Zip Code Of Residence Research Articles

Abstract 4123370: Distance to a Cardiac Imaging Center and Likelihood of Imaging Receipt: Defining Imaging Deserts

Background: Cardiovascular imaging is critical for the diagnosis and management of cardiovascular disease. Whether geographic distance to a cardiovascular imaging center (CVIC) impacts access to care is unknown. Methods: We evaluated all Medicare beneficiaries (Fee-for-service and Medicare Advantage) from 2018-2022, excluding those < 65, without continuous Medicare enrollment in the previous year, individuals missing zip code of residence, or CVICs missing zip codes. We estimated distance from the centroid of an individual’s zip code of residence to the centroid of the zip code with the nearest CVIC (defined as > 10 imaging procedures/year). Multivariable regression models were used to estimate likelihood of imaging receipt by distance. Results/Data: A total of 64,260,530 individuals (age 73.0 ± 8 years, 54.6% female, 80.1% White) received care at 3,886 CVICS. The vast majority (95%) lived within 16 miles of a CVIC, but varied considerably by modality with substantially greater distances for cardiac CT, cardiac MRI, and PET (Median [IQR] distance in miles to CVIC, Echo: 3.4 [0.4-7.0]; SPECT: 3.8 [1.3-7.9]; cardiac CT: 8.1 [3.7-21.3]; cardiac MRI: 17.4 [7.3-43.3]; PET: 88.9 [26.2-194.6]). CVICs performing cardiac CT, cardiac MRI, or PET were nearly all in metropolitan locations. Likelihood of imaging receipt was triphasic: lowest within 0-10 miles of a CVIC (mainly metropolitan locations), greater within 10-15 miles, and then increasingly lower beyond 15 miles ( Figure 1 ). Sites beyond the 16-mile threshold were predominantly in the Midwest and West ( Figure 2 ). Conclusions: In this study of 64 million Medicare beneficiaries, 2018-2022, 95% of the US population was found to live within 16 miles of a CVIC, though varied by modality. While those living > 16 miles from a CVIC received less imaging, the lowest use was identified among individuals living in the same zip code as a CVIC, suggesting a possible disconnect between access to imaging care and proximity.

Follow-up Trends in Patients Undergoing Modified Wendler Glottoplasty.

After modified Wendler glottoplasty (mWG), close follow-up with laryngologist and speech-language pathologist (SLP) is thought to be essential to achieve best outcomes. This study presents a case series of patients undergoing mWG at a single institution to identify factors associated with trends in post-operative follow-up. Retrospective review of trans women patients who underwent mWG between March 2018 and July 2023 was performed. Demographic data, pre-operative care, and post-operative course were reviewed. Lost to follow-up (LTFU) was defined as a failure to return to the office or schedule a follow-up appointment as recommended, for ≥2 months after last visit. Logistic regressions were utilized to identify possible factors associated with being LTFU. Eight (50%) of 16 patients met LTFU criteria. Patients were considered not LTFU if they completed care (n = 3, 19%) or were still undergoing care (n = 5, 31%). Patients with chronic diseases were less likely to become LTFU (p = 0.03). Those lost to follow-up had more no-show visits (p = 0.04). Total number of gender-affirming surgeries, distance from hospital, socioeconomic status of residential zip code, race/ethnicity, other psychological history, and patient-reported outcome measure scores did not affect LTFU rates. Fifty percent of patients were LTFU after modified Wendler glottoplasty. Even one no-show visit increased risk of being LTFU, whereas the presence of chronic diseases was protective against this. This study illustrates that increased efforts are needed following mWG to better understand the factors associated with being LTFU and to facilitate patients' ability to complete post-operative care successfully. 4 Laryngoscope, 2024.

Ambient beta particle radioactivity and lung cancer survival: Results from the Boston Lung Cancer Study

BackgroundExposure to ionizing radiation is known to increase the risk of lung cancer. However, studies on the effect of environmental radiation associated with ambient particle air pollution on lung cancer survival are limited. We investigated the association between ambient beta particle radioactivity (PR-β) after a diagnosis and lung cancer survivals. MethodsThe Boston Lung Cancer Survival (BLCS) cohort consisted of histologically confirmed patients enrolled at Massachusetts General Hospital (MGH) and the Dana-Farber Cancer Institute (DFCI) in Boston, U.S. The primary outcomes included overall survival, 5-year survival, and 3-year survival probability. We estimated ambient PR-β exposure at the ZIP code of residence from 2001 through 2017. Cox-proportional hazards models were constructed to estimate hazard ratios (HRs) for the associations between ambient PR-β and survival outcomes while controlling for covariates. ResultsThe analysis included 2795 patients with complete information, with 97,330 person-months of follow-up. The interquartile range (IQR) increase in PR-β was significantly associated with worse overall survival (HR:1.63, 95% CI:1.52, 1.76), 5-year survival (HR:1.33, 95% CI:1.23, 1.44), and 3-year survival (HR:1.22, 95% CI:1.12, 1.33) while adjusting for covariates, including age at diagnosis, sex, race, smoking, stage, histology, and adjusted gross income. Similar associations were found while additionally adjusting for the estimated residential radon exposure. In addition, the survival associated with PR-β exposure was significantly worse for patients in the early stages (HR:2.16, 95% CI:1.84, 2.52). ConclusionThe findings from this study provide new evidence suggesting that environmental exposure to radioactive particles after lung cancer diagnosis may have a pronounced effect on survival, particularly in patients with early stages.

