Understanding the relationship between perceived discrimination and mortality in United States adults.

OBJECTIVE: To understand the relationship between mortality and three types of perceived discrimination (lifetime, daily, chronic job) using a nationally representative sample of U.S. adults. METHODS: Data from 4562 adults in the Midlife in the United States (MIDUS) between 2004 and 2006 (MIDUS II and MIDUS African American sample) were analyzed. Unadjusted associations between primary independent discrimination variables (lifetime, chronic job, daily) and mortality were analyzed using univariate Cox's proportional hazards regression models. Covariates were added to the models by group: predisposing (sex, age, race/ethnicity, education, marital status); enabling (household income, employment status, insurance status); and need factors (body mass index, diabetes, hypertension, stroke, cancer) to estimate hazard ratios. RESULTS: After adjusting for all covariates, hazard ratios for lifetime discrimination (HR: 1.09, p = 0.034) and daily discrimination (HR: 1.03, p = 0.030) were statistically significant. There was no relationship between mortality and chronic job discrimination (HR:1.03, p = 0.15). CONCLUSIONS: Adults experiencing lifetime and daily discrimination had significantly increased risk of mortality after adjusting for predisposing, enabling, and need factors. The findings highlight the importance of screening patients during clinical encounters for experiences of discrimination and providing appropriate resources to mitigate the negative impact of discriminatory events on mortality. Future research should work to fully understand the mechanism by which discrimination increases risk of mortality. These future findings should be used to develop targets for interventions designed to decrease mortality among adults who have experienced discrimination.

Relationship between housing insecurity, diabetes processes of care, and self-care behaviors.

BACKGROUND: The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity. METHODS: Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count. RESULTS: 38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99). CONCLUSIONS: Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.

Correlates of Insulin Selection as a First-Line Pharmacological Treatment for Gestational Diabetes.

OBJECTIVE: The aim of this study was to investigate prenatal factors associated with insulin prescription as a first-line pharmacotherapy for gestational diabetes mellitus (GDM; compared with oral antidiabetic medication) after failed medical nutrition therapy. STUDY DESIGN: This is a retrospective cohort study of 437 women with a singleton pregnancy and diagnosis of A2GDM (GDM requiring pharmacotherapy), delivering in a university hospital between 2015 and 2019. Maternal sociodemographic and clinical characteristics, as well as GDM-related factors, including provider type that manages GDM, were compared between women who received insulin versus oral antidiabetic medication (metformin or glyburide) as the first-line pharmacotherapy using univariable and multivariable analyses. RESULTS: In univariable analysis, maternal age, race and ethnicity, insurance, chronic hypertension, gestational age at GDM diagnosis, glucose level after 50-g glucose loading test, and provider type were associated with insulin prescription. In multivariable analysis, after adjusting for sociodemographic and clinical maternal factors, GDM characteristics and provider type, Hispanic ethnicity (0.26, 95% confidence interval [CI]: 0.09-0.73), and lack of insurance (0.34, 95% CI: 0.13-0.89) remained associated with lower odds of insulin prescription, whereas endocrinology management of GDM (compared with obstetrics and gynecology [OBGYN]) (8.07, 95% CI: 3.27-19.90) remained associated with higher odds of insulin prescription. CONCLUSION: Women of Hispanic ethnicity and women with no insurance were less likely to receive insulin and more likely to receive oral antidiabetic medication for GDM pharmacotherapy, while management by endocrinology was associated with higher odds of insulin prescription.This finding deserves more investigation to understand if differences are due to patient choice or a health disparity in the choice of pharmacologic agent for A2GDM. KEY POINTS: · Insulin is recommended as a first-line pharmacotherapy for gestational diabetes.. · Women of Hispanic ethnicity were less likely to receive insulin as first line.. · Lack of insurance was also associated with lower odds of insulin prescription..

Comparison of Lag Versus Nonlag Screw Fixation for Long Oblique Proximal Phalanx Fractures: A Biomechanical Study.

