Reducing Racial Inequalities in Prostate Cancer Treatment: Healthcare Access Barriers.

Inequalities in healthcare for patients with prostate cancer can result in treatment and mortality disparities. Despite Black men with prostate cancer having higher incidence and mortality from prostate cancer, the study by Hammarlund and colleagues found that they are less likely to receive appropriate treatment compared with their White counterparts. Given that Black men with prostate cancer have similar or better survival when participating in clinical trials or receiving equal treatment from an equal access to healthcare system, identifying factors contributing to inequitable treatment is essential to improve the overall health and survival of Black men with prostate cancer. See related article by Hammarlund and colleagues, Cancer Epidemiol Biomarkers Prev 2024;33:435-41.

A particular epidemiological profile: disparities in access to contraceptive methods in Brazil during the SARS-CoV-2 (COVID-19) pandemic.

Our objective was to study disparities in access to contraception during the COVID-19 pandemic. We performed a cross-sectional study at the University of Campinas, Brazil using a Google questionnaire applied from December 2021 until February 2022, disseminated via snowball technique. The survey asked about sociodemographic characteristics and contraceptive use, as well as the demand for new methods and difficulties in continuing to use contraceptives during the COVID-19 pandemic. We analyzed 1018 completed questionnaires; in total, 742 (72.9%) were women aged between 20 and 39 years, 746 (73.3%) were White and 602 (59.2%) used contraceptives. During the COVID-19 pandemic, about 23% of respondents changed their method and approximately 20% of respondents looked for new methods. Among the latter, 31.3% reported some difficulty with obtaining guidance on new methods while only 5.3% of the respondents reported some difficulty with continuing their contraceptive. The main difficulty in both cases was the difficulty with getting a healthcare provider appointment. Our results point to a particular epidemiological population, of younger black and biracial women, with lower education and lower income, which suffered health disparities during the COVID-19 pandemic and found difficulties with using contraceptives and accessing family planning services.

The impact of regional disparities on the availability of meningococcal vaccines in the US.

BACKGROUND: In the United States (US), three types of vaccines are available to prevent invasive meningococcal disease (IMD), a severe and potentially fatal infection: quadrivalent conjugate vaccines against serogroups A, C, W, Y (MenACWY), and monovalent vaccines against serogroup B (MenB) as well as a newly licensed pentavalent vaccine (MenABCWY) protecting against serogroup A, B, C, W, and Y. The CDC's Advisory Committee on Immunization Practices (ACIP) routinely recommends MenACWY vaccine for all 11- to 12-year-olds with a booster dose at 16 years. MenB vaccination is recommended based on shared clinical decision-making (SCDM) for 16- to 23-year-olds. Recently, the pentavalent meningococcal vaccine (MenABCWY) was recommended by the ACIP. Meningococcal vaccine uptake is suboptimal across the country, particularly among individuals with lower socioeconomic status (SES), despite these recommendations. The objective of the spatial analyses was to assess the relationship between stocking of MenACWY and MenB vaccines, area-level SES, and state-level policies. METHODS: The number of MenACWY and MenB doses stocked by vaccinators was obtained from IQVIA and the CDC's Vaccine for Children (VFC) program and compiled into a county-level dataset from 2016 to 2019. SES, as measured using the CDC's Social Vulnerability Index (SVI), state-level school recommendations, and universal purchasing programs were among the main county-level covariates included to control for factors likely influencing stocking. Data were stratified by public and private market. Bayesian spatial regression models were developed to quantify the variations in rates of stocking and the relative rates of stocking of both vaccines. RESULTS: After accounting for county-level characteristics, lower SES counties tended to have fewer doses of MenB relative to MenACWY on both public and private markets. Lower SES counties tended to have more supply of public vs. private doses. Universal purchasing programs had a strong effect on the markets for both vaccines shifting nearly all doses to the public market. School vaccination strategy was key for improving stocking rates. CONCLUSIONS: Overall, the results show that MenACWY has greater stock relative to MenB across the US. This difference is exacerbated in vulnerable areas without school entry requirements for vaccination and results in inequity of vaccine availability. Beyond state-level policy and SES differences, SCDM recommendations may be a contributing factor, although this was not directly assessed by our model.

Expressions of inequalities in access to health services in Latin America: a scoping review. / Expressões das desigualdades no acesso aos serviços de saúde na América Latina: uma revisão de escopo.

