Socioeconomic Distress Research Articles

P-020: IMPLICATIONS OF SOCIOECONOMIC DISTRESS ON NUTRITIONAL STATUS AND KIDNEY FUNCTION IN PEOPLE WITH SICKLE CELL ANEMIA

Purpose: Sickle cell anemia (SCA) is characterized by a myriad of acute and chronic complications. These complications negatively impact the ability to achieve educational and occupational goals making this group a particularly vulnerable population to socioeconomic challenges (PMID 30540112). In the general population, indices of socioeconomic distress are associated with poor nutrition and kidney disease risk (PMID 25573510). The association of socioeconomic distress with nutritional status and kidney function in people with SCA is unknown. Materials and methods: We conducted a cross-sectional study to describe the burden of socioeconomic distress and its impact on nutritional status and kidney function in an SCA cohort (n=332) treated at an urban academic institution. The distressed community index (DCI), a composite of socioeconomic indicators that estimate the economic well-being of a community, was determined for each individual using the following website: https://eig.org/dci/interactive-map. A higher DCI score indicates a more distressed community. The associations of DCI with measures of nutritional status (serum albumin, body mass index [BMI], vitamin D 25-OH) and kidney function (estimated glomerular filtration rate [eGFR]; albuminuria; serum bicarbonate, potassium, and erythropoietin levels), were determined using linear or logistic regression. The analyses were adjusted for age, sex, and hydroxyurea use for nutritional status as well as for APOL1 G1 and G2 risk status for kidney function. The beta coefficients provided are based on increments of 10 for DCI. Median and interquartile ranges (IQR) are provided. Results: The median age of the cohort was 31 years (IQR, 24 – 41 years), 55% were female, and 53% were on hydroxyurea therapy. The median DCI in this cohort was 87 (IQR, 61 – 96) with 61% of SCA patients living in a distressed tier (DCI≥ 80) and only 5% living in a prosperous tier (DCI< 20). The DCI tiers for SCA patients trended towards more socioeconomically distressed communities compared to the general African American population (P=0.1) (Figure 1A). A higher DCI, reflecting an increase in socioeconomic distress, was associated with a trend for a lower odds ratio (OR) of being on hydroxyurea therapy (OR 0.93, 95% CI: 0.86 – 1.01; P=0.08). An increasing DCI was significantly associated with lower serum albumin (β= -0.02; P=0.016) (Figure 1B), BMI (β= -0.01; P=0.045), and vitamin D 25-OH levels (β= -0.7; P=0.001) (Figure 1C). A higher DCI was associated with a trend for a lower eGFR (β= -0.6; P=0.09) (Figure 1D) while no association was observed with urine albumin concentration (P=0.8). Lower serum bicarbonate (β= -0.1; P=0.02) and lower erythropoietin (β= -0.9; P=0.1) levels, but not serum potassium concentration (P=0.9), were also associated with higher DCI. Conclusion: In conclusion, we demonstrate that a high proportion of patients with SCA treated at an urban academic institution live in distressed socioeconomic communities. Furthermore, higher distressed community indices are associated with lower measures of nutritional status and with some markers of impaired kidney function. Future studies investigating the effects of socioeconomic distress on access to healthy foods and kidney disease risk may guide public health strategies to improve health disparities in the SCA population.Figure 1. The authors do not declare any conflict of interest

Socioeconomic distress is associated with failure to rescue in cardiac surgery

ObjectiveThe influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue. MethodsPatients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue. ResultsA total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044). ConclusionsIncreasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.

Socioeconomic Distress Associated With Increased Use of Percutaneous Coronary Intervention Over Coronary Artery Bypass Grafting

