Racial,ethnic and neighborhood socioeconomic differences in incidence of dementia: A regional retrospective cohort study

Background

Evidence on the effects of neighborhood socioeconomic disadvantage on dementia risk in racially and ethically diverse populations is limited. Our objective was to evaluate the relative extent to which neighborhood disadvantage accounts for racial/ethnic variation in dementia incidence rates. Secondarily, we evaluated the spatial relationship between neighborhood disadvantage and dementia risk.

Methods

In this retrospective study using electronic health records (EHR) at two regional health systems in Northeast Ohio, participants included 253,421 patients aged >60 years who had an outpatient primary care visit between January 1, 2005 and December 31, 2015. The date of the first qualifying visit served as the study baseline. Cumulative incidence of composite dementia outcome, defined as EHR-documented dementia diagnosis or dementia-related death, stratified by neighborhood socioeconomic deprivation (as measured by Area Deprivation Index) was determined by competing-risk regression analysis, with non-dementia-related death as the competing risk. Fine-Gray sub-distribution hazard ratios were determined for neighborhood socioeconomic deprivation, race/ethnicity, and clinical risk factors. The degree to which neighborhood socioeconomic position accounted for racial/ethnic disparities in the incidence of composite dementia outcome was evaluated via mediation analysis with Poisson rate models.

Results

Increasing neighborhood disadvantage was associated with increased risk of EHR-documented dementia diagnosis or dementia-related death (most vs. least disadvantaged ADI quintile HR = 1.76, 95% confidence interval = 1.69–1.84) after adjusting for age and sex. The effect of neighborhood disadvantage on this composite dementia outcome remained after accounting for known medical risk factors of dementia. Mediation analysis indicated that neighborhood disadvantage accounted for 34% and 29% of the elevated risk for composite dementia outcome in Hispanic and Black patients compared to White patients, respectively.

Conclusion

Neighborhood disadvantage is related to the risk of EHR-documented dementia diagnosis or dementia-related death and accounts for a portion of racial/ethnic differences in dementia burden, even after adjustment for clinically important confounders.     

A narrative review of sociodemographic risk and disparities in screening,diagnosis, treatment,and outcomes of the most common extrathoracic malignancies in the United States

There is a well-established association between multiple sociodemographic risk factors and disparities in cancer care. These risk factors include minority race and ethnicity, low socioeconomic status (SES) including low income and education level, non-English primary language, immigrant status, and residential segregation, and distance to facilities that deliver cancer care. As cancer care advances, existing disparities in screening, treatment, and outcomes have become more evident. Lung cancer remains the most common and fatal malignancy in the United States, with breast, colorectal, and prostate cancer being the three most common and deadly extrathoracic malignancies. Achieving the best outcomes for patients with these malignancies relies on strong physician-patient relationships leading to robust screening, early diagnosis, and early referral to facilities that can deliver multidisciplinary care and multimodal therapy. It is likely that challenges experienced in developing patient trust and understanding, providing access to screening, and building referral pipelines for definitive therapy in lung cancer care to vulnerable populations are paralleled by those in extrathoracic malignancies. Likewise, progress made in delivering optimal care to all patients across sociodemographic and geographic barriers can serve as a roadmap. Therefore, we provide a narrative review of current disparities in screening, treatment, and outcomes for patients with breast, prostate, and colorectal malignancies.     

Differential relationship between colorectal cancer and diabetes in a nationally representative sample of adults

Background

Diabetes has been identified as a risk factor for developing colorectal cancer (CRC); however, the literature identifying groups most at risk is sparse. This study aims to understand the relationship between CRC and diabetes by age and race/ethnicity.

Racial and Socioeconomic Disparities in Bone Density Testing Before and After Hip Fracture

