Ambient ultraviolet-B radiation, supplements and other factors interact to impact vitamin D status differently depending on ethnicity: A cross-sectional study.

BACKGROUND & AIMS: Many determinants of vitamin D status have been well-described, yet supplementation guidelines largely follow a one-size-for-all model and deficiency remains common. We hypothesised that accounting accurately for ultraviolet-B (UVB) radiation and considering interactions could advance understanding of vitamin D status. METHODS: Asian, Black, and White participants from the UK Biobank cohort were included (N = 438,978). The Tropospheric Emission Monitoring Internet Service provided UVB data which we linked to participants' place of residence. UVB dose over 135 days prior to blood draw was weighted and added, yielding cumulative and weighted UVB (CW-D-UVB). The association between 25(OH)D and selected variables was assessed in multivariable linear regression models with and without interactions, stratified by ethnicity. Predictors were ranked using standardised ß-coefficients. RESULTS: Median 25(OH)D differed by ethnicity (Asian: 25.4 nmol/L (10.2 ng/mL), Black: 30.6 nmol/L (12.2 ng/mL), White: 47.9 nmol/L (19.2 ng/mL), p-value < 0.001). CW-D-UVB was strongly associated with 25(OH)D in all ethnicities. It was the most important predictor in White (ßAsian = 0.15, ßBlack = 0.20, ßWhite = 0.35), whereas supplementation was in Asian and Black participants (ßAsian = 0.30, ßBlack = 0.24, ßWhite = 0.21). We identified statistically significant interactions between BMI:supplementation (all), CW-D-UVB:sex (Asian and White), and CW-D-UVB:age (Black and White), and in White population between CW-D-UVB and supplementation, BMI, and cholesterol. CONCLUSION: Vitamin D deficiency was widespread, particularly among non-White individuals. UVB was a strong predictor of 25(OH)D and the effect was modified by other factors. Findings suggest that accurately measured ambient-UVB radiation and interactions could improve 25(OH)D prediction models, and support personalised approaches to vitamin D optimisation.

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.

Utilization of Traditional Complementary and Alternative Medicine Across Ethnically Diverse Asian Americans.

We conducted an analysis to identify factors influencing the use of traditional complementary and alternative medicine (TCAM), with a particular emphasis on ethnic variations. Using the 2015 Asian American Quality of Life survey (N = 2,609), logistic regression analyses were performed, considering acculturation, health status, healthcare accessibility/utilization, and socio-demographic factors. Ethnicity, specifically being Chinese or Korean Americans, having chronic medical conditions, experiencing unmet healthcare needs, and having regular check-ups were significant predictors of TCAM use among Asian Americans as a whole. However, when we delved into sub-ethnic groups, different patterns were found. Among Vietnamese and Filipino Americans, having unmet healthcare needs emerged as the most prominent predictor of TCAM use. Furthermore, acculturation level and English proficiency were significant in predicting Vietnamese and Filipino Americans' TCAM use, with the direction varying by sub-ethnicity. Being old emerged as a predictor of TCAM use for Chinese, Indian, Korean, and 'other' Americans. Our findings underscore the importance of adopting an ethnically sensitive approach when addressing the healthcare needs of diverse Asian American populations.

Association of Race and Ethnicity With Incidence of Dementia Among Older Adults.

