The Use of Telemedicine by US Nephrologists for In-Center Hemodialysis Care During the Pandemic: An Analysis of National Medicare Claims.

Rationale & Objective: Because of coronavirus disease 2019 (COVID-19), the US government issued emergency waivers in March 2020 that removed regulatory barriers around the use of telemedicine. For the first time, nephrologists were reimbursed for telemedicine care delivered during in-center hemodialysis. We examined the use of telemedicine for in-center hemodialysis during the first 16 months of the pandemic. Study Design: We ascertained telemedicine modifiers on nephrologist claims. We used multivariable regression to examine time trends and patient, dialysis facility, and geographic correlates of telemedicine use. We also examined whether the estimated effects of predictors of telemedicine use changed over time. Setting & Participants: US Medicare beneficiaries receiving in-center hemodialysis between March 1, 2020, and June 30, 2021. Exposures: Patient, geographic, and dialysis facility characteristics. Outcomes: The use of telehealth for in-center hemodialysis care. Analytic Approach: Retrospective cohort analysis. Results: Among 267,434 Medicare beneficiaries identified, the reported use of telemedicine peaked at 9% of patient-months in April 2020 and declined to 2% of patient-months by June 2021. Telemedicine use varied geographically and was more common in areas that were remote and socioeconomically disadvantaged. Patients were more likely to receive care by telemedicine in areas with higher incidence of COVID-19, although the predictive value of COVID-19 diminished later in the pandemic. Patients were more likely to receive care using telemedicine if they were at facilities with more staff, and the use of telemedicine varied by facility ownership type. Limitations: Limited reporting of telemedicine on claims could lead to underestimation of its use. Reported telemedicine use was higher in an analysis designed to address this limitation by focusing on patients whose physicians used telemedicine at least once during the pandemic. Conclusions: Some US nephrologists continued to use telemedicine for in-center hemodialysis throughout the pandemic, even as the association between COVID-19 incidence and telemedicine use diminished over time. These findings highlight unique challenges and opportunities to the future use of telemedicine in dialysis care.

Emergency waivers issued during the coronavirus disease 2019 pandemic enabled reimbursement to US nephrologists for telemedicine care delivered during in-center hemodialysis. Using modifiers from Medicare claims, we examined telemedicine use in the first 16 months of the pandemic. Reported telemedicine use peaked early in the pandemic and declined subsequently. Telemedicine use was more common in areas that were remote and socioeconomically disadvantaged and at facilities with more staff. Telemedicine use also varied by facility ownership type. Some nephrologists continued to use telemedicine for in-center hemodialysis throughout the pandemic, even as the association between coronavirus disease 2019 incidence and telemedicine use diminished over time. These findings highlight unique challenges and opportunities to the future use of telemedicine in dialysis care.

Socioeconomic disparities based on shooting intent in pediatric firearm injury.

BACKGROUND: Pediatric firearm injury is often associated with socioeconomically disadvantaged neighborhoods. Most studies only include fatal injuries and do not differentiate by shooting intent. We hypothesized that differences in neighborhood socioeconomic disadvantage would be observed among shooting intents of fatal and nonfatal cases. METHODS: A linked integrated database of pediatric fatal and nonfatal firearm injuries was developed from trauma center and medical examiner records in Harris County, Texas (2018-2020). Geospatial analysis was utilized to map victim residence locations, stratified by shooting intent. Area Deprivation Index (ADI), a composite measure of neighborhood socioeconomic disadvantage at the census tract level was linked to shooting intent. Differences in high ADI (more deprived) versus low ADI among the shooting intents were assessed. Unadjusted and adjusted regression models assessed differences in ADI scores across shooting intent, adjusted models controlled for age, gender, and race/ethnicity. RESULTS: Of 324 pediatric firearm injuries, 28% were fatal; 77% were classified as interpersonal violence, 15% unintentional, and 8% self-harm. Differences were noted among shooting intent across the ADI quartiles; with increases in ADI score, the odds of interpersonal violence injuries compared to self-harm injuries significantly increased by 5%; however, when adjusting for individual-level variables of age, gender, and race and ethnicity, no significant differences in ADI were noted. CONCLUSIONS: Our results suggest that children living in disadvantaged neighborhoods are more likely to be affected by interpersonal firearm violence compared to self-harm; however, when differences in race/ethnicity are considered, the differences attributable to neighborhood-level disadvantage disappeared. Resources should be dedicated to improving structural aspects of neighborhood disadvantage, which disproportionately impact racial/ethnic minoritized populations. Furthermore, firearm self-harm injuries occurred among children living in the less disadvantaged neighborhoods. Understanding the associations among individual and neighborhood-level factors are important for developing streamlined injury prevention interventions by shooting intent. LEVEL OF EVIDENCE: Level IVStudy TypePrognostic/Epidemiological.

