Racial and ethnic associations with comprehensive cancer center access and clinical trial enrollment for acute leukemia.

BACKGROUND: Clinical trial participation at Comprehensive Cancer Centers (CCC) is inequitable for minoritized racial and ethnic groups with acute leukemia. CCCs care for a high proportion of adults with acute leukemia. It is unclear if participation inequities are due to CCC access, post-access enrollment, or both. METHODS: We conducted a retrospective cohort study of adults with acute leukemia (2010-2019) residing within Massachusetts, the designated catchment area of the Dana-Farber/Harvard Cancer Center (DF/HCC). Individuals were categorized as non-Hispanic Asian (NHA), Black (NHB), White (NHW), Hispanic White (HW), or Other. Decomposition analyses assessed covariate contributions to disparities in (1) access to DF/HCC care and (2) post-access enrollment. RESULTS: Of 3698 individuals with acute leukemia, 85.9% were NHW, 4.5% HW, 4.3% NHB, 3.7% NHA, and 1.3% Other. Access was lower for HW (age- and sex-adjusted OR = 0.64, 95% CI = 0.45 to 0.90) and reduced post-access enrollment for HW (aOR = 0.54, 95% CI =0.34 to 0.86) and NHB (aOR = 0.60, 95% CI = 0.39 to 0.92) compared to NHW. Payor and socioeconomic status (SES) accounted for 25.2% and 21.2% of the +1.1% absolute difference in HW access. Marital status and SES accounted for 8.0% and 7.0% of the -8.8% absolute disparity in HW enrollment; 76.4% of the disparity was unexplained. SES and marital status accounted for 8.2% and 7.1% of the -9.1% absolute disparity in NHB enrollment; 73.0% of the disparity was unexplained. CONCLUSIONS: A substantial proportion of racial and ethnic inequities in acute leukemia trial enrollment at CCCs are from post-access enrollment, the majority of which was not explained by sociodemographic factors.

Disparities and Underutilization of Surgery for Early Stage Small Cell Lung Cancer.

BACKGROUND: The National Comprehensive Cancer Network recommends surgical resection for stage I small cell lung cancer (SCLC). Despite these recommendations and the curative potential of such surgery, many continue to underutilize surgery. Our aim is to investigate factors that contribute to underutilization of surgery for stage I SCLC. METHODS: The National Cancer Database was queried to identify patients with SCLC stage I-IV from 2004 to 2018. Staging was defined by the American Joint Committee on Cancer guidelines. Cochran-Armitage analysis was performed to analyze trends in surgical treatment for patients diagnosed with stage I SCLC. Multivariable logistic regression assessed relationships between patient factors and surgical treatment. RESULTS: A total of 296,583 patients were diagnosed with SCLC. Of the stage I patients (n = 13,003), only 29.4.% (n = 3823) underwent surgery. Trend analysis demonstrated increased frequency of surgical treatment for stage I SCLC over years 2004 to 2017, from 14.9% to 39.6% (P < .0001). Factors that were associated with underutilization of surgery for stage I SCLC include African American race, lower median income, nonprivate insurance or Medicare, community facility, and geographic regions other than the Northeast. CONCLUSIONS: Surgical treatment for stage I SCLC remains underutilized and our study identifies notable associated factors. The recognition of these factors may help patients overcome barriers to receiving recommended treatments, improve guideline adherence, and overall quality of care for stage I SCLC patients.

Demographic disparities in receipt of care at a comprehensive cancer center.

