The current situation of health equity in underserved areas of Afghanistan.

Background: In Afghanistan, providing universal health coverage (UHC) in accordance with the principles of the UHC declaration is challenging on two fronts: the geographic topography of the country and the prevailing gender dynamics within the local culture. Methods: We conducted a desk review of underserved areas in the context of health services by gathering and analyzing existing literature, reports, and data using a combination of keywords and phrases such as: "underserved areas," "healthcare disparities," "access to healthcare," and "health services." The primary data were derived from an analysis of underserved populations conducted by the World Health Organization (WHO) Afghanistan's Emergency Program, supplemented by information from in-country partners. In addition to other reports, this review focused on analyzing the geographical availability of primary healthcare (PHC) services by employing the guidelines set forth in the SPHERE framework. It also took into account the social dynamics within the Afghan population that may create barriers to equity in terms of demand and access to PHC services. Results: Although there are a significant number of primary healthcare facilities in operation (4,242), they are unevenly distributed across different regions of Afghanistan, resulting in almost 25% of the population being underserved. The underserved population is nearly equally distributed between genders, with the majority residing in rural communities. Women of childbearing age represent 28% of the underserved population. Children under the age of five represent 16-18% of the underserved population in all regions, except in the western region, where they represent between 12 and 13%. Individuals over 60 years of age represent 1-3% of the underserved population across all regions. More than 50% of the population in the Central Highlands of Afghanistan is underserved, followed by the western and southern regions. Ghor province in the western region has the highest proportion of underserved populations, followed by Zabul province in the southern region. Conclusion: Afghanistan is currently experiencing a protracted humanitarian crisis, with millions of people living in poverty and lacking access to healthcare. This situation exposes them to serious risks such as disease epidemics, starvation, and maternal and child mortality. It is crucial to implement alternative strategies to reach the most affected populations and to increase funding for the delivery of healthcare services in Afghanistan.

Equity of access to free maternal and child health services among reproductive-age women in Delta State, Nigeria.

Objective: The study aimed to assess the equity of access to free maternal and child health services among reproductive-age women in Delta State, Nigeria. Design: the study adopted a descriptive cross-sectional survey design. Participants: The population for the study were 368 women of reproductive age (15-49 years) who had given birth between April 2015 and December 2015 in two randomly selected senatorial districts of Delta State. Data were collected using a pre-tested interviewer-administered questionnaire. Results: 368 women were recruited for the study, consisting of 73.3% (N =270) from the urban setting and 26.7% (N=98) from the rural setting. 54.1% (N=199) had completed secondary school, while 28.8% (N=106) had completed tertiary education. Most respondents were aged 21 to 30 years 217(59.0%). 20% of respondents belonged to the poorest, poor and least poor socioeconomic status (SES) groups and 19.8% to average poor and rich SES groups. The results showed equity between different SES (0.014) and educational (0.027) backgrounds, as indicated in concentration curves. However, the concentration index between the geographical areas (-0.0200) indicates inequity in access in favour of urban dwellers. Conclusion: Free maternal and child health services (FMCHS) were equitable across the different SES groups and educational levels. However, there was inequity in access due to distance to the hospitals among the women of childbearing age in the communities. This study is relevant to all healthcare professionals, especially those in public health, because it will encourage them to exercise their energy towards home care to reduce maternal and child mortality. Funding: None declared.

Breast cancer diagnosis and staging in Chile: A non-randomized survey-based study to assess frequency and delays. / Diagnóstico y etapificación de cáncer de mama en Chile: estudio por encuesta no probabilística de III a IV frecuencia y tiempos.

