Temporal Trends in Stroke Thrombolysis in the US by Race and Ethnicity, 2009-2018

This study investigates the temporal trend in racial and ethnic differences in use of intravenous thrombolysis for stroke treatment between 2009 and 2018 in a representative sample of US adults.

Non-English Primary Language Is Associated with Short-Term Outcomes After Supratentorial Tumor Resection

BACKGROUND

Despite research indicating that patients with non-English primary language (NEPL) have increased hospital length of stay (LOS) for craniotomies, there is a paucity of neurosurgical research examining the impact of language on short-term outcomes. This study sought to evaluate short-term outcomes for patients with English primary language (EPL) and NEPL admitted for resection of a supratentorial tumor.

METHODS

Using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project New Jersey State Inpatient Database, this study included patients 18-90 years old who underwent resection of a supratentorial primary brain tumor, meningioma, or brain metastasis from 2009 to 2017. The primary outcomes were total, preoperative, and postoperative LOS. Secondary outcomes were complications, mortality, and discharge disposition. Univariable and multivariable analyses compared Spanish primary language (SPL), non-English non-Spanish (NENS) primary language, and EPL groups.

RESULTS

A total of 7324 patients were included: 2962 with primary brain tumor, 2091 with meningioma, and 2271 with brain metastasis. Patients with SPL (n = 297) were younger and more likely to have noncommercial insurance, lower income, and fewer comorbidities. Patients with NENS (n = 257) had similar age and comorbidities to the EPL group but had a greater proportion of noncommercially insured and low-income patients (P < 0.001). Multivariable analysis showed that patients with NENS had increased postoperative LOS (adjusted incidence rate ratio, 1.10; P = 0.008) and higher odds of a complication (adjusted odds ratio, 1.36; P = 0.015), and patients with SPL had higher odds of being discharged home (adjusted odds ratio, 1.55; P = 0.017).

CONCLUSIONS

Patients with NEPL have different short-term outcomes after supratentorial tumor resection that varies based on primary language. More research is needed to understand the mechanisms driving these findings and to clarify unique experiences for different populations with NEPL.

Spinocerebellar ataxias in Asia: Prevalence, phenotypes and management

This paper reviews and summarizes three main aspects of spinocerebellar ataxias (SCA) in the Asian population. First, epidemiological studies were comprehensively reviewed. Overall, the most common subtypes include SCA1, SCA2, SCA3, and SCA6, but there are large differences in the relative prevalence of these and other SCA subtypes between Asian countries. Some subtypes such as SCA12 and SCA31 are rather specific to certain Asian populations. Second, we summarized distinctive phenotypic manifestations of SCA patients of Asian origin, for example a frequent co-occurrence of parkinsonism in some SCA subtypes. Lastly, we have conducted an exploratory survey study to map SCA-specific expertise, resources, and management in various Asian countries. This showed large differences in accessibility, genetic testing facilities, and treatment options between lower and higher income Asian countries. Currently, many Asian SCA patients remain without a final genetic diagnosis. Lack of prevalence data on SCA, lack of patient registries, and insufficient access to genetic testing facilities hamper a wider understanding of these diseases in several (particularly lower income) Asian countries.

Toward an Anti-Racist Approach to Biomedical and Neuroscience Research

Racism is a threat to public health. Race is a sociopolitical construct that has been used for generations to create disparities in educational access, housing conditions, exposure to environmental contaminants, and access to health care. Collectively, these disparities have a negative impact on the health of non-white Americans. The National Institutes of Health (NIH) funds biomedical research, including basic neuroscience research, aimed at understanding the mechanisms and consequences of health and disease in Americans. NIH has recently acknowledged its own structural racism, the disadvantage this perpetuates in the biomedical research enterprise, and has announced its commitment to eliminating these disparities. Here, we discuss different rates of disease in U.S. citizens from different racial backgrounds. We next describe ways in which the biomedical research enterprise (1) has contributed to health disparities and (2) can contribute to the solving this problem. Based on our own scientific expertise, we use neuroscience in general and mental health/addiction disorders more specifically as examples of a broader issue. The NIH, including its neuroscience-focused Institutes, and NIH-funded scientists, including neuroscientists, should prioritize research topics that reflect the health conditions that affect all Americans, not just white Americans.

