Socioeconomic Status Quintile Research Articles

The Effect of Socioeconomic Status and Race/Ethnicity on the Risk of Presenting With Advanced Stage at Diagnosis in Embryonal Tumors.

We evaluated whether socioeconomic status (SES), race/ethnicity, and their interaction were associated with the presentation of advanced stage at diagnosis in embryonal tumors. Children 0 to 19 years of age diagnosed with embryonal tumors between 2006 and 2018 were identified from the US Surveillance, Epidemiology, and End Results program database specialized with Census Tract SES/Rurality. SES quintile was derived from a composite index for census tracts. We performed logistic regression to estimate odds ratios (ORs) and 95% confidence intervals by SES and race/ethnicity, adjusting for sex, age, and diagnosis year. Overall, no significant associations were found between either SES or race/ethnicity and the risk of presenting with advanced stage at diagnosis, although patterns of risk reductions were observed in atypical teratoid/rhabdoid tumors and embryonal rhabdomyosarcoma with increasing SES. In the stratified analysis, decreased odds of presenting with advanced-stage embryonal rhabdomyosarcoma were observed for Hispanics with higher SES (OR: 0.24, 95% Confidence Interval: 0.08-0.75) compared with Hispanics with lower SES. Future studies incorporating individual-level SES, cancer-specific staging information, and potential demographic, clinical, epidemiological, and genetic risk factors are warranted to confirm our findings.

Long-Term Implications of Socioeconomic Status on Major Adverse Cardiovascular, Cerebrovascular Events (MACCE), and All-Cause Mortality

Socio-economic status (SES) has a large impact on health through a complex interplay of upstream, midstream and downstream factors. However, little is known about the predictive role of SES on long-term major adverse cardiovascular, cerebrovascular events, and mortality (MACCE). To determine the long-term relationship between SES and MACCE for men and women. The secondary endpoint was to determine the relationship between SES and all-cause mortality. A total of 3,034 participants (1,494 women and 1,540 men) were assessed at baseline in the Geelong Osteoporosis Study, a large regional Australian population cohort study. Area-based SES was assessed, utilising the Index of Relative Socio-Economic Disadvantage (IRSD) and grouped into quintiles. The primary endpoint, MACCE, was defined as a composite of myocardial infarction, heart failure hospitalisation, malignant arrhythmias, stroke, and all-cause mortality. The secondary endpoint was all-cause mortality. Baseline data including age, sex, smoking status and alcohol use, and comorbidities were collected between 1993-1997 for women, and 2001-2006 for men, with follow-up over 30 and 22 years, respectively. Logistic regression was utilised to assess MACCE and all-cause mortality outcomes across the SES quintiles. Participants lost to follow-up or with incomplete data collection were excluded leaving 2,173 participants eligible for analysis. SES was associated with MACCE outcomes. Compared with Quintile I (lowest SES stratum), the odds of MACCE for each IRSD stratum were: Quintile II, odds ratio (OR) 0.85 (95% confidence interval [CI] 0.65-1.13); Quintile III, OR 0.69 (95% CI 0.51-0.91); Quintile IV, OR 0.66 (95% CI 0.50-0.88); and, Quintile V, OR 0.55 (95% CI 0.41-0.72). In the adjusted model, an inverse trend was noted, with reducing MACCE outcomes with an increasing SES status; IRSD Quintile II, OR 0.85 (95% CI 0.62-1.17); Quintile III, OR 0.70 (95% CI 0.50-0.97); Quintile IV, OR 0.73 (95% CI 0.52-1.02); and, Quintile V, OR 0.54 (95% CI 0.39-0.74). SES was inversely associated with all-cause mortality; IRSD Quintile II (OR 0.87, 95% CI 0.66-1.16) failed to achieve significance however IRSD Quintile III (OR 0.65, 95% CI 0.48-0.88), Quintile IV (OR 0.59, 95% CI 0.44-0.80) and Quintile V (OR 0.46, 95% CI 0.34-0.62) had a lower risk of mortality compared with Quintile I. In the adjusted model, an inversely proportional trend was noted between SES and all-cause mortality; IRSD Quintile II (OR 0.82, 95% CI 0.59-1.15), IRSD Quintile III (OR 0.63, 95% CI 0.49-0.95), Quintile IV (OR 0.59, 95% CI 0.45-0.90) and Quintile V (OR 0.44, 95% CI 0.31-0.61) had fewer mortality events compared with IRSD Quintile I. Our research indicates that being part of a lower socio-economic stratum is linked to a higher likelihood of experiencing negative cardiovascular and cerebrovascular events, along with an increased risk of overall mortality. SES is an important risk stratification marker for long-term prognosis of cardiovascular diseases and stroke, and warrants further investigation.