Effects of fine particulate matter from wildfire and non-wildfire sources on emergency-department visits in people who were housed and unhoused in San Diego County (CA, USA) during 2012–20: a time-stratified case–crossover study

Being unhoused can increase vulnerability to adverse health effects due to air pollution. We aimed to quantify changes in emergency-department visits during and after exposure to wildfire-specific and non-wildfire particulate matter 2·5 μm or less in diameter (PM2·5) in San Diego County (CA, USA) in people who were both unhoused and housed. For this time-stratified case-crossover study, we used data on exposure to wildfire-specific PM2·5 in California and individual-level data for people admitted to the emergency departments of two hospitals (UC San Diego Health emergency departments at La Jolla and Hillcrest, San Diego) in San Diego County between July 1, 2012, and Dec 31, 2020. People with a postcode outside of San Diego County were excluded. Demographic information was age group, race or ethnicity, and transport to the emergency department. Wildfire-specific PM2·5 concentration at the postcode level was previously estimated using an ensemble model that combined multiple machine-learning algorithms and explanatory variables obtained via data on 24-h mean PM2·5 concentrations from the US Environmental Protection Agency Air Quality System. Conditional logistic regression models were applied, adjusting for specific humidity, wind velocity, and maximum temperature extracted from the US Gridded Surface Meteorological Dataset. Housing status was established by registration staff or triage nurses on arrival at the emergency department. For people who were unhoused, exposure was defined based on the weighted mean PM2·5 concentration at the city level proportional to the number of people who were unhoused in each specific city across urban centres in San Diego County. For people who were housed, we used residence postcode to measure exposure. We assessed the association between PM2·5 from wildfire and non-wildfire sources and emergency-department visits in people who were housed and unhoused. There were 587 562 emergency-department visits at the two hospitals, 76 407 (13·0%) of which were by people who were unhoused. People who were housed had a higher exposure to overall PM2·5 (24-h mean over the study period of 9·904 mg/m3, SD 3·445) and non-wildfire PM2·5 (9·663, 2·977) than people who were unhoused (9·863, 3·221; 9·557, 2·599). However, people who were unhoused had a higher exposure to wildfire-specific PM2·5 (0·305, 1·797) than people who were housed (0·240, 1·690). Overall PM2·5 exposure was associated with increased odds of emergency-department visits for both people who were housed (odds ratio 1·003, 95% CI 1·001-1·004 per 1 μg/m3 PM2·5 for 0-3 days after exposure) and people who were unhoused (1·004, 1·000-1·008 for 0-3 days after exposure). We found that non-wildfire PM2·5 was associated with emergency-department visits among people who were housed (1·003, 1·002-1·005 for 0-3 days after exposure) and wildfire-specific PM2·5 was associated with emergency-department visits in people who were unhoused (1·006, 1·001-1·011 for 0-3 days after exposure). People who were unhoused in San Diego County were more likely to visit emergency departments after exposure to increased wildfire-specific PM2·5. As the intensity and frequency of wildfires increase, understanding risk factors for vulnerable populations, such as people who are unhoused, is crucial to develop effective adaptation strategies. US National Institutes of Health, National Institute on Aging.

The effect of air pollution on hospitalizations with Parkinson’s disease among medicare beneficiaries nationwide

We examined the effect of annual exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3), on the rate of first hospitalization with a PD-related diagnosis (hospitalization with PD) among Medicare Fee-for-Service beneficiaries (2001-2016). Machine learning-derived annual air pollution concentrations were linked to residential ZIP codes. For each exposure, we fitted four models: 1) traditional outcome stratification, 2) marginal structural, 3) doubly robust, and 4) generalized propensity score matching Poisson regression models, adjusted for sociodemographic and meteorological confounders and long-term trends. Among 49,121,026 beneficiaries, incidence rate ratios of 1.08 (95% CI: 1.07, 1.10), 1.07 (95% CI: 1.05, 1.08), and 1.03 (95% CI: 1.02, 1.05) for an interquartile range increase in PM2.5 (3.72 µg/m3), NO2 (13.84 ppb), and O3 (10.09 ppb), respectively, were estimated from doubly robust models. Results were similar across modeling approaches. In this nationwide study, higher air pollution exposure increased the rate of hospitalizations with PD.

Access and models of obstructive sleep apnea care: a cross-national comparison of Canadian and Australian patient survey data.