Racial disparity in taxane-induced neutropenia among cancer patients

BACKGROUND

Large interindividual variations have been reported in chemotherapy-induced toxicities. Little is known whether racial disparities exist in neutropenia associated with taxanes.

METHODS

Patients with a diagnosis of primary cancer who underwent chemotherapy with taxanes were identified from Vanderbilt University Medical Center's Synthetic Derivative. Multinomial regression models were applied to evaluate odds ratios (ORs) and 95% confidence intervals (CIs) of neutropenia associated with race, with adjustments for demographic variables, baseline neutrophil count, chemotherapy-related information, prior treatments, and cancer site.

RESULTS

A total of 3492 patients were included in the study. Compared with White patients, grade 2 or higher neutropenia was more frequently recorded among Black patients who received taxanes overall (42.2% vs. 32.7%, p < 0.001) or paclitaxel (43.0% vs. 36.7%, p < 0.001) but not among those who received docetaxel (32.0% vs. 30.2%, p = 0.821). After adjustments for multiple covariates, Black patients who received chemotherapy with any taxanes had significantly higher risk of grade 2 (OR = 1.53; 95% CI = 1.09-2.14) and grade 3 (OR = 1.91; 95% CI = 1.36-2.67) neutropenia but comparable risk of grade 4 neutropenia (OR = 1.19; 95% CI = 0.79-1.79). Similar association patterns were observed for Black patients who specifically received paclitaxel, but a null association was found for those treated with docetaxel.

CONCLUSION

Black cancer patients treated with taxanes for any cancer had a higher risk of neutropenia compared with their White counterparts, especially those who received paclitaxel. More research is needed to understand the mechanism(s) underlying this racial disparity in order to enhance the delivery of patient-centered oncology.

Trends and Disparities in Treatment for Co-occurring Major Depression and Substance Use Disorders Among US Adolescents From 2011 to 2019

IMPORTANCE

Major depression and substance use disorders (SUD) commonly co-occur among adolescents, yet little is known about treatment use among adolescents with both conditions. Given the reciprocal influence of these conditions on each other and low prevalence of treatment overall, current information on quantification and trends in treatment of co-occurring depression and SUD is critical toward assessing how the field is performing in reaching youth in need of these services, and among youth with sociodemographic risk factors.

OBJECTIVE

To examine temporal trends and sociodemographic disparities in the treatment of co-occurring major depression and SUD among US adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used publicly available data for adolescents aged 12 to 17 years from the annual cross-sectional surveys of the National Survey on Drug Use and Health from 2011 to 2019 to assess co-occurrence of major depressive episodes (MDE) and SUD through time and prevalence of treatment for either or both of these conditions. Data were analyzed between October 2020 and February 2021.

EXPOSURES

Survey years, adolescent age, gender, race and ethnicity, type of insurance, annual household income, family structure, and residential stability.

MAIN OUTCOMES AND MEASURES

Presence and treatment of co-occurring 12-month MDE and SUD.

RESULTS

In total, 136 262 adolescents participated in the 2011 to 2019 surveys, among whom 69 584 (51.1%) were boys and 66 678 (49.0%) were girls, 46 548 (34.1%) were aged 16 to 17 years, and 18 173 (13.8%) were Black, 28 687 (23.2%) were Hispanic, and 74 512 (53.6%) were White. From 2011 to 2019, the annual prevalence of co-occurring MDE and SUD remained stable, at between 1.4% and 1.7%. Among adolescents with co-occurring MDE and SUD, the prevalence of treatment use for MDE only increased significantly from 28.5% in 2011 to 42.5% in 2019 (odds ratio [OR], 1.07; 95% CI, 1.02-1.11; P = .005), whereas the prevalence of treatment use for SUD only decreased from 4.8% to 1.5% (OR, 0.92; 95% CI, 0.85-0.99; P = .04). Overall, the prevalence of treatment use for both conditions fluctuated between 4.5% and 11.6%, without a significant linear trend over time (OR, 0.95; 95% CI, 0.87-1.03; P = .24). Extensive disparities in treatment use were found among boys for SUD and both conditions, older adolescents for MDE, Hispanic adolescents for co-occurring conditions (adjusted OR, 0.52; 95% CI, 0.27-0.98; P = .04), and Asian, Native Hawaiian, or Pacific Islander adolescents for MDE (adjusted OR, 0.24; 95% CI, 0.10-0.58; P = .002) and co-occurring conditions (adjusted OR, 0.04; 95% CI, 0.01-0.33; P = .003). Moving households 3 or more times in the past 12 months was associated with higher odds that adolescents received treatment for both conditions (adjusted OR, 2.52; 95% CI, 1.26-5.05; P = .009).