Latin America is one of the most unequal regions in the world. Due to colonization and occupation of the territory, structural inequalities mark people's living and health conditions. In health, we can observe how different dimensions of inequalities condition access and user experience in the service. This scoping review aimed to map and analyze the expressions of inequalities in access to health services in Latin American countries from the scientific production of the last ten years, from which 272 articles were selected. The categorical analysis classified articles into five dimensions, which characterize the expressions of inequalities in access to health services: socioeconomic, geospatial, ethnic/racial, gender, and people with disabilities. The most frequent access barriers were socioeconomic or ability to pay, geographic or transportation difficulty, availability of services, cultural/ethnic, communication, and architecture. The main conditioning factors of health inequalities were income, schooling, transportation, and living conditions. Combating health inequalities requires proposing structuring and sectorial policies.

A América Latina é uma das regiões mais desiguais do mundo. Desigualdades estruturais, fruto dos processos de colonização e ocupação do território, marcam as condições de vida e saúde das pessoas. Na saúde, é possível observar como diferentes dimensões das desigualdades condicionam o acesso e a experiência do usuário no serviço. Objetivou-se mapear e analisar as expressões das desigualdades no acesso aos serviços de saúde nos países da América Latina a partir da produção científica dos últimos dez anos. O desenho de estudo foi a revisão de escopo, por meio da qual foram selecionados 272 artigos. A análise categorial permitiu a classificação dos artigos em cinco dimensões, que caracterizam as expressões das desigualdades no acesso aos serviços de saúde: socioeconômica, geoespacial, étnica/racial, gênero e de pessoas com deficiência. As barreiras de acesso mais frequentes foram: socioeconômica ou capacidade de pagamento; geográfica ou dificuldade de transporte; disponibilidade de serviços; cultural/étnica; comunicação; e arquitetônica. Os principais fatores condicionantes das desigualdades em saúde foram renda, escolaridade, transporte e condições de moradia. O enfrentamento das desigualdades em saúde requer a proposição de políticas estruturantes e setoriais.

Racial disparities in colorectal cancer outcomes and access to care: a multi-cohort analysis.

Introduction: Non-Hispanic Black (NHB) Americans have a higher incidence of colorectal cancer (CRC) and worse survival than non-Hispanic white (NHW) Americans, but the relative contributions of biological versus access to care remain poorly characterized. This study used two nationwide cohorts in different healthcare contexts to study health system effects on this disparity. Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER) registry as well as the United States Veterans Health Administration (VA) to identify adults diagnosed with colorectal cancer between 2010 and 2020 who identified as non-Hispanic Black (NHB) or non-Hispanic white (NHW). Stratified survival analyses were performed using a primary endpoint of overall survival, and sensitivity analyses were performed using cancer-specific survival. Results: We identified 263,893 CRC patients in the SEER registry (36,662 (14%) NHB; 226,271 (86%) NHW) and 24,375 VA patients (4,860 (20%) NHB; 19,515 (80%) NHW). In the SEER registry, NHB patients had worse OS than NHW patients: median OS of 57 months (95% confidence interval (CI) 55-58) versus 72 months (95% CI 71-73) (hazard ratio (HR) 1.14, 95% CI 1.12-1.15, p = 0.001). In contrast, VA NHB median OS was 65 months (95% CI 62-69) versus NHW 69 months (95% CI 97-71) (HR 1.02, 95% CI 0.98-1.07, p = 0.375). There was significant interaction in the SEER registry between race and Medicare age eligibility (p < 0.001); NHB race had more effect in patients <65 years old (HR 1.44, 95% CI 1.39-1.49, p < 0.001) than in those ≥65 (HR 1.13, 95% CI 1.11-1.15, p < 0.001). In the VA, age stratification was not significant (p = 0.21). Discussion: Racial disparities in CRC survival in the general US population are significantly attenuated in Medicare-aged patients. This pattern is not present in the VA, suggesting that access to care may be an important component of racial disparities in this disease.

Emergent inequity of glycaemic metrics for Maori children with type 1 diabetes is negated by early use of continuous glucose monitoring.

