US Geographic Regions Research Articles

Stage IA papillary and chromophobe renal cell carcinoma: effectiveness of cryoablation and partial nephrectomy

ObjectivesTo evaluate the effectiveness of cryoablation compared to partial nephrectomy in patients with stage IA papillary and chromophobe renal cell carcinoma (pRCC; chRCC).Material and methodsThe 2004–2016 National Cancer Database was queried for adult patients with stage IA pRCC or chRCC treated with cryoablation or partial nephrectomy. Patients receiving systemic therapy or radiotherapy, as well as those with bilateral RCC or prior malignant disease were excluded. Overall survival (OS) was assessed using Kaplan–Meier plots and Cox proportional hazard regression models. Nearest neighbor propensity matching (1:1 cryoablation:partial nephrectomy, stratified for pRCC and chRCC) was used to account for potential confounders.ResultsA total of 11122 stage IA renal cell carcinoma patients were included (pRCC 8030; chRCC 3092). Cryoablation was performed in 607 (5.5%) patients, and partial nephrectomy in 10515 (94.5%) patients. A higher likelihood of cryoablation treatment was observed in older patients with non-private healthcare insurance, as well as in those with smaller diameter low-grade pRCC treated at non-academic centers in specific US geographic regions. After propensity score matching to account for confounders, there was no statistically significant difference in OS comparing cryoablation vs partial nephrectomy in patients with pRCC (HR = 1.3, 95% CI: 0.96–1.75, p = 0.09) and those with chRCC (HR = 1.38, 95% CI: 0.67–2.82, p = 0.38).ConclusionAfter accounting for confounders, cryoablation, and partial nephrectomy demonstrated comparable OS in patients with stage IA papillary and chromophobe RCC. Cryoablation is a reasonable treatment alternative to partial nephrectomy for these histological RCC subtypes when radiologically suspected or diagnosed after biopsy.Critical relevance statementCryoablation might be considered as an upfront treatment alternative to partial nephrectomy in patients with papillary and chromophobe stage IA renal cell carcinoma, as both treatment approaches yield comparable oncological outcomes.Key PointsThe utilization of cryoablation for stage IA papillary and chromophobe RCC increases.In the National Cancer Database, we found specific patterns of use of cryoablation.Cryoablation and partial nephrectomy demonstrate comparable outcomes after accounting for confounders.Graphical

Epidemiology and prevalence of dementia and Alzheimer's disease in American Indians: Data from the Strong Heart Study.

Accurate epidemiologic estimates for dementia are lacking for American Indians, despite substantive social and health disparities. The Strong Heart Study, a population-based cohort of 11 American Indian tribes, conducted detailed cognitive testing and examinations over two visits approximately 7 years apart. An expert panel reviewed case materials for consensus adjudication of cognitive status (intact; mild cognitive impairment [MCI]; dementia; other impaired/not MCI) and probable etiology (Alzheimer's disease [AD], vascular bain injury [VBI], traumatic brain injury [TBI], other). American Indians aged 70-95 years had 54% cognitive impairment including 10% dementia. VBI and AD were primary etiology approximately equal proportions (>40%). Apolipoprotein (APO) Eε4 carriers were more common among those with dementia (p=0.040). Plasma pTau, glial fibrillary acidic protein (GFAP), and neurofilament light chain (NfL) were higher among those with cognitive impairment, but not amyloid beta (Aβ). Cognitive intact had mean 3MSE 92.2 (SD 6.4) and mean Montreal Cognitive Assessment (MoCA) score of 21.3 (SD 3.2). This is the first population-based study to estimate the prevalence of vascular and Alzheimer's dementias in a population-based study of American Indians. The Strong Heart Study is a population-based cohort of American Indian tribes, conducted over 30+ years and three US geographic regions (Northern Plains, Southern Plains, Southwest). Our teams conducted detailed cognitive testing, neurological examination, and brain imaging over two visits approximately 7 years apart. An expert panel reviewed collected materials for consensus-based adjudication of cognitive status (intact; MCI; dementia; other impaired/not MCI) and probable underlying etiology (AD; VBI; TBI; other). In this cohort of American Indians aged 70-95, 54% were adjudicated with cognitive impairment, including approximately 35% MCI and 10% dementia. These data expand on prior reports from studies using electronic health records, which had suggested prevalence, and incidence of dementia in American Indians to be more comparable to the majority population or non-Hispanic White individuals, perhaps due to latent case undercounts in clinical settings. Vascular and neurodegenerative injuries were approximately equally responsible for cognitive impairment, suggesting that reduction of cardiovascular disease is needed for primary prevention. Traumatic injury was more prevalent than in other populations, and common among those in the "other/not MCI" cognitive impairment category. Mean scores for common dementia screening instruments-even among those adjudicated as unimpaired-were relatively low compared to other populations (mean unimpaired 3MSE 92.2, SD 6.4; mean unimpaired MoCA 21.3, SD 3.2), suggesting the need for cultural and environmental adaptation of common screening and evaluation instruments.

Geographical Variations in Early Onset Colorectal Cancer in the United States between 2001 and 2020.