BackgroundThe influence of socioeconomic determinants of health on choice of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) for coronary artery disease is unknown. We hypothesized that higher Distressed Communities Index (DCI) scores, a comprehensive socioeconomic ranking by zip code, would be associated with more frequent PCI. MethodsAll patients undergoing isolated CABG or PCI in a regional American College of Cardiology CathPCI registry and The Society of Thoracic Surgeons database (2018-2021) were assigned DCI scores (0 = no distress, 100 = severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. Patients who presented with ST-segment elevation myocardial infarction or emergent procedures were excluded. The most distressed quintile (DCI ≥80) was compared with all other patients. Multivariable logistic regression analyzed the association between DCI and procedure type. ResultsA total of 23 223 patients underwent either PCI (n = 16 079) or CABG (n = 7144) for coronary artery disease across 28 centers during the study period. Before adjustment, high socioeconomic distress occurred more frequently among CABG patients (DCI ≥80, 12.4% vs 8.42%; P < .001). After multivariable adjustment, high socioeconomic distress was associated with greater odds of receiving PCI, relative to CABG (odds ratio 1.26; 95% CI, 1.07-1.49; P = .007). High socioeconomic distress was significantly associated with postprocedural mortality (odds ratio 1.52; 95% CI, 1.02-2.26; P = .039). ConclusionsHigh socioeconomic distress is associated with greater risk-adjusted odds of receiving PCI, relative to CABG, as well as higher postprocedural mortality. Targeted resource allocation in high DCI areas may help eliminate barriers to CABG.

Protest, Change, and Democracy: Locating Current Farmers Protest Movement in Dube’s Construct of “Understanding Change”

S. C. Dube’s contributions to the understanding of social change are as relevant today as these were in the decades of the twentieth century. He cautioned saying “good economics is not always good sociology.” Decades following economic liberalization inequalities have continued to rise, socioeconomic distress and more recently farmers resistance to proposed agricultural reforms revalidate some of his prophecies. He cautioned that if cultural norms and the “hold traditional agricultural practises have on people’s way of life are ignored, reforms will be resisted.” In this presentation, an attempt is made to revisit some of his invaluable contributions in understanding farmers protest movement that lasted for more than a year and was withdrawn only after a public announcement by the Prime Minister of India that the three laws against which persistent protests were organized are unequivocally withdrawn. This Dube Memorial Lecture was presented on the invitations of Indian National Confederation and Academy of Anthropologists on February 22, 2021, when the protest movement was on for nearly 8 months. Tarrow’s construct of protest movements and inherent contestations in movements provides theoretical framework to explore longevity and outcome of this prolonged resistance on reforms and restructuring of political configurations.

Disparities in coronary artery bypass grafting between high- and low-volume surgeons and hospitals

BackgroundHigh-volume surgeons and hospitals performing coronary artery bypass grafting have been associated with improved patient outcomes. However, patients of increased socioeconomic distress may have worse outcomes because of health care disparities. We sought to identify trends and outcomes in patients of elevated distress undergoing bypass grafting. MethodsThe Florida Agency for Healthcare Administration administrative data set was merged with Centers for Medicare and Medicaid Services Physician and Hospital Compare and Economic Innovation Group Distressed Community Index data sets to build a comprehensive database. The data set was queried to identify patients undergoing coronary artery bypass procedures between 2016 and 2020. High- and low-volume hospitals and surgeons were compared. Patient and hospital demographics, comorbidities, length of stay, and postoperative complications were analyzed by χ2 and t test where appropriate. ResultsA total of 41,571 coronary artery bypass grafting procedures were performed by 174 surgeons at 67 Florida hospitals. Low- and high-volume hospitals did not differ with respect to hospital ownership, overall star rating, national comparisons of mortality, readmission, or cost effectiveness. Patients from at-risk and distressed communities were more likely to undergo surgery at low-volume hospitals. Hospital length of stay was increased for low-volume hospitals (10.2 vs 9.4 days, P < .05). Postoperative complications including pneumonia, arrhythmia, respiratory failure, acute renal failure, shock, pleural effusion, and sepsis were more frequent at low-volume hospitals and for low-volume surgeons. ConclusionHigh-volume hospitals and surgeons have improved postoperative outcomes and hospital length of stay when compared to low-volume hospitals and surgeons performing coronary artery bypass grafting. At-risk and distressed populations are more likely to undergo bypass surgery at low-volume hospitals, potentially contributing to worse patient outcome. Efforts should be made to mitigate the potential impact of low socioeconomic status to improve outcomes in this population.

Effect of Socioeconomic Distress on Risk-Adjusted Mortality After Valve Surgery for Infective Endocarditis

Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P=0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis.

Changing associations between socioeconomic status and self-reported discrimination from the 1990s to the 2010s in the United States.