AIM: We investigated if continuous glucose monitoring (CGM) in children with type 1 diabetes (T1D) within 12 months of being diagnosed modifies the development of glycaemic outcome inequity on the basis of either ethnicity or socio-economic status (SES). METHOD: De-identified clinical and SES data from the KIWIDIAB data network were collected 12 months after diagnosis in children under 15 years diagnosed with T1D between 1 October 2020 and 1 October 2021. RESULTS: There were 206 children with new onset T1D: CGM use was 56.7% for Maori and 77.2% for Europeans. Mean (SD) HbA1c was 62.4 (14.2) mmol/mol at 12 months post diagnosis, but Maori were 9.4mmol/mol higher compared to Europeans (p<0.001). For those without CGM, Maori had an HbA1c 10.8 (95% CI 2.3 to 19.4, p=0.013) mmol/mol higher than Europeans, whereas there was no evidence of a difference between Maori and Europeans using CGM (62.1 [9.3] mmol/mol vs 58.5 [12.4] mmol/mol p=0.53 respectively). Comparing quintiles of SES, HbA1c was 10.8 (95% CI 4.7 to 16.9, p<0.001) mmol/mol higher in the lowest quintile of SES compared to the highest. CONCLUSION: These observational data suggest CGM use ameliorates the ethnic disparity in HbA1c at 12 months in new onset T1D.

Socioeconomic and Geographical Inequities in Burden and Treatment seeking Behavior for Hypertension among Women in the Reproductive Age (15-45 years) Group in India: Findings from a Nationally Representative Survey.

BACKGROUND: Socioeconomic disparity changed healthcare seeking and management cascade of hypertension due to inequity in hypertension care cascade pathway. OBJECTIVES: The inequities in burden and treatment-seeking behavior of hypertension among reproductive age group women were studied from National Family Health Survey-4 (NFHS-4) data. MATERIALS AND METHODS: We analyzed the data from NFHS-4 of women of reproductive age group between 15 and 49 years among the selected households contributing to 699,686 women. Socioeconomic inequities were assessed by expenditure quintile. Inequities in burden and treatment-seeking behavior were reported using the concentration curve and concentration index. RESULTS: The prevalence of hypertension in India was 15% (95% confidence interval: 14.9%-15.4%). One-third (32%) of the hypertensive population received treatment and only 28% of the women had controlled blood pressure. Wealth and education-based inequalities were more in high wealth index. The inequity in screening and awareness was in the northern and northeastern regions. CONCLUSION: There was inequity in the overall hypertension care cascade pathway with more inequity in the northern and northeastern region.

Age-specific differences in breast cancer treatment between screen-detected and non-screen-detected breast cancers in women aged 40-74 years at diagnosis in Sweden 2008-2017.

BACKGROUND AND PURPOSE: We have recently demonstrated that screen-detected invasive breast cancers had more favourable tumour characteristics than non-screen-detected. The objective of the study was to analyse differences in breast cancer treatment between screen-detected and non-screen-detected cases by age at diagnosis, with and without adjustment for tumour (T) and nodal (N) status, within a nationwide, population-based mammography screening programme utilising register data. MATERIAL AND METHODS: Data spanning 2008-2017 were collected from the National Quality Register for Breast Cancer. Multivariable logistic regression analysis was used to estimate odds ratios and 95% confidence intervals for treatment disparities between screen-detected and non-screen-detected breast cancer. RESULTS: Among 46,481 women diagnosed with invasive breast cancer aged 40-74 and invited for mammography screening, significant differences in treatment were observed. Screen-detected cases showed higher likelihoods of partial mastectomy compared to mastectomy, endocrine therapy, and radiotherapy, whereas chemotherapy and antibody therapy were less likely compared to non-screen-detected cases. However, when adjusting for surgery type, screen-detected cases showed lower likelihoods of radiotherapy. Age at diagnosis significantly influenced treatment odds ratios, with interactions observed for all treatments except radiotherapy adjusted for surgery. Differences increased with age, except for endocrine therapy. Radiotherapy adjusted for surgery type showed no age-related interaction. Adjusting for T and N did not alter these patterns. INTERPRETATION: In general, screen-detected cases received less aggressive treatment, such as mastectomy, chemotherapy, and antibody therapy, compared to non-screen-detected cases. Disparities increased with age, except for endocrine therapy and radiotherapy adjusted for surgery. Differences persisted after adjusting for T and N, suggesting that these factors cannot solely explain the results.

Biomarker Testing Disparities in Metastatic Colorectal Cancer.

