Laboratory abnormalities at the onset of treatment of end-stage renal disease: are there racial or socioeconomic disparities in care?

BACKGROUND: Laboratory abnormalities at the start of treatment of end-stage renal disease (ESRD) have been reported as worse in racial/ethnic minorities than in white patients, suggesting racial disparities in care. It is not known whether these differences are attributable to racial/ethnic differences in socioeconomic status (SES). METHODS: We tested associations between race/ethnicity, SES, and type of medical insurance and serum creatinine level, estimated glomerular filtration rate, serum albumin level, and hematocrit at the start of treatment of ESRD and use of epoietin before ESRD treatment in a large national population-based sample. Data on 515 561 patients beginning ESRD treatment between January 1, 1996, and June 30, 2004, were obtained for this cross-sectional survey from the United States Renal Data System. RESULTS: Race/ethnicity had a much stronger association than SES with each laboratory measure. Adjusted mean serum creatinine levels were lowest in white patients (7.5 mg/dL [663.0 micromol/L]; 95% confidence interval [CI], 7.45-7.49) and highest in black patients (8.9 mg/dL [786.7 micromol/L]; 95% CI, 8.92-8.97) (P<.001 across racial/ethnic groups). Adjusted mean hematocrit for white patients (29.5%; 95% CI, 29.4%-29.6%) was significantly higher and for black patients (28.3%; 95% CI, 28.2%-28.4%) significantly lower than that of all other racial/ethnic groups (P<.001 across racial/ethnic groups). Less marked differences were present for estimated glomerular filtration rate and serum albumin level. In contrast, predialysis use of epoietin was associated with race/ethnicity (black vs white: odds ratio, 0.80; 95% CI, 0.78-0.81; Hispanic vs white: odds ratio, 0.87; 95% CI, 0.85-0.89) and showed a graded decrease with decreasing SES (odds ratio for the lowest vs highest socioeconomic quartile 0.68; 95% CI, 0.67-0.70). Patients without medical insurance had more abnormal laboratory values than those with insurance, but these associations were weaker than those of race/ethnicity. CONCLUSIONS: Minorities, particularly black patients, had more severe laboratory abnormalities at the start of ESRD treatment than white patients. These differences were not readily attributable to SES differences. Absence of medical insurance, SES, and race/ethnicity were associated with the likelihood of predialysis use of epoietin.     

Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, 1971-1992

BACKGROUND: The comparative long-term risk of non-traumatic lower extremity amputation (LEA) in black and white Americans, 2 groups with strikingly different rates of diabetes mellitus, is not known. OBJECTIVE: To examine the 20-year incidence of LEA in relation to race and diabetes mellitus. METHODS: The 14 407 subjects in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study were observed prospectively between 1971 and 1992. Prevalent diabetes mellitus was ascertained at the baseline examination, and incident diabetes mellitus, during follow-up. Lower extremity amputation was ascertained from hospital discharge records. Cox regression analysis was used to estimate associations between race, diabetes mellitus, and risk of first LEA. RESULTS: During the study period, 158 LEAs occurred among 108 subjects. While black subjects constituted 15.2% of the cohort, they represented 27.8% of the subjects with amputation (P = .002). The 20-year age-adjusted rate ratio of first LEAs for black subjects-white subjects was 2.14. Regression analyses confirmed the importance of diabetes mellitus as a key LEA risk factor. The association between prevalent diabetes mellitus and LEA risk was substantially higher (relative risk [RR], 7.19; 95% confidence interval [CI], 4.61-11.22) than that for incident diabetes mellitus (RR, 3.15 [CI, 1.84-5.37]), highlighting the importance of diabetes mellitus duration on LEA risk. While preliminary analyses adjusted for age and diabetes indicated a significant association between race and LEA risk (RR, 1.93 [95% CI, 1.26-2.96]), the effect of race diminished (RR, 1.49 [95% CI, 0.95-2.34]) following adjustment for education, hypertension, and smoking. CONCLUSIONS: Although black subjects experienced higher age- and diabetes mellitus-adjusted rates of amputation than their white counterparts, a combination of social and environmental factors may account for the apparent ethnic difference. More research into nonbiological factors associated with LEA may reduce the occurrence of these procedures in both black and white individuals.     

