Disparities in Mohs utilization and margin outcomes in sebaceous carcinoma: A response to Zhou et al.

PHS17 - Racial disparities in total Ankle Arthroplasty Utilization and outcomes

In the context of China's aging population and increasing internal migration, "old age" and "mobility" are the special dual attributes of the older adult migrants, and their utilization of basic public health services and health protection is also a major public health issue. Against the backdrop of growing urban-rural development disparities in China, this study aims to examine the differences in public health service utilization and health status between urban and rural older adult migrants and quantify the contribution of relevant influencing factors. This study utilized data from the 2018 China Migrants Dynamic Survey (CMDS). After data cleaning, a final sample size of 4,198 participants was analyzed. Descriptive analysis and chi-square tests were used to examine the distribution of three types of public health services-health education, health record establishment, and family doctor contracting-as well as self-reported health status among urban and rural older adult migrants. Multiple linear regression models were applied to identify factors associated with public health service utilization and health status. Finally, the Blinder-Oaxaca decomposition method was used to quantify the extent to which various factors contributed to urban-rural disparities in health service utilization and health outcomes. Rural older adult migrants exhibited slightly higher utilization rates of public health services-health education, health records, and family doctor contracting-compared to their urban counterparts. However, their self-reported health status was significantly lower (76.88% vs. 79.12%). Regression analysis revealed that age, mobility range, education level, income, health insurance coverage, and geographic region were significant factors influencing both service utilization and health outcomes. Public health service use was positively associated with better health in both urban and rural groups. The Blinder-Oaxaca decomposition indicated that age, mobility range, and household income were the primary contributors to urban-rural disparities in health education; age, mobility range, and region contributed most to differences in health record establishment and family doctor contracting; and family doctor contracting, age, mobility range, and region were key drivers of disparities in health status. There are differences in public health service utilization and health status between urban and rural older adult migrants in China. While rural older adult migrants use public health services at a slightly higher rate, they experience worse health outcomes than their urban counterparts-largely due to socio-economic and regional disparities. Targeted interventions aimed at improving access, enhancing health education, optimizing service delivery, and strengthening policy support are essential to narrowing these urban-rural health gaps and promoting health equity among older adult migrants.

Allogeneic hematopoietic stem cell transplant (allo-HSCT) is increasingly being used in the United States (US) and across the world as a curative therapeutic option for patients with certain high-risk hematologic malignancies and non-malignant diseases. However, racial and ethnic disparities in utilization of the procedure and in outcome following transplant remain major problems. Racial and ethnic minority patients are consistently under-represented in the proportion of patients who undergo allo-HSCT in the US. The transplant outcomes in these patients are also inferior. The interrelated driving forces responsible for the differences in the utilization and transplant outcome of the medical intervention are socioeconomic status, complexity of the procedure, geographical barriers, and the results of differences in the genetics and comorbidities across different races. Bridging the disparity gaps is important not only to provide equity and inclusion in the utilization of this potentially life-saving procedure but also in ensuring that minority groups are well represented for research studies about allo-HSCT. This is required to determine interventions that may be more efficacious in particular racial and ethnic groups. Various strategies at the Federal, State, and Program levels have been designed to bridge the disparity gaps with varying successes. In this review paper, we will examine the disparities and discuss the strategies currently available to address the utilization and outcome gaps between patients of different races in the US.

Text2Breathe: Text-Message Intervention for Parent Communication and Pediatric Asthma.

BackgroundLong-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence.MethodsIn this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an “App” group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an “App+Feedback” group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a “Usual Care” group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence.DiscussionA successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the “Triple Aim” – reduce costs while improving health outcomes and the patient care experience.Trial registrationNCT03592771. Prospectively registered on July 19, 2018.

