Racial Differences in the Predictors of Interest in Bariatric Surgery in the Rural, Southeastern USA.

BACKGROUND: Although African-Americans have a higher prevalence of severe obesity than Whites, they are less likely to have bariatric surgery. Demographic, healthcare, and knowledge variables contribute to this racial disparity but have not been examined separately by race. OBJECTIVES: Examine the role of demographic, healthcare, and knowledge variables in African-Americans' versus Whites' interest in bariatric surgery. METHODS: A random sample of 293 African-American and 259 White adults were surveyed door-to-door in the rural south. The survey assessed weight, height, demographics, access to healthcare, and knowledge of and interest in bariatric surgery. RESULTS: African-Americans had significantly lower knowledge of bariatric surgery than Whites but there were no racial differences in interest in the surgery. The logistic regression predicting African-Americans' interest in the surgery from demographic, healthcare, obesity, and knowledge variables revealed that obesity (OR = 4.7) and the health benefits (OR = 3.3) were the only predictors. The same regression for Whites found that knowing someone who had the surgery (OR = 3.7) was the sole predictor. CONCLUSIONS: Knowledge variables may be stronger than healthcare and demographic variables as predictors of interest in bariatric surgery among rural, southern, African-Americans and Whites. Whites' willingness to consider the surgery might be enhanced by favorable stories/blogs by those who had the surgery, whereas African-Americans' interest might be increased by information on the additional health benefits of the surgery. These culturally tailored messages from healthcare providers might increase utilization of and reduce racial disparities in bariatric surgery.

Assessment of the US Federal Retailer Violation Rate as an Estimate of the Proportion of Retailers That Illegally Sell Tobacco to Adolescents.

Importance: Despite progress against tobacco sales to minors, retailers continue to violate state and federal laws and supply adolescent smokers with tobacco products. Government-sanctioned surveys underestimate the extent of the problem, and retailer associations use these data to block stricter enforcement policies. Objectives: To assess the validity of the US federal retailer violation rate (RVR) as an estimate of the proportion of retailers that sell tobacco to minors and to investigate what proportion always or almost always sells vs refuses to sell cigarettes to minors. Design, Setting, and Participants: This survey study was conducted October 6, 2012, to September 8, 2013; data were analyzed between September 28, 2017, and March 21, 2018. The setting was a suburban county adjacent to Denver, Colorado. Participants were a systematically selected, population-based cluster sample of retailers that stock cigarettes for sale. Retailers were masked to the survey. Main Outcomes and Measures: Each retailer was visited 6 times by supervised minors who attempted to purchase cigarettes at each visit. The main outcome was whether cigarettes were sold. Other measures included whether government-issued photo identification (ID) was requested as required by law, how ID was examined, and what the demographic characteristics of study minors and clerks were. Results: The sample of 201 retailers (44.8% of the 449 listed population) included convenience stores (n = 77), liquor stores (n = 63), grocery stores/supermarkets (n = 33), pharmacies (n = 17), tobacco stores (n = 7), and stand-alone gas stations (n = 4). Bars, clubs, and adult establishments were excluded. A total of 1181 purchase attempts were analyzed; 25 (2.1%) were excluded for missing data. The mean RVR across 6 rounds of checks was 18.0% (95% CI, 14.7%-21.2%) and ranged from 13.7% to 28.0% per round. Most retailers (54.7% [110 of 201]) violated at least once in 6 visits, 26.4% (53 of 201) violated at least twice, and 11.9% (24 of 201) violated half or more times. How retailers examined proof of age largely determined whether violations occurred. Conclusions and Relevance: The proportion of retailers that sold cigarettes to a minor at least once in 6 attempts was 3 times higher than the mean RVR based on a single inspection per retailer. Larger replication studies are needed. Enforcement protocols should reflect the fact that each retailer does not respond consistently when adolescents try to buy tobacco products, and many retailers are not properly validating ID that shows proof of age.

Racial disparities in healthcare provider advice to quit smoking.

African-American/Black smokers are less likely than White smokers to be told to quit smoking by healthcare providers. This preliminary study examined the predictors of being told to quit separately by race for the first time to potentially highlight the source of this racial disparity. A random, household sample of 1670 Black and White adults from a southeastern county of the United States completed a brief survey on their demographics, smoking, access to healthcare, health status, and receipt of healthcare provider advice to quit smoking. Analyses are based on the 512 Black and White smokers in that sample. The logistic regression for all smokers revealed that after controlling for demographic, healthcare, and health status variables, White smokers were 2.39 times more likely than Black smokers to have ever been told to quit smoking. The regression for Black smokers revealed that women and older people were more likely to be told to quit, and that healthcare and health status did not contribute. In the regression for White smokers, no predictor was statistically significant. These findings suggest that one possible reason that African-Americans receive cessation advice less often than Whites is that such advice varies with their age and gender, whereas for Whites this is not the case.