Impact of hospital volume on racial disparities in cardiovascular procedure mortality.

OBJECTIVES: We assessed use of low-volume hospitals by race and ethnicity for major cardiovascular procedures and determined whether hospital volume is an important factor explaining racial and ethnic differences in post-procedure mortality. BACKGROUND: Low hospital volume predicts mortality for cardiovascular procedures and could be a mediator of racial and ethnic differences in procedure outcomes. METHODS: We analyzed data from 719,679 hospitalizations for cardiac artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) from 1998 to 2001 using the Nationwide Inpatient Sample. We used multivariate logistic regression to assess whether race predicts use of low-volume hospitals and the relative contribution of hospital volume to racial disparity in post-procedure in-hospital mortality. RESULTS: Black and Hispanic patients were more likely than white patients to receive cardiovascular procedures in low-volume hospitals. Black patients had greater risk-adjusted mortality than white patients after elective AAA repair (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.20 to 2.84), CABG (OR, 1.19; 95% CI, 1.06 to 1.33), and CEA (OR, 1.56; 95% CI, 1.07 to 2.27), but not PTCA. Hispanic patients did not have higher risk-adjusted mortality than white patients. Adjusting for hospital volume did not substantially reduce the relative risk of death for black patients compared with white patients. CONCLUSIONS: Black and Hispanic patients were more likely to receive cardiovascular procedures in low-volume hospitals, but hospital volume did not explain a large proportion of racial differences in post-procedure mortality. Additional research is needed to determine why black patients have increased mortality after cardiovascular procedures and how these mortality rates can be reduced.     

Understanding the Racial and Ethnic Differences in Cost and Mortality Among Advanced Stage Prostate Cancer Patients (STROBE)

The aims of the study were to understand the racial/ethnic differences in cost of care and mortality in Medicare elderly with advanced stage prostate cancer.This retrospective, observational study used SEER-Medicare data. Cohort consisted of 10,509 men aged 66 or older and diagnosed with advanced-stage prostate cancer between 2001and 2004. The cohort was followed retrospectively up to 2009. Racial/ethnic variation in cost was analyzed using 2 part-models and quantile regression. Step-wise GLM log-link and Cox regression was used to study the association between race/ethnicity and cost and mortality. Propensity score approach was used to minimize selection bias.Pattern of cost and mortality varies between racial/ethnic groups. Compared with other racial/ethnic groups, non-Hispanic white patients had higher unadjusted costs in treatment and follow-up phases. Quintile regression results indicated that in treatment phase, Hispanics had higher costs in the 95th quantile and non-Hispanic blacks had lower cost in the 95th quantile, compared with non-Hispanic white men. In terminal phase non-Hispanic blacks and Hispanics had higher cost. After controlling for treatment, all-cause and prostate cancer-specific mortality was not significant for non-Hispanic black men, compared with non-Hispanic white men. However, for Asians, mortality remained significantly lower compared with non-Hispanic white men.In conclusion, relationship between race/ethnicity, cost of care, and mortality is intricate. For non-Hispanic black men, disparity in mortality can be attributed to treatment differences. To reduce racial/ethnic disparities in prostate cancer care and outcomes, tailored policies to address underuse, overuse, and misuse of treatment and health services are necessary.     