Introduction: Breast cancer progression involves physiological mechanisms such as metastasis. Delays in diagnosis and treatment increase the risk of mortality and are associated with barriers to healthcare access. In Chile, breast cancer is highly prevalent, and early diagnosis has improved, although disparities in the disease evolution persist. This study characterized diagnostic and staging tests, waiting times, and sociodemographic profiles to identify delays and inequities in care. Methods: Survey study. Using a non-probabilistic sample, a questionnaire was applied in an encrypted platform with prior informed consent. The instrument collected data on requested tests, associated times, staging, and sociodemographic characteristics. These variables were analyzed using descriptive statistics, tests of association, confidence intervals, and comparison tests using bootstrapping. Results: A sample of 263 persons was obtained. The most requested tests were biopsy (99.62%) and blood tests (80.23%). The median number of tests requested was six (Q1:4, Q3:8), with a mean of 5.87 (standard deviation: 2.24). No significant differences were observed in the percentage of persons from whom the total number of examinations were requested according to the studied variables. The day-hour-result intervals ranged from 1 to 365 days. The median day-hour-result of the biopsy was 15 days (Q1:10, Q3:30). People between 40 and 49 years old, non-residents of the capital city, belonging to income quintile I, with high school education, from the public health system, with late-stage diagnosis had higher median day-hour-result in biopsy. There was no significant difference in the number of requested tests according to staging (I and II, or III and IV). Conclusions: Biopsy in Chile is the test of choice for diagnostic confirmation in breast cancer. Other tests are requested regardless of the diagnosis stage, contrary to the recommendations of clinical guidelines. Cancer prognosis is crucial, especially in countries with greater inequalities.

Introducción: La progresión del cáncer de mama involucra mecanismos fisiológicos como metástasis. Los retrasos en diagnóstico y tratamiento aumentan el riesgo de mortalidad y se asocian a barreras de acceso a la salud. En Chile, el cáncer de mama es altamente prevalente y su diagnóstico temprano ha mejorado, aunque persisten disparidades en el proceso de enfermedad. Este estudio caracterizó exámenes de diagnóstico y etapificación, tiempos de espera y perfiles sociodemográficos para identificar demoras e inequidades en la atención. Métodos: Estudio de encuesta. Utilizando una muestra no probabilística, se aplicó un cuestionario en plataforma encriptada previo consentimiento informado. En el instrumento se recogieron datos de exámenes solicitados, tiempos asociados, etapificación y características sociodemográficas. Estas variables fueron analizadas utilizando estadística descriptiva, test de asociación, intervalos de confianza y test de comparación utilizando . Resultados: Se logró una muestra de 263 personas. Los exámenes más solicitados fueron biopsia (99,62%) y exámenes de sangre (80,23%). La mediana de exámenes solicitados fue de 6 (Q1:4, Q3:8), con media 5,87 (desviación estándar: 2,24). No se observaron diferencias significativas en el porcentaje de personas a quienes se solicitó la totalidad de exámenes según variables estudiadas. Los intervalos día-hora-resultado oscilaron entre 1 y 365 días. La mediana día-hora-resultado de la biopsia fue de 15 días (Q1:10, Q3:30). Las personas entre 40 y 49 años, no residentes de la capital, pertenecientes al quintil I de ingreso, con educación media, del sistema público de salud, con diagnóstico en etapa tardía presentaron mayores medianas de día-hora-resultado en biopsia. No hubo diferencia significativa en la cantidad de exámenes solicitados según etapificación (I a II y III a IV). Conclusiones: La biopsia en Chile es el examen de elección para la confirmación diagnóstica en cáncer de mama. Otros exámenes son solicitados independientemente de la etapa del diagnóstico, existiendo una discordancia con las recomendaciones de la guía clínica. El pronóstico del cáncer es crucial, especialmente en países con mayores inequidades.

Reducing disparities in the care of atopic dermatitis.

Atopic Dermatitis (AD) is associated with a number of published disparities, including those related to self-identified racial/ethnic populations. Black/African American populations in the United States experience greater AD prevalence, severity, and persistence compared to other demographic groups, such as those who self-identify as White. There is consistent evidence that healthcare, environmental, and socioeconomic factors affect the prevalence, severity, and/or persistence of AD. Additionally, because of institutional and systemic racism, these same risk factors are more prevalent in racial and ethnic minority populations. Herein, we review the underlying causes of racial/ethnic disparities in AD and potential strategies to improve AD diagnosis and disease control.

Inequalities in the risk and prevention of invasive meningococcal disease in the United States - A systematic literature review.

