Disparities in Telemedicine Use Among Louisiana Medicaid Beneficiaries During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic led to an increased reliance on telemedicine. Whether this exacerbated existing disparities within vulnerable populations is not yet known. OBJECTIVES: Characterize changes in outpatient telemedicine evaluation and management (E&M) services for Louisiana Medicaid beneficiaries by race, ethnicity, and rurality during the COVID-19 pandemic. RESEARCH DESIGN: Interrupted time series regression models estimated pre-COVID-19 trends and changes in E&M service use at the April and July 2020 peaks in COVID-19 infections in Louisiana and in December 2020 after those peaks had subsided. SUBJECTS: Louisiana Medicaid beneficiaries continuously enrolled between January 2018 and December 2020 who were not also enrolled in Medicare. MEASURES: Monthly outpatient E&M claims per 1000 beneficiaries. RESULTS: Prepandemic differences in service use between non-Hispanic White and non-Hispanic Black beneficiaries narrowed by 34% through December 2020 (95% CI: 17.6%-50.6%), while differences between non-Hispanic White and Hispanic beneficiaries increased by 10.5% (95% CI: 0.1%-20.7%). Non-Hispanic White beneficiaries used telemedicine at higher rates than non-Hispanic Black (difference=24.9 claims per 1000 beneficiaries, 95% CI: 22.3-27.4) and Hispanic beneficiaries (difference=42.3 claims per 1000 beneficiaries, 95% CI: 39.1-45.5) during the first wave of COVID-19 infections in Louisiana. Telemedicine use increased slightly for rural beneficiaries compared with urban beneficiaries (difference=5.3 claims per 1000 beneficiaries, 95% CI: 4.0-6.6). CONCLUSIONS: The COVID-19 pandemic narrowed gaps in outpatient E&M service use between non-Hispanic White and non-Hispanic Black Louisiana Medicaid beneficiaries, though gaps in telemedicine use emerged. Hispanic beneficiaries experienced large reductions in service use and relatively small increases in telemedicine use.

The Economic Burden of Racial, Ethnic, and Educational Health Inequities in the US.

Importance: Health inequities exist for racial and ethnic minorities and persons with lower educational attainment due to differential exposure to economic, social, structural, and environmental health risks and limited access to health care. Objective: To estimate the economic burden of health inequities for racial and ethnic minority populations (American Indian and Alaska Native, Asian, Black, Latino, and Native Hawaiian and Other Pacific Islander) and adults 25 years and older with less than a 4-year college degree in the US. Outcomes include the sum of excess medical care expenditures, lost labor market productivity, and the value of excess premature death (younger than 78 years) by race and ethnicity and the highest level of educational attainment compared with health equity goals. Evidence Review: Analysis of 2016-2019 data from the Medical Expenditure Panel Survey (MEPS) and state-level Behavioral Risk Factor Surveillance System (BRFSS) and 2016-2018 mortality data from the National Vital Statistics System and 2018 IPUMS American Community Survey. There were 87 855 survey respondents to MEPS, 1 792 023 survey respondents to the BRFSS, and 8 416 203 death records from the National Vital Statistics System. Findings: In 2018, the estimated economic burden of racial and ethnic health inequities was $421 billion (using MEPS) or $451 billion (using BRFSS data) and the estimated burden of education-related health inequities was $940 billion (using MEPS) or $978 billion (using BRFSS). Most of the economic burden was attributable to the poor health of the Black population; however, the burden attributable to American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander populations was disproportionately greater than their share of the population. Most of the education-related economic burden was incurred by adults with a high school diploma or General Educational Development equivalency credential. However, adults with less than a high school diploma accounted for a disproportionate share of the burden. Although they make up only 9% of the population, they bore 26% of the costs. Conclusions and Relevance: The economic burden of racial and ethnic and educational health inequities is unacceptably high. Federal, state, and local policy makers should continue to invest resources to develop research, policies, and practices to eliminate health inequities in the US.

Pre-COVID-19 Disparities in Telemedicine Use Among Louisiana Medicaid Beneficiaries.