Access to Ontario Midwifery Care by Neighbourhood-Level Material Deprivation Quintile, 2006–2017: A Retrospective Cohort Study

Objective: To describe access to Ontario midwifery care based on socio-economic status.Design: Two retrospective cohort studies.Setting: Ontario, Canada.Participants: (1) All Ontario midwifery billable courses of care discharged between April 1, 2006, and March 31, 2017 (N = 187,009), and (2) all Ontario residents who gave birth (≥ 20 weeks) in Ontario between April 1, 2012, and March 31, 2017 (N = 699,843). Data Sources: The Ontario Midwifery Program Legacy Database and the Better Outcomes Registry & Network’s Ontario perinatal registry.Measurements and Findings: We used residential postal codes to assign socio-economic status quintiles, using the Ontario Marginalization Index’s material deprivation measure. Between 2006 and 2017, the proportion of midwifery clients in the two least-marginalized quintiles was consistently greater than the proportion of midwifery clients in the two most-marginalized quintiles. Between 2012 and 2017, physicians cared for a larger proportion of people in the most-marginalized quintile than midwives, while midwives cared for a larger proportion of people in the least-marginalized quintile. Key Conclusions: People of low socio-economic status in Ontario are less likely to receive midwifery care than people of high socio-economic status. There was little change in this pattern over an 11-year period from 2006 to 2017.Implications: Efforts to reduce inequities in access to midwifery care should be prioritized and will require a multi-pronged approach that is supported by practicing midwives, government, midwifery stakeholder organizations, and other health care professionals. This article has been peer reviewed.

Characteristics and Practice Patterns of Non-certified Surgeons Treating Medicare Patients.

The objective of this study is to explore the patient characteristics and practice patterns of non-certified surgeons who treat Medicare patients in the United States. While most surgeons in the United States are board-certified, non-certified surgeons are permitted to practice in many locations. At the same time, surgical workforce shortages threaten access to surgical care for many patients. It is possible that non-certified surgeons may be able to help fill these access gaps. However, little is known about the practice patterns of non-certified surgeons. A 100% sample of Medicare claims data from 2014-2019 were used to identify practicing general surgeons. Surgeons were categorized as certified or non-certified in general surgery​​ based on data from the American Board of Surgery. Surgeon practice patterns and patient characteristics were analyzed. A total of 2,097,206 patient cases were included in the study. These patients were treated by 16,076 surgeons, of which 6% were identified as non-certified surgeons. Compared to certified surgeons, non-certified surgeons were less frequently fellowship-trained (20.5% vs. 24.2%, P=0.008) and more likely to be a foreign medical graduate (14.5% vs. 9.2%, P<0.001). Non-certified surgeons were more frequently practicing in for-profit hospitals (21.2% vs. 14.2%, P<0.001) and critical access hospitals (2.2% vs. 1.3%, P<0.001), and were less likely to practice in a teaching hospital (63.2% vs. 72.4%, P<0.001). Compared to certified surgeons, non-certified surgeons treated more non-White patients (19.6% vs. 14%, P<0.001) as well as a higher percentage of patients in the two lowest socioeconomic status (SES) quintiles (36.2% vs. 29.2%, P<0.001). Operations related to emergency admissions were more common amongst non-certified surgeons (68.8% vs. 55.7%, P<0.001). There were no differences in gender or age of the patients treated by certified and non-certified surgeons. For Medicare patients, non-certified surgeons treated more patients who are non-White, of lower SES, and in more rural, critical-access hospitals.

787 Higher County-Level Socioeconomic Status Is Associated With Increased Meningioma Survival But Does Not Impact Likelihood of Surgical Treatment: A CBTRUS Analysis

INTRODUCTION: Prior literature suggests that individual socioeconomic status (SES) may influence access to treatment and outcomes for primary brain tumors. To date, no population-level studies have assessed the correlation between meningioma treatment and outcome with county-level SES. METHODS: Incidence data were extracted from the Central Brain Tumor Registry of the United States(CBTRUS), a combined dataset including the CDC’s National Program of Cancer Registries (NPCR) and NCI’s Surveillance, Epidemiology, and End Results Program data, for diagnosis years 2006-2019, and survival data were extracted from the NPCR survival analytic dataset from 2006-2018. SES quintiles were created using American Community Survey data. Logistic regression and Cox proportional hazards models were used to assess the relationship the odds of receiving treatment and overall survival and SES and the individual SES factors. RESULTS: There were 409,681 meningioma cases available from CBTRUS. Asian/Pacific-Islander non-Hispanic individuals (odds ratio [OR] = 1.28, p &lt; 0.001) were more likely and Black non-Hispanic (BNH) individuals (OR = 0.90, p &lt; 0.001) were less likely to receive surgery than White non-Hispanic (WNH) individuals. Female sex (OR = 1.31, p &lt; 0.001), living in a metropolitan area (OR = 0.96, p &lt; 0.001), and increased age at diagnosis (OR = 0.96, p &lt; 0.001) were associated with decreased likelihood of surgery. There was no association between SES and likelihood to receive surgery. Overall median survival was 137 months and survival was higher in higher SES counties, which held true for both WNH and BNH. Age at diagnosis(hazard ratio [HR] = 1.01, p &lt; 0.001), male sex (HR = 1.51, p &lt; 0.001), BNH (HR = 1.31, p &lt; 0.001), subtotal resection (HR = 1.38, p &lt; 0.001), and malignant behavior(HR = 1.64, p &lt; 0.001) were associated with increased hazard of death. CONCLUSIONS: In the US, county-level SES did not impact treatment patterns, but higher SES was associated with increased survival. These findings provide valuable insight into socioeconomic factors influencing treatment and outcomes in meningioma patients.

Association between county-level socioeconomic status and the incidence of and surgical treatment for pituitary adenoma.

