Differences in Donor Heart Acceptance by Race and Gender of Patients on the Transplant Waiting List.

Importance: Barriers to heart transplant must be overcome prior to listing. It is unclear why Black men and women remain less likely to receive a heart transplant after listing than White men and women. Objective: To evaluate whether race or gender of a heart transplant candidate (ie, patient on the transplant waiting list) is associated with the probability of a donor heart being accepted by the transplant center team with each offer. Design, Setting, and Participants: This cohort study used the United Network for Organ Sharing datasets to identify organ acceptance with each offer for US non-Hispanic Black (hereafter, Black) and non-Hispanic White (hereafter, White) adults listed for heart transplant from October 18, 2018, through March 31, 2023. Exposures: Black or White race and gender (men, women) of a heart transplant candidate. Main Outcomes and Measures: The main outcome was heart offer acceptance by the transplant center team. The number of offers to acceptance was assessed using discrete time-to-event analyses, nonparametrically (stratified by race and gender) and parametrically. The hazard probability of offer acceptance for each offer was modeled using generalized linear mixed models adjusted for candidate-, donor-, and offer-level variables. Results: Among 159 177 heart offers with 13 760 donors, there were 14 890 candidates listed for heart transplant; 30.9% were Black, 69.1% were White, 73.6% were men, and 26.4% were women. The cumulative incidence of offer acceptance was highest for White women followed by Black women, White men, and Black men (P < .001). Odds of acceptance were less for Black candidates than for White candidates for the first offer (odds ratio [OR], 0.76; 95% CI, 0.69-0.84) through the 16th offer. Odds of acceptance were higher for women than for men for the first offer (OR, 1.53; 95% CI, 1.39-1.68) through the sixth offer and were lower for the 10th through 31st offers. Conclusions and Relevance: The cumulative incidence of heart offer acceptance by a transplant center team was consistently lower for Black candidates than for White candidates of the same gender and higher for women than for men. These disparities persisted after adjusting for candidate-, donor-, and offer-level variables, possibly suggesting racial and gender bias in the decision-making process. Further investigation of site-level decision-making may reveal strategies for equitable donor heart acceptance.

Pilot test of a multicomponent implementation strategy for equity in advanced heart failure allocation.

Advanced heart failure (AHF) therapy allocation is vulnerable to bias related to subjective assessments and poor group dynamics. Our objective was to determine whether an implementation strategy for AHF team members could feasibly contribute to organizational and culture change supporting equity in AHF allocation. Using a pretest-posttest design, the strategy included an 8-week multicomponent training on bias reduction, standardized numerical social assessments, and enhanced group dynamics at an AHF center. Evaluations of organizational and cultural changes included pretest-posttest AHF team member surveys, transcripts of AHF meetings to assess group dynamics using a standardized scoring system, and posttest interviews guided by a framework for implementing a complex strategy. Results were analyzed with qualitative descriptive methods and Brunner-Munzel tests for relative effect (RE, RE >0.5 signals posttest improvement). The majority of survey metrics revealed potential benefit with RE >0.5. REs were >0.5 for 5 of 6 group dynamics metrics. Themes for implementation included (1) promoting equitable distribution of scarce resources, (2) requiring a change in team members' time investment to correct bias and change the meeting structure, (3) slowing and then accelerating the allocation process, and (4) adaptable beyond AHF and reinforceable with semi-annual trainings. An implementation strategy for AHF equity demonstrated the feasibility for organizational and culture changes.

Changing epidemiology and outcomes of acute kidney injury in hospitalized patients with cirrhosis - a US population-based study.