Background: We examine trends in telemedicine use by race, geography, and age among Louisiana Medicaid beneficiaries in the months preceding the COVID-19 pandemic. Methods: Using Louisiana Medicaid claims data from January 2018 through February 2020, we calculated a relative ratio of telemedicine use as the share of telemedicine claims by race, age, and geography and conducted two-sample t-tests. Results: In 2018, White beneficiaries used telemedicine at a relative ratio of 1.92 compared with Black beneficiaries (p < 0.001) and 2.02 compared with Hispanic beneficiaries (p < 0.001). Rural beneficiaries used telemedicine at a relative ratio of 1.27 (p < 0.001) compared with urban beneficiaries. Children and adolescents used telemedicine at a higher rate than other age groups. Racial and geographic disparities narrowed in the first months of 2020. Conclusions: Telemedicine use in Louisiana Medicaid was low but growing before the pandemic with narrowing disparities by race and geography and emerging disparities by age.

Cockroach exposure and perceived stress interact to predict clinical outcomes in childhood asthma.

BACKGROUND: Nonpharmacologic interventions for asthma management rely on identification and mitigation of important asthma triggers. Cockroach exposure is strongly associated with asthma morbidity. It is also associated with stress, another risk factor for asthma. Despite high prevalence of both in vulnerable populations, the impact of joint exposure has not been examined. METHODS: Participants included 173 children with asthma in New Orleans, Louisiana. Cockroach exposure was based on visual inspection using standard protocols. Caregiver stress was measured using Cohen's 4-item Perceived Stress Scale. Outcomes included unscheduled clinic or emergency department (ED) visits, hospitalization, and pulmonary function. Multivariable logistic regression was performed to assess independent effects of the exposure on the outcome and effect modification was examined in stratified analysis based on stress. Path analysis to explore the mediation effect by stress was performed using a probit link with parameters based on Bayes' method with non-informative priors. RESULTS: Adjusting for stress and other covariates, cockroach exposure was associated with unscheduled clinic/ED visits (aOR = 6.2; 95% CI 1.8, 21.7). Positive associations were also found for hospitalization and FEV1 < 80%. High stress modified the relationship with unscheduled clinic/ED visits (high aOR = 7.7 95% CI 1.0, 60.2, versus normal aOR = 4.1 95% CI 0.8, 21.9). Path models identified direct and indirect effects (p = 0.05) indicating that a majority of the total effect on unscheduled clinic/ED visits is attributed directly to cockroach exposure. CONCLUSION: The strong association between cockroach exposure and asthma morbidity is not due to uncontrolled confounding by stress. The combination of cockroach exposure and high stress, common in urban homes, are modifiable factors associated with poor asthma outcomes.

Religious Coping and Quality of Life Among Black and White Men With Prostate Cancer.

Prostate cancer is a significant impediment in men's lives as this condition often exacerbates stress and reduces quality of life. Faith can be a resource through which men cope with health crises; however, few studies examine how religion or spirituality can have implications for racial disparities in health outcomes among men. The purpose of this study is to assess the associations between religious coping and quality of life among black and white men with prostate cancer. Data for this investigation were drawn from the Diagnosis and Decisions in Prostate Cancer Treatment Outcomes Study that consisted of 624 black and white men with complete information on the primary outcome and predictor variables. The primary outcome for this study was overall quality of life as measured by the Functional Assessment of Cancer Therapy-Prostate questionnaire. The main independent variable was religious coping measured by 2 subscales capturing positive and negative forms of coping. Black men in the study had lower overall quality of life scores (134.6 ± 19.6) than their white peers (139.8 ± 14.1). Black men in the sample also had higher average positive religious coping scores (12.9 ± 3.3) than white men (10.3 ± 4.5). Fully adjusted linear regression models of the total sample produced results indicating that positive religious coping was correlated with an increase in quality of life (ß = .38, standard error [SE] = 0.18, P < .05). Negative religious coping was associated with a reduction in quality of life (ß = -1.48, SE = 0.40, P < .001). Faith-oriented beliefs or perceptions can have implications for quality of life among men with prostate cancer. Sensitivity to the role of religion, spirituality, and faith should be seen by providers of health care as potential opportunities for improved outcomes in patients with prostate cancer and survivors.

The Role of Social Support in Moderating the Relationship between Race and Hypertension in a Low-Income, Urban, Racially Integrated Community.

