Census Tract Of Residence Research Articles

Geographic Variation in Late-Stage Cervical Cancer Diagnosis

There are stark disparities in cervical cancer burden in the United States, notably by race and ethnicity and geography. Late-stage diagnosis is an indicator of inadequate access to and utilization of screening. To identify geospatial clusters of late-stage cervical cancer at time of diagnosis in Texas. This population-based cross-sectional study used incident cervical cancer data from the Texas Cancer Registry from 2014 to 2018 of female patients aged 18 years or older. Late-stage cervical cancer cases were geocoded at the census tract level (n = 5265) using their residential coordinates (latitude and longitude) at the time of diagnosis. Statistical analysis was performed from April to September 2023. Census tract of residence at diagnosis. Late-stage cervical cancer diagnosis (ie, cases classified by the National Cancer Institute Surveillance, Epidemiology and End Results summary stages 2 to 4 [regional spread] or 7 [distant metastasis]). A Poisson probability-based model of the SaTScan purely spatial scan statistics was applied at the census tract-level to identify geographic clusters of higher (hot spots) or lower (cold spots) proportions than expected of late-stage cervical cancer diagnosis and adjusted for age. Among a total of 6484 female patients with incident cervical cancer cases (mean [SD] age, 48.7 [14.7] years), 2300 (35.5%) were Hispanic, 798 (12.3%) were non-Hispanic Black, 3090 (47.6%) were non-Hispanic White, and 296 (4.6%) were other race or ethnicity. Of the 6484 patients, 2892 with late-stage diagnosis (mean [SD] age, 51.8 [14.4] years were analyzed. Among patients with late-stage diagnosis, 1069 (37.0%) were Hispanic, 417 (14.4%) were non-Hispanic Black, 1307 (45.2%) were non-Hispanic White, and 99 (3.4%) were other race or ethnicity. SaTScan spatial analysis identified 7 statistically significant clusters of late-stage cervical cancer diagnosis in Texas, of which 4 were hot spots and 3 were cold spots. Hot spots included 1128 census tracts, predominantly in the South Texas Plains, Gulf Coast, and Prairies and Lakes (North Texas) regions. Of the 2892 patients with late-stage cervical cancer, 880 (30.4%) were observed within hot spots. Census tract-level comparison of characteristics of clusters suggested that hot spots differed significantly from cold spots and the rest of Texas by proportions of racial and ethnic groups, non-US born persons, and socioeconomic status. In this cross-sectional study examining geospatial clusters of late-stage cervical cancer diagnosis, place-based disparities were found in late-stage cervical cancer diagnosis in Texas. These findings suggest that these communities may benefit from aggressive cervical cancer interventions.

Abstract 15643: Social Determinants of Health, Epigenetic Aging, and Subclinical Cardiovascular Disease: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

Introduction: Associations of social determinants of health (SDOH) with subclinical cardiovascular disease (CVD), such as left ventricular mass index (LVMI) and coronary artery calcification (CAC), are poorly described. Mechanisms of such associations may involve epigenetic changes like DNA methylation. We sought to examine associations between selected SDOH measures and subclinical CVD, and potential mediation by GrimAge acceleration (GrimAA), a measure of epigenetic aging. Methods: We included 2932 Black and White adults from the CARDIA year 20 (Y20) exam (mean age 45y, 48% Black, 57% female). Associations between SDOH measures at Y20 (or cumulative up to Y20) and Y25 ln(CAC score +1) or LVMI (in g/m 2.7 ) were examined using linear regression. Statistical mediation analysis was used to estimate the proportion of associations attributable to GrimAA among 880 participants in whom it was measured. Results: All selected SDOH measures at Y20 - residential racial segregation (G* Score); census tract poverty; food insecurity; difficulty paying for basics, medications, or healthcare; and maximum years of participant or parental education - were associated with LVMI at Y25 (Table). For example, each 1% higher census tract poverty was associated with an average 0.95 g/m 2.7 higher LVMI. Several SDOH measures were also associated with CAC score at Y25. Similar associations were observed between cumulative SDOH exposures from Y0-Y20 and Y25 subclinical CVD. GrimAA mediated >30% of the statistical association between participant education and LVMI or CAC (Table), and >20% of the associations of residential segregation and census tract poverty with LVMI. Conclusions: SDOH metrics were significantly and longitudinally associated with subclinical CVD in midlife. DNA methylation, as represented by GrimAge acceleration, appears to statistically mediate these associations, suggesting possible molecular mechanisms by which SDOH may accelerate CVD risk.

Abstract 18140: Is Socioeconomic Status Associated With a Novel Clinical Risk Prediction Score for Sudden Cardiac Death?