BACKGROUND & AIMS: Acute kidney injury (AKI) is a significant clinical event in cirrhosis yet contemporary population-based studies on the impact of AKI on hospitalized cirrhotics are lacking. We aimed to characterize longitudinal trends in incidence, healthcare burden and outcomes of hospitalized cirrhotics with and without AKI using a nationally representative dataset. METHODS: Using the 2004-2016 National Inpatient Sample (NIS), admissions for cirrhosis with and without AKI were identified using ICD-9 and ICD-10 codes. Regression analysis was used to analyze the trends in hospitalizations, costs, length of stay and inpatient mortality. Descriptive statistics, simple and multivariable logistic regression were used to assess associations between individual characteristics, comorbidities, and cirrhosis complications with AKI and death. RESULTS: In over 3.6 million admissions for cirrhosis, 22% had AKI. AKI admissions were more costly (median $13,127 [IQR $7,367-$24,891] vs. $8,079 [IQR $4,956-$13,693]) and longer (median 6 [IQR 3-11] days vs. 4 [IQR 2-7] days). Over time, AKI prevalence doubled from 15% in 2004 to 30% in 2016. CKD was independently and strongly associated with AKI (adjusted odds ratio 3.75; 95% CI 3.72-3.77). Importantly, AKI admissions were 3.75 times more likely to result in death (adjusted odds ratio 3.75; 95% CI 3.71-3.79) and presence of AKI increased risk of mortality in key subgroups of cirrhosis, such as those with infections and portal hypertension-related complications. CONCLUSIONS: The prevalence of AKI is significantly increased among hospitalized cirrhotics. AKI substantially increases the healthcare burden associated with cirrhosis. Despite advances in cirrhosis care, a significant gap remains in outcomes between cirrhotics with and without AKI, suggesting that AKI continues to represent a major clinical challenge. LAY SUMMARY: Sudden damage to the kidneys is becoming more common in people who are hospitalized and have cirrhosis. Despite advances in cirrhosis care, those with damage to the kidneys remain at higher risk of dying.

Improving Outcomes of Bariatric Surgery in Patients With Cirrhosis in the United States: A Nationwide Assessment.

INTRODUCTION: With increasing burden of obesity and liver disease in the United States, a better understanding of bariatric surgery in context of cirrhosis is needed. We described trends of hospital-based outcomes of bariatric surgery among cirrhotics and determined effect of volume status and type of surgery on these outcomes. METHODS: In this population-based study, admissions for bariatric surgery were extracted from the National Inpatient Sample using International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes from 2004 to 2016 and grouped by cirrhosis status, type of bariatric surgery, and center volume. In-hospital mortality, complications, and their trends were compared between these groups using weighted counts, odds ratios [ORs], and logistic regression. RESULTS: Among 1,679,828 admissions for bariatric surgery, 9,802 (0.58%) had cirrhosis. Cirrhosis admissions were more likely to be in white men, had higher Elixhauser Index, and higher in-hospital complications rates including death (1.81% vs 0.17%), acute kidney injury (4.5% vs 1.2%), bleeding (2.9% vs 1.1%), and operative complications (2% vs 0.6%) (P < 0.001 for all) compared to those without cirrhosis. Overtime, restrictive surgeries have grown in number (12%-71%) and complications rates have trended down in both groups. Cirrhotics undergoing bariatric surgery at low-volume centers (<50 procedures per year) and nonrestrictive surgery had a higher inpatient mortality rate (adjusted OR 4.50, 95% confidence interval 3.14-6.45, adjusted OR 4.00, 95% confidence interval 2.68-5.97, respectively). DISCUSSION: Contemporary data indicate that among admissions for bariatric surgery, there is a shift to restrictive-type surgeries with an improvement in-hospital complications and mortality. However, patients with cirrhosis especially those at low-volume centers have significantly higher risk of worse outcomes (see Visual abstract, Supplementary Digital Content, http://links.lww.com/AJG/B648).

Extent and Predictors of Potentially Inappropriate Antidepressant Use Among Older Adults With Dementia and Major Depressive Disorder.

OBJECTIVE: To quantify the extent and identify predictors of potentially inappropriate antidepressant use among older adults with dementia and newly diagnosed major depressive disorders (MDD). METHODS: This retrospective cohort study included older adults (aged ≥65 years) with dementia and newly diagnosed MDD using Medicare 5% sample claims data (2012-2013). Based on Healthcare Effectiveness Data and Information Set guidelines, intake period for new antidepressant medication use was from May 1, 2012, through April 30, 2013. Index prescription start date was the first date of antidepressant prescription claim during the intake period. Dependent variable of this study was potentially inappropriate antidepressant use as defined by the Beers Criteria and the Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria. The authors conducted multiple logistic regression analysis to identify individual-level predictors of potentially inappropriate antidepressant use. RESULTS: The authors' final study sample consisted of 7,625 older adults with dementia and newly diagnosed MDD, among which 7.59% (N = 579) initiated treatment with a potentially inappropriate antidepressant. Paroxetine (N = 394) was the most commonly initiated potentially inappropriate antidepressant followed by amitriptyline (N = 104), nortriptyline (N = 35), and doxepin (N = 32). Initiation of a potentially inappropriate antidepressant was associated with age and baseline use of anxiolytic medications. CONCLUSION: More than 7% of older adults in the study sample initiated a potentially inappropriate antidepressant, and the authors identified a few individual-level factors significantly associated with it. Appropriately tailored interventions to address modifiable and nonmodifiable factors significantly associated with potentially inappropriate antidepressant prescribing are required to minimize risks in this vulnerable population.