Risk of fracture in women with type 2 diabetes: the Women's Health Initiative Observational Study

CONTEXT: Some but not all studies have shown higher rates of fracture in individuals with type 2 diabetes. OBJECTIVE: The objective of the study was to determine the risk of fracture in postmenopausal women with type 2 diabetes and determine whether risk varies by fracture site, ethnicity, and baseline bone density. DESIGN, SETTING, AND PARTICIPANTS: Women with clinically diagnosed type 2 diabetes at baseline in the Women's Health Initiative Observational Cohort, a prospective study of postmenopausal women (n = 93,676), were compared with women without diagnosed diabetes and risk of fracture overall and at specific sites determined. MAIN OUTCOME MEASURES: All fractures and specific sites separately (hip/pelvis/upper leg; lower leg/ankle/knee; foot; upper arm/shoulder/elbow; lower arm/wrist/hand; spine/tailbone) were measured. Bone mineral density (BMD) in a subset also was measured. RESULTS: The overall risk of fracture after 7 yr of follow-up was higher in women with diabetes at baseline after controlling for multiple risk factors including frequency of falls [adjusted relative risk (RR) 1.20, 95% confidence interval (CI) 1.11-1.30]. In a subsample of women with baseline BMD scores, women with diabetes had greater hip and spine BMD. The elevated fracture risk was found at multiple sites (hip/pelvis/upper leg; foot; spine/tailbone) among black women (RR 1.33, 95% CI 1.00-1.75) and women with increased baseline bone density (RR 1.26, 95% CI 0.96-1.66). CONCLUSION: Women with type 2 diabetes are at increased risk for fractures. This risk is also seen among black and non-Hispanic white women after adjustment for multiple risk factors including frequent falls and increased BMD (in a subset).     

Race/ethnicity and outcomes following inpatient rehabilitation for hip fracture

BACKGROUND: Hip fracture results in severe and often permanent reductions in overall health and quality of life for many older adults. As the U.S. population grows older and more diverse, there is an increasing need to assess and improve outcomes across racial/ethnic cohorts of older hip fracture patients. METHODS: We examined data from 42,479 patients receiving inpatient rehabilitation for hip fracture who were discharged in 2003 from 825 facilities across the United States. Outcomes of interest included length of stay, discharge setting, and functional status at discharge and 3- to 6-month follow-up. RESULTS: Mean age was 80.2 (standard deviation [SD] = 8.0) years. A majority of the sample was non-Hispanic white (91%), followed by non-Hispanic black (4%), Hispanic (4%), and Asian (1%). After controlling for sociodemographic factors and case severity, significant (p <.05) differences between the non-Hispanic white and minority groups were observed for predicted lengths of stay in days (Asian: 1.1; 95% confidence interval [CI], 0.5-1.7; non-Hispanic black: 0.8; 95% CI, 0.6-1.1), odds of home discharge (Asian: 2.1; 95% CI, 1.6-2.8; non-Hispanic black: 2.0; 95% CI, 1.8-2.3; Hispanic: 1.9; 95% CI, 1.6-2.2), lower discharge Functional Independence Measure (FIM) ratings (non-Hispanic black: 3.6; 95% CI, 3.0-4.2; Hispanic: 1.6; 95% CI, 0.9-2.2 points lower), and lower follow-up FIM ratings (Hispanic: 4.4; 95% CI, 2.8-5.9). CONCLUSIONS: Race/ethnicity differences in outcomes were present in a national sample of hip fracture patients following inpatient rehabilitation. Recognizing these differences is the first step toward identifying and understanding potential mechanisms underlying the relationship between race/ethnicity and outcomes. These mechanisms may then be addressed to improve hip fracture care for all patients.     

Factors associated with vaccination of medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003