We examined whether prevalence of social class discrimination-and its association with psychological distress-has changed between 1990s and 2010s in the United States. Data were from the original Midlife in the United States (MIDUS) study with data collections in 1995-1996 (n=2931) and 2004-2005 (n=1708), and the new MIDUS Refresher sample from 2011 to 2014 (n=2543). Socioeconomic status (SES) became more strongly associated with self-rated discrimination over time, with individuals with the lowest SES experiencing more discrimination (B=0.75, p< .001) and those with the highest SES less discrimination (B=0.36, p < .001) over time: at baseline, the difference in self-rated discrimination between the highest and lowest SES groups was 15.3% versus 10.8% (4.7% point difference). This difference increased to 20.0% versus 7.4% in the last study wave (12.6% point difference). Association between self-reported discrimination and psychological distress strengthened over time, but the associations between socioeconomic indicators and distress did not change. The results suggest that people with low SES had higher risk of encountering unfair and disrespectful treatment in the 2010s compared to the 1990s.

Postacute Care Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities After Total Joint Arthroplasty.

Racial and socioeconomic disparities have been associated with complications and poorer patient-reported outcomes after THA and TKA, but little is known regarding the variation of postacute care resource utilization based on socioeconomic difference in the communities in which patients reside. Hip and knee arthroplasty are among the most common elective orthopaedic procedures. Therefore, understanding social factors provides insight into patients at risk for readmission and the way in which these patients use other postoperative resources. This knowledge can help surgeons better understand which patients are at risk for complications or preventable readmissions and how to anticipate when additional surveillance or intervention might reduce this risk. (1) Do patients from communities with a higher distress level experience higher rates of readmission after THA and TKA? (2) Do patients from distressed communities have increased postoperative resource utilization? Demographics, ZIP code of residence, and Charlson comorbidity index (CCI) were recorded for each patient undergoing TKA or THA between 2016 and 2019 at two high-volume hospitals. Patients were classified according to the Distressed Communities Index (DCI) score of their ZIP code of residence. The DCI combines seven metrics of socioeconomic well-being (high school graduation, poverty rate, unemployment, housing vacancy, household income, change in employment, and change in establishment) to create a single score. ZIP codes are then classified by scores into five categories based on national quintiles (prosperous, comfortable, mid-tier, at-risk, and distressed). The DCI was chosen because it provides a single composite measure of multiple important socioeconomic factors. Multivariate analysis with logistic, negative binomial regression, or Poisson was used to investigate the association of DCI category with postoperative resource utilization while controlling forage, gender, BMI, and comorbidities. The primary outcome was 90-day readmissions. Secondary outcomes included postoperative medication prescriptions from the orthopaedic team, patient telephone calls to the surgeon's office, physical therapy sessions attended, follow-up office visits, and emergency department visits. A total of 5077 patients who underwent TKA (mean age 66 ± 9 years, 59% [2983 of 5077] are women, and 69% [3519 of 5077] are White), and 5299 who underwent THA (mean age 63 ± 11 years, 50% [2654 of 5299] are women, and 74% [3903 of 5299] are White) were included. When adjusting for age, gender, race and CCI, readmission risk was higher in distressed communities compared with prosperous communities for patients undergoing TKA (odds ratio 1.6 [95% confidence interval 1.1 to 2.3]; p = 0.02) but not for THA. For secondary outcomes after TKA, at-risk communities had more postoperative prescriptions compared with prosperous communities, but no other differences were found. After THA, no major differences were found in the likelihood to utilize postoperative resources based on DCI category. Race was not associated with readmissions or resource utilization. We found that socioeconomic distress was associated with readmission after TKA, but, after controlling for relevant confounding variables, race had no association. Patients from these communities do not demonstrate an increased or decreased use of other resources after post-TKA discharge. Increased awareness of these disparities may allow for closer monitoring and improved patient education and communication, with the goal of reducing the frequency of complications and preventable readmissions. Level III, therapeutic study.

Post-Brexit Britain and Socioeconomic Distress in Ali Smith’s Autumn

Ali Smith’s novel “Autumn” (2016) is a Brexlit novel that depicts aspects of English society associated with a landmark in British history, the 2016 referendum that decided its exit from the EU. The article focuses on socioeconomic aspects touched upon by Smith, including the social division among communities and the communitarian disunity, financial and economic hardship, bureaucratic insensitiveness, the issue of immigration, as well as the public social submissiveness or protest while facing all of these plights. Even though these may not be the central themes of Smith’s novel, the depiction of the ‘hard times’ of people living during a time of change, uncertainty, division, chaos and mixed feelings emerges as an equally important concern, as the current paper aims to explore.