Introduction: Lower socioeconomic status (SES) is associated with higher risk of sudden cardiac death (SCD), but SES has not been used for SCD risk stratification. We have recently developed a novel risk score (VFRisk) for avertable SCD (8 clinical factors, 4 ECG markers, and 1 echocardiographic marker). We evaluated the association of the clinical components of the VFRisk score with SES. Hypothesis: Higher VFRisk scores will associate with lower SES. Methods: Individuals with SCD (2002-2019), were identified from a large ongoing study in a northwest US metro area (pop ~1 million). For each SCD case, a partial VFRisk score was calculated limited to the 8 clinical components (VFRisk-clinical; diabetes, HF, stroke, atrial fibrillation, COPD, history of MI, seizure, and syncope). The VFRisk-clinical score was categorized as low (<25 th percentile), moderate (25 th -75 th ), and high (>75 th percentile). SES was defined for each SCD case by residential census tract median household income and categorized into quintiles. Results: Among 4,412 SCD cases, data for SES and VFRisk-clinical was available for 3,606 (82%) with a median VFRisk of 2.8 (min 0 - max 13.4). There was a weak negative linear correlation between median household income quintile and VFRisk-clinical score (r = -0.05, p=0.002) and mean VFRisk-clinical score was slightly lower with higher SES quintile (Figure). However, there was no significant trend in the proportion of SCD cases with a high VFRisk-clinical score (>75 th percentile) by median income quintile (p=0.13). In a logistic regression model, income quintile was not significantly associated with a high VFRisk-clinical score (p=0.60). Conclusions: No clear association was observed between the VFRisk-clinical score and SES, possibly due to involvement of SES early in the causal pathway of these clinical conditions, or due to effects of SES on risk pathways for SCD separate from the components of the VFRisk score.

Brief Report: Ryan White Participation Increased the Prevalence of COVID-19 Vaccination Among People Living with HIV in Michigan.

People living with HIV (PLWH) have higher prevalence of adverse COVID-19 outcomes, and many reside in socially vulnerable communities. Our aim was to evaluate how engagement in HIV care may increase vaccination likelihood. Michigan HIV surveillance data were extracted from the Enhanced HIV/AIDS Reporting System and matched at the person-level to COVID-19 vaccination records from the Michigan Care Improvement Registry (through December 31, 2021 [n = 15,537]). Based on residential census tract, we classified PLWH into quartiles (<25th percentile [least vulnerable], 25th to <50th, 50th to <75th, ≥75th [most vulnerable]) of the 2018 CDC Social Vulnerability Index. Using log binomial regression, we estimated the relative prevalence of COVID-19 vaccine series initiation among PLWH by quartile of social vulnerability and Ryan White participation; models were adjusted for covariates. By December 31, 2021, 67% of PLWH in Michigan had initiated a COVID-19 vaccine series; 47% resided in an area deemed most vulnerable and 54% had participated in Ryan White services. Compared with PLWH in the most vulnerable quartile, those who resided in least vulnerable quartiles had higher prevalence of vaccine initiation (Prevalence Ratio [95% Confidence Interval]: 1.67 [1.50 to 1.86]). Participants in Ryan White had greater prevalence of initiation (1.52 [1.42 to 1.62]) compared with those who were not participants; initiation remained higher when adjusted for covariates including social vulnerability quartile. Ryan White participation was associated with increased COVID-19 vaccine initiation regardless of community-level vulnerability. Wraparound services may be key in vaccine promotion interventions in this vulnerable population.

Association of Neighborhood Recreation Centers and Poststroke Outcomes in a Population-Based Cohort.

Higher neighborhood socioeconomic status has been favorably associated with stroke outcomes. This may be due to these areas having more beneficial resources such as recreational centers. We aimed to determine if neighborhood density of recreation centers is favorably associated with stroke outcomes. We conducted analyses of data from the Brain Attack Surveillance in Corpus Christi project, a cohort of stroke survivors ≥45 years of age residing in Nueces County, TX (2009-2020). We included non-Hispanic White and Mexican American incident stroke survivors, who were not institutionalized prestroke and completed baseline and follow-up assessments (N=1392). We calculated the density of fitness and recreational sports centers within their residential census tract during the year of their stroke. Outcomes included function (self-ratings on activities of daily living and instrumental activities of daily living), cognition (modified mini-mental state exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life Scale). We fit confounder-adjusted gamma-distributed mixed generalized linear models with a log link for each outcome and considered interaction with stroke severity. On average, participants were 65 years old, 53% male, and 63% Mexican American. Median recreational centers were 1.60 per square mile (interquartile range, 0.41-3.06). Among moderate-severe stroke survivors, greater density of recreation centers (75th versus 25th percentile) was associated with more favorable function and possibly quality of life (activities of daily living/instrumental activities of daily living, 4.8% change [95% CI, -0.11% to -9.27%]; Stroke-Specific Quality of Life Scale, 3.7% change [95% CI, -0.7% to 8.2%]). Minimal nonsignificant differences were observed among the overall stroke population and those with mild stroke. The availability of recreation centers may be beneficial for poststroke function and quality of life among those with moderate-severe stroke. If further research confirms recreation centers to be beneficial, this could inform rehabilitation following stroke.

Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population

ObjectiveThe purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. Summary background dataGrowing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. MethodsThis was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012–2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. ResultsOverall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p ​< ​0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p ​< ​0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. ConclusionsHigh SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.

Structural Racism and Adolescent Mental Health Disparities in Northern California

Understanding how structural racism is associated with adolescent mental health is critical to advance health equity. To assess associations between neighborhood privilege, measured by the Index of Concentration at the Extremes (ICE) and adolescent depressive symptoms, suicidality, and related racial and ethnic disparities. This was a retrospective cohort study using electronic health records of adolescents aged 12 to 16 years who attended well-teen visits between 2017 and 2021. Kaiser Permanente Northern California is an integrated health care delivery system serving 4.6 million members. The cohort included 34 252 individuals born singleton at an affiliated facility from January 1, 2005, to December 31, 2009, and who had completed at least 1 mental health screener during a well-teen visit by November 23, 2021. American Community Survey 2016 to 2021 5-year estimates were used to calculate ICE scores for adolescents' residential census tract at ages 10 to 11. Three ICE measures were used as proxies of structural racism: racial privilege (ICE-race and ethnicity; hereinafter ICE-race), economic privilege (ICE-income), and combined economic and racial privilege (ICE-income plus race and ethnicity; herinafter ICE-income plus race). ICE scores were categorized into quintiles based on California statewide distributions. Depressive symptoms and suicidality were assessed through self-report screeners during well-teen visits. Depressive symptoms were considered to be present if patients had a score on the Patient Health Questionnaire-2 of 3 or higher (the tool uses a Likert scale to determine the frequency [0 = not at all; 3 = nearly every day] that they had depressed mood and lack of pleasure in usual activities in the past 2 weeks; responses were summed and dichotomized). Analyses included 34 252 adolescents (12-16 years of age; mean [SD] age, 13.7 [0.8] years; 17 557 [51.3%] male, 7284 [21.3%] Asian or Pacific Islander, 2587 [7.6%] Black], 9061 [26.5%] Hispanic, 75 [0.2%] American Indian or Indigenous, 12 176 [35.5%] White, and 3069 [9%] other or unknown). Risks of depressive symptoms and suicidality generally increased with each level of declining neighborhood privilege. Adjusted risk ratios comparing adolescents from neighborhoods with the least to most racial and economic privilege were 1.37 (95% CI, 1.20-1.55) for depressive symptoms and 1.59 (95% CI, 1.23-2.05) for suicidality. Racial disparities between Black and White youth and Hispanic and White youth decreased after adjusting for each ICE measure, and became nonsignificant in models adjusting for ICE-race and ICE-income plus race. In this cohort study, lower neighborhood privilege was associated with greater risks of adolescent depressive symptoms and suicidality. Furthermore, adjusting for neighborhood privilege reduced mental health disparities affecting Black and Hispanic adolescents. These findings suggest that efforts to promote equity in adolescent mental health should extend beyond the clinical setting and consider the inequitable neighborhood contexts that are shaped by structural racism.

Socio-economic inequalities in lung cancer mortality in Spain: a nation-wide study using area-based deprivation