OBJECTIVES: To examine vaccination in seniors in the five U.S. communities of the Racial and Ethnic Adult Disparities in Immunization Initiative. DESIGN: Cross-sectional telephone survey in spring 2003 using stratified sampling by ZIP code and race/ethnicity. SETTING: New York, Texas, Wisconsin, Illinois, and Mississippi. PARTICIPANTS: Four thousand five hundred seventy-seven Medicare beneficiaries. MEASUREMENTS: Outcomes were pneumococcal vaccination ever and influenza vaccination in 2002/03 and were determined according to race/ethnicity, awareness of vaccination, and provider recommendation. Survey questions also asked about future plans for vaccination, whether respondents believed they had become sick from prior influenza vaccination, and whether unvaccinated respondents would be vaccinated if a health professional recommended it. RESULTS: Pneumococcal vaccination coverage was 70.3% for whites, 40.8% for blacks, and 53.2% for Hispanics, and the proportion reporting provider recommendation for vaccination differed significantly according to race/ethnicity. In multivariate regression, provider recommendation (risk ratio (RR) = 2.32, 95% confidence intervals (CI) = 2.10-2.57) and awareness of vaccination (RR = 1.60, 95% CI = 1.40-1.82) were associated with greater pneumococcal vaccination. Influenza vaccination coverage was 76.2% for whites, 50.7% for blacks, and 65.7% for Hispanics. A little more than half of respondents reported provider recommendation for influenza vaccination, with no differences according to race/ethnicity. Provider recommendation was associated with influenza vaccination (RR = 1.31, 95% CI = 1.25-1.38). More blacks and Hispanics believed they had become sick from prior influenza vaccination than whites, and this belief was associated with lower vaccination rates. CONCLUSION: This survey details vaccination patterns in an ethnically and geographically diverse sample of seniors and identifies some differences between blacks, Hispanics, and whites that may contribute to disparities in vaccination coverage. Survey findings highlight the importance of provider vaccination recommendations.     

The Association Between Socioeconomic Status,Sex, Race / Ethnicity and In-Hospital Mortality Among Patients Hospitalized for Heart Failure

BackgroundThe association between socioeconomic status (SES), sex, race / ethnicity and outcomes during hospitalization for heart failure (HF) has not previously been investigated.Methods and ResultsWe analyzed HF hospitalizations in the United States National Inpatient Sample between 2015 and 2017. Using a hierarchical, multivariable Poisson regression model to adjust for hospital- and patient-level factors, we assessed the association between SES, sex, and race / ethnicity and all-cause in-hospital mortality. We estimated the direct costs (USD) across SES groups. Among 4,287,478 HF hospitalizations, 40.8% were in high SES, 48.7% in female, and 70.0% in White patients. Relative to these comparators, low SES (homelessness or lowest quartile of median neighborhood income) (relative risk [RR] 1.02, 95% confidence interval [CI] 1.00–1.05) and male sex (RR 1.09, 95% CI 1.07–1.11) were associated with increased risk, whereas Black (RR 0.79, 95% CI 0.76–0.81) and Hispanic (RR 0.90, 95% CI 0.86–0.93) race / ethnicity were associated with a decreased risk of in-hospital mortality (5.1% of all hospitalizations). There were significant interactions between race / ethnicity and both, SES (P < .01) and sex (P = .04), such that racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients. The median direct cost of admission was lower in low vs high SES groups ($9324.60 vs $10,940.40), female vs male patients ($9866.60 vs $10,217.10), and Black vs White patients ($9077.20 vs $10,019.80). The median costs increased with SES in all demographic groups primarily related to greater procedural utilization.ConclusionsSES, sex, and race / ethnicity were independently associated with in-hospital mortality during HF hospitalization, highlighting possible care disparities. Racial/ethnic differences in outcome were more pronounced in low SES groups and in male patients.     

Ethnic differences in the presentation, treatment strategy, and outcomes of percutaneous coronary intervention (a report from the National Heart, Lung, and Blood Institute Dynamic Registry)