To describe similarities and differences in OSA care pathways and their impact on patients in Australia and Canada, including among urban versus rural participants. In this secondary data analysis of patient surveys exploring OSA care in Australia and Canada, we recruited adults with a prior diagnosis of OSA from market research companies, social media, and patient-facing medical associations. Residential postal codes were used to classify participants as urban or rural. Survey domains included wait times and travel distances for care, providers, and treatments. Data from 589 Canadians (21% rural; 42% female, mean [SD] age = 57 [13] years) and 412 Australians (38% rural; 45% female, mean [SD] age = 58 [14] years) with OSA were included. Participants in both countries most commonly sought initial care for suspected OSA from a primary care practitioner. Canadian participants waited longer to seek care than Australian participants (37% vs 51% within 12 months of symptom onset). Wait times for diagnostic testing were longer in Canada (59% vs 76% within 3 months of initial assessment), especially in urban settings (58% vs 78%). In both countries, >80% of participants were offered positive airway pressure (PAP) therapy. Overall, a greater variety of treatments were offered and used by Australian participants. Greater access to diagnostic testing and a greater variety of treatments were found in Australia compared to Canada. Further research is needed to determine if reduced diagnostic wait times and presentation of increased therapy options found in Australia translate into better patient outcomes.

Interfacility Transfer of Children With Time-Sensitive Surgical Conditions, 2002-2017

Surgical care for children in the United States has become increasingly regionalized among fewer centers over time. The degree to which regionalization may be associated with access to urgent surgical care for time-sensitive conditions is not clear. To investigate whether transfers and travel distance have increased for 4 surgical conditions, and whether changes in transfers and travel distance have been more pronounced for rural vs urban children. This retrospective cross-sectional study analyzed data from 9 State Inpatient Databases from 2002 to 2017. Participants included children aged younger than 18 years undergoing urgent or emergent procedures for malrotation with volvulus, esophageal foreign body, and ovarian and testicular torsion. Residential and hospital zip codes were categorized as rural or urban. Hospitals were categorized as pediatric hospitals, adult hospitals with pediatric services, and adult hospitals without pediatric services. Primary outcomes were transfer for care and travel distance between patients' home residences and the hospitals where care was provided. Transfer and travel distance were analyzed using multivariable regression models. Among the 5865 children younger than 18 years undergoing procedures for malrotation with volvulus, esophageal foreign body, ovarian torsion, or testicular torsion, 461 (7.9%) resided in a rural area; 1097 (20.5%) were Hispanic, 1334 (24.9%) were non-Hispanic Black, and 2255 (42.0%) were non-Hispanic White; 2763 (47.1%) were covered by private insurance and 2535 (43.2%) were covered by Medicaid; and the median (IQR) age was 9 (2-14) years. Most care was provided at adult hospitals (73.4% with and 16.9% without pediatric services); the number of hospitals providing this care decreased from 493 to 292 hospitals (2002 vs 2017). Transfer was associated with rural residence (adjusted odds ratio [aRR], 2.3 [95% CI, 1.8-3.0]; P < .001) and increased over time (2017 vs 2002: aOR, 2.8 [95% CI, 2.0-3.8]; P < .001). Similarly, travel distance was associated with rural residence (adjusted risk ratio [aRR], 4.4 [95% CI, 3.9-4.8]; P < .001) and increased over time (2017 vs 2002: aRR, 1.3 [95% CI, 1.2-1.4]; P < .001). Rural children were more frequently transferred (2017 vs 2002) for esophageal foreign body (48.0% [12 of 25] vs 7.3% [4 of 55]; P < .001), ovarian torsion (26.7% [4 of 15] vs 0% [0 of 18]; P = .01), and testicular torsion (18.2% [2 of 11] vs 0% [0 of 16]; P = .04). Travel distance for rural children increased the most for torsions, from a median (IQR) of 19.1 (2.3-35.4) to 43.0 (21.6-98.8) miles (P = .03) for ovarian torsion and from 7.3 (0.4-23.7) to 44.5 (33.1-48.8) miles (P < .001) for testicular torsion. In this cross-sectional study of children with time-sensitive surgical conditions, the number of hospitals providing urgent surgical care to children decreased over time. Transfers of care, especially among rural children, and travel distance, especially for those with ovarian and testicular torsion, increased over time.

Weather conditions and legionellosis: a nationwide case-crossover study among Medicare recipients.

