Role of Sex in the Association of Socioeconomic Status With Cardiovascular Health in Black Americans: The Jackson Heart Study.

BACKGROUND: Socioeconomic status (SES) is associated with cardiovascular health (CVH). Potential differences by sex in this association remain incompletely understood in Black Americans, where SES disparities are posited to be partially responsible for cardiovascular inequities. The association of SES measures (income, education, occupation, and insurance) with CVH scores was examined in the Jackson Heart Study. METHODS AND RESULTS: American Heart Association CVH components (non-high-density-lipoprotein cholesterol, blood pressure, diet, tobacco use, physical activity, sleep, glycemia, and body mass index) were scored cross-sectionally at baseline (scale: 0-100). Differences in CVH and 95% CIs (Estimate, 95% CI) were calculated using linear regression, adjusting for age, sex, and discrimination. Heterogeneity by sex was assessed. Participants had a mean age of 54.8 years (SD 12.6 years), and 65% were women. Lower income, education, occupation (non-management/professional versus management/professional occupations), and insurance status (uninsured, Medicaid, Veterans Affairs, or Medicare versus private insurance) were associated with lower CVH scores (all P<0.01). There was heterogeneity by sex, with greater magnitude of associations of SES measures with CVH in women versus men. The lowest education level (high school) was associated with 8.8-point lower (95% CI: -10.2 to -7.3) and 5.4-point lower (95% CI: -7.2 to -3.6) CVH scores in women and men, respectively (interaction P=0.003). The lowest (<25 000) versus highest level of income (≥$75 000) was associated with a greater reduction in CVH scores in women than men (interaction P=0.1142). CONCLUSIONS: Among Black Americans, measures of SES were associated with CVH, with a greater magnitude in women compared with men for education and income. Interventions aimed to address CVH through SES should consider the role of sex.

Association of Socioeconomic Status With Ideal Cardiovascular Health in Black Men.

Background Black men are burdened by high cardiovascular risk and the highest all-cause mortality rate in the United States. Socioeconomic status (SES) is associated with improved cardiovascular risk factors in majority populations, but there is a paucity of data in Black men. Methods and Results We examined the association of SES measures including educational attainment, annual income, employment status, and health insurance status with an ideal cardiovascular health (ICH) score, which included blood pressure, glucose, cholesterol, body mass index, physical activity, and smoking in African American Male Wellness Walks. Six metrics of ICH were categorized into a 3-tiered ICH score 0 to 2, 3 to 4, and 5 to 6. Multinomial logistic regression modeling was performed to examine the association of SES measures with ICH scores adjusted for age. Among 1444 men, 7% attained 5 to 6 ICH metrics. Annual income <$20 000 was associated with a 56% lower odds of attaining 3 to 4 versus 0 to 2 ICH components compared with ≥$75 000 (P=0.016). Medicare and no insurance were associated with a 39% and 35% lower odds of 3 to 4 versus 0 to 2 ICH components, respectively, compared with private insurance (all P<0.05). Education and employment status were not associated with higher attainment of ICH in Black men. Conclusions Among community-dwelling Black men, higher attainment of measures of SES showed mixed associations with greater attainment of ICH. The lack of association of higher levels of educational attainment and employment status with ICH suggests that in order to address the long-standing health inequities that affect Black men, strategies to increase attainment of cardiovascular health may need to address additional components beyond SES.

Impact of Race/Ethnicity and County-Level Vulnerability on Receipt of Surgery Among Older Medicare Beneficiaries With the Diagnosis of Early Pancreatic Cancer.

BACKGROUND: Patients can experience barriers and disparities to access high-quality cancer care. This study sought to characterize receipt of surgery and chemotherapy among Medicare beneficiaries with a diagnosis of early-stage pancreatic adenocarcinoma cancer (PDAC) relative to race/ethnicity and social vulnerability. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify patients with a diagnosis of early-stage (stage 1 or 2) PDAC between 2004 and 2016. Data were merged with the CDC's Social Vulnerability Index (SVI) at the beneficiary's county of residence. Multivariable, mixed-effects logistic regression was used to assess the association of SVI with resection. RESULTS: Among 15,931 older Medicare beneficiaries with early-stage PDAC (median age, 77 years; interquartile range [IQR], 71-82 years), the majority was White (n = 12,737, 80.0 %), whereas a smaller subset was Black or Latino (n = 3194, 20.0 %) A minority of patients was more likely to live in highly vulnerable communities (low SVI: white [90.5 %] vs minority [9.5 %] vs high SVI: white [71.9 %] vs minority [28.1 %]; p < 0.001). Use of resection for early-stage PDAC was lowest among the patients who resided in high-SVI areas (low [38.0 %] vs average [34.3 %] vs high [31.9 %]; p < 0.001). The minority patients were less likely to undergo resection than the White patients (no resection: white [64.1 %] vs minority [70.7 %]; p < 0.001). The median SVI was higher among the patients who underwent resection (57.6; IQR, 36.0-81.0) than among those who did not (60.4; IQR, 41.9-84.3), and increased SVI resulted in a decline in the likelihood of resection (SVI trend: OR, 0.98; 95 % confidence interval [CI], 0.97-1.00), especially among the minority patients. Minority patients from high-SVI counties had markedly lower odds of preoperative chemotherapy than minority patients from a low-SVI neighborhood (OR, 0.62; 95 % CI, 0.52-0.73). CONCLUSIONS: Older Medicare beneficiaries with early-stage PDAC residing in counties with higher social vulnerability had lower odds of undergoing pancreatic resection, which was more pronounced among minority versus older White Medicare beneficiaries.