Importance: The racial and ethnic diversity of the US, including among patients receiving their care at the Veterans Health Administration (VHA), is increasing. Dementia is a significant public health challenge and may have greater incidence among older adults from underrepresented racial and ethnic minority groups. Objective: To determine dementia incidence across 5 racial and ethnic groups and by US geographical region within a large, diverse, national cohort of older veterans who received care in the largest integrated health care system in the US. Design, Setting, and Participants: Retrospective cohort study within the VHA of a random sample (5% sample selected for each fiscal year) of 1 869 090 participants aged 55 years or older evaluated from October 1, 1999, to September 30, 2019 (the date of final follow-up). Exposures: Self-reported racial and ethnic data were obtained from the National Patient Care Database. US region was determined using Centers for Disease Control and Prevention (CDC) regions from residential zip codes. Main Outcomes and Measures: Incident diagnosis of dementia (9th and 10th editions of the International Classification of Diseases). Fine-Gray proportional hazards models were used to examine time to diagnosis, with age as the time scale and accounting for competing risk of death. Results: Among the 1 869 090 study participants (mean age, 69.4 [SD, 7.9] years; 42 870 women [2%]; 6865 American Indian or Alaska Native [0.4%], 9391 Asian [0.5%], 176 795 Black [9.5%], 20 663 Hispanic [1.0%], and 1 655 376 White [88.6%]), 13% received a diagnosis of dementia over a mean follow-up of 10.1 years. Age-adjusted incidence of dementia per 1000 person-years was 14.2 (95% CI, 13.3-15.1) for American Indian or Alaska Native participants, 12.4 (95% CI, 11.7-13.1) for Asian participants, 19.4 (95% CI, 19.2-19.6) for Black participants, 20.7 (95% CI, 20.1-21.3) for Hispanic participants, and 11.5 (95% CI, 11.4-11.6) for White participants. Compared with White participants, the fully adjusted hazard ratios were 1.05 (95% CI, 0.98-1.13) for American Indian or Alaska Native participants, 1.20 (95% CI, 1.13-1.28) for Asian participants, 1.54 (95% CI, 1.51-1.57) for Black participants, and 1.92 (95% CI, 1.82-2.02) for Hispanic participants. Across most US regions, age-adjusted dementia incidence rates were highest for Black and Hispanic participants, with rates similar among American Indian or Alaska Native, Asian, and White participants. Conclusions and Relevance: Among older adults who received care at VHA medical centers, there were significant differences in dementia incidence based on race and ethnicity. Further research is needed to understand the mechanisms responsible for these differences.

Racial and Ethnic Disparities in Prostate Cancer Outcomes in the Veterans Affairs Health Care System.

Importance: Prostate cancer (PCa) disproportionately affects African American men, but research evaluating the extent of racial and ethnic disparities across the PCa continuum in equal-access settings remains limited at the national level. The US Department of Veterans Affairs (VA) Veterans Hospital Administration health care system offers a setting of relatively equal access to care in which to assess racial and ethnic disparities in self-identified African American (or Black) veterans and White veterans. Objective: To determine the extent of racial and ethnic disparities in the incidence of PCa, clinical stage, and outcomes between African American patients and White patients who received a diagnosis or were treated at a VA hospital. Design, Setting, and Participants: This retrospective cohort study included 7 889 984 veterans undergoing routine care in VA hospitals nationwide from 2005 through 2019 (incidence cohort). The age-adjusted incidence of localized and de novo metastatic PCa was estimated. Treatment response was evaluated, and PCa-specific outcomes were compared between African American veterans and White veterans. Residual disparity in PCa outcome, defined as the leftover racial and ethnic disparity in the outcomes despite equal response to treatment, was estimated. Exposures: Self-identified African American (or Black) and White race and ethnicity. Main Outcomes and Measures: Time to distant metastasis following PCa diagnosis was the primary outcome. Descriptive analyses were used to compare baseline demographics and clinic characteristics. Multivariable logistic regression was used to evaluate race and ethnicity association with pretreatment clinical variables. Multivariable Cox regression was used to estimate the risk of metastasis. Results: Data from 7 889 984 veterans from the incidence cohort were used to estimate incidence, whereas data from 92 269 veterans with localized PCa were used to assess treatment response. Among 92 269 veterans, African American men (n = 28 802 [31%]) were younger (median [IQR], 63 [58-68] vs 65 [62-71] years) and had higher prostate-specific antigen levels (>20 ng/mL) at the time of diagnosis compared with White men (n = 63 467; [69%]). Consistent with US population-level data, African American veterans displayed a nearly 2-fold greater incidence of localized and de novo metastatic PCa compared with White men across VA centers nationwide. Among veterans screened for PCa, African American men had a 29% increased risk of PCa detection on a diagnostic prostate biopsy compared with White (hazard ratio, 1.29; 95% CI, 1.27-1.31; P < .001). African American men who received definitive primary treatment of PCa experienced a lower risk of metastasis (hazard ratio, 0.89; 95% CI, 0.83-0.95; P < .001). However, African American men who received nondefinitive treatment classified as "other" were more likely to develop metastasis (adjusted hazard ratio, 1.29; 95% CI, 1.17-1.42; P < .001). Using the actual rate of metastasis from veterans who received definitive primary treatment, a persistent residual metastatic burden for African American men was observed across all National Comprehensive Cancer Network risk groups (low risk, 4 vs 2 per 100 000; intermediate risk, 13 vs 6 per 100 000; high risk, 19 vs 9 per 100 000). Conclusions and Relevance: This cohort analysis found significant disparities in the incidence of localized and metastatic PCa between African American veterans and White veterans. This increased incidence is a major factor associated with the residual disparity in PCa metastasis observed in African American veterans compared with White veterans despite their nearly equal response to treatment.