Legionellosis is a respiratory infection caused by Legionella sp. that is found in water and soil. Infection may cause pneumonia (Legionnaires' Disease) and a milder form (Pontiac Fever). Legionella colonizes water systems and results in exposure by inhalation of aerosolized bacteria. The incubation period ranges from 2 to 14 days. Precipitation and humidity may be associated with increased risk. We used Medicare records from 1999 to 2020 to identify hospitalizations for legionellosis. Precipitation, temperature, and relative humidity were obtained from the PRISM Climate Group for the zip code of residence. We used a time-stratified bi-directional case-crossover design with lags of 20 days. Data were analyzed using conditional logistic regression and distributed lag non-linear models. A total of 37883 hospitalizations were identified. Precipitation and relative humidity at lags 8 through 13 days were associated with an increased risk of legionellosis. The strongest association was precipitation at day 10 lag (OR = 1.08, 95% CI = 1.05-1.11 per 1 cm). Over 20 days, 3 cm of precipitation increased the odds of legionellosis over four times. The association was strongest in the Northeast and Midwest and during summer and fall. Precipitation and humidity were associated with hospitalization among Medicare recipients for legionellosis at lags consistent with the incubation period for infection.

Population-Level Exposure to PM2.5, NO2, Greenness (NDVI), Accessible Greenspace, Road Noise, and Rail Noise in England

Air pollution, greenspace and noise are interrelated environmental factors with the potential to influence human health outcomes. Research has measured these exposures in diverse ways across the globe, but no study has yet performed a country-wide analysis of air pollution, greenspace, and noise in England. This study examined cross-sectional PM2.5, NO2, greenness, accessible greenspace, road noise, and rail noise exposure data at all residential postcodes in England (n = 1,227,681). Restricted cubic spline models were fitted between each environmental exposure and a measure of socioeconomic status, the Index of Multiple Deprivation (IMD) rank. Population-weighted exposures by IMD deciles, urbanicity, and region were subsequently estimated. Restricted cubic spline models were also fitted between greenness and each other environmental exposure in the study. The results show some evidence of inequalities in exposure to air pollutants, greenspace, and noise across England. Notably, there is a socioeconomic gradient in greenness, NO2, PM2.5, and road noise in London. In addition, NO2, PM2.5, and road noise exposure decrease as greenness increases in urban areas. Concerningly, almost all air pollution estimates in our study exceed international health guidelines. Further research is needed to elucidate the socioeconomic patterns and health impacts of air pollution, greenspace, and noise over time.

8118 Effect of Rurality on Diabetes Technology Use Among Medicaid-Insured Youth Enrolled in a Mid-Western Accountable Care Organization

Abstract Disclosure: E.E. Bell-Sambataro: None. J. Kilbarger: None. A. Lahoti: None. J.M. Ladd: None. Background: Diabetes technology (continuous glucose monitors (CGM) and insulin pumps), is associated with improved glycemic control and quality of life in children with type 1 diabetes (T1D), but technology use is not equitable. We explored whether rural/urban disparities exist in CGM and pump use among pediatric patients with T1D enrolled in an Accountable Care Organization (ACO) and thus on Medicaid. Methods: We conducted a retrospective cohort study using claims data from the central Ohio ACO database from January 1, 2018 to September 30, 2022. Individuals aged 1 to &amp;lt;21years were identified using T1D-specific billing codes. CGM or pump use was defined using established prescription codes. Rurality was based on zip codes of residence linked to RUCA codes. For descriptive analyses, we calculated proportions, means and standard deviations. T-tests were used to compare continuous variables; chi-square tests were used to compare categorical variables. Multivariable Poisson regression was used to model the association between rurality and CGM or pump use, adjusted for age, sex, race, and era (pre-/post-COVID pandemic). Results: We identified 1079 enrolled individuals with T1D during the study period; 878 (81.4%) were using CGM and 259 (24%) were using insulin pumps. In descriptive analysis, CGM users were younger than non-users (users 11.4±4.4years vs non-users 15.3±3.8years, p&amp;lt;0.01). The distribution of rurality between CGM users and non-users was similar (users 73.5% urban, 26.3% rural vs non-users 66.6% urban, 33.3% rural, p=0.05). There were no age or rurality differences between pump users and non-users (users 12.2±3.8years vs non-users 12.1±4.8years, p=0.86; users 72.6% urban vs non-users 72.1% urban, p=0.92). In regression modeling, rurality was not significantly associated with CGM use (adjusted risk ratio (aRR) 0.95, 95% confidence interval (CI) 0.89-1.02) whereas age, race, era, and pump use were significantly associated. Rurality was significantly associated with pump use (aRR 0.79, 95% CI 0.63-0.99) as were age, race and era. Conclusions: In this cohort limited to pediatric patients with T1D on Medicaid, rural residence did not have a significant effect on CGM use but did make pump use less likely. Those of older age or non-White race were significantly less likely to use CGM and pumps. Future efforts targeting these disparities should be undertaken to increase use of these standard of care technologies among all children. Presentation: 6/2/2024

Ambient Air Pollution Exposure and Outcomes in Patients Receiving Lung Transplant