Colorectal cancer remains the second leading cause of cancer-related death in the US. As early-onset colorectal cancer (EO-CRC) becomes more prevalent in the US, research attention has shifted towards identifying at-risk populations. Previous studies have highlighted the rising rate of early-onset adenocarcinoma (ADC) and neuroendocrine tumors (NET) in the US. However, data on geographical variations of EO-CRC are scarce. Hence, our study aims to analyze time trends in EO-CRC incidence rates across various US regions and to assess these trends by sex and histopathological subtypes (ADC and NET). We analyze data spanning from 2001 to 2020 from the United States Cancer Statistics (USCS) database, covering nearly 98% of the US population. Using SEER*Stat software version (8.4.2, NCI), we calculated EO-CRC incidence rates among adults aged 20-54 years, adjusting for the age standard 2000 US population. The rates were categorized by sex and US geographical regions into west, midwest, northeast, and south. Time trends, reported as annual percentage change (APC) and average APC (AAPC), were generated via Joinpoint Regression software (v.5.0.2, NCI) utilizing the weighted Bayesian Information Criteria "BIC" method to generate the best-fit trends with a two-sided p-value cutoff at 0.05. The rates were also stratified by histopathology into ADC and NET. Between 2001 and 2020, a total of 514,875 individuals were diagnosed with early-onset CRC in the US, with 54.78% being men. Incidence rates and trends varied across geographical regions. In the western region (comprising 106,685 patients, 54.85% men), incidence rates significantly increased in both women (AAPC = 1.37, p < 0.001) and men (AAPC = 1.34, p < 0.001). Similarly, in the midwestern region (with 110,380 patients, 55.46% men), there were significant increases in incidence rates among women (AAPC = 1.06, p < 0.001) and men (AAPC = 1.35, p < 0.001). The northeastern region (with 94,758 patients, 54.53% men) also witnessed significant increases in incidence rates for both women (AAPC = 0.71, p < 0.001) and men (AAPC = 0.84, p < 0.001). In contrast, the southern region (with 203,052 patients, 54.48% men) experienced slower increases in incidence rates among both women and men (AAPC = 0.25, p < 0.05 in women; AAPC = 0.66, p < 0.05 in men). When stratified by histopathology, incidence rates for adenocarcinomas (ADC) increased in all regions, most notably in the west (AAPC = 1.45, p < 0.05), and least in the south (AAPC = 0.46, p < 0.05). Conversely, for neuroendocrine tumors (NET), while incidence rates increased similarly across all regions, the pace was notably faster compared to ADC, particularly in the west (AAPC = 3.26, p < 0.05) and slower in the south (AAPC = 2.24, p < 0.05) Discussion: Our analysis of nationwide US data spanning two decades and encompassing over half a million early-onset CRC patients, representing nearly 98% of the US population, highlights significant temporal variation in incidence rates across various geographical regions. The most substantial increases in incidence rates were observed in the west, while the least pronounced changes were noted in the south, affecting both men and women. These trends persisted across the main CRC histopathological subtypes, with NET exhibiting a notably swifter pace of increase compared with ADC. These findings hold important implications for public health strategies and underscore the need for targeted interventions to address the rising burden of early-onset CRC across different regions in the US.

Respiratory Syncytial Virus Hospital-Based Burden of Disease in Children Younger Than 5 Years, 2015-2022

Respiratory syncytial virus (RSV) resurgences have been noted following the COVID-19 pandemic in many countries. Recent findings suggest that the 2021 and 2022 RSV seasons were more severe than in past seasons, and age distribution may have shifted toward older children in the younger than 5 years age group. To estimate age-specific changes in RSV hospital-based burden of disease before and after the COVID-19 pandemic and to compare incidence by Medicaid use. This retrospective cohort study included children younger than 5 years diagnosed with RSV and bronchiolitis at 50 US children's hospitals in 10 US geographic regions. The included participants had an encounter in intensive care, inpatient, emergency, or observational units, between June 1, 2015, and March 31, 2023. Diagnosis of RSV, bronchiolitis, or both at encounter. Incidence rate ratio of hospital use within each care unit before vs after the COVID-19 pandemic. It was hypothesized a priori that incidence of hospital use would increase overall in 2021 and 2022 compared with 2015 to 2019 and that the increase would be greater among children 12 months and older. Of 924 061 study participants (median [IQR] age, 8 (5-16) months; 535 619 [58.0%] male), 348 077 (37.7%) were diagnosed with RSV. Of these, 187 850 (54.0%) were hospitalized. Incidence rate ratios of hospitalization increased for all ages in 2021 and 2022 compared with 2015 to 2019. Children aged 24 to 59 months were 4.86 (95% CI, 4.75-4.98) times as likely to be hospitalized in 2022 compared with 2015 to 2019, whereas infants aged 0 to 5 months were 1.77 (95% CI, 1.74-1.80) times as likely. Medicaid patients were more likely to be hospitalized than non-Medicaid patients regardless of year. Hospitalizations for RSV and bronchiolitis demonstrated atypical seasonality in 2021 and 2022, with an overall increase in RSV encounters. Postpandemic RSV hospitalization increased for all ages, but especially among older children, whereas bronchiolitis hospitalization was decreased or unchanged compared with earlier seasons. These findings suggest some of the observed increase in RSV hospital use may be due to increased testing.