BackgroundLung cancer is the main cause of cancer mortality worldwide and in Spain. Several previous studies have documented socio-economic inequalities in lung cancer mortality but these have focused on specific provinces or cities. The goal of this study was to describe lung cancer mortality in Spain by sex as a function of socio-economic deprivation.MethodsWe analysed all registered deaths from lung cancer during the period 2011–2017 in Spain. Mortality data was obtained from the National Institute of Statistics, and socio-economic level was measured with the small-area deprivation index developed by the Spanish Society of Epidemiology, with the census tract of residence at the time of death as the unit of analysis. We computed crude and age-standardized rates per 100,000 inhabitants by sex, deprivation quintile, and type of municipality (rural, semi-rural, urban) considering the 2013 European standard population (ASR-E). We further calculated ASR-E ratios between the most deprived (Q5) and the least deprived (Q1) areas and mapped census tract smoothed standardized lung cancer mortality ratios by sex.ResultsWe observed 148,425 lung cancer deaths (80.7% in men), with 73.5 deaths per 100,000 men and 17.1 deaths per 100,000 women. Deaths from lung cancer in men were five times more frequent than in women (ASR-E ratio = 5.3). Women residing in the least deprived areas had higher mortality from lung cancer (ASR-E = 22.2), compared to women residing in the most deprived areas (ASR-E = 13.2), with a clear gradient among the quintiles of deprivation. For men, this pattern was reversed, with the highest mortality occurring in areas of lower socio-economic level (ASR-E = 99.0 in Q5 vs. ASR-E = 86.6 in Q1). These socio-economic inequalities remained fairly stable over time and across urban and rural areas.ConclusionsSocio-economic status is strongly related to lung cancer mortality, showing opposite patterns in men and women, such that mortality is highest in women residing in the least deprived areas and men residing in the most deprived areas. Systematic surveillance of lung cancer mortality by socio-economic status may facilitate the assessment of public health interventions aimed at mitigating cancer inequalities in Spain.

Does Urban Greenspace Reduce Mortality Inequalities Based on Poverty, Race, or Both in Philadelphia, PA?

While past research suggests that urban greenspace is associated with weaker income-based mortality inequities, little is known about associations with racial inequities, which may be distinct owing to historical and contemporary forms of racism. We quantified the extent to which different measures of greenspace modified socioeconomic and racial/ethnic inequities in all-cause and cardiovascular disease mortality. For every residential census tract in Philadelphia, PA (N = 376), we linked counts of all-cause and cardiovascular mortality (years 2008-2015) with measures of greenspace (proportion tree canopy or grass/shrub cover, proportion residents reporting park access, and the normalized difference vegetation index measure of overall greenness) and American Community Survey-based measures of sociodemographic composition (proportion of residents living in poverty, proportion identifying as non-Hispanic Black, and the index of concentration at the extremes (ICE) representing racialized economic deprivation). We used age- and sex-adjusted negative binomial models, with the natural logarithm of age-specific population counts as an offset, to quantify the magnitude of inequities by each composition variable, overall and stratified by categories of each greenspace measure. Inequities in mortality were weaker among neighborhoods with higher proportion grass/shrub cover or overall greenness. The most substantially narrowed inequities were those by the ICE. Mortality inequities did not differ substantially by perceived park access, and tree canopy was associated with weaker ICE-based inequities only. In this ecologic analysis, neighborhood greenspace was associated with weaker mortality inequities. However, associations varied across greenspace type and sociodemographic composition metrics, with generally stronger associations with overall greenness and grass/shrub coverage, and for ICE-basedinequities.

Social Drivers of COVID-19 Disease Severity in Pregnant Patients.

While coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had global impact in all populations, certain groups of patients have experienced disproportionate rates of morbidity and mortality. The purpose of this study was to assess the relationship between COVID-19 disease severity, demographic variables, race and ethnicity, and social determinants of health among pregnant patients in a diverse urban population. A retrospective analysis was performed of all pregnant patients diagnosed with COVID-19 at two urban tertiary care centers in Houston, TX between March and August 2020. Maternal demographic, COVID-19 illness criteria, and delivery characteristics were collected. The Centers for Disease Control and Prevention Social Vulnerability Index (SVI) and COVID-19 Community Vulnerability Index (CCVI) were obtained based on a patients' census tract of residence. Analyses compared persons with asymptomatic, mild, or severe-critical disease at diagnosis. A total of 317 persons tested positive for COVID-19 during this time period. Asymptomatic persons were more likely to be diagnosed at later gestational ages, but there were no other differences in baseline maternal characteristics. Persons with more severe disease had greater social vulnerability specifically for housing and transportation than those with mild disease (mean SVI [standard error]: 0.72 [0.06] vs. 0.58 [0.2], p = 0.03). Total SVI, total CCVI, and other themed SVI and CCVI indices were not significantly different between groups. In this cohort of pregnant persons infected with SARS-CoV-2, an association was shown between disease severity and increased vulnerability in living conditions and transportation. Drivers of the pandemic and COVID-19 outcomes are complex and multifactorial, and likely change over time. However, continued efforts to accurately identify and measure social determinants of health in medicine will likely help identify geographic areas and patient populations that are at risk of higher disease burden. This could facilitate preventative and mitigation measures in these areas in future disaster or pandemic situations. · SVI and CCVI estimate social determinants of health.. · COVID-19 is associated with housing and transportation vulnerability.. · Social determinants contribute to disease burden in pregnancy..

