However, there was no significant difference between Non-Hispanic black and Hispanic girls (P &amp;gt; 0.05 for all 5 years). Conclusions: Reasons for racial disparity in receiving a physician recommendation need to be identified and addressed to achieve the desired level of HPV vaccine uptake among US adolescent girls, irrespective of race/ethnicity.

Racial Variation in Anatomic Distribution of Coronary Artery Lesions: New Zealand Maori are Seldom Treated for Right Coronary Disease

Identifying the underlying reasons for racial disparities in health care outcomes is a global priority. The anatomic distribution of coronary artery lesions has been shown to be highly heritable. We examine whether there is interracial variation in specific lesion location in patients undergoing coronary artery angioplasty. Ethnicity data was cross-referenced with data from a database containing all angioplasties performed at Christchurch Hospital between 01 January 2000 and 31 December 2004. In a total of 1992 patients there were 3426 lesions treated with coronary angioplasty. The distribution of these lesions varied significantly between Europeans and Maori (Chi-squared p=0.031). In Europeans 40% of lesions were in the left anterior descending coronary artery and 36% in the right coronary artery. In Maori 58% of lesions were in the left anterior descending coronary artery and 13% in the right coronary artery. This provides first evidence for there being inter-racial differences in the nature of coronary artery disease.

Have racial disparities in ovarian cancer increased over time? An analysis of SEER data

ObjectiveRace has been postulated to be a prognostic factor in women with ovarian cancer. The reasons for racial disparities are multifactorial. Recent literature suggests that racial disparities in ovarian cancer survival emerged in the 1980s, when modern treatments such as aggressive surgical debulking and platinum-based chemotherapy first gained widespread use. We suspect that as improvements in treatment have evolved, the effects of access to treatment have amplified racial disparities in survival from ovarian cancer. MethodsSEER 9 data were analyzed, including African American and white patients diagnosed with ovarian cancer from 1973 to 2007, with 2008 as the cutoff for follow-up. Using the Kaplan–Meier method, we evaluated racial differences in survival, to determine whether this difference has increased over time. ResultsThere were 44,562 white and 3190 African American women available for analysis. Overall African Americans had 1.10 times the crude hazard (95% CI 1.06–1.15) of all-cause mortality compared to whites, with a widening trend over time (p<0.01). Adjusted for SEER registry, age, tumor stage, marital status and time of diagnosis, the hazard ratio (HR) for all-cause mortality comparing African Americans to whites was 1.31 (95% CI 1.26–1.37). When the receipt of surgery was added to the model, the HR for all-cause mortality remained higher for African American women at 1.27 (95% CI 1.21–1.34). ConclusionsAfrican Americans diagnosed with ovarian cancer have worse survival than whites, and this disparity has increased over time. Measured differences in treatment, such as receipt of surgery, account for part of the disparity.

Factors Associated with Delays to Diagnosis and Treatment of Breast Cancer in Women in a Louisiana Urban Safety Net Hospital

Only lung cancer surpasses breast cancer as a cause of death from cancer. However, the burden of cancer is not borne equally across racial and ethnic groups. In the United States, African American women have significantly higher mortality rates from breast cancer than white women. Delayed follow-up of breast abnormalities and delays from diagnosis to treatment may contribute to higher mortality. This study examined factors associated with delays to diagnosis and treatment of breast cancer in a group of white and African American women. Identified from tumor registry records were 247 women with pathology-confirmed first primary in situ and invasive breast carcinomas with no known previous cancer diagnosis. Factors associated with delays from provider recognition of abnormality to breast cancer diagnosis (diagnostic delays) and from diagnosis to treatment (treatment delays) were determined using chi-square tests and logistic regression. Factors that were considered included age, race, stage of disease at diagnosis, tumor size, type of abnormality, type of medical service at presentation, and prior mammogram within the past two years. The proportion of women experiencing diagnostic delays was high, with more African American women experiencing delays than white women (34% versus 17%, respectively). African American and white women did not differ in distribution of stage of cancer at diagnosis. Significantly smaller tumor sizes were found in women experiencing diagnostic delays compared to those not experiencing delays. Conversely, women experiencing treatment delays were significantly older and had larger tumor sizes compared to those not experiencing delays. More African American women experienced delays in diagnosis; however these delays did not appear to affect outcomes. Older age as a significant factor in treatment delays suggests that comorbidities as well as other possible barriers to treatment warrant further investigation in older women. The reasons for racial disparities in breast cancer outcomes remain and call for further study.

Race and shared decision-making: Perspectives of African-Americans with diabetes

Shared decision-making (SDM) is an important component of patient-centered healthcare and is positively associated with improved health outcomes (e.g. diabetes and hypertension control). In shared decision-making, patients and physicians engage in bidirectional dialogue about patients' symptoms and treatment options, and select treatment plans that address patient preferences. Existing research shows that African-Americans experience SDM less often than whites, a fact which may contribute to racial disparities in diabetes outcomes. Yet little is known about the reasons for racial disparities in shared decision-making. We explored patient perceptions of how race may influence SDM between African-American patients and their physicians. We conducted in-depth interviews (n=24) and five focus groups (n=27) among a purposeful sample of African-American diabetes patients aged over 21 years, at an urban academic medical center in Chicago. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was conducted iteratively; each transcription was independently coded by two research team members. Although there was heterogeneity in patients' perceptions about the influence of race on SDM, in each of the SDM domains (information-sharing, deliberation/physician recommendations, and decision-making), participants identified a range of race-related issues that may influence SDM. Participants identified physician bias/discrimination and/or cultural discordance as issues that may influence physician-related SDM behaviors (e.g. less likely to share information such as test results and more likely to be domineering with African-American patients). They identified mistrust of white physicians, negative attitudes and internalized racism as patient-related issues that may influence African-American patients' SDM behaviors (e.g. less forthcoming with physicians about health information, more deference to physicians, less likely to adhere to treatment regimens). This study suggests that race-related patient and physician-related barriers may serve as significant barriers to shared decision-making between African-American patients and their physicians. Finding innovative ways to address such communication barriers is an important area of future research.