Racial/Ethnic Disparities in Health Care Setting Choice for Adults Seeking Severe Acute Respiratory Syndrome Coronavirus 2 Testing.

OBJECTIVES: Equitable access to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing is important for reducing disparities. We sought to examine differences in the health care setting choice for SARS-CoV-2 testing by race/ethnicity and insurance. Options included traditional health care settings and mobile testing units (MTUs) targeting communities experiencing disproportionately high coronavirus disease 2019 (COVID-19) rates. METHODS: We conducted a retrospective, observational study among patients in a large health system in the Southeastern US. Descriptive statistics and multinomial logistic regression analyses were employed to evaluate associations between patient characteristics and health care setting choice for SARS-CoV-2 testing, defined as: (1) outpatient (OP) care; (2) emergency department (ED); (3) urgent care (UC); and (4) MTUs. Patient characteristics included race/ethnicity, insurance, and the existence of an established relationship with the health care system. RESULTS: Our analytic sample included 105,386 adult patients tested for SARS-CoV-2. Overall, 55% of patients sought care at OP, 24% at ED, 12% at UC, and 9% at MTU. The sample was 58% White, 24% Black, 11% Hispanic, and 8% other race/ethnicity. Black patients had a higher likelihood of getting tested through the ED compared with White patients. Hispanic patients had the highest likelihood of testing at MTUs. Patients without a primary care provider had a higher relative risk of being tested through the ED and MTUs versus OP. CONCLUSIONS: Disparities by race/ethnicity were present in health care setting choice for SARS-CoV-2 testing. Health care systems may consider implementing mobile care delivery models to reach vulnerable populations. Our findings support the need for systemic change to increase primary care and health care access beyond short-term pandemic solutions.

Accelerated coronary calcium burden in breast cancer patients after radiotherapy: a comparison with age and race matched healthy women.

BACKGROUND: Radiotherapy (RT) might lead to atherosclerotic plaque buildup and coronary artery stenosis of breast cancer (BC) survivors, and coronary artery calcium (CAC) might be a sign of preclinical atherosclerosis. This study explores possible determinants affecting the acceleration of CAC burden in BC patients after adjuvant RT. METHODS: Female BC patients receiving adjuvant RT from 2002 to 2010 were included. All patients received noncontrast computed tomography (NCCT) of thorax before and after adjuvant RT. Their CAC burden was compared with healthy controls from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. The progression of the CAC burden was manifested by the increment of CAC percentiles (%CACinc). RESULTS: Ninety-four patients, including both left- and right-side BC, were enrolled in this study. From undergoing the first to second NCCT, the %CACinc in BC patients significantly increased rather than non-BC women. In addition, the %CACinc was significantly higher in left-side than right-side BC patients (p < 0.05), and significant differences in most heart outcomes were found between the two groups. Besides, the lower the mean right coronary artery (RCA) dose, the lower the risks of CAC percentiles increase ≥ 50% after adjusting the disease's laterality. CONCLUSIONS: A significantly higher accelerated CAC burden in BC patients than non-BC women represents that BC could affect accelerated CAC. A higher risk of accelerated CAC burden was found in left-side than right-side BC patients after adjuvant RT. A decrease of the mean RCA dose could reduce more than 50% of the risk of accelerated CAC burden in BC patients.