Development, Implementation, and Evaluation of Three Outreach Events to Improve COVID-19 Vaccine Uptake Among Racial and Ethnic Minority Communities in Houston, Texas, 2022.

OBJECTIVES: Lack of access to timely, accurate, and linguistically appropriate COVID-19 information has complicated the dissemination of evidence-based information and contributed to vaccine hesitancy among racial and ethnic minority groups in the United States. We developed community events that provided outreach, education, and access to COVID-19 vaccination to overcome vaccine hesitancy in these communities. METHODS: Using spatial analysis techniques, we identified 3 communities with low vaccine uptake in Houston, Texas, in fall 2021; engaged 20 stakeholders from these communities via 4 focus groups to understand barriers to vaccination; and developed and implemented 3 COVID-19 vaccine education and outreach events tailored to the needs of these communities in January-March 2022. We used program evaluation surveys to assess attendee characteristics and satisfaction with the events. Vaccinated attendees also completed surveys on what motivated them to get vaccinated. RESULTS: Two communities were predominantly Hispanic, and the third had an equal number of Black and Hispanic residents. Based on community stakeholder input, the study team organized 2 health fairs and 1 community festival featuring dialogue-based COVID-19 vaccine engagement in January and March 2022. Across the 3 events, a total of 865 attendees received COVID-19 education and 205 (24.0%) attendees received a COVID-19 vaccine or booster. Of 90 attendees who completed program evaluation surveys, 81 (90%) rated the outreach event as good or excellent. Of 145 attendees who completed postvaccination surveys, 132 (91%) endorsed ≥1 key program feature as motivating them to either get vaccinated or vaccinate their child that day. CONCLUSION: Community outreach events are important strategies for disseminating information, building trust, and facilitating COVID-19 vaccine uptake.

Geographic Variation in Late-Stage Cervical Cancer Diagnosis.

Importance: There are stark disparities in cervical cancer burden in the United States, notably by race and ethnicity and geography. Late-stage diagnosis is an indicator of inadequate access to and utilization of screening. Objective: To identify geospatial clusters of late-stage cervical cancer at time of diagnosis in Texas. Design, Setting, and Participants: This population-based cross-sectional study used incident cervical cancer data from the Texas Cancer Registry from 2014 to 2018 of female patients aged 18 years or older. Late-stage cervical cancer cases were geocoded at the census tract level (n = 5265) using their residential coordinates (latitude and longitude) at the time of diagnosis. Statistical analysis was performed from April to September 2023. Exposures: Census tract of residence at diagnosis. Main Outcome and Measures: Late-stage cervical cancer diagnosis (ie, cases classified by the National Cancer Institute Surveillance, Epidemiology and End Results summary stages 2 to 4 [regional spread] or 7 [distant metastasis]). A Poisson probability-based model of the SaTScan purely spatial scan statistics was applied at the census tract-level to identify geographic clusters of higher (hot spots) or lower (cold spots) proportions than expected of late-stage cervical cancer diagnosis and adjusted for age. Results: Among a total of 6484 female patients with incident cervical cancer cases (mean [SD] age, 48.7 [14.7] years), 2300 (35.5%) were Hispanic, 798 (12.3%) were non-Hispanic Black, 3090 (47.6%) were non-Hispanic White, and 296 (4.6%) were other race or ethnicity. Of the 6484 patients, 2892 with late-stage diagnosis (mean [SD] age, 51.8 [14.4] years were analyzed. Among patients with late-stage diagnosis, 1069 (37.0%) were Hispanic, 417 (14.4%) were non-Hispanic Black, 1307 (45.2%) were non-Hispanic White, and 99 (3.4%) were other race or ethnicity. SaTScan spatial analysis identified 7 statistically significant clusters of late-stage cervical cancer diagnosis in Texas, of which 4 were hot spots and 3 were cold spots. Hot spots included 1128 census tracts, predominantly in the South Texas Plains, Gulf Coast, and Prairies and Lakes (North Texas) regions. Of the 2892 patients with late-stage cervical cancer, 880 (30.4%) were observed within hot spots. Census tract-level comparison of characteristics of clusters suggested that hot spots differed significantly from cold spots and the rest of Texas by proportions of racial and ethnic groups, non-US born persons, and socioeconomic status. Conclusions and Relevance: In this cross-sectional study examining geospatial clusters of late-stage cervical cancer diagnosis, place-based disparities were found in late-stage cervical cancer diagnosis in Texas. These findings suggest that these communities may benefit from aggressive cervical cancer interventions.