Perioperative Inotrope Therapy and Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery: Evidence of a Racial Disparity.

BACKGROUND AND OBJECTIVE: Following coronary artery bypass graft (CABG) surgery, mortality rates are significantly higher among black patients who experience postoperative atrial fibrillation (POAF). Perioperative inotropic therapy (PINOT) was associated with POAF in previous reports, but the extent to which race influences this association is unknown. In the present study, the relationship between PINOT, race, and POAF was examined in patients undergoing CABG surgery. METHODS AND SETTING: Clinical records were examined from a prospectively maintained cohort of 11,855 patients (median age 64 yrs; 70% male; 16% black) undergoing primary isolated CABG at a large cardiovascular institute in the southeastern region of the United States. Relative risk (RR) and 95% confidence intervals (CIs) were computed using log-binomial regression. MAIN RESULTS: The association between PINOT and POAF was significantly increased among black patients (adjusted RR 1.7, CI 1.4-2.0) compared with white patients (adjusted RR 1.3, CI 1.2-1.4) (pinteraction  = 0.013). CONCLUSIONS: These findings suggest that PINOT may be disproportionately associated with POAF among black patients undergoing CABG surgery. Additional studies are needed to examine further the potential underlying mechanisms of this association.

Residential Segregation and Racial Cancer Disparities: A Systematic Review.

BACKGROUND: This paper provides the first review of empirical studies of segregation and black-white cancer disparities. METHODS: We searched all years of PubMed (through May 2016) using these terms: racial segregation, residential segregation, neighborhood racial composition (first terms) and (second terms) cancer incidence, mortality, survival, stage at diagnosis, screening. The 17 (of 668) articles that measured both segregation and a cancer outcome were retained. RESULTS: Segregation contributed significantly to cancer and to racial cancer disparities in 70% of analyses, even after controlling for socioeconomic status and health insurance. Residing in segregated African-American areas was associated with higher odds of later-stage diagnosis of breast and lung cancers, higher mortality rates and lower survival rates from breast and lung cancers, and higher cumulative cancer risks associated with exposure to ambient air toxics. There were no studies of many types of cancer (e.g., cervical). Studies differed in their measure of segregation, and 40% used an invalid measure. Possible mediators of the segregation effect usually were not tested. CONCLUSIONS: Empirical analysis of segregation and racial cancer disparities is a recent area of research. The literature is limited to 17 studies that focused primarily on breast cancer. Studies differed in their measure of segregation, yet segregation nonetheless contributed to cancer and to racial cancer disparities in 70% of analyses. This suggests the need for further research that uses valid measures of segregation, examines a variety of types of cancers, and explores the variables that may mediate the segregation effect.

Rural Shop-Based Health Program Planning: a Formative Research Approach Among Owners.

African American barbershops and beauty salons are settings that have been identified as a significant and culturally relevant venue to reach minority populations for health promotion activities. By being located in almost every town in the USA, this setting is a viable means to promote healthy lifestyles among African Americans. The purpose of this formative research project was to assess African American barbershop and beauty salon owners' perceptions of providing health promotion programming in their shops, as well as to obtain information on health topics of interest and strategies for implementation. Interviewees were recruited using snowballing among clientele and owner referrals, between November 2014 and August 2015. A total of 20 barbershop and salon owners, across 11 counties in eastern North Carolina, completed face-to-face interviews. Responses were stratified by barbershops and beauty salons. Across both groups, all owners stated it would be a good idea to have health programs/interventions within the shop setting. Most noted topics of interest included diet and nutrition, hypertension, and (wo)men's reproductive health. When asked further about these desired topics, both benefits and relevance to customers and the African American community were the reasons for their selections. In addition, across barbershops and salons, 90 % of owners stated interest in having a program implemented in their shop. This information will be used to guide the development of shop-based interventions, with the aid of a community advisory board composed of shop owners, individual barbers and stylists and customers.

Inequities in tobacco retailer sales to minors by neighbourhood racial/ethnic composition, poverty and segregation, USA, 2015.