Factors Influencing the Compliance of Pregnant Women with Iron and Folic Acid Supplementation in the Philippines: 2017 Philippine Demographic and Health Survey Analysis.

Anemia in pregnancy, which is a public health concern for most developing countries, is predominantly caused by iron deficiency. At least, 180 days of iron and folic acid (IFA) supplementation is recommended for pregnant women to mitigate anemia and its adverse effects. This study aimed to examine compliance with the recommendation of IFA supplementation and its underlying factors using the 2017 Philippine National Demographic and Health Survey data. The variables assessed included age, highest level of education, occupation, wealth index, ethnicity, religion, residence, number of pregnancies, time of first antenatal care (ANC) visit and number of ANC visits. Compliance with the recommendation of at least 180 days of IFA supplementation was the outcome variable. The study assessed 7983 women aged 15-49 years with a history of pregnancy. Of these participants, 25.8% complied with the IFA supplementation recommendation. Multiple logistic regression analysis showed that pregnant women of Islamic faith and non-Indigenous Muslim ethnicity were less likely to comply with the IFA supplementation recommendation. Being aged between 25 and 34 years, having better education and higher wealth status, rural residency, initiating ANC visits during the first trimester of pregnancy and having at least four ANC visits positively influenced compliance with IFA supplementation. The effect of residence on IFA adherence differed across the wealth classes. Strategies targeted at specific groups, such as religious minorities, poor urban residents, the less educated and young women, should be strengthened to encourage early and regular antenatal care visits for improving compliance.

Internalizing problems are associated with oral health-related quality of life in early childhood: Outcomes from an Asian multi-ethnic prospective birth cohort.

Oral health status ideally warrants for a holistic biopsychosocial approach to health and wellness. Little is known about the impact of behavioral problems on oral health-related quality of life (OHRQoL) in children due to the paucity of studies in early childhood, particularly in Asian multi-ethnic populations. This study evaluated the relationship between early child's socioemotional factors and OHRQoL, as well as its association with orofacial pain (OFP) and early childhood caries (ECC) in the Asian GUSTO birth cohort. Mother-child dyads were postnatally assessed at 3 time points. The Child Behavior Checklist (CBCL) was used to assess the child's socioemotional and behavioral problems at age 4-4.5 years together with other validated questionnaires to evaluate maternal anxiety and depression. ECC detection was performed at age 5, and OHRQoL (primary) and OFP (secondary) outcomes were assessed at age 6 from a total of 555 mother-child dyads. After a univariate regression analysis was performed to identify potential predictors and confounders, a multivariate regression model was run with predisposing factors (CBCL internalization and externalization problems, OFP, ECC) and adjusted for confounders (maternal psychosocial states, maternal education) to determine associations with OHRQoL. Results showed an association between CBCL internalization scores and poorer OHRQoL (RR = 1.03, p = 0.033, 95% CI 1.01 to 1.05), although the limited risk ratio may not have a practical applicability in psychosocially healthy children, alike the majority of those evaluated in this cohort. The average OHRQoL overall score among children with OFP was 2.39 times more than those without OFP (OR = 2.39, p < 0.001, 95% CI 2.00 to 2.86). Thus, in early childhood, OFP, and to lesser extent internalizing behaviors, may negatively impact OHRQoL. This study therefore highlights the complex relationship between OHRQoL and its predisposing socioemotional and somatic pain factors, and demands further investigations in clinically relevant populations.

COVID-19 Vaccination Coverage Among Insured Persons Aged ≥16 Years, by Race/Ethnicity and Other Selected Characteristics - Eight Integrated Health Care Organizations, United States, December 14, 2020-May 15, 2021.