Elevated ambient fine particulate matter (PM2.5) air pollution exposure has been associated with poor health outcomes across several domains, but its associated outcomes among lung transplant recipients are poorly understood. To investigate whether greater PM2.5 exposure at the zip code of residence is associated with a higher hazard for mortality and graft failure in patients with lung transplants. This retrospective cohort study used panel data provided by the United Network for Organ Sharing, which includes patients receiving transplants across all active US lung transplant programs. Adult patients who received lung transplants between May 2005 and December 2016 were included, with a last follow-up of September 10, 2020. Data were analyzed from September 2022 to May 2023. Zip code-level annual PM2.5 exposure was constructed using previously published North American estimates. The primary outcome was time to death or lung allograft failure after lung transplant. A gamma shared frailty Cox proportional hazards model was used to produce unadjusted and adjusted hazard ratios (HRs) to estimate the association of zip code PM2.5 exposure at the time of transplant with graft failure or mortality. Among 18 265 lung transplant recipients (mean [SD] age, 55.3 [13.2] years; 7328 female [40.2%]), the resident zip code's annual PM2.5 exposure level was greater than or equal to the Environmental Protection Agency (EPA) standard of 12μg/m3 for 1790 patients (9.8%) and less than the standard for 16 475 patients (90.2%). In unadjusted analysis, median graft survival was 4.87 years (95% CI, 4.57-5.23 years) for recipients living in high PM2.5 areas and 5.84 years (95% CI, 5.71-5.96 years) for recipients in the low PM2.5 group. Having an annual PM2.5 exposure level greater than or equal to the EPA standard 12 μg/m3 was associated with an increase in the hazard of death or graft failure (HR, 1.11; 95% CI, 1.05-1.18; P < .001) in the unadjusted analysis and after adjusting for covariates (HR, 1.08; 95% CI, 1.01-1.15; P = .02). Each 1 μg/m3 increase in exposure was associated with an increase in the hazard of death or graft failure (adjusted HR, 1.01; 95% CI, 1.00-1.02; P = .004) when treating PM2.5 exposure as a continuous variable. In this study, elevated zip code-level ambient PM2.5 exposure was associated with an increased hazard of death or graft failure in lung transplant recipients. Further study is needed to better understand this association, which may help guide risk modification strategies at individual and population levels.

Association of area-level broadband and non-small cell lung cancer diagnosis and guideline-concordant care in the US.

96 Background: Access to broadband is a social determinant of health facilitating connections with healthcare services and other resources and alleviating burdens of travel distance, time, and cost. We used nationwide data to examine the association of zip code-level broadband usage and stage at diagnosis, as well as the receipt of quality care among individuals newly diagnosed with non-small cell lung cancer (NSCLC). Methods: Individuals ≥18 years newly diagnosed with first primary NSCLC between April - December of 2019-2021, were identified from the National Cancer Database (January - March were excluded to match the COVID-19 timeframe in 2020). Broadband usage percentage (the percentage of individuals per zip code with access to fixed broadband at speeds of 25 Mbps/3 Mbps in 2020) were combined with the cohort based on individual’s residential zip code. Multivariable logistic regression models examined associations between broadband usage quartiles and stage at diagnosis, as well as the receipt of guideline-concordant care based on National Comprehensive Cancer Network guidelines, including surgery and radiation, ≥10 lymph nodes sampling, chemotherapy, and neoadjuvant chemoradiation (NACR). Analyses were conducted overall and stratified by metropolitan status and year, adjusting for age group, sex, race and ethnicity, comorbidity, distance to facility, state, and zip code-level social deprivation index (SDI). Results: Cohort included 305,198 individuals newly diagnosed with NSCLC. Individuals living in areas with the highest broadband usage were more likely to be aged 65-74 years, female, non-Hispanic White, with Medicare coverage, living in metropolitan and low SDI areas. In adjusted models, individuals living in areas with the highest broadband usage were more likely to be diagnosed with stage I NSCLC (adjusted odds ratio [AOR] = 1.10, 95% confidence interval [95%CI] = 1.01-1.20) and to receive guideline-concordant NACR (AOR = 1.38, 95%CI = 1.09-1.73) compared with those living in areas with the lowest broadband usage in 2020. When stratified by metropolitan status, associations of broadband and diagnosis and receipt of NACR were only observed among individuals living in non-metropolitan areas with medium-low and medium-high broadband usage, respectively (AOR = 1.15, 95%CI = 1.01-1.32; AOR = 1.80, 95%CI = 1.25-2.58). No significant associations were identified for other care modalities or during 2019 and 2021. Conclusions: Increased access to broadband usage is associated with earlier stage NSCLC diagnosis and receiving guideline-concordant NACR in 2020. Our results suggest that increased broadband access, combined with the expansion of telehealth services during the COVID-19 pandemic, may have improved telehealth utilization throughout 2020, leading to enhanced quality of cancer care, particularly benefiting individuals residing in non-metropolitan areas.

Dietary Restriction, Socioeconomic Factors, Access to Kidney Transplantation, and Waitlist Mortality.