The objective of this study was to evaluate the association between county-level socioeconomic status (SES) and the incidence of and surgical treatment for pituitary adenoma (PA). Using the Centers for Disease Control and Prevention's National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology, and End Results database, the authors identified the average annual age-adjusted incidence rates and calculated odds ratios (ORs) for surgical treatment of PA, stratified by a county-level index for SES, race/ethnicity, metropolitan status, and other confounders. From 2006 to 2018, 167,121 PA cases were identified. There was no significant trend in the incidence of PA by county-level SES overall (incidence rate ratio [IRR] 0.98, 95% CI 0.96-1.00, p = 0.05, comparing highest to lowest quintile of SES). Among Asian or Pacific Islander (API; IRR 0.82, 95% CI 0.71-0.95, p = 0.007) and American Indian/Alaska Native (AIAN) participants (IRR 0.82, 95% CI 0.71-0.95, p = 0.009), the incidence of PA was statistically significantly lower with higher SES, while among Black individuals, the incidence of PA was higher with higher SES (IRR 1.10, 95% CI 1.05-1.15, p < 0.001, comparing 5th to 1st quintile of SES). Higher SES quintile was associated with surgical treatment of PA (OR 1.04, 95% CI 0.99-1.09, comparing highest to lowest quintile, p value for trend = 0.02). Males were more likely than females to undergo surgery (OR 1.50, 95% CI 1.47-1.53, p < 0.001), and Black (OR 0.89, 95% CI 0.86-0.91, p < 0.001) and AIAN individuals (OR 0.88, 95% CI 0.78-0.99, p = 0.04) were less likely to undergo surgery than White individuals, whereas API individuals were more likely to undergo surgery (OR 1.15, 95% CI 1.09-1.21, p < 0.001). Higher county-level SES in the US was associated with a higher incidence of PA among Black individuals, but not among White individuals, while API and AIAN individuals had a lower PA incidence with higher SES. After multivariable adjustment, higher county-level SES was associated with surgical treatment of PA, and White and API individuals were significantly more likely to undergo surgery than Black or AIAN individuals.

Rural-Urban Disparities in the Continuum of Thyroid Cancer Care: Analysis of 92,794 Cases.

Objective: Rurality is associated with higher incidence and higher disease-specific mortality for most cancers. Outcomes for rural and ultrarural ("frontier") patients with thyroid cancer are poorly understood. This study aimed to identify actionable deficits in thyroid cancer outcomes for rural patients. Methods: We queried linked California Cancer Registry and California Office of Statewide Health Planning and Development databases for patients diagnosed with thyroid cancer (1999-2017). We analyzed time from disease stage at diagnosis, time from diagnosis to surgery, receipt of appropriate radioactive iodine ablation, surveillance status, and overall and disease-specific mortality for urban, rural, and frontier patients. Cox and logistic regression models controlled for clinical and demographic covariates a stepwise manner. All incidence figures are expressed as a proportion of newly diagnosed cases. Results: Our cohort comprised 92,794 subjects: (65,475 women [70.6%]; mean age 50.0 years). Compared to urban patients, rural and frontier patients were more likely to be American Indian, White, uninsured, and from lower quintiles of socioeconomic status (p < 0.01). Distant disease at diagnosis was more common in rural (56.0 vs. 50.4 cases per 1000 new cases, p < 0.01) and frontier patients (80.9 vs. 50.4 per 1000, p < 0.01) compared to urban patients. The incidence of medullary thyroid cancer was greater in rural patients (17.9 vs. 13.6 cases per 1000, p < 0.01) and frontier patients (31.0 vs. 13.6 per 1000, p < 0.01) compared to urban patients. The incidence of anaplastic thyroid cancer was higher in frontier versus urban patients (15.5 vs. 7.1 per 1000, p < 0.01). When compared to urban patients, rural and frontier patients were more often lost to follow-up (odds ratio [OR] 1.69 [confidence interval, CI 1.54-1.85], and OR 3.03 [CI 1.89-5.26], respectively) and had higher disease-specific mortality (OR 1.18 [CI 1.07-1.30], and OR 1.92 [CI 1.22-2.77], respectively). Rural and frontier residence was independently associated with being lost to follow-up, suggesting that it is a key driver of disparities. Conclusion: Compared to their urban counterparts, rural and frontier patients with thyroid cancer present with later-stage disease and experience higher disease-specific mortality. They also are more often lost to follow-up, which presents an opportunity for targeted outreach to reduce the observed disparities in outcomes.

Impact of socioeconomic status on presentation, care quality and outcomes of patients attended by emergency medical services for dyspnoea: a population-based cohort study

BackgroundLow socioeconomic status (SES) has been linked to poor outcomes in many conditions. It is unknown whether these disparities extend to individuals presenting with dyspnoea. We aimed to evaluate the...

Towards closing socio-economic status disparities in COVID-19 premature mortality: a nationwide and trend analysis in Chile.

Socio-economic status (SES) disparities in coronavirus disease 2019 (COVID-19) mortality have been reported but complete information and time trends are scarce. In this study, we analysed the years of life lost (YLL) due to COVID-19 premature mortality during the pandemic in Chile and its evolution according to SES and sex compared with a counterfactual scenario [cerebrovascular accidents (stroke)]. We used Chile's national mortality databases from 2020 to 2022. YLL and age-standardized YLL and mortality rates by sex and by epidemic waves were determined. The 346 communes were stratified into SES groups according to their poverty index quintile. Negative binomial regression models were used to test trends. In >2 years of the pandemic, the COVID-19 YLL was 975 937, corresponding to 61 174 deaths. The YLL rate per 100 000 inhabitants was 1027 for males and 594 for females. There was a heterogeneous distribution of YLL rates and the regional level. Communes in the most advantaged SES quintile (Q5) had the highest YLL during the first wave compared with those in the lowest SES quintile (Q1) (P < 0.001) but the opposite was true during the second wave. COVID-19 YLL trends declined and differences between Q1 and Q2 vs Q5 converged from the second to the fourth waves (0.33 and 0.15, Ptrend < 0.001 and Ptrend = 0.024). YLL declined but differences persisted in stroke (-0.002, Ptrend = 0.979). COVID-19 deaths resulted in a higher impact on premature death in Chile, especially in men, with a heterogeneous geographic distribution along the territory. SES and sex disparities in COVID-19 premature mortality had narrowed by the end of the pandemic.