COVID-19 vaccination is critical to ending the COVID-19 pandemic. Members of minority racial and ethnic groups have experienced disproportionate COVID-19-associated morbidity and mortality (1); however, COVID-19 vaccination coverage is lower in these groups (2). CDC used data from CDC's Vaccine Safety Datalink (VSD)* to assess disparities in vaccination coverage among persons aged ≥16 years by race and ethnicity during December 14, 2020-May 15, 2021. Measures of coverage included receipt of ≥1 COVID-19 vaccine dose (i.e., receipt of the first dose of the Pfizer-BioNTech or Moderna COVID-19 vaccines or 1 dose of the Janssen COVID-19 vaccine [Johnson & Johnson]) and full vaccination (receipt of 2 doses of the Pfizer-BioNTech or Moderna COVID-19 vaccines or 1 dose of Janssen COVID-19 vaccine). Among 9.6 million persons aged ≥16 years enrolled in VSD during December 14, 2020-May 15, 2021, ≥1-dose coverage was 48.3%, and 38.3% were fully vaccinated. As of May 15, 2021, coverage with ≥1 dose was lower among non-Hispanic Black (Black) and Hispanic persons (40.7% and 41.1%, respectively) than it was among non-Hispanic White (White) persons (54.6%). Coverage was highest among non-Hispanic Asian (Asian) persons (57.4%). Coverage with ≥1 dose was higher among persons with certain medical conditions that place them at higher risk for severe COVID-19 (high-risk conditions) (63.8%) than it was among persons without such conditions (41.5%) and was higher among persons who had not had COVID-19 (48.8%) than it was among those who had (42.4%). Persons aged 18-24 years had the lowest ≥1-dose coverage (28.7%) among all age groups. Continued monitoring of vaccination coverage and efforts to improve equity in coverage are critical, especially among populations disproportionately affected by COVID-19.

Racial and Ethnic Disparities in Access to Local Anesthesia for Inguinal Hernia Repair.

BACKGROUND: Many studies have identified racial disparities in healthcare, but few have described disparities in the use of anesthesia modalities. We examined racial disparities in the use of local versus general anesthesia for inguinal hernia repair. We hypothesized that African American and Hispanic patients would be less likely than Caucasians to receive local anesthesia for inguinal hernia repair. MATERIALS AND METHODS: We included 78,766 patients aged ≥ 18 years in the Veterans Affairs Surgical Quality Improvement Program database who underwent elective, unilateral, open inguinal hernia repair under general or local anesthesia from 1998-2018. We used multiple logistic regression to compare use of local versus general anesthesia and 30-day postoperative complications by race/ethnicity. RESULTS: In total, 17,892 (23%) patients received local anesthesia. Caucasian patients more frequently received local anesthesia (15,009; 24%), compared to African Americans (2353; 17%) and Hispanics (530; 19%), P < 0.05. After adjusting for covariates, we found that African Americans (OR 0.82, 95% CI 0.77-0.86) and Hispanics (OR 0.77, 95% CI 0.69-0.87) were significantly less likely to have hernia surgery under local anesthesia compared to Caucasians. Additionally, local anesthesia was associated with fewer postoperative complications for African American patients (OR 0.46, 95% CI 0.27-0.77). CONCLUSIONS: Although local anesthesia was associated with enhanced recovery for African American patients, they were less likely to have inguinal hernias repaired under local than Caucasians. Addressing this disparity requires a better understanding of how surgeons, anesthesiologists, and patient-related factors may affect the choice of anesthesia modality for hernia repair.

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 inequities in maternal health among women living in communities of social disadvantage and ethnic diversity.