Changes in air pollution exposure after residential relocation and body mass index in children and adolescents: A natural experiment study

Air pollution exposure may affect child weight gain, but observational studies provide inconsistent evidence. Residential relocation can be leveraged as a natural experiment by studying changes in health outcomes after a sudden change in exposure within an individual. We aimed to evaluate whether changes in air pollution exposure due to residential relocation are associated with changes in body mass index (BMI) in children and adolescents in a natural experiment study. This population-based study included children and adolescents, between 2 and 17 years, who moved during 2011–2018 and were registered in the primary healthcare in Catalonia, Spain (N = 46,644). Outdoor air pollutants (nitrogen dioxides (NO2), particulate matter <10 μm (PM10) and <2.5 μm (PM2.5)) were estimated at residential census tract level before and after relocation; tertile cut-offs were used to define changes in exposure. Routinely measured weight and height were used to calculate age-sex-specific BMI z-scores. A minimum of 180 days after moving was considered to observe zBMI changes according to changes in exposure using linear fixed effects regression. The majority of participants (60–67% depending on the pollutant) moved to areas with similar levels of air pollution, 15–49% to less polluted, and 14–31% to more polluted areas. Moving to areas with more air pollution was associated with zBMI increases for all air pollutants (β NO2 = 0.10(95%CI 0.09; 0.12), β PM2.5 0.06(0.04; 0.07), β PM10 0.08(0.06; 0.10)). Moving to similar air pollution areas was associated with decreases in zBMI for all pollutants. No associations were found for those moving to less polluted areas. Associations with moving to more polluted areas were stronger in preschool- and primary school-ages. Associations did not differ by area deprivation strata. This large, natural experiment study suggests that increases in outdoor air pollution may be associated with child weight gain, supporting ongoing efforts to lower air pollution levels.

Association Between Historical Neighborhood Redlining and Cardiovascular Outcomes Among US Veterans With Atherosclerotic Cardiovascular Diseases

In the 1930s, the government-sponsored Home Owners' Loan Corporation (HOLC) established maps of US neighborhoods that identified mortgage risk (grade A [green] characterizing lowest-risk neighborhoods in the US through mechanisms that transcend traditional risk factors to grade D [red] characterizing highest risk). This practice led to disinvestments and segregation in neighborhoods considered redlined. Very few studies have targeted whether there is an association between redlining and cardiovascular disease. To evaluate whether redlining is associated with adverse cardiovascular outcomes in US veterans. In this longitudinal cohort study, US veterans were followed up (January 1, 2016, to December 31, 2019) for a median of 4 years. Data, including self-reported race and ethnicity, were obtained from Veterans Affairs medical centers across the US on individuals receiving care for established atherosclerotic disease (coronary artery disease, peripheral vascular disease, or stroke). Data analysis was performed in June 2022. Home Owners' Loan Corporation grade of the census tracts of residence. The first occurrence of major adverse cardiovascular events (MACE), comprising myocardial infarction, stroke, major adverse extremity events, and all-cause mortality. The adjusted association between HOLC grade and adverse outcomes was measured using Cox proportional hazards regression. Competing risks were used to model individual nonfatal components of MACE. Of 79 997 patients (mean [SD] age, 74.46 [10.16] years, female, 2.9%; White, 55.7%; Black, 37.3%; and Hispanic, 5.4%), a total of 7% of the individuals resided in HOLC grade A neighborhoods, 20% in B neighborhoods, 42% in C neighborhoods, and 31% in D neighborhoods. Compared with grade A neighborhoods, patients residing in HOLC grade D (redlined) neighborhoods were more likely to be Black or Hispanic with a higher prevalence of diabetes, heart failure, and chronic kidney disease. There were no associations between HOLC and MACE in unadjusted models. After adjustment for demographic factors, compared with grade A neighborhoods, those residing in redlined neighborhoods had an increased risk of MACE (hazard ratio [HR], 1.139; 95% CI, 1.083-1.198; P < .001) and all-cause mortality (HR, 1.129; 95% CI, 1.072-1.190; P < .001). Similarly, veterans residing in redlined neighborhoods had a higher risk of myocardial infarction (HR, 1.148; 95% CI, 1.011-1.303; P < .001) but not stroke (HR, 0.889; 95% CI, 0.584-1.353; P = .58). Hazard ratios were smaller, but remained significant, after adjustment for risk factors and social vulnerability. In this cohort study of US veterans, the findings suggest that those with atherosclerotic cardiovascular disease who reside in historically redlined neighborhoods continue to have a higher prevalence of traditional cardiovascular risk factors and higher cardiovascular risk. Even close to a century after this practice was discontinued, redlining appears to still be adversely associated with adverse cardiovascular events.