BACKGROUND: National Cancer Institute cancer centers (NCICCs) provide specialized cancer care including precision oncology and clinical treatment trials. While these centers can offer novel therapeutic options, less is known about when patients access these centers or at what timepoint in their disease course they receive specialized care. This is especially important since precision diagnostics and receipt of the optimal therapy upfront can impact patient outcomes and previous research suggests that access to these centers may vary by demographic characteristics. Here, we examine the timing of patients' presentation at Moffitt Cancer Center (MCC) relative to their initial diagnosis across several demographic characteristics. METHODS: A retrospective cohort study was conducted among patients who presented to MCC with breast, colon, lung, melanoma, and prostate cancers between December 2008 and April 2020. Patient demographic and clinical characteristics were obtained from the Moffitt Cancer Registry. The association between patient characteristics and the timing of patient presentation to MCC relative to the patient's cancer diagnosis was examined using logistic regression. RESULTS: Black patients (median days = 510) had a longer time between diagnosis and presentation to MCC compared to Whites (median days = 368). Black patients were also more likely to have received their initial cancer care outside of MCC compared to White patients (odds ratio [OR] and 95% confidence interval [CI] = 1.45 [1.32-1.60]). Furthermore, Hispanics were more likely to present to MCC at an advanced stage compared to non-Hispanic patients (OR [95% CI] = 1.28 [1.05-1.55]). CONCLUSIONS: We observed racial and ethnic differences in timing of receipt of care at MCC. Future studies should aim to identify contributing factors for the development of novel mitigation strategies and assess whether timing differences in referral to an NCICC correlate with long-term patient outcomes.

Disparities in Oral Nutritional Supplement Usage and Dispensing Patterns across Primary Care in Ireland: ONSPres Project.

When treating malnutrition, oral nutritional supplements (ONSs) are advised when optimising the diet is insufficient; however, ONS usage and user characteristics have not been previously analysed. A retrospective secondary analysis was performed on dispensed pharmacy claim data for 14,282 anonymised adult patients in primary care in Ireland in 2018. Patient sex, age, residential status, ONS volume (units) and ONS cost (EUR) were analysed. The categories of 'Moderate' (<75th centile), 'High' (75th-89th centile) and 'Very High' ONS users (≥90th centile) were created. The analyses among groups utilised t-tests, Mann-Whitney U tests and chi-squared tests. This cohort was 58.2% female, median age was 76 years, with 18.7% in residential care. The most frequently dispensed ONS type was very-high-energy sip feeds (45% of cohort). Younger males were dispensed more ONSs than females (<65 years: median units, 136 vs. 90; p < 0.01). Patients living independently were dispensed half the volume of those in residential care (112 vs. 240 units; p < 0.01). 'Moderate' ONS users were dispensed a yearly median of 84 ONS units (median cost, EUR 153), 'High' users were dispensed 420 units (EUR 806) and 'Very High' users 892 yearly units (EUR 2402; p < 0.01). Further analyses should focus on elucidating the reasons for high ONS usage in residential care patients and younger males.

Ethnic inequalities in mental health and socioeconomic status among older women living with HIV: results from the PRIME Study.

OBJECTIVES: Women living with HIV in the UK are an ethnically diverse group with significant psychosocial challenges. Increasing numbers are reaching older age. We describe psychological and socioeconomic factors among women with HIV in England aged 45-60 and explore associations with ethnicity. METHODS: Analysis of cross-sectional data on 724 women recruited to the PRIME Study. Psychological symptoms were measured using the Patient Health Questionnaire 4 and social isolation with a modified Duke-UNC Functional Social Support Scale. RESULTS: Black African (BA) women were more likely than Black Caribbean or White British (WB) women to have a university education (48.3%, 27.0%, 25.7%, respectively, p<0.001), but were not more likely to be employed (68.4%, 61.4%, 65.2%, p=0.56) and were less likely to have enough money to meet their basic needs (56.4%, 63.0%, 82.9%, p<0.001). BA women were less likely to report being diagnosed with depression than WB women (adjusted odds ratio (aOR) 0.40, p<0.001) but more likely to report current psychological distress (aOR 3.34, p<0.05). CONCLUSIONS: We report high levels of poverty, psychological distress and social isolation in this ethnically diverse group of midlife women with HIV, especially among those who were BA. Despite being more likely to experience psychological distress, BA women were less likely to have been diagnosed with depression suggesting a possible inequity in access to mental health services. Holistic HIV care requires awareness of the psychosocial needs of older women living with HIV, which may be more pronounced in racially minoritised communities, and prompt referral for support including psychology, peer support and advice about benefits.

Assessing Inequities in Cervical Cancer Quality of Care and Survival Related to Ethnicity and Socioeconomic Factors.