County-level crash prediction models for Pennsylvania accounting for income characteristics

The majority of current safety prediction models utilize roadway and traffic data as independent variables to describe safety performance at a microscopic level. Recent work moves toward predicting these measures within some region as a function of roadway and traffic data, as well as non-traditional variables, such as socioeconomic measures. This paper aims to provide a holistic view of the intersection of socioeconomics and safety in Pennsylvania by investigating possible relationships between wealth and various aspects of safety performance, including crash frequency, severity, and cost. The analyses presented in this paper serve as case studies with intentions to promote the development of more robust, wealth-inclusive safety analyses in the future. The study reveals relationships between socioeconomic-related measures and crash frequency, severity, and cost estimations. These relationships indicate counties with increased levels of socioeconomic distress (quantified by multiple socioeconomic-related variables) are estimated to experience more crashes – particularlyrelated to alcohol usage – and higher total crash costs, and crashes that occur in counties with increased levels of socioeconomic distress are estimated to be more likely to result in an increased injury severity level compared to crashes that occur elsewhere. These resultssupport previous work andexpand on that work by considering multiple socioeconomic-related variables and their impacts on three unique safety-related measures. The existence of a relationship between crash frequency, severity, and cost and wealth-related variables opens the door to further exploration of including wealth in traditional safety analyses. This paper discusses these relationships and offers recommendations for future work.

The current situation of small and medium-sized businesses in Russia

The article examines the situation related to the development and problems in Russian small and medium-sized enterprises over the past decade. The assessment of the institutional environment of entrepreneurship at the present stage of its existence is given. The subject of the study is the processes taking place in this sector of the economy. The purpose of the article is to study the peculiarities of the development and existence of Russian small and medium-sized businesses.The theoretical and methodological basis was made up of articles by authors directly involved in business, as well as authors considering this economic activity from a methodological point of view. Changes in the institutional environment of the economy are becoming particularly relevant due to the challenges associated with sanctions restrictions against the country, as well as the serious dependence of the budget on oil and gas trade in raw materials, where energy prices have recently collapsed.The materials of the article can be used by mass media focused on the problems of domestic entrepreneurship. The novelty of the article primarily consists in a comprehensive analysis of the situation in this sector of the economy over the past decade. The state of the country's economy directly depends not only on the players of big business, but also largely on the objects of small and medium-sized enterprises, since they use local labor, raw materials and production resources on the territory. Therefore, economic diversification is currently an important issue for the state economic policy of the state, and it is small and medium-sized businesses that could become the locomotive that would allow the country to get out of further technological and socio-economic distress.

Later life depression as a risk factor for developing dementia: how much influence does the post-pandemic era have?

By the year 2050, it is estimated that at least 20% of the world’s population will be over the age of 65. Depression in late life is a serious public health problem that has a negative and substantial impact on the quality of life of older adults, their families, and their social circle. Depression, in turn, constitutes a risk and prognostic factor for the development or worsening of dementia, a condition present in about 10% of the population over 60 years of age, and which increases and intensifies with age, being up to 40% at age 90. In the context of the current COVID-19 pandemic, aspects such as persistent isolation and loneliness, socioeconomic distress, lack of family and professional support, fear of illness and death, are potential negative risk factors for developing depression and worsening the prognosis of dementia in older adults.

Recurrent Hypertriglyceridemia-Associated Pancreatitis in a Pregnant Woman Complicated by Severe Socioeconomic Insecurity