Assessing performance of ZCTA-level and Census Tract-level social and environmental risk factors in a model predicting hospital events

Predictive analytics are used in primary care to efficiently direct health care resources to high-risk patients to prevent unnecessary health care utilization and improve health. Social determinants of health (SDOH) are important features in these models, but they are poorly measured in administrative claims data. Area-level SDOH can be proxies for unavailable individual-level indicators, but the extent to which the granularity of risk factors impacts predictive models is unclear. We examined whether increasing the granularity of area-based SDOH features from ZIP code tabulation area (ZCTA) to Census Tract strengthened an existing clinical prediction model for avoidable hospitalizations (AH events) in Maryland Medicare fee-for-service beneficiaries. We created a person-month dataset for 465,749 beneficiaries (59.4% female; 69.8% White; 22.7% Black) with 144 features indexing medical history and demographics using Medicare claims (September 2018 through July 2021). Claims data were linked with 37 SDOH features associated with AH events from 11 publicly-available sources (e.g., American Community Survey) based on the beneficiaries’ ZCTA and Census Tract of residence. Individual AH risk was estimated using six discrete time survival models with different combinations of demographic, condition/utilization, and SDOH features. Each model used stepwise variable selection to retain only meaningful predictors. We compared model fit, predictive performance, and interpretation across models. Results showed that increasing the granularity of area-based risk factors did not dramatically improve model fit or predictive performance. However, it did affect model interpretation by altering which SDOH features were retained during variable selection. Further, the inclusion of SDOH at either granularity level meaningfully reduced the risk that was attributed to demographic predictors (e.g., race, dual-eligibility for Medicaid). Differences in interpretation are critical given that this model is used by primary care staff to inform the allocation of care management resources, including those available to address drivers of health beyond the bounds of traditional health care.

Social Vulnerability and Initiation of Pharmacotherapy for Gestational Diabetes Mellitus in a Medicaid Population.

Our study examines the association between social vulnerability index (SVI) and pharmacotherapy initiation for gestational diabetes mellitus (GDM). We studied a retrospective cohort of pregnant patients with GDM, enrolled in Tennessee Medicaid, who gave birth between 2007 and 2019. Enrollment files were linked to birth and death certificates, state hospitalization registries, and pharmacy claims. SVI, measured at the community level and determined by residential census tract, ranged from 0 to 100 (low to high vulnerability). Multivariable logistic regression assessed the association between SVI and the odds of initiating the most common pharmacotherapies for GDM-insulin, glyburide, or metformin-and adjusted for relevant covariates. SVI was modeled with restricted cubic splines to account for nonlinear associations, using the median Tennessee SVI as a reference. Secondary analysis assessed associations with the SVI subthemes. Among 33,291 patients with GDM, 21.7% (7,209) initiated pharmacotherapy during pregnancy. Patients from areas with higher SVI were more likely to be non-Hispanic Black with higher body mass index, whereas those with lower SVI were more likely to be nulliparous. Multivariable modeling demonstrated a complex nonlinear association between SVI and GDM pharmacotherapy initiation, relative to the reference. Higher SVI was associated with elevated odds of GDM pharmacotherapy initiation (e.g., odds ratio 1.11 [95% confidence interval 1.02-1.22] for SVI 80) and low to medium SVI had variable nonsignificant associations with GDM pharmacotherapy initiation, relative to the reference (lower odds of initiation for values 25-50, higher odds of initiation for values<25). Secondary analysis demonstrated a nonlinear association between subtheme 3 and the odds of GDM pharmacotherapy initiation. Social vulnerability is associated with initiation of pharmacotherapy for GDM, highlighting the possible role of social determinants of health in achieving glycemic control.

Trends in Disparities in Advanced Neuroimaging Utilization in Acute Stroke: A Population-Based Study.