Dietary restrictions for patients with end-stage kidney disease (ESKD) are burdensome. Kidney transplantation (KT) candidates who lack neighborhood resources and are burdened by dietary restrictions may have decreased access to KT. In our two-center prospective cohort study (2014-2023), 2471 ESKD patients who were evaluated for KT (candidates) reported their perceived burden of dietary restrictions (not at all, somewhat/moderately, or extremely bothered). Neighborhood-level socioeconomic factors were derived from residential ZIP codes. We quantified the association of perceived burden of the dietary restrictions with a chance of listing using Cox models and risk of waitlist mortality using competing risks models. Then we tested whether these associations differed by neighborhood-level socioeconomic factors. At evaluation, 18% of KT candidates felt extremely bothered by dietary restrictions. Those who felt extremely bothered were less likely to be listed for KT (adjusted hazard ratio [aHR]=0.75, 95% confidence interval [CI]: 0.64-0.87); this association did not differ by neighborhood-level socioeconomic factors. Overall, the burden of dietary restrictions was not associated with waitlist mortality (p=0.62). However, among candidates living in high food insecurity neighborhoods, those who felt extremely bothered had higher waitlist mortality (adjusted subhazard ratio [aSHR]=2.07, 95% CI: 1.14-3.75, p[interaction]=0.02). The association between dietary burden and waitlist mortality did not differ by neighborhood-level healthy food access. The perceived burden of dietary restrictions is associated with a lower chance of listing for KT, and higher waitlist mortality only among candidates residing in neighborhoods with high food insecurity. Transplant centers should identify vulnerable patients and support them with nutrition education and access to food assistance programs.

Association between social determinants of health and select neurosurgical procedures in the National Spina Bifida Patient Registry.

Myelomeningocele (MMC) is a lifelong condition requiring complex multidisciplinary management. Using the National Spina Bifida Patient Registry (NSBPR), the authors tested the association between sociodemographic variables and odds of undergoing neurosurgical procedures. The authors extracted sociodemographic, clinical, and neurosurgical procedure data on participants with MMC aged ≥ 1 year who visited an NSBPR clinic between 2009 and 2020. The zip code of the participant's residence at the time of the last spina bifida clinic visit was linked to the Distressed Communities Index (DCI) tier. Multivariate models were built to identify factors associated with undergoing CSF diversion, shunt revision, tethered cord release (TCR), and Chiari decompression. There were 7924 participants with a median visit age of 13 years (IQR 7-20 years); 49.1% were male, 30.2% were non-Hispanic Black or Hispanic, 54.5% had public/supplemental insurance, and 16.9% were from distressed communities. CSF diversion, shunt revision, TCR, and Chiari decompression were performed in 81.8%, 47.7%, 22.9%, and 8.7% of participants, respectively. In multivariate analyses controlling for age, sex, insurance, DCI tier, lesion level, and surgical closure timing, Hispanic individuals were less likely than their non-Hispanic White counterparts to undergo shunt revision (p = 0.013). Non-Hispanic Black and Hispanic individuals were less likely to undergo TCR (p < 0.001 each) or Chiari decompression (p < 0.001 each). Compared with privately insured individuals, publicly insured individuals were more likely to undergo CSF diversion (p = 0.031). Those in distressed communities had increased odds of undergoing CSF diversion (p = 0.004) than those in prosperous communities. Among individuals with MMC participating in the NSBPR, there were differences in receiving neurosurgical procedures by race/ethnicity, insurance type, and DCI tier. Additional prospective studies are necessary to elucidate the reasons for these variations and their impact on long-term outcomes for this patient population in order to created targeted interventions.

The sphere of exposure: centering user experience in community science air monitoring

Community science has increased in popularity in communities where residents hope to investigate the relationship between environmental issues and personal health. This study partnered with neighborhoods in the most polluted residential zip code in the US to conduct community science air quality monitoring. We conducted 60 semi-structured interviews after two monitoring deployments to understand participants’ subjective experiences of pollution exposure, their engagement with low-cost air quality monitors, and their data interpretation. We utilize the environmental health concept ‘exposure experience’ to analyze how participants use personal monitors, understand their data, and reinterpret their pollution exposure as a result. We further explore how participants’ understandings are circumscribed by the technological features of low-cost monitors. We find that participants adopt both protective and mitigating behavioral changes based on information gained from personal experiments and hypothesis testing while using the monitors. Of their own accord, 40% of participants in this study adopted mitigation behaviors after identifying sources that impacted their personal air quality. Our analysis reveals that real-time data accessibility through low-cost monitors builds exposure awareness and enables residents of environmental justice communities to test, validate, or invalidate sensory experiences and challenge existing assumptions. These findings point to specific pathways for using low-cost monitors to support individual decision-making and contribute to behavioral change. Findings also identify some limitations of low-cost monitors; designers of low-cost monitors should consider how composite Air Quality Scores may encourage community scientists to equally value scientifically-established pollutants (e.g., PM) with less scientifically-established pollutants (e.g., TVOCs), without additional scientific training and health-related information.