PURPOSE: To compare lag versus nonlag screw fixation for long oblique proximal phalanx (P1) fractures in a cadaveric model of finger motion via the flexor and extensor tendons. METHODS: We simulated long oblique P1 fractures with a 45° oblique cut in the index, middle, and ring fingers of 4 matched pairs of cadaveric hands for a total of 24 simulated fractures. Fractures were stabilized using 1 of 3 techniques: two 1.5-mm fully threaded bicortical screws using a lag technique, two 1.5-mm fully threaded bicortical nonlag screws, or 2 crossed 1.14-mm K-wires as a separate control. The fixation method was randomized for each of the 3 fractures per matched-pair hand, with each fixation being used in each hand and 8 total P1 fractures per fixation group. Hands were mounted to a custom frame where a computer-controlled, motor-driven, linear actuator powered movement of the flexor and extensor tendons. All fingers underwent 2,000 full flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer. Our primary outcome was the difference in the mean P1 fragment displacement between lag and nonlag screw fixation at 2,000 cycles. RESULTS: The observed differences in mean displacement between lag and nonlag screw fixation were not statistically significant throughout all time points. A two one-sided test procedure for paired samples confirmed statistical equivalence in the fragment displacement between these fixation methods at all time points, including the primary end point of 2,000 cycles. CONCLUSIONS: Nonlag screws provided equivalent biomechanical stability to lag screws for simulated long oblique P1 fractures during cyclic testing in this cadaveric model. CLINICAL RELEVANCE: Fixation of long oblique P1 fractures with nonlag screws has the potential to simplify treatment without sacrificing fracture stability during immediate postoperative range of motion.

Social Adaptability Index and Pregnancy Outcomes in Women With Diabetes During Pregnancy.

OBJECTIVE: The social adaptability index (SAI) is a composite indicator capturing an individual's social adaptability within society and socioeconomic status to predict overall health outcomes. The objective of this analysis was to examine whether the SAI is an independent risk factor for adverse pregnancy outcomes in women with and without diabetes during pregnancy. METHODS: Data from the 2011-2017 National Survey of Family Growth were analyzed using a cross-sectional methodology. Women aged 18-44 years with a singleton gestation were included in the analysis. Maternal diabetes was defined as either presence of pregestational diabetes or diagnosis of gestational diabetes. The SAI was developed from the following maternal variables: educational level, employment status, income, marital status, and substance abuse. A higher score indicated lower risk. A series of multivariable logistic regression models were run stratified by maternal diabetes status to assess the association between SAI and pregnancy outcomes, including cesarean delivery, macrosomia (birth weight ≥4,000 g) and preterm birth (<37 weeks). All analyses were weighted and P <0.05 was considered significant. RESULTS: A total of 17,772 women were included in the analysis, with 1,965 (10.7%) having maternal diabetes during pregnancy. The SAI was lower in women with diabetes during pregnancy compared with control subjects (6.7 ± 0.2 vs. 7.2 ± 0.1, P <0.001). After adjusting for maternal race and ethnicity, insurance status, BMI, age, and partner support of the index pregnancy, SAI was associated with preterm birth among women with diabetes during pregnancy (adjusted odds ratio 0.83, 95% CI 0.72-0.94). The SAI was not significantly associated with cesarean delivery or macrosomia in women with diabetes during pregnancy and was not associated with these outcomes in women without diabetes during pregnancy. CONCLUSION: Among women with diabetes during pregnancy, a higher SAI is independently associated with a lower risk of preterm birth. The SAI could be a useful index to identify women at high risk of preterm birth in addition to traditionally defined demographic risk groups among women with diabetes during pregnancy.

Minimally Invasive Intramedullary Screw Versus Plate Fixation for Proximal Phalanx Fractures: A Biomechanical Study.

PURPOSE: To compare the maximum interfragmentary displacement of short oblique proximal phalanx (P1) fractures fixed with an intramedullary headless compression screw (IMHCS) versus a plate-and-screws construct in a cadaveric model that generates finger motion via the flexor and extensor tendons of the fingers. METHODS: We created a 30° oblique cut in 24 P1s of the index, middle, ring, and little fingers for 3 matched pairs of cadaveric hands. Twelve fractures were stabilized with an IMHCS using an antegrade, dorsal articular margin technique at the P1 base. The 12 matched-pair P1 fractures were stabilized with a radially placed 2.0-mm plate with 2 bicortical nonlocking screws on each side of the fracture. Hands were mounted to a frame allowing a computer-controlled, motor-driven, linear actuator powered movement of fingers via the flexor and extensor tendons. All fingers underwent 2,000 full-flexion and extension cycles. Maximum interfragmentary displacement was continuously measured using a differential variable reluctance transducer. RESULTS: The observed mean displacement differences between IMHCS and plate-and-screws fixation was not statistically significant throughout all time points during the 2,000 cycles. A 2 one-sided test procedure for paired samples confirmed statistical equivalence in fracture displacement between fixation methods at the final 2,000-cycle time point. CONCLUSIONS: The IMHCS provided biomechanical stability equivalent to plate-and-screws for short oblique P1 fractures at the 2,000-cycle mark in this cadaveric model. CLINICAL RELEVANCE: Short oblique P1 fracture fixation with an IMHCS may provide adequate stability to withstand immediate postoperative active range of motion therapy.

Maternal racial and ethnic disparities in glycemic threshold for pharmacotherapy initiation for gestational diabetes.