Association of county-level socioeconomic status with meningioma incidence and outcomes.

Prior literature suggests that individual socioeconomic status (SES) may influence incidence, treatments, and survival of brain tumor cases. We aim to conduct the first national study to evaluate the association between US county-level SES and incidence, treatment, and survival in meningioma. The Central Brain Tumor Registry of the United States analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and National Cancer Institute's Surveillance, Epidemiology, and End Results Program, was used to identify meningioma cases from 2006 to 2019. SES quintiles were created using American Community Survey data. Logistic regression models were used to evaluate associations between SES and meningioma. Cox proportional hazard models were constructed to assess the effect of SES on survival using the NPCR analytic dataset. A total of 409 681 meningioma cases were identified. Meningioma incidence increased with higher county-level SES with Q5 (highest quintile) having a 12% higher incidence than Q1 (incidence rate ratios (IRR) = 1.12, 95%CI: 1.10-1.14; P < .0001). The Hispanic group was the only racial-ethnic group that had lower SES associated with increased meningioma incidence (Q5: age-adjusted incidence ratio (AAIR) = 9.02, 95%CI: 8.87-9.17 vs. Q1: AAIR = 9.33, 95%CI: 9.08-9.59; IRR = 0.97, 95%CI: 0.94-1.00; P = .0409). Increased likelihood of surgical treatment was associated with Asian or Pacific Islander non-Hispanic individuals (compared to White non-Hispanic (WNH)) (OR = 1.28, 95%CI: 1.23-1.33, P < .001) and males (OR = 1.31, 95%CI: 1.29-1.33, P < .001). Black non-Hispanic individuals (OR = 0.90, 95%CI: 0.88-0.92, P < .001) and those residing in metropolitan areas (OR = 0.96, 95%CI: 0.96-0.96, P < .001) were less likely to receive surgical treatment compared to WNH individuals. Overall median survival was 137 months, and survival was higher in higher SES counties (Q5 median survival = 142 months). Higher county-level SES was associated with increased meningioma incidence, surgical treatment, and overall survival. Racial-ethnic stratification identified potential disparities within the meningioma population. Further work is needed to understand the underpinnings of socioeconomic and racial disparities for meningioma patients.

Understanding school-going adolescent’s preferences for accessing HIV and contraceptive care: findings from a discrete choice experiment among learners in Gauteng, South Africa

BackgroundMany Adolescents in Sub-Saharan Africa do not access HIV and reproductive health services optimally. To improve uptake of these services, it is important to understand the Learners’ preferences for how services are delivered so that implementation strategies can reflect this.MethodsA discrete choice experiment (DCE) was used to elicit preferences. The DCE was completed between 07/2018 and 09/2019 and conducted in 10 high schools situated in neighbourhoods of varying socio-economic status (SES) in Gauteng (South Africa). Learners aged ≥ 15 years (Grades 9–12) were consented and enrolled in the DCE. Parental consent and assent were required if < 18 years old. Conditional logistic regression was used to determine preferred attributes for HIV and contraceptive service delivery. Results were stratified by gender and neighbourhood SES quintile (1 = Lowest SES; 5 = Highest SES).Results805 Learners were enrolled (67% female; 66% 15–17 years; 51% in grades 9–10). 54% of Learners in quintile 1 schools had no monthly income (family support, grants, part-time jobs etc.); 38% in quintile 5 schools had access to R100 ($7.55) per month. Preferences for accessing HIV and contraceptive services were similar for male and female Learners. Learners strongly preferred services provided by friendly, non-judgmental staff (Odds ratio 1.63; 95% Confidence Interval: 1.55–1.72) where confidentiality was ensured (1.33; 1.26–1.40). They preferred services offered after school (1.14; 1.04–1.25) with value-added services like free Wi-Fi (1.19; 1.07–1.32), food (1.23; 1.11–1.37) and youth-only waiting areas (1.18; 1.07–1.32). Learners did not have a specific location preference, but preferred not to receive services within the community (0.82; 0.74–0.91) or school (0.88; 0.80–0.96). Costs to access services were a deterrent for most Learners irrespective of school neighbourhood; female Learners were deterred by costs ≥$3.85 (0.79; 0.70–0.91); males by costs ≥ R100 ($7.55) (0.86; 0.74-1.00).ConclusionsPreferences that encourage utilisation of services do not significantly differ by gender or school neighbourhood SES. Staff attitude and confidentiality are key issues affecting Learners’ decisions to access HIV and contraceptive services. Addressing how healthcare providers respond to young people seeking sexual and reproductive health services is critical for improving adolescents’ uptake of these services.