BACKGROUND Racial and socioeconomic disparities have been identified in osteoporosis screening. OBJECTIVE To determine whether racial and socioeconomic disparities in osteoporosis screening diminish after hip fracture. DESIGN Retrospective cohort study of female Medicare patients. SETTING Entire states of Illinois, New York, and Florida. PARTICIPANTS Female Medicare recipients aged 65–89 years old with hip fractures between January 2001 and June 2003. MEASUREMENTS Differences in bone density testing by race/ethnicity and zip-code level socioeconomic characteristics during the 2-year period preceding and the 6-month period following a hip fracture. RESULTS Among all 35,681 women with hip fractures, 20.7% underwent bone mineral density testing in the 2 years prior to fracture and another 6.2% underwent testing in the 6 months after fracture. In a logistic regression model adjusted for age, state, and comorbidity, women of black race were about half as likely (RR 0.52 [0.43, 0.62]) and Hispanic women about 2/3 as likely (RR 0.66 [0.54, 0.80]) as white women to undergo testing before their fracture. They remained less likely (RR 0.66 [0.50, 0.88] and 0.58 [0.39, 0.87], respectively) to undergo testing after fracture. In contrast, women residing in zip codes in the lowest tertile of income and education were less likely than those in higher-income and educational tertiles to undergo testing before fracture, but were no less likely to undergo testing in the 6 months after fracture. CONCLUSIONS Racial, but not socioeconomic, differences in osteoporosis evaluation continued to occur even after Medicare patients had demonstrated their propensity to fracture. Future interventions may need to target racial/ethnic and socioeconomic disparities differently.     

Disparities between black and white patients in functional improvement after hospitalization for an acute illness

The aim of this study was to determine whether older black and white patients experience different rates of improvement in functioning after being acutely hospitalized. Of the 2,364 community-living patients in this prospective cohort study, 25% self-reported their race/ethnicity to be black. The outcomes were improvement in basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) from admission to discharge and 90 days postdischarge. Multivariable models that included statistical adjustment for age, illness severity, in-hospital social service referral, dementia, admission level of functioning, and change in functioning from 2 weeks before admission were computed to determine whether black and white patients experienced significantly different rates of recovery at discharge and 90 days after discharge in ADL and IADL functioning. Black patients were as likely as white patients to improve in ADL functioning by discharge (odds ratio (OR)=0.97, 95% confidence interval (CI)=0.76-1.24) or by 90 days after discharge (OR=0.95, 95% CI=0.73-1.24) but significantly less likely to improve IADL functioning by discharge (OR=0.72, 95% CI=0.56-0.93) or by 90 days after discharge (OR=0.68, 95% CI=0.51-0.90). The findings suggest that differential rates of recovery in functioning after an acute hospitalization may contribute to racial/ethnic disparities in IADL functioning, which has implications for the setting of future interventions oriented toward reducing these disparities.     

Geographic and racial variation in asthma prevalence and emergency department use among Medicaid-enrolled children in 14 southern states

Background: Despite evidence-based prevention and practice guidelines, asthma prevalence, treatment, and outcomes vary widely at individual and community levels. Asthma disproportionate/ly affects low-income and minority children, who comprise a large segment of the Medicaid population. Methods: 2007 Medicaid claims data from 14 southern states was mapped for 556 counties to describe the local area variation in 1-year asthma prevalence rates, emergency department (ED) visit rates, and racial disparity rate ratios. Results: One-year period prevalence of asthma ranged from 2.8% in Florida to 6.4% in Alabama, with a median prevalence rate of 4.1%. At the county level, the prevalence was higher for Black children and ranged from 1.03% in Manatee County, FL, to 21.0% in Hockley County, TX. Black–White rate ratios of prevalence ranged from 0.49 in LeFlore County, MS, to 3.87 in Flagler County, FL. Adjusted asthma ED visit rates ranged from 2.2 per 1000 children in Maryland to 16.5 in Alabama, with a median Black–White ED-visit rate ratio of 2.4. Rates were higher for Black children, ranging from 0.80 per 1000 in Wicomico County, MD, to 70 per 1000 in DeSoto County, FL. Rate ratios of ED visits ranged from 0.25 in Vernon Parish, LA, to 25.28 in Nelson County, KY. Conclusions and relevance: Low-income children with Medicaid coverage still experience substantial variation in asthma prevalence and outcomes from one community to another. The pattern of worse outcomes for Black children also varies widely across counties. Eliminating this variation could substantially improve overall outcomes and eliminate asthma disparities.     

Alcohol-related health disparities and treatment-related epidemiological findings among whites,blacks, and Hispanics in the United States

This article briefly reviews the alcohol epidemiological evidence on health disparities across whites, blacks, and Hispanics. Compared with whites, Hispanic men have higher rates of alcohol-related problems, intimate partner violence, and cirrhosis mortality; black men have higher rates of intimate partner violence and cirrhosis mortality. All groups see treatment as an appropriate intervention to address alcohol problems, and there also is support for prevention.     