To describe utilization of prenatal care and outcomes of low birth weight and preterm birth among adolescent births in Mexico. We used birth certificate data and included live births to individuals 10-24 years, 2008-2019. Our outcomes were binary measures of adequate prenatal care, low birth weight, and preterm birth. We compared adolescents (10-14 years, 15-16, and 17-19) to those 20-24 years. We included individual-, clinical-, and municipality-level variables, used multivariable logistic regression, and calculated adjusted predicted probabilities. We also tested whether receipt of prenatal care moderated the relationship of age with preterm birth and low birth weight. We included a total of 12 106 710 births to women 10-24 years. The adjusted predicted probability of adequate prenatal care increased with age: 56.07% (95% CI 55.82-56.31%) adjusted probability among adolescents 10-14 years compared with 65.51% (95% CI 65.48%-65.55%) among individuals 20-24 years. Receipt of adequate prenatal care in part mitigated disparities in preterm birth and low birthweight across all age groups: 7.30% (95% CI 7.17%-7.43%) adjusted probability of delivering a preterm infant among those 10-14 years who received adequate prenatal care compared with 9.37% (95% CI 9.20%-9.53%) among those 10-14 years without adequate prenatal care. In Mexico, adolescent pregnancies are associated with inadequate prenatal care as well as higher odds of preterm delivery and low birth weight. Youngest adolescents (10-14 years) have the highest probability of adverse outcomes. Adequate prenatal care may help partially mitigate disparities in poor perinatal outcomes.

ABSTRACTBackgroundYoung people with intellectual disability may exhibit poorer general health, higher mortality rates and greater limitations from physical or mental illnesses compared to the general population. It is important to understand how this may relate to healthcare utilisation, including factors influencing healthcare access for young people with intellectual disability. This systematic review aimed to examine healthcare utilisation and to identify common barriers and facilitators of healthcare access for young people with intellectual disability.MethodFive databases (MEDLINE, Scopus, EMBASE, PsycINFO and CINAHL) were searched from 1 January 2013 to 31 October 2024 to identify articles that examined healthcare utilisation for young people (≤ 18 years old) with intellectual disability. and full‐text screening were conducted by two reviewers; data from included articles were critically appraised.ResultsThirty‐three studies were included for synthesis and focused on utilisation of hospital inpatient services (n = 22), emergency department (ED) services (n = 13), mental health or psychiatric services (n = 7) and mental health day programmes or outreach services (n = 1). Young people with intellectual disability generally had a higher proportion of hospital admissions, ED visits, hospital length of stay, mental health outpatient visits, mortality, 30‐day hospital readmission and complications of care, compared to young people without intellectual disability. Common facilitators of healthcare access and engagement included having health insurance coverage and the use of visual aids and tools for the young person with intellectual disability. Barriers included low socio‐economic status and poor provider communication and knowledge about intellectual disability.ConclusionsThere are clear disparities in health service outcomes for young people with intellectual disability compared to the general population, which may be influenced by socio‐cultural factors and access to knowledgeable and empathetic healthcare providers. Targeted education for healthcare providers may enhance the provision of high‐quality care and improve healthcare utilisation and health outcomes for young people with intellectual disability.

Racial differences in the use and outcomes of intravascular imaging (IVI) and invasive physiology (IP) during percutaneous coronary intervention (PCI) are underreported in the United States. Medicare Fee-For-Service claims data were used to examine the use and outcomes of IVI- and IP-guided PCI by Black versus White race (2016-2023). Multivariable logistic regression was used to assess the association between race and IVI/IP use. The primary outcome was major adverse cardiovascular events, which included myocardial infarction, repeat revascularization, and death. Outcomes were compared by race according to the device used (IVI versus none; IP versus none; and among all IVI/IP recipients). Cox regression was used to estimate the association between race and 2-year outcomes, adjusting for all baseline characteristics. The study included 1 481 343 PCI patients (5.9% Black patients, 63.6% male, mean age 75.3±7.0 years). IVI was used in 17.6% of PCIs in White patients and 15.0% in Black patients; IP use was 7.1% and 5.7%, respectively. After adjustment, Black adults were less likely to receive IVI (odds ratio, 0.94 [95% CI, 0.93-0.96]) or IP (odds ratio, 0.83 [95% CI, 0.81-0.85]). IVI- and IP-guided PCI had lower major adverse cardiovascular event risk at 2-years in both racial groups compared with angiography alone: IVI (White patients: hazard ratio [HR], 0.93 [95% CI, 0.92-0.94]; Black patients: HR, 0.85 [95% CI, 0.84-0.87]) and IP (White patients: HR, 0.95 [95% CI, 0.92-0.98]); Black patients: HR, 0.87 [95% CI, 0.83-0.91]). However, despite global benefits with IVI/IP, Black adults had a higher adjusted risk of major adverse cardiovascular events compared with White adults (HR, 1.02 [95% CI, 1.01-1.03]). IVI- and IP-guided PCI were associated with improved outcomes in both Black and White beneficiaries, yet these technologies were less frequently used in Black adults, and overall PCI outcomes remained worse for this group.