Postoperative imaging surveillance for hepatocellular carcinoma: How much is enough?

BACKGROUND: The objective of the current study was to define trends in postoperative surveillance imaging following liver-directed treatment of hepatocellular carcinoma (HCC), and characterize the impact of high-intensity surveillance on long-term survival. METHODS: Patients who underwent liver- directed therapy for HCC between 2004 and 2016 were identified using the SEER-Medicare database. Trends in surveillance intensity over time, factors associated with high surveillance intensity and the impact of surveillance on long-term outcomes were examined. RESULTS: Utilization of high-intensity surveillance abdominal imaging (≥6 scans over 2 years) following liver-directed therapy of HCC decreased over time (2004-2007: n = 130, 36.1% vs. 2008-2011: n = 181, 29.5% vs. 2012-2016: n = 111, 24.5%; ptrend < 0.001). History of chronic viral hepatitis (hepatitis B: odds ratio [OR], 1.98; 95% confidence interval [CI]: 1.15-3.43; hepatitis C: OR, 1.79; 95% CI: 1.32-2.43), presence of regional (vs. local-only) disease (OR, 1.47; 95% CI: 1.09-1.98) and receipt of transplantation (OR, 2.23; 95% CI: 1.57-3.17) were associated with higher odds of high intensity surveillance. Intensity of surveillance imaging was not associated with long-term survival (5-year overall survival: low-intensity, 48.1% vs. high-intensity, 48.9%; hazards ratio, 0.94; 95% CI: 0.78-1.13). CONCLUSION: Utilization of posttreatment surveillance imaging decreased over time following liver-directed therapy for HCC. While utilization of high-intensity screening varied by HCC procedure performed, intensity of surveillance had no effect on survival.

Sounding the Alarm: Six Strategies for Medical Students to Champion Anti-Racism Advocacy.

Every year, incoming medical students take the Hippocratic Oath and pledge that they: "will be an advocate for patients in need and strive for justice in the care of the sick," yet guidance on how to engage in community and public health advocacy is not a mandatory component of medical education. Therefore, students often feel insufficiently qualified to engage in advocacy efforts. As the nation has struggled with a viral pandemic (COVID-19) and witnessed an uprising against anti-Black racism and police brutality, it became immediately apparent that activism that marries medicine to anti-racism advocacy was needed. Further, we deduced that anti-racism activism at medical institutions would need to position medical students, often low in the medical hierarchy, as essential to the response. With the support of our leaders and mentors, we created a concerted series of strategies for medical students to become front and center in advocacy efforts. In this paper, we outline six strategies for medical students across the nation to champion anti-racism advocacy, based on our successful experiences in Central Ohio. This approach may have utility for other medical schools across the nation. These strategies include: embracing a common agenda; establishing formal structures; engaging affinity groups and allies; endorsing legislative advocacy; encouraging curricular reform; and enriching the pipeline. It is our hope that medical students will feel empowered and activated to lead and organize "good trouble" efforts that will ultimately improve the lives and health of the communities and patients they are being trained to serve.

High Social Vulnerability and "Textbook Outcomes" after Cancer Operation.

BACKGROUND: The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer. METHODS: Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression. RESULTS: Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05). CONCLUSIONS: Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.

Sex-based differences in time to surgical care among pancreatic cancer patients: A national study of Medicare beneficiaries.

INTRODUCTION: The objective of this study was to characterize time from cancer symptoms to diagnosis and time from diagnosis to surgical treatment among patients undergoing pancreatectomy for cancer. METHODS: Medicare beneficiaries who underwent pancreatectomy for cancer between 2013 and 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Mixed effects negative binomial regression models were utilized to determine which factors were associated with the number of weeks to diagnosis and pancreatic resection. RESULTS: Among 7647 Medicare beneficiaries, two-thirds (n = 5127, 67%) had symptoms associated with a pancreatic cancer diagnosis before surgery. Median time from the first symptom to diagnosis was 6 weeks (IQR: 1-25) and the median time from diagnosis to surgery was 4 weeks (IQR: 2-15). In risk-adjusted models, female patients had 13% longer waiting times from identification of a related symptom to pancreatic cancer diagnosis (OR = 1.13, 95% CI: 1.05-1.21) and 12% longer waiting times from diagnosis to surgery (OR = 1.12, 95% CI: 1.07-1.18). Older age was associated with 10% longer waiting times from symptom identification to diagnosis (p < .0001). CONCLUSIONS: Female and older patients had longer wait times between symptom presentation and pancreatic cancer diagnosis. Sex-based disparities in cancer care need to be recognized and addressed by policymakers and health care institutions.