The response to the coronavirus outbreak and how the disease and its societal consequences pose risks to already vulnerable groups such those who are socioeconomically disadvantaged and ethnic minority groups. Researchers and community groups analysed how the COVID-19 crisis has exacerbated persisting vulnerabilities, socio-economic and structural disadvantage and discrimination faced by many communities of social disadvantage and ethnic diversity, and discussed future strategies on how best to engage and involve local groups in research to improve outcomes for childbearing women experiencing mental illness and those living in areas of social disadvantage and ethnic diversity. Discussions centred around: access, engagement and quality of care; racism, discrimination and trust; the need for engagement with community stakeholders; and the impact of wider social and economic inequalities. Addressing biomedical factors alone is not sufficient, and integrative and holistic long-term public health strategies that address societal and structural racism and overall disadvantage in society are urgently needed to improve health disparities and can only be implemented in partnership with local communities.

Assessment of Racial/Ethnic Disparities in Hospitalization and Mortality in Patients With COVID-19 in New York City.

Importance: Black and Hispanic populations have higher rates of coronavirus disease 2019 (COVID-19) hospitalization and mortality than White populations but lower in-hospital case-fatality rates. The extent to which neighborhood characteristics and comorbidity explain these disparities is unclear. Outcomes in Asian American populations have not been explored. Objective: To compare COVID-19 outcomes based on race and ethnicity and assess the association of any disparities with comorbidity and neighborhood characteristics. Design, Setting, and Participants: This retrospective cohort study was conducted within the New York University Langone Health system, which includes over 260 outpatient practices and 4 acute care hospitals. All patients within the system's integrated health record who were tested for severe acute respiratory syndrome coronavirus 2 between March 1, 2020, and April 8, 2020, were identified and followed up through May 13, 2020. Data were analyzed in June 2020. Among 11 547 patients tested, outcomes were compared by race and ethnicity and examined against differences by age, sex, body mass index, comorbidity, insurance type, and neighborhood socioeconomic status. Exposures: Race and ethnicity categorized using self-reported electronic health record data (ie, non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and multiracial/other patients). Main Outcomes and Measures: The likelihood of receiving a positive test, hospitalization, and critical illness (defined as a composite of care in the intensive care unit, use of mechanical ventilation, discharge to hospice, or death). Results: Among 9722 patients (mean [SD] age, 50.7 [17.5] years; 58.8% women), 4843 (49.8%) were positive for COVID-19; 2623 (54.2%) of those were admitted for hospitalization (1047 [39.9%] White, 375 [14.3%] Black, 715 [27.3%] Hispanic, 180 [6.9%] Asian, 207 [7.9%] multiracial/other). In fully adjusted models, Black patients (odds ratio [OR], 1.3; 95% CI, 1.2-1.6) and Hispanic patients (OR, 1.5; 95% CI, 1.3-1.7) were more likely than White patients to test positive. Among those who tested positive, odds of hospitalization were similar among White, Hispanic, and Black patients, but higher among Asian (OR, 1.6, 95% CI, 1.1-2.3) and multiracial patients (OR, 1.4; 95% CI, 1.0-1.9) compared with White patients. Among those hospitalized, Black patients were less likely than White patients to have severe illness (OR, 0.6; 95% CI, 0.4-0.8) and to die or be discharged to hospice (hazard ratio, 0.7; 95% CI, 0.6-0.9). Conclusions and Relevance: In this cohort study of patients in a large health system in New York City, Black and Hispanic patients were more likely, and Asian patients less likely, than White patients to test positive; once hospitalized, Black patients were less likely than White patients to have critical illness or die after adjustment for comorbidity and neighborhood characteristics. This supports the assertion that existing structural determinants pervasive in Black and Hispanic communities may explain the disproportionately higher out-of-hospital deaths due to COVID-19 infections in these populations.

Use of Latent Class Analysis and k-Means Clustering to Identify Complex Patient Profiles.

Importance: Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. Objective: To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. Design, Setting, and Participants: This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. Main Outcomes and Measures: Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. Results: The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. Conclusions and Relevance: The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.

Healthcare Utilisation of Moluccans in the Netherlands: Equal Care for Equal Need after 60 Years of Residence in the Host Country?