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Background: Despite advances in extracorporeal membrane oxygenation (ECMO) for cardiogenic shock (CS), little is known about gender-based differences in its utilization and clinical outcomes. We aimed to assess whether gender influences ECMO use and outcomes in CS using Nationwide Inpatient Sample (NIS) Database. Methods: We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS, 2016–2020), identifying adults (≥18 years) hospitalized with cardiogenic shock. ECMO use was identified using ICD-10-PCS codes. Survey-weighted logistic and linear regression models were used to assess gender differences in ECMO utilization, in-hospital mortality, length of stay (LOS), hospitalization costs, and major complications. Models adjusted for demographics, comorbidities (Elixhauser index), and hospital characteristics. Results: Among 13,005 patients receiving ECMO for CS, only 33.9% were female. Female patients were significantly less likely to receive ECMO (adjusted OR 0.89; 95% CI 0.82–0.97; p = 0.011). Female ECMO recipients were younger than males (mean age 47.7 vs. 52.8 years; p < 0.001). There was no significant difference in in-hospital mortality by gender (aOR 1.12; 95% CI 0.92–1.35; p = 0.258). Length of stay was similar between genders (23.6 days), with a non-significant trend toward shorter LOS in females (β = –2.25; p = 0.071). Adjusted total hospital charges were significantly lower in females (β = –$95,269; p = 0.017) (Figure 1). Notably, complication rates varied by gender. Females had significantly lower adjusted odds of requiring dialysis (aOR 0.77; 95% CI 0.63–0.95; p = 0.013), developing acute kidney injury (aOR 0.71; 95% CI 0.57–0.88; p = 0.002), arrhythmias (aOR 0.67; 95% CI 0.56–0.80; p < 0.001), and acute myocardial infarction (aOR 0.75; 95% CI 0.61–0.92; p = 0.007). However, female patients had higher adjusted odds of developing pericardial complications (aOR 1.35; 95% CI 1.04–1.74; p = 0.022) and pulmonary embolism (aOR 1.68; 95% CI 1.25–2.26; p = 0.001) (Figure 2). Conclusions: Women were less likely to receive ECMO for cardiogenic shock and tended to be younger at the time of receiving it. While in-hospital mortality and length of stay did not differ by gender, females had significantly lower hospital charges and distinct complication patterns. These findings highlight potential gender-based disparities in ECMO utilization and underscore the need for further investigation to ensure equitable access and outcomes.