Lead Author's Financial Disclosures Nothing to disclose. Study Funding None. Background/Synopsis At 26 weeks gestation, a 24-year-old pregnant woman with type 2 diabetes mellitus (T2DM) and hypertriglyceridemia (HTG) was hospitalized for her second episode of acute pancreatitis (AP) associated with triglycerides (TG) > 4000 mg/dL. Medical therapy including plasma exchange resulted in dramatic improvement of TG, and the remaining hospital course was uneventful. She was discharged with plan for twice weekly plasma exchange. However, she did not have adequate childcare or transportation to enable treatment and the tunneled catheter had to be removed due to infection before she could receive any outpatient plasma exchange. This case highlights potential barriers to management of severe HTG and the need for effective therapy. Objective/Purpose To review a clinical scenario where severe inherited lipid abnormality and socioeconomic distress complicate care. Methods Laboratory testing was performed by University of Pennsylvania Health System Cernmill Laboratory. Results A 24-year-old G6P3 woman at 26 weeks gestation with T2DM presented to the hospital with intractable abdominal pain and was found to have diabetic ketoacidosis (DKA) and severe HTG causing AP (Table 1). Her medical history was notable for one prior episode of AP at age 21, during which she was first diagnosed with HTG and T2DM and treated with gemfibrozil and insulin. Subsequent medical care was disrupted by limited financial resources and housing insecurity. Follow-up lipid testing while on this regimen did not achieve TG less than 1000 mg/dl. She was admitted to the obstetrics unit for intravenous fluids and insulin and kept nill per os (NPO) resulting in resolution of the DKA. She underwent plasma exchange resulting in TG reduction and resolution of abdominal pain and elevated pancreatic enzymes. TG levels rose to >1200 mg/dL two days after plasma exchange despite clear liquid diet. A prolonged discussion about the risk of recurrent AP to her and her pregnancy, the interventions to manage HTG-associated AP, and available resources supported the role of once- or twice-weekly plasma exchange until delivery. Unfortunately, this plan was abandoned one week after discharge from the hospital because of inadequate access to appropriate childcare, transportation costs, and difficulty with safe maintenance of her tunneled IV access catheter. Present therapy includes close monitoring, dietary counseling, and combination of gemfibrozil and high dose omega-3 fatty acid supplementation. Conclusions This case illustrates a treatment dilemma stemming from the intersection of lipid biology, pregnancy, diabetes, and social determinants of health. Our patient has features of familial (FCS) and multifactorial chylomicronemia syndrome (MCS). Proper diagnosis may inform expectations from pharmacotherapy (e.g. gemfibrozil and high dose omega-3 fatty acid supplementation). In this case, the decision was made to initiate twice-weekly plasma exchange until delivery. There are no clinical trials to directly inform clinical decision-making for this rare condition. However, HTG-associated AP during pregnancy is reportedly more severe than non-pregnancy associated AP and intensive treatment is sensible given the expectation of worsening HTG in the last trimester and the high stakes for the patient and fetus. Unfortunately, our patient's socioeconomic barriers did not allow for appropriate treatment with plasma exchange and the social safety net could not solve these problems in the time required. This case serves as a reminder that our patients may face barriers to accessing complex healthcare and further highlights the need for more effective, convenient, and reliable HTG treatments for both FCS and MCS. Nothing to disclose.

Association between Socioeconomic Status and Psychological Distress among Rwandan Refugees in Zambia: a Gender Perspective

Urban refugees face several challenges which affect their emotional, social, and psychological well-being. This study utilised a quantitative cross-sectional design. The study assessed the association between socioeconomic status (SES) and psychological distress from a gender perspective among Rwandan refugees in Lusaka, Zambia. Two hundred and sixty-seven refugees between 18 and 65(M=33.99 years) participated in the study. The sample comprised men (47.9%) and women (52.1%) who were selected from Lusaka townships using purposive and convenience sampling techniques. SES was measured by assessing participants’ educational attainment, occupational status or employment, income, and financial support, whereas subjective psychological distress was evaluated using the General Health Questionnaire (GHQ-28). Framed within the feminist and the ecological systems perspectives, the study established an association between SES and psychological distress. The proportions of female participants in the lower education and unemployment categories and lower-income bracket were considerably higher than males in the same category. Similarly, the study revealed that the proportion of females (27%) with severe depression was higher than males (19%). However, the gender difference was negligible with other subscales such as the somatic symptoms, anxiety and insomnia, and social dysfunction. Bivariate associations revealed well-established gender differences, where women with low education and financial support reported higher levels of psychological distress. Multivariate analysis revealed that employment predicted a lower level of psychological distress in both men and women. The findings highlight that refugees’ access to employment is an essential factor in determining psychological well-being. Well-defined intervention strategies by government and humanitarian bodies are critical and should aim to empower refugees towards easy access to formal and informal labour market opportunities.

