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1.
Article in English | MEDLINE | ID: mdl-31725027

ABSTRACT

BACKGROUND: Healthcare disparities are an issue in the surgical management of orthopaedic conditions in children. Although insurance expansion efforts may mitigate racial disparities in surgical outcomes, prior studies have not examined these effects on differences in pediatric orthopaedic care. To assess for racial disparities in pediatric orthopaedic care that may persist despite insurance expansion, we performed a case-control study of the outcomes of children treated for osteomyelitis in the TRICARE system, the healthcare program of the United States Department of Defense and a model of universal insurance and healthcare access. QUESTIONS/PURPOSES: We asked whether (1) the rates of surgical intervention and (2) 90-day outcomes (defined as emergency department visits, readmission, and complications) were different among TRICARE-insured pediatric patients with osteomyelitis when analyzed based on black versus white race and military rank-defined socioeconomic status. METHODS: We analyzed TRICARE claims from 2005 to 2016. We identified 2906 pediatric patients, of whom 62% (1810) were white and 18% (520) were black. A surgical intervention was performed in 9% of the patients (253 of 2906 patients). The primary outcome was receipt of surgical intervention for osteomyelitis. Secondary outcomes included 90-day complications, readmissions, and returns to the emergency department. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of socioeconomic status before and during enlistment, and enlisted service members, particularly junior enlisted service members, may be at risk of having the same medical conditions that affect civilian members of lower socioeconomic strata. Patient demographic information (age, sex, race, sponsor rank, beneficiary category [whether the patient is an insurance beneficiary from an active-duty or retired service member], and geographic region) and clinical information (prior comorbidities, environment of care [whether clinical care was provided in a civilian or military facility], treatment setting, and length of stay) were used as covariates in multivariable logistic regression analyses. RESULTS: After controlling for demographic and clinical factors including age, sex, sponsor rank, beneficiary category, geographic region, Charlson comorbidity index (as a measure of baseline health), environment of care, and treatment setting (inpatient versus outpatient), we found that black children were more likely to undergo surgical interventions for osteomyelitis than white children (odds ratio 1.78; 95% confidence interval, 1.26-2.50; p = 0.001). When stratified by environment of care, this finding persisted only in the civilian healthcare setting (OR 1.85; 95% CI, 1.26-2.74; p = 0.002). Additionally, after controlling for demographic and clinical factors, lower socioeconomic status (junior enlisted personnel) was associated with a higher likelihood of 90-day emergency department use overall (OR 1.60; 95% CI, 1.02-2.51; p = 0.040). CONCLUSIONS: We found that for pediatric patients with osteomyelitis in the universally insured TRICARE system, many of the historically reported disparities in care were absent, suggesting these patients benefitted from improved access to healthcare. However, despite universal coverage, racial disparities persisted in the civilian care environment, suggesting that no single intervention such as universal insurance sufficiently addresses differences in racial disparities in care. Future studies can address the pervasiveness of these disparities in other patient populations and the various mechanisms through which they exert their effects, as well as potential interventions to mitigate these disparities. LEVEL OF EVIDENCE: Level III, prognostic study.

2.
Cardiovasc Revasc Med ; 20(10): 836-837, 2019 Oct.
Article in English | MEDLINE | ID: mdl-31733710
5.
Article in English | MEDLINE | ID: mdl-31743389

ABSTRACT

PURPOSE: The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. SUMMARY: To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Efforts may include training in cultural humility and cultural competency, education about the organization's vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities. CONCLUSION: By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers-and helping pave the road towards equity throughout the US health care system.