BACKGROUND: In many countries, recent migrants have difficulties using healthcare to the same extent as host populations. It is uncertain whether these differences persist for long-settled migrants. This study examined healthcare utilisation of Moluccans in 2012, more than 60 years after they migrated from Indonesia to the Netherlands. METHODS: A survey was held among 715 Moluccans and 3417 Dutch persons. Differences in healthcare utilisation were assessed using regression analyses adjusting for age, gender, indicators of health, religious affiliation, and education. RESULTS: Moluccans had lower rates of healthcare use, including visits to the general practitioner (odds ratio (OR) = 0.67), outpatient medical specialist (OR = 0.50), dentist (OR = 0.65), and physiotherapist (OR = 0.56), as well as the use of paid housekeeping services (OR = 0.37). Among those who visited a healthcare service, no difference was found between Moluccans and Dutch in the frequency of visits, except for physiotherapist visits (rate ratio (RR) = 0.51). For the risk of hospitalisation, no difference was found; however, of those admitted to the hospital, the frequency of admission was lower among Moluccans than Dutch (RR = 0.74). CONCLUSIONS: Despite their long residence in the host country, equal utilisation of healthcare services has not been achieved for Moluccans in the Netherlands. Demand-based factors (e.g., family networks, health beliefs, and use of traditional medicine) may contribute to the persistence of such differences and require further investigation.

Recurrent Atherosclerotic Cardiovascular Event Rates Differ Among Patients Meeting the Very High Risk Definition According to Age, Sex, Race/Ethnicity, and Socioeconomic Status.

Background The risk for atherosclerotic cardiovascular disease (ASCVD) events may differ by sociodemographic factors among patients meeting the definition of very high risk according to the 2018 American Heart Association/American College of Cardiology cholesterol guideline, leading to treatment disparities. We estimated the risk for recurrent ASCVD events among adults meeting the definition of very high risk by age, sex, race/ethnicity, and socioeconomic status in a US integrated healthcare system. Methods and Results The study cohort included Kaiser Permanente Southern California members aged ≥21 years with a history of clinical ASCVD on September 30, 2009. Very high risk for recurrent ASCVD was defined by a history of ≥2 major ASCVD events or a history of 1 major event along with ≥2 high-risk conditions. Patients were followed through 2015 for a first recurrent ASCVD event. Of 77 101 patients with ASCVD, 50.8% met the definition for very high risk. Among patients meeting the definition of very high risk, recurrent ASCVD rates were higher in older (>75 years) versus younger patients (21-40 years) (sex-adjusted hazard ratio [HR] [95% CI] 1.85; 1.23-2.79), non-Hispanic Black patients versus non-Hispanic White patients (age-, sex-adjusted HR, 1.32; 1.23-1.41), those who lived in neighborhoods with lower (<$35k) versus higher annual household income (≥$80k) (HR, 1.20; 1.11-1.30), or with lower (≥31.2%) versus higher education levels (<8.8% high school or lower) (HR, 1.26; 1.19-1.34). Conclusions Disparities in the risk for recurrent ASCVD events were present across sociodemographic factors among very high risk patients. The addition of sociodemographic factors to current definitions of very high risk could reduce health disparities.

Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations.

OBJECTIVE: To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs. DATA SOURCES: We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm. STUDY DESIGN: Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow-up visits after acute care; all-cause emergency department (ED) visits, all-cause readmissions, and ambulatory care-sensitive admissions). We decomposed these "total" disparities into within-PO and between-PO components using models with PO random effects. We then pair-matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within-PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator. DATA COLLECTION/EXTRACTION METHODS: Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule. PRINCIPAL FINDINGS: We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within-PO disparities exceeded between-PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P < .05): 1.6 percentage points smaller black-white disparities in follow-up after ED visits and 0.6 percentage points smaller Hispanic-white disparities in breast cancer screening. CONCLUSIONS: We find no evidence that system-affiliated POs have smaller racial and ethnic disparities than nonaffiliated POs. Where differences existed, disparities were slightly larger in affiliated POs.

Patterns of COVID-19 testing and mortality by race and ethnicity among United States veterans: A nationwide cohort study.

BACKGROUND: There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States. METHODS AND FINDINGS: This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health. CONCLUSIONS: In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.