Trends in Up-To-Date Colorectal Cancer Screening Among U.S. Adults Aged 50-75 Years and Variations by Race/Ethnicity and U.S. Census Bureau Divisions.

Introduction: Mortality rates from colorectal cancer have declined over the past decades owing to population-based life-saving screening interventions. However, screening inequalities continue among racial and ethnic minorities despite having a higher disease burden. In this study, we assessed the patterns of up-to-date colorectal cancer screening rates among racial/ethnic groups across the U.S. Census Bureau Divisions. Methods: This population-based cross-sectional study used weighted data from 4 cycles of the Behavioral Risk Factors Surveillance System (2014, 2016, 2018, and 2020) of adults aged 50‒75 years without a previous diagnosis of colorectal cancer. The primary outcome was guideline-recommended up-to-date colorectal cancer screening. We used logistic regression models to examine temporal trends in up-to-date colorectal cancer screening from 2014 to 2020. In addition, we conducted detailed descriptive statistics of up-to-date screening rates, comparing trends in 2020 with those in 2014 overall by race/ethnicity and U.S. census divisions. Results: The overall proportion of individuals with up-to-date colorectal cancer screening increased from 66.5% in 2014 to 72.5% in 2020 (p<0.001). For racial/ethnic subgroups, from 2014 to 2020, screening rates increased significantly among non-Hispanic Whites (68.5%‒74.5%, p<0.001), non-Hispanic Blacks (68.0%‒74.6%, p<0.001), and Hispanics (51.5%‒62.8%, p<0.001). However, increases were not observed in all U.S. Census Bureau Divisions. Conclusions: Although colorectal cancer screening rates improved over time, they fall short of the 80% target. Substantial racial/ethnic and geographic disparities remain. Future studies investigating the factors influencing these disparities are needed.

Integrating participant feedback and concerns to improve community and individual level chemical exposure assessment reports.