Information about the impact of race/ethnicity on adverse outcomes after percutaneous coronary intervention (PCI) in the modern era is limited. Using consecutive patients from the National Heart, Lung, and Blood Institute Dynamic Registry, this study investigated differences in clinical presentation, treatment strategy, and acute and long-term outcomes in 3,669 white, 446 black, 301 Hispanic, and 201 Asian patients who underwent PCI. All comparisons were made to whites. Blacks were more likely than whites to be younger, women, and to present with a higher prevalence of cardiovascular risk factors (hypertension, diabetes, and smoking). Hispanics tended to be younger, hypertensive, diabetic, and to be undergoing their first cardiovascular procedure. Asians were, on average, younger, men, and presented more often with hypertension and diabetes than whites. Although the rate of stent implantation was significantly lower in blacks compared with whites (63% vs 74%, p <0.001), angiographic and procedural success rates were high (> or =95%) and did not differ by race/ethnicity. In-hospital mortality (0.2% vs 1.7%, p <0.05) and death/myocardial infarction (MI)/coronary artery bypass grafting (CABG) (3.1% vs 5.5%, p <0.05) were lower in blacks. All other in-hospital complications were similar to whites. At 1 year, there were no statistical differences in cumulative adverse event rates by ethnicity; however by 2 years there was a modestly higher mortality rate (adjusted RR 1.87; 95% confidence interval 1.15 to 3.04) and adverse event rate (death/MI, death/MI/CABG) among black patients. Thus, although differences in patient demographics, clinical presentation, angiographic characteristics and treatment strategies did not impact the incidence of acute and 1-year adverse outcomes of non-whites, there appears to be a significant reduction in event-free survival among blacks by 2 years.     

Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation.

OBJECTIVES: This study was designed to study racial/ethnic differences in the risk for intracranial hemorrhage (ICH) and the effect of warfarin on ICH risk among patients with atrial fibrillation (AF). BACKGROUND: Nonwhites are at greater risk for ICH than whites in the general population. Whether this applies to patients with AF and whether warfarin therapy is associated with comparable risk of ICH in nonwhites are unknown. METHODS: We retrospectively identified a multiethnic stroke-free cohort hospitalized with nonrheumatic AF. Warfarin use and anticoagulation intensity were assessed by searching pharmacy and laboratory records. Crude ICH event rates were calculated by Poisson regression. Cox proportional hazard models were constructed to assess the independent effect of race/ethnicity on ICH after adjusting for age, gender, hypertension, diabetes, heart failure, and warfarin exposure. RESULTS: Between 1995 and 2000, we identified 18,867 qualifying AF hospitalizations (78.5% white, 8% black, 9.5% Hispanic, and 3.9% Asian) and 173 qualifying ICH events over 3.3 years follow-up. Achieved anticoagulation intensity was lower among blacks but not different between the other groups. Warfarin was associated with increased ICH risk in all races, but the magnitude of risk was greater among nonwhites. There were no gender differences. The hazard ratio for ICH with whites as referent was 4.06 for Asians (95% confidence interval [CI] 2.47 to 6.65), 2.06 for Hispanics (95% CI 1.31 to 3.24), and 2.04 (95% CI 1.25 to 3.35) for blacks. CONCLUSIONS: Nonwhites with AF were at greater risk for warfarin-related ICH. Blacks, Hispanics, and Asians were at successively greater ICH risk than whites.     

Comparison of risk factors for cardiovascular mortality in black and white adults

BACKGROUND: Recent attention to racial and ethnic disparities in health outcomes highlights the excess coronary heart disease mortality in black patients compared with white patients. We investigated whether traditional cardiovascular disease (CVD) risk factors were similarly associated with CVD mortality in black and white men and women. METHODS: Participants included 3741 black and 33,246 white men and women (44%) without a history of myocardial infarction, aged 18 to 64 years at baseline (1967-1973) from the Chicago Heart Association Detection Project in Industry study. Blood pressure, total cholesterol level, body mass index, cigarette smoking, and physician-diagnosed diabetes were assessed at baseline using standard methods. RESULTS: Through 2002, there were 107, 1586, 177, and 2866 deaths from CVD in black women, white women, black men, and white men, respectively. In general, the magnitude and direction of associations between traditional risk factors and CVD mortality were similar by race. However, in black women the multivariable-adjusted hazard ratio (HR) per 12 mm Hg of diastolic blood pressure was 1.08 (95% confidence interval [CI], 0.90-1.29), whereas it was 1.31 in white women (95% CI, 1.25-1.38). There was no association between higher cholesterol level (per 40 mg/dL [1.04 mmol/L]) and CVD mortality in black men (HR, 0.94; 95% CI, 0.80-1.10), whereas the risk was elevated in white men (HR, 1.21; 95% CI, 1.16-1.26). CONCLUSIONS: Most traditional risk factors demonstrated similar associations with mortality in black and white adults of the same sex. Small differences were primarily in the strength, not the direction, of association.     