OBJECTIVE: This study aimed to assess the effect that race and socioeconomic factors have on the provision of care to cervical cancer patients based on National Comprehensive Cancer Network (NCCN) recommended treatment guidelines. MATERIALS AND METHODS: To do this, we completed a retrospective cohort study using the American College of Surgeon's Nation Cancer Database from 2004 to 2016. We identified all reported cases of cervical cancer in that period. Two cohorts were created using self-reported racial demographic data, Hispanic- and White, non-Hispanic-identified patients. Our primary outcome variables were adherence to NCCN-recommended treatment and 5-year overall survival. Adherence to NCCN-recommended treatment was determined by the provision of surgical and/or radiation and/or chemotherapy treatment based on the clinical stage at time of diagnosis and the presence or absence of lymphovascular space invasion. We used bivariate analyses to compare baseline characteristics between the 2 cohorts, multivariable logistic regression to identify independent predictors of 5-year survival, and Cox proportional hazards models to compute survival by group. RESULTS: The difference in NCCN-adherent care between the 2 cohorts was found to be not statistically significant (p = .880). A log rank (Mantel-Cox) χ2 test showed that there was a statistically significant difference between the 2 groups in overall survival with the Hispanic-identified patients living longer (p < .001). Our study is limited by the effect large databases confer on finding statistical significance. CONCLUSIONS: Hispanic-identified women with cervical cancer receive NCCN-compliant care and live longer than their White, non-Hispanic counterparts.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Racial/Ethnic Disparities in the Performance of Prediction Models for Death by Suicide After Mental Health Visits.

Importance: Clinical prediction models estimated with health records data may perpetuate inequities. Objective: To evaluate racial/ethnic differences in the performance of statistical models that predict suicide. Design, Setting, and Participants: In this diagnostic/prognostic study, performed from January 1, 2009, to September 30, 2017, with follow-up through December 31, 2017, all outpatient mental health visits to 7 large integrated health care systems by patients 13 years or older were evaluated. Prediction models were estimated using logistic regression with LASSO variable selection and random forest in a training set that contained all visits from a 50% random sample of patients (6 984 184 visits). Performance was evaluated in the remaining 6 996 386 visits, including visits from White (4 031 135 visits), Hispanic (1 664 166 visits), Black (578 508 visits), Asian (313 011 visits), and American Indian/Alaskan Native (48 025 visits) patients and patients without race/ethnicity recorded (274 702 visits). Data analysis was performed from January 1, 2019, to February 1, 2021. Exposures: Demographic, diagnosis, prescription, and utilization variables and Patient Health Questionnaire 9 responses. Main Outcomes and Measures: Suicide death in the 90 days after a visit. Results: This study included 13 980 570 visits by 1 433 543 patients (64% female; mean [SD] age, 42 [18] years. A total of 768 suicide deaths were observed within 90 days after 3143 visits. Suicide rates were highest for visits by patients with no race/ethnicity recorded (n = 313 visits followed by suicide within 90 days, rate = 5.71 per 10 000 visits), followed by visits by Asian (n = 187 visits followed by suicide within 90 days, rate = 2.99 per 10 000 visits), White (n = 2134 visits followed by suicide within 90 days, rate = 2.65 per 10 000 visits), American Indian/Alaskan Native (n = 21 visits followed by suicide within 90 days, rate = 2.18 per 10 000 visits), Hispanic (n = 392 visits followed by suicide within 90 days, rate = 1.18 per 10 000 visits), and Black (n = 65 visits followed by suicide within 90 days, rate = 0.56 per 10 000 visits) patients. The area under the curve (AUC) and sensitivity of both models were high for White, Hispanic, and Asian patients and poor for Black and American Indian/Alaskan Native patients and patients without race/ethnicity recorded. For example, the AUC for the logistic regression model was 0.828 (95% CI, 0.815-0.840) for White patients compared with 0.640 (95% CI, 0.598-0.681) for patients with unrecorded race/ethnicity and 0.599 (95% CI, 0.513-0.686) for American Indian/Alaskan Native patients. Sensitivity at the 90th percentile was 62.2% (95% CI, 59.2%-65.0%) for White patients compared with 27.5% (95% CI, 21.0%-34.7%) for patients with unrecorded race/ethnicity and 10.0% (95% CI, 0%-23.0%) for Black patients. Results were similar for random forest models, with an AUC of 0.812 (95% CI, 0.800-0.826) for White patients compared with 0.676 (95% CI, 0.638-0.714) for patients with unrecorded race/ethnicity and 0.642 (95% CI, 0.579-0.710) for American Indian/Alaskan Native patients and sensitivities at the 90th percentile of 52.8% (95% CI, 50.0%-55.8%) for White patients, 29.3% (95% CI, 22.8%-36.5%) for patients with unrecorded race/ethnicity, and 6.7% (95% CI, 0%-16.7%) for Black patients. Conclusions and Relevance: These suicide prediction models may provide fewer benefits and more potential harms to American Indian/Alaskan Native or Black patients or those with undrecorded race/ethnicity compared with White, Hispanic, and Asian patients. Improving predictive performance in disadvantaged populations should be prioritized to improve, rather than exacerbate, health disparities.