6.
Am J Health Promot ; : 890117119883583, 2019 Oct 30.
Article in English | MEDLINE | ID: mdl-31665895

ABSTRACT

PURPOSE: To examine associations between socioeconomic status and two forms of social capital, namely, neighborhood and network measures, and how these distinct forms of capital are associated with body mass index (BMI) among Black residents of low-income communities. DESIGN: Respondent-driven sampling was used to engage residents in a household survey to collect data on the respondents' personal network, perceptions about their neighborhood environment, and health. SETTING: Eight special emphasis neighborhoods in Greenville, South Carolina. PARTICIPANTS: N = 337 black/African American older adults, nearly half of whom have a household income of less than $15 000 and a high school education, were included. MEASURES: Neighborhood capital was assessed via three scales on social cohesion, collective efficacy, and social support from neighbors. Network capital was calculated via a position generator, common in egocentric network surveys. Body mass index was calculated with self-reported height and weight. ANALYSIS: Multilevel linear regression models were used to examine the association between neighborhood and network capital and obesity among respondents within sampling chains. RESULTS: Higher household income was associated with greater neighborhood capital, whereas higher educational attainment was associated with greater network capital. Social cohesion was negatively associated with BMI (b = -1.25, 95% confidence interval [CI]: -2.39 to -0.11); network diversity was positively associated with BMI (b = 0.31, 95% CI: 0.08 to 0.55). CONCLUSION: The findings shed light on how social capital may be patterned by socioeconomic status and, further, how distinct forms of capital may be differentially associated with health among black Americans.

7.
Anticancer Res ; 39(11): 6359-6363, 2019 Nov.
Article in English | MEDLINE | ID: mdl-31704868

ABSTRACT

BACKGROUND/AIM: To analyze whether demographic and facility type characteristics cause inequality in the type of biopsy performed in patients with cutaneous melanoma. PATIENTS AND METHODS: The skin cancer National Cancer Database was assessed. Men and women of all ages with cutaneous melanoma in situ and malignant melanoma at any stage of the disease were included. Patients were selected who underwent one of the following biopsy types: excisional, punch, shave, or incisional. Bivariate and multivariate analyses were performed. RESULTS: We found that the likelihood of undergoing an excisional biopsy decreased in patients who were: Hispanic [odds ratio (OR)=0.63, confidence interval (CI)=0.55-0.71], non-White (OR=0.66, CI=0.58-0.76), older than 80 years (OR=0.77, CI=0.72-0.87), or in Comprehensive Community Cancer Programs (OR=0.33, CI=0.31-0.36), Community Cancer Programs (OR=0.52, CI=0.50-0.54) and Integrated Network Cancer Programs (OR=0.58, CI=0.55-0.61). CONCLUSION: Our study results demonstrate disparities in biopsy type in the treatment of melanoma.


Subject(s)
Biopsy/methods , Healthcare Disparities , Melanoma/pathology , Skin Neoplasms/pathology , Standard of Care , Age Factors , Biopsy/standards , Continental Population Groups , Ethnic Groups , Female , Healthcare Disparities/ethnology , Hispanic Americans , Humans , Insurance Coverage/statistics & numerical data , Male , Middle Aged , Multivariate Analysis , Regression Analysis , Residence Characteristics , Sex Factors , Socioeconomic Factors
8.
Article in English | MEDLINE | ID: mdl-31729067

ABSTRACT

OBJECTIVES: Income inequalities in access to dental care have been reported worldwide. While geographical accessibility may affect inequalities, no study has examined whether the use of public transportation reduces income inequalities in access to dental care. Therefore, we examined whether the use of public transportation is associated with reduced income inequalities in access to dental care. METHODS: This cross-sectional study used data from the Japan Gerontological Evaluation Study conducted in 2016. Self-reported questionnaires were distributed to 34 567 community-dwelling independent older adults aged 65 years or over from 39 municipalities. The dependent variable was dental attendance for any treatment. The independent variables were daily public transportation use and household equivalent income. The covariates were age, years of education, marital status, self-rated health, number of teeth, car use, having bus stops or railway stations nearby for individual level and density of dental clinics for community level. After multiple imputation, a two-level linear regression analysis was performed and stratified by sex. RESULTS: The mean age of the 19 664 participants (response rate: 69.9%) was 73.8 years (standard deviation = 6.1). Among the participants with dental attendance for treatment in the past six months, daily public transportation users represented 45.5% of men and 56.1% of women. These users had higher levels of dental attendance for treatment (ß = .109, 95% confidence interval (CI) = 0.051-0.166 for men, ß = .094, 95% CI = 0.039-0.149 for women) than nondaily users. Household equivalent income was positively associated with higher dental attendance for treatment (ß = .046, 95% CI = 0.029-0.062 for men, ß = .029, 95% CI = 0.013-0.045 for women). Income inequalities in access to dental care were smaller among the daily public transportation users than in nondaily users, and a statistically significant interaction was observed only in men (P-value interactions = .025 for men, .188 for women). CONCLUSION: Income inequalities in access to dental care were smaller among older daily users of public transportation than in nondaily users. These results suggest that providing environment in which people can conveniently use public transportation is needed for reducing income inequalities in access to dental care, especially for men.