Community-engaged and community-based participatory research to promote American Heart Association Life's Simple 7 among African American adults: A systematic review.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the United States and African Americans (AA) have a disproportionately greater burden of CVD as compared to Whites. The American Heart Association (AHA) Life's Simple 7 (LS7) framework outlines goals for attaining ideal cardiovascular health. Yet, there is a lack of evidence summarizing best practices to maximize LS7 attainment. The objective of the present study was to systematically review the extant peer-reviewed literature on community-engaged and community-based participatory research (CBPR) aimed at improving one or more LS7 metrics among AA. METHODS: PubMed, CINAHL, and Embase databases were searched. We included articles that reported quantitative results for one or more of the following LS7 metrics: physical activity, diet, cholesterol, blood pressure, body mass index, smoking, and glycemia. We included analyses with a greater than 50% AA study population focused on adults (≥18 years of age). RESULTS: Of the 1008 unique studies identified, 54 met inclusion criteria; 27 of which were randomized controlled trials. 50% of studies assessed more than one LS7 metric but only two studies evaluated all seven of the LS7 metrics. No studies had a high proportion of AA males. 40 studies improved at least one LS7 metric at the study end-point. Formative research was used in many studies to guide intervention design. Studies were of varying quality, but overall rated "fair" using a modified approach to the National Institute of Health quality assessment tool. CONCLUSION: There is insufficient data to recommend a specific community-engaged or CBPR intervention to improve attainment of LS7 metrics among AA. Future studies using rigorous methodology with increased gender diversity and utilizing the AHA LS7 framework are required to establish a validated program to improve LS7 in AAs.

The association of neighborhood social vulnerability with surgical textbook outcomes among patients undergoing hepatopancreatic surgery.

BACKGROUND: Previous studies have largely examined social determinants of health relative to individual surgery quality metrics. We sought to characterize possible differences in "textbook outcome," a composite measure of quality, relative to social vulnerability index. METHODS: The Medicare Standard Analytical Files from 2013 to 2017 were used to identify beneficiaries who underwent hepatopancreatic surgery. Individuals were stratified into 3 groups dependent on their social vulnerability (low, average, high). Textbook outcome was defined as absence of postoperative surgical complications, prolonged length of stay, 90-day readmission, and 90-day mortality. RESULTS: Among 32,142 patients who underwent hepatopancreatic surgery, 18,841 (58.6%) patients underwent a pancreatectomy, whereas 13,301 (41.4%) underwent a hepatectomy. The overall incidence of textbook outcome after hepatopancreatic surgery was 51.2% (n = 16,445). Patients with a low social vulnerability index who underwent pancreatic resection more often achieved a textbook outcome versus patients who had an average or high social vulnerability index (low social vulnerability index: 48.3% vs average social vulnerability index: 46.5% vs high social vulnerability index: 44.9%; P = .004). The odds of obtaining a textbook outcome after pancreatic surgery was inversely associated with degree of vulnerability (low social vulnerability index, referent: average social vulnerability index: odds ratio 0.94, 95% confidence interval 0.87-1.00 vs high social vulnerability index: odds ratio 0.89, 95% confidence interval 0.82-0.97). Similarly, social vulnerability index was independently associated with textbook outcome after hepatic resection. Likewise, there were increased risks and incidence of various postoperative surgical outcomes, including 90-day mortality and complications as the social vulnerability index increased. CONCLUSION: Only one-half (51.2%) of Medicare beneficiaries achieved the composite quality textbook outcome metric. Social vulnerability was associated with lower attainment of textbook outcome and an increased risk of adverse postoperative surgical outcomes after hepatopancreatic surgery.

The association of ideal cardiovascular health with self-reported health, diabetes, and adiposity in African American males.

African American (AA) men have the highest age-adjusted all-cause mortality rate in the United States of America (US) and a high burden of cardiovascular risk factors. The African American Male Wellness Walk (AAMWW) seeks to reduce such health disparities among AA males. The association of a combination of ideal cardiovascular health (ICH) metrics (blood pressure, glucose, cholesterol, body mass index (BMI), physical activity, and smoking) with self-reported health, diabetes, and body fat percentage was examined among 729 AA male participants from the 2017 and 2018 AAMWWs. Six metrics of ICH were categorized into a three-tiered ICH score 0-2, 3-4, 5-6. Linear and logistic regression modeling was performed with adjustment for age and insurance. Seven percent of men attained 5-6 ICH metrics at baseline. Participants with 5-6 ICH metrics versus 0-2 had 256% higher odds of excellent self-reported health compared to good, fair or poor (p < 0.0001). After exclusion of glucose from the ideal cardiovascular health score, participants with 3-4 versus 0-2 ICH metrics had a 48% lower odds of diabetes (p < 0.0031). After exclusion of BMI from the ICH score, participants with 5 ICH metrics had a 14.1% lower body fat percentage versus participants with 0-2 ICH metrics (p = 0.0057). Attainment of higher ideal cardiovascular health scores is associated with higher odds of self-reported health, lower odds of diabetes and lower body fat percentage among AA men. Future strategies leading to greater attainment of cardiovascular health in AA males will be important to advance health equity.