Addressing the huge poor-rich gap of inequalities in accessing safe childbirth care: A first step to achieving universal maternal health coverage in Tanzania.

INTRODUCTION: Despite skilled attendance during childbirth has been linked with the reduction of maternal deaths, equality in accessing this safe childbirth care is highly needed to achieving universal maternal health coverage. However, little information is available regarding the extent of inequalities in accessing safe childbirth care in Tanzania. This study was performed to assess the current extent, trend, and potential contributors of poor-rich inequalities in accessing safe childbirth care among women in Tanzania. METHODS: This study used data from 2004, 2010, and 2016 Tanzania Demographic Health Surveys. The two maternal health services 1) institutional delivery and 2) skilled birth attendance was used to measures access to safe childbirth care. The inequalities were assessed by using concentration curves and concentration indices. The decomposition analysis was computed to identify the potential contributors to the inequalities in accessing safe childbirth care. RESULTS: A total of 8725, 8176, and 10052 women between 15 and 49 years old from 2004, 2010, and 2016 surveys respectively were included in the study. There is an average gap (>50%) between the poorest and richest in accessing safe childbirth care during the study period. The concentration curves were below the line of inequality which means women from rich households have higher access to the institutional delivery and skilled birth attendance inequalities in accessing institutional delivery and skilled birth attendance. These were also, confirmed with their respective positive concentration indices. The decomposition analysis was able to unveil that household's wealth status, place of residence, and maternal education as the major contributors to the persistent inequalities in accessing safe childbirth care. CONCLUSION: The calls for an integrated policy approach which includes fiscal policies, social protection, labor market, and employment policies need to improve education and wealth status for women from poor households. This might be the first step toward achieving universal maternal health coverage.

Active Surveillance for Men with Intermediate Risk Prostate Cancer.

PURPOSE: Optimal treatment of intermediate risk prostate cancer remains unclear. National Comprehensive Cancer Network® guidelines recommend active surveillance, prostatectomy or radiotherapy. Recent trials demonstrated no difference in prostate cancer specific mortality for men undergoing active surveillance for low risk prostate cancer compared to prostatectomy or radiotherapy. The use of active surveillance for intermediate risk prostate cancer is less clear. In this study we characterize U.S. national trends for demographic, clinical and socioeconomic factors associated with active surveillance for men with intermediate risk prostate cancer. MATERIALS AND METHODS: This retrospective cohort study examined 176,122 men diagnosed with intermediate risk prostate cancer from 2010 to 2016 in the National Cancer Database. Temporal trends in demographic, clinical and socioeconomic factors among men with intermediate risk prostate cancer and association with the use of active surveillance were characterized. The analysis was performed in April 2020. RESULTS: In total, 176,122 men were identified with intermediate risk prostate cancer from 2010 to 2016. Of these men 57.3% underwent prostatectomy, 36.4% underwent radiotherapy and 3.2% underwent active surveillance. Active surveillance nearly tripled from 1.6% in 2010 to 4.6% in 2016 (p <0.001). On multivariate analysis use of active surveillance was associated with older age, diagnosis in recent years, lower Gleason score and tumor stage, type of insurance, treatment at an academic center and proximity to facility, and attaining higher education (p <0.05). Race and comorbidities were not associated with active surveillance. CONCLUSIONS: Our findings highlight increasing active surveillance use for men with intermediate risk prostate cancer demonstrating clinical and socioeconomic disparities. Prospective data and improved risk stratification are needed to guide optimal treatment for men with intermediate risk prostate cancer.