In the US, African Americans have a higher prevalence of hypertension than Whites. Previous studies show that social support contributes to the racial differences in hypertension but are limited in accounting for the social and environmental effects of racial residential segregation. We examined whether the association between race and hypertension varies by the level of social support among African Americans and Whites living in similar social and environmental conditions, specifically an urban, low-income, racially integrated community. Using data from the Exploring Health Disparities in Integrated Communities-Southwest Baltimore (EHDIC-SWB) sample, we hypothesized that social support moderates the relationship between race and hypertension and the racial difference in hypertension is smaller as the level of social support increases. Hypertension was defined as having systolic blood pressure greater than 140 mmHg and/or diastolic blood pressure greater than 90 mmHg, or the participant reports of taking antihypertensive medication(s). The study only included participants that self-reported as "Black/African American" or "White." Social support was measured as functional social support and marital status. After adjusting for demographics and health-related characteristics, we found no interaction between social support and race (DUFSS score, prevalence ratio 1.00; 95% confidence interval 0.99, 1.01; marital status, prevalence ratio 1.02; 95% confidence interval 0.86, 1.21); thus the hypothesis was not supported. A plausible explanation is that the buffering factor of social support cannot overcome the social and environmental conditions which the participants live in. Further, these findings emphasize social and environmental conditions of participants in EHDIC-SWB may equally impact race and hypertension.

The Association Between Perceived Racial Discrimination and Hypertension in a Low-Income, Racially Integrated Urban Community.

We examined the association between perceived racial discrimination and hypertension among African Americans and whites who live in a low-income, racially integrated, urban community. Hypertension was defined as having a systolic blood pressure 140 mm Hg or more, a diastolic blood pressure 90 mm Hg or more, or taking antihypertensive medication(s). Perceived racial discrimination was based on self-reported responses of experiencing racial discrimination in various settings. Using modified Poisson multivariable regression models, we found no association between perceived racial discrimination and hypertension (prevalence ratio: 0.96, 95% confidence interval: 0.90-1.04). Findings suggest that social context may play a role in the relationship between perceived racial discrimination and hypertension.

Higher expression of SATB2 in hepatocellular carcinoma of African Americans determines more aggressive phenotypes than those of Caucasian Americans.

In the United States, Hepatocellular Carcinoma (HCC) incidence has tripled over the past two decades. The disease has disproportionately affected minority and disadvantaged populations. The purpose of this study was to examine the expression of SATB2 gene in HCC cells derived from African Americans (AA) and Caucasian Americans (CA) and assess its oncogenic potential by measuring cell viability, spheroid formation, epithelial-mesenchymal transition (EMT), stem cell markers and pluripotency maintaining factors in cancer stem cells (CSCs). We compared the expression of SATB2 in human primary hepatocytes, HCC cells derived from AA and CA, and HCC CSCs. Hepatocellular carcinoma cells derived from AA expressed the higher level of SATB2 than those from CA. By comparison, normal human hepatocytes did not express SATB2. Higher expression of SATB2 in HCC cells from AA was associated with greater growth rate, cell viability, colony formation and EMT characteristics than those from CA. Knockout of SATB2 in CSCs by Crispr/Cas9 technique significantly inhibited the expression of SATB2 gene, stem cell markers (CD24, CD44 and CD133), pluripotency maintaining factors (c-Myc, KLF4, SOX2 and OCT4), and EMT compared with non-targeting control group. The expression of SATB2 was negatively correlated with miR34a. SATB2 rescued the miR-34a-mediated inhibition of CSC's viability. These data suggest that SATB2 is an oncogenic factor, and its higher expression may explain the disparity in HCC outcomes among AA.

Coping, Discrimination, and Physical Health Conditions Among Predominantly Poor, Urban African Americans: Implications for Community-Level Health Services.

African Americans and ethnic minorities experience racial discrimination in a variety of settings. Racial discrimination is a potent stressor that has been linked to psychosocial stress and poor physical health. To cope with discriminatory experiences and daily life event stressors, African Americans frequently use the concept of John Henryism (a high effort coping strategy with prolonged exposure to stress). This cross-sectional analysis explored the relationship between racism/discrimination, John Henryism, and health problems in a predominately African American sample. Data were collected through health care screenings for hypertension, diabetes, and obesity and a self-report survey to assess experiences of discrimination and use of John Henryism. Logistic and linear regression models were used to assess the relationship between the John Henryism score, racism/discrimination score, and health problems among 352 participants. John Henryism was associated with a decrease in systolic blood pressure (b = - 12.50, 95% CI = - 23.05, - 1.95) among men, after adjusting for experiences of racism/discrimination and demographic characteristics. Experiences of racism/discrimination were associated with an increase in systolic blood pressure (b = 11.23, 95% CI = 0.38, 22.09) among men, after adjusting for John Henryism and demographic characteristics. Among women, there was no association found between John Henryism and experiences of racism/discrimination with systolic blood pressure. No association was found between John Henryism and experiences of racism/discrimination with being overweight/obese in women nor men. The study found that John Henryism was positively associated with the health of men, while experiences of racism/discrimination were negatively associated with their health. Limitations of the study are discussed, and recommendations are made to guide future research exploring the concept of John Henryism as a relevant factor between stress, racial discrimination and poor health.