Extreme variations in racial rates of total hip arthroplasty for primary coxarthrosis: a population-based study in San Francisco.

OBJECTIVES--To compare the incidence of all total hip arthroplasty, and total hip arthroplasty for primary coxarthrosis, among the Asian, black, Hispanic, and white populations living in one locale. METHODS--We identified all San Francisco residents who underwent total hip replacements (THR) in the 17 hospitals for adults within or near San Francisco County during a five year period. Preoperative pelvic radiographs were read without prior knowledge of the gender or race of the subject, to diagnose the specific hip diseases. Age standardised THR incidence by race and gender was determined, as was the comparative THR incidence for specific diagnosis (primary and secondary osteoarthritis). RESULTS--The greatest annual rate of total hip replacement occurred in white women (97 per 100,000 population), followed by white men, black women, black men, Hispanic women, and Hispanic men. The smallest numbers were found in Asians, whose THR rate was 10% that of whites. A primary coxarthrosis diagnosis was greatest among white subjects (66%), followed by black subjects (54%), Hispanics (53%), and Asians (28%). Age standardised THR rates for primary coxarthrosis per 100,000 population were likewise greatest among whites (43.0) and least among Asians (1.3 for Chinese). Mean age of patients undergoing THR for primary coxarthrosis was 70 years for white subjects and almost a decade younger in all other groups. CONCLUSIONS--THR rates are much lower for Asians, Hispanics, and black subjects than for the white population living in San Francisco. The low rates of total hip arthroplasty in the non-white groups was related to the much lower incidence of THR for primary coxarthrosis among non-whites than among whites. The racial distribution of primary coxarthrosis among patients who underwent THR is consistent with distribution patterns reported internationally.     

Patient race and surgical outcomes after total knee arthroplasty: An analysis of a large regional database

Objective

To examine racial differences in surgical complications, mortality, and revision rates after total knee arthroplasty.

Methods

We studied patients undergoing primary total knee arthroplasty using 2001–2007 Pennsylvania Health Care Cost Containment Council data. We conducted bivariate analyses to assess the risk of complications such as myocardial infarction, venous thromboembolism, wound infections, and failure of prosthesis, as well as 30‐day and 1‐year overall mortality after elective total knee arthroplasty, between racial groups. We estimated Kaplan‐Meier 1‐ and 5‐year surgical revision rates, and fit multivariable Cox proportional hazards models to compare surgical revision by race, incorporating 5 years of followup. We adjusted for patient age, sex, length of hospital stay, surgical risk of death, type of health insurance, hospital surgical volume, and hospital teaching status.

Results

In unadjusted analyses, there were no significant differences by racial group for either overall 30‐day or in‐hospital complication rates, or 30‐day and 1‐year mortality rates. Adjusted Cox models incorporating 5 years of followup showed an increased risk of revisions for African American patients (hazard ratio [HR] 1.39, 95% confidence interval [95% CI] 1.08–1.80), younger patients (HR 2.30, 95% CI 1.96–2.69), and lower risk for female patients (HR 0.81, 95% CI 0.71–0.92).

Conclusion

In this sample of patients who underwent knee arthroplasty, we found no significant racial differences in major complication rates or mortality. However, African American patients, younger patients, and male patients all had significantly higher rates of revision based on 5 years of followup.     