Adherence to treatment guidelines as a major determinant of survival disparities between black and white patients with ovarian cancer.

OBJECTIVE: To evaluate whether non-adherence to National Comprehensive Cancer Network (NCCN) treatment guidelines and other factors related to treatment access contribute to racial disparities in ovarian cancer survival. METHODS: This large cohort study included patients from the National Cancer Database who were diagnosed with ovarian cancer between 2004 and 2014, with follow-up data up to 2017. The multivariable Cox regression was used to assess the effect of study variables on five-year overall survival. The proportion contributions of prognostic factors to the survival disparities were estimated using individual and sequential adjustment of these factors based on the Cox proportional hazards models. RESULTS: Of the 120,712 patients eligible for this study, 110,032 (91.1%) were whites and 10,680 (8.9%) were blacks. Black patients, compared with their white counterparts, had a lower adherence to NCCN guidelines (60.8% vs. 70.4%, respectively, P < 0.001), and a higher five-year mortality after cancer diagnosis (age- and tumor characteristics- adjusted hazard ratio: 1.22, 95% confidence interval: 1.19-1.25). Non-adherence to NCCN treatment guidelines was the most significant contributor to racial disparity in ovarian cancer survival, followed by access to care and comorbidity, each explaining 36.4%, 22.7%, and 18.2% of the racial differences in five-year overall survival, respectively. These factors combined explain 59.1% of racial survival disparities. Risk factors identified for non-adherence to treatment guidelines among blacks include insurance status, treatment facility type, educational attainment, age, and comorbidity. CONCLUSIONS: Adherence status to NCCN treatment guidelines is the most important contributor to the survival disparities between black and white patients with ovarian cancer. Our findings call for measures to promote equitable access to guideline-adherence care to improve the survival of black women with ovarian cancer.

Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States.

BACKGROUND: Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. METHODS AND FINDINGS: Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. CONCLUSION: Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

Horizontal inequity in the use and access to health care in Uruguay.

BACKGROUND: In 2007 Uruguay began a reform in the health sector towards the construction of a National Integrated Health System (SNIS), based on public insurance with private and public provision. The main objective of the reform was to universalize access to health services. METHODS: Data comes from the first National Health Survey conducted in 2014 and available since 2016. Concentration indices are calculated for different indicators of use and access to medical services, for the population 18 years of age and older, and for different subgroups (age, sex, region and type of coverage). The indices are decomposed into need and non-need variables and the contribution of each of them to total inequality is analyzed. Horizontal inequity is calculated. RESULTS: Results show pro-rich inequality for medical consultations, medical analysis, medication use and non-access due to costs. Type of health coverage is the variable that explains most of the inequality: private coverage is pro-rich while public coverage is pro-poor. Income does not appear as significant to explain inequality, except for access issues. From the population subgroups' analysis, there is no evidence of inequality for the group of 60 years old or more. On the other hand, studies such as Pap Smear and prostate, which may be associated with preventive studies,, shows pro-rich inequality and, in both cases, the main contribution is given by income. CONCLUSIONS: The analysis of health inequity shows pro-rich inequity in medical consultations, medical analysis, medication use and lack of access due to costs. The type of health coverage explains these inequalities; in particular, private coverage is pro-rich. These results suggest that the type of health coverage are capturing the income factor, since higher income individuals will be more likely to be treated in the private system.

Disparities in outpatient visits for mental health and/or substance use disorders during the COVID surge and partial reopening in Massachusetts.