OBJECTIVE: Tobacco retailers are an important source of tobacco products for minors. Previous research shows racial discrimination in sales to minors, but no national study has examined neighbourhood correlates of retailer under-age sales. METHODS: We accessed publicly available results of 2015 US Food and Drug Administration (FDA) inspections of tobacco retailers (n=108 614). In this cross-sectional study, we used multilevel logistic regression to predict the likelihood of retailer sale to a minor based on tract characteristics. We assessed the proportion of residents identifying as American Indian, Asian, Black, Latino and White; Isolation Index scores for each racial/ethnic group; the proportion of people less than age 65 living in poverty; and the proportion of residents age 10-17 in relation to retailer inspection results. RESULTS: The proportion of American Indian residents, Black residents, Latino residents and residents less than age 65 under the poverty line in a neighbourhood are independently, positively associated with the likelihood that a retailer in that neighbourhood will fail an under-age buy inspection. The proportion of White residents and residents age 10-17 are independently, negatively associated with the likelihood of sale of tobacco products to a minor. Isolation Index scores show a similar pattern. In multivariable models holding neighbourhood characteristics constant, higher proportions of Black (+), Latino (+) and age 10-17 (-) residents remained significant predictors of the likelihood of under-age sale. DISCUSSION: Regulatory agencies should consider oversampling retailers in areas with higher likelihood of sales to minors for inspection. Interventions with tobacco retailers to reduce inequities in youth access should be implemented.

Comparison of Risk of Atrial Fibrillation in Black Versus White Patients After Coronary Artery Bypass Grafting.

Obesity has been identified as a risk factor for postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG). However, no studies have addressed the influence of race on this association. A total of 13,594 patients undergoing first-time, isolated CABG without preoperative AF between 1992 and 2011 were included in our study. The association between body mass index and POAF was compared by race. Relative risk and 95% CIs were computed using maximum likelihood log-binomial regression. Increasing levels of body mass index were associated with higher POAF risk after CABG in black but not white patients (pinteraction = 0.0009).

Sociocultural correlates of cigarette smoking among African-American men versus women: Implications for culturally specific cessation interventions.

Low socioeconomic status, racial discrimination, and low acculturation are the major sociocultural correlates of smoking among African-American adults. This study is the first to examine all three variables simultaneously and to analyze gender differences in their association with smoking. Results for the sample revealed that low education and low acculturation predicted smoking but racial discrimination did not. For women, low acculturation was the sole predictor of smoking, whereas for men, socioeconomic status variables were the sole predictors. This suggests that low acculturation may be associated with smoking among African-American women only. Hence, culturally specific smoking cessation programs designed for low-acculturated African-Americans might be effective for African-American women alone.

Conditional long-term survival following minimally invasive robotic mitral valve repair: a health services perspective.

BACKGROUND: Conditional survival is defined as the probability of surviving an additional number of years beyond that already survived. The aim of this study was to compute conditional survival in patients who received a robotically assisted, minimally invasive mitral valve repair procedure (RMVP). METHODS: Patients who received RMVP with annuloplasty band from May 2000 through April 2011 were included. A 5- and 10-year conditional survival model was computed using a multivariable product-limit method. RESULTS: Non-smoking men (≤65 years) who presented in sinus rhythm had a 96% probability of surviving at least 10 years if they survived their first year following surgery. In contrast, recent female smokers (>65 years) with preoperative atrial fibrillation only had an 11% probability of surviving beyond 10 years if alive after one year post-surgery. CONCLUSIONS: In the context of an increasingly managed healthcare environment, conditional survival provides useful information for patients needing to make important treatment decisions, physicians seeking to select patients most likely to benefit long-term following RMVP, and hospital administrators needing to comparatively assess the life-course economic value of high-tech surgical procedures.

Increased Long-Term Mortality among Black CABG Patients Receiving Preoperative Inotropic Agents.

The aim of this study was to examine racial differences in long-term mortality after coronary artery bypass grafting (CABG), stratified by preoperative use of inotropic agents. Black and white patients who required preoperative inotropic support prior to undergoing CABG procedures between 1992 and 2011 were compared. Mortality probabilities were computed using the Kaplan-Meier product-limit method. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 15,765 patients underwent CABG, of whom 211 received preoperative inotropic agents within 48 hours of surgery. Long-term mortality differed by race (black versus white) among preoperative inotropic category (inotropes: adjusted HR = 1.6, 95% CI = 1.009-2.4; no inotropes: adjusted HR = 1.15, 95% CI = 1.08-1.2; P(interaction) < 0.0001). Our study identified an independent preoperative risk-factor for long-term mortality among blacks receiving CABG. This outcome provides information that may be useful for surgeons, primary care providers, and their patients.