Age,socioeconomic features,and clinical factors predict receipt of endoscopic retrograde cholangiopancreatography in pancreatic cancer

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP) is the recommended technique for biliary decompression in pancreatic cancer. Previous studies have suggested racial, socioeconomic and geographic differences in diagnosis,treatment and outcomes of pancreatic cancer patients.AIM To examine geographic, racial, socioeconomic and clinical factors associated with utilization of ERCP.METHODS Surveillance, Epidemiology and End Results and linked Medicare claims data were used to identify pancreatic cancer patients between 2000-2011. Claims data were used to identify patients who had ERCP and other treatments. The primary outcome was receipt of ERCP. Chi-squared analyses were used to compare demographic information. Trends in use of ERCP over time were assessed using Cochran Armitage test. Adjusted odds ratios(aORs) and 95% confidence intervals(CIs) for receipt ERCP were calculated using logistic regression,controlling for other characteristics.RESULTS Among 32510 pancreatic cancer patients, 14704(45.2%) underwent ERCP.Patients who had cancer located in the head of the pancreas(aOR 3.27, 95%CI:2.99-3.57), had jaundice(aOR 7.59, 95%CI: 7.06-8.17), cholangitis(aOR 4.22,95%CI: 3.71-4.81) or pruritus(aOR 1.42, 95%CI: 1.22-1.66) and lived in lower education zip codes(aOR 1.14, 95%CI: 1.04-1.24) were more likely to receive ERCP. In contrast, patients who were older(aOR 0.88, 95%CI: 0.83, 0.94), not married(aOR 0.92, 95%CI: 0.86, 0.98), and lived in a non-metropolitan area(aOR0.89, 95%CI: 0.82, 0.98) were less likely to receive ERCP. Compared to white patients, non-white/non-black patients(aOR 0.83, 95%CI: 0.70-0.97) were less likely to receive ERCP. Patients diagnosed later in the study period were less likely to receive ERCP(aOR 2004-2007 0.85, 95%CI: 0.78-0.92; aOR 2008-2011 0.76,95%CI: 0.70-0.83). After stratifying by indications for ERCP including jaundice,racial differences persisted(aOR black patients 0.80, 95%CI: 0.67-0.95,nonwhite/nonblack patients 0.73, 95%CI: 0.58-0.91). Among patients with jaundice, those who underwent surgery were less likely to undergo ERCP(aOR0.60, 95%CI: 0.52, 0.69).CONCLUSION ERCP utilization in pancreatic cancer varies based on patient age, marital status,and factors related to where the patient lives. Further studies are needed to guide appropriate biliary intervention for these patients.     

White/Black Racial Differences in Risk of End-stage Renal Disease and Death

Background

End-stage renal disease disproportionately affects black persons, but it is unknown when in the course of chronic kidney disease racial differences arise. Understanding the natural history of racial differences in kidney disease may help guide efforts to reduce disparities.

Methods

We compared white/black differences in the risk of end-stage renal disease and death by level of estimated glomerular filtration rate (eGFR) at baseline in a national sample of 2,015,891 veterans between 2001 and 2005.

Results

Rates of end-stage renal disease among black patients exceeded those among white patients at all levels of baseline eGFR. The adjusted hazard ratios for end-stage renal disease associated with black versus white race for patients with an eGFR ≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73m², respectively, were 2.14 (95% confidence interval [CI], 1.72-2.65), 2.30 (95% CI, 2.02-2.61), 3.08 (95% CI, 2.74-3.46), 2.47 (95% CI, 2.26-2.70), 1.86 (95% CI, 1.75-1.98), and 1.23 (95% CI, 1.12-1.34). We observed a similar pattern for mortality, with equal or higher rates of death among black persons at all levels of eGFR. The highest risk of mortality associated with black race also was observed among those with an eGFR 45-59 mL/min/1.73m² (hazard ratio 1.32, 95% CI, 1.27-1.36).

Conclusion

Racial differences in the risk of end-stage renal disease appear early in the course of kidney disease and are not explained by a survival advantage among blacks. Efforts to identify and slow progression of chronic kidney disease at earlier stages may be needed to reduce racial disparities.