Vaccination remains the most effective strategy to prevent invasive meningococcal disease (IMD), with MenACWY, MenB and MenABCWY recommended for adolescents/young adults in the United States (US). However, vaccination coverage remains suboptimal, which could be related to population inequalities. To understand the impact of IMD risk, prevention and control inequalities, a global systematic literature review (Medline, Embase, 2012-2022) was conducted on individual, socioeconomic, and environmental inequalities associated with IMD risk, prevention and control in all ages. Studies on IMD risk (n = 15) and prevention (n = 14) inequalities were identified. IMD incidence proportions were higher in Medicaid versus commercially insured populations, and IMD mortality was higher in poorer neighborhoods. White adolescents, adolescents from lower income families, and with lower maternal education were more likely to receive MenB vaccination; while Black and Hispanic adolescents, and adolescents with higher family incomes, were more likely to receive MenACWY vaccination. Meningococcal vaccination was associated with being up-to-date with other vaccinations, having multiple healthcare/well child visits, having a pediatrician as healthcare provider (HCP), and attending private facilities; while being uninsured was associated with lower vaccination. States with a MenACWY vaccination mandate and higher pediatrician-to-children ratios had higher vaccination rates. Important inequalities were due to individual differences, socioeconomic, and environmental factors. IMD prevention is suboptimal, especially among adolescents/young adults. To improve health equity, health policy makers could ameliorate meningococcal vaccination coverage across the US, with simplified and stronger meningococcal vaccine recommendations from public health authorities, and initiatives to enhance parental/patient and HCP knowledge of IMD and vaccine recommendations.

(1) What is the context?Invasive meningococcal disease (IMD) is a severe disease with a high risk of death and long-term sequelae in survivors. Three types of vaccines are recommended in the United States (US) to prevent IMD among adolescents and young adults: MenACWY, MenB, and MenABCWY. According to the World Health Organization, access to vaccination, regardless of socioeconomic status, is one of the most important ways to achieve equitable health standards. However, US vaccine coverage is suboptimal, especially among older adolescents and young adults, possibly because of population-based inequalities. This study investigated the impact of inequalities on IMD incidence, mortality, and vaccination in the US.(2) What is new?A systematic literature review identified several studies reporting on inequalities for IMD risk and prevention.IMD cases and deaths were more likely in poorer populations. Vaccination coverage varied according to race/ethnicity, income, and education levels. Vaccination was more likely in people with frequent healthcare visits, those who received other vaccinations, those who visit a pediatrician, and those who go to a non-public/private facility for care. Vaccination was less likely in uninsured people. States with a MenACWY vaccination mandate and with greater access to pediatricians had better vaccination rates.(3) What is the impact?Many inequalities exist in relation to the risk of getting IMD and the chances of getting vaccinated against IMD. To improve IMD prevention, health policy makers need to strengthen and simplify current meningococcal vaccine recommendations, and introduce/support initiatives that increase parental/patient and HCP awareness of IMD and vaccine recommendations.

Disparities in Screening for Substance Use Among Injured Adolescents.

This cohort study compares rates of biochemical substance use screening among injured adolescents by sociodemographic characteristics including sex, race, ethnicity, and insurance status.

Perceived discrimination and refraining from seeking physician's care in Sweden: an intersectional analysis of individual heterogeneity and discriminatory accuracy (AIHDA).

BACKGROUND: Discrimination may further impede access to medical care for individuals in socially disadvantaged positions. Sociodemographic information and perceived discrimination intersect and define multiple contexts or strata that condition the risk of refraining from seeking physician's care. By applying analysis of individual heterogeneity and discriminatory accuracy (AIHDA) we aimed to improve the mapping of risk by considering both strata average risk differences and the accuracy of such strata risks for distinguishing between individuals who did or did not refrain from seeking physician's care. METHODS: We analysed nine annual National Public Health Surveys (2004, 2007-2014) in Sweden including 73,815 participants. We investigated the risk of refraining from seeking physician's care across 64 intersectional strata defined by sex, education, age, country of birth, and perceived discrimination. We calculated strata-specific prevalences and prevalence ratios (PR) with 95% confidence intervals (CI), and the area under the receiver operating characteristic curve (AUC) to evaluate the discriminatory accuracy (DA). RESULTS: Discriminated foreign-born women aged 35-49 with a low educational level show a six times higher risk (PR = 6.07, 95% CI 5.05-7.30) than non-discriminated native men with a high educational level aged 35-49. However, the DA of the intersectional strata was small (AUC = 0.64). Overall, discrimination increased the absolute risk of refraining from seeking physician's care, over and above age, sex, and educational level. CONCLUSIONS: AIHDA disclosed complex intersectional inequalities in the average risk of refraining from seeking physician's care. This risk was rather high in some strata, which is relevant from an individual perspective. However, from a population perspective, the low DA of the intersectional strata suggests that potential interventions to reduce such inequalities should be universal but tailored to the specific contextual characteristics of the strata. Discrimination impairs access to healthcare.