Disparities in Sarcoidosis Mortality by Region,Urbanization, and Race in the United States: A Multiple Cause of Death Analysis

PurposeSex, race/ethnicity, and geographic disparities in sarcoidosis-associated mortality were assessed for the most recent period.MethodsUS data for multiple causes of death for 1999-2016 were used to determine numbers of deaths and age-adjusted rates for sarcoidosis as an underlying or a contributing cause of death using International Classification of Diseases, 10th Revision code D86 for Hispanics, non-Hispanic blacks, and non-Hispanic whites.ResultsFor persons of all ages in the United States in 1999-2016, there were a total of 28,923 sarcoidosis-associated deaths. In 2008-2016, 9112 deaths had sarcoidosis as the underlying cause (56%) compared with 16,129 with sarcoidosis listed as any cause. Age-adjusted annual death rates per 100,000 were 5.7 (95% confidence interval [CI], 5.6-5.8) for females and 4.1 (95% CI, 4.0-4.2) for males. Age-adjusted annual death rates were 1.5 (95% CI, 1.4-1.6) for Hispanics and 5.4 (95% CI, 5.3-5.4) for non-Hispanics. Rates in non-Hispanic blacks were 8 times those in non-Hispanic whites. Among females, the highest rate was in non-Hispanic blacks in the East-Central division. Between 1999-2007 and 2008-2016, rates increased most in non-Hispanic white males (52.5%) and least in non-Hispanic black females (5.8%).ConclusionsSarcoidosis-related multiple cause of death mortality rates were highest in females and in non-Hispanic blacks, and they varied geographically.     

Epidemiology of cervical spine injury victims.

STUDY OBJECTIVE: We sought to characterize demographics and injury patterns among patients undergoing emergency department cervical spine radiography for blunt traumatic injury. METHODS: All patients with blunt trauma undergoing cervical spine radiography at 21 centers were enrolled in this prospective, observational study. Patients' date of birth, age, sex, and ethnicity were noted before cervical spine radiography. RESULTS: Demographic factors associated with cervical spine injury, present in 818 of 33,922 patients, included the following: age of 65 years or older (relative risk [RR] 2.09; 95% confidence interval [CI] 1.77 to 2.59); "other" ethnicity (RR 1.79, 95% CI 1.46 to 2.19); male sex (RR 1.72, 95% CI 1.48 to 2.00); and white ethnicity (RR 1.50, 95% CI 1.31 to 1.72). Hispanic ethnicity (RR 0.64, 95% CI 0.51 to 0.79), female sex (RR 0.58, 95% CI 0.50 to 0.67), black ethnicity (RR 0.55, 95% CI 0.45 to 0.66), and age of less than 18 years (RR 0.39, 95% CI 0.27 to 0.55) were associated with reduced risk of cervical spine injury. CONCLUSION: Among patients undergoing ED cervical spine radiography, cervical spine injury is more common among the elderly, male subjects, and patients of white or "other" ethnicity. Because cervical spine injury occurs in patients in all demographic categories, however, this information cannot be used to select individual patients who should or should not undergo imaging.     

Racial and ethnic differences in survival of children with acute lymphoblastic leukemia

Black children with acute lymphoblastic leukemia (ALL) have poor outcomes, but limited information is available for children from other racial and ethnic backgrounds, such as Hispanic and Asian. We undertook a retrospective cohort study of children with ALL treated on Children's Cancer Group therapeutic protocols to determine outcomes by racial and ethnic backgrounds of patients treated with contemporary risk-based therapy. In total, 8447 children (white, n = 6703; Hispanic, n = 1071; black, n = 506; and Asian, n = 167) with newly diagnosed ALL between 1983 and 1995 were observed for a median of 6.5 years. Analysis of disease outcome was measured as overall survival (OS) and event-free survival (EFS) and was adjusted for known predictors of outcome including clinical features, disease biology, socioeconomic status, and treatment era (1983-1989 vs 1989-1995). There was a statistically significant difference in survival by ethnicity (P <.001). Five-year EFS rates were: Asian, 75.1% +/- 3.5%; white, 72.8% +/- 0.6%; Hispanic, 65.9% +/- 1.5%; and black, 61.5% +/- 2.2%. Multivariate analysis revealed that when compared with white children, black and Hispanic children had worse outcomes and Asian children had better outcomes after adjusting for known risk factors. The poorer outcomes among black children were most apparent among patients with standard-risk features (relative risk [RR], 2.0; 95% confidence interval [CI], 1.6-2.5), whereas poorer outcomes in Hispanic children (RR, 1.4; 95% CI, 1.2-1.6) were most evident among patients with high-risk features. Asian children had better outcomes than all racial and ethnic groups among high-risk patients, particularly in the recent era (5-year EFS, 90.9% +/- 6.1%). Racial and ethnic differences in OS and EFS persist among children with ALL who receive contemporary risk-based therapy. Future studies should focus on reasons-perhaps compliance or pharmacogenetics-for those differences.     