CONCLUSIONS AND RELEVANCE

This survey study found that from 2011 to 2019, less than 12% of adolescents with major depression and SUD received treatment for both conditions from 2011 to 2019. Findings from this study call for expanded service provision for adolescents with co-occurring conditions, improved coordination between service delivery systems, and enhanced policy and funding support for adolescents with unmet treatment needs.

Characteristics, Trends, and Outcomes of Liver Transplantation for Primary Sclerosing Cholangitis in Female Versus Male Patients: An Analysis From the European Liver Transplant Registry

BACKGROUND

The influence of sex on primary sclerosing cholangitis (PSC), pre- and postliver transplantation (LT) is unclear. Aims are to assess whether there have been changes in incidence, profile, and outcome in LT-PSC patients in Europe with specific emphasis on sex.

METHODS

Analysis of the European Liver Transplant Registry database (PSC patients registered before 2018), including baseline demographics, donor, biochemical, and clinical data at LT, immunosuppression, and outcome.

RESULTS

European Liver Transplant Registry analysis (n = 6463, 32% female individuals) demonstrated an increasing number by cohort (1980-1989, n = 159; 1990-1999, n = 1282; 2000-2009, n = 2316; 2010-2017, n = 2549) representing on average 4% of all transplant indications. This increase was more pronounced in women (from 1.8% in the first cohort to 4.3% in the last cohort). Graft survival rate at 1, 5, 10, 15, 20, and 30 y was 83.6%, 70.8%, 57.7%, 44.9%, 30.8%, and 11.6%, respectively. Variables independently associated with worse survival were male sex, donor and recipient age, cholangiocarcinoma at LT, nondonation after brain death donor, and reduced size of the graft. These findings were confirmed using a more recent LT population closer to the current standard of care (LT after the y 2000).

CONCLUSIONS

An increasing number of PSC patients, particularly women, are being transplanted in European countries with better graft outcomes in female recipients. Other variables impacting outcome include donor and recipient age, cholangiocarcinoma, nondonation after brain death donor, and reduced graft size.

Evaluation of Racial, Ethnic, and Socioeconomic Disparities in Initiation of Kidney Failure Treatment During the First 4 Months of the COVID-19 Pandemic

Importance

Persons with kidney failure require treatment (ie, dialysis or transplantation) for survival. The burden of the COVID-19 pandemic and pandemic-related disruptions in care have disproportionately affected racial and ethnic minority and socially disadvantaged populations, raising the importance of understanding disparities in treatment initiation for kidney failure during the pandemic.

Objective

To examine changes in the number and demographic characteristics of patients initiating treatment for incident kidney failure following the COVID-19 pandemic by race and ethnicity, county-level COVID-19 mortality rate, and neighborhood-level social disadvantage.

Design, Setting, and Participants

This cross-sectional time-trend study used data from US patients who developed kidney failure between January 1, 2018, and June 30, 2020. Data were analyzed between January and July 2021.

Exposures

COVID-19 pandemic.

Main Outcomes and Measures

Number of patients initiating treatment for incident kidney failure and mean estimated glomerular filtration rate (eGFR) at treatment initiation.