OBJECTIVE: To compare the glycemic threshold for pharmacotherapy initiation in women with gestational diabetes (GDM) based on maternal race/ethnicity. METHODS: A retrospective cohort study of women with GDM who received pharmacotherapy during pregnancy, in addition to diet and exercise, between 2015 and 2019 in a university center. The primary outcome was percent of elevated capillary blood glucoses (CBGs) prior to pharmacotherapy initiation. This was compared between four maternal racial and ethnic groups: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic and other race and ethnicity group that included Asian, American Indian and Alaskan Native. Univariable and multivariable analyses were done to estimate whether there was an independent association between maternal race and ethnicity and the percent of elevated CBGs prior to pharmacotherapy initiation. RESULTS: A total of 440 women met inclusion criteria. In univariable analysis, NHB women, Hispanic, and women of other race and ethnicity had higher percent of elevated CBGs prior to pharmacotherapy initiation, compared to NHW women (45.5 ± 22.5% for NHW, 65.2 ± 25.4% for NHB, 58.3 ± 21.7% for Hispanic and 51.6 ± 26.8% for other race and ethnicity, respectively, p < .001). After the adjustment for maternal demographic and clinical factors, maternal race and ethnicity remained to be significantly associated with timing of pharmacotherapy initiation, with women of racial and ethnic minority having a higher percent of elevated CBGs prior to pharmacotherapy initiation (adjusted linear regression coefficient 18.1, 95% CI 11.3-25.0 for NHB, adjusted linear regression coefficient 13.2, 95% CI 5.0-21.4 for Hispanic, and adjusted linear regression coefficient 9.8, 95% CI 2.6-16.9 for women of other race and ethnicity). CONCLUSION: A significant variation was identified in glycemic threshold for pharmacotherapy initiation in women with GDM across different maternal racial and ethnic groups with minority women starting pharmacotherapy at higher percent of elevated CBGs.

Disparities Limit the Effect and Benefit of a Web-Based Clinic Intake System.

With increasing value being placed on patient-centered care and the focus on efficiency and workflow in health care delivery, the authors have implemented a web-based system for demographic, medical history, and patient-reported outcomes data collection for every clinical visit at their specialty upper-extremity center. They evaluated initial success and disparities in use after 12 months. The authors evaluated questionnaire parameters from 2018 patients, focusing primarily on the new patient intake form. They analyzed form-completion time relative to appointment time and form-completion percentage at various times before the appointment. The authors grouped patients by age, sex, race, income, education, employment status, transportation access, self-reported pain, and quality-of-life scores. Waiting room time was evaluated. Of new patients, 94% used the web-based platform to complete the intake form. Of the 4898 completed forms, 69.7% were done more than 1 hour before appointment time, indicating that a personal device was used. When grouped by patient characteristics and controlling for all demographic factors, patients who were male, non-White, and older than 40 years; had lower family income; and had a high school education or less were significantly associated with later form completion. Of the 1136 patients for whom the authors had adequate waiting room time data, late form completion significantly increased odds of waiting more than 15 minutes to be placed into an examination room. These data indicate that the authors are reliably capturing important patient information before appointment time. This could improve clinical workflow and overall quality of care and also identify limits in access and online system use, providing opportunities to improve capture by developing targeted interventions for specific patient populations. [Orthopedics. 2021;44(3):e434-e439.].

Adolescents' Patterns of Well-Care Use Over Time: Who Stays Connected.

INTRODUCTION: Well-care use can positively impact adolescents' current and future health. Understanding adolescents' longitudinal well-care use is critical to determine to whom and when to target engagement strategies to improve healthcare access. This study describes prospective well-care use patterns from childhood through adolescence stratified by sex. METHODS: The sample (N=6,872) was drawn from the Child/Young Adult component of the household-based 1979 National Longitudinal Survey of Youth consisting of biological children born to female respondents (1980-1997). Well-care use (routine checkup with a doctor within last year) data were assessed from age 5 years (1986-2003) until age 17 years (1998-2015). Conducted in 2019, latent class analyses stratified by sex identified well-care use patterns reported over 7 biennial time points adjusted for cohort, race/ethnicity, urbanicity, maternal education, and insurance. RESULTS: A total of 4 well-care use classes emerged for female adolescents: the majority belonged to Engaged (37%) and Moderately Engaged (39%) classes and the remainder belonged to Gradually Re-engaged (14%) and Disengaged-with-Rebound (10%) classes. A total of 3 classes emerged for male adolescents: the majority belonged to the Persistently Disengaged (48%) class and the remainder belonged to Engaged (34%) and Gradually Re-engaged (18%) classes. For both sexes, comparing each cohort with the first, Engaged class membership increased for subsequent cohorts. Less engaged well-care use classes had more non-Hispanic White adolescents living in rural areas with lower insurance coverage. Maternal education differentiated well-care use classes for male but not for female adolescents, being higher for male adolescents in the Engaged class than in other classes. CONCLUSIONS: These findings highlight that well-care use patterns for both sexes changed during the transition from childhood to adolescence and that class membership differed by covariates. These results suggest that sex-specific strategies may be needed to enhance adolescents' well-care use engagement over time.