Importance: Among patients with metastatic colorectal cancer (mCRC), data are limited on disparate biomarker testing and its association with clinical outcomes on a national scale. Objective: To evaluate the socioeconomic and demographic inequities in microsatellite instability (MSI) and KRAS biomarker testing among patients with mCRC and to explore the association of testing with overall survival (OS). Design, Setting, and Participants: This cohort study, conducted between November 2022 and March 2024, included patients who were diagnosed with mCRC between January 1, 2010, and December 31, 2017. The study obtained data from the National Cancer Database, a hospital-based cancer registry in the US. Patients with mCRC and available information on biomarker testing were included. Patients were classified based on whether they completed or did not complete MSI or KRAS tests. Exposure: Demographic and socioeconomic factors, such as age, race, ethnicity, educational level in area of residence, median household income, insurance type, area of residence, facility type, and facility location were evaluated. Main Outcomes and Measures: The main outcomes were MSI and KRAS testing between the date of diagnosis and the date of first-course therapy. Univariable and multivariable logistic regressions were used to identify the relevant factors in MSI and KRAS testing. The OS outcomes were also evaluated. Results: Among the 41 061 patients included (22 362 males [54.5%]; mean [SD] age, 62.3 [10.1] years; 17.3% identified as Black individuals, 78.0% as White individuals, 4.7% as individuals of other race, with 6.5% Hispanic or 93.5% non-Hispanic ethnicity), 28.8% underwent KRAS testing and 43.7% received MSI testing. A significant proportion of patients had Medicare insurance (43.6%), received treatment at a comprehensive community cancer program (40.5%), and lived in an area with lower educational level (51.3%). Factors associated with a lower likelihood of MSI testing included age of 70 to 79 years (relative risk [RR], 0.70; 95% CI, 0.66-0.74; P < .001), treatment at a community cancer program (RR, 0.74; 95% CI, 0.70-0.79; P < .001), rural residency (RR, 0.80; 95% CI, 0.69-0.92; P < .001), lower educational level in area of residence (RR, 0.84; 95% CI, 0.79-0.89; P < .001), and treatment at East South Central facilities (RR, 0.67; 95% CI, 0.61-0.73; P < .001). Similar patterns were observed for KRAS testing. Survival analysis showed modest OS improvement in patients with MSI testing (hazard ratio, 0.93; 95% CI, 0.91-0.96; P < .001). The median (IQR) follow-up time for the survival analysis was 13.96 (3.71-29.34) months. Conclusions and Relevance: This cohort study of patients with mCRC found that older age, community-setting treatment, lower educational level in area of residence, and treatment at East South Central facilities were associated with a reduced likelihood of MSI and KRAS testing. Highlighting the sociodemographic-based disparities in biomarker testing can inform the development of strategies that promote equity in cancer care and improve outcomes for underserved populations.

Medicare Eligibility and Changes in Coverage, Access to Care, and Health by Sexual Orientation and Gender Identity.

Importance: Medicare provides nearly universal insurance coverage at age 65 years. However, how Medicare eligibility affects disparities in health insurance coverage, access to care, and health status among individuals by sexual orientation and gender identity is poorly understood. Objective: To assess the association of Medicare eligibility with disparities in health insurance coverage, access to care, and self-reported health status among individuals by sexual orientation and by gender identity. Design, Setting, and Participants: This cross-sectional study used the age discontinuity for Medicare eligibility at age 65 years to isolate the association of Medicare with health insurance coverage, access to care, and self-reported health status, by their sexual orientation and by their gender identity. Data were collected from the Behavioral Risk Factor Surveillance System for respondents from 51 to 79 years old from 2014 to 2021. Data analysis was performed from September 2022 to April 2023. Exposures: Medicare eligibility at age 65 years. Main Outcomes and Measures: Proportions of respondents with health insurance coverage, usual source of care, cost barriers to care, influenza vaccination, and self-reported health status. Results: The study population included 927 952 individuals (mean [SD] age, 64.4 [7.7] years; 524 972 [56.6%] females and 402 670 [43.4%] males), of whom 28 077 (3.03%) identified as a sexual minority-lesbian, gay, bisexual, or another sexual minority identity (LGB+) and 3286 (0.35%) as transgender or gender diverse. Respondents who identified as heterosexual had greater improvements at age 65 years in insurance coverage (4.2 percentage points [pp]; 95% CI, 4.0-4.4 pp) than those who identified as LGB+ (3.6 pp; 95% CI, 2.3-4.8 pp), except when the analysis was limited to a subsample of married respondents. For access to care, improvements in usual source of care, cost barriers to care, and influenza vaccination were larger at age 65 years for heterosexual respondents compared with LGB+ respondents, although confidence intervals were overlapping and less precise for LGB+ individuals. For self-reported health status, the analyses found larger improvements at age 65 years for LGB+ respondents compared with heterosexual respondents. There was considerable heterogeneity by state in disparities by sexual orientation among individuals who were nearly eligible for Medicare (close to 65 years old), with the US South and Central states demonstrating the highest disparities. Among the top-10 highest-disparities states, Medicare eligibility was associated with greater increases in coverage (6.7 pp vs 5.0 pp) and access to a usual source of care (1.4 pp vs 0.6 pp) for LGB+ respondents compared with heterosexual respondents. Conclusions and Relevance: The findings of this cross-sectional study indicate that Medicare eligibility was not associated with consistently greater improvements in health insurance coverage and access to care among LGBTQI+ individuals compared with heterosexual and/or cisgender individuals. However, among sexual minority individuals, Medicare may be associated with closing gaps in self-reported health status, and among states with the highest disparities, it may improve health insurance coverage, access to care, and self-reported health status.