Abstract C129: Impact of COVID-19 on colorectal cancer screening disparities: Results from a large commercially insured population in the United States

Abstract Background: Although colorectal cancer (CRC) screening reduces both CRC incidence and CRC-related mortality, it is underutilized, especially among those with lower socioeconomic status (SES) and in racial and ethnic minoritized populations who have been disproportionately impacted by COVID-19. The shift in healthcare priorities to contain and mitigate COVID-19 over the last few years reduced clinical capacity for non-urgent care, including CRC screening. This study aimed to assess the impact of COVID-19 on disparities in CRC screening. Methods: Blue Cross Blue Shield (BCBS) insures approximately one third of Americans. We leveraged BCBS Axis data to examine temporal patterns in CRC screening among individuals aged 45-75 years during 2017-2021, focusing on three periods: 1) first wave of COVID-19 outbreak (Mar-Apr 2020); 2) second wave of COVID-19 outbreak (i.e., the Delta variant, Jan-Feb 2021); and 3) the most recent 2-month interval for which data are available (Nov-Dec 2021). Both invasive and non-invasive CRC screening procedures were identified, and beneficiaries who received screening one year before were excluded. Screening rates within each 2-month interval were calculated. Neighborhood SES was assessed by Social Deprivation Index at the zip code level and categorized into quintiles. Results: The study cohort included 27,628,570 individuals. Throughout the 5-year period, except for the 1st wave of COVID-19 outbreak, screening rates were higher in areas with higher SES. Prior to the pandemic (Jan 2017–Feb 2020), the average bimonthly screening rate in areas with the highest SES was 2.1%, compared to 1.7% in areas with the lowest SES (p &amp;lt;0.001). During the 1st wave of COVID-19 outbreak, screening rate decreased to approximately 0.8% across all SES quintiles. During the 2nd wave of COVID-19 outbreak, screening rates were 1.7% and 1.3% in the highest and lowest SES areas, respectively. For the last 2-month interval in our study period (Nov-Dec 2021), screening rates increased to 2.4% and 1.8% in areas with the highest and lowest SES, respectively. Among 9,565,516 beneficiaries with known race and ethnicity, 8.0%, 11.0%, 3.3% and 0.4% were non-Hispanic Black, Hispanic/Latino, Asian, and Native Americans/Pacific Islanders, respectively. Across all racial and ethnic groups, the average bimonthly screening rate was 1.9% prior to the pandemic, 0.7% in Mar-Apr 2020, 1.5% in Jan-Feb 2021, and 2.1% in Nov-Dec 2021. Conclusion: After the onset of COVID-19, CRC screening rate decreased broadly and reached a similar level in all SES groups in early 2020, but it then recovered at a different pace for individuals with different SES, maintaining and even exacerbating inequities that existed prior to the pandemic. Screening patterns were comparable across different racial and ethnic groups who were privately insured through BCBS. Findings from this very large study may help inform interventions to address social and structural determinants of health and reduce the disproportionate burden of CRC in individuals residing in socially deprived areas. Citation Format: Arfan Siddique, Rong Wang, Jacquelyne Gaddy, Cary Gross, Xiaomei Ma. Impact of COVID-19 on colorectal cancer screening disparities: Results from a large commercially insured population in the United States [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C129.

Race- and Gender-Specific Associations between Neighborhood-Level Socioeconomic Status and Body Mass Index: Evidence from the Southern Community Cohort Study.

Obesity and a low socioeconomic status (SES), measured at the neighborhood level, are more common among Americans of Black race and with a low individual-level SES. We examined the association between the neighborhood SES and body mass index (BMI) using data from 80,970 participants in the Southern Community Cohort Study, a cohort that oversamples Black and low-SES participants. BMI (kg/m2) was examined both continuously and categorically using cut points defined by the CDC. Neighborhood SES was measured using a neighborhood deprivation index composed of census-tract variables in the domains of education, employment, occupation, housing, and poverty. Generally, the participants in lower-SES neighborhoods were more likely to have a higher BMI and to be considered obese. We found effect modification by race and sex, where the neighborhood-BMI association was most apparent in White female participants in all the quintiles of the neighborhood SES (ORQ2 = 1.55, 95%CI = 1.34, 1.78; ORQ3 = 1.71, 95%CI = 1.48, 1.98; ORQ4 = 1.76, 95%CI = 1.52, 2.03; ORQ5 = 1.64, 95%SE = 1.39, 1.93). Conversely, the neighborhood-BMI association was mostly null in Black male participants (ORQ2 = 0.91, 95%CI = 0.72, 1.15; ORQ3 = 1.05, 95%CI = 0.84, 1.31; βQ4 = 1.00, 95%CI = 0.81, 1.23; ORQ5 = 0.76, 95%CI = 0.63, 0.93). Within all the subgroups, the associations were attenuated or null in participants residing in the lowest-SES neighborhoods. These findings suggest that the associations between the neighborhood SES and BMI vary, and that other factors aside from the neighborhood SES may better predict the BMI in Black and low-SES groups.

Inequities in Autologous Stem Cell Transplantation, Chimeric Antigen Receptor T-Cell Therapy and Clinical Trial Participation in Patients Receiving Second-Line and Later Multiple Myeloma Treatment