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.     

Differential use of coronary revascularization and hospital mortality following acute myocardial infarction

BACKGROUND: The effect of racial/ethnic disparity in the use of cardiac procedures on short-term outcomes, such as hospital mortality, is limited. We sought to determine the association of revascularization procedures (percutaneous transluminal coronary angioplasty or coronary artery bypass graft) to hospital mortality in non-Hispanic black and white patients and Hispanic patients with acute myocardial infarction. METHODS: Analysis of the New York State Department of Health Statewide Planning and Research Cooperate System (SPARCS) data for 12 555 patients admitted to New York City hospitals with acute myocardial infarction in 1996. Revascularization procedure frequencies and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for hospital mortality were calculated. RESULTS: Whites were older than Hispanics and blacks (mean +/- SD age, 70 +/- 13.3 vs 64 +/- 13.3 and 64 +/- 12.9 years, respectively; P<.001) and more likely to have heart failure (36.3% vs 29.1% and 29.6%, respectively; P<.001). Blacks were least likely to be revascularized compared with Hispanics and whites (15.8% vs 25.8% and 25.2%, respectively; P<.001). Hispanics were more likely to survive than whites (adjusted OR, 0.73 [95% CI, 0.59-0.91]); this difference was not significant for blacks (adjusted OR, 0.83 [95% CI, 0.69-1.00]). Nonrevascularized blacks and Hispanics were more likely to be discharged alive than nonrevascularized whites (OR, 0.80 [95% CI, 0.66-0.98] for blacks; OR, 0.74 [95% CI, 0.59-0.93] for Hispanics). There were no significant racial/ethnic differences in hospital survival among revascularized patients. CONCLUSIONS: Nonclinical and clinical factors appear to account for blacks being least likely to have been revascularized. Despite these differences in revascularization rates, survival was similar for blacks and whites, whereas Hispanics were more likely to survive than whites.     

The impact of body mass index on later total hip arthroplasty for primary osteoarthritis: a cohort study in 1.2 million persons

OBJECTIVE: To investigate the effects of body mass index (BMI), height, and age on the risk of later total hip arthroplasty for primary osteoarthritis (OA). METHODS: We matched screening data on body height and weight from 1,152,006 persons ages 18-67 years who attended a compulsory screening for tuberculosis in 1963-1975 with data from the Norwegian Arthroplasty Register for the years 1987-2003. We identified 28,425 total hip replacements because of primary OA. RESULTS: We found dose-response associations between both height and BMI and later hip arthroplasty. The relative risk (RR) among men with a BMI > or = 32 kg/m2 versus a BMI of 20.5-21.9 kg/m2 was 3.4 (95% confidence interval [95% CI] 2.9-4.0). The corresponding RR in women was 2.3 (95% CI 2.1-2.4). There was a decreasing trend in the RR with an increasing age at screening. Among men, the RR for an increase of 5 kg/m2 in the BMI was 2.1 (95% CI 1.7-2.5) when measured at age <25 years and 1.5 (95% CI 1.3-1.7) when measured at ages 55-59 years. Among women, the corresponding RR values were 1.7 (95% CI 1.5-1.9) and 1.1 (95% CI 1.1-1.2). CONCLUSION: There was a strong dose-response association between BMI and later total arthroplasty for OA of the hip. Being overweight entailed the highest RR among young participants, and the participants who were overweight at a young age maintained an excess RR for arthroplasty throughout the followup period.