Results

The study population included 127 149 patients with incident kidney failure between January 1, 2018, and June 30, 2020 (mean [SD] age, 62.8 [15.3] years; 53 021 [41.7%] female, 32 932 [25.9%] non-Hispanic Black, and 19 835 [15.6%] Hispanic/Latino patients). Compared with the pre-COVID-19 period, in the first 4 months of the pandemic (ie, March 1 through June 30, 2020), there were significant decreases in the proportion of patients with incident kidney failure receiving preemptive transplantation (1805 [2.1%] pre-COVID-19 vs 551 [1.4%] during COVID-19; P < .001) and initiating hemodialysis treatment with an arteriovenous fistula (2430 [15.8%] pre-COVID-19 vs 914 [13.4%] during COVID-19; P < .001). The mean (SD) eGFR at initiation declined from 9.6 (5.0) mL/min/1.73 m2 to 9.5 (4.9) mL/min/1.73 m2 during the pandemic (P < .001). In stratified analyses by race/ethnicity, these declines were exclusively observed among non-Hispanic Black patients (mean [SD] eGFR: 8.4 [4.6] mL/min/1.73 m2 pre-COVID-19 vs 8.1 [4.5] mL/min/1.73 m2 during COVID-19; P < .001). There were significant declines in eGFR at initiation for patients residing in counties in the highest quintile of COVID-19 mortality rates (9.5 [5.0] mL/min/1.73 m2 pre-COVID-19 vs 9.2 [5.0] mL/min/1.73 m2 during COVID-19; P < .001), but not for patients residing in other counties. The number of patients initiating treatment for incident kidney failure was approximately 30% lower than projected in April 2020.

Conclusions and Relevance

In this cross-sectional study of US adults, the COVID-19 pandemic was associated with a substantially lower number of patients initiating treatment for incident kidney failure and treatment initiation at lower levels of kidney function during the first 4 months, particularly for Black patients and people living in counties with high COVID-19 mortality rates.

Inequalities in the decline and recovery of pathological cancer diagnoses during the first six months of the COVID-19 pandemic: a population-based study

BACKGROUND

The restructuring of healthcare systems to cope with the demands of the COVID-19 pandemic has led to a reduction in clinical services such as cancer screening and diagnostics.

METHODS

Data from the four Northern Ireland pathology laboratories were used to assess trends in pathological cancer diagnoses from 1st March to 12th September 2020 overall and by cancer site, sex and age. These trends were compared to the same timeframe from 2017 to 2019.

RESULTS

Between 1st March and 12th September 2020, there was a 23% reduction in cancer diagnoses compared to the same time period in the preceding 3 years. Although some recovery occurred in August and September 2020, this revealed inequalities across certain patient groups. Pathological diagnoses of lung, prostate and gynaecological malignancies remained well below pre-pandemic levels. Males and younger/middle-aged adults, particularly the 50-59-year-old patient group, also lagged behind other population demographic groups in terms of returning to expected numbers of pathological cancer diagnoses.

CONCLUSIONS

There is a critical need to protect cancer diagnostic services in the ongoing pandemic to facilitate timely investigation of potential cancer cases. Targeted public health campaigns may be needed to reduce emerging inequalities in cancer diagnoses as the COVID-19 pandemic continues.

Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States

OBJECTIVE

To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI).

METHODS

Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level.

RESULTS

Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001).

CONCLUSIONS

A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018

IMPORTANCE

The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades.

OBJECTIVE

To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US.

DESIGN, SETTING, AND PARTICIPANTS

Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults.

EXPOSURES

Self-reported race, ethnicity, and income level.

MAIN OUTCOMES AND MEASURES

Rates and racial and ethnic differences in self-reported health status and health care access and affordability.

RESULTS

The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification.

CONCLUSIONS AND RELEVANCE

In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.

Trends and Regional Variation in Prevalence of Cardiovascular Risk Factors and Association With Socioeconomic Status in Canada, 2005-2016

IMPORTANCE

Cardiovascular disease remains the second leading cause of death in Canada. Monitoring and tracking the trends and disparities in major cardiovascular risk factors could provide benchmarks for future cardiovascular health strategies.

OBJECTIVE

To investigate the temporal trends, regional variations, and socioeconomic disparities in major cardiovascular risk factors in Canada from 2005 to 2016.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional survey study included adults aged 20 years and older from 6 Canadian Community Health Survey cycles between 2005 and 2016. Cardiovascular risk factors included hypertension, diabetes, obesity, and current smoking. Socioeconomic status was measured using equivalized household income. Data analysis was performed from September 2019 to April 2020.