Disentangling Race and Place in Depressive Symptoms in Men.

African American men report lower levels of depressive symptoms that their white peers in national data. However, the value of these studies is often undermined by data that confound race, socioeconomic status, and segregation. We sought to determine whether race differences in depressive symptoms were present after minimizing the effects of socioeconomic status and segregation within a cohort of southwest Baltimore (SWB) men using the data from the Exploring Health Disparities in Integrated Communities (EHDIC), a novel study of racial disparities within communities where African American and non-Hispanic white males live together and have similar median incomes. Using the Patient Health Questionnaire, a standard instrument for assessing mental disorders, we categorized participants as experiencing depressive symptoms (including depressive syndrome and major depression) or not experiencing depressive symptoms. Logistic regression was performed to examine the association between depressive symptoms and race in EHDIC-SWB, adjusting for age, marital status, income, education, insurance, physical inactivity, current smoking or drinking status, poor/fair health, hypertension, heart disease, diabetes, stroke, and obesity. Of the 628 study participants, 12.6% of white men and 8.6% of African American men reported depressive symptoms. African American males had similar odds of reporting depressive symptoms (odds ratio = 0.61, 95% confidence interval = 0.34-1.11) as compared with white men. Within this low-income urban racially integrated community, race differences in depressive symptoms among men were not observed. This finding suggests that social and environmental conditions may impact the race differences in depressive symptoms.

Psychometric Properties of the Medical Mistrust Index (MMI) in Latina Immigrants.

Medical mistrust measures have not been validated in Latino immigrants. This study examined the psychometric properties of the Medical Mistrust Index and its association with health care satisfaction in a sample of Latina immigrants. Participants were 168 self-identified Latinas ≥40 years old. Women were recruited from three Latino-serving health clinics and through a Latino radio program. A bilingual interviewer administered the Medical Mistrust Index in Spanish along with items pertaining to sociodemographic and health care factors. Principal component extraction method was used to evaluate internal consistency reliability to examine Medical Mistrust Index underlying factors. Construct validity was assessed by analyzing the relationship between the Medical Mistrust Index with three related measures (racism, discrimination, trust in doctors). To assess the criterion validity of the Medical Mistrust Index, a logistic regression model examined whether medical mistrust was associated with Latina women's satisfaction with health care controlling for sociodemographic and health care factors. Participants were 51 years old on average, around half had completed High school or less and were uninsured. Most were monolingual Spanish speakers. Two factors: competence and suspicion explained 40% of the total Medical Mistrust Index variance. Internal consistency was favorable and construct validity was supported. Results support the reliability and validity of the Medical Mistrust Index and its association with Latina's satisfaction with health care.

Racial discrimination, John Henryism coping, and behavioral health conditions among predominantly poor, urban African Americans: Implications for community-level opioid problems and mental health services.

The current study examined the relationship between John Henryism Active Coping (JHAC), experiences of racial discrimination, and behavioral health outcomes in a community sample of 319 Black adults. Assessments included primary health care screenings as well as self-reported survey questions to assess JHAC, experiences of discrimination, and self-reported behavioral health. Logistic regression models, adjusted for control variables, found a significant relationship between JHAC and having an opioid problem (odds ratio [OR] = 0.95, p = 0.003) and needing mental health services (OR = 0.95, p < 0.001), such that higher levels of coping were associated with lower odds of reporting an opioid problem and needing mental health services. Notably, racial discrimination was not significantly independently associated with behavioral health. Implications for interventions and community programming are discussed.

Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation.

An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.

The Role of Social Context in Racial Disparities in Self-Rated Health.

Race disparities in self-rated health in the USA are well-documented, such that African Americans rate their health more poorly than whites. However, after adjusting for health status, socioeconomic status (SES), and health behaviors, residual race differences are observed. This suggests the importance of unmeasured variables. Because African Americans and whites tend to live in differing social contexts, it is possible that accounting for social and environmental conditions may reduce racial disparities in self-rated health. Differences in self-rated health among whites and African Americans were assessed in a low-income, urban integrated community (Exploring Health Disparities in Integrated Communities (EHDIC)) and compared with a national sample (National Health Interview Survey (NHIS)). Controlling for demographics, SES, health insurance, status, and behaviors, African Americans in NHIS had higher odds of reporting fair or poor health (odds ratio [OR] = 1.40, 95% confidence interval [CI] = 1.18-1.66) than whites. In EHDIC, there was no race difference in self-rated health (OR = 0.83, 95% CI = 0.63-1.11). These results demonstrate the importance of social context in understanding race disparities in self-rated health.