Prevalence and disparities in receiving medical advice to quit tobacco use in the US adult population.

Introduction: Evidence suggests that advice from health care professionals (HCP) increases the likelihood of quit attempts and successful quitting of tobacco use. However, previous studies primarily focussed on cigarette smoking and did not include all forms of tobacco products. This study aimed to investigate the prevalence and disparities in receiving HCP's advice to quit tobacco use (combustible or noncombustible) in the US adult population. Methods: Using the 2022 National Health Information Survey (NHIS) data, we examined 4,424 adults who reported (i) any tobacco product use within the past 12 months and (ii) having seen an HCP within the past 12 months. The outcome variable included the receipt of advice to quit tobacco use from an HCP, and predictors included sociodemographic variables. Weighted prevalence estimates were calculated, and multivariable regression analyses were conducted. Results: Over 38% of tobacco users who visited an HCP were advised to quit. The odds of receiving such advice were lower among Hispanics (AOR: 0.625; 95% confidence interval (CI) [0.464-0.843];p = 0.002), males (AOR: 0.767; 95% CI [0.659-0.893], p = 0.001), those above the poverty level (AOR: 0.795; 95% CI [0.641-0.987];p = 0.037), foreign-born (AOR: 0.664; 95% CI [0.496-0.888]; p = 0.006), those with a bachelor's degree or higher educational level (AOR: 0.477; 95% CI [0.349-0.653]; p < 0.001) and those aged less than 45 years (AOR: 0.404; 95% CI: [0.344-0.473]; p < 0.001). Conclusion: The prevalence of receiving HCP's advice to quit tobacco use remains suboptimal and disparate among sociodemographic groups. Our findings call for strategic implementation of the USPHS's recommendation on treating tobacco use and taking further actions to equip HCPs with the training and resources needed to provide appropriate advice to quit tobacco.

Hip Arthroscopy Utilization Disparities and Complications Amongst Ethnic Groups.

While hip arthroscopy (HA) has increased in recent years, limited data exists regarding utilization and outcomes among racial groups. The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent HA from 2006 to 2017. Patients were stratified into 6 self-reported racial/ethnic categories: White, African American, Hispanic, Asian and Pacific Islander, Native American, and Unknown. Major and minor complications in the 30-day post-operative period were identified. Data were available for 2230 patients who underwent HA. There were significant differences in the proportions of HA procedures when examining by race. White patients comprised 69% of the patient sample, African American patients 5.6%, Hispanic patients 3.9%, Asian patients 2.5%, Native American patients 0.7% and Unknown race/ethnicity patients 18.3% (P < .05). HA utilization increased significantly over time by all groups but remained low among ethnic minorities compared to the White cohort. Overall, major, and minor 30-day complication rates were 1.3%, 0.5%, and 0.9%, respectively. Although African American and Hispanic patients had higher overall complication rates than White patients, the differences were not statistically significant. Surgeons should be aware of the underutilization of HA among racial/ethnic minorities, and further studies evaluating insurance status and access to care are needed.

Effects of Social Determinants of Health on Acute Stroke Care Among Patients With Acute Ischemic Stroke: A Retrospective Cohort Study.