Racial and ethnic differences in psychotropic medication use among community-dwelling persons with dementia in the United States.

OBJECTIVES: Little is known about the patterns of psychotropic medication use in community-dwelling minority persons with dementia (PWD). The purpose of this study was to investigate racial/ethnic differences in psychotropic medication use across a diverse population of community-dwelling PWD and to examine the extent to which caregiver characteristics influence this use. METHOD: Data were drawn from the baseline assessment of the Resources for Enhancing Alzheimer's Caregiver Health II trial. Generalized linear models were used to identify racial/ethnic differences in psychotropic medication use. Akaike Information Criterion (AIC) model selection was used to evaluate possible explanations for observed differences across racial/ethnic group. RESULTS: Differences in anxiolytic and antipsychotic medication use were observed across racial/ethnic groups; however, race/ethnicity alone was not sufficient to explain those differences. Perceptions of caregiving and caregiver socioeconomic status were important predictors of anxiolytic use while PWD characteristics, including cognitive impairment, functional impairment, problem behavior frequency, pain, relationship to the caregiver, sex, and age were important for antipsychotic use. CONCLUSION: Racial/ethnic differences in psychotropic medication use among community-dwelling PWD cannot be explained by race/ethnicity alone. The importance of caregiver characteristics in predicting anxiolytic medication use suggest that interventions aimed at caregivers may hold promise as an effective alternative to pharmacotherapy.

Association between social vulnerability index and admission urgency for transcatheter aortic valve replacement.

Background: Transcatheter aortic valve replacement (TAVR) are not offered equitably to vulnerable population groups. Adequate levels of insurance may narrow gaps among patients with higher social vulnerability index (SVI). Among a national population of individuals with commercial or Medicare insurance, we sought to determine whether SVI was associated with urgency of receipt of TAVR for aortic stenosis. Methods and results: Using Optum's de-identified Clinformatics Data Mart Database (CDM), we identified admissions for TAVR with aortic stenosis between January 2018 and March 2022. Admission urgency was identified by CDM claims codes. SVI was cross-referenced to patient zip codes and grouped into quintiles. Generalized linear mixed effects models were used to predict the probability of a TAVR admission being urgent based on SVI quintiles, adjusting for patient and hospital-level covariates. Results: Among 6680 admissions for TAVR [median age 80 years (interquartile range 75-85), 43.9 % female], 8.5 % (n = 567) were classified as urgent. After adjusting for patient and hospital-level variables, there were no significant differences in the odds of urgent admission for TAVR according to SVI quintiles [OR 5th (greatest social vulnerability) vs 1st quintile (least social vulnerability): 1.29 (95 % CI: 0.90-1.85)]. Conclusions: Among commercial or Medicare beneficiaries with aortic stenosis, SVI was not associated with admission urgency for TAVR. To clarify whether cardiovascular care delivery is improved across SVI with higher paying beneficiaries, future investigation should identify whether relationships between SVI and TAVR urgency vary for Medicaid beneficiaries compared to commercial beneficiaries.

Hospital frailty risk score is superior to legacy comorbidity indices for risk adjustment of in-hospital cirrhosis cases.