9.
Nervenarzt ; 90(11): 1187-1200, 2019 Nov.
Article in German | MEDLINE | ID: mdl-31667532

ABSTRACT

Social inequality refers to the inequitable distribution of social prosperity including the resource of health. The relationship between social inequality and mental health can be established by means of indicators of social inequality throughout all age groups in Germany. There are social gradients of mental health on the population level, i.e. the linear relationship between social classes or status and state of health. Fundamental determinants of health disparity are cultural, social, political, and geographical conditions, which interact with the genetic make-up and epigenetic processes. These determinants also influence the management of developmental tasks during the life course and are of utmost importance for the development of mental disorders. The maladaptation to chronic stress is at the core of health disparity. Interventions at the individual behavioral level should comprise the development of stress management and coping strategies.


Subject(s)
Healthcare Disparities/ethnology , Mental Disorders , Mental Health Services/statistics & numerical data , Mental Health , Germany , Humans , Mental Disorders/ethnology , Social Class , Socioeconomic Factors
10.
J Orthop Surg Res ; 14(1): 359, 2019 Nov 12.
Article in English | MEDLINE | ID: mdl-31718674

ABSTRACT

BACKGROUND: Socio-demographic factors have been suggested to contribute to differences in healthcare utilization for several elective orthopedic procedures. Reports on disparities in utilization of orthopedic trauma procedures remain limited. The purpose of our study is to assess the roles of clinical and socio-demographic variables in utilization of operative fixation of calcaneus fractures in the USA. METHODS: The National Inpatient Sample (NIS) dataset was used to analyze all patients from 2005 to 2014 with closed calcaneal fractures. Multivariate logistic regression analyses were performed to evaluate the impact of clinical and socio-demographic variables on the utilization of surgical versus non-surgical treatment. RESULTS: A total of 17,156 patients with closed calcaneus fractures were identified. Operative treatment was rendered in 7039 patients (41.03%). A multivariate logistic regression demonstrated multiple clinical and socio-demographic factors to significantly influence the utilization of surgical treatment including age, gender, insurance status, race/ethnicity, income, diabetes, peripheral vascular disease, psychosis, drug abuse, and alcohol abuse (p <  0.05). In addition, hospital size and hospital type (teaching versus non-teaching) showed a statistically significant difference (p <  0.05). CONCLUSIONS: Besides different clinical variables, we identified several socio-demographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Further studies need to identify the specific patient-related, provider-related, and system-related factors leading to these disparities.