BACKGROUND AND OBJECTIVES: Social determinants of health (SDOH) are important contributors to poor stroke-related outcomes. While some have suggested that this association is driven by the increased incidence of stroke observed with poor SDOH, others have raised concerns regarding disparities in acute stroke care. This study aimed to determine the association between SDOH and the administration of thrombolytic therapy and mechanical thrombectomy among patients with acute ischemic stroke. METHODS: A retrospective cohort analysis was conducted using Texas Emergency Department Public Use Data (2016-2019), including adult patients diagnosed with acute ischemic stroke. The risk ratios (RRs) of administering thrombolysis and thrombectomy based on variables representing SDOH and a collective measure (Social Vulnerability Index [SVI]) were computed using mixed-effects Poisson regression models accounting for the nested nature of patients in hospitals and neighborhoods. The Charlson comorbidity score was considered as a covariate. RESULTS: Of the 139,852 patients with ischemic stroke (female, 51.7%; White, 67.2%; Black, 16.6%; Hispanic, 25.1%), 16,831 (12.3%) received thrombolytic therapy and 5,951 (4.3%) received mechanical thrombectomy. Age older than 65 years (RR 0.578 [0.537-0.621]) vs 18-45 years, Black (RR 0.801 [0.761-0.844]) vs White, Hispanic (RR 0.936 [0.895-0.98]) vs non-Hispanic, Medicare/Medicaid/Veterans Affairs (VA) (RR 0.917 [0.882-0.954]) or uninsured (RR 0.883 [0.833-0.935]) vs private insurance, and rural (RR 0.782 [0.723-0.845]) vs urban dwelling were less likely to be associated with thrombolysis. Patients in the highest quintile based on the SVI were less likely to receive thrombolysis than those in the lowest quintile (RR 0.926 [0.867-0.989]). Patients were less likely to receive thrombectomy if they were 65 years and older (RR 0.787 [0.691-0.895]), belonged to the Black race (RR 0.745 [0.679-0.818]) or Hispanic ethnicity (RR 0.919 [0.851-0.992]), had Medicare/Medicaid/VA insurance (RR 0.909 [0.851-0.971]), or were from a rural area (RR 0.909 [0.851-0.971]). Similarly, SVI decreased the likelihood of undergoing mechanical thrombectomy (RR 0.842 [0.747-0.95]). DISCUSSION: Despite many improvements in stroke management, SDOH continue to be a significant driver of treatment access for acute ischemic stroke. While our findings are limited to Texas, our results should raise awareness and promote more studies regarding the effects of these SDOH at the national and international levels.

Racial and Ethnic Disparities in the Time to Ovarian Cancer Surgery in Patients at an Integrated Health Care Delivery System.

BACKGROUND: Disparities in ovarian cancer survival for African American women are multifactorial. We evaluated racial and ethnic differences in time to ovarian cancer surgery in members of an integrated health care system. PATIENTS AND METHODS: In this retrospective cohort study, we identified women diagnosed with invasive epithelial-type ovarian cancer between January 1, 2008, through December 31, 2014, at an integrated health care system in the United States. We extracted data on cancer-related variables and sociodemographic variables from the health care system's cancer registry and electronic health records. We included patients who received ovarian cancer surgery without neoadjuvant chemotherapy. We defined time to surgery as the number of days between diagnostic imaging study and surgery. We used Cox proportional hazards regression to evaluate crude and adjusted association of race and ethnicity with time to surgery. RESULTS: Of 872 patients included, 55.1% were non-Hispanic White (hereafter, White), 24.9% were Hispanic, 14.6% were Asian/Pacific Islander (PI)/Native American, and 5.5% were African American. Median age at diagnosis was 59.0 years. African American patients were diagnosed at an older age and were more likely to come from deprived neighborhoods than other racial and ethnic groups. Median time to surgery was longer for African American patients compared with White, Hispanic, and Asian/PI/Native American patients (median days: 27.5 vs 21.0, 24.5, and 26.0, respectively; P<.0001). In adjusted models, the likelihood of having received surgery at any given time post diagnostic imaging was 31% lower for African American patients compared with White patients (HR, 0.69; 95% CI, 0.51-0.93). This likelihood was also lower for Hispanic and Asian/PI/Native American patients, but not statistically significant. CONCLUSIONS: Our findings showed that patients with ovarian cancer from racial and ethnic minorities had a lower likelihood of having received surgery at any given time post diagnostic imaging compared with White patients, demonstrating that racial and ethnic differences exist in time to ovarian cancer surgery in patients with relatively equal access to care.

Racial and ethnic differences in healthcare access and utilization among U.S. adults with melanoma and keratinocyte carcinomas in the NIH All of Us Research Program.

There is a paucity of information on racial and ethnic disparities relating to barriers to care in healthcare access and utilization in patients with cutaneous malignancies. We conducted a cross-sectional analysis of adults with melanoma, basal cell carcinoma (BCC) and cutaneous squamous cell carcinoma (cSCC) in the National Institutes of Health (NIH) All of Us Research Program collected between May 2018 and July 2022. Participants included adults (aged 18 or older) with cutaneous malignancy who completed the Health Care Access and Utilization survey. We identified 5,817 adults who were diagnosed with BCC (67%), cSCC (28.9%), and melanoma (23.9%). Non-Hispanic Black (NHB) and Hispanic patients were more likely than non-Hispanic White (NHW) patients to delay a primary care visit due to cost (p = 0.005 and p = 0.015, respectively). NHB patients were also more likely to delay care due to lack of transportation (p < 0.001). NHB and Hispanic patients were more likely to place importance on seeing a provider from the same background (NHB p < 0.002; Hispanic p = 0.002) and also were more likely to report never being able to see such a provider (NHB p < 0.001; Hispanic p = 0.002). Medicaid/Medicare patients, non-college graduates, and those with lower incomes also faced increased barriers to care, including delays due to cost and transportation issues. People of color with cutaneous malignancies are more likely to delay care in seeing primary care providers due to cost or transportation issues. This study provides important insights on disproportionate healthcare usage among racial/ethnic groups that may help mitigate healthcare disparities.