Racial Disparities in the Treatment of Depression in Low-Income Persons With Diabetes

OBJECTIVEIndividuals with diabetes are at higher risk for depression than the general population. Although depression can be treated with antidepressant medications, patients with diabetes and comorbid depression often go untreated. The goal of this study was to examine racial disparities in the treatment of depression with antidepressant medication in the southeastern U.S.RESEARCH DESIGN AND METHODSCross-sectional data were collected at baseline from 69,068 participants (71% African American, 60% female, and 82% with incomes <$25,000) recruited from community health centers and enrolled in the Southern Cohort Community Study (SCCS). The SCCS is a prospective epidemiological cohort study designed to explore causes of health disparities in adults aged 40–79 years. Binary logistic regression was used to identify factors associated with antidepressant use among those with diabetes (n = 14,279).RESULTSIndividuals with diagnosed diabetes (14,279) were classified with no depressive symptoms (54.7%), or with mild (24.2%), moderate (12.8%), or severe depressive symptoms (8.3%). After controlling for sex, age, insurance, income, education, BMI, smoking status, alcohol consumption, and level of depression, African Americans with diabetes were much less likely to report taking antidepressant medication than whites (adjusted odds ratio 0.32 [95% CI 0.29–0.35], P < 0.0001).CONCLUSIONSAntidepressant use is much less common among African Americans than among whites with diabetes. Reasons for racial disparities in treatment of depressive symptoms are unclear but may include a combination of differential diagnosis and treatment by health professionals as well as cultural differences in seeking help for emotional distress.

Race as an Independent Risk Factor for Breast Cancer Survival: Breast Cancer Outcomes From the Medical College of Georgia Tumor Registry

Background Causes of racial disparities in breast cancer survival remain unclear. This study assesses overall survival (OS) after diagnosis between black and white women and examines factors that might correlate with this disparity. Patients and Methods Data were obtained from the Medical College of Georgia Tumor Registry. Cases included those diagnosed between 1990 and 2005. We analyzed race, stage, age of diagnosis, and treatment received: chemotherapy, radiation, surgery, and hormonal therapy. A Cox proportional hazards model was used to determine differences in OS. Results Compared with 670 white women, 489 black women were more likely to be younger, have later-stage disease at diagnosis, and were less likely to have received hormonal therapy. Both groups received similar rates of radiation, surgery, and chemotherapy. Black women had significantly poorer OS (adjusted hazard ratio, 1.35; 95% CI, 1.12–1.63). White women had a 5-year OS of 54% compared with 45% in black women ( P = .0031). Having received radiation, surgery, or chemotherapy was not associated with OS. White women were more likely to have received hormonal therapy, which had a significant protective effect. However, a stratified analysis (between those who received hormonal therapy and those who did not) showed similar results, whereas black women experienced poorer OS in both strata. Conclusion Black women with breast cancer had a significantly poorer OS compared with white women. White women received more hormonal therapy, which had a protective effect. There were no differences in treatment received regarding radiation, surgery, or chemotherapy, and these treatments were not associated with OS. The reasons for racial disparities in breast cancer OS remain complex.

TUCKER ET AL. RESPOND

We appreciate Holtzman’s interest in our efforts to gain insight into the reasons for racial disparities in maternal mortality. The persistent 3- to 4-times greater risk of pregnancy-related mortality for Black women is the largest gap among the traditional indicators of maternal and infant health in the United States. We, too, are concerned that racial disparities also exist for infant outcomes and that they, like those for pregnancy-related mortality, remain largely unexplained. The role of stress, neuroendocrine pathways, and immune system functions are all areas of biomedical research that we hope will help us to better understand why some groups have increased risks for adverse health outcomes. In addition, as implied by Holtzman, we must make efforts to understand how biology is affected by the larger context of women’s lives. Further, while we work to identify and change factors that convey susceptibility to pregnancy complications, preterm birth, and infant mortality, it is critical to improve access and quality of care for all women and infants.

Unraveling the racial disparities associated with kidney disease1

In the United States, chronic kidney disease (CKD), and in particular end-stage renal disease (ESRD), represent a growing problem. Many other countries also have an increasing number of ESRD cases. Racial/ethnic disparities have been documented globally in the prevalence, incidence, and treatment of CKD, most extensively in the United States, but also in the United Kingdom, Australia, and New Zealand, among others. In many circumstances, these disparities are of a negative nature, that is, certain racial/ethnic groups fare worse than their white counterparts with respect to the treatment or outcome of CKD. However, in a few circumstances, they are of a positive nature, such as the survival advantage seen in minorities with ESRD compared with whites. The reasons for racial disparities in the prevalence, incidence, and treatment of CKD are not fully understood, although they are explained partly by coexisting medical conditions and modifiable risk factors, such as socioeconomic, lifestyle, and cultural. It is likely, however, that the complete picture incorporates a complex interaction between these sociocultural, genetic, and environmental factors. In a global society that prides itself on a high level of sensitivity and equality, there is an ethical and moral imperative to address the continuing racial/ethnic disparities in CKD and many of the factors underlying this epidemic. We review data highlighting the racial/ethnic disparities that exist in the incidence and treatment of CKD, with particular emphasis on ESRD. A better understanding of both the negative and positive racial/ethnic disparities may yield important insights, which can inform future research strategies and improve health outcomes for all patients afflicted with CKD.