11.
MMWR Morb Mortal Wkly Rep ; 68(45): 1020-1023, 2019 Nov 15.
Article in English | MEDLINE | ID: mdl-31725705

ABSTRACT

Approximately 30 million persons in the United States have diabetes.* Persons with diabetes are at risk for vision loss from diabetic retinopathy and other eye diseases (1). Diabetic retinopathy, the most common diabetes-related eye disease, affects 29% of U.S. adults aged ≥40 years with diabetes (2) and is the leading cause of incident blindness among working-age adults (1). It is caused by chronically high blood glucose damaging blood vessels in the retina.† Annual dilated eye exams are recommended for persons with diabetes because early detection and timely treatment of diabetic eye diseases can prevent irreversible vision loss§,¶ (3,4). Studies have documented prevalence of annual eye exams among U.S. adults with diabetes (5,6); however, a lack of recent state-level data limits identification of geographic disparities in adherence to this recommendation. Medicare claims from the 50 states, the District of Columbia (DC), Puerto Rico, and U.S. Virgin Islands (USVI) were examined to assess the prevalence of eye exams in 2017 among beneficiaries with diabetes who were continuously enrolled in Part B fee-for-service insurance, which covers annual eye exams for beneficiaries with diabetes.** This report also examines disparities, by state and race/ethnicity, in receipt of eye exams. Nationally, 54.1% of beneficiaries with diabetes had an eye exam in 2017. Prevalence ranged from 43.9% in Puerto Rico to 64.8% in Rhode Island. Fewer than 50% of beneficiaries received an eye exam in seven states (Alabama, Alaska, Kentucky, Louisiana, Nevada, West Virginia, and Wyoming) and Puerto Rico. Non-Hispanic white (white) beneficiaries had a higher prevalence of receiving an eye exam (55.6%) than did non-Hispanic blacks (blacks) (48.9%) and Hispanics (48.2%). Barriers to receiving eye care (e.g., suboptimal clinical care coordination and referral, low health literacy, and lack of perceived need for care) might limit Medicare beneficiaries' ability to follow this preventive care recommendation. Understanding and addressing these barriers might prevent irreversible vision loss among persons with diabetes.


Subject(s)
Diabetes Mellitus/epidemiology , Fee-for-Service Plans/statistics & numerical data , Healthcare Disparities , Medicare Part B/economics , Vision Screening , Adolescent , Adult , Aged , Aged, 80 and over , Female , Healthcare Disparities/ethnology , Humans , Male , Middle Aged , United States/epidemiology , Young Adult
12.
J Bone Joint Surg Am ; 101(22): e121, 2019 Nov 20.
Article in English | MEDLINE | ID: mdl-31764373

ABSTRACT

The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.

13.
Urology ; 2019 Nov 23.
Article in English | MEDLINE | ID: mdl-31770548

ABSTRACT

For prostate cancer (PCa), we review racial differences in incidence, androgen pathways, growth factors, tumor location, rate of definitive treatment, and outcomes. We review the effect of race on risk-stratification and discuss studies of active surveillance in the African American (AA) population. For bladder cancer, race- and gender- associated differences in incidence, sex hormone pathways. For renal cell carcinoma (RCC), disparities in incidence, genetic factors, tumor pathology, time to presentation, and disease specific survival have been observed. We evaluate the impact of race and ethnicity on tumor pathology and discuss gaps in our current understanding of RCC pathogenesis.

14.
Nurs Clin North Am ; 54(4): 551-559, 2019 12.
Article in English | MEDLINE | ID: mdl-31703780

ABSTRACT

Transgender individuals are at an increased risk of experiencing health inequalities, such as anxiety, depression, and HIV. It is important that providers and staff in the health care setting are prepared to care for this population to ensure best patient outcomes. An understanding of transgender terminology and the experience of gender dysphoria is key. In addition, a transinclusive environment should be created to reduce the likelihood of transgender-related discrimination. Developing an understanding of potential gender-affirming treatments and surgeries also optimizes patient care. Improving the quality care will reduce health disparities commonly faced by the transgender population.