Racial and Ethnic Disparities in Pediatric Atopic Dermatitis.

OBJECTIVES: Atopic dermatitis (AD) is one of the most common chronic childhood conditions. Disparities in treatment and access to care can result in poor disease control and decreased quality of life. The aim of this study was to determine whether race and ethnicity affect treatment and healthcare utilization for pediatric atopic dermatitis in central Florida. METHODS: This study of 4008 children with AD compared healthcare utilization and management using the numbers of AD-related healthcare visits, prescriptions, testing, and subspecialty referrals. Multivariable models were used to compare racial and ethnic groups (Black, Hispanic, Asian, and Other) with the reference group of non-Hispanic White, while adjusting for common confounders. RESULTS: The mean number of urgent care visits for the Hispanic group was 1.61 times that of the non-Hispanic White group, and the mean number of emergency department visits was 3.71 (P < 0.001) times the reference group. Black or African American patients had a mean number of emergency department visits that was 1.52 times that of non-Hispanic White patients (P = 0.021). The mean count of primary care visits was lower among Hispanic patients and higher among Asian patients (P = 0.012). Visits to subspecialty clinics and hospitalizations did not differ significantly. There were no consistent patterns in differences of AD-related prescriptions, testing, or subspecialty referrals. CONCLUSIONS: This study indicates that racial and ethnic disparities exist in healthcare utilization in pediatric AD. The underlying factors contributing to these disparities need to be further studied and addressed to reach health equity within pediatric AD.

Inequalities changes in health services utilization among middle-aged and older adult disabled people in China: based on CHARLS 2011-2018.

Background: Multiple intersections, including socioeconomic inequalities, influence health equity for disabled people and sub-populations. However, this association has not been sufficiently analyzed among Chinese-impaired persons. This study aimed to investigate the health services utilization and inequalities in middle and older adult persons with disabilities and subgroups. Methods: The China Health and Retirement Longitudinal Study (CHARLS) database in 2011, 2013, 2015, and 2018 were used. Health services utilization was measured by outpatient, inpatient, and self-treatment service utilization. Types of disabilities were classified into six categories. The pooled cross-section regression, concentration index, horizontal inequity index, and concentration index decomposition were used to evaluate inequalities and explore their main contributing factor. Results: The utilization and non-utilization of healthcare services showed variations across years (p < 0.05). The CIs and HIs for inpatient health service utilization were positive for all years and disability types. The total CIs of inpatient utilization were the highest (0.248). The highest disparities in utilization of inpatient services were for physical disabilities (0.4515 for CI in 2011), and the highest in self-treatment services were for intellectual disability (0.1538 for CI in 2011). The expenditure factor was the main contributor to inequalities. Chronic disease, educational level, and health insurance factors also contribute to the utilization inequalities. Conclusion: Policies should promote medical insurance and assistance for disabled people with serious impairment and poor. It is crucial to improve the provision of basic medical services, including meeting the demand for varied disabilities and the accessibility of facilities and equipment to enhance the access and well-being of people with disabilities.

Current Burden of and Geographic Disparities in Liver Mortality and Access to Liver Transplant.