Abstract A051: Association of residential economic and racial segregation with pediatric cancer survival

Abstract Purpose: Studies have linked residential segregation to inferior outcomes in adult-onset cancers. However, its association with pediatric cancer outcomes remains poorly understood. Racial and ethnic disparities in pediatric cancer outcomes are well-documented, and residential segregation may contribute, at least in part, to these disparities. This study examines the association between residential economic and racial segregation and survival in a statewide, population-based cohort of pediatric oncology patients. Methods: We studied a cohort of children diagnosed with their initial cancer between 2009 and 2016 at age 21 or younger, who were treated at Children’s Healthcare of Atlanta. The Index of Concentration at the Extremes (ICE) was mapped to the ZIP Codes of patient residence at diagnosis to measure economic and racial segregation. ICE was calculated by the difference between the number of non-Hispanic White people with &amp;gt;80th percentile household income and non-Hispanic Black people with &amp;lt;20th percentile household income, divided by the total number of people in the ZIP Code. ICE tertiles were categorized from the most deprived/segregated (tertile 1) to the most privileged/least segregated (tertile 3). We used the Cox proportional hazards model to estimate 5-, 3-, and 1-year overall survival from diagnosis by ICE tertiles, or by ICE tertiles and patient race. All models adjusted for sociodemographic (age at diagnosis, sex, health insurance, rurality) and clinical factors (cancer type, year of diagnosis). Results: Of our cohort (N=2,790), a higher proportion of non-Hispanic Black patients (50.8% vs. 13.4%) and publicly insured patients (62.3% vs. 30.8%) was found in tertile 1 compared to tertile 3. Patients living in tertile 1 consistently exhibited a higher risk of death at 5 years (adjusted hazard ratio [aHR]=1.32, 95% confidence interval [CI]=1.03-1.69, p=0.026), 3 years (aHR=1.35, 95% CI=1.04-1.75, p=0.026), and 1 year (aHR=1.38, 95% CI=0.94-2.03, p=0.099) post diagnosis, compared to those in tertile 3. In addition, compared to non-Hispanic White patients living in ICE tertiles 2-3 (more privileged areas), no survival difference was found among non-Hispanic Black children living in the same tertiles, while non- Hispanic Black children living in ICE tertile 1 had a significantly higher risk of death at 5 years (aHR=1.46, 95% CI=1.11-1.90, p=0.006), 3 years (aHR=1.56, 95% CI=1.17-2.07, p=0.002), and 1 year (aHR=1.65, 95% CI=1.11-2.45, p=0.014) post diagnosis. Conclusion: Our data indicate that residence in more racially segregated and economically deprived neighborhoods is associated with poorer overall survival among children diagnosed with cancer. Further research should explore the mediation and moderation effects of residential segregation on racial disparities in pediatric cancer-specific survival. Citation Format: Xu Ji, Lu Zhang, Xuesong Han, Heeju Sohn, Kinsey Meggett, Rebecca Williamson Lewis, Sharon M Castellino. Association of residential economic and racial segregation with pediatric cancer survival [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A051.

Abstract C125: Improving access to genetic counseling and testing for underserved populations through telehealth

Abstract Introduction: A lack of access to genetic counseling for hereditary cancer risk in rural and underserved areas is well-documented and can exacerbate disparities in cancer risk reduction and early detection. Telehealth has the potential to bridge this gap, providing remote access to specialized care. The COVID-19 pandemic accelerated telehealth availability, allowing estimation of the causal effects of shifting to a model of virtual care delivery for genetic counseling services. Methods: The Stanford Cancer Genetic Counseling Clinic provided solely in-person care at two clinical sites (Palo Alto and San Jose, CA) until March 2020, and solely virtual care from April 2020 onward. We performed a regression discontinuity design, allowing outcomes comparison before and after the threshold of early 2020, to evaluate the impact of telehealth genetic counseling on access to care for patients living in areas of higher deprivation. The assignment variable (the exposure measured before versus after the threshold) was the three-month period during which the patients were seen, with the March-May 2020 quarter excluded because of disruption of care during the early COVID-19 pandemic. The primary endpoint was proportion of patients whose primary residence zip code had a state area deprivation index of at least 4. Secondary endpoints included driving distance to the primary clinic location in Palo Alto, CA, insurance type, race/ethnicity, and primary language. Results: The study included N=5,957 patients seen in the Stanford Cancer Genetics Program between January 2017 and February 2020, and N=9,469 patients seen between June 2020 and April 2024. The regression discontinuity analysis revealed a significant discontinuity at the threshold for telehealth in access for patients living in areas of higher deprivation, who accounted for 22% of patients seen just prior to telehealth implementation and 27% just after telehealth implementation, a proportional increase of 21% (p=0.006). Mean driving distance to Palo Alto, CA also increased, from 49 minutes just prior to the threshold to 56 minutes just after (p=0.003). There were no significant differences in insurance type, race/ethnicity, or primary language across the threshold. Conclusion: The implementation of telehealth services at the Stanford Cancer Genetic Counseling Clinic significantly improved access to genetic counseling for patients from areas with higher deprivation, as evidenced by a 21% increase in the proportion of such patients among those seen. These results quantify the effectiveness of telehealth in reducing geographical and socioeconomic barriers to specialized genetic counseling and testing services. Citation Format: Jennifer L. Caswell-Jin, Hao Tang, Mina Satoyoshi, Kerry Kingham, Allison W. Kurian. Improving access to genetic counseling and testing for underserved populations through telehealth [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C125.