Increased coronary artery disease severity in black women undergoing coronary bypass surgery.

Race and sex disparities are believed to play an important role in heart disease. The purpose of this study was to examine the association between race, sex, and number of diseased vessels at the time of coronary artery bypass grafting (CABG), and subsequent postoperative outcomes. The 13,774 patients undergoing first-time, isolated CABG between 1992 and 2011 were included. Trend in the number of diseased vessels between black and white patients, stratified by sex, were analyzed using a Cochran-Armitage trend test. Models were adjusted for age, procedural status (elective vs. nonelective), and payor type (private vs. nonprivate insurance). Black female CABG patients presented with an increasingly greater number of diseased vessels than white female CABG patients (adjusted P(trend) = 0.0021). A similar trend was not observed between black and white male CABG patients (adjusted P(trend) = 0.18). Black female CABG patients were also more likely to have longer intensive care unit and hospital lengths of stay than other race-sex groups.Our findings suggest that black female CABG patients have more advanced coronary artery disease than white female CABG patients. Further research is needed to determine the benefit of targeted preventive care and preoperative workup for this high-risk group.

Targeting cancer information to African Americans: the trouble with talking about disparities.

Cancer messages that are designed for African Americans often include information on Black-White cancer disparities to raise Black adults' perceived cancer risk and increase cancer screening. Whether disparities messages achieve this, and how Blacks feel about hearing that they are worse off than are Whites, largely remain unknown. This study examined Blacks' responses to two mock newspaper articles on colorectal cancer: a disparities article and a nondisparities article. A random sample of 400 Black adults read the articles and answered questions on their reactions to both. Results revealed that readers of the disparities article felt significantly more insulted, discouraged, and angry about it than did readers of the nondisparities article. Article type played no role in desires or intentions to have colon cancer screening among participants of screening age, and no role in perceived cancer risk or intentions to suggest colon cancer screening to family among participants of any age. These findings suggest that disparities messages might not increase perceived cancer risk or increase interest in cancer screening as widely theorized and intended; instead, they simply may elicit anger and discouragement among African Americans.

The effect of preoperative ß-blocker use and race on long-term survival after coronary artery bypass grafting.

OBJECTIVE: To date, racial differences in the long-term survival of coronary artery bypass grafting (CABG) patients who receive preoperative ß-blockers have not been specifically examined. The purpose of this study was to examine the effect of preoperative ß-blockers on long-term survival among black CABG patients and to compare the magnitude of this effect with white patients. DESIGN: A retrospective cohort study. SETTING: A tertiary referral heart hospital. PARTICIPANTS: 13,354 patients undergoing CABG between 1992 and 2011. MEASUREMENTS AND MAIN RESULTS: Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 1,448 (62%) black and 6,094 (55%) white patients had a history of preoperative ß-blocker use. Among black patients, those receiving ß-blockers survived longer than those not receiving ß-blockers (adjusted HR = 0.77, 95% CI = 0.67-0.88). The survival advantage was comparable to that observed among white patients (adjusted HR = 0.88, 95% CI = 0.82-0.93). CONCLUSION: Black CABG patients benefited from preoperative ß-blockers and the magnitude of the effect was comparable to that among white patients.

Race, insurance type, and stage of presentation among lung cancer patients.

The purpose of this study was to determine whether African-American lung cancer patients are diagnosed at a later stage than white patients, regardless of insurance type. The relationship between race and stage at diagnosis by insurance type was assessed using a Poisson regression model, with relative risk as the measure of association. The setting of the study was a large tertiary care cancer center located in the southeastern United States. Patients who were diagnosed with lung cancer between 2001 and 2010 were included in the study. A total of 717 (31%) African-American and 1,634 (69%) white lung cancer patients were treated at our facility during the study period. Adjusting for age, sex, and smoking-related histology, African-American patients were diagnosed at a statistically significant later stage (III/IV versus I/II) than whites for all insurance types, with the exception of Medicaid. Our results suggest that equivalent insurance coverage may not ensure equal presentation of stage between African-American and white lung cancer patients. Future research is needed to determine whether other factors such as treatment delays, suboptimal preventive care, inappropriate specialist referral, community segregation, and a lack of patient trust in health care providers may explain the continuing racial disparities observed in the current study.

Telephone Surveys Underestimate Cigarette Smoking among African-Americans.

BACKGROUND: This study tested the hypothesis that data from random digit-dial telephone surveys underestimate the prevalence of cigarette smoking among African-American adults. METHOD: A novel, community-sampling method was used to obtain a statewide, random sample of N = 2118 California (CA) African-American/Black adults, surveyed door-to-door. This Black community sample was compared to the Blacks in the CA Health Interview Survey (N = 2315), a statewide, random digit-dial telephone survey conducted simultaneously. RESULTS: Smoking prevalence was significantly higher among community (33%) than among telephone survey (19%) Blacks, even after controlling for sample differences in demographics. CONCLUSION: Telephone surveys underestimate smoking among African-Americans and probably underestimate other health risk behaviors as well. Alternative methods are needed to obtain accurate data on African-American health behaviors and on the magnitude of racial disparities in them.

The relation of race and type of health insurance to long-term risk of mortality among lung cancer patients in rural Eastern North Carolina.

BACKGROUND: Black patients with lung cancer have a higher mortality rate than do their white counterparts. Differences in insurance coverage, demographic characteristics, and treatment profiles may explain this disparity. The purpose of this study was to compare the longterm risk of mortality of black lung cancer patients with that of white lung cancer patients, by insurance type. METHODS: Patients who were diagnosed with lung cancer in Eastern North Carolina and treated at the Leo Jenkins Cancer Center between 2001 and 2010 were included in this study. A Cox regression model was used to compare the risk of mortality of black patients with that of white patients. RESULTS: A total of 2,351 lung cancer patients (717 black and 1,634 white) were treated at the Leo Jenkins Cancer Center during the study period. Independent of age and sex, black patients with lung cancer were observed to die sooner than their white counterparts (hazard ratio = 1.2; 95% confidence interval, 1.04-1.3; P = .0070). However, this difference was not statistically significant after controlling for and stratifying by insurance type. LIMITATIONS: Residual confounding and the misclassification of some variables could have biased estimated study effects. CONCLUSION: The racial disparity in lung cancer mortality observed in Eastern North Carolina is no longer apparent after health insurance type is accounted for.

Polytobacco use and multiple-product smoking among a random community sample of African-American adults.

OBJECTIVES: Little is known about polytobacco use among African-American adults. This study is the first to explore this among a random, statewide, community sample of African-American adults. SETTING: Community-based sampling obtained a random, household-probability sample of African-American adults from California, surveyed door to door in randomly selected census tracts statewide. PARTICIPANTS: Participants were a statewide, random-household sample of N=2118 African-American adults from California who completed a survey on past 30-day smoking of cigarettes, blunts, bidis, kreteks, cigarillos, marijuana and cigars. RESULTS: Almost half (49.3%) of the African-American cigarette-smokers and 14.9% of the cigarette non-smokers had smoked at least one non-cigarette product in the past 30 days. Smokers had a substantial prevalence of smoking cigarillos (28.7%) and blunts (27.7%). Logistic regressions revealed that the odds of smoking most of the non-cigarette products were higher for cigarette smokers and men, inversely related to age, and unrelated to socioeconomic status. However, smoking of blunts, bidis and kreteks was not predicted by cigarette smoking. CONCLUSIONS: Smoking of cigarillos (eg, Phillies, Black & Mild) and blunts may be prevalent among African-American cigarette-smokers and non-smokers alike, but such products are not examined in most population-level smoking research. Smoking of these products should be included in surveillance studies, in cancer prevention programmes and in healthcare provider-assessment of smoking, and addressed in smoking cessation programmes as well.

Racial discrimination and health-promoting vs damaging behaviors among African-American adults.

Studies have found relationships between racial discrimination and increased health-damaging behaviors among African-Americans, but have not examined possible concomitant decreased health-promoting behaviors. We explored the role of discrimination in two health-promoting behaviors, consuming ≥ 5 fruits/vegetables daily (FVC) and physical activity (PA), for the first time, and likewise examined discrimination's contribution to cigarette smoking, among a sample of N = 2118 African-American adults. Results revealed that discrimination contributed positively to smoking and to PA but was unrelated to FVC. These findings suggest that both adaptive and maladaptive health behaviors might be used to cope with the stress of discrimination.