Background & Aims: The hospital frailty risk score (HFRS) identifies older patients at risk of poor outcomes and may have value in cirrhosis. We compared the Charlson (CCI), Elixhauser (ECI), and cirrhosis (CirCom) comorbidity indices with the HFRS in predicting outcomes for cirrhosis hospitalisations. Methods: Using the National Inpatient Sample (quarter 4 of 2015-2019), we analysed cirrhosis hospitalisations. For each index, we described the prevalence of comorbid conditions and inpatient mortality. We compared the ability of CCI, ECI, CirCom, and HFRS to predict inpatient mortality. Raw and adjusted models predicting inpatient mortality were compared using the area under the receiver operating characteristic curve and the Akaike information criterion. Results: The cohort's (N = 626,553) median age was 61 years (IQR 52-68 years), 60% were male, cirrhosis was caused by alcohol in 43%, and 38% had ascites. The median comorbidity scores are as follows: ECI 4 (IQR 3-6), CCI 5 (IQR 4-8), and HFRS 5.6 (IQR 3.0-8.6). The most common CirCom score was 0 + 0 (44%). Across the range of values of each index, we observed different mortality ranges: CCI 1.9-13.1%, ECI 3.2-8.7%, CirCom 4.9-13.8%, and HFRS 1.0-15.2%. An adjusted model with HFRS had the highest area under the receiver operating characteristic curve in predicting mortality (HFRS 0.782 vs. ECI 0.689, CCI 0.695, and CirCom 0.692). We observed substantial variation in mortality with HFRS within each level of CCI, ECI, and CirCom. For example, for ECI 4, mortality increased from 0.6 to 16.4%, as HFRS increased from 0 to 15. Conclusions: Comorbidity indices predict inpatient cirrhosis mortality, but HFRS performs better than CCI, ECI, and CirCom. HFRS is an ideal tool for measuring comorbidity burden and disease severity risk adjustment in cirrhosis-related administrative database studies. Impact and Implications: We compared commonly used comorbidity indices to a more recently described risk score (hospital frailty risk score [HFRS]) in patients with cirrhosis using a national sample of hospital records. Comorbid conditions are common in hospitalised patients with cirrhosis. There is significant variability in mortality across the range of each index. HFRS outperforms the Charlson comorbidity index, Elixhauser comorbidity index, and CirCom (cirrhosis-specific comorbidity scoring system) in predicting inpatient mortality. HFRS is a valuable index for risk adjustment in inpatient administrative database studies.

Trends in Racial and Ethnic Disparities in the Receipt of Lifesaving Procedures for Hospitalized Patients With Decompensated Cirrhosis in the US, 2009-2018.

Importance: Patients with decompensated cirrhosis are hospitalized for acute management with temporizing and lifesaving procedures. Published data to inform intervention development in this area are more than a decade old, and it is not clear whether there have been improvements in disparities in the receipt of these procedures over time. Objective: To evaluate the associations of race and ethnicity with receipt of procedures to treat decompensated cirrhosis over time in the US. Design, Setting, and Participants: This retrospective cross-sectional study analyzed National Inpatient Sample data on cirrhosis admissions among patients with portal hypertension-related complications from 2009 to 2018. All hospital discharges for individuals aged 18 years and older from 2009 to 2018 were assessed for inclusion. Admissions were included if they contained at least 1 cirrhosis-related International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code and at least 1 cirrhosis-related complication ICD-9-CM or ICD-10-CM code (ie, ascites, hepatic encephalopathy, variceal hemorrhage [VH], and hepatorenal syndrome [HRS]). Data were analyzed from January to June 2022. Exposure: Hospitalization for decompensated cirrhosis. Main Outcomes and Measures: The outcomes of interest were trends in the odds ratios (ORs) for receiving procedures (upper endoscopy, transjugular portosystemic shunt [TIPS], hemodialysis, and liver transplantation [LT]) for decompensated cirrhosis and mortality by race and ethnicity, modeled over time. Multivariable logistic regression was used to assess these outcomes. Results: Among 717 580 admissions (median [IQR] age, 58 [52-67] years), 345 644 patients (9.8%) were Black, 623 991 patients (17.6%) were Hispanic, and 2 340 031 patients (47.4%) were White. Based on the modeled trends, by 2018, there were no significant differences by race or ethnicity in the odds of receiving upper endoscopy for VH. However, Black patients remained less likely than White patients to undergo TIPS for VH (OR, 0.54; 95% CI, 0.47-0.62) and ascites (OR, 0.34; 95% CI, 0.31-0.38). The disparity in receipt of LT improved for Black and Hispanic patients over the study period; however, by 2018, both groups remained less likely to undergo LT than their White counterparts (Black: OR, 0.66; 95% CI, 0.61-0.70; Hispanic: OR, 0.74; 95% CI, 0.70-0.78). The odds of death in Black and Hispanic patients declined over the study period but remained higher in Black patients than White patients in 2018 (OR, 1.08; 95% CI, 1.05-1.11). Conclusions and Relevance: In this cross-sectional study of individuals hospitalized with decompensated cirrhosis, there were racial and ethnic disparities in receipt of complex lifesaving procedures and in mortality that persisted over time.