Improving Outcomes in Child Care Subsidy Voucher Programs under Regional Asymmetries

Related to several efforts by governments to attain United Nations Sustainable Development Goals, subsidy vouchers are used to provide monetary support to income‐eligible (IE) families who cannot afford child care. However, IE families are often unable to accept an offered voucher due to an inadequate supply of voucher‐accepting child care providers that best suit their needs. Child Care Resource and Referral agencies (CCR&amp;Rs), which administer these programs, can influence the family's propensity to accept a voucher by investing funds both in outreach to increase the number of voucher‐accepting providers in each region, and in provider services to improve the service delivery to families. This study analyzes how a CCR&amp;R should allocate its limited funds between these two types of activities to ensure equitable access to child care across the different regions of its service area. We show that it might be optimal for the CCR&amp;R to invest more funds in outreach in the region with a lower proportion of IE families. This is especially true when: the external considerations (e.g., public transportation and infrastructure) in that region have a greater impact on a family's acceptance propensity; the marginal return of investment in outreach in that region is higher and abundant funds are available; the socioeconomic distress experienced by families in that region is significantly higher; or a large amount of funds is earmarked for outreach in that region. We contextualize our study for a CCR&amp;R in Massachusetts and conclude that the proposed investment decisions can improve equity outcomes by 7.0%.

Adult mental health and child maltreatment: An ecological study across rural-urban and economic continua with implications for post-pandemic human services.

This ecological, county-level, cross-sectional study examines relationships between the mental health of adults (IV) and child maltreatment report rates (DV), as they vary by socioeconomic distress and rurality (n = 3015 counties), using the most recent available data from several linked sources. In a two-way model, maltreatment reports increased 20.1% for each additional half day of poor mental health in metro counties, 11.7% in nonmetro counties, and 13% in rural counties. Our zero-inflated negative binomial model, moderated by rurality and economic distress, showed a significant relationship between the number of poor mental health days and increased child maltreatment report rates in counties (χ2 = 145.52, p < 0.0001). Investment in prevention and treatment of adult mental health concerns is imperative, especially in light of the increase in mental health problems caused by the coronavirus disease 2019 pandemic and increased tension within national political debate. Our results indicate successful support of adult mental health will prevent child maltreatment and reduce the cyclical financial burden of child maltreatment and mental health concerns.

Abstract 12969: Community-Level Socioeconomic Distress, Race, and Risk of Adverse Outcomes Following Heart Failure Hospitalization Among Medicare Beneficiaries

Background: Socioeconomic (SE) disadvantage is a strong determinant of adverse outcomes in patients with HF. The contribution of SE disparities to adverse outcomes in HF may differ among Black vs. White patients and has not been well studied. Methods: Using the 100% CMS MedPAR data, Black and White patients hospitalized with HF between 2014 and 2017 were identified and stratified based on the distressed community index (DCI)—a measure of the SE disadvantage of residential ZIP codes on a continuous scale (range 0-100, see Fig. legend)—into two groups: SE distressed (Q5) vs. non-distressed (Q1-4). The rates of 30-day and 1-year mortality and readmission were compared across the distressed vs. non-distressed race groups. The adjusted association between DCI and risk of adverse outcomes was assessed separately across the race groups using adjusted hierarchical logistic regression models with restricted cubic splines. Results: The study included 1,238,537 White (14.8% distressed) and 190,721 Black (44.4% distressed) patients. White patients living in SE distressed communities had a significantly higher risk of adverse outcomes at 30-days and 1-year f/u (Fig. A). In contrast, among Black patients, the risk of adverse outcomes among those living in distressed vs. non-distressed communities were not meaningfully different at 30-days and became more prominent by 1-year f/u. Similar results were noted in the restricted cubic spline analysis with stronger and more graded association between DCI score and risk of adverse outcomes in White (vs. Black) patients (Fig. B). Conclusion: SE distress is strongly associated with risk of adverse outcomes in White patients with HF. Among Black patients, SE distress is more common, but its adverse effects are less evident during short-term f/u and are better highlighted in the long-term. Other societal factors such as structural racism and poor access to care may be important prognostic determinants in Black patients with HF.