Introduction: Despite improvements in care and novel therapies for the treatment of multiple myeloma (MM), nearly all patients experience relapse. However, few real-world studies have focused on treatment inequities that occur later in the MM patient journey with subsequent lines of therapy - the setting of particular interest for salvage treatment and novel drug development. The objectives of this study were to measure receipt of autologous stem cell transplantation (ASCT), chimeric antigen receptor T-cell therapy (CAR-T) and participation in clinical trials following initiation of second-line (2L) MM treatment and to describe inequities by race/ethnicity and area-level sociodemographic factors. Methods: This was a retrospective cohort study using the nationwide, electronic health record-derived Flatiron Health de-identified database. We included patients that previously received therapy for newly diagnosed MM and were initiating 2L between 2011 and 2023. The exposures of interest were race/ethnicity and area-level (census block group) socioeconomic status (SES) measured by the Yost index. Outcomes of interest were receipt of ASCT, CAR-T and clinical trial participation. Patients were followed from the date of 2L initiation until the first of the outcome of interest, death or end of the study period. Multivariable cause-specific hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for associations with receipt of ASCT, CAR-T and clinical trial participation separately and as a single outcome. Informed by the Institute of Medicine's framework for healthcare disparities, models were adjusted for clinical factors, specifically, age, sex, and Eastern Cooperative Oncology Group (ECOG) performance status. Results: In a cohort of 2,017 patients with MM that were ASCT and CAR-T naïve with a median age of 72 years (interquartile range [IQR] 63-79), 52% were male, 52% had ECOG scores of 0 or 1, and 59% were treated in community oncology practices. Prior to 2L, 73% received fluorescence in situ hybridization testing for cytogenetic abnormalities and most patients received either doublet (34%) or triplet (51%) therapy. The majority of patients included were non-Latinx (NL)-White (61%), 21% were NL-Black and 4% were Latinx. Compared to NL-White patients, fewer NL-Black patients received FISH testing (70% versus 73%) and either doublet or triplet therapy (81% versus 86%) for newly diagnosed MM. A higher proportion of Black and Latinx patients resided in areas in the lowest quintile of SES (42% and 40% respectively) compared to NL-White patients (8%). Overall, 12.7% received ASCT, 0.8% received CAR-T and 1.3% participated in a clinical trial following the start of 2L. Compared with NL-White patients, Black and Latinx patients had lower rates of treatment with ASCT and CAR-T; and clinical trial participation was also lower among Latinx patients relative to NL-White patients (see Figure). Patients living in the highest quintile of SES had higher rates of ASCT (19.2%), CAR-T (0.8%) and clinical trial participation (2.3%) compared to those living in the lowest quintile of SES (10.1%, 0.3% and 1.5% respectively). In multivariable models, NL-Black (HR 0.57, 95% CI 0.42-0.76) and Latinx (HR 0.41, 95% CI 0.25-0.76) patients had a lower likelihood of receiving these treatments or participating in a clinical trial compared to NL-White patients; similarly, living in the lowest SES quintile (HR 0.38, 95% CI 0.26-0.56) was also associated with lower likelihood of these outcomes. Other area-level factors associated with inequities in ASCT, CAR-T and trial participation included living in segregated Black neighborhoods and areas with greater concentration of non-citizen residence and no vehicle ownership. Conclusion: We observed lower receipt of ASCT, CAR-T, and participation in clinical trials among Black and Latinx patients initiating 2L or later MM therapy, as well as patients living in areas of low SES. Persistent inequities in MM span the entirety of the patient journey, including the limited uptake and availability of novel therapies at later stages of the disease and a lack of representation in trials investigating new MM therapies.

Use of machine learning to predict mortality in patients with type 2 diabetes mellitus, according to socioeconomic status

Abstract Introduction Patients with Type 2 diabetes mellitus (T2DM) are at increased risk of developing cardiovascular disease (CVD) that adversely affects prognosis. Socioeconomic deprivation may be associated with lifestyle choices that contribute to adverse outcomes. The influence of social deprivation on the prognosis of T2DM is rarely investigated in large cohorts. Therefore, we assessed the associations between socioeconomic status and survival in patients with T2DM by applying conventional statistical methods and state-of-the-art, machine learning (ML) models. Methods We obtained routinely collected, linked administrative data for individuals with T2DM aged &amp;gt;50 years from the National Health Service (NHS) Scotland, including demographic data, laboratory measurements, prescriptions, death records and primary and secondary care diagnostic codes. We developed a random survival forest model for predicting all-cause mortality, overall and for each quintile of socioeconomic status using the Scottish Index of Multiple Deprivation (SIMD), which is based on postcodes that reflect a combination of income, employment, local crime rates, education, housing and health. We used Cox proportional hazards models to investigate the risk between the most and least deprived quintiles. Subsequently, we applied Shapely Additive Explanations (SHAP), a state-of-the-art ML interpretability method, to identify key prognostic factors that influence the survival probability prediction score for each sub-group. Results 30,495 people had a newly recorded diagnosis of T2DM between 2009-2019, of whom 4,300 died within 10 years. Table 1 shows the c-index (global assessment of model discrimination) and time-brier score (measure of calibration for time-dependent probability prediction) for the whole cohort and for each SIMD quintile: use of loop diuretics, older age, lower serum concentrations of albumin and alanine transaminase (ALT) and estimated glomerular function rate (eGFR) were strong predictors of death for all quintiles. Prevalence of chronic obstructive pulmonary disease (COPD) was strongly associated with mortality for the most deprived quintile (Q1, whilst strokes were strongly associated with mortality for the most affluent (Q5). A history of heart failure, in addition to use of loop diuretics, predicted a higher risk, in 3 of the 5 quintiles. Overall Q1 had a 36% higher mortality than Q5 (HR: adjusted for age and sex 1.36 [95% CI 1.24 – 1.50 (&amp;lt;0.005)]). Conclusion Greater socioeconomic deprivation is associated with a worse prognosis in patients with T2DM. Results of commonly measured blood tests, allied to readily available patient characteristics (including heart failure and use of loop diuretics) predict mortality risks across all deprivation groups for people with T2DM.Table:Predictors of Mortality in T2DM

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 (&lt;25 th percentile), moderate (25 th -75 th ), and high (&gt;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 (&gt;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.