EXPOSURES

A total of 112 health regions and socioeconomic status.

MAIN OUTCOMES AND MEASURES

Age- and sex-adjusted prevalence of hypertension, diabetes, obesity, and current smoking by year; health regions; and socioeconomic status. Absolute numbers were rounded to base 100 for confidentiality purposes, and percentages were based on weighted numbers. Slope index of inequality (SII) and relative index of inequality (RII) were calculated to assess absolute and relative socioeconomic inequalities, respectively.

RESULTS

A total of 670 000 respondents (329 000 [49.1%] men; 341 000 [50.9%] women) aged 20 years and older from 6 survey cycles were enrolled for this study. The largest age group was those aged 40 to 59 years (eg, 2005 cycle: 40.2% [95% CI, 39.9%-40.6%]). In the 2015/2016 cycle, the overall age- and sex-adjusted prevalence rates of hypertension, diabetes, obesity, and current smoking were 20.7% (95% CI, 20.4%-21.1%), 7.2% (95% CI, 7.0%-7.5%), 20.1% (95% CI, 19.7%-20.6%), and 17.8% (95% CI, 17.4%-18.2%), respectively. From 2005 to 2016, there was a significant increase in the prevalence of hypertension, diabetes, and obesity (eg, prevalence of diabetes in both sexes, 2005: 5.8% [95% CI, 5.6%-6.0%]; 2015/2016: 7.2% [95% CI, 7.0%-7.5%]; P < .001) but a significant decrease in the prevalence of current smoking (both sexes, 2005: 22.1% [95% CI, 21.7%-22.5%]; 2015/2016: 17.8% [95% CI, 17.4%-18.2%]; P < .001). The prevalence of all the risk factors varied widely across health regions (eg, obesity, Vancouver Health Service Delivery Area: 6.7% [95% CI, 4.5%-9.0%]; Miramichi Area: 36.8% [95% CI, 27.3%-46.3%]). In addition to obesity among men, all risk factors tended to be more common among those with lower income (eg, prevalence of hypertension in both sexes, 2015/2016, lowest income group: 23.2% [95% CI, 22.4%-24.0%]; highest income group: 18.4% [95% CI, 17.7%-19.1%]). The SII and RII indicated consistent absolute and relative socioeconomic inequalities in hypertension, diabetes, and current smoking over time (eg, RII for hypertension in both sexes, 2005: 1.25; 95% CI, 1.18-1.33; 2015/2016: 1.34; 95% CI, 1.26-1.43). However, the phenomenon of absolute and relative socioeconomic inequalities in obesity was only observed among women (eg, RII for 2015/2016 for obesity in women; 1.74 (95% CI, 1.56-1.93); men: 1.09; 95% CI, 0.99-1.21).

CONCLUSIONS AND RELEVANCE

During the study period, the prevalence of hypertension, diabetes, and obesity significantly increased, while the prevalence of current smoking significantly decreased. Geographic and socioeconomic gaps should be considered and addressed in future interventions and policies targeted at reducing these cardiovascular risk factors in Canada.

Impact of COVID-19 on the imaging diagnosis of cardiac disease in Europe

OBJECTIVES

We aimed to explore the impact of the COVID-19 pandemic on cardiac diagnostic testing and practice and to assess its impact in different regions in Europe.

METHODS

The online survey organised by the International Atomic Energy Agency Division of Human Health collected information on changes in cardiac imaging procedural volumes between March 2019 and March/April 2020. Data were collected from 909 centres in 108 countries.

RESULTS

Centres in Northern and Southern Europe were more likely to cancel all outpatient activities compared with Western and Eastern Europe. There was a greater reduction in total procedure volumes in Europe compared with the rest of the world in March 2020 (45% vs 41%, p=0.003), with a more marked reduction in Southern Europe (58%), but by April 2020 this was similar in Europe and the rest of the world (69% vs 63%, p=0.261). Regional variations were apparent between imaging modalities, but the largest reductions were in Southern Europe for nearly all modalities. In March 2020, location in Southern Europe was the only independent predictor of the reduction in procedure volume. However, in April 2020, lower gross domestic product and higher COVID-19 deaths were the only independent predictors.