OBJECTIVE: To examine changes in outpatient visits for mental health and/or substance use disorders (MH/SUD) in an integrated healthcare organization during the initial Massachusetts COVID-19 surge and partial state reopening. METHODS: Observational study of outpatient MH/SUD visits January 1st-June 30th, 2018-2020 by: 1) visit diagnosis group, 2) provider type, 3) patient race/ethnicity, 4) insurance, and 5) visit method (telemedicine vs. in-person). RESULTS: Each year, January-June 52,907-73,184 patients were seen for a MH/SUD visit. While non-MH/SUD visits declined during the surge relative to 2020 pre-pandemic (-38.2%), MH/SUD visits increased (9.1%)-concentrated in primary care (35.3%) and non-Hispanic Whites (10.5%). During the surge, MH visit volume increased 11.7% while SUD decreased 12.7%. During partial reopening, while MH visits returned to 2020 pre-pandemic levels, SUD visits declined 31.1%; MH/SUD visits decreased by Hispanics (-33.0%) and non-Hispanic Blacks (-24.6%), and among Medicaid (-19.4%) and Medicare enrollees (-20.9%). Telemedicine accounted for ~5% of MH/SUD visits pre-pandemic and 83.3%-83.5% since the surge. CONCLUSIONS: MH/SUD visit volume increased during the COVID surge and was supported by rapidly-scaled telemedicine. Despite this, widening diagnostic and racial/ethnic disparities in MH/SUD visit volume during the surge and reopening suggest additional barriers for these vulnerable populations, and warrant continued monitoring and research.

Electronic Patient Portal Use in Orthopaedic Surgery Is Associated with Disparities, Improved Satisfaction, and Lower No-Show Rates.

BACKGROUND: Electronic patient portal (EPP) use has been associated with a number of benefits in the internal medicine setting. Few studies have examined the disparities in and the benefits of EPP utilization among surgical patients. The purposes of this study were to examine factors associated with EPP use among patients undergoing an orthopaedic surgical procedure and to determine if EPP use is associated with improved outcomes or satisfaction after orthopaedic surgical procedures. METHODS: We queried all patients undergoing an orthopaedic surgical procedure from May 2015 to December 2018 at 2 academic medical centers in an integrated hospital system. Patient demographic characteristics, operative characteristics, satisfaction scores, and patient-reported outcome measures (PROMs) were collected. Multivariable logistic regression was used to identify disparities in EPP use. Adjusted logistic and linear regressions were then used to assess the association between EPP use and the various outcome metrics while controlling for confounders identified in the previous analysis. RESULTS: Numerous demographic factors were independently associated with EPP use among patients undergoing an orthopaedic surgical procedure, including English speakers compared with non-English speakers (odds ratio [OR], 2.37 [95% confidence interval (CI), 2.01 to 2.79]); African-American or black race (OR, 0.42 [95% CI, 0.36 to 0.48]) and Hispanic race (OR, 0.52 [95% CI, 0.44 to 0.61]) compared with white race; college education compared with high school education (OR, 2.30 [95% CI, 2.12 to 2.49]); and a surgical procedure for orthopaedic trauma compared with that for the hand or upper extremity (OR, 0.51 [95% CI, 0.45 to 0.58]) (p < 0.001 for all), among others. EPP use was independently associated with the increased likelihood of completing a PROM (OR, 1.57 [95% CI, 1.45 to 1.7]) and a satisfaction survey (OR, 2.38 [95% CI, 2.17 to 2.61]) and improved overall patient satisfaction (mean difference, 2.61 points [95% CI, 1.79 to 3.43 points]) (p < 0.001 for all). Finally, EPP use was independently associated with lower mean no-show rates (6.8% [95% CI, 6.4% to 7.2%] compared with 9.3% [95% CI, 8.9% to 9.7%]). The lower no-show rate for EPP users corresponded to an estimated $218,225 in savings for our institution within the first postoperative year. CONCLUSIONS: This study identified significant disparities in EPP use among patients undergoing an orthopaedic surgical procedure. Given that EPP use was independently associated with lower no-show rates and improved patient satisfaction among patients undergoing an orthopaedic procedure, efforts to reduce these disparities are warranted. CLINICAL RELEVANCE: EPPs are increasingly being used by health-care systems to improve communication between providers and patients; however, providers should be aware of and strive to eliminate disparities in EPP utilization among orthopaedic patients. Within orthopaedic surgery, EPPs are associated with a number of benefits, including lower no-show rates and increased patient satisfaction.