BACKGROUND: As exposure assessment has shifted towards community-engaged research there has been an increasing trend towards reporting results to participants. Reports aim to increase environmental health literacy, but this can be challenging due to the many unknowns regarding chemical exposure and human health effects. This includes when reports encompass a wide-range of chemicals, limited reference or health standards exist for those chemicals, and/or incompatibility of data generated from exposure assessment tools with published reference values (e.g., comparing a wristband concentration to an oral reference dose). METHODS: Houston Hurricane Harvey Health (Houston-3H) participants wore silicone wristbands that were analyzed for 1,530 organic compounds at two time-points surrounding Hurricane Harvey. Three focus groups were conducted in separate neighborhoods in the Houston metropolitan area to evaluate response to prototype community and individual level report-backs. Participants (n = 31) evaluated prototype drafts using Likert scales and discussion prompts. Focus groups were audio-recorded, and transcripts were analyzed using a qualitative data analysis program for common themes, and quantitative data (ranking, Likert scales) were statistically analyzed. RESULTS: Four main themes emerged from analysis of the transcripts: (1) views on the report layout; (2) expression of concern over how chemicals might impact their individual or community health; (3) participants emotional response towards the researchers; and (4) participants ability to comprehend and evaluate environmental health information. Evaluation of the report and key concerns differed across the three focus groups. However, there was agreement amongst the focus groups about the desire to obtain personal exposure results despite the uncertainty of what the participant results meant. CONCLUSIONS: The report-back of research results (RBRR) for community and individual level exposure assessment data should keep the following key principles in mind: materials should be accessible (language level, data visualization options, graph literacy), identify known information vs unknown (e.g., provide context for what exposure assessment data means, acknowledge lack of current health standards or guidelines), recognize and respect community knowledge and history, and set participant expectations for what they can expect from the report.

Geospatial Distribution of Obsessive-Compulsive Disorder Specialists: Understanding Access as a Function of Distance, Insurance Status, and Neighborhood Socioeconomic Status.

Obsessive-compulsive disorder is an impairing psychiatric condition affecting 1-2% of adults and youth. Cognitive-behavioral therapy with exposure and response prevention (CBT) is an efficacious intervention but requires specialty training and access is often limited. While certain factors are associated with treatment access, one key barrier that has not been explored is the geographic availability of OCD treatment providers. Using integrated geographically-referenced data, we examined the geographic distribution of OCD CBT specialty providers across the state of Texas, with particular attention to the relationship to neighborhood socioeconomic disadvantage, insurance status, and rural versus urban status. We found that specialist providers are almost exclusively located inside the highly urbanized parts of the state, primarily in more affluent areas, and often only accept self-pay. The characteristics of the areas located the furthest away from specialty OCD care include a high proportion of persons identifying as Hispanic; a high proportion of non-English speakers, households with income below poverty; households with no vehicles; and persons with no health insurance. Average household income decreased as distances from specialist providers increased. Broadly, findings confirm that OCD CBT specialty providers are clustered in large socially advantaged areas and that economic disadvantage remains a significant barrier to care. As inadequate or inappropriate treatment of OCD is likely to result in sustained and impairing symptoms, this is of great concern.

The Effects of COVID-19 Lockdown on Social Connectedness and Psychological Distress in U.S. Adults with Chronic Diseases.

Lockdown measures enacted in 2020 to control the spread of COVID-19 led to increases in the prevalence of mental health problems. Due to their high-risk status, individuals with chronic diseases may be at increased risk and disproportionately adversely affected by the COVID-19 pandemic. The investigators examined associations between having a high-risk chronic condition, social connectedness, and general distress and COVID-19-specific distress among U.S. adults during the COVID-19 lockdown. Baseline measures of a longitudinal survey collected at the beginning of the pandemic (April to June 2020) were analyzed to identify factors associated with loss of social connectedness from pre- to post-lockdown. The associations between social connectedness and both general and COVID-19-specific psychological distress were adjusted for certain high-risk chronic illnesses and interaction effects. The sample available for analysis included 1354 subjects (262 high-risk chronic diseases and 1092 without chronic illness). Those reporting the loss of social connectedness were younger (median = 39 vs. 42) and more likely to be unemployed because of the pandemic (19.4% vs. 11.0%). Adjustment for interaction demonstrated a stronger negative association between social connectedness change and the psychosocial impact of COVID-19 for those with high-risk illness(es) (change in connectedness*chronic illness OR = 0.88, 95%CI: 0.79-0.98, p = 0.020). These findings inform our understanding of the distribution and intersection of responses to public health lockdown orders in the U.S. and build further evidence of the importance of social connectedness on psychological distress.

Clustering of Pediatric Brain Tumors in Texas, 2000-2017.