Racial and Ethnic Disparities in Ambulatory Heart Failure Ventricular Assist Device Implantation and Survival.

BACKGROUND: Durable left ventricular assist devices (VADs) improve survival in eligible patients, but allocation has been associated with patient race in addition to presumed heart failure (HF) severity. OBJECTIVES: This study sought to determine racial and ethnic differences in VAD implantation rates and post-VAD survival among patients with ambulatory HF. METHODS: Using the INTERMACS (Interagency Registry of Mechanically Assisted Circulatory Support) database (2012-2017), this study examined census-adjusted VAD implantation rates by race, ethnicity, and sex in patients with ambulatory HF (INTERMACS profile 4-7) using negative binomial models with quadratic effect of time. Survival was evaluated using Kaplan-Meier estimates and Cox models adjusted for clinically relevant variables and an interaction of time with race/ethnicity. RESULTS: VADs were implanted in 2,256 adult patients with ambulatory HF (78.3% White, 16.4% Black, and 5.3% Hispanic). The median age at implantation was lowest in Black patients. Implantation rates peaked between 2013 and 2015 before declining in all demographic groups. From 2012 to 2017, implantation rates overlapped for Black and White patients but were lower for Hispanic patients. Post-VAD survival was significantly different among the 3 groups (log rank P = 0.0067), with higher estimated survival among Black vs White patients (12-month survival: Black patients: 90% [95% CI: 86%-93%]; White patients: 82% [95% CI: 80%-84%]). Low sample size for Hispanic patients resulted in imprecise survival estimates (12-month survival: 85% [95% CI: 76%-90%]). CONCLUSIONS: Black and White patients with ambulatory HF had similar VAD implantation rates but rates were lower for Hispanic patients. Survival differed among the 3 groups, with the highest estimated survival at 12 months in Black patients. Given higher HF burden in minoritized populations, further investigation is needed to understand differences in VAD implantation rates in Black and Hispanic patients.

Association Between Race, Cardiology Care, and the Receipt of Guideline-Directed Medical Therapy in Peripartum Cardiomyopathy.

BACKGROUND: Black patients with peripartum cardiomyopathy (PPCM) have disproportionately worse outcomes than White patients, possibly related to variable involvement of cardiovascular specialists in their clinical care. We sought to determine whether race was associated with cardiology involvement in clinical care during inpatient admission and whether cardiology involvement in care was associated with higher claims of guideline-directed medical therapy (GDMT) a week after hospital discharge. METHODS: Using Optum's de-identified Clinformatics® Data Mart (CDM), we included Black and White patients' first hospital admission for PPCM from 2008 to 2021. Cardiology involvement in clinical care was defined as the receipt of attending care from a cardiovascular specialist during admission. GDMT included beta-blockers (BB) for all patients and triple therapy (BB, angiotensin-responsive medications, and mineralocorticoid receptor antagonists) for non-pregnant patients. Logistic regression was used to determine the associations between cardiology involvement in clinical care during admission and (1) patient race and (2) GDMT prescription, adjusting for age and comorbidities. RESULTS: Among 668 patients (32.6% Black, 67.4% White, 93.3% commercially insured), there was no significant difference in the odds of cardiology involvement in clinical care by race (aOR: 1.41; 95%CI: 0.87-2.33, P=0.17). Inpatient cardiology care was associated with 2.75 times increased odds of having a prescription claim for GDMT (BB) for White patients (aOR: 2.75; 95%CI 1.50-5.06, P=0.001), and the estimated effect size was similar but not statistically significant for Black patients (aOR: 2.20, 95% CI, 0.84-5.71, P=0.11). The interaction between race and cardiology involvement in clinical care was not statistically significant for the receipt of BB prescription. Among 274 non-pregnant patients with PPCM (37.2% Black, 62.8% White), 5.8% received triple GDMT. Of these, none of the Black patients lacking cardiology care had triple GDMT. However, cardiology involvement in care was not significantly associated with triple GDMT for either race. CONCLUSIONS: Among a commercially insured population within PPCM, race was not associated with cardiology involvement in clinical care during hospitalization. However, cardiology involvement in care was associated with significantly higher odds of prescription claims for BB for only White patients. Additional strategies are needed to support equitable GDMT prescription.