Abstract 12965: Race-Specific Models to Predict In-Hospital Mortality in Patients With Heart Failure Using Machine Learning: The American Heart Association Get With the Guidelines Registry

Background: Prior prognostic models for acute decompensated HF (ADHF) have incorporated race as a covariate may not have completely account for the social and biological factors that underlie the racial disparities in outcomes. We developed race-specific models to improve risk prediction and better identify race-specific predictors of mortality in patients with ADHF using machine learning (ML) methods. Methods: Race-specific ML-models for in-hospital mortality were developed and validated in ADHF patients enrolled in the GWTG-HF registry between 2007 to 2020 (14,586 Black and 50,351 Non-Black adults) using over 40 candidate variables. External validation was performed among participants from the ARIC study with ADHF (n=1,115 Black and 2,028 Non-Black adults). The discrimination and calibration was compared with a previously validated risk score and cohort-specific logistic regression (LR) models. The changes in model reclassification performance with addition of zip-code level data of socioeconomic (SES) parameters was also assessed. Results: In the GWTG-HF cohort, the ML models had superior performance in both Black and Non-Black participants compared with the traditional GWTG-HF risk score ( Table ). The superior performance of the ML-model was also observed in the external validation cohort as compared with the other LR models ( Table ). Addition of measures of SES did not meaningfully change the performance but improved the reclassification metrics of the ML-models with net up-classification of risk in Black [NRI = 0.21 (0.07, 0.35)] and down-classification in Non-Black patients [NRI = -0.08 (-0.12, -0.04)]. SES was responsible for 21.7% of the total attributable mortality risk in Black adults compared to 0.4% in Non-Black adults. Conclusion: Race-specific, ML-based mortality models demonstrated superior performance when compared to traditional HF mortality risk models. Socioeconomic distress is an important contributor to risk in Black adults.

Extreme rainfall deficits were not the cause of recurring colonial era famines of southern Indian semi-arid regions

Using information contained in the eighteenth to twentieth century British administrative documents, preserved in the National Archives of India (NAI), we present a 218-year (1729–1947 AD) record of socioeconomic disruptions and human impacts (famines) associated with ‘rain failures’ that affected the semi-arid regions (SARs) of southern India. By mapping the southern Indian famine record onto long-term spatiotemporal measures of regional rainfall variability, we demonstrate that the SARs of southern India repeatedly experienced famines when annual rainfall reduced by ~ one standard deviation (1 SD), or more, from long-term averages. In other words, ‘rain failures’ listed in the colonial documents as causes of extreme socioeconomic disruptions, food shortages and human distress (famines) in the southern Indian SARs were fluctuations in precipitation well within the normal range of regional rainfall variability and not extreme rainfall deficits (≥ 3 SD). Our study demonstrates that extreme climate events were not necessary conditions for extreme socioeconomic disruptions and human impacts rendered by the colonial era famines in peninsular India. Based on our findings, we suggest that climate change risk assessement should consider the potential impacts of more frequent low-level anomalies (e.g. 1 SD) in drought prone semi-arid regions.

Towards a better understanding of attitudes and beliefs held by traditional healers and recipients of traditional medicine concerning mental health conditions in post-conflict Liberia: a qualitative investigation.

A better understanding of attitudes and beliefs held by traditional healers and utilizers of traditional medicine concerning mental health conditions in Liberia is important as Liberia seeks to improve its delivery of mental healthcare in the context of scarce resources and recovery from civil war. A qualitative research design was used to collect data from 24 Liberian traditional healers, and 11 utilizers of Liberian traditional medicine. Participants were queried about mental health problems in Liberia, treatments, and attitudes towards modern healthcare. Qualitative data were probed and aggregated using content analysis. Mental health problems described by study participants included: Open Mole, African Science, Epilepsy, Depression and Mental Illness (trauma/substance use). Mental health problems were often associated with socioeconomic distress, and participants described their attitudes and beliefs concerning mental healthcare, traditional medicine, and modern healthcare. Traditional medicine is an important part of mental healthcare in Africa. Mental illness, social factors, and healthcare access were important problems in Liberia. Mental health problems blended local cultural beliefs with Westernized nosology and social factors. Traditional healer's attitudes towards Western medicine reflected ambivalence. There is a desire for collaboration with 'modern' health care providers, but this will require reciprocal trust-building.