Implicit and Explicit Weight Bias among Midwives: Variations Across Demographic Characteristics.

Weight bias toward individuals with higher body weights is present in health care settings. However, there has been limited quantitative exploration into weight bias among perinatal care providers and its potential variations based on demographic characteristics. The aim of this study was to examine if the direction and extent of weight bias among midwives certified by the American Midwifery Certification Board (AMCB) varied across age, years since certification, body mass index (BMI), race, ethnicity, and US geographic region. Through direct email listservs, postcard distribution, social media accounts, and professional networks, midwives were invited to complete an online survey of their implicit weight bias (using the Implicit Association Test) and their explicit weight bias using the Anti-Fat Attitudes Questionnaire (AFA), Fat Phobia Scale (FPS), and Preference for Thin People (PTP) measure. A total of 2106 midwives who identified as Black or White and resided in one of 4 US geographic regions participated in the survey. Midwives with a lower BMI expressed higher levels of implicit (P <.01) and explicit (P ≤.01) weight bias across all 4 measures except for the AFA Fear of Fat Subscale. Implicit weight bias levels also varied by age (P <.001) and years since certification (P <.001), with lower levels among younger midwives (vs older) and those with fewer years (vs more) since certification. Only age and BMI remained significant (P <.001) after adjusting for other demographic characteristics. Lower explicit weight bias levels were found among midwives who identified as Black (vs White) on 2 measures (FPS: adjusted β = -0.07, P =.004; PTP: P =.01). This was the first quantitative study of how weight bias varies across demographic characteristics among a national sample of midwives. Further exploration is needed in more diverse samples. In addition, research to determine whether weight bias influences clinical decision-making and quality of care is warranted.

Photoprotective measures among adolescents stratified by region: An analysis utilizing the National College Health Assessment.

Exposure to sunlight has been shown to cause pigmentary alterations, photoaging and photocarcinogenesis. Understanding photoprotective patterns in adolescent populations is beneficial to public health initiatives. We utilized data provided by the American College Health Association's National College Health Assessment to evaluate photoprotective behaviors among adolescent populations. Behavioral questions related to photoprotection were analyzed from the American College Health Association (ACHA) National College Health Assessment (NCHA) (Version III). When comparing races, Black/African American respondents had the lowest association of practicing photoprotective behaviors in comparison to white respondents (p < .05). When comparing US geographic regions, the south had the lowest association of photoprotective measures (p < .05). The response rate of each institution varied, although there was still a large quantity of respondents. Finally, we cannot discern the specific reasoning for adolescent populations not using sunscreen. These data identify demographics where efforts to enhance education on photoprotective behaviors, specifically among skin of color and southern population, to support public health initiatives.

Rising Incidence of Syphilitic Uveitis–Related Hospitalizations in the US

The number of syphilis cases continues to increase in the US every year since 2001 with a 74% increase observed since 2017. In addition, there remains a national shortage of injectable penicillin G. Despite the increase in reported cases, to the authors' knowledge, there has been no recent nationwide study investigating the trends in incidence of syphilitic uveitis. To evaluate the national and regional incidence of syphilitic uveitis-related hospitalizations in the US. This was a retrospective, cross-sectional study. The Nationwide Inpatient Sample was queried to identify all inpatient admissions with a diagnosis of syphilitic uveitis in the US between the years 2010 and 2019. Analyses were performed to determine baseline sociodemographic characteristics and identify national and regional trends in incidence. All patients hospitalized with a diagnosis of syphilis, uveitis, and/or syphilitic uveitis were eligible for inclusion. Statistical analysis of study data took place in June 2023. Diagnosis of syphilis, uveitis, and/or syphilitic uveitis on inpatient admissions during the years 2010 to 2019 in the Nationwide Inpatient Sample. The primary outcome was to determine trends in the national and regional incidence of syphilitic uveitis-related hospitalizations in the US. Secondary outcome measures included sociodemographic characteristics of patients with syphilitic uveitis, incidence stratified by sex and race and ethnicity, and median charge per syphilitic uveitis hospital admission. From the Nationwide Inpatient Sample, inpatient data from 444 674 patients (median [IQR] age, 53 [37-67] years; 54.8% male) were analyzed. There were an estimated 5581 syphilitic uveitis-related hospitalizations during the 10-year study period. The median (IQR) age of individuals with syphilitic uveitis was 45 (35-55) years, and 4395 patients (78.9%) were male. Syphilitic uveitis disproportionately affected African American individuals (1787 patients [32%], although they compose 13.6% of the population) and those belonging to the lowest median household income quartile (2163 [38.8%]). The national incidence was 0.15 per 100 000 population and showed an increasing trend over the years, with the lowest incidence in 2011 (0.08 per 100 000 population) and the highest incidence in 2019 (0.23 per 100 000 population; P = .04). Regional analysis showed an increase in incidence across all 4 US geographical regions. A total of 1293 patients (23.2%) had comorbid AIDS. Although this cross-sectional study only captured inpatient diagnosis, an increasing incidence of syphilitic uveitis-related hospitalizations was observed in the US between 2010 and 2019. Given the concomitant national shortage of injectable penicillin G, results suggest that clinicians should maintain a high index of suspicion for syphilis when evaluating patients with intraocular inflammation.

Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020)

The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a six-year period (2015-2020) within an insurance claims database. This retrospective database cohort study utilized data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The ICD10 data was correlated to the CPT code for shoulder arthroplasty [proximal humeral prosthetic replacement (23616), shoulder hemiarthroplasty (HA)(23470), reverse total shoulder arthroplasty (rTSA)(23472)] or open reduction internal fixation (ORIF) [open treatment of proximal humerus fracture with internal fixation (23615), open treatment of proximal humerus fracture-dislocation with internal fixation (23680)] We investigated the number of proximal humerus fracture operative cases per year, percent arthroplasty used per year, rTSA and HA per year, hospital cost information as well as percent arthroplasty per US geographic region. A total of 8,057 operative proximal humerus fractures cases were identified in 7,697 patients over 65 years of age, with 0.45% (360/8,057) being bilateral. There was a 40.8 % decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 +/- 146.6) and second half of the study period (2018-2020, 998.3 +/- 258.7). Arthroplasty accounted for 78.7% of all surgeries, and 91% of those being rTSA. The total number of cases, rTSA and ORIF performed decreased per year (p=.01). The downward trend of percent ORIF per year approached significance (p=.054). Arthroplasty was a more expensive payment for total case option by almost $850.00 (p=.001). There was a larger percentage of arthroplasty performed in the Northeast, and North central US geographic regions. Despite the rise of both the elderly population and related geriatric proximal humerus fractures, there were less operatively represented in this insurance claims database across the six-year period. There may be a trend to utilize less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, Arthroplasty was being performed at a higher percentage in the Northeast, and North central regions of the United States.

A Mixed-Methods Approach to the Development of a Disaster Food Security Framework

BackgroundLimited research on food systems and food insecurity (FI) following disasters finds contextual differences in post-disaster food systems that shape dimensions of FI. Measurement limitations make it difficult to address FI and develop effective practices for disaster-affected communities. ObjectiveTo develop, validate, and test a Disaster Food Security Framework (DFSF). DesignMixed-methods approach was used, including in-depth interviews to understand lived experiences during disasters; expert panel input to validate DFSF designed using responses from in-depth interviews; and quantitative testing of robustness of DFSF using the coronavirus disease 2019 pandemic as a disaster example. Participants and settingThe in-depth interviews included participants from Vermont (n = 5), North Carolina (n = 3), and Oklahoma (n = 2) who had been living in those states during Hurricane Irene (2011), Hurricane Florence (2018), the Moore tornadoes (2013), and coronavirus disease 2019 pandemic (2020). The expert panel consisted of researchers and practitioners from different US geographical regions and food-related disciplines (n = 18). For the quantitative testing survey, data from 4 US states (New York, New Mexico, Vermont, and Maryland; n = 3,228) from the National Food Access and COVID Research Team was used. Main outcome measuresThe outcomes from the in-depth interviews were dimensions of disaster FI, those from the expert panel was a content validity ratio, and those from the quantitative testing was the number of items and components to be included. Analyses performedInductive and deductive reasoning were using when reporting on the in-depth interviews and expert panel results, including frequencies. The quantitative testing was conducted using multiple correspondence analysis. ResultsThe in-depth interviews revealed four dimensions of FI: availability (supply and donation), accessibility (economic, physical, and social), acceptability (preference and health), and agency (infrastructure and self-efficacy). The panel of experts reported high content validity for the DFSF and its dimensions (content validity ratio >0.42), thus giving higher credibility to the DFSF. Multiple correspondence analysis performed on 25 food-related variables identified one component with 13 indicators representing three of the four dimensions: availability, acceptability, and accessibility, but not agency.

Variation in Ischemic Stroke Payments in the USA: A Medicare Beneficiary Study

Introduction: The growing cost of stroke care has created the need for outcome-oriented and cost-saving payment models. Identifying imbalances in the current reimbursement model is an essential step toward designing impactful value-based reimbursement strategies. This study describes the variation in reimbursement fees for ischemic stroke management across the USA. Methods: This Medicare Fee-For-Service claims study examines USA beneficiaries who suffered an ischemic stroke from 2021Q1 to 2022Q2 identified using the Medicare-Severity Diagnosis-Related Groups (MS-DRGs). Demographic national and regional US data were extracted from the Census Bureau. The MS-DRG codes were grouped into four categories according to treatment modality and clinical complexity. Our primary outcome of interest was payments made across individual USA and US geographic regions, assessed by computing the mean incremental payment in cases of comparable complexity. Differences between states for each MS-DRG were statistically evaluated using a linear regression model of the logarithmic transformed payments. Results: 227,273 ischemic stroke cases were included in our analysis. Significant variations were observed among all DRGs defined by medical complexity, treatment modality, and states (p < 0.001). Differences in mean payment per case with the same MS-DRG vary by as high as 500% among individual states. Although higher payment rates were observed in MS-DRG codes with major comorbidities or complexity (MCC), the variation was more expressive for codes without MCC. It was not possible to identify a standard mean incremental fee at a state level. At a regional level, the Northeast registered the highest fees, followed by the West, Midwest, and South, which correlate with poverty rates and median household income in the regions. Conclusions: The payment variability observed across USA suggests that the current reimbursement system needs to be aligned with stroke treatment costs. Future studies may go one step further to evaluate accurate stroke management costs to guide policymakers in introducing health policies that promote better care for stroke patients.