Trajectory of medical expenditure and regional disparities in hypertensive patients in South Korea.

The aim of this study is to understand how different regions influence the management and financial burden of hypertension, and to identify regional disparities in hypertension management and medical expenditure. The study utilized data from the Korean Health Panel Survey conducted between 2014 and 2018, focusing on individuals with hypertension. Medical expenditures were classified into three trajectory groups: "Persistent Low," "Expenditure Increasing," and "Persistent High" over a five-year period using trajectory analysis. Inverse Probability Weighting (IPW) analysis was then employed to identify the association between regions and medical expenditure trajectories. The results indicate that individuals residing in metropolitan cities (Busan, Daegu, Incheon, Gwangju, Daejeon, and Ulsan) and rural areas were more likely to belong to the "Expenditure Increasing" group compared to the "Persistent Low Expenditure" group (OR = 1.07; 95% CI; p < 0.001), as opposed to those in the capital city (Seoul) (OR = 1.07; 95% CI; p < 0.001). Additionally, residents of rural areas were more likely to be in the "High Expenditure" group compared to the "Persistent Low Expenditure" group than those residing in the capital city (OR = 1.05; 95% CI; p = 0.001). These findings suggest that individuals in rural areas may be receiving relatively inadequate management for hypertension, leading to higher medical expenditures compared to those in the capital region. These disparities signify health inequality and highlight the need for policy efforts to address regional imbalances in social structures and healthcare resource distribution to ensure equitable chronic disease management across different regions.

Comparison Between Black Non-Hispanic and White Non-Hispanic Simultaneous Pancreas-Kidney Transplant Candidates and Recipients.

INTRODUCTION: This study examined simultaneous pancreas-kidney transplant (SPKt) in Black and White patients to identify disparities in transplantation, days on the waitlist, and reasons for SPKt waitlist removal. METHODS: Using the United Network for Organ Sharing Standard Transplant Analysis and Research file, patients between January 1, 2009, and May 31, 2021, were included. Three cohorts (overall, SPKt recipients only, and those not transplanted) were selected using propensity score matching. Conditional logistic regression was used for categorical outcomes. Days on the waitlist were compared using negative binomial regression. RESULTS: Black patients had increased odds of receiving a  SPKt (OR, 1.25 [95% CI, 1.11-1.40], p < 0.001). White patients had increased odds of receiving a kidney-only transplant (OR 0.48 [95% CI, 0.38-0.61], p < 0.001), and specifically increased odds of receiving a living donor kidney (OR 0.34 [0.25-0.45], p < 0.001). CONCLUSION: This study found that Black patients are more likely to receive a SPKt. Results suggest that there are opportunities for additional inquiry related to patient removal from the waitlist, particularly considering White patients received or accepted more kidney-only transplants and were more likely to receive a living donor kidney-only transplant.

Neighbourhood effect and inequality in access to essential health services among mother-child paired samples: a decomposition analysis of data from 58 low- and middle-income countries.