Importance: Liver disease is a leading cause of mortality in the US. Liver transplant can be a lifesaving procedure for patients with severe liver disease. Objective: To assess temporal trends and geographic variance in liver-related mortality (LRM) and liver transplant in the US. Design, Setting, and Participants: In this cohort study, the frequencies and geographic variance of LRM in 2018 and 2021 were obtained in a cross-sectional analysis of the Underlying Cause of Death data available on the Centers for Disease Control and Prevention's Epidemiologic Research database. The number of livers donated and transplanted according to the state of residence of each donor and recipient were obtained from the United Network for Organ Sharing. Main Outcomes and Measures: Liver-related mortality in 2018 and 2021, overall and by state, as well as the liver transplant rate according to state of residence of recipient and donor. Results: Overall LRM in the US was 93 418 in 2021, with a crude rate of 28.1 per 100 000 individuals, an increase of 19.1% compared with rates seen immediately prior to the COVID-19 pandemic in 2018 (77 282 [23.6 per 100 000 individuals]). Liver-related mortality in 2021 varied several-fold between states, from 18.4 per 100 000 individuals per year in Utah to 65.9 per 100 000 individuals per year in New Mexico. The mean number of liver-related deaths per transplant from all donor sources (in state and out of state) was 7.2 in the lowest LRM quintile compared with 21.5 in the highest (95% CI, 12.1-16.6; SE, 1.1; P < .001). Ten states had no liver transplant center. Paradoxically, residents of states with the highest LRM had a much lower rate of liver transplant (at any location) from organs procured from in-state residents than states with the lowest LRM quintile (13.0% vs 35.2% in-state donors; 95% CI, 14.1%-30.3%; SE, 3.9%; P < .001). Conclusions and Relevance: This study suggests that rates of LRM have increased dramatically since the COVID-19 pandemic and vary several-fold between states. Rates of liver transplant are paradoxically lowest among residents living in states with the highest LRM. These findings highlight apparent geographic disparities in access to liver transplant that allocation policy cannot address.

The Impact of Race and Ethnicity in Microvascular Head and Neck Reconstruction Postoperative Outcomes: A Nationwide Data Analysis.

BACKGROUND: Racial and ethnic disparities have been extensively reported across surgical specialties, highlighting existing healthcare inequities. Nevertheless, evidence is lacking regarding their influence on postoperative outcomes after head and neck reconstruction. This study aimed to evaluate the impact of race and ethnicity on postoperative complications in head and neck microvascular reconstruction. METHODS: The ACS-NSQIP database was used to identify patients who underwent head and neck microvascular reconstruction between 2012 and 2022. Baseline characteristics were compared based on race (White, non-White) and ethnicity (Hispanic, non-Hispanic). Group differences were assessed using t tests and Fisher Exact tests. Multivariable logistic regression models were constructed to evaluate postoperative complications between the groups. A Cochran-Armitage test was conducted to evaluate the significance of trends over time. RESULTS: A total of 11,373 patients met inclusion criteria. Among them, 9,082 participants reported race, and 9,428 reported ethnicity. Multivariable analysis demonstrated that Hispanic patients were more likely to experience 30-day readmission (OR 6.7; 95% CI, 1.17-38.4; P=0.032) and had an average total length of stay of 5.25 days longer (95% CI, 0.84-9.65; P=0.020) compared with non-Hispanic patients. Additional subgroup analyses revealed higher rates of all readmissions among non-White patients, particularly those indicated by malignancy (OR 1.23; 95% CI, 1.1-1.4; P=0.002). No significant differences were found in mortality, reoperation rates, and operative times between racial and ethnic groups. CONCLUSIONS: The findings of this study suggest that ethnicity may be a significant risk factor for readmission in head and neck microvascular reconstruction. However, future studies are needed to further clarify the impact of race and ethnicity on longer postoperative outcomes, particularly in head and neck cancer minorities.

Urban and rural disparities in general hospital accessibility within a Chinese metropolis.

Accessibility is one of the crucial criteria for measuring the ease of access to public services in a region. Given China's historical rural-urban dualism and rapid urbanization process, there exist significant disparities in public services within metropolises. This study selects Nanjing as a representative metropolis and employs the Gaussian two-step floating catchment area method and an improved potential model to calculate the accessibility of comprehensive hospitals. Spatial autocorrelation and urban-rural disparities are analyzed, confirming spatial variations in healthcare service equity. The results show that: ①The spatial variability of accessibility to comprehensive hospitals is significant. The Gaussian two-step floating catchment method overestimates overall accessibility, and for Nanjing, the improved potential model with ß = 1.5 proves more suitable. ②Accessibility exhibits pronounced clustering characteristics. Healthcare conditions for residents in the northern part of Liuhe District, eastern part of Qixia District, western part of Pukou District, peripheral areas of Jiangning District, eastern part of Gaochun District, and residents in Lishui District need improvement. ③Comprehensive healthcare services are relatively lacking in nearly 60% of rural areas. Our research findings provide valuable insights for improving spatial justice in public infrastructure in metropolises of developing countries.