Disparities in preventative diabetic foot examination.

The objective of this study was to assess the overall differences in the standard of preventive foot care for patients at risk of diabetic foot ulceration and to identify specific demographic factors affecting these health care practices, including race and ethnicity. The National Health and Nutrition Examination Survey data for 2011 to 2018 were analyzed. Participants (20 years and older) with diabetes were categorized as White, Black, Hispanic, Asian, and others (including multiracial participants) based on self-reported race and ethnicity. The primary outcome was foot examination over the past year administered by a medical professional. Logistic regression was performed to examine the effects of race and ethnicity on the annual diabetic foot examination, controlling for age (65 years and older), gender, and health insurance status. Among the 2,836 participants included in the study (weighted percentage: 61.1% were White, 13.9% were Black, 15.1% were Hispanic, 5.4% were Asian, and 4.5% were other), 2,018 (weighted percentage: 71.6%) received annual diabetic foot examination over the past year. Hispanic participants (adjusted odds ratio [aOR] = 0.685; 95% CI, 0.52-0.90) were significantly less likely than White participants to receive an annual foot examination (Black participants: aOR = 1.11; 95% CI, 0.83-1.49; Asian participants: aOR = 0.80; 95% CI, 0.60-1.07; other participants: aOR = 0.66; 95% CI, 0.40-1.10). Factors associated with receipt of foot examination were age 65 years or older (aOR = 1.42; 95% CI, 1.05-1.92) and having health insurance (aOR = 3.02; 95% CI, 2.27-4.03). Our findings suggest that Hispanic adults with diabetes are receiving disproportionately lower rates of preventive foot care compared with their White counterparts. This significant variation in the standard of care for individuals with diabetes reflects the need to further identify factors driving the disparities in preventive foot care services among racial and ethnic minority groups.

Group Dynamics and Allocation of Advanced Heart Failure Therapies-Heart Transplants and Ventricular Assist Devices-By Gender, Racial, and Ethnic Group.

Background US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. Methods and Results We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. Conclusions Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation.

Association Between the Affordable Care Act Medicaid Expansion and Receipt of Cardiac Resynchronization Therapy by Race and Ethnicity.

Background Black and Hispanic patients are less likely to receive cardiac resynchronization therapy (CRT) than White patients. Medicaid expansion has been associated with increased access to cardiovascular care among racial and ethnic groups with higher prevalence of underinsurance. It is unknown whether the Medicaid expansion was associated with increased receipt of CRT by race and ethnicity. Methods and Results Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington, DC, we analyzed 1061 patients from early-adopter states (Medicaid expansion by January 2014) and 745 patients from nonadopter states (no implementation 2013-2014). Estimates of change in census-adjusted rates of CRT with or without defibrillator by race and ethnicity and Medicaid adopter status 1 year before and after January 2014 were conducted using a quasi-Poisson regression model. Following the Medicaid expansion, the rate of CRT did not significantly change among Black individuals from early-adopter states (1.07 [95% CI, 0.78-1.48]) or nonadopter states (0.79 [95% CI, 0.57-1.09]). There were no significant changes in rates of CRT among Hispanic individuals from early-adopter states (0.99 [95% CI, 0.70-1.38]) or nonadopter states (1.01 [95% CI, 0.65-1.57]). There was a 34% increase in CRT rates among White individuals from early-adopter states (1.34 [95% CI, 1.05-1.70]), and no significant change among White individuals from nonadopter states (0.77 [95% CI, 0.59-1.02]). The change in CRT rates among White individuals was associated with the timing of the Medicaid implementation (P=0.003). Conclusions Among states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, implementation of Medicaid expansion was associated with increase in CRT rates among White individuals residing in states that adopted the Medicaid expansion policy. Further work is needed to address disparities in CRT among Black and Hispanic patients.

Rates of Diabetes-Related Major Amputations Among Racial and Ethnic Minority Adults Following Medicaid Expansion Under the Patient Protection and Affordable Care Act.

Importance: It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations. Objective: To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs). Design, Setting, and Participants: This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021. Exposures: States were categorized into early-adopter states (expansion by January 2014) and nonadopter states. Main Outcomes and Measures: Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population. Results: Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (P for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, -6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, -10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion. Conclusions and Relevance: This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.

Relationships between 2018 UNOS heart policy and transplant outcomes in metropolitan, micropolitan, and rural settings.