High Levels of Medical Mistrust Are Associated With Low Quality of Life Among Black and White Men With Prostate Cancer.

BACKGROUND: Medical mistrust is thought to affect health care-based decisions and has been linked to poor health outcomes. The effects of medical mistrust among men with prostate cancer are unknown. Thus, the goal of the current study is to examine the association between medical mistrust and quality of life (QOL) among black and white men with prostate cancer. METHODS: A total of 877 men (415 black, 462 white) with prostate cancer between the ages of 40 to 81 years who entered the North Carolina Central Cancer Registry during the years 2007 and 2008 were retrospectively recruited. The dependent variable was overall QOL measured by the Functional Assessment of Cancer Therapy-Prostate questionnaire. The primary independent variable was medical mistrust. Multivariate regression analysis was used to assess the association between medical mistrust and overall QOL. RESULTS: Compared with white men, black men reported a higher level of medical mistrust (black = 2.7, white = 2.4; P < .001) and lower QOL (black = 134.4, white = 139.5; P < 0.001). After controlling for demographical and clinical variables, higher levels of medical mistrust were associated with a reduction in overall QOL among men with prostate cancer (beta = -7.73; standard error = 1.54) CONCLUSIONS: Higher levels of medical mistrust are associated with reduced overall QOL among black and white men with prostate cancer. Interventions targeted to reduce medical mistrust may be effective in increasing the overall QOL of men with prostate cancer.

Dollar for Dollar: Racial and ethnic inequalities in health and health-related outcomes among persons with very high income.

Racial and ethnic disparities in health have been well-documented, and low SES is widely considered to be a driver of this relationship. However, the race-social class-health interrelationship is complex, as several studies have found race disparities between racial/ethnic minorities and whites at middle- income levels. Research on higher income persons is complicated by the lack of data for persons with incomes about $75,000. Most national datasets collect income data in categories with the highest income category being $75,000 and above. In our study, we examined racial/ethnic disparities in health status and behaviors among persons of very high income, reported income of $175,000 or above per year. Data are from the Medical Expenditure Panel Surveys (MEPS). Our findings revealed health disparities in 10 of the 16 health-related outcomes selected. African Americans were most dissimilar to whites at this income and with disadvantages on 6 health outcomes relative to whites. While results also showed some disparities for Asian Americans and Hispanic Americans relative to whites, these groups were advantaged, relative to whites on several health outcomes. Our findings indicate that income does not fully explain racial/ethnic disparities in health. Most public interventions are targeted to low income persons. However, public health interventions should target minority individuals of very high income as well, especially African Americans.

Prevalence and Correlates of Major Depressive Symptoms among Black Men with Prostate Cancer.

Objectives: The objectives of our study were to determine the prevalence of major depressive symptoms and identify factors that are associated with major depressive symptoms among Black men with prostate cancer (PCa). Design: This study consisted of 415 Black men aged 40-81 years that entered the North Carolina Central Cancer Registry during the years 2007-2008. The primary outcome variable was depressive symptoms (CES-D). Factors included age, income, education, insurance status, treatment received, time between diagnosis and treatment, Gleason score, medical mistrust and experience with racism/discrimination. Logistic regression models were used to assess factors associated with the odds of having major depressive symptoms. Results: The prevalence of major depressive symptoms (≥16 on CES-D) among our sample of Black men with PCa was approximately 33%. Approximately 15% of the study participants underwent radiation beam treatment. Age was significantly associated with the odds of reporting major depressive symptoms (OR= .95, CI .91-.99) among Black men. In addition, compared with all other forms of treatment, Black men who underwent radiation beam treatment had higher odds (OR=2.38, CI 1.02- 5.51) of reporting major depressive symptoms. Conclusion: Nearly one-third of Black men with PCa in this study reported major depressive symptoms. Clinicians should pay closer attention to the mental health status of Black men with PCa, especially those who are younger and those who have undergone radiation beam treatment. Cancer survivorship, particularly quality of life, may be enhanced by opportunities for assessment, evaluation and intervention of depressive symptoms among these men disproportionately affected by PCa.