Are there more acute cardiac hospitalizations in winter in patients with systemic sclerosis? An analysis from the National Inpatient Sample

Objective: Cold-induced transient myocardial ischemia has been described in patients with systemic sclerosis. The clinical impact of cold exposure in systemic sclerosis patients with acute cardiac conditions is unknown. We compared the seasonal variation of acute cardiac hospitalizations in patients with and without systemic sclerosis. Methods: We performed a retrospective cross-sectional study using the National Inpatient Sample from 2016 to 2019. The primary outcome was acute cardiac hospitalization primarily due to heart failure, acute myocardial infarction, or cardiac arrhythmias. We compared the proportion of acute cardiac hospitalizations in each season in patients with and without systemic sclerosis. We also performed a subgroup analysis by US geographic region (Northeast, Midwest, South, West). Results: There were a total of 10,118,002 acute cardiac hospitalizations over the 4-year study period. Compared to those without systemic sclerosis, patients with systemic sclerosis who were hospitalized for acute cardiac care were younger (mean age 67 ± 13 vs 70 ± 14 years, p &lt; 0.01), a greater proportion were female (82% vs 45%, p &lt; 0.01), and a smaller proportion were Caucasian (68% vs 71%, p &lt; 0.01). There was a lesser proportion of traditional cardiovascular risk factors in systemic sclerosis compared to non-systemic sclerosis patients. There was no significant difference in the proportion of winter admissions between systemic sclerosis and non-systemic sclerosis patients for total acute cardiac hospitalizations (26.4% vs 25.9%, p = 0.51), heart failure (27.0% vs 26.5%, p = 0.64), acute myocardial infarction (26.9% vs 25.5%, p = 0.50), or arrhythmias (24.3% vs 25.0%, p = 0.68). The results were consistent across all four US geographic regions. Conclusion: Our study did not support that patients with systemic sclerosis had a disproportionally higher risk of acute cardiac hospitalization in winter compared to the general population. We found that systemic sclerosis patients hospitalized for acute cardiac care had a lower burden of traditional cardiovascular risk factors than their non-systemic sclerosis counterparts.

Associations Between Breastfeeding and Post-perinatal Infant Deaths in the U.S.

Initiation of breastfeeding has been associated with reduced post-perinatal infant mortality. Although most states have initiatives to protect, promote, and support breastfeeding, no analysis of the association between breastfeeding and infant mortality has been conducted at the state and regional levels. To understand the associations between breastfeeding and post-perinatal infant mortality, the initiation of breastfeeding with post-perinatal infant mortality was analyzed by geographic region and individual states within each region. This study was a prospective cohort analysis linking U.S. national birth and post-perinatal infant death data for nearly 10 million infants born in 2016-2018, who were then followed for one year after birth and analyzed in 2021-2022. A total of 9,711,567 live births and 20,632 post-perinatal infant deaths from 48 states and the District of Columbia were included in the analysis. The overall AOR and 95% CIs for breastfeeding initiation with post-perinatal infant mortality was 0.67 (0.65, 0.69, p<0.0001) for days 7-364. All seven U.S. geographic regions had significant reductions in postperinatal infant deaths associated with breastfeeding initiation; Mid-Atlantic and Northeast regions had the largest reductions with AOR of 0.56 (95% CI=0.51, 0.61, p<0.001 and 0.50, 0.63, p<0.001, respectively), whereas the Southeast had the smallest reduction with AOR of 0.79 (95% CI=0.75, 0.84, p<0.001). Statistically significant results were noted for 35 individual states for reduction in total post-perinatal infant deaths. Although regional and state variation in the magnitude of the association between breastfeeding and infant mortality exists, the consistency of reduced risk, together with existing literature, suggests that breastfeeding promotion and support may be a strategy to reduce infant mortality in the U.S.

Disparities Associated with Shared Decision-making in Prostate Cancer Screening

BackgroundProstate cancer screening guidelines recommend shared decision-making (SDM) regarding prostate-specific antigen (PSA) testing. However, it is unclear who undergoes SDM and whether any disparities exist. ObjectiveTo examine sociodemographic differences in participation of SDM and its association with PSA testing in prostate cancer screening. Design, setting, and participantsA retrospective cross-sectional study was conducted among men aged 45–75 yr undergoing PSA screening, using the 2018 National Health Interview Survey database. The evaluated sociodemographic features included age, race, marital status, sexual orientation, smoking status, working status, financial difficulty, US geographic regions, and cancer history. Questions regarding self-reported PSA testing and whether respondents discussed its advantages and disadvantages with their healthcare provider were analyzed. Outcome measurements and statistical analysisOur primary outcome was to evaluate the possible associations between various sociodemographic factors and undergoing PSA screening and SDM. We used multivariable logistic regression analyses to detect potential associations. Results and limitationsA total of 59596 men were identified, of whom 5605 answered the question regarding PSA testing, with 2288 (40.6%) undergoing PSA testing. Of these men, 39.5% (n = 2226) discussed the advantages and 25.6% (n = 1434) discussed the disadvantages of PSA testing. On a multivariable analysis, older (odds ratio [OR] 1.092; 95% confidence interval [CI] 1.081–1.103, p < 0.001) and married (OR 1.488; 95% CI 1.287–1.720, p < 0.001) men were more likely to undergo PSA testing. Although Black men were more likely to discuss PSA advantages (OR 1.421; 95% CI 1.150–1.756, p = 0.001) and disadvantages (OR 1.554; 95% CI 1.240–1.947, p < 0.001) than White men, this did not correlate with higher rates of PSA screening (OR 1.086; 95% CI 0.865–1.364, p = 0.477). The lack of important clinical data remains a limitation. ConclusionsOverall, SDM rates were low. Older and married men had an increased likelihood of SDM and PSA testing. Despite higher rates of SDM, Black men had similar rates of PSA testing to White men. Patient summaryWe evaluated sociodemographic differences in shared decision-making (SDM) in prostate cancer screening using a large national database. We found that SDM had varying results in different sociodemographic groups.