Low Socioeconomic Status Confers Poorer Real-World Overall Survival for Patients with Acute Myeloid Leukemia Treated in the Modern Era

Introduction: There has been considerable growth in the treatment armamentarium of acute myeloid leukemia (AML) in the last decade. However, there is a lack of recent real-world evidence examining trends in survival amidst this rapidly changing treatment landscape. Further, prior literature has demonstrated significant heterogeneity in outcomes across different demographic groups, with scant data to understand how newer therapies have impacted survival outcomes across demographic groups in a real-world setting. The objective of this study is to describe recent trends in overall survival (rwOS) among patients with AML and to examine associations between race, ethnicity, and socioeconomic status (SES) with rwOS over time. Methods: We conducted a retrospective cohort study with data from the nationwide Flatiron health (FH) electronic health record-derived de-identified database, which is comprised of predominantly community oncology-based sites. We included patients with ≥2 visits in the FH network with a confirmed diagnosis of AML between Jan 1, 2014 and Dec 31, 2022, with potential follow-up through May 31, 2023. Our exposures included year of diagnosis in 3-year periods (2014-2016, 2017-2019, 2020-2022), race, ethnicity, and area-level SES, as measured using the Yost Index at census block group level. Patient characteristics and treatment patterns were described overall and by time periods of AML diagnosis. The Kaplan-Meier method was used to estimate median rwOS and 95% confidence intervals (CIs) from the time of initial AML diagnosis; overall and stratified by time period of AML diagnosis. Cox proportional hazards models were used to estimate unadjusted and minimally-adjusted (for age and sex) hazard ratios (HR) and 95% CIs for associations between race, ethnicity, and SES (modeled separately) with rwOS overall and by year of AML diagnosis.. Results: A total of 10,062 patients were included in the analysis. The median (IQR) age at diagnosis was 70 years (58, 78) and 57% of patients were male. Three-fourths of the study population was White, and 70% of the cohort received care at the community oncology clinic. We identified more patients ≥75 years at diagnosis in 2020-2022 versus 2014-2016 (38% vs 31%) and an overall decrease in patients who underwent hematopoietic stem cell transplant (15% vs 21%). Although the overall proportion of patients receiving any first-line treatment was similar across time periods, fewer patients received induction chemotherapy-based regimens (29%) compared to less intensive therapies (e.g., venetoclax + hypomethylating agent; 34%) in later years. There were 6,132 deaths and an overall median rwOS was 14.2 months (95% CI 13.7-14.7). Age and sex-adjusted Cox models indicated no evidence of decreased risk of death for diagnoses in 2020-2022 (HR 0.98, 95% CI 0.92-1.05) or 2017-2019 (HR 0.95, 95% CI 0.90, 1.02) compared to diagnoses in 2014-2016. Adjusted Cox models showed no statistically significant associations between race or ethnicity with survival overall and across strata of AML diagnosis time periods. Consistent associations between the lowest SES and increased risk of overall mortality among patients with AML were observed across all time periods. Patients residing in areas in the lowest quintile of SES had increased risks of death across all three time periods (2014-2016: HR 1.18, 95% CI 1.00-1.38; 2017-2019: HR 1.28, 95% CI 1.09-1.50; 2020-2022: HR 1.21, 95% CI 1.02-1.43). Conclusion: Results of this real-world study indicate that persons with AML who are in the lowest SES group are associated with increased mortality risk, and this association persists across recent time periods. Race and ethnicity were not associated with survival in this study, although sample size was limited for some groups. Despite introduction of new therapeutic options and an increased utilization of less intensive therapies, we did not observe an increase in the overall proportion of patients with AML receiving first-line treatment. Additionally, we observed no improvement in survival outcomes across these time periods in a predominantly community-based setting. Our study adds to the growing evidence on the complex health inequities in AML and supports the persistent need for tolerable and accessible therapy to improve OS in AML. Future strategies and policies are urgently needed to offset the adverse effects of low SES to further improve outcomes for all patients with AML.

Lower Socioeconomic Status is Associated with an Increased Incidence and Spectrum of Major Congenital Heart Disease and Associated Extracardiac Pathology.

Several studies have suggested an inverse relationship between lower socioeconomic status (SES) and the incidence of congenital heart disease (CHD) among live births. We sought to examine this relationship further in a Canada-wide population study, exploring CHD subtypes, trends, and associated noncardiac abnormalities. Infants born in Canada (less Quebec) from 2008 to 2018 with CHD requiring intervention in the first year were identified using ICD-10 codes through the Canadian Institute for Health Information Discharge Abstract Database. Births of CHD patients were stratified by SES (census-based income quintiles) and compared against national birth proportions using X2 tests. Proportions with extracardiac defects (ED) and nonlethal genetic syndromes (GS) were also explored. From 2008 to 2018, 7711 infants born with CHD were included. The proportions of major CHD distributed across SES quintiles were 27.1%, 20.1%, 19.2%, 18.6%, and 15.0% from lowest to highest, with significant differences relative to national birth proportions (22.0%, 20.0%, 20.6%, 20.7%, and 16.7% from lowest (1) to highest (5)) (p < 0.0001). No temporal trends in the CHD proportions across SES categories were observed over the study period. The distribution across SES quintiles was different only for specific CHD subtypes (double-outlet right ventricle (n = 485, p = 0.03), hypoplastic left heart syndrome (n = 547, p = 0.006), heterotaxy (n = 224, p = 0.03), tetralogy of Fallot (n = 1007, p = 0.008), truncus arteriosus (n = 126, p < 0.0001), and ventricular septal defect (n = 1916, p < 0.0001)), with highest proportions observed in the lowest quintile. The proportion of the total population with ED but not GS was highest in lower SES quintiles (< 0.0001) commensurate with increased proportion of CHD. Our study suggests a negative association between SES and certain CHD lesions and ED.