Our primary objective was to evaluate if disparities in race, sex, age, and socioeconomic status (SES) exist in utilization of advanced neuroimaging in year 2015 in a population-based study. Our secondary objective was to identify the disparity trends and overall imaging utilization as compared with years 2005 and 2010. This was a retrospective, population-based study that utilized the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) data. Patients with stroke and transient ischemic attack were identified in the years 2005, 2010, and 2015 in a metropolitan population of 1.3 million. The proportion of imaging use within 2 days of stroke/transient ischemic attack onset or hospital admission date was computed. SES determined by the percentage below the poverty level within a given respondent's US census tract of residence was dichotomized. Multivariable logistic regression was used to determine the odds of advanced neuroimaging use (computed tomography angiogram/magnetic resonance imaging/magnetic resonance angiogram) for age, race, gender, and SES. There was a total of 10 526 stroke/transient ischemic attack events in the combined study year periods of 2005, 2010, and 2015. The utilization of advanced imaging progressively increased (48% in 2005, 63% in 2010, and 75% in 2015 [P<0.001]). In the combined study year multivariable model, advanced imaging was associated with age and SES. Younger patients (≤55 years) were more likely to have advanced imaging compared with older patients (adjusted odds ratio, 1.85 [95% CI, 1.62-2.12]; P<0.01), and low SES patients were less likely to have advanced imaging compared with high SES (adjusted odds ratio, 0.83 [95% CI, 0.75-0.93]; P<0.01). A significant interaction was found between age and race. Stratified by age, the adjusted odds of advanced imaging were higher for Black patients compared with White patients among older patients (>55 years; adjusted odds ratio, 1.34 [95% CI, 1.15-1.57]; P<0.01), but no racial differences among the young. Racial, age, and SES-related disparities exist in the utilization of advanced neuroimaging for patients with acute stroke. There was no evidence of a change in trend of these disparities between the study periods.

Neighborhood disinvestment and severe maternal morbidity in the state of California

Social determinants of health, including neighborhood context, may be a key driver of severe maternal morbidity and its related racial and ethnic inequities; however, investigations remain limited. This study aimed to examine the associations between neighborhood socioeconomic characteristics and severe maternal morbidity, as well as whether the associations between neighborhood socioeconomic characteristics and severe maternal morbidity were modified by race and ethnicity. This study leveraged a California statewide data resource on all hospital births at ≥20 weeks of gestation (1997-2018). Severe maternal morbidity was defined as having at least 1 of 21 diagnoses and procedures (eg, blood transfusion or hysterectomy) as outlined by the Centers for Disease Control and Prevention. Neighborhoods were defined as residential census tracts (n=8022; an average of 1295 births per neighborhood), and the neighborhood deprivation index was a summary measure of 8 census indicators (eg, percentage of poverty, unemployment, and public assistance). Mixed-effects logistic regression models (individuals nested within neighborhoods) were used to compare odds of severe maternal morbidity across quartiles (quartile 1 [the least deprived] to quartile 4 [the most deprived]) of the neighborhood deprivation index before and after adjustments for maternal sociodemographic and pregnancy-related factors and comorbidities. Moreover, cross-product terms were created to determine whether associations were modified by race and ethnicity. Of 10,384,976 births, the prevalence of severe maternal morbidity was 1.2% (N=120,487). In fully adjusted mixed-effects models, the odds of severe maternal morbidity increased with increasing neighborhood deprivation index (odds ratios: quartile 1, reference; quartile 4, 1.23 [95% confidence interval, 1.20-1.26]; quartile 3, 1.13 [95% confidence interval, 1.10-1.16]; quartile 2, 1.06 [95% confidence interval, 1.03-1.08]). The associations were modified by race and ethnicity such that associations (quartile 4 vs quartile 1) were the strongest among individuals in the "other" racial and ethnic category (1.39; 95% confidence interval, 1.03-1.86) and the weakest among Black individuals (1.07; 95% confidence interval, 0.98-1.16). Study findings suggest that neighborhood deprivation contributes to an increased risk of severe maternal morbidity. Future research should examine which aspects of neighborhood environments matter most across racial and ethnic groups.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients

IntroductionThe Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients. MethodsSurgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal–Wallis and Fisher's exact tests. ResultsOf 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group. ConclusionsThe SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

Effect of an Automated Hemoglobin A1c Reflex on Socioeconomic Disparities in Testing Frequency and Glycemic Control