Subject(s)
Delivery of Health Care , Healthcare Disparities , Transgender Persons/psychology , Gender Dysphoria , Humans
15.
J Am Heart Assoc ; 8(20): e013057, 2019 Oct 15.
Article in English | MEDLINE | ID: mdl-31581873

ABSTRACT

Background There is a scarcity of knowledge as to whether rates of myocardial reperfusion use and 30-day mortality for patients with ST-segment-elevation myocardial infarction are similar among patients using the Brazilian Public Health System (SUS) and those using the private healthcare system. Methods and Results A total of 707 patients were analyzed using the VICTIM (Via Crucis for the Treatment of Myocardial Infarction) register database; 589 patients from the SUS and 118 from the private network with ST-segment-elevation myocardial infarction, who attended hospitals with the capacity to perform primary percutaneous coronary intervention (PCI) were investigated. The timeline, rates of use of PCI, and the 30-day probability of death were investigated, comparing the SUS patients to those in the private system. The mean time between symptom onset and arrival at the PCI hospital was higher for SUS patients compared with users of the private system (25.4±36.5 versus 9.0±21 hours; P<0.001, respectively). Rates of primary PCI were low in both groups, but significantly lower for the SUS patients (45% versus 78%; P<0.001). The 30-day mortality rate of SUS patients was 11.9% and of private patients was 5.9% (P=0.04). In the fully adjusted model, the odds ratio for 30-day mortality for the SUS patients was higher (odds ratio, 2.96; 95% CI, 1.15-7.61; P=0.02). Conclusions The delay in reaching a PCI hospital was almost 3 times higher for the SUS patients. Primary PCI was underused in both groups, especially in the SUS patients. The SUS patients were more likely to die during the 30-day follow-up.

16.
Clin Rheumatol ; 2019 Oct 11.
Article in English | MEDLINE | ID: mdl-31602534

ABSTRACT

All fields of medicine are victim to health inequity worldwide, including rheumatology. While the health system is a key proponent to health access for all, other social determinants of health also impact world health. We describe herein the current state of global healthcare disparities in rheumatology and attempts at optimizing graduate medical education and resources for optimized healthcare, international research collaborations and a future of universal health equity. We performed a comprehensive search through Pubmed using the following keywords: healthcare disparities, medical education, access to care, community health. Key Points • Healthcare disparities are ubiquitous globally, including the field of rheumatology. • The heterogeneity of global healthcare disparities emphasizes the importance of addressing unmet needs at a regional level. • A standardized approach to incorporating healthcare disparities education in the medical field is lacking. Intervening at this level provides a foundation of increasing provider awareness of regional healthcare disparities so as to establish a framework of addressing such disparities in a culturally competent manner.

17.
J Community Health ; 2019 Oct 14.
Article in English | MEDLINE | ID: mdl-31612369

ABSTRACT

Chronic hepatitis B (CHB) disproportionately affects non-US born Asians. The Hmong have been shown to have the highest rates of CHB and mortality from liver cancer compared to other Asian groups. From September 2014 to September 2017, testing for CHB within Sacramento County was conducted through community-based testing events and an electronic health record alert that identified Asian patients by surname. Demographic and laboratory data were collected for analysis and patients were followed through the study period to assess linkage to care and treatment to compare differences between Asian origin groups. Of 4350 patients tested for CHB, 318 (7.3%) were HBsAg positive, including 90 Chinese, 47 Hmong, and 101 Vietnamese. Hmong were more likely to have Medicaid insurance compared to other Asian origin groups (15%, p < 0.001). Hmong had significantly lower rates of hepatitis B DNA testing (p < 0.001), referral to hepatology (p < 0.001), attendance of first (p < 0.001) and second medical visit (p = 0.0003), and lower rates of antiviral treatment compared to other Asian origin groups. Hmong also had the highest proportion of non-English speakers (p < 0.001). Hmong patients in the Sacramento CHB testing and linkage to care program experience socioeconomic disadvantages compared to Vietnamese and Chinese patients. These factors may contribute to decreased linkage of care and decreased anti-viral treatment rates for CHB.