A Prospective Pilot Study of Vascular Assessment of the Upper Extremity With Laser Angiography.

Background: Our goal was to investigate patients' upper extremity tissue perfusion changes using an indocyanine green laser angiography imaging system for various pathologic states and interventions. Methods: This prospective observational study used Spy Elite/LUNA laser angiography to evaluate perfusion in patients with upper extremity vascular compromise. All patients had Spy Elite/LUNA imaging as well as clinical and handheld Doppler examinations preintervention, intraoperatively, if applicable, and at 1 week, 2 weeks, and 2 months postintervention. For each laser angiography scan, we used an unaffected control area with uninjured skin to quantitatively compare with the dysvascular tissues. Results: Twelve patients, 7 men and 5 women, had a total of 16 upper extremities evaluated. The mean age was 53 years, and half of the patients entering the study were smokers. Etiologies of vascular compromise were trauma, primary and secondary vasospastic disease, scleroderma, and intravascular drug injection. Interventions included surgical repair/reconstruction, botulinum toxin injections, and/or systemic medications. Improvement in perfusion following intervention was statistically significant, demonstrated by an increase in Spy Elite/LUNA quantitative score postintervention compared with preintervention scans. Adjusting for other variables, such as smoking and handheld Doppler signal status, demonstrated an independent statistically significant increase in Spy Elite/LUNA scores at all postintervention time points compared with preintervention scores. Laser angiography was able to confirm adequate vascular status, with ultimate tissue survival, in some cases when Doppler signals were not initially present. Conclusions: Laser angiography provided objective data to document improved upper extremity tissue perfusion following various interventions.

Redesigning primary care in an academic medical center: lessons, challenges, and opportunities.

PURPOSE: To evaluate patient access, provider productivity, and patient satisfaction during a 24-month redesign process of an academic medical center, which requires balance between clinical and educational missions. METHODS: A series of activities were conducted to optimize primary care across 17 attending physicians, 6 Advanced Practice Providers (APPs), and 39 residents. Patient access was defined as the next available appointment for either existing/established patients or new patients. Productivity was measured using panel sizes for each provider. Patient satisfaction was based on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS). RESULTS: Despite decreasing clinical effort to allow faculty and APPs to participate in education and research, there was an overall increase in access for both new and established patients, and an increase the percent of each providers' panel that was full from 78.89% in 2017 to 115.29% in 2019. When comparing panel sizes for the 11 faculty present before and after strategic changes, we found significant increase in both overall panel size, and actual to expected ratios between 2017 and 2019. In addition, throughout the time period, patient satisfaction remained high with no significant changes. CONCLUSIONS: While this project was limited to one site, the inclusion of a set of well-planned metrics, and tracking of processes over time can provide insight for ongoing primary care redesign efforts at similar sites seeking to balance the academic mission with clinical productivity and high patient satisfaction.

Adolescents' and Young Adults' Routine Care Use: The Role of Their Mothers' Care Use Behaviors.

PURPOSE: Little is known whether mothers' own care use is differentially associated with their adolescents' routine care use by gender. The main purpose of this study is to examine whether mothers' healthcare use prospectively predicts their adolescents' routine care use stratified by gender, after controlling for predisposing (child's age, race/ethnicity, region of residence, urbanicity, and mother's age at child's birth), enabling (mother's education, adolescent and mother health insurance), and need (child health status) factors. METHODS: In 2018, a prospective analysis was conducted using data from 5,040 adolescents aged 9-24 and their mothers who completed the two-generation National Longitudinal Survey of Youth in 2006 (first interview) and 2008 (second interview). Findings include percentages and adjusted odds ratios of the factors that predict adolescents' self-report of routine care use in the past year measured at the second interview. RESULTS: In 2008, over half of participants reported a routine doctor visit during the prior 12 months and this varied by gender; more females (68.7%) had a visit than males (53.5%). Factors that independently predicted a greater odds of adolescents' routine doctor visits included mothers with routine doctor visits at both interviews or the second interview only, and adolescents' health insurance and past routine visit, regardless of gender. Males aged 18-20 and 21-24 years had lower odds of having a routine doctor visit than males aged 9-11 years. CONCLUSIONS: This study provides evidence for the potential role that mothers' care use can play in their adolescents' routine care use, especially for their sons, independent of insurance status.