INTRODUCTION: Neighbourhood effect on health outcomes is well established, but little is known about its effect on access to essential health services (EHS). Therefore, this study aimed to assess the contributing factors to access to EHS in slum versus non-slum settings. METHODOLOGY: The most recent data from 58 Demographic and Health Surveys (DHS) conducted between 2011 and 2018 were used, including a total of 157,000 pairs of currently married women aged 15-49 and their children aged 12-23 months. We used meta-analysis techniques to examine the inequality gaps in suboptimal access to EHS between mother-children pairs living in slums and non-slums. Blinder-Oaxaca decomposition technique was used to identify the factors contributing to the inequality gaps in each low- and middle-income country (LMIC) included. RESULT: The percentage of mother-child pairs living in slums ranged from 0.5% in Egypt to 63.7% in Congo. Meta-analysis of proportions for the pooled sample revealed that 31.2% [27.1, 35.5] of slum residents and 20.0% [15.3, 25.2] among non-slum residents had suboptimal access to EHS. We observed significant pro-slum inequalities in suboptimal access to EHS in 28 of the 52 LMICs with sufficient data. Of the 34 African countries included, 16 showed statistically significant pro-slum inequality in suboptimal access to EHS, with the highest in Egypt and Mali (2.64 [0.84-4.44] and 1.76 [1.65, 1.87] respectively). Findings from the decomposition analysis showed that, on average, household wealth, neighbourhood education level, access to media, and neighbourhood-level illiteracy contributed mostly to slum & non-slum inequality gaps in suboptimal access to EHS. CONCLUSION: The study showed evidence of inequality in access to EHS due to neighbourhood effects in 26 LMICs. This evidence suggests that increased focus on the urban poor might be a important for increasing access to EHS and achieving the universal health coverage (UHC) goals.

Geographic Disparities in Access to Assisted Reproductive Technology Centers in China: Spatial-Statistical Study.

A study on infertility in China found that while 543 health care institutions are approved for assisted reproductive technology (ART), only 10.1% offer all ART services, with a significant skew toward the eastern regions, highlighting the accessibility challenges faced by rural and remote populations; this study recommends government measures including travel subsidies and education initiatives to improve ART access for economically disadvantaged individuals.

Health care accessibility and mobility in breast cancer: a Latin American perspective.

BACKGROUND: Latin America (LATAM) encompasses a vast region with diverse populations. Despite publicly funded health care systems providing universal coverage, significant socioeconomic and ethno-racial disparities persist in health care access across the region. Breast cancer (BC) incidence and mortality rates in Brazil are comparable to those in other LATAM countries, supporting the relevance of Brazilian data, with Brazil's health care policies and expenditures often serving as models for neighboring countries. We evaluated the impact of mobility on oncological outcomes in LATAM by analyzing studies of patients with BC reporting commuting routes or travel distances to receive treatment or diagnosis. METHODS: We searched MEDLINE (PubMed), Embase, Cochrane CENTRAL, LILACS, and Google Scholar databases. Studies eligible for inclusion were randomized controlled trials and observational studies of patients with BC published in English, Portuguese, or Spanish and conducted in LATAM. The primary outcome was the impact of mobility or travel distance on oncological outcomes. Secondary outcomes included factors related to mobility barriers and access to health services. For studies meeting eligibility, relevant data were extracted using standardized forms. Risk of bias was assessed using the Newcastle-Ottawa Scale. Quantitative and qualitative evidence synthesis focused on estimating travel distances based on available data. Heterogeneity across distance traveled or travel time was addressed by converting reported travel time to kilometers traveled and estimating distances for unspecified locations. RESULTS: Of 1142 records identified, 14 were included (12 from Brazil, 1 from Mexico, and 1 from Argentina). Meta-analysis revealed an average travel distance of 77.8 km (95% CI, 49.1-106.48) to access BC-related diagnostic or therapeutic resources. Nonetheless, this average fails to precisely encapsulate the distinct characteristics of each region, where notable variations persist in travel distance, ranging from 88 km in the South to 448 km in the North. CONCLUSION: The influence of mobility and travel distance on access to BC care is multifaceted and should consider the complex interplay of geographic barriers, sociodemographic factors, health system issues, and policy-related challenges. Further research is needed to comprehensively understand the variables impacting access to health services, particularly in LATAM countries, where the challenges women face during treatment remain understudied. TRIAL REGISTRATION: CRD42023446936.

Veterans Affairs Medical Center Racial and Ethnic Composition and Initiation of Anticoagulation for Atrial Fibrillation.