CONCLUSION

The first wave of the COVID-19 pandemic had a significant impact on care of patients with cardiac disease, with substantial regional variations in Europe. This has potential long-term implications for patients and plans are required to enable the diagnosis of non-COVID-19 conditions during the ongoing pandemic.

Impact of dementia: Health disparities, population trends, care interventions, and economic costs

INTRODUCTION

The dementia experience is not a monolithic phenomenon-and while core elements of dementia are considered universal-people living with dementia experience the disorder differently. Understanding the patterning of Alzheimer's disease and related dementias (ADRD) in the population with regards to incidence, risk factors, impacts on dementia care, and economic costs associated with ADRD can provide clues to target risk and protective factors for all populations as well as addressing health disparities.

METHODS

We discuss information presented at the 2020 National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers, Theme 1: Impact of Dementia. In this article, we describe select population trends, care interventions, and economic impacts, health disparities and implications for future research from the perspective of our diverse panel comprised of academic stakeholders, and persons living with dementia, and care partners.

RESULTS

Dementia incidence is decreasing yet the advances in population health are uneven. Studies examining the educational, geographic and race/ethnic distribution of ADRD have identified clear disparities. Disparities in health and healthcare may be amplified by significant gaps in the evidence base for pharmacological and non-pharmacological interventions. The economic costs for persons living with dementia and the value of family care partners' time are high, and may persist into future generations.

CONCLUSIONS

Significant research gaps remain. Ensuring that ADRD healthcare services and long-term care services and supports are accessible, affordable, and effective for all segments of our population is essential for health equity. Policy-level interventions are in short supply to redress broad unmet needs and systemic sources of disparities. Whole of society challenges demand research producing whole of society solutions. The urgency, complexity, and scale merit a "whole of government" approach involving collaboration across numerous federal agencies.

The new normal for breast cancer surgery during COVID-19 pandemic: An international survey conducted by SENATURK

PURPOSE

The COVID-19 pandemic has changed the way many health institutions approach their workload. Physicians managing patients with cancer now have to deal not only with the disease but also the restrictions and limitations imposed because of the global pandemic. We aimed to determine how surgical preferences in breast cancer management were affected globally using a questionnaire-based survey.

METHODS

Under the auspices of the Turkish Senology Society (SENATURK) we asked 122 surgeons from 27 countries to reply to a 26-question survey designed to measure the impact of COVID-19 on their surgical practice when treating patients with breast cancer.

RESULTS

The characteristics of participant surgeons were statistically similar when comparing the participants' answers from Turkey and other countries. From the responses given to our questionnaire, it was understood that breast cancer surgery decreased by 25% (p<0.05) in institutions all over the world, including Turkey, but there was no change in the approach technique to the axilla.

CONCLUSIONS

Globally breast surgeons have adapted to the new normal due to the COVID-19 pandemic. Many surgical approaches and some follow up protocols have been changed, although the degree of change has varied from country to country. In addition, the availability of multidisciplinary case conferences has been reduced in some centers which may affect the quality of services provided to patients.

Identifying Disparities in Health Outcomes and Mortality for American Indian and Alaska Native Populations Using Tribally Disaggregated Vital Statistics and Health Survey Data

Objectives. To determine the impact of disaggregated mortality and health surveillance data on the ability to identify health disparities for American Indian and Alaska Native (AI/AN) subpopulations. Methods. We conducted a systematic review of reporting categories for AI/AN decedents on official death certificates for all 50 US states. Using public data from the 2017-2018 California Health Interview Survey (CHIS), we conducted bivariate and multivariate analyses to assess disparities in health conditions and outcomes for tribally enrolled and non‒tribally enrolled AI/AN persons compared with non-Hispanic Whites. Results. There was no standard for the collection of tribal enrollment data or AI/AN race on death certificates across all 50 states. There were stark differences in the incidence and prevalence of various health risk factors and chronic diseases for the tribally enrolled AI/AN subpopulation, non‒tribally enrolled AI/AN subpopulation, and non-Hispanic White comparison group. Conclusions. The collection of tribal enrollment data in vital statistics and health surveillance systems is necessary to identify and respond to health disparities among AI/AN subpopulations. These efforts must be conducted in partnership with tribal nations and consider Indigenous data sovereignty.