18.
Zhonghua Yu Fang Yi Xue Za Zhi ; 53(10): 1038-1042, 2019 Oct 06.
Article in Chinese | MEDLINE | ID: mdl-31607052

ABSTRACT

Objective: To analyze the urban-rural disparity of childhood stunting and its association with subnational economic growth among Chinese Han students aged 7-18 years. Methods: We used the data from 2014 Chinese National Survey on Students' Constitution and Health. 213 940 Chinese Han students aged 7-18 years with complete height records were included in this study. Stunting was defined according to the Screening Criteria of Malnutrition for School-age Children and Adolescents(2014 version, in Chinese). We divided students into two groups (economically developed and underdeveloped areas) according to the provincial GDP per capita. Spearman correlation coefficient was used to explore the association between the difference of urban-rural stunting prevalence and the provincial GDP per capita. Logistic regression models were established to assess the risk of stunting in rural children compared with urban children. Results: Among 213 940 students, 107 033 (50.0%) were from urban areas. The average height of 7-18 years old and 18 years old [(152.9±15.7) and (166.1±8.7) cm] of urban students were both higher than those of rural students [(150.7±16.0) and (165.1±8.6) cm] (P<0.001). The stunting prevalence of Chinese urban students (0.4%) was statistically significant lower than that of rural students (1.1%) (P<0.001), which was consistent in all age groups (P<0.05). The urban-rural disparity was found in 60% (18/30) of Chinese provinces. The difference of urban-rural stunting prevalence was negatively associated with provincial GDP per capita (r=-0.62, P<0.001). In economically underdeveloped areas, the risk of stunting for rural students aged 7-9 years was 4.69 (95%CI: 2.93-7.52) times that for urban children, while for students aged 10-18 years, the odds ratio was 2.44 (95%CI: 2.02-2.96). In economically developed areas, the risk of stunting for rural students aged 7-9 years was 5.43 (95%CI: 3.67-8.03) times that for urban children, while for students aged 10-18 years, the odds ratio was 2.15 (95%CI: 1.85-2.49). Conclusions: The urban-rural disparity of childhood stunting existed in most places in China. The difference of growth retardation between urban and rural areas was related to regional economic development.


Subject(s)
Economic Development , Growth Disorders/epidemiology , Healthcare Disparities , Rural Population , Adolescent , Child , China/epidemiology , Humans , Prevalence , Students
19.
Int J Equity Health ; 18(1): 150, 2019 10 11.
Article in English | MEDLINE | ID: mdl-31604437

ABSTRACT

BACKGROUND: Type 1 diabetes is a complex chronic condition which requires lifelong treatment with insulin. Health outcomes are dependent on ability to self-manage the condition. Socioeconomic inequalities have been demonstrated in access to treatment and health outcomes for adults with type 1 diabetes; however, there is a paucity of research exploring how these disparities occur. This study explores the influence of socioeconomic factors in gaining access to intensive insulin regimens for adults with type 1 diabetes. METHODS: We undertook a qualitative descriptive study informed by a phenomenological perspective. In-depth face-to-face interviews were conducted with 28 patients and 6 healthcare professionals involved in their care. The interviews were analysed using a thematic approach. The Candidacy theory for access to healthcare for vulnerable groups framed the analysis. RESULTS: Access to intensive insulin regimens was through hospital-based specialist services in this sample. Patients from lower socioeconomic groups had difficulty accessing hospital-based services if they were in low paid work and because they lacked the ability to navigate the healthcare system. Once these patients were in the specialist system, access to intensive insulin regimens was limited by non-alignment with healthcare professional goals, poor health literacy, psychosocial problems and poor quality communication. These factors could also affect access to structured diabetes education which itself improved access to intensive insulin regimens. Contact with diabetes specialist nurses and attendance at structured diabetes education courses could ameliorate these barriers. CONCLUSIONS: Access to intensive insulin regimens was hindered for people in lower socioeconomic groups by a complex mix of factors relating to the permeability of specialist services, ability to navigate the healthcare system and patient interactions with healthcare providers. Improving access to diabetes specialist nurses and structured diabetes education for vulnerable patients could lessen socioeconomic disparities in both access to services and health outcomes.

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