Syndemic Perspectives to Guide Black Maternal Health Research and Prevention During the COVID-19 Pandemic.

The coronavirus 2019 (COVID-19) pandemic and related policies have led to an unequal distribution of morbidity and mortality in the U.S. For Black women and birthing people, endemic vulnerabilities and disparities may exacerbate deleterious COVID-19 impacts. Historical and ongoing macro-level policies and forces over time have induced disproportionately higher rates of maternal morbidity and mortality among Black women and birthing people, and contemporary macroeconomic and healthcare policies and factors continue to hold particular consequence. These factors induce detrimental psychological, health, and behavioral responses that contribute to maternal health disparities. The COVID-19 pandemic is likely to disproportionately impact Black women and birthing people, as policy responses have failed to account for the their unique socioeconomic and healthcare contexts. The resulting consequences may form a 'vicious cycle', with upstream impacts that exacerbate upstream macro-level policies and forces that can further perpetuate the clustering of maternal morbidity and mortality in this population. Understanding the impacts of COVID-19 among Black women and birthing people requires theoretical frameworks that can sufficiently conceptualize their multi-level, interacting, and dynamic nature. Thus, we advocate for the proliferation of syndemic perspectives to guide maternal disparities research and prevention during the COVID-19 pandemic. These perspectives can enable a holistic and nuanced understanding of the intersection of endemic and COVID-19-specific vulnerabilities and disparities experienced by Black women and birthing people. Syndemic-informed research can then lead to impactful multi-level prevention strategies that simultaneously tackle both endemic and COVID-19-specific factors and outcomes that lead to the clustering of vulnerabilities and disparities over time.

Differences in realized access to healthcare among newly arrived refugees in Germany: results from a natural quasi-experiment.

BACKGROUND: Germany has a statutory health insurance (SHI) that covers nearly the entire population and most of the health services provided. Newly arrived refugees whose asylum claim is still being processed are initially excluded from the SHI. Instead, their entitlements are restricted and parallel access models have been implemented. We assessed differences in realized access of healthcare services between these access models. METHODS: In Germany's largest federal state, North Rhine-Westphalia, two different access models have been implemented in the 396 municipalities: the healthcare voucher (HcV) model and the electronic health card (eHC) model. As refugees are quasi-randomly assigned to municipalities, we were able to realize a natural quasi-experiment including all newly assigned refugees from six municipalities (three for each model) in 2016 and 2017. Using claims data, we compared the standardized incidence rates (SIR) of specialist services use, emergency services use, and hospitalization due to ambulatory care sensitive conditions (ACSC) between both models. We indirectly standardized utilization patterns first for age and then for the sex. RESULTS: SIRs of emergency use were higher in municipalities with HcV (ranging from 1.41 to 2.63) compared to emergency rates in municipalities with eHC (ranging from 1.40 to 1.71) and differed significantly from the expected rates derived from official health reporting. SIRs of emergency and specialist use in municipalities with eHC converged with the expected rates over time. There were no significant differences in standardized hospitalization rates for ACSC. CONCLUSION: The results suggest that the eHC model is slightly better able to provide refugees with SHI-like access to specialist services and goes along with lower utilization of emergency services compared to the HcV model. No difference between the models was found for hospitalizations due to ACSC. Results might be slightly biased due to incompletely documented service use and due to (self-) selection on the level of municipalities with municipalities interested in facilitating access showing more interest in joining the project.

Comparison between urban and rural mortality in patients with acute myocardial infarction: a nationwide longitudinal cohort study in South Korea.

OBJECTIVES: This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence. DESIGN: A nationwide longitudinal cohort. SETTING: National Health Insurance Service database of South Korea. PARTICIPANTS: This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database. PRIMARY OUTCOME MEASURE: The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year. RESULTS: Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients. CONCLUSIONS: To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.