Importance: Racial and ethnic disparities exist in anticoagulation therapy for atrial fibrillation (AF). Whether medical center racial and ethnic composition is associated with these disparities is unclear. Objective: To determine whether medical center racial and ethnic composition is associated with overall anticoagulation and disparities in anticoagulation for AF. Design, Setting, and Participants: Retrospective cohort study of Black, White, and Hispanic patients with incident AF from 2018 to 2021 at 140 Veterans Health Administration medical centers (VAMCs). Data were analyzed from March to November 2023. Exposure: VAMC racial and ethnic composition, defined as the proportion of patients from minoritized racial and ethnic groups treated at a VAMC, categorized into quartiles. VAMCs in quartile 1 (Q1) had the lowest percentage of patients from minoritized groups (ie, the reference group). Main Outcomes and Measures: The odds of initiating any anticoagulant, direct-acting oral anticoagulant (DOAC), or warfarin therapy within 90 days of an index AF diagnosis, adjusting for sociodemographics, medical comorbidities, and facility factors. Results: The cohort comprised 89 791 patients with a mean (SD) age of 73.0 (10.1) years; 87 647 (97.6%) were male, 9063 (10.1%) were Black, 3355 (3.7%) were Hispanic, and 77 373 (86.2%) were White. Overall, 64 770 individuals (72.1%) initiated any anticoagulant, 60 362 (67.2%) initiated DOAC therapy, and 4408 (4.9%) initiated warfarin. Compared with White patients, Black and Hispanic patients had lower rates of any anticoagulant and DOAC therapy initiation but higher rates of warfarin initiation across all quartiles of VAMC racial and ethnic composition. Any anticoagulant therapy initiation was lower in Q4 than Q1 (69.8% vs 74.9%; adjusted odds ratio [aOR], 0.80; 95% CI, 0.69-0.92; P < .001). DOAC and warfarin initiation were also lower in Q4 than in Q1 (DOAC, 69.4% vs 65.3%; aOR, 0.85; 95% CI, 0.74-0.97; P < .001; warfarin, 5.4% vs 4.5%; aOR, 0.82; 95% CI, 0.67-1.00; P < .001). In adjusted models, patients in Q4 were significantly less likely to initiate any anticoagulant therapy than those in Q1 (aOR, 0.88; 95% CI, 0.78-0.99). Patients in Q3 (aOR, 0.75; 95% CI, 0.60-0.93) and Q4 (aOR, 0.69; 95% CI, 0.55-0.87) were significantly less likely to initiate warfarin therapy than those in Q1. There was no significant difference in the adjusted odds of initiating DOAC therapy across racial and ethnic composition quartiles. Although significant Black-White and Hispanic-White differences in initiation of any anticoagulant, DOAC, and warfarin therapy were observed, interactions between patient race and ethnicity and VAMC racial composition were not significant. Conclusions and Relevance: In a national cohort of VA patients with AF, initiation of any anticoagulant and warfarin, but not DOAC therapy, was lower in VAMCs serving more minoritized patients.

Rural Health Disparities in Skin Cancer Amplified Among Skin of Color.

Limited studies explore the role social determinants of health have on urban-rural health disparities, particularly for Skin of Color. To further evaluate this relationship, a cross-sectional study was conducted on data from five states using the 2018 to 2021 Behavior Risk Factor Surveillance Survey, a national state-run health survey. Prevalence of skin cancer history and urban/rural status were evaluated across these social determinants of health: sex, age, race, insurance status, number of personal healthcare providers, and household income. Overall, rural counterparts were significantly more likely to have a positive skin cancer history across most social determinants of health. Rural populations had a higher prevalence of skin cancer history across all races (P<.001). Rural non-Hispanic Whites had greater odds than their urban counterparts (OR=1.40; 95% CI 1.34 - 1.46). The odds were approximately twice as high for rural Black (OR=1.74; 95% CI 1.14 - 2.65), Hispanic (OR=2.31; 95% CI 1.56 - 3.41), and Other Race, non-Hispanic (OR=1.99; 95% CI 1.51 - 2.61), and twenty times higher for Asians (OR=20.46; 95% CI 8.63 - 48.54), although no significant difference was seen for American Indian/Alaskan Native (OR=1.5; 95% CI 0.99 - 2.28). However, when household income exceeded $100,000 no significant difference in prevalence or odds was seen between urban and rural settings. Despite increasing awareness of metropolitan-based health inequity, urban-rural disparities in skin cancer prevalence continue to persist and may be magnified by social determinants such as income and race. J Drugs Dermatol. 2024;23(6):480-484.    doi:10.36849/JDD.8094.

Health disparities in psoriasis: geographic barriers to access in the United States.