Abstract The American Diabetes Association recommends semiannual hemoglobin A1c (A1c) testing for diabetic patients with stable glycemic control and quarterly testing for patients with a change in therapy or who do not meet A1c goals. To aid in achieving this goal our laboratory performs an automated, add-on A1c test for any diabetic and hospitalized patient with no A1c ordered in the previous 60 days. The primary aim of this study was to determine the impact of an automated reflex on A1c testing frequency and glycemic control. Our second aim was to determine socioeconomic differences of reflexed A1c testing. All A1c results performed by the BJH laboratory from 5/1/2016-1/22/22 and associated patient demographics were retrieved from the laboratory information system. Patient addresses were geocoded, and a CDC-validated social vulnerability index (SVI) was assigned to each patient based on their census tract of residence. Patients were then stratified in the bottom SVI half (most vulnerable) and the upper SVI half (least vulnerable). A total of 32,861 A1c’s were performed on 17,699 patients, 6,341 of whom had &amp;gt;1 test. 2,952 (46.6%) patients had at least one reflexed A1c (add-on group). The median average time between A1c tests was 144.4 days in the add-on group and 209.0 days in the no add-on group (p&amp;lt;0.001). The average time between A1c tests for patients in the add-on group in the bottom SVI half was 143.8 days vs. 145.3 days in the top SVI half (p=0.84). In contrast, the median average time between A1c tests for patients in the no add-on group in the bottom SVI half was 215.5 days and was 199.5 days in the top SVI half (p&amp;lt;0.05). The number of patients with A1c in the uncontrolled range (A1c =9%) decreased by 11.5% in the add-on group compared to 1.7% in the no add-on group (p&amp;lt;0.001). In those with add-on testing, the proportion of patients in the bottom SVI with initial A1c =9% and a longitudinal decrease in A1c was 11.3% compared to 11.9% in the top SVI half (p=0.39). In the no add-ons group, the proportion of patients with A1c =9% increased by 3.3% in the bottom SVI and decreased by 12.1% in the top SVI (p=0.01). A socioeconomic disparity is observed in A1c testing frequency and rates of uncontrolled diabetes over time for patients without add-on testing, but not for patients with add-on testing. Automatic add-on testing for hospitalized diabetic patients may reduce socioeconomic disparities in A1c testing frequency and glycemic control.

Patient characteristics and neighborhood attributes associated with hepatitis C screening and positivity in Philadelphia

Among patients of an urban primary care network in Philadelphia with a universal hepatitis C virus (HCV) screening policy for patients born during 1945–1965, we examined whether being unscreened and HCV positivity were associated with attributes of the census tracts where patients resided, which we considered as proxies for social health determinants. For patients with at least one clinic visit between 2014 and mid-2017, we linked demographic and HCV screening information from electronic health records with metrics that described the census tracts where patients resided. We used generalized estimating equations to estimate adjusted relative risk ratios (aRRs) for being unscreened and HCV positive. Overall, 28% of 6,906 patients were unscreened. Black race, male gender, and residence in census tracts with relatively high levels of violent crime, low levels of educational attainment and household incomes, and evidence of residential segregation by Hispanic ethnicity were associated with lower aRRs for being unscreened. Among screened patients, 9% were HCV positive. Factors associated with lower risks of being unscreened were, in general, associated with higher HCV positivity. Attributes of census tracts where patients reside are probably less apparent to clinicians than patients’ gender or race but might reflect unmeasured patient characteristics that affected screening practices, along with preconceptions regarding the likelihood of HCV infection based on prior screening observations or implicit biases. Approaching complete detection of HCV-infected people would be hastened by focusing on residents of census tracts with attributes associated with higher infection levels or, if known, higher infection levels directly.

Racial Distribution of Neighborhood-Level Social Deprivation in a Retrospective Cohort of Prostate Cancer Survivors.

Background: A better understanding of neighborhood-level factors’ contribution is needed in order to increase the precision of cancer control interventions that target geographic determinants of cancer health disparities. This study characterized the distribution of neighborhood deprivation in a racially diverse cohort of prostate cancer survivors. Methods: A retrospective cohort of 253 prostate cancer patients who were treated with radical prostatectomy from 2011 to 2019 was established at the Medical University of South Carolina. Individual-level data on clinical variables (e.g., stage, grade) and race were abstracted. Social Deprivation Index (SDI) and Healthcare Professional Shortage (HPS) status was obtained from the Robert Graham Center and assigned to participants based on their residential census tract. Data were analyzed with descriptive statistics and multivariable logistic regression. Results: The cohort of 253 men consisted of 168 white, 81 African American, 1 Hispanic and 3 multiracial men. Approximately 49% of 249 men lived in areas with high SDI (e.g., SDI score of 48 to 98). The mean for SDI was 44.5 (+27.4), and the range was 97 (1–98) for all study participants. African American men had a significantly greater likelihood of living in a socially deprived neighborhood compared to white men (OR = 3.7, 95% C.I. 2.1–6.7, p < 0.01), while men who lived in areas with higher HPS shortage status were significantly more likely to live in a neighborhood that had high SDI compared to men who lived in areas with lower HPS shortages (OR = 4.7, 95% C.I. = 2.1–10.7, p < 0.01). African Americans had a higher likelihood of developing biochemical reoccurrence (OR = 3.7, 95% C.I. = 1.7–8.0) compared with white men. There were no significant association between SDI and clinical characteristics of prostate cancer. Conclusions: This study demonstrates that SDI varies considerably by race among men with prostate cancer treated with radical prostatectomy. Using SDI to understand the social environment could be -particularly useful as part of precision medicine and precision public health approaches and could be used by cancer centers, public health providers, and other health care specialists to inform operational decisions about how to target health promotion and disease prevention efforts in catchment areas and patient populations.