Racial Disparities in Survival of Patients with High-Risk LA SCCHN in the U.S.

Approximately 50-67% of patients with squamous cell carcinomas of the head and neck (SCCHN) present with locally advanced (LA) disease. Human papillomavirus (HPV) associated SCCHN has improved survival compared to non-HPV SCCHN. Studies have analyzed racial disparities in LA SCCHN but few have adjusted for HPV status and socio-economic status (SES). Our objective was to characterize disparities in LA SCCHN. We identified high-risk patients from 2010-2017 with AJCC v8 Stage IVA/IVB SCCHN of the oral cavity, oropharynx (OP), larynx or hypopharynx, or Stage III SCCHN of the OP in the Surveillance, Epidemiology, and End Results (SEER) with HPV Status and Census Tract-level SES/Rurality Combined Database. We excluded OP patients with missing HPV data. SEER-reported treatment was used to classify initial treatment as definitive therapy (DT) categories: surgical DT, non-surgical DT or non-DT. The Kaplan Meier method was used to estimate overall survival (OS) with 95% confidence intervals (CI). Multivariable cox proportional hazard models were used for associations between covariates and hazard ratio (HR) of death, adjusted for age, sex, race, ethnicity, DT category, marital status, rurality, tumor size, cancer stage, and HPV status. We explored the impact of additionally adjusting for Yost SES index quintiles. We identified 17,818 eligible patients: 79.3% White, 14.4% Black, 5.8% Asian/Pacific Islander (A/PI), and 0.6% American Indian/Alaska Native (AI/AN). Primary tumor sites were oral cavity (36.8%), larynx (29.0%), OP (24.4%), and hypopharynx (9.9%). 10.4% were HPV-associated. Race and SES quintiles were related (chi-squared, p<0.001) and the majority (56.5%) of black patients were in the lowest SES quintile. mOS was shorter and risk of death was significantly higher for black vs white patients in both the all-site and OP-only cohorts. When we added SES to multivariable analyses, Black race was no longer associated with increased risk of death in the all-site or OP-only cohorts. (Table 1) CONCLUSION: We found that when adjusting for sociodemographic and clinical factors, Black race was independently associated with a higher risk of death compared to white patients. When we adjusted for SES in multivariable analysis the association between Black race and risk of death was no longer significant, consistent with previously published analyses and indicative of a complex relationship between race and SES. Further research is needed to identify and address the causative factors of disparities in LA HNSCC.

Do Physician Patient Sharing Networks Impact Disparities in Access to Multidisciplinary Cancer Consultation for Early-Stage Lung Cancer? A SEER-Medicare Network Analysis

To examine early-stage non-small cell lung cancer (NSCLC) patient and physician network characteristics associated with receipt of multidisciplinary cancer consultations (MDCCs), defined as an encounter with both a surgeon and a radiation oncologist after diagnosis. We tested the hypothesis that physician roles in patient-sharing networks can modify disparities in access to surgical and radiotherapy care. Specifically, we investigated the role of "linchpin physicians" using a novel network measure that assesses the extent to which a physician is the sole type of specialist in their physician patient sharing network, and the association of these physicians on patterns of care. The study cohort included patients diagnosed with stage I/IIA NSCLC in 2016-17 using Surveillance, Epidemiology and End Results (SEER)-Medicare data. We assembled a physician patient-sharing network using all NSCLC patient encounters between 3 months prior to and 12 months following diagnosis. We weighted physicians' patient-sharing ties by the number of shared patients and calculated physician's linchpin scores as a continuous variable measuring the extent to which a physicians' peers in the network lack ties to others of the same specialty as the focal physician. Physicians in the top 15%ile were considered a linchpin specialist. We then derived the proportion of linchpin surgeons or radiation oncologists per hospital referral region (HRR). We assessed patient characteristics including age, sex, race, ethnicity, cancer stage, comorbidity index, rurality, and socioeconomic status (SES). The study outcome was a surgical, radiation oncology, or MDCC in the 2 months following diagnosis. We then performed multivariable logistic regressions (MLR) to assess whether linchpins modified disparities in MDCC. Of 6,148 patients in the study, 12% received a MDCC, 28% only saw a radiation oncologist, 33% only saw a surgeon, and 27% saw neither for 2 months after diagnosis. On MLR, Hispanic patients were significantly less likely than White patients to receive consultations with a radiation oncologist, while patients in lowest SES quintile were significantly less likely to receive a surgical consultation than those in the highest SES. The proportion of linchpin surgeons and radiation oncologists per HRR was negatively associated with receipt of MDCC (OR low vs high [95% CI] = 0.75 [0.66 to 0.86]; 0.70 [0.61 to 0.80, respectively), but our regressions did not show that any demographic or SES disparities were modified by linchpin specialists. Linchpin specialists do not impact known disparities in access to cancer consultations. Identifying additional system-level factors that contribute to disparities in cancer consultations may lead to policy insights aimed at reducing unwarranted variation in care.