PURPOSE: Providers who treat patients with psoriasis are unevenly distributed across the United States, with more in urban than rural areas. This retrospective claims analysis characterized disparities in access to care for US patients with psoriasis using data from the STATinMED database. MATERIALS AND METHODS: Patients (≥18 years) had ≥1 claim with a psoriasis diagnosis and ≥1 claim for advanced psoriasis therapy (apremilast or biologics) between January 2015 and December 2019. Access to psoriasis care was determined using the proportion of patients with 0, 1-2, 3-4, or ≥5 providers in their local area. RESULTS: Overall, 179,688 patients were included in the analysis, 80.0% in urban areas. The access ratio was highest for internal medicine physicians (97.1 per 1000 patients) and lowest for dermatologists (4.4 per 1000 patients) and family practice physicians (3.9 per 1000 patients). In urban areas, 41% of patients had access to ≥5 dermatologists versus 7% in rural areas. Whereas 2% of patients in urban areas sought care outside of their local area, 75% in rural areas did so. Use of advanced therapies was low in all states (<17%). CONCLUSION: Access to psoriasis-treating providers varied widely. Regardless of access, utilization of advanced treatments was low, suggesting the need for effective, easy-to-administer therapy.

Decomposition Analysis of Socioeconomic Inequalities in Vaccination Dropout in Remote and Underserved Settings in Ethiopia.

Despite increments in immunization coverage over the past decades, substantial inequality due to wealth status has persisted in Ethiopia. This study aimed to decompose the concentration index into the contributions of individual factors to socioeconomic inequalities of childhood vaccination dropout in remote and underserved settings in Ethiopia by using a decomposition approach. A wealth index was developed by reducing 41 variables related to women's household living standards into nine factors by using principal component analysis. The components were further totaled into a composite score and divided into five quintiles (poorest, poorer, middle, richer, and richest). Vaccination dropout was calculated as the proportion of children who did not get the pentavalent-3 vaccine among those who received the pentavalent-1 vaccine. The concentration index was used to estimate socioeconomic inequalities in childhood vaccination dropout, which was then decomposed to examine the factors contributing to socioeconomic inequalities in vaccination dropout. The overall concentration index was -0.179 (P <0.01), confirming the concentration of vaccination dropout among the lowest wealth strata. The decomposition analyses showed that wealth index significantly contributed to inequalities in vaccination dropout (49.7%). Place of residence also explained -16.2% of the inequality. Skilled birth attendance and availability of a health facility in the kebele (the lowest administrative government structure) also significantly contributed (33.6% and 12.6%, respectively) to inequalities in vaccination dropout. Wealth index, place of residence, skilled birth attendance, and availability of a health facility in the kebele largely contributed to the concentration of vaccination dropout among the lowest wealth strata. Policymakers should address vaccination inequality by designing more effective strategies.

Racial Disparities Exist in 90-Day Unplanned Return to the Emergency Department Following Orthopaedic Trauma Surgery.

OBJECTIVES: Racial disparities in healthcare outcomes exist, including in orthopaedic trauma care. The aim of this study was to determine the impact of race, social deprivation, and payor status on 90-day emergency department (ED) revisits among orthopaedic trauma surgery patients at a Level 1 trauma academic medical center. DESIGN: Retrospective chart review analysis. SETTING: Level 1 trauma academic center in Durham, NC. PATIENT SELECTION CRITERIA: Adult patients undergoing orthopaedic trauma surgery between 2017 and 2021. OUTCOME MEASURES AND COMPARISONS: The primary outcome of this retrospective cohort study was 90-day return to the ED. Logistic regression analysis was performed for variables of interest [race, social deprivation (measured by the Area Deprivation Index), and payor status] separately and combined, with each model adjusting for distance to the hospital. Results were interpreted as odds ratios (ORs) of 90-day ED revisits comparing levels of the respective variables. Statistical significance was assessed at α = 0.05. RESULTS: A total of 3120 adult patients who underwent orthopaedic trauma surgery between 2017 and 2021 were included in the analysis. Black race (OR = 1.47; 95% confidence interval [CI]: 1.17-1.84, P < 0.001) and Medicaid coverage (OR = 1.63, 95% CI: 1.20-2.21, P = 0.002) were significantly associated with higher odds of return to ED compared with non-Black or non-Medicaid-covered patients. While ethnic minority (Hispanic/Latino or non-White) was statistically significant while adjusting only for distance to the hospital (OR = 1.23, 95% CI: 1.00-1.50, P = 0.047), it was no longer significant after adjusting for the other sociodemographic variables (OR = 1.13, 95% CI: 0.91-1.39, P = 0.27). The weighted Area Deprivation Index was not associated with a difference in odds of return to ED in any adjusted models. CONCLUSIONS: The results highlight the presence of racial and socioeconomic disparities in ED utilization, with Black race and Medicaid coverage significantly associated with higher odds of return to the ED. Future research should delve deeper into comprehending the root causes contributing to these racial and socioeconomic utilization disparities and evaluate the effectiveness of targeted interventions to reduce them. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.