Neighborhood Deprivation and Association With Neonatal Intensive Care Unit Mortality and Morbidity for Extremely Premature Infants

Socioeconomic status affects pregnancy and neurodevelopment, but its association with hospital outcomes among premature infants is unknown. The Area Deprivation Index (ADI) is a validated measure of neighborhood disadvantage that uses US Census Bureau data on income, educational level, employment, and housing quality. To determine whether ADI is associated with neonatal intensive care unit (NICU) mortality and morbidity in extremely premature infants. This retrospective cohort study was performed at 4 level IV NICUs in the US Northeast, Mid-Atlantic, Midwest, and South regions. Non-Hispanic White and Black infants with gestational age of less than 29 weeks and born between January 1, 2012, and December 31, 2020, were included in the analysis. Addresses were converted to census blocks, identified by Federal Information Processing Series codes, to link residences to national ADI percentiles. ADI, race, birth weight, sex, and outborn status. In the primary outcome, the association between ADI and NICU mortality was analyzed using bayesian logistic regression adjusted for race, birth weight, outborn status, and sex. Risk factors were considered significant if the 95% credible intervals excluded zero. In the secondary outcome, the association between ADI and NICU morbidities, including late-onset sepsis, necrotizing enterocolitis (NEC), and severe intraventricular hemorrhage (IVH), were also analyzed. A total of 2765 infants with a mean (SD) gestational age of 25.6 (1.7) weeks and mean (SD) birth weight of 805 (241) g were included in the analysis. Of these, 1391 (50.3%) were boys, 1325 (47.9%) reported Black maternal race, 498 (18.0%) died before NICU discharge, 692 (25.0%) developed sepsis or NEC, and 353 (12.8%) had severe IVH. In univariate analysis, higher median ADI was found among Black compared with White infants (77 [IQR, 45-93] vs 57 [IQR, 32-77]; P < .001), those who died before NICU discharge vs survived (71 [IQR, 45-89] vs 64 [IQR, 36-86]), those with late-onset sepsis or NEC vs those without (68 [IQR, 41-88] vs 64 [IQR, 35-86]), and those with severe IVH vs those without (69 [IQR, 44-90] vs 64 [IQR, 36-86]). In a multivariable bayesian logistic regression model, lower birth weight, higher ADI, and male sex were risk factors for mortality (95% credible intervals excluded zero), while Black race and outborn status were not. The ADI was also identified as a risk factor for sepsis or NEC and severe IVH. The findings of this cohort study of extremely preterm infants admitted to 4 NICUs in different US geographic regions suggest that ADI was a risk factor for mortality and morbidity after adjusting for multiple covariates.

Adverse health events and recommended health research priorities in agility dogs as reported by dog owners.

To understand relative frequency of adverse health events, defined as injuries or infectious diseases, in dogs participating in agility and to determine health research priorities of agility dog owners. An internet-based questionnaire distributed to agility dog owners included items related to experiences with infectious diseases and injuries in agility dogs, reasons for retirement of dogs from competition, and ranking of health research priorities. Frequencies of infectious diseases in US geographic regions were compared with Chi-square tests. Research priority rankings were determined as median and interquartile range (IQR) for each topic. Rank-based tests (Kruskal Wallis and Mann-Whitney) compared rankings between participants in different agility organizations, between veterinarian and non-veterinarian competitors, and between respondents who had competed in national championship events and other respondents. There were 1,322 respondents who had competed in canine agility in the previous 6 months, with those respondents reporting a median time competing in the sport of 13 years (IQR = 8-20 years); 50% of respondents had competed in at least one national championship agility event in the preceding 5 years. Overall, 1,015 respondents (77%) indicated that one or more of their dogs had been injured and approximately one-third (n = 477, 36%) indicated that one or more dogs had likely acquired one or more infectious diseases as a result of agility activities. Specific types of infectious diseases acquired varied by geographic region in the US. Research priority rankings were similar regardless of preferred agility organization or respondent experience. The highest-ranking research topics were identification of risk factors for specific types of injuries, improvements in equipment and understanding of safe course design, and physical conditioning programs to prevent injury. Agility competitors prioritize research in areas that advance understanding of injury prevention in their dogs. Research priorities are nearly uniform among competitors regardless of their preferred agility organization or level of experience, providing a strong rationale for agility organizations to collaborate in research initiatives that improve safety and well-being for dogs competing in the sport. There has been little published research focusing on the high-priority research areas identified by competitors.