BACKGROUND: In 2018, United Network for Organ Sharing (UNOS) extended the radius for which a heart transplant candidate can match with a donor, and outcomes across population densities are unknown. We sought to determine whether the policy change was associated with differences in heart transplant waitlist time or death post-transplant for patients from rural, micropolitan, and metropolitan settings. METHODS: Using the Scientific Registry of Transplant Recipients, we evaluated U.S. adult patients listed for heart transplant from Janurary 2017 to September 2019 with follow-up through March 2020. Patients were stratified by home zip-codes to either metropolitan, micropolitan, or rural settings. Fine and Gray and Cox models were respectively used to estimate Sub-distribution hazard ratios (SHR) of heart transplant with death or removal from transplant list as a competing event, and HR of death post-transplant within population densities after versus before the UNOS policy change date, October 18, 2018. Analyses were adjusted for demographics, comorbidities, and labs. RESULTS: Among 8,747 patients listed for heart transplant, 84.7% were from metropolitan, 8.6% micropolitan, and 6.6% rural settings. The 2018 UNOS policy was associated with earlier receipt of heart transplant for metropolitan [SHR 1.56 (95% CI: 1.46-1.66)] and micropolitan [SHR 1.48 (95% CI: 1.21-1.82)] populations, but not significantly for rural [SHR 1.20 (95% CI: 0.93-1.54)]; however, the interaction between policy and densities was not significant (p = .14). Policy changes were not associated with risk of death post-transplant [metropolitan: HR 1.04 (95% CI: 0.80-1.34); micropolitan: HR 1.10 (95% CI: 0.55-2.23); rural: HR 1.04 (95% CI: 0.52-2.08); interaction p = .99]. CONCLUSIONS: The 2018 UNOS heart transplant policy was associated with earlier receipt of heart transplant and no difference in post-transplant survival within population densities. Additional follow-up is needed to determine whether improvements are sustained.

Race and Gender-Based Perceptions of Older Septuagenarian Adults.

Objectives: Older adults face racism, sexism, and ageism. As the U.S. population ages, it is important to understand how the current population views older adults. Methods: Participants recruited through Amazon's Mechanical Turk provided perceptions of older Black and White models' photographs. Using mixed-effect models, we assessed interactions between race and gender of participants and models. Results: Among Participants of Color and White participants (n = 712, 70% non-Hispanic White, 70% women, mean 37.81 years), Black models were perceived as more attractive, less threatening, and sadder than White models, but differences were greater for White participants (race-by-race interaction: attractive p = 0.003, threatening p = 0.009, sad p = 0.016). Each gender perceived their respective gender as more attractive (gender-by-gender interaction p < 0.0001). Male and female participants perceived male models as happier than female models, but differences were greater for male participants (p = 0.026). Irrespective of participant age group, women were perceived as more threatening (p = 0.012). Other perceptions were not significant. Discussion: Participants had few biases toward older Black and White models, while gender biases favored men.

Sex Disparities in Organ Donation: Finding an Equitable Donor Pool.

Background The majority of living organ donors are women, but few are deceased organ donors, which increases risks associated with sex mismatched organs. We sought to identify reasons for sex disparities in organ donation and strategies for equity. Methods and Results Using Amazon's Mechanical Turk, we examined US adults' perceptions regarding donation in a mixed-methods survey study. Results were compared by sex with Fisher's exact test and T-tests for quantitative results and qualitative descriptive analyses for write-in responses. Among 667 participants (55% women), the majority of men (64.8%) and women (63.4%) self-identified as registered donors. Women's willingness to donate their own organs to family members (P=0.03) or strangers (P=0.03) was significantly higher than men. Donors from both sexes were guided by: desire to help, personal experience, and believing organs would be useless to deceased donors. Non-donors from both sexes were guided by: no reason, medical mistrust, contemplating donation. When considering whether to donate organs of a deceased family member, women were equally guided by a family member's wishes and believing the family member had no further use for organs. Men had similar themes but valued the family member's wishes more. Among non-donors, both sexes would consider donation if more information was provided. Conclusions In a national survey, both sexes had similar reasons for becoming and not becoming an organ donor. However, compared with men, women were more willing to donate their organs to family members and strangers. Improving education and communicating wishes regarding organ donation with direct relatives may increase sex equity in deceased organ donation.