Geographical Mapping of COVID-19 Testing Rates in St. Louis: Influence of the Socioeconomic Index and Race on Testing in the Early Phase and Peak of the COVID-19 Pandemic

Purpose: This study aimed to explore how race and the socioeconomic index (SES) of residential zip codes influenced COVID-19 testing rates in St. Louis during the early and peak phases of the pandemic. Method: An ecological study was conducted using COVID-19 testing data from March to November 2020 in St. Louis City, including 16,915 tests from 30 residential zip codes. Geographical mapping identified areas lacking testing, descriptive statistics characterized testing rates by race and SES, and robust linear regression modeled the association between testing rates and race, controlling for SES. Results: The overall testing rate was 303.97 per 10,000 population. Testing rates among Blacks, Whites, American Indians/Alaskan Natives, and Asians were 374.26, 247.77, 360.63, and 242.41 per 10,000, respectively. Higher rates were observed in low- and middle-SES zip codes compared with high-SES areas. Adjusted for SES, testing rates per 10,000 were higher by 125 (1.25%), 448 (4.48%), and 32 (0.32%) among Blacks, American Indians/Alaskan Natives, and Asians compared with Whites. Testing rates decreased by 56 (0.56%) per unit SES improvement. There was statistically significant SES finding and that of the difference between American Indians/Alaskan Natives and Whites. Geographical mapping showed higher rates in the inner core and lower rates in the periphery of St. Louis. Conclusions: Race and SES influence testing rates. Targeted interventions are needed in areas with low testing rates in St. Louis.

Greenness moderates the relationship between self-rated social standing and depression among older adults in the Canadian longitudinal study on aging

IntroductionGreenness is considered to be a health-promoting feature of both natural and built environments and has the potential to influence mental health outcomes. However, most studies to date have neglected to address whether greenness differentially affects mental health outcomes for individuals across the socioeconomic spectrum. Our study explored if greenness is a moderating factor in the relationship between socioeconomic status (SES) and mental health using data from the Canadian Longitudinal Study on Aging (CLSA).MethodsA cross-sectional design was used to compare mental health outcomes between individuals with different levels of SES and residential greenness. We used self-rated social standing as a measure of SES and depression score measured using the Centre for Epidemiologic Studies 10-Item Depression Scale (CESD-10) as a measure of mental health. Greenness was measured using the annual maximum Normalized Difference Vegetation Index (NDVI) within a 1,000 m buffer area of participants' residential postal code locations.ResultsThere was a statistically significant moderating effect of greenness for the relationship between self-rated social standing and depression score. As greenness increased, individuals with lower self-rated social standing had the greatest decreases in depression score.DiscussionThe results of our study suggests that targeting greening interventions at individuals and communities with low SES may reduce depressive symptoms overall, as well as decrease socioeconomic inequalities in depression.

Urban Trail Exposure in Winnipeg, Canada: Longitudinal Cohort Development for a 20-Year Difference-in-Differences Analysis of a Natural Experiment with Varied Duration of Exposure Times

ObjectiveDevelop a cohort to evaluate a real-world experiment of the built environment on the incidence of disease, accounting for movement of people, postal codes, incidence of disease and changing demographics. ApproachThe City of Winnipeg, Canada built multi-use trails in 2010-2012. We used the administrative data housed at the Manitoba Centre for Health Policy to evaluate the effect of this change in the built environment on the incidence of cardiovascular disease events (CVDE) and risk factors (CVDRF) before (2000-2009) and after (2012-2019) the trails were built. The Manitoba Health Insurance Registry contains postal code and demographic information on nearly all city residents and was utilized for cohort creation and person-time exposure. Individuals’ residential postal codes were linked to geo-spatial data to determine proximity to built trails at 400m, 800m and 1200m. Semi-annual postal code changes accounted for movement within/outside city limits or exclusion from the cohort. Diagnoses from hospital abstract and physician visit data and outpatient prescription dispensations were used to access prevalence and incidence of a CVDE composite measure of congestive heart failure, ischemic heart disease and stroke and a CVDRF composite measure of diabetes, dyslipidemia and hypertension. Conclusions and ImplicationsLeveraging a diverse set of administrative databases, we built a cohort evaluate the effect of building multi-use trails in Winnipeg on the reduction on CVDE and CVDRF. This demonstrates how administrative data can be used to evaluate natural, real-world experiments with minimal direct data measurement or public intrusion, resulting in actionable results to inform public policy.