This Addressing Healthcare Inequities in IDD special issue advances current thinking and research to increase our understanding of health inequities and approaches to improve health care for people with intellectual and developmental disabilities (IDD). In this introduction, we briefly describe health and healthcare inequities for children and adults with IDD, arguing that the quest to improve healthcare quality must include an intentional pursuit of equity. Two articles follow that analyze existing data by factors including diagnosis and other characteristics to explore healthcare disparities. The final three studies explore approaches to advance trainee and clinician competencies to provide quality care to patients with IDD. The inclusion of Dr. Karrie A. Shogren's American Association on Intellectual and Developmental Disabilities (AAIDD) 2022 Presidential Address extends the discussion with a robust reflection on systemic barriers and offers a vision for equity and inclusion that has implications for health care as an aspect of every good life.In 2001, a seminal report published by the Institute of Medicine's Committee on Quality of Healthcare in America Project, "Crossing the Quality Chasm," provided clear evidence of gaps in the quality of healthcare and catalyzed the establishment and growth of quality improvement efforts across the complex systems of healthcare. "The Triple Aim," developed and described by Berwick and colleagues (2008), offered guidance to move towards enhancing patient experience, reducing cost, and optimizing population health. As systems have engaged with this and other quality improvement frameworks, significant disparities based on race, ethnicity, income, and disability status have become increasingly apparent. For example, people with IDD experience inequities in health and health care (Havercamp & Scott, 2015; Krahn & Fox, 2014). People with IDD have high rates of chronic health conditions, yet poorer access to health care compared to people without disabilities (Reichard et al., 2011). They report barriers to accessing health care, high rates of unmet health care needs, and dissatisfaction with the health care they receive compared to people without disabilities (Ali et al., 2013; Doherty et al., 2020; Prokup et al., 2017; World Health Organization [WHO], 2011). Disability-related health inequities are compounded when people with IDD have other marginalized identities, such as those based on race, ethnicity, sexual orientation, gender identity, poverty, or rural place of living (Courtney-Long et al., 2017; Dembo et al., 2022; Magaña et al., 2016). Inequities in health outcomes are understood to result, in part, from differences in social circumstances (e.g., discrimination, poverty) that affect health (Angelelli et al., 2022; Krahn et al., 2006), disparities in healthcare access (Lauer et al., 2021), and inequities in data collection and failure to monitor their health (e.g., Havercamp & Krahn, 2019; Fox et al., 2015; WHO, 2021). The global COVID-19 pandemic dramatically illustrates that the burden of infectious disease falls most heavily on those populations already disadvantaged by systemic discrimination and oppression, including people with IDD (Ruprecht et al., 2021; Turk et al., 2020).The pursuit of healthcare equity for patients with IDD depends on health system research that identifies people with IDD in the data as well as other marginalized identities, where possible. The next two articles in this special issue leverage existing health services data to explore healthcare disparities. Acosta and colleagues used the Nationwide Emergency Data Sample (NEDS) to compare the rates of emergency department visits leading to hospital admission and reasons for hospital admission as a function of intellectual disability (ID) diagnosis, age group, and other characteristics. In the third article, McMaughan and colleagues present the results of a cross-sectional analysis of the 2016 Kids' Inpatient Database to discover the most frequent principal diagnoses for inpatient stays among children and youth with autism, the costs associated with these hospitalizations, and the length of hospital stays. Understanding these factors is needed to advocate for and develop appropriate community-based support services to reduce the burden of hospitalizations and to inform the development of value-based care models. Taken together, these articles demonstrate opportunities to use existing health service datasets to identify disparate healthcare utilization patterns and outcomes in people with IDD."The Quadruple Aim" introduced the quality priorities of clinician work-life and experience in 2014 (Bodenheimer & Sinsky, 2014). Healthcare professionals hold negative and ableist attitudes and beliefs about disability and report feeling uncomfortable and unprepared to meet the health needs of patients with disabilities (Desroches et al., 2019; Iezzoni et al., 2021). Without explicit disability training, health care providers are likely to view disability as a negative health outcome and to hold low expectations for the function and quality of life of individuals with disabilities. Training can prepare clinicians to communicate effectively and provide accessible, patient-centered assessment and treatment to patients with disabilities. In 2022, the National Council on Disability released a policy brief, Health Equity Framework for People with Disabilities, calling for comprehensive disability clinical-care curricula and disability competency education in all U.S. medical, nursing, and other healthcare professional schools (National Council on Disability, 2022).The next three articles in this special issue have direct implications for health care delivery for people with IDD, emphasizing the critical role of training and experience of clinicians. Recognizing the relationship between feeling prepared to care for a patient and positive patient experience, the Golub-Victor team explored perceived self-confidence to care for adults with ID among students in interprofessional healthcare training programs. This study explored the influence of several factors on trainee's self-confidence. Program-related characteristics such as the number of years in the program, healthcare discipline, and individual characteristics such as gender identity, and prior experience or training in ID are described. In the fifth article, Sheppard and colleagues describe an innovative school-clinic partnership where medical students spent a day with a special education faculty member observing children with disabilities in school settings. This pilot study explored the feasibility of implementing this experiential learning activity during a pediatric clerkship and, similar to Golub-Victor and colleagues, students' perceived competence. In the sixth article, Berens and colleagues explore the feasibility, acceptability, and impact of a behavioral intervention to reduce the need for sedation, general anesthesia, and restraint in dental care for adults with IDD.In the final article, taken from her 2022 AAIDD Presidential Address, Shogren likens ableism to racism and sexism in the harm it causes people with disabilities and its insidious nature. She calls on us to 1) recognize and name systemic barriers including ableism, and 2) take action to break down these barriers to advance equity.As editors of this special issue, we have learned much from the contributing authors and are appreciative of readers who will use these findings to improve health care for children and adults with IDD. We hope this special issue inspires readers to seek opportunities to identify and dismantle barriers to equity in health and health care for people with IDD.