Risk factors for pediatric brain tumors are largely unknown. Identifying spatial clusters of these rare tumors on the basis of residential address may provide insights into childhood socio-environmental factors that increase susceptibility. From 2000-2017, the Texas Cancer Registry recorded 4305 primary brain tumors diagnosed among children (≤19 years old). We performed a spatial analysis in SaTScan to identify neighborhoods (census tracts) where the observed number of pediatric brain tumors was higher than expected. Within each census tract, the number of pediatric brain tumors was summed on the basis of residential address at diagnosis. The population estimate from the 2007-2011 American Community Survey of 0- to 19-year-olds was used as the at-risk population. p-values were calculated using Monte Carlo hypothesis testing. The age-standardized rate was 54.3 per 1,000,000. SaTScan identified twenty clusters, of which two were statistically significant (p < 0.05). Some of the clusters identified in Texas spatially implicated potential sources of environmental risk factors (e.g., proximity to petroleum production processes) to explore in future research. This work provides hypothesis-generating data for further investigations of spatially relevant risk factors of pediatric brain tumors in Texas.

Racial/Ethnic Disparities in Cervical Cancer Stage at Diagnosis: Mediating Effects of Neighborhood-level Socioeconomic Deprivation.

BACKGROUND: Mortality from cervical cancer has declined steadily in the United States over the past several decades due to widespread screening for precancerous and early-stage cervical cancer (ECC), which are significantly easier to treat compared with late-stage cervical cancer (LCC). Unequal screening access continues to cause significant racial/ethnic disparities in cervical cancer diagnosis stage. This study examined the underlying role of neighborhood-level socioeconomic disadvantage as a potential mediator of the association between race/ethnicity and cervical cancer diagnosis stage. METHODS: We analyzed Texas Cancer Registry data for cervical cancer cases diagnosed among women ages 18 or older from 2010 to 2018. We performed causal mediation analyses of the association between race/ethnicity and cervical cancer stage at diagnosis mediated by neighborhood-level socioeconomic disadvantage. RESULTS: Of the 9,192 women with cervical cancer, 4,720 (51.3%) had LCC at diagnosis. Compared with non-Hispanic white (NHW) women (106.13, standard deviation (SD) = 13.32), non-Hispanic Black (NHB; 111.46, SD = 9.55) and Hispanic (112.32, SD = 9.42) women had higher area deprivation index (ADI) and had greater odds of LCC diagnosis [total effects: adjusted odds ratios (AOR) = 1.29 (95% CI, 1.11-1.46) and AOR 1.14 (95% CI, 1.03-1.25), respectively]. Approximately 34.7% and 71.6% of the disparity in LCC diagnosis were attributable to higher neighborhood socioeconomic disadvantage among NHB and Hispanic women, respectively. CONCLUSIONS: LCC disparity varied by race/ethnicity and was partly attributable to neighborhood disadvantage. The disparity among Hispanic women due to neighborhood deprivation was twice as high among NHB women. IMPACT: Findings may be used to develop targeted race- and place-specific interventions to improve cancer care equity.

Area deprivation index and segregation on the risk of HIV: a U.S. Veteran case-control study.

Background: Preventing HIV infection remains a critically important tool in the continuing fight against HIV/AIDS. The primary aim is to evaluate the effect and interactions between a composite area-level social determinants of health measure and an area-level measure of residential segregation on the risk of HIV/AIDS in U.S. Veterans. Methods: Using the individual-level patient data from the U.S. Department of Veterans Affairs, we constructed a case-control study of veterans living with HIV/AIDS (VLWH) and age-, sex assigned at birth- and index date-matched controls. We geocoded patient's residential address to ascertain their neighborhood and linked their information to two measures of neighborhood-level disadvantage: area deprivation index (ADI) and isolation index (ISOL). We used logistic regression to estimate the odds ratio (OR) and 95% confidence interval (CI) for comparing VLWH with matched controls. We performed analyses for the entire U.S. and separately for each U.S. Census division. Findings: Overall, living in minority-segregated neighborhoods was associated with a higher risk of HIV (OR: 1.88 (95% CI: 1.79-1.97) while living in higher ADI neighborhoods was associated with a lower risk of HIV (OR: 0.88; 95% CI: 0.84-0.92). The association between living in a higher ADI neighborhood and HIV was inconsistent across divisions, while living in minority-segregated neighborhoods was consistently associated with increased risk across all divisions. In the interaction model, individuals from low ADI and high ISOL neighborhoods had a higher risk of HIV in three divisions: East South Central; West South Central, and Pacific. Interpretation: Our results suggest that residential segregation may prevent people in disadvantaged neighborhoods from protecting themselves from HIV independent from access to health care. There is the need to advance knowledge about the neighborhood-level social-structural factors that influence HIV vulnerability toward developing interventions needed to achieve the goal of ending the HIV epidemic. Funding: US National Cancer Institute.