Teledermatology: Improving Access or Widening Healthcare Disparities?

Teledermatology, the form of telemedicine directed toward dermatology patients, is one of the earliest technological innovations that advanced remote medical care. Developed in 1995, teledermatology was established with the mission of increasing healthcare access among patients in rural geographic locations who had limited access to specialist care.1.

Assessment of Racial/Ethnic Disparities in Timeliness and Comprehensiveness of Dementia Diagnosis in California

Importance

The US aging population is rapidly becoming more racially and ethnically diverse. Early diagnosis of dementia is a health care priority.

Objective

To examine the associations between race/ethnicity and timeliness of dementia diagnosis and comprehensiveness of diagnostic evaluation.

Design, Setting, and Participants

This retrospective cross-sectional study used 2013-2015 California Medicare fee-for-service data to examine the associations of race/ethnicity, individual factors, and contextual factors with the timeliness and comprehensiveness of dementia diagnosis. Data from 10 472 unique beneficiaries were analyzed. The sample was selected on the basis of the following criteria: presence of 1 or more claims; no diagnoses of dementia or mild cognitive impairment in 2013 to 2014; continuous enrollment in Medicare Parts A and B; Asian, Black, Hispanic, or White race/ethnicity; and incident diagnoses of dementia or mild cognitive impairment in January through June 2015. Data analyses were conducted from November 1, 2019, through November 10, 2020.

Main Outcomes and Measures

Timeliness of diagnosis, defined as incident diagnosis of mild cognitive impairment vs dementia, and comprehensiveness of diagnostic evaluation, defined as presence of the following services in claims within 6 months before or after the incident diagnosis date: specialist evaluation, laboratory testing, and neuroimaging studies.

Results

The sample comprised 10 472 unique Medicare beneficiaries with incident diagnoses of dementia or mild cognitive impairment (6504 women [62.1%]; mean [SD] age, 82.9 [8.0] years) and included 993 individuals who identified as Asian (9.5%), 407 as Black (3.9%), 1255 as Hispanic (12.0%), and 7817 as White (74.6%). Compared with White beneficiaries, those who identified as Asian (odds ratio, 0.46; 95% CI, 0.38-0.56), Black (odds ratio, 0.73; 95% CI, 0.56-0.94), or Hispanic (odds ratio, 0.62; 95% CI, 0.52-0.72) were less likely to receive a timely diagnosis. Asian beneficiaries (incidence rate ratio, 0.81; 95% CI, 0.74-0.87) also received fewer diagnostic evaluation elements. These associations remained significant after adjusting for age, sex, comorbidity burden, neighborhood disadvantage, and rurality.

Conclusions and Relevance

These findings highlight substantial disparities in the timeliness and comprehensiveness of dementia diagnosis. Public health interventions are needed to achieve equitable care for people living with dementia across all racial/ethnic groups.

Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study

BACKGROUND

Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those prescribed opioids for chronic pain. We explored the likelihood of securing a new primary care provider (PCP) among people with varying histories of opioid use who had recently lost access to their PCP.