Cross-Sectional Survey of Acupuncturists in the United States Who Prescribed Chinese Herbal Medicine for Patients with Symptoms Likely Related to COVID-19.

Objective: The objective of this study was to examine the prescribing of Chinese herbal medicine (CHM) by licensed acupuncturists in the United States during the COVID-19 pandemic. Methods: A 28-question survey with nine branching questions was disseminated through collegial networks, paid advertisements, and a study website in April-July 2021. Participants indicated that they were licensed acupuncturists who treated more than five patients for symptoms likely related to COVID-19 to gain entry to the full survey. Surveys were undertaken electronically through the Research Electronic Data Capture (REDCap) system. Results: The survey was undertaken by 103 participants representing all US geographic regions and had an average of 17 years in practice. Sixty-five percent received or intended to receive the COVID-19 vaccine. Phone and videoconference were the predominant methods of patient contact; granules and pill forms of CHM were the most prescribed. A wide variety of information sources were used in devising patient treatments inclusive of anecdotal, observational, and scientific sources. Most patients were not receiving biomedical treatment. Ninety-seven percent of participants reported that they had no patients die of COVID-19, and the majority reported that <25% of their patients developed long hauler syndrome (post-acute sequelae SARS-CoV-2 infection). Conclusions: This study demonstrates that licensed acupuncturists were treating COVID-19 infected individuals in the United States during the early stages of the pandemic, and for many such patients this was the only therapeutic intervention they had access to from a licensed health care provider. Information disseminated from China through collegial networks, along with published sources including scientific studies, informed the approach to treatment. This study provides insight into an unusual circumstance in which clinicians needed to establish evidence-based approaches to the treatment of a new disease during a public health emergency.

Social determinants of health (SDOH) and survival among patients with metastatic prostate cancer (mPC): A systematic literature review (SLR).

25 Background: Population level data show strong associations between race and other SDOH including income, education, and geographic region of residence. The relationship between SDOH and clinical outcomes has become increasingly recognized. This review examines the impact of SDOH on survival in patients with mPC in real-world (RW) settings. Methods: A systematic literature search in accordance with Cochrane guidelines was conducted on July 7, 2022, searching for RW studies published as full-text (Jan 2012-July 2022) and conferences (Jan 2019-July 2022) using Ovid MEDLINE, Embase, and Cochrane. A manual search of key congress websites for conference abstracts was also conducted. Studies which assessed the impact of SDOHs on survival, treatment access, and other clinical outcomes in patients with mPC were included in the overall SLR. Here, we present results from studies which assessed the impact of SDOH on overall survival (OS) and prostate cancer specific mortality (PCSM). Clinical trials were excluded. Results: Of 3,228 records screened, 86 studies were included, with findings reported in 67 full-text publications (60 US and 7 ex-US) and 28 conference abstracts (22 US and 6 ex-US). The impact of race on survival was reported in 54 studies. While most studies showed no difference between Black vs White for both OS (n=22) and PCSM (n=8), for patients on specific mPC treatments, there was an association between Black race and improved OS (n=5). Asian patients had improved OS vs White patients (n=4), and reduced PCSM vs White (n=6) and Black patients (n=1). Higher income was generally associated with improved OS (n=7), but no difference in PCSM (n=3). Although the regions compared differed, most studies found disparities in OS among US geographic regions (n=5). Education level was generally not associated with OS (n=2) or PCSM (n=3). Most studies showed that married patients had improved OS (n=4) and reduced PCSM (n=3) compared to unmarried patients. Conclusions: This SLR demonstrated that various SDOH are associated with disparities in survival among mPC patients. Asian race, which is generally associated with higher frequency of better SDOH risk factors, was linked with better OS. In contrast, Black race, which is generally associated with higher frequency of worse SDOH risk factors, was associated with similar or better OS. Having lower income and being unmarried were both associated with reduced OS, while disparities in OS were reported across geographic regions of the US. More studies are needed to understand why SDOH are linked with poor outcomes, including their connection with access to care.

Validity of Patient-Reported Outcomes Measurement Information System Physical, Mental, and Social Health Measures After Left Ventricular Assist Device Implantation and Implications for Patient Care.