Not all healthcare inequities in diabetes are equal: a comparison of two medically underserved cohorts.

INTRODUCTION: Diabetes disparities exist based on socioeconomic status, race, and ethnicity. The aim of this study is to compare two cohorts with diabetes from California and Florida to better elucidate how health outcomes are stratified within underserved communities according to state location, race, and ethnicity. RESEARCH DESIGN AND METHODS: Two cohorts were recruited for comparison from 20 Federally Qualified Health Centers as part of a larger ECHO Diabetes program. Participant-level data included surveys and HbA1c collection. Center-level data included Healthcare Effectiveness Data and Information Set metrics. Demographic characteristics were summarized overall and stratified by state (frequencies, percentages, means (95% CIs)). Generalized linear mixed models were used to compute and compare model-estimated rates and means. RESULTS: Participant-level cohort: 582 adults with diabetes were recruited (33.0% type 1 diabetes (T1D), 67.0% type 2 diabetes (T2D)). Mean age was 51.1 years (95% CI 49.5, 52.6); 80.7% publicly insured or uninsured; 43.7% non-Hispanic white (NHW), 31.6% Hispanic, 7.9% non-Hispanic black (NHB) and 16.8% other. Center-level cohort: 32 796 adults with diabetes were represented (3.4% with T1D, 96.6% with T2D; 72.7% publicly insured or uninsured). Florida had higher rates of uninsured (p<0.0001), lower continuous glucose monitor (CGM) use (18.3% Florida; 35.9% California, p<0.0001), and pump use (10.2% Florida; 26.5% California, p<0.0001), and higher proportions of people with T1D/T2D>9% HbA1c (p<0.001). Risk was stratified within states with NHB participants having higher HbA1c (mean 9.5 (95% CI 8.9, 10.0) compared with NHW with a mean of 8.4 (95% CI 7.8, 9.0), p=0.0058), lower pump use (p=0.0426) and CGM use (p=0.0192). People who prefer to speak English were more likely to use a CGM (p=0.0386). CONCLUSIONS: Characteristics of medically underserved communities with diabetes vary by state and by race and ethnicity. Florida's lack of Medicaid expansion could be a factor in worsened risks for vulnerable communities with diabetes.

Disparities in pediatric parotid cancer treatment and presentation: A National study.

OBJECTIVES: Although parotid gland malignancies are uncommon, they nevertheless represent a cause of morbidity and mortality in the pediatric population. Few studies have sought to identify disparities related to their presentation, treatment, and survival. There is a need to understand these variations to improve care for historically underrepresented groups. STUDY DESIGN: Retrospective Cohort Study. SETTING: Surveillance, Epidemiology, and End Results (SEER) Program Database. METHODS: Analysis of pediatric patients with parotid gland malignancies between 2000 and 2019. Race and ethnicity were classified as Non-Hispanic White, Non-Hispanic Black, Asian, and Hispanic for multivariable analysis. Outcomes included tumor size and stage at diagnosis, survival, and need for facial nerve sacrifice. Kaplan-Meier analysis was used to analyze survival. Multivariable logistic regression was conducted to identify predictors of outcomes. RESULTS: 149 patients met the criteria for inclusion. Stratified by race/ethnicity, Non-Hispanic Black (Median 23 mm, IQR 15-33), Asian (30 mm, 14-32), and Hispanic (23 mm, 20-28) patients had larger tumors at presentation than Non-Hispanic White patients (18 mm, 12-25, p = 0.017). Disease-specific survival differed by time-to-treatment (log-rank, p = 0.01) and overall survival differed by income (p < 0.001). On multivariable analysis, Hispanic patients were more likely to experience facial nerve sacrifice (OR 3.71, 95%CI 1.25-11.6, p = 0.020), and Non-Hispanic Black (OR 3.37, 0.95-11.6, = 0.053) and Asian (OR 5.67, 1.46-22.2, p = 0.011) patients presented with larger tumors compared to Non-Hispanic White patients. CONCLUSIONS: Variations in presentation and treatment exist across race and ethnicity in pediatric parotid cancer. Identifying these disparities may help improve access and outcomes for underserved patient populations. LEVEL OF EVIDENCE: III.