Ethnic disparities in childhood leukemia survival by border residence: A Texas population-based analysis.

BACKGROUND: The US-Mexico border is a medically underserved region where survival disparities have been observed in adults diagnosed and treated for various malignancies. Studies examining survival disparities among children living in this region and diagnosed with cancer are lacking. The objective of this study was to evaluate the impact of border residence on survival among children with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), and living near the Texas-Mexico border at the time of their diagnosis. The authors hypothesized that this group experiences inferior survival compared with patients with childhood leukemia living in nonborder areas. METHODS: The authors conducted a retrospective survival analysis leveraging data from the Texas Cancer Registry. The study included patients aged birth to 19 years who were diagnosed with ALL or AML between 1995 and 2017. Cox proportional hazards models were used to evaluate the factors associated with the risk of death. Overall survival estimates were calculated using Kaplan-Meier methods. RESULTS: During the study period, there were 6002 children diagnosed with ALL and 1279 diagnosed with AML. Inferior 5-year overall survival was observed among children with ALL living along the border region compared with those living in nonborder areas (77.5% vs. 85.8%). In adjusted models, children with ALL living along the border experienced a 30% increased hazard of death versus children living in nonborder areas. In contrast, for children with AML, survival estimates did not vary by border versus nonborder residence. CONCLUSIONS: Living along the border was associated with inferior survival among children with ALL, but not among children with AML. Additional studies are urgently needed to identify the factors driving these disparities to effectively design multilevel interventions and influence state and national cancer control programs.

Neighborhood-Level Factors Contribute to Disparities in Hepatocellular Carcinoma Incidence in Texas.

BACKGROUND AND AIMS: Texas has the highest hepatocellular carcinoma (HCC) incidence rates in the continental United States, but these rates vary by race-ethnicity. We examined racial-ethnic disparities through a geospatial analysis of the social determinants of health. METHODS: Using data from the Texas Cancer Registry, we assembled 11,547 HCC cases diagnosed between 2011 and 2015 into Texas's census tracts geographic units. Twenty-nine neighborhood measures representing demographics and socioeconomic, and employment domains were retrieved from the U.S. Census Bureau. We performed a series of aspatial and spatially weighted regression models to identify neighborhood-level characteristics associated with HCC risk. RESULTS: We found positive associations between HCC and proportion of population in census tracts that are Black or African American, Hispanic, over 60 years of age, in the construction industry, and in the service occupation but an inverse association with the proportion of population employed in the agricultural industry. The magnitude of these associations varied across Texas census tracts. CONCLUSIONS: We found evidence that neighborhood-level factors are differentially associated with variations in HCC incidence across Texas. Our findings reinforce existing knowledge about HCC risk factors and expose others, including neighborhood-level employment status.

Remote Care Adoption in Underserved Congenital Heart Disease Patients During the COVID-19 Era.