METHODS AND FINDINGS

We conducted a retrospective cohort study using linked administrative data among residents of Ontario, Canada whose enrolment with a physician practicing in a primary care enrolment model (PEM) was terminated between January 2016 and December 2017. We assigned individuals to 3 groups based upon their opioid use on the date enrolment ended: long-term opioid pain therapy (OPT), opioid agonist therapy (OAT), or no opioid. We fit multivariable models assessing the primary outcome of primary care reattachment within 1 year, adjusting for demographic characteristics, clinical comorbidities, and health services utilization. Secondary outcomes included rates of emergency department (ED) visits and opioid toxicity events. Among 154,970 Ontarians who lost their PCP, 1,727 (1.1%) were OAT recipients, 3,644 (2.4%) were receiving long-term OPT, and 149,599 (96.5%) had no recent prescription opioid exposure. In general, OAT recipients were younger (median age 36) than those receiving long-term OPT (59 years) and those with no recent prescription opioid exposure (44 years). In all exposure groups, the majority of individuals had their enrolment terminated by their physician (range 78.1% to 88.8%). In the primary analysis, as compared to those not receiving opioids, OAT recipients were significantly less likely to find a PCP within 1 year (adjusted hazard ratio [aHR] 0.55, 95% confidence interval [CI] 0.50 to 0.61, p < 0.0001). We observed no significant difference between long-term OPT and opioid unexposed individuals (aHR 0.96; 95% CI 0.92 to 1.01, p = 0.12). In our secondary analysis comparing the period of PCP loss to the year prior, we found that rates of ED visits were elevated among people not receiving opioids (adjusted rate ratio (aRR) 1.20, 95% CI 1.18 to 1.22, p < 0.0001) and people receiving long-term OPT (aRR 1.37, 95% CI 1.28 to 1.48, p < 0.0001). We found no such increase among OAT recipients, and no significant increase in opioid toxicity events in the period following provider loss for any exposure group. The main limitation of our findings relates to their generalizability outside of PEMs and in jurisdictions with different financial incentives incorporated into primary care provision.

CONCLUSIONS

In this study, we observed gaps in access to primary care among people who receive prescription opioids, particularly among OAT recipients. Ongoing efforts are needed to address the stigma, discrimination, and financial disincentives that may introduce barriers to the healthcare system, and to facilitate access to high-quality, consistent primary care services for chronic pain patients and those with OUD.

Liver Transplantation of HCV-viremic Donors Into HCV-negative Recipients in the United States: Increasing Frequency With Profound Geographic Variation

BACKGROUND

Direct-acting antiviral therapy made possible the novel practice of utilizing hepatitis C virus (HCV)-viremic (HCV RNA-positive) donors into HCV-negative recipients in the United States. Although initial reports of outcomes have been satisfactory, higher-quality longer-term outcomes remain to be elucidated.

METHODS

National data were examined from the Organ Procurement and Transplantation Network on adult patients in the United States who underwent a primary, single organ, deceased donor liver transplant from January 1, 2016 to March 31, 2020. Outcomes of HCV-negative recipients (R-) who received an allograft from donors who were HCV RNA-positive (D HCV+) donors were compared with HCV RNA-negative (D HCV-) donors.

RESULTS

There has been a 35-fold increase in D HCV+/R- liver transplants over the past 4 y in the United States, from 8 in 2016 to 280 in 2019. There was an almost 6-fold difference in this practice among UNOS geographic regions. Graft survival following D HCV+/R- liver transplantation was excellent, with 1-y rates being 91% and 90% and 2-y rates being 88.5% and 87% for D HCV+/R- and D HCV-/R-, respectively (P = 0.672). In multivariate analysis, adjusting for other donor and recipient attributes, D HCV+/R- was not associated with patient or graft survival.

CONCLUSIONS

The practice of D HCV+/R- continues to increase without discernible impact on medium-term outcomes. Notable geographic variation exists, suggesting inconsistent perceptions about the impact of D HCV+/R- transplantation on outcomes. These results strengthen the perceived safety in utilizing HCV-viremic donor organs as a donor pool expansion strategy, not only in the United States, but also worldwide.

The changing health needs of the UK population

The demographics of the UK population are changing and so is the need for health care. In this Health Policy, we explore the current health of the population, the changing health needs, and future threats to health. Relative to other high-income countries, the UK is lagging on many health outcomes, such as life expectancy and infant mortality, and there is a growing burden of mental illness. Successes exist, such as the striking improvements in oral health, but inequalities in health persist as well. The growth of the ageing population relative to the working-age population, the rise of multimorbidity, and persistent health inequalities, particularly for preventable illness, are all issues that the National Health Service (NHS) will face in the years to come. Meeting the challenges of the future will require an increased focus on health promotion and disease prevention, involving a more concerted effort to understand and tackle the multiple social, environmental, and economic factors that lie at the heart of health inequalities. The immediate priority of the NHS will be to mitigate the wider and long-term health consequences of the COVID-19 pandemic, but it must also strengthen its resilience to reduce the impact of other threats to health, such as the UK leaving the EU, climate change, and antimicrobial resistance.