A better understanding is needed of the burdens and benefits of left ventricular assist device (LVAD) implantation on patients' physical, mental, and social well-being. The purpose of this report was to evaluate the validity of Patient-Reported Outcomes Measurement Information System (PROMIS) measures for LVAD patients and to estimate clinically important score differences likely to have implications for patient treatment or care. Adults from 12 sites across all US geographic regions completed PROMIS measures ≥3 months post-LVAD implantation. Other patient-reported outcomes (eg, Kansas City Cardiomyopathy Questionnaire-12 item), clinician ratings, performance tests, and clinical adverse events were used as validity indicators. Criterion and construct validity and clinically important differences were estimated with Pearson correlations, ANOVA methods, and Cohen d effect sizes. Participants' (n=648) mean age was 58 years, and the majority were men (78%), non-Hispanic White people (68%), with dilated cardiomyopathy (55%), long-term implantation strategy (57%), and New York Heart Association classes I and II (54%). Most correlations between validity indicators and PROMIS measures were medium to large (≥0.3; p<0.01). Most validity analyses demonstrated medium-to-large effect sizes (≥0.5) and clinically important differences in mean PROMIS scores (up to 14.8 points). Ranges of minimally important differences for 4 PROMIS measures were as follows: fatigue (3-5 points), physical function (2-3), ability to participate in social roles and activities (3), and satisfaction with social roles and activities (3-5). The findings provide convincing evidence for the relevance and validity of PROMIS physical, mental, and social health measures in patients from early-to-late post-LVAD implantation. Findings may inform shared decision-making when patients consider treatment options. Patients with an LVAD, their caregivers, and their clinicians should find it useful to interpret the meaning of their PROMIS scores in relation to the general population, that is, PROMIS may help to monitor a return to normalcy in everyday life.

Reaching Populations at Risk for HIV Through Targeted Facebook Advertisements: Cost-Consequence Analysis

An undiagnosed HIV infection remains a public health challenge. In the digital era, social media and digital health communication have been widely used to accelerate research, improve consumer health, and facilitate public health interventions including HIV prevention. We aimed to evaluate and compare the projected cost and efficacy of different simulated Facebook (FB) advertisement (ad) approaches targeting at-risk populations for HIV based on new HIV diagnosis rates by age group and geographic region in the United States. We used the FB ad platform to simulate (without actually launching) an automatically placed video ad for a 10-day duration targeting at-risk populations for HIV. We compared the estimated total ad audience, daily reach, daily clicks, and cost. We tested ads for the age group of 13 to 24 years (in which undiagnosed HIV is most prevalent), other age groups, US geographic regions and states, and different campaign budgets. We then estimated the ad cost per new HIV diagnosis based on HIV positivity rates and the average health care industry conversion rate. On April 20, 2021, the potential reach of targeted ads to at-risk populations for HIV in the United States was approximately 16 million for all age groups and 3.3 million for age group 13 to 24 years, with the highest potential reach in California, Texas, Florida, and New York. When using different FB ad budgets, the daily reach and daily clicks per US dollar followed a cumulative distribution curve of an exponential function. Using multiple US $10 ten-day ads, the cost per every new HIV diagnosis ranged from US $13.09 to US $37.82, with an average cost of US $19.45. In contrast, a 1-time national ad had a cost of US $72.76 to US $452.25 per new HIV diagnosis (mean US $166.79). The estimated cost per new HIV diagnosis ranged from US $13.96 to US $55.10 for all age groups (highest potential reach and lowest cost in the age groups 20-29 and 30-39 years) and from US $12.55 to US $24.67 for all US regions (with the highest potential reach of 6.2 million and the lowest cost per new HIV diagnosis at US $12.55 in the US South). Targeted personalized FB ads are a potential means to encourage at-risk populations for HIV to be tested, especially those aged 20 to 39 years in the US South, where the disease burden and potential reach on FB are high and the ad cost per new HIV diagnosis is low. Considering the cost efficiency of ads, the combined cost of multiple low-cost ads may be more economical than a single high-cost ad, suggesting that local FB ads could be more cost-effective than a single large-budget national FB ad.

Repeat Annual Lung Cancer Screening After Baseline Screening Among Screen-Negative Individuals: No-Cost Coverage Is Not Enough.

Adherence to lung cancer screening (LCS) is central to effective screening. The authors evaluated the likelihood of repeat annual LCS in a national commercially insured population and associations with individual characteristics, insurance characteristics, and annual out-of-pocket cost (OOPC) burden. Using claims data from an employer-insured population (Clinformatics), individuals 55 to 80 years of age undergoing LCS between January 1, 2015, to September 30, 2019, with "negative" LCS were included. Repeat LCS was defined as low-dose chest CT occurring 10 to 15 months after the preceding LCS. Analysis was conducted over a 6-year period. Multivariable logistic regression was used to evaluate associations between repeat LCS and individual characteristics, insurance characteristics, and total OOPC incurred by the individual in the year of the index LCS, even if unrelated to LCS. Of 14,943 individuals with negative LCS, 4,561 (30.5%) underwent repeat LCS. Likelihood of repeat LCS was decreased for men (adjusted odds ratio [aOR], 0.91; 95% confidence interval [CI], 0.86-0.97), Hispanic ethnicity (aOR, 0.82; 95% CI, 0.69-0.97), and indemnity insurance plans (aOR, 0.36; 95% CI, 0.25-0.53). Relative to New England, individuals in nearly all US geographic regions were less likely to undergo repeat LCS. Finally, individuals with total OOPC in the highest two quartiles were less likely to undergo repeat LCS (aOR, 0.85 [95% CI, 0.77-0.92] for OOPC >$1,069.02-$2,475.09 vs $0-$351.82; aOR, 0.75 [95% CI, 0.68-0.82] for OOPC >$2,475.09 vs $0-$351.82). Although federal policies facilitate LCS without cost sharing, individuals incurring high OOPC, even when unrelated to LCS, are less likely to undergo repeat LCS. Future policy design should consider the permeative burden of OOPC across the health continuum on preventive services use.