The COVID-19 pandemic restricted in-person appointments and prompted an increase in remote healthcare delivery. Our goal was to assess access to remote care for complex pediatric cardiology patients. We performed a retrospective chart review of Texas Children's Hospital (TCH) pediatric cardiology outpatient appointments from March 2020 to December 2020 for established congenital heart disease (CHD) patients 1 to 17 yo. Primary outcome variables were remote care use of telemedicine and patient portal activation. Primary predictor variables were age, sex, insurance, race/ethnicity, language, and location. Descriptive statistics were used to analyze patient demographics. Multivariate logistic regression determined associations with remote care use (p < 0.05). We identified 5,410 established patients with clinic appointments during the identified timeframe. Adopters of telemedicine included 13% of patients (n = 691). Of the prior non patient portal users, 4.5% activated their accounts. On multivariate analysis, older age (10-17 yo) was associated with increased telemedicine (OR 2.04, 95%CI 1.71, 2.43) and patient portal use (OR 1.70, 95%CI 1.33, 2.17). Public insurance (OR 1.66, 95%CI 1.25, 2.20) and Spanish speaking were associated with increased patient portal adoption. Race/ethnicity was not significantly associated with telemedicine use or patient portal adoption. Telehealth adoption among older children may be indicative of their ability to aid in the use of these technologies. Higher participation in patient portal activation among publicly insured and Spanish speaking patients is encouraging and demonstrates ability to navigate some degree of remote patient care. Adoption of remote patient care may assist in reducing access to care disparities.

Trends and Racial/Ethnic Differences in Predictors of Cervical Cancer Screening among US Women Ages 30-64 Years.

BACKGROUND: Cervical cancer screening (CCS) participation has decreased in the United States over the last several decades, contributing to cervical cancer's sustained incidence and mortality. This study examined recent trends and racial/ethnic differences in predictors of CCS uptake among US women. METHODS: We analyzed combined data from the 2016 to 2020 Behavioral Risk Factor Surveillance System (BRFSS) and included 235,713 women ages 30 to 64 years without a hysterectomy. We used simple linear regression to assess trends over time and multivariable logistic regression models to evaluate racial/ethnic differences in predictors of up-to-date CCS. RESULTS: We found little change in CCS over the 5-year interval and screening rates disparities among racial minority women. The overall population showed stable CCS completion rates from 2016 to 2018 (84.2% vs. 84.6%), and then a small dip from 2018 to 2020 (from 84.6% to 83.3%). Despite a slight decline in 2020, HPV-based testing increased significantly among all subgroups and overall, from 2016 to 2020 (from 43.4% to 52.7%). Multivariable regression models showed racial/ethnic differences in predictors of CCS. Across all racial/ethnic subgroups, older women were less likely to receive timely screening. Women who had routine check-ups had higher odds of being up to date. However, the link between CCS and socioeconomic status varied. CONCLUSIONS: Age and racial/ethnic disparities persist in CCS, and predictors of screening vary. Notwithstanding, routine health examinations was positively associated with screening regardless of race/ethnicity. IMPACT: Our analyses suggest that leveraging primary care to optimize CCS uptake may reduce gaps in screening.

COVID-19 Vaccine Uptake among US Adults According to Standard Occupational Groups.

This cross-sectional ecological study examined the relationship between neighborhood-level standard occupational groups in the USA and COVID-19 vaccine uptake using 774 census tract data, each consisting of approximately 1600 housing units. The neighborhood-level COVID-19 vaccination uptake data were retrieved from Harris County Public Health, Harris County, Texas. The standard occupational group data were from the US Census Bureau. We calculated the incidence rate ratios (IRRs) for vaccine uptake using bivariate and multivariable Poisson regression models. In the adjusted models, we found that the healthcare practitioner/technician (IRR: 1.008; 95% CI: 1.003−1.014; p = 0.001), business/management/legal (IRR: 1.011; 95% CI: 1.008−1.013; p < 0.001), computer/engineering/life/physical/social science (IRR: 1.018; 95% CI: 1.013−1.023; p < 0.001), and arts/design/entertainment/sports/media (IRR: 1.031; 95% CI: 1.018−1.044; p < 0.001) occupational groups were more likely to have received the full regimen of a COVID-19 vaccine. On the contrary, the building/installation/maintenance/repair (IRR: 0.991; 95% CI: 0.987−0.995; p < 0.001), construction/extraction/production (IRR: 0.991; 95% CI: 0.988−0.995; p < 0.001), transportation/material moving (IRR: 0.992; 95% CI: 0.987−0.997; p = 0.002), food preparation/serving related (IRR: 0.995; 95% CI: 0.990−0.999; p = 0.023), and personal care/services (IRR: 0.991; 95% CI: 0.985−0.998; p = 0.017) groups were less likely to have received the complete dose of a COVID-19 vaccine. White-collar workers were more likely to be vaccinated than blue-collar workers. We adjusted for age, sex, and race/ethnicity in the multivariable analysis. The low vaccine uptake among certain occupational groups remains a barrier to pandemic control. Engaging labor-centered stakeholders in the development of vaccination interventions may increase uptake.

Associating Increased Chemical Exposure to Hurricane Harvey in a Longitudinal Panel Using Silicone Wristbands.

Hurricane Harvey was associated with flood-related damage to chemical plants and oil refineries, and the flooding of hazardous waste sites, including 13 Superfund sites. As clean-up efforts began, concerns were raised regarding the human health impact of possible increased chemical exposure resulting from the hurricane and subsequent flooding. Personal sampling devices in the form of silicone wristbands were deployed to a longitudinal panel of individuals (n = 99) within 45 days of the hurricane and again one year later in the Houston metropolitan area. Using gas chromatography−mass spectroscopy, each wristband was screened for 1500 chemicals and analyzed for 63 polycyclic aromatic hydrocarbons (PAHs). Chemical exposure levels found on the wristbands were generally higher post-Hurricane Harvey. In the 1500 screen, 188 chemicals were detected, 29 were detected in at least 30% of the study population, and of those, 79% (n = 23) were found in significantly higher concentrations (p < 0.05) post-Hurricane Harvey. Similarly, in PAH analysis, 51 chemicals were detected, 31 were detected in at least 30% of the study population, and 39% (n = 12) were found at statistically higher concentrations (p < 0.05) post-Hurricane Harvey. This study indicates that there were increased levels of chemical exposure after Hurricane Harvey in the Houston metropolitan area.

Patterns of venous thromboembolism risk, treatment, and outcomes among patients with cancer from uninsured and vulnerable populations.

The epidemiology of cancer-associated thrombosis (CAT) among uninsured and vulnerable populations in the US is not well-characterized. We performed a retrospective cohort study for patients with newly diagnosed cancer from 2011 to 2020 at Harris Health System, which cares for uninsured residents in the Houston metropolitan area. Patient demographics, NCI comorbidity index, area of deprivation index (ADI), cancer histology, staging, and systemic therapy data were extracted. CAT included overall venous thromboembolism (VTE) or pulmonary embolism +/- lower extremity deep vein thrombosis (PE/LE-DVT) within 1 year of diagnosis. We used multivariable Fine-Gray models to assess the associations with CAT accounting for death as a competing risk. Among 15 342 patients, 74% were uninsured and 84% lived in socioeconomically disadvantaged neighborhoods. There were 16% Non-Hispanic White (NHW), 28% Non-Hispanic Black (NHB), 50% Hispanic (27% Mexican), and 6% Asian/Pacific Islanders (API). The 1-year CAT incidence rate was 14.6%. Overall VTE was lower for Hispanics versus NHW (SHR 0.87 [0.76-0.99]) and API versus NHW (SHR 0.58 [0.44-0.77]). PE/LE-DVT was higher for NHB versus NHW (SHR 1.18 [1.01-1.39]). CAT was also associated with chemotherapy-based regimens (+/- immunotherapy), age, obesity, cancer type/staging, VTE history, and recent hospitalization. NCI comorbidity and ADI scores were associated with mortality but not CAT. In a large cohort of underserved patients with cancer, we identified an elevated incidence of CAT with known and novel risk predictors. Hispanics had lower adjusted rates of CAT and mortality. Our findings highlight the need to investigate and incorporate vulnerable populations in clinical trials.