Racial/Ethnic Disparities in Diabetes Quality of Care: the Role of Healthcare Access and Socioeconomic Status

Ethnoracial Representation in U.S. Clinical Trials for Retinal Vein Occlusion

PURPOSE

Retinal vein occlusion (RVO) is the second most common cause of vision loss from retinal vascular disease. Clinical trials often lack adequate representation of minority groups, limiting the external validity and equity of trial results. We aimed to characterize the evolution of ethnoracial demographic reporting, changes in the racial & ethnic composition of RVO trial participants, and correlations with trial sponsor and collaborator types.

DESIGN

Retrospective trend study SUBJECTS: Participants, sponsors, and collaborators in RVO clinical trials based in the United States (U.S.) METHODS: We assessed the ethnoracial distribution of patients and sponsors & collaborators in RVO clinical trials. Trial data was sourced from ClinicalTrials.gov and compared with 2022 U.S. Census Bureau data.

MAIN OUTCOME MEASURES

Change in ethnoracial reporting and representation, and comparison of representation within RVO clinical trials with 2022 U.S. Census demographics.

RESULTS

Racial data was not documented for all 6 (12.2%) trials completed between 2008 and 2011. There was increased ethnoracial reporting between January 2012 to June 2017 (n = 6/29, 20.7%) vs July 2017 to December 2022 (n = 13/14, 92.9%) (OR 49.8; 95% CI: 5.39-460.47; p<0.0001). The proportion of Asian participants increased from 4.2% to 15.9% (OR 4.37; 95% CI 2.49-8.37; p<0.0001), and Black participants rose from 6.1% to 20.7% (OR 4.03; 95% CI 2.51-6.85; p<0.0001). Conversely, White participants decreased from 73.8% to 56.0% (OR 0.45, 95% CI 0.34-0.59; p<0.0001), and Hispanic/Latino participants decreased from 13.1% to 5.4% (OR 0.38; 95% CI 0.26-0.56; p<0.0001). Compared to the 2022 US Census data, the ethnoracial distribution of the total U.S. population is significantly different than the total enrollment in RVO clinical trials (p<0.0001). Government and academic involvement were correlated with less White and more Black representation respectively (p≤0.01).

CONCLUSIONS

From 2008 to 2022, there has been a notable increase in the documentation of racial and ethnic demographics in RVO clinical trials. Although the recruitment of Asian and Black patients has increased, the Hispanic population remains significantly underrepresented among RVO trial participants, highlighting the need for greater inclusivity in enrollment.

A Randomized Clinical Trial of a Culturally Tailored Diabetes Education Curriculum With and Without Real-Time Continuous Glucose Monitoring in a Latino Population With Type 2 Diabetes: The CUT-DM With Continuous Glucose Monitoring Study

BACKGROUND

Data on culturally tailored diabetes education with and without real-time continuous glucose monitoring (RT-CGM) in Latinos with type 2 diabetes, who are not on intensive insulin management, is lacking.

RESEARCH DESIGN AND METHODS

This is an open-label randomized control trial of Latinos with uncontrolled (HbA1c > 8.0%) type 2 diabetes conducted in a Federally Qualified Health Center (FQHC). All participants received 12 one-hour culturally tailored education sessions. Patients were randomized (1:1) to education sessions only (blinded CGM) or cyclic (50 days wear: 10 days on, 7 days off) RT-CGM. The primary outcome was a change in HbA1c from baseline to 12 weeks in those with or without CGM. Secondary outcomes included 24-week HbA1c, CGM, and metabolic parameters.

RESULTS

Participants (n = 120) were 46 years old on average, 44% female, 98% preferred Spanish language, 30% with income <$25,000, 68% uninsured and 26% using basal insulin only. Mean 1-hour session attendance and RT-CGM wear was 7.0 (±4.4) and 27.9 (±20.5) days, respectively. Mean baseline HbA1c was 10.5% (±1.8). HbA1c reduced by 1.9% (95% confidence interval [CI]: 1.5-2.3) overall (P < .001). Participants in the RT-CGM group reduced HbA1c at 12 weeks by 2.3% (95% CI: 1.5-3.2) compared to 1.5% (95% CI: 0.6-2.3) in the blinded CGM group (P =.04). At 24 weeks, overall HbA1c reduction was maintained but between-group differences attenuated.

CONCLUSIONS

In a Latino type 2 diabetes population that was primarily noninsulin-requiring, virtually delivered, culturally tailored education improved HbA1c, with RT-CGM conferring greater improvement. RT-CGM should be an adjunctive therapy to diabetes education, irrespective of insulin use but continued cyclic CGM use may be needed for sustained effect.

Health Impact and Cost-Effectiveness of Testing and Treatment of Mycobacterium Tuberculosis Infection Among Asian and Hispanic Persons With Diagnosed Diabetes in the United States

OBJECTIVES

To evaluate the cost-effectiveness of testing and treatment for Mycobacterium tuberculosis (Mtb) infection among Asian and Hispanic persons with diagnosed diabetes in the United States.

METHODS

We estimated population size and Mtb infection prevalence for Asian and Hispanic persons aged ≥15 years with diagnosed, nongestational diabetes, by age and US-born status. We assumed a 1-time test for Mtb infection intervention, with positive-testing persons offered treatment. Using a deterministic, transmission-dynamic model of incident tuberculosis (TB) in the United States, we estimated costs, TB cases and deaths averted, and quality-adjusted life years gained under the intervention compared with no intervention. We estimated incremental cost-effectiveness ratios (ICERs), calculated as costs per quality-adjusted life years gained, from a TB health services perspective, including diagnosis and treatment for TB infection and disease. We also assessed health services and societal perspectives. We estimated 95% uncertainty intervals via probabilistic sensitivity analysis.

RESULTS

TB cases averted per 100 000 persons tested ranged from 7.5 (95% uncertainty interval: 6.9-8.1) among US-born Hispanic persons to 238.9 (225.2-254.3) among non-US-born Asian persons. TB deaths averted per 100 000 persons tested ranged from 1.3 (1.2-1.4) among US-born Hispanic persons to 53.7 (51.4-56.1) among non-US-born Asian persons. ICERs for US-born Asian and Hispanic populations were $856 671 ($533 506-$1 234 032) and $1 081 646 ($673 142-$1 551 264), respectively. ICERs for non-US-born Asian and Hispanic populations were lower: $66 664 ($41 456-$93 625) and $68 749 ($43 136-$97 044), respectively. ICERs were 2% to 19% higher under a societal perspective.

CONCLUSIONS

Although the intervention produced health benefits for all populations assessed, health benefits were greater-and ICERs more favorable-for non-US-born Asian and Hispanic populations with diagnosed diabetes.

Low-moderate alcohol use effects on glycemic control of patients presenting in the ED

BACKGROUND

The prevalence of Type 2 Diabetes Mellitus (DM2) is rising, affecting 462 million globally, including 21 million in the U.S. Emergency Department (ED) visits by adults with diabetes in the U.S. increased by 54% from 2012 to 2021 and represent a significant portion of global ED visits. Concurrently, 62% of U.S. adults report lifetime alcohol consumption. This study aimed to correlate AUDIT-C scores to changes in glucose and HbA1c levels in patients with DM2. Previous research has produced mixed results on whether light-to-moderate alcohol use improves or worsens glycemic control. Using a large urban ED dataset, this study seeks to better define this relationship and guide interventions for alcohol use in patients with DM2.

METHODS

Data from Long Island Jewish ED (January 2022-October 2023) was analyzed. Patients were included based on an HbA1c ≥ 6.5 or a secondary discharge diagnosis of DM2. AUDIT-C scores were treated as a categorical variable, as no dose-dependent relationship was observed. Statistical analysis was conducted using SPSS 26.

RESULTS

Non-zero AUDIT-C scores were significantly associated with increases in POCT-Blood Glucose, estimated average glucose, and HbA1c. A linear regression model showed an R-value of 0.047 (p < 0.001) for POCT-Blood Glucose in patients with HbA1c ≥ 6.5. Patients with an AUDIT-C score ≥ 1 had higher mean POCT-Blood Glucose (249.72 vs. 226.48, t = 4.240, p < 0.001). Estimated average glucose showed an R-value of 0.045 (p < 0.001), with a mean difference of 11.872 (t = 4.155, p < 0.001). For HbA1c, the R-value was 0.036 (p = 0.004), with higher levels in patients with AUDIT-C ≥ 1 (8.265 vs. 7.904, t = 2.844, p = 0.005). The effects were more pronounced in African-American and Asian-American populations.

CONCLUSION

Alcohol use, even at moderate levels (AUDIT-C = 1), was associated with higher glucose and HbA1c levels in patients with DM2, particularly among African-American and Asian-American populations. These findings suggest the need for substance use interventions at lower AUDIT-C thresholds and further considerations to mitigate future risk in this population.

Association Between Patient Race/Ethnicity, Health Literacy, Socio-Economic Status, and Incidence of Medication Errors: A Systematic Review

INTRODUCTION

Medication errors represent a significant source of healthcare-related harm, leading to mortality, morbidity, and substantial costs to health systems. Existing evidence highlights dissatisfaction and perceived discrimination experienced by patients from minority ethnic and disadvantaged backgrounds within healthcare settings.

OBJECTIVE

The study aimed to systematically review the literature on associations between patient race/ethnicity, socio-economic status, health literacy, and the incidence or patient experience of medication errors in healthcare and community (home) settings.

METHODS

A systematic review was conducted by searching an electronic database including EMBASE, MEDLINE, and PsycINFO. Studies published in English from January 2010 to October 2023, which explored the association between ethnicity, social disadvantage, and medication errors, were included.

RESULTS

Thirteen studies met the inclusion criteria from an initial identification of 2075 titles. Findings indicated that minority ethnic patients were more susceptible to prescription errors, undertreatment, administration errors, and suboptimal medication monitoring and follow-up by healthcare providers. Patients with low health literacy and limited English proficiency were also significantly likely to experience comprehension errors and medication discrepancies. Furthermore, ethnicity and social disadvantages were also associated with an increased risk of overdosing in pediatric medication administration, particularly among parents using dosing cups.

CONCLUSION

Minority ethnic background, low socio-economic status, and low health literacy can risk a higher likelihood of patients experiencing medication errors. Increasing awareness of these disparities among healthcare staff is essential for developing targeted interventions to mitigate inequalities in patient experiences and care outcomes in relation to medication use and safety. Future research should investigate the importance of intersectionality, such as multiple social disadvantages in this context.

Racial Differences in Adoption and Outcomes of Transcarotid Artery Revascularization among High-Risk Adults with Carotid Artery Stenosis

BACKGROUND

Differential access to new technologies may contribute to racial disparities in surgical outcomes but has not been well-studied in the treatment of carotid artery stenosis. We examined race-based differences in adoption and outcomes of transcarotid artery revascularization (TCAR) among high-risk non-Hispanic (NH) Black and NH white adults undergoing carotid revascularization.

METHODS

We conducted a retrospective analysis of TCAR, transfemoral carotid artery stenting (TF-CAS), and carotid endarterectomy (CEA) procedures performed for carotid artery stenosis from January 2015 to July 2023 in the Vascular Quality Initiative. NH Black and NH white adults were included if they met Centers for Medicare & Medicaid Services high-risk criteria. Hospitals and physicians were categorized as TCAR-capable if they had previously performed at least one TCAR prior to the time of a given procedure. We fit logistic and linear regressions, adjusted a priori for common demographic, clinical, and disease characteristics, to estimate associations of race with receipt of TCAR (versus CEA or TF-CAS), and to explore associations between race, hospital and physician characteristics, and perioperative composite stroke/death/myocardial infarction.

RESULTS

Of 159,471 high-risk patients undergoing revascularization for carotid artery stenosis (mean age 72 years, 38.5% female, 5.3% NH Black), 28,722 (18.0%) received TCAR, including 16.9% of NH Black adults and 18.1% of NH white adults (P < 0.001). After controlling for patient and disease characteristics, NH Black patients were less likely than NH white patients to receive TCAR (aOR 0.92, 95% CI 0.87-0.99). The use of TCAR did not vary by race among patients treated at TCAR-capable hospitals (aOR 0.98, 95% CI 0.91-1.05) or by TCAR-capable physicians (aOR 1.01, 95% CI 0.93-1.10); however, NH Black race was associated with lower odds of receiving treatment in these settings (TCAR-capable hospital: aOR 0.93 [0.88-0.98]; TCAR-capable physician: aOR 0.92 [0.87-0.98]). NH Black race was associated with higher odds of stroke/death/MI in the full cohort (aOR 1.18, 95% CI 1.03-1.36), but not in the subgroup of patients who received TCAR (aOR 0.87, 95% CI 0.56-1.34).

CONCLUSIONS

TCAR attenuated racial disparities in perioperative morbidity and mortality associated with carotid revascularization, but NH Black adults were less likely than NH white adults to receive TCAR. Relatively worse access for NH Black adults to technologically-advanced treatment settings may partially explain the broader persistence of race-based differences in carotid revascularization treatment patterns and outcomes.

Diabetes disparities in diabetes health care access and outcomes during the COVID-19 pandemic in the United States

OBJECTIVES

To investigate the impact of COVID-19 on hospitalization and consequent diabetes-related complications in patients with type 2 diabetes mellitus (diabetes).

METHODS

We conducted a retrospective cohort study of patients with diabetes. Interrupted time series analysis (ITS) was used to analyze the monthly trends in diabetes-related hospitalization rates, including short- and long-term complications, 1-year before and after onset of COVID-19.

RESULTS

Persons with diabetes experienced a significant (p < 0.001) rapid drop in monthly hospital admission rates at onset of COVID-19, then rose significantly (p = 0.003) to higher than pre-COVID-19 levels. Older age, lower education, and income levels were associated with higher base-level monthly hospital admission rates and a greater rate reduction at COVID-19 onset. ITS analysis showed monthly hospital admission rates from short-term complications surged to higher level 6 months after COVID-19 onset. Hospital admissions due to long-term complications decreased immediately post-COVID-19, but rose significantly (p < 0.001) to higher than pre-COVID levels, with patients experiencing higher nephropathy, angiography, and dermatological complications post-COVID-19.

CONCLUSION

COVID-19 had a negative impact on diabetes-related hospitalization access, resulting in increased short- and long-term complications. Long-term effects of deferred care due to COVID-19 on diabetes-related complications may persist, emphasizing the need for continued education toward improved diabetes self-management.

Glucagon-like peptide 1 receptor agonists and cancer risk: advancing precision medicine through mechanistic understanding and clinical evidence

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have emerged as a primary first-line treatment for type 2 diabetes. This has raised concerns about their impact on cancer risk, spurring extensive research. This review systematically examines the varied effects of GLP-1RAs on the risk of different types of tumors, including overall cancer risk and specific cancers such as thyroid, pancreatic, reproductive system, liver, and colorectal cancers. The potential biological mechanisms underlying their influence on cancer risk are complex, involving metabolic regulation, direct antitumor effects, immune modulation, and epigenetic changes. A systematic comparison with other antidiabetic agents reveals notable differences in their influence on cancer risk across drug classes. Additionally, critical factors that shape the relationship between GLP-1RAs and cancer risk are thoroughly analyzed, including patient demographics, comorbidities, treatment regimens, and lifestyle factors, offering essential insights for developing individualized treatment protocols. Despite significant research progress, critical gaps remain. Future research should prioritize elucidating the molecular mechanisms behind the antitumor effects, refining individualized treatment strategies, investigating early tumor prevention applications, assessing potential benefits for non-diabetic populations, advancing the development of novel therapies, establishing robust safety monitoring frameworks, and building precision medicine decision-making platforms. These efforts aim to establish novel roles for GLP-1RAs in cancer prevention. and treatment, thereby advancing the progress of precision medicine.

From inequalities to solutions: an explanatory sequential study on type 2 diabetes health services utilization

BACKGROUND

Health inequities are a significant issue. This study aimed to measure and decompose socioeconomic inequality in the utilization of type 2 diabetes (T2D) services and propose solutions to mitigate these inequalities.

METHODS

This explanatory sequential mixed-method study was conducted in two phases: quantitative and qualitative. A total of 2000 T2D patients from health centers, hospitals, and diabetes clinics in Isfahan and Khuzestan provinces, Iran, were selected. In the quantitative phase, the existence of inequality in the utilization of T2D services was examined using the Concentration Index (CI) approach. To determine the contribution of each explanatory variable to T2D inequality, we used concentration index decomposition analysis. In the qualitative phase, based on the main contributors identified in the quantitative phase, we conducted semi-structured interviews with purposefully selected key experts to identify solutions for reducing inequality in the utilization of T2D services.

RESULTS

The sample consisted of 65.3% men, with 40% of T2D patients being over 60 years old. The CI values were 0.31 (p < 0.05) for outpatient services, -0.10 (p > 0.05) for inpatient services, and 0.11 (p < 0.05) for pharmaceutical services. This indicates an inequality in the utilization of outpatient and pharmaceutical services among T2D patients, while the inequality in inpatient services was not significant. The main variables contributing to inequality in outpatient services were health status (33.54%), basic insurance (27.43%), and socioeconomic status (24.08%). For pharmaceutical services, the contributing variables were health status (22.20%), basic insurance (13.63%), and socioeconomic status (34.35%). Experts' solutions to reduce socioeconomic inequalities in Iran were classified into three main themes: socioeconomic status, health status, and basic insurance, with 29 sub-themes.

CONCLUSION

The results suggest that targeted health interventions for poor T2D patients are recommended. Efforts towards universal coverage in outpatient care and commonly used pharmaceutical items, such as: Antidiabetic Drugs, Triglyceride Control Drugs, Cardiovascular Drugs, Neuropathy Drugs, and Nephropathy Drugs, should be considered.

Racial disparities in acute care utilization among individuals with myasthenia gravis

Objective

In myasthenia gravis (MG), evidence on the impact of social determinants of health on disparities in disease burden and healthcare resource utilization is limited. This study aimed to investigate the independent association between race/ethnicity and acute care utilization during the 2 years post-diagnosis among patients with MG.

Methods

A retrospective cohort study was conducted among adults (≥18 years) with newly diagnosed MG in the United States using Optum's de-identified Market Clarity Data from January 1, 2010, to December 31, 2019. Multivariable regression models were used to assess the association between acute care utilization and race/ethnicity, insurance, exacerbation at index, and other covariates.

Results

A total of 7,058 patients met the study inclusion criteria, of whom 57% (n = 4,052) identified as Caucasian, 6% (n = 445) African American, 3% (n = 235) Hispanic, 1% (n = 94) Asian, and 32% (n = 2,232) with missing race/ethnicity information. Compared with patients identifying as Caucasian, those identifying as African American had 37% higher odds of having an emergency department visit in year 1, and those identifying as Hispanic had 70% increase in odds of having a hospitalization event in year 2 post-diagnosis. Among other covariates, Medicaid usage, exacerbation at index, and number of outpatient visits were significantly associated with acute care utilization.

Conclusion

Racial disparities significantly impacted acute care utilization in the first 2 years post-MG diagnosis. Future studies should aim to examine specific factors that may contribute to disparities such as barriers to healthcare access, greater severity of MG symptoms, and poorly controlled disease.

Who's really footing the bill? Sex and ethnicity disparities in the cost of diabetic foot ulcer-related amputations in a major healthcare system

Diabetic foot ulcers (DFU)-related amputations are associated with enormous expenditures. Understanding why amputation services are more expensive for certain patients is crucial for reforming healthcare expenditure and insurance practices. This analysis examined differences in cost of DFU-related amputations services in patients insured by HealthFirst, a Medicaid-managed insurance company. Data from HealthFirst were collected for patients admitted for DFU-related amputation between 2021 and 2023. Demographics and laboratory values were extracted from the electronic health record. Demographics, laboratory values, total costs, and paid amounts were analyzed. Clinical variables were tested as predictors of expenditure levels through bivariate analysis. In our cohort of 140 patients, 65.3 % of patients were male, with a mean age of 60.6 (S.D. 12) years, diagnosis of type 2 diabetes (96.3 %) and ethnically Hispanic-Latino (56.1 %). Common comorbidities were chronic kidney disease (57.9 %) and hypertension (86.2 %). DFU- related amputation charges were higher for Hispanic-Latino individuals, RR 1.97 (CI 1.04, 3.71), and those with chronic kidney disease, RR 1.36 (CI 1.0, 1.86) and moderately associated with female sex. Serum glucose, RR 1 (1.0 -1.0), body mass index, RR 0.98 (0.96-1.0), and Hemoglobin A1c, RR 1.01 (CI 0.93-1.09) were not found to be associated with higher cost. Overall, Hispanic-Latino individuals, persons with chronic kidney disease, and women incurred higher DFU related charges, highlighting the need for heightened DFU prevention in these populations. LEVEL OF CLINICAL EVIDENCE: Retrospective cohort study= 2 or 3.

COVID-19 Prevention and Mitigation Decision-Making Processes While Navigating Chronic Disease Care: Perspectives of Black Adults with Heart Failure and Diabetes

BACKGROUND

Heart failure and diabetes are comorbidities that disproportionately contribute to high morbidity and mortality among Blacks. Further compounding the racial and ethnic disparities in COVID-19 health outcomes, Blacks with cardiometabolic diseases are at high risk of experiencing serious complications or mortality from COVID-19. This study aimed to assess how Blacks with heart failure and diabetes navigated chronic care management during the COVID-19 pandemic.

METHODS

A mixed methods study including in-depth interviews and surveys with adults diagnosed with heart failure and diabetes (n = 17) was conducted in 2021-2022. Verbatim transcripts were analyzed using a thematic analysis approach.

RESULTS

Participants reported that while the pandemic initially caused delays in access to health services, shifts to telemedicine allowed for continued care despite preferences for in-person appointments. Various sources of information were used in different ways to make decisions on how to best reduce health risks due to COVID-19, but individuals and institutions affiliated with science and medicine, or who promoted information from these sources, were considered to be the most trusted sources of information among those who relied on outside guidance when making health-related decisions. Individuals' self-awareness of their own high-risk status and perceived control over their exposure levels to the virus informed what COVID-19 prevention and mitigation strategies people used.

CONCLUSION

Information backed by scientific data was an important health communication tool that alongside other factors, such as fear of mortality due to COVID-19, encouraged individuals to get vaccinated and adopt other COVID-19 prevention and mitigation behaviors.

A network analysis to explore illness perceptions in Black adults with type 2 diabetes

OBJECTIVES

This study explores the structure of beliefs about type 2 diabetes among Black adults and informs potential targets to reframe negative beliefs and enhance diabetes self-management.

RESEARCH DESIGN AND METHODS

We applied network analysis to investigate the interrelated structure and clusters of beliefs about diabetes and identify specific items that could serve as behavioural targets. We obtained self-reported survey data from 170 Black adults with type 2 diabetes. Regularised partial correlation networks and a Gaussian graphical model were used to explore and visualise the interrelationship among 21 items of a culturally adapted Illness Perception Questionnaire-Revised.

RESULTS

Overwhelming negative emotions representing the current and long-term effects of diabetes were central to the illness perceptions network among Black adults, with feeling depressed having the highest node strength of centrality indices in the network. Four beliefs had a bridging effect with the central cluster: diabetes taking away the ability to enjoy food, diabetes keeping me away from the job I want, being poor contributed to my having diabetes, and I receive encouragement from friends and family.

CONCLUSIONS

In addition to highlighting the overwhelming feeling of diabetes, the illness perception network further differentiated the role of racial identity and social determinants of health as discrete, though both are related sociocultural influence constructs. To enhance self-management for Black adults with type 2 diabetes, this network informs promising intervention targets focused on culturally tailored education related to emotional regulation, internalised stigma and healthy food adaptation, and leveraging support to address social determinants of health.

Investigation of geographic disparities and temporal changes of non-gestational diabetes-related emergency department visits in Florida: a retrospective ecological study

Background

Rates of diabetes-related Emergency Department (ED) visits in Florida increased by 54% between 2011 and 2016. However, little information is available on geographic disparities of ED visit rates and how these disparities changed over time in Florida and yet this information is important for guiding resource allocation for diabetes control programs. Therefore, the objectives of this study were to (a) investigate geographic disparities and temporal changes in non-gestational diabetes-related ED visit rates in Florida and (b) identify predictors of geographic disparities in non-gestational diabetes-related ED visit rates.

Methods

The ED data for the period between 2016 and 2019 were obtained from the Florida Agency for Healthcare Administration. Records of non-gestational diabetes-related ED visits were extracted using the International Classification of Diseases (ICD)-10 codes. Monthly non-gestational diabetes-related ED visit rates were computed and temporal changes were investigated using the Cochran-Armitage trend test. County-level non-gestational diabetes-related ED visit rates per 100,000 person-years were calculated and their geographic distributions were visualized using choropleth maps. Clusters of counties with high non-gestational diabetes-related ED visit rates were identified using Kulldorff's circular and Tango's flexible spatial scan statistics. Predictors of non-gestational diabetes-related ED visit rates were investigated using negative binomial model. The geographic distributions of significant (p ≤ 0.05) high-rate clusters and predictors of ED visit rates were displayed on maps.

Results

There was a significant (p < 0.001) increase in non-gestational diabetes-related ED visit rates from 266 visits per 100,000 person-months in January 2016 to 332 visits per 100,000 person-months in December 2019. Clusters of high non-gestational diabetes-related ED visit rates were identified in the northern and south-central parts of Florida. Counties with high percentages of non-Hispanic Black, current smokers, uninsured, and populations with diabetes had significantly higher non-gestational diabetes-related ED visit rates, while counties with high percentages of married populations had significantly lower ED visit rates.

Conclusions

The study findings confirm geographic disparities of non-gestational diabetes-related ED visit rates in Florida with high-rate areas observed in the rural northern and south-central parts of the state. Specific attention is required to address disparities in counties with high diabetes prevalence, high percentages of non-Hispanic Black, and uninsured populations. These findings are useful for guiding public health efforts geared at reducing disparities and improving diabetes outcomes in Florida.

Technology usage and glycaemic outcomes in a single tertiary centre with an ethnically diverse and socioeconomically deprived cohort of children with type 1 diabetes mellitus

Background

The UK National Paediatric Diabetes Audit (NPDA) data reports disparities in Haemoglobin A1c (HbA1c) levels among children and young people (CYP) with Type 1 Diabetes (T1D), with higher levels in those of Black ethnic background and lower socioeconomic status who have less access to technology. We investigate HbA1c differences in a T1D cohort with higher than national average technology uptake where > 60% come from an ethnic minority and/or socioeconomically deprived population.

Design & methods

Retrospective cross-sectional study investigating the influence of demographic factors, technology use, and socioeconomic status (SES) on glycaemic outcomes. The study population was 222 CYP with T1D who attended the diabetes clinic in 2022 at a single tertiary paediatric diabetes centre.

Results

Among 222 CYP, 60% were of ethnic minority (Asian, Black, Mixed and Other were 32%, 12%, 6% and 10% respectively) and 40% of white heritage. 94% used Continuous Glucose Monitoring (CGM) and 60% used Continuous Subcutaneous Insulin Infusion (CSII) via open or closed loop. 6% used Self-Monitoring of Blood Glucose (SMBG) and Multiple Daily Injections (MDI), 34% used CGM and MDI, 38% used CGM and CSII and 22% used Hybrid Closed-Loop (HCL) systems. Significant differences in HbA1c across therapy groups (p < 0.001) was noted with lowest HbA1c in HCL group (55 mmol/mol; p <0.001). Despite adjusting for therapy type, the Black group had higher HbA1c than their white and Asian counterparts (p<0.001). CYP from the most deprived tertile had significantly higher HbA1c levels (p < 0.001) but the difference was not sustained after adjusting for therapy type.

Conclusion

Advanced diabetes technologies improve glycaemic control. Whilst equalising technology access mitigates socioeconomic disparities in HbA1c, CYP from Black ethnic background continue to display a higher HbA1c. The study underscores the necessity of fair technology distribution and further research into elevated HbA1c levels among Black CYP using advanced diabetes technology.

"Life with Diabetes": A Pilot Study on an Experiential Continuous Glucose Monitoring Curriculum for Resident Physicians

BACKGROUND

The use of technology in diabetes mellitus (DM) management has been growing. The indications and coverage for continuous glucose monitoring (CGM) have increased. Primary care (PC) clinics, including resident continuity clinics, are the frontline for DM management; however, they struggle to adopt CGM.

AIM

To implement a CGM curriculum to resident physicians to improve knowledge and confidence.

SETTING

An internal medicine (IM) resident PC clinic in an urban academic medical institution.

PARTICIPANTS

Twenty-four IM residents.

DESCRIPTION

We designed a curriculum that included a lecture about CGM indications, interpretation, ordering, and insurance consideration; and a voluntary, experiential learning module in which the residents wore a CGM.

EVALUATION

We conducted a retrospective pre-post survey with a 4-point Likert scale. Average self-reported scores in knowledge increased for CGM (1) indications from 1.85 to 3.45, (2) ordering from 1.35 to 3.05, (3) functioning from 2.20 to 3.50, and (4) data interpretation from 1.85 to 3.25 (all p < 0.0001). Confidence for "describing CGM monitoring" and "fielding questions about CGM" increased from 2.25 to 3.65 (p < 0.0001) and 1.90 to 3.30 (p < 0.0001).

DISCUSSION

Given the demand for DM management in the PC setting, this targeted CGM curriculum has promise to help residents adopt CGM into their practice.

Predictors of anterior chamber angle status at the time of neovascular glaucoma diagnosis

Purpose

To identify clinical features which may predict the angle status of a large cohort of NVG eyes at the time of diagnosis.

Observations

Chart review was performed for all NVG eyes from 2010 to 2022. Complete angle closure was defined as having >75 % PAS, partial angle closure as having 1-75 % PAS, and open angles as having 0 % PAS. Among 190 eyes (174 patients) with a diagnosis of NVG, 29 eyes (28 patients) had a prior NVG diagnosis and 32 eyes (31 patients) did not undergo gonioscopy; 129 eyes (115 patients, mean 65.5 years, 50 % women) had a gonioscopy documented at the time of diagnosis. There were 32 eyes (25 %) with open angles, 39 eyes (30 %) with partially closed angles, and 58 eyes (45 %) with completely closed angles. Mean BCVAs were 20/138 (logMar 0.84, CI = 0.78-0.90), 20/662 (logMar 1.52, CI = 1.41-1.62), and 20/4375 (logMar 2.34, CI = 2.17-2.51), respectively (p < 0.05). The mean presenting IOP was 31 mmHg, 40 mmHg, and 59 mmHg, and the proportion of eyes that were phakic were 47 %, 46 %, and 67 %, respectively. The proportion of eyes presenting to the emergency room were 6 %, 21 %, and 26 %, respectively.

Conclusions and importance

Among NVG eyes with a documented initial gonioscopy, nearly half had total synechial closure. While eyes with increasing degrees of angle closure trended towards worse vision and higher IOP, these clinical characteristics are not perfectly predictive of angle anatomy and should not replace gonioscopy. Eyes with closed angles trended towards being phakic, presenting to the emergency department (ED), having undergone prior panretinal photocoagulation (PRP), and belonging to new patients.

Decomposing rural-urban differences in depression prevalence: a cross-sectional analysis of two community-based southern Indian cohorts

Introduction

Depression is a growing public health concern in India but its prevalence is uneven across the country, possibly influenced by several sociodemographic factors. We aimed to assess the rural-urban disparity in the prevalence of depression and their associated sociodemographic and lifestyle-related factors.

Methods

Participants were middle-aged and older adults (≥45 years) from two parallel, prospective cohorts from rural (CBR-SANSCOG, n=4493) and urban (CBR-TLSA, n=972) southern India. We used cross-sectional data from the baseline clinical and biochemical assessments of the above two cohorts. The Geriatric Depression Scale (GDS-30) was used to screen for depression (cut-off ≥10). Logistic regression was used to assess the relationship between place of residence (rural vs urban) and prevalence of depression, adjusting for age, sex, education, income, marital status, Body Mass Index (BMI), alcohol use, tobacco use and number of comorbidities. The Fairlie decomposition analysis was used to decompose the rural-urban disparity.

Results

We found that the prevalence of depression was significantly higher in rural than in urban participants (14.49% vs 8.23%, p<0.001). The fully adjusted binary logistic regression model showed that rural-dwelling individuals were 1.57 times more likely to have depression than urban residents (AOR: 1.57, 95% CI: 1.03, 2.39). In the decomposition analysis, the variables included in this model (age, sex, education, income, marital status, BMI, alcohol use, tobacco use and number of comorbidities) explained 35.21% of the rural-urban disparity in the prevalence of depression, with sex and marital status being the significant contributors.

Conclusion

Participants in our rural cohort had significantly higher odds for depression as compared to their urban counterparts, with sociodemographic factors playing a key role in this disparity. This underscores the need for scaling up mental health services in the rural communities of India including training primary healthcare providers to promptly identify and manage depression.

Exploring Type 2 Diabetes Self-Management Practices Among African Americans in Rural Counties: A Qualitative Study

PURPOSE

The purpose of the study was to understand diabetes self-management practices among African American individuals living with type 2 diabetes (T2D) in rural communities.

METHODS

This qualitative descriptive study, undergirded by the theory of integration, purposively sampled African Americans (N = 34) diagnosed with T2D living in rural communities. Thematic analysis employed both a priori and inductive coding to identify salient themes.

RESULTS

Participants' mean age was 65.9 (SD 12.3) years, with an average T2D diagnosis duration of 14 (SE 11.2) years. Two major themes emerged: deciphering the cues and body sensing, which the participants used to monitor their glucose level using a personalized feedback loop. Those with longer diabetes duration demonstrated an ability to recognize hypoglycemic or hyperglycemic symptoms (deciphering the cues), informing their decision-making and self-management strategies (body sensing).

CONCLUSIONS

The decision-making involved in glycemic level management emerges as a complex developmental process influenced by disease trajectory and cultural and environmental factors. These findings may inform a conceptual framework to guide future inquiries and provide insights for primary care clinicians and diabetes care and education specialists to better understand the complexities of T2D management among African American individuals in rural settings.

Type 2 diabetes complications in ethnic minority compared with European host populations: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to quantify differences in type 2 diabetes (T2D) complications between ethnic minority populations and European host populations, in both cross-sectional and prospective studies. Following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, we searched multiple databases for studies (until July 1, 2024) with T2D complications as outcome. Studies were included if they compared ethnic minority populations to the host population and were conducted in Europe. T2D complications included mortality, macrovascular and microvascular complications and mental disorders. Risk of bias was assessed with the assessment tool for observational cohort and cross-sectional studies. Risk estimates were pooled using random effects models. From a total of 2901 references, 58 studies were included, comprising 805 to 1 230 410 individuals for the meta-analyzed complications. Compared with the host population, ethnic minority populations generally had a lower risk of all-cause mortality (RR 0.70 (95% CI 0.63; 0.77); I2=87%)) and macrovascular complications (RR 0.72 (95% CI 0.58; 0.88); I2=88%). South Asians, however, showed comparable risks for most macrovascular complications and a slighthly higher risk of major adverse cardiovascular events. Increased risks for microvascular complications, nephropathy and retinopathy were observed (eg, in prospective studies RR 1.50 (95% CI 1.14; 1.96); I2=86% for nephropathy). No ethnic differences were observed for mental disorders. Ethnic minority populations with T2D in Europe are generally at reduced risk of all-cause mortality and macrovascular complications, but at higher risk of nephropathy and retinopathy. Our findings may help to further identify high-risk populations and to develop guidelines and future interventions. PROSPERO registration number:PROSPERO 2022 CRD42022366854.

Health Disparities Across the Spectrum of Amputation Care: A Review of Literature

Limb loss is a common and disabling experience for patients, frequently caused by critical limb ischemia or deterioration of chronic wounds. Disparities in outcomes for prevention of amputation, level of amputation, and postamputation outcomes have been described. Understanding the nature of these disparities and the populations most affected can help clinicians and policymakers target interventions and programs. This article reviews existing literature regarding disparities in amputation care, including prevention methods, surgical outcomes, and postamputation outcomes. The authors identified several potential racial, socioeconomic, and gender disparities, particularly affecting Black, Native American, and Latino/a/x patients, female gender, and those in rural settings.

Inequities in Access to Tricuspid Valve Treatments: The Impact of Procedure and Volume Requirements

Background

Opportunities to minimize inequities in accessing treatments for tricuspid regurgitation disease should be considered.

Objective

The objective of this study was to explore how access to new tricuspid regurgitation technologies change when heart centers are restricted by payer coverage requirements.

Methods

This case series study identified U.S. hospitals with a record of performing transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and tricuspid and mitral valve procedures for the calendar year 2021. Population 65+ years of age and Area Deprivation Index (ADI), were identified by zip code. We created 10 scenarios based on low, medium, and high hospital volumes for combinations of transcatheter aortic valve replacement, transcatheter edge-to-edge repair, tricuspid and mitral valve procedures. Distance from a zip code to scenario eligible hospitals was determined; the closest hospital to a zip code was identified as the distance someone with tricuspid regurgitation would have to travel for care. Each scenario was modeled with the dependent variable as the distance to the nearest scenario eligible hospital by ADI, controlling for population size 65+ years of age.

Results

A total of 929 U.S. hospitals met our study inclusion. ADI was statistically significant in every scenario-when ADI goes up (more deprivation), distance to the nearest hospital increases. Patients in zip codes with low ADI travel an average of 15 to 52 miles, medium ADI 31 to 67 miles, and high ADI 47 to 95 miles.

Conclusions

Patients in higher socioeconomic deprivation areas travel longer distances to hospitals meeting procedure volume requirements. Policymakers and patient advocacy groups should consider this to ensure equitable access to potentially life-saving technologies.

Racial and ethnic disparities in the natural history of alcohol-associated liver disease in the United States

BACKGROUND

Outcomes in alcohol-associated liver disease (ALD) are influenced by several race and ethnic factors, yet its natural history across the continuum of patients in different stages of the disease is unknown.

METHODS

We conducted a retrospective cohort study of U.S. adults from 2011 to 2018, using three nationally representative databases to examine potential disparities in relevant outcomes among racial and ethnic groups. Our analysis included logistic and linear regressions, along with competing risk analysis.

RESULTS

Black individuals had the highest daily alcohol consumption (12.6 g/day) while Hispanic participants had the largest prevalence of heavy episodic drinking (33.5%). In a multivariable-adjusted model, Hispanic and Asian participants were independently associated with a higher ALD prevalence compared to Non-Hispanic White interviewees (OR: 1.4, 95% CI: 1.1-1.8 and OR: 1.5 95% CI:1.1-2.0, respectively), while Blacks participants had a lower ALD prevalence (OR: .7 95% CI: .6-.9), and a lower risk of mortality during hospitalization due to ALD (OR: .83 95% CI: .73-.94). Finally, a multivariate competing-risk analysis showed that Hispanic ethnicity had a decreased probability of liver transplantation if waitlisted for ALD (SHR: .7, 95% CI: .6-.8) along with female Asian population (HR: .40, 95% CI: .26-.62).

CONCLUSIONS

After accounting for key social and biological health determinants, the Hispanic population showed an increased risk of ALD prevalence, even with lower alcohol consumption. Additionally, Hispanic and Asian female patients had reduced access to liver transplantation compared to other enlisted patients.

Impact of continuous glucose monitoring on emergency department visits and all-cause hospitalization rates among Medicaid beneficiaries with type 2 diabetes treated with multiple daily insulin or basal insulin therapy

BACKGROUND

The increasing prevalence of diabetes in the United States continues to drive a steady rise in health care resource utilization, especially emergency department visits and all-cause hospitalizations, and the associated costs.

OBJECTIVE

To investigate the impact of continuous glucose monitoring (CGM) on emergency department visits and all-cause hospitalizations among Medicaid beneficiaries with type 2 diabetes (T2D) treated with multiple daily insulin injections (MDIs) or basal insulin therapy (BIT) in a real-world setting.

METHODS

In this retrospective, 12-month analysis, we used the Inovalon Insights claims dataset to evaluate the effects of CGM acquisition on emergency department visits and all-cause hospitalizations in the Managed Medicaid population. The analysis included 44,941 beneficiaries with T2D who were treated with MDIs (n = 35,367) or BIT (n = 9,574). Primary outcomes were changes in the number of emergency department visits and all-cause hospitalizations following 6 months after acquisition of CGM (post-index period) compared with 6 month prior to CGM acquisition (pre-index period). The first claim for CGM was the index date. Inclusion criteria were as follows: aged younger than 65 years, diagnosis of T2D, claims for short- or rapid-acting insulin (MDI group) or basal insulin (not rapid-acting) (BIT group), acquisition of a CGM device between January 1, 2017, and September 30, 2022, and continuous enrollment in their health plan throughout the pre-index and post-index periods.

RESULTS

In the MDI group, all-cause inpatient hospitalization rates decreased from 3.25 to 2.29 events/patient-year (hazard ratio = 0.12; 95% CI = 0.11-0.13; P < 0.001) and emergency department visit rates decreased from 2.15 to 1.86 events/patient-year (hazard ratio = 0.52; 95% CI = 0.50-0.53; P < 0.001). In the BIT group, all-cause inpatient hospitalization rates decreased from 1.63 to 1.39 events/patient-year (hazard ratio = 0.11; 95% CI = 0.09-0.12; P < 0.001) and emergency department visit rates decreased from 1.60 to 1.43 events/patient-year (hazard ratio = 0.47; 95% CI = 0.44-0.50; P < 0.001).

CONCLUSIONS

Acquisition of CGM is associated with significant reductions in emergency department visits and all-cause hospitalizations among people with T2D treated with MDIs or BIT.

Racial Disparities in Foot Examination among People with Diabetes in Brazil: A Nationwide Survey, 2019

Objective

To assess the absence of diabetic foot examination in Brazil and how ethnicity affected this outcome.

Design

This is an analysis of a nationwide survey held in Brazil in 2019. Participants with diabetes and that were 15 years of age or older were eligible for inclusion in the analysis. Adjusted Poisson regression with robust variance was used to calculate prevalence ratios (PRs) and 95% confidence intervals (95% CIs) of never having had the foot examined, with separate models according to ethnicity. Stata 14.2 was used for all calculations.

Results

We included 6216 individuals with diabetes; 52.1% (95%CI: 50.0%-54.2%) reported never having had their feet examined by a health care professional and 61% self-declared as Black (Black and Brown [Brazilian mixed race]). A higher frequency of negligence was observed among Black individuals (55.3%; 52.5%-58.1%) than among White individuals (48.2%; 45.0%-51.5%). Negligence was higher between 15- to 39-year-old participants (PR = 1.34, 1.14-1.57), lower educational level (PR = 1.37, 1.13-1.65), higher alcohol consumption (PR = 1.18, 1.06-1.31), fair health status (PR = 1.11, 1.01-1.21), and diabetes diagnosis of up to 10 years (PR = 1.42, 1.28-1.57). Among Blacks, tobacco use and other factors increased the frequency of the outcome, whereas participation in the Brazilian Unified Health System primary care program was a protection factor (P<.05).

Conclusion

Black Brazilians with diabetes had higher negligence of foot examination by health care professionals. Strengthening primary care would help mitigate systemic racism in Brazil.

Chronic Work Discrimination, Allostatic Load, and HbA1c in Older Workers

BACKGROUND AND OBJECTIVE

Work discrimination is an important public health problem with consequences for health. This study examined the effect of chronic work discrimination on 4-year changes in HbA1c, as a reflection of glucose control and type 2 diabetes risk in older workers and assessed whether allostatic load (AL) affected the strength of this association.

RESEARCH DESIGN AND METHODS

We used Health and Retirement Study data (2010-2016, n = 3,246). Conditional change multinomial logistic regression examined the association between chronic work discrimination, high AL (4 or more out of 8 high-risk biomarkers), and HbA1c, while accounting for relevant covariates.

RESULTS

Black participants had the highest rates of baseline (22.7%) and follow-up (28%) HbA1c levels, AL (38%), and chronic work discrimination (39%; p < .01). Severe chronic work discrimination was associated with elevated HbA1c (relative risk ratio [RRR] = 1.61, 95% confidence interval [CI] = 1.07, 2.43). AL was associated with elevated HbA1c (RRR = 1.49, 95% CI = 1.04, 2.14). Relative to White participants, Hispanic (RRR = 1.52, 95% CI = 1.07, 2.16, RRR = 1.81, 95% CI = 1.051, 3.12), and Black (RRR = 2.42, 95% CI = 1.82, 3.23; RRR = 3.00, 95% CI = 1.97, 4.56) participants had an increased risk of intermediate and elevated HbA1c, respectively. Among those with long job tenure (≥5 years), both moderate (RRR = 1.81, 95% CI = 1.11, 2.96) and severe (RRR = 1.90, 95% CI = 1.15, 3.12) chronic work discrimination was associated with elevated HbA1c.

DISCUSSION AND IMPLICATIONS

Chronic work discrimination was associated with HbA1c; however, no moderating effects of AL were observed. Findings underscore a need for organizational and public health measures to establish strong anti-discrimination laws in the workplace to improve the work environment of older workers and reduce diabetes risk.

Race, Social Determinants of Health, and the Quality of Diabetic Eye Care

Importance

Besides race, little is known about how other social determinants of health (SDOH) affect quality of diabetic eye care.

Objective

To evaluate the association between multiple SDOH and monitoring for diabetic retinopathy (DR) in accordance with clinical practice guidelines (CPGs).

Design, Setting, and Participants

This cohort study was conducted in 11 US medical centers and included adult patients (18-75 years old) with diabetes. Patients received care from 2012 to 2023 and had 18 months or more of follow-up.

Exposures

Multiple SDOH and associated factors, including ethnicity, urbanicity of residence, health insurance type, and diabetes type.

Main Outcomes and Measures

Adjusted odds ratio (aOR) of receiving 1 or more eye-care visits and 1 or more dilated fundus examinations in accordance with CPGs.

Results

The study cohort included 37 397 adults with diabetes: 10 157 Black patients and 27 240 White patients. The mean (SD) age was 58 (11) years for Black patients and 59 (11) years for White patients. Of the Black patients, 6422 (63.2%) were female and 3735 (36.8%) male; of the White patients, 13 120 (48.1) were female and 14 120 (51.8) were male. Compared with those of the same race in urban communities, Black patients (aOR, 0.12; 95% CI, 0.04-0.31) and White patients (aOR, 0.75; 95% CI, 0.62-0.91) with diabetes living in rural communities had 88% and 25% lower odds of having eye-care visits, respectively. Sicker Black and White patients, defined by the Charlson Comorbidity Index, had 4% (aOR, 1.04; 95% CI, 1.02-1.06) and 5% (aOR, 1.05, CI 1.04-1.06) higher odds of having an eye-care visit, respectively. Black patients with preexisting DR had 15% lower odds of visits (aOR, 0.85, CI 0.73-0.99) compared with those without preexisting DR while White patients with preexisting DR had 16% higher odds of eye-care visits (aOR, 1.16; 95% CI, 1.05-1.28). White patients with Medicare (aOR, 0.85; 95% CI, 0.80-0.91) and Medicaid (aOR, 0.81; 95% CI, 0.68-0.96) had lower odds of eye-care visits vs patients with commercial health insurance. Hispanic White patients had 15% lower odds of eye-care visits (aOR, 0.85; 95% CI, 0.74-0.98) vs non-Hispanic White patients. White patients with type 1 diabetes had 17% lower odds of eye-care visits (aOR, 0.83; 95% CI, 0.76-0.90) vs those with type 2 diabetes. Among patients who had eye-care visits, those with preexisting DR (Black: aOR, 1.68; 95% CI, 1.11-2.53; White: aOR, 1.51; 95% CI, 1.16-1.96) were more likely to undergo dilated fundus examinations.

Conclusions and Relevance

This study found that certain SDOH affected monitoring for DR similarly for Black and White patients with diabetes while others affected them differently. Patients living in rural communities, Black patients with preexisting DR, and Hispanic White patients were not receiving eye care in accordance with CPGs, which may contribute to worse outcomes.

Disparities in Stage at Diagnosis among Hispanic Patients with Gastric Cancer in the United States

INTRODUCTION

Racial disparities in gastric cancer outcomes, including stage at diagnosis and overall survival, continue to affect Hispanic and non-Hispanic populations. This study aims to evaluate these disparities across different racial groups.

PATIENTS AND METHODS

We conducted a retrospective cohort study using SEER data from 2018 to 2021, including 18,984 patients diagnosed with gastric cancer. Patients were selected based on ICD-O-3 codes for "stomach" with malignant behavior. Using ordered logistic regression, the association between race and stage at diagnosis was analyzed, while Cox proportional hazards models were used to assess OS and CSS.

RESULTS

Hispanic patients were significantly more likely to be diagnosed at a later stage compared to non-Hispanic patients (OR: 1.19; 95% CI: 1.10-1.28). Both Hispanic and Black patients had worse OS compared to Non-Hispanic Whites (HR 1.10 CI 1.03-1.17, p = 0.003 and HR 1.13 CI 1.04-1.22, p = 0.002, respectively) as well as CSS.

CONCLUSIONS

Hispanic patients are more likely to be diagnosed with advanced-stage gastric cancer and have poorer survival outcomes compared to non-Hispanic Whites. These disparities may be linked to differences in healthcare access, insurance, language barriers, and preventive care utilization.

Racial and Ethnic Differences in Diabetes Care Quality in A National Sample of Cancer Survivors Relative to Non-Cancer Controls

BACKGROUND

Among cancer survivors, diabetes is associated with greater morbidity and mortality. The objective of this study is to describe racial/ethnic disparities in diabetes care quality (DCQ) among cancer survivors compared to non-cancer controls.

METHODS

We used Medical Expenditure Panel Survey Household Component data (2010-2018). Black, non-Hispanic White (NHW), and Hispanic respondents diagnosed with diabetes and cancer were frequency matched 1:5 to non-cancer controls. Multivariable logistic regression estimated associations for specific indices and overall DCQ by race/ethnicity stratified by cancer site/status in partially adjusted (not controlling for socioeconomic indicators) and fully adjusted models.

RESULTS

The final sample of 4775 included cancer survivors (n = 907 all cancers; n = 401 breast; n = 167 colon; n = 339 prostate) and non-cancer controls (n = 3868) matched by age, race/ethnicity, and year. In partially adjusted models, Black (adjusted odds ratio, AOR) 0.67 [95% CI 0.54-0.83]) and Hispanic (AOR 0.68 [95% CI 0.54-0.87]) non-cancer controls had significant disparities for overall DCQ compared to NHWs. Among cancer survivors, DCQ disparities for Black (AOR 0.62, [95% CI 0.4-0.96]) and Hispanics (AOR 0.60, [95% CI 0.38-0.97]) were identified. Among prostate cancer survivors, DCQ disparities were identified for Blacks (AOR 0.38; [95% CI 0.20-0.72]) and Hispanics (AOR 0.39; [95% CI 0.17-0.89]) compared to NHWs. Racial disparities among Black controls and Black prostate cancer survivors remained significant in fully adjusted models.

CONCLUSION

Diabetes care disparities are evident among cancer survivors and salient among non-cancer controls. Strategies to promote health equity should target specific care indices among survivors and emphasize equitable DCQ strategies among Black and Hispanic communities.

Patient Factors Associated with Missed Otolaryngology Appointments at an Urban Safety-Net Hospital

OBJECTIVE

To determine if patient factors related to ethnicity, socioeconomic status (SES), medical comorbidities, or appointment characteristics increase the risk of missing an initial adult otolaryngology appointment.

METHODS

This study is a retrospective case control study at Boston Medical Center (BMC) in Boston, Massachusetts, that took place in 2019. Patient demographic and medical comorbidity data as well as appointment characteristic data were collected and compared between those that attended their initial otolaryngology appointment versus those who missed their initial appointment. Chi-square and ANOVA tests were used to calculate differences between attendance outcomes. Multivariate analysis was used to compare the odds of missing an appointment based on various patient- and appointment-related factors.

RESULTS

Patients who were more likely to miss their appointments were more often female, of lower education, disabled, not employed, Black or Hispanic, and Spanish-speaking. Spring and Fall appointments were more likely to be missed. When a multivariate regression was conducted to control for social determinants of health (SDOH) such as race, insurance status, employment, and education status, the odds of females, Spanish-speaking, students, and disabled patients missing their appointment were no longer statistically significant.

CONCLUSION

A majority of patients at BMC come from lower SES backgrounds and have multiple medical comorbidities. Those who reside closer to BMC, often areas of lower average income, had higher rates of missed appointments. Interventions such as decreasing lag time, providing handicap-accessible free transportation, and increasing accessibility of telemedicine for patients could help improve attendance rates at BMC.

LEVEL OF EVIDENCE

IV Laryngoscope, 134:4003-4010, 2024.

Ethnic disparities in quality of diabetes care in Scotland: A national cohort study

AIMS

The aim of this study is to compare quality of diabetes care in people with type 2 diabetes by ethnicity, in Scotland.

METHODS

Using a linked national diabetes registry, we included 162,122 people newly diagnosed with type 2 diabetes between 2009 and 2018. We compared receipt of nine guideline indicated processes of care in the first-year post-diabetes diagnosis using logistic regression, comparing eight ethnicity groups to the White group. We compared annual receipt of HbA1c and eye screening during the entire follow-up using generalised linear mixed effects. All analyses adjusted for confounders.

RESULTS

Receipt of diabetes care was lower in other ethnic groups compared to White people in the first-year post-diagnosis. Differences were most pronounced for people in the: African, Caribbean or Black; Indian; and other ethnicity groups for almost all processes of care. For example, compared to White people, odds of HbA1c monitoring were: 44% lower in African, Caribbean or Black people (OR 0.56 [95% CI 0.48, 0.66]); 47% lower in Indian people (OR 0.53 [95% CI 0.47, 0.61]); and 50% lower in people in the other ethnicity group (OR 0.50 [95% CI 0.46, 0.58]). Odds of receipt of eye screening were 30%-40% lower in most ethnic groups compared to the White group. During median 5 year follow-up, differences in HbA1c monitoring and eye screening largely persisted, but attenuated slightly for the former.

CONCLUSIONS

There are marked ethnic disparities in routine diabetes care in Scotland in the short- and medium-term following diabetes diagnosis. Further investigation is needed to establish and effectively address the underlying reasons.

Improved Diabetes Screening for Women After Gestational Diabetes Mellitus

OBJECTIVE

This study aimed to assess the need for practice-wide quality improvement to support evidence-based type 2 diabetes screening for women with a history of gestational diabetes mellitus (GDM) receiving primary care. We sought to add the diagnosis of GDM to the problem list of women who did not have it at baseline.

RESEARCH DESIGN AND METHODS

We identified all women in our practice with a history of GDM diagnosed between 2002 and 2023, quantified the proportion with GDM documented in their problem list, and examined patient- and clinician-level factors associated with having GDM appropriately documented at baseline.

RESULTS

We identified 203 women with GDM receiving primary care within internal medicine. Of the 203 women, 73 (35.0%) did not have GDM documented in their problem list. Of those without GDM included on the problem list, 52% were overdue for type 2 diabetes screening compared with 41% of those with GDM documented before our intervention. We found race, parity, and previous abnormal glycemic laboratory test results to be highly predictive of whether the history of GDM was on patients' problem list. Upon completion of our intervention, we successfully achieved a 100% documentation rate for GDM diagnosis for women who previously lacked documentation in their problem list.

CONCLUSION

This work paves the way for targeted interventions aimed at improving care for women with a history of GDM, including delivery of interventions and education to prevent the onset of an appropriate clinical screening for type 2 diabetes.

Understanding Health Care Disparities Based on Medicare Use for Inflammatory and Infectious Eye Diseases

Purpose

Inflammatory and infectious eye diseases are an important cause of visual impairment in patients older than 65 years of age. Health care disparities for eye care are present for general eye care. However, there is lack of national data on health disparities regarding eye care use for inflammatory and infectious eye diseases. Our study examines the effect of gender and race on eye care in patients with inflammatory and infectious eye diseases who are equal or greater than 65 years of age.

Methods

We have used Medicare data to examine the effect gender and race on use of eye care services in patients with inflammatory and infectious eye diseases for 2014 to 2018. Medicare is a national insurance program administered by the government of United States to insure people age 65 years or older. Owing to its high enrollment, those in Medicare are representative of the U.S. population aged 65 and older.

Results

We found that females have higher use for Medicare for inflammatory and infectious eye diseases across all races from 2014 to 2018. On examining the effect of race, African Americans have lower use as compared with Whites. People of Asian descent have the highest use, followed by Hispanic people.

Conclusions

Health care disparities exist for eye care use for inflammatory and infectious eye diseases for patients 65 years of age and older. Future studies are required to address these disparities to provide equitable eye care.

Translational Relevance

Identification of eye care disparities is the first step to addressing these disparities.

Diabetes and Financial Well-Being: Differential Hardship Among Vulnerable Populations

PURPOSE

The purpose of the study was to examine financial well-being among a diverse population of individuals with and without diabetes.

METHODS

Data from the Understanding America Survey, a nationally representative, longitudinal panel, were utilized to identify adults with self-reported diabetes diagnoses between 2014 and 2020. We used longitudinal mixed effects regression models to assess the association between diabetes and financial well-being score (FWBS) among racial and ethnic population subgroups. Models included sex, age, marital status, household size, income, education, race/ethnicity, insurance, body mass index, employment, and health insurance, incorporating individual- and household-level fixed effects. Racial and ethnic differentials were captured using group-condition interactions.

RESULTS

Black participants (17.06%) had the highest prevalence of diabetes, followed by White participants (12.2%), "other" racial groups (10.7%), and Hispanic participants (10.0%). In contrast, White participants (M = 67.66, SD = 22.63) and other racial groups (M = 67.99, SD = 18.45) had the highest FWBSs, followed by Hispanic participants (M = 59.31, SD = 22.78) and Black participants (M = 55.86, SD = 25.67). Compared to White participants, Black participants (β = -5.49, SE = 0.71) and Hispanic participants (β = -2.06, SE = 0.63) have significantly lower FWBSs. Compared to males, females (β = -3.25, SE = 0.41) had lower FWBSs among individuals with diabetes. FWBSs of individuals with diabetes was 2.71 points lower (SE = 0.52), on average, than those without diabetes. Education, household size, age, marital status, and income were also significantly associated with FWBSs.

CONCLUSIONS

Findings suggest potential disparities in the financial ramifications of diabetes among socially marginalized populations.

Examining Diabetes Status by the Social Determinants of Health Among Adults in Hawai'i

The social determinants of health (SDoH) influence health outcomes based on conditions from birth, growth, living, and age factors. Diabetes is a chronic condition, impacted by race, education, and income, which may lead to serious health consequences. In Hawai'i, approximately 11.2% of adults have been diagnosed with diabetes. The objective of this secondary cross-sectional study is to assess the relationship between the prevalence of diabetes and the social determinants of health among Hawai'i adults who participated in the Behavioral Risk Factor Surveillance System between 2018-2020. The prevalence of diabetes among adults was 11.0% (CI: 10.4-11.5%). Filipino, Japanese and Native Hawaiian adults had the highest prevalence of diabetes at 14.4% (CI: 12.7-16.2%), 14.2% (CI: 12.7-15.7%), and 13.2% (CI: 12.0-14.4%), respectively. Poverty level and education were significantly associated with diabetes status. Within employment categories, the adjusted odds ratio (AOR) for retired and unable to work adults were large at AOR: 1.51 (CI: 1.26-1.81) and AOR: 2.91 (CI: 2.28-3.72), respectively. SDoH can impact the development and management of diabetes. Understanding the role SDoH plays on diabetes status is crucial for promoting health equity, building community capacity, and improving diabetes management.

Racial, ethnic and regional differences in the effect of sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists on cardiovascular and renal outcomes: a systematic review and meta-analysis of cardiovascular outcome trials

OBJECTIVES

The cardiorenal protective effects of sodium-glucose co-transporter 2 inhibitors (SGLT2-Is) and glucagon-like peptide 1 receptor agonists (GLP1-RAs) across racial and ethnic groups are not well defined. By conducting a systematic review and meta-analysis of all randomised, placebo-controlled, cardiovascular disease (CVD) outcomes trials (CVOTs), we aimed to compare racial/ethnic as well as regional patterns in the effects of SGLT2-Is and GLP1-RAs on cardiovascular and renal outcomes in patients with type 2 diabetes (T2D).

DESIGN

Trials were identified from MEDLINE, Embase, the Cochrane Library, and search of bibliographies to 7 July 2023. Setting North America, South/Central America, Europe (Eastern and Western), Asia, Australia-New Zealand (Pacific), Asia/Pacific, and Africa.

SETTING

North America, South/Central America, Europe (Eastern and Western), Asia, Australia-New Zealand (Pacific), Asia/Pacific, and Africa.

PARTICIPANTS

people with type 2 diabetes enrolled in cardiovascular outcome trials of SGLT2-Is and GLP1-RAs.

MAIN OUTCOME MEASURES

Outcomes were (i) major adverse cardiovascular events (MACE), (ii) composite CVD death/heart failure (HF) hospitalization; (iii) composite renal outcome; and (iv) their components. Study-specific hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled.

RESULTS

In total, 14 unique CVOTs (7 comparing SGLT2-Is vs placebo and 7 comparing GLP1-RAs vs placebo) were eligible. The proportion of participants enrolled in the trials ranged from 66.6-93.2% for White populations, 1.2-21.6% for Asian populations, 2.4-8.3% for Black populations and 0.9-23.1% for Other populations. The HR (95% CI) for MACE comparing SGLT2-Is vs placebo was 0.92 (0.86-0.98), 0.69 (0.53-0.92) and 0.70 (0.54-0.91) for White, Asian and Hispanic/Latino populations, respectively. Comparing GLP1-RAs vs placebo, the corresponding HR (95% CI) was 0.88 (0.80-0.97), 0.76 (0.63-0.93) and 0.82 (0.70-0.95), respectively. SGLT2-Is reduced the risk of all other cardiorenal outcomes in White and Asian populations, except for HF hospitalizations in Asians. No effects were observed in Black populations except for a reduced risk of HF hospitalizations by SGLT2-I. SGLT1-Is reduced the risk of composite CVD death/HF hospitalization in North America and Europe, whereas GLP1-RAs reduced the risk of MACE in Europe. GRADE certainty of evidence ranged from moderate to high.

CONCLUSIONS

There appears to be substantial racial/ethnic differences in the cardiorenal effects of SGLT2-Is and GLP1-RAs in patients with T2D, with consistent benefits observed among White and Asian populations and consistent lack of benefits in Black populations. Whether the differences are due to issues with under-representation of Black populations and low statistical power or racial/ethnic variations in the pharmacokinetics, pharmacodynamics and safety of SGLT2-Is and GLP1-RAs need further investigation.PROSPERO Registration: CRD42023401734.

Diabetes Distress and Associated Factors Among Chinese Americans with Type 2 Diabetes in New York City

Purpose

The purpose of this study is to describe diabetes distress and related factors among Chinese Americans with type 2 diabetes in New York City (NYC).

Methods

We conducted a secondary data analysis of the baseline data from three research studies conducted among community-dwelling Chinese American adults with type 2 diabetes. Diabetes Distress Scale (DDS) was used to measure sources of diabetes distress including emotional-, regimen-, interpersonal-, and physician-related distress. A score of 2 or greater indicates moderate diabetes distress or higher. Patient Health Questionnaire-2 (PHQ-2) was used to measure depressive symptoms. Participants' sociodemographic information was also collected. Descriptive statistics were used to describe diabetes distress, and logistic least absolute shrinkage and selection operator (LASSO) regression was used to examine factors associated with diabetes distress level.

Results

Data from 178 participants (mean age 63.55±13.56 years) were analyzed. Most participants were married (76.40%), had a high school degree or less (65.73%), had a household annual income < $25,000 (70.25%), and reported limited English proficiency (93.22%). About 25.84% reported moderate or higher overall distress. The most common sources of distress were emotional burden (29.78%), followed by regimen- (28.65%), interpersonal- (18.54%), and physician-related distress (14.04%). Participants who were younger, female, limited English proficient, and had elevated depressive symptoms were more likely to have higher diabetes distress.

Conclusion

Diabetes distress is prevalent among Chinese immigrants with type 2 diabetes, especially emotional- and regimen-related distress. Given the known link between diabetes distress and poor glycemic control, it is critical to screen for diabetes distress at primary care clinics and incorporate psychological counseling in diabetes care in this underserved population.

Racial disparity in postoperative complications following shoulder arthroplasty (SA): A systematic review and meta-analysis

Introduction

There has been an emphasis on racial disparities in orthopedic surgery. Recently, literature suggested Black and Hispanic patients at increased risk for adverse outcomes after Shoulder Arthroplasty (SA), but data regarding it is sparse and inconclusive. Therefore, we aim to conduct a meta-analysis to assess the role of racial disparity in causing adverse outcomes after SA.

Methods

Following PRISMA guidelines, electronic databases PubMed, Scopus, Cochrane, and Google Scholar were queried. Studies meeting inclusion criteria were included. Results were analyzed by pooling Odds ratios along 95% Confidence interval, using random-effects model on RevMan 5.3.

Results

A total of 14 selected studies evaluated 1,781,783 patients. We found Black patients at higher risk of post-SA complications than White patients (OR 1.32(95% CI 1.25-1.39; p < 0.00001; I2 = 0%). No significant risk in Hispanics compared to white patients (OR 0.94(95% CI 0.81-1.09); p = 0.41; I2 = 65%). Compared to whites, black patients were at higher risk of an extended length of stay, postoperative blood transfusion, sepsis, venous thromboembolism, and non-home discharge. Compared to white patients, Hispanics were at higher risk for postoperative blood transfusion. Whites showed increased risk for readmission.

Conclusion

Following SA, Black patients were likely to develop complications compared to White patients but no significant risk in Hispanics compared to Whites.

Racial Differences in Diabetic Cardiomyopathy: The ARISE-HF Trial

BACKGROUND

Diabetic cardiomyopathy (DbCM) increases risk of overt heart failure in individuals with diabetes mellitus. Racial and ethnic differences in DbCM remain unexplored.

OBJECTIVES

The authors sought to identify racial and ethnic differences among individuals with type 2 diabetes mellitus, structural heart disease, and impaired exercise capacity.

METHODS

The ARISE-HF (Aldolase Reductase Inhibitor for Stabilization of Exercise Capacity in Heart Failure) trial is assessing the efficacy of an aldose reductase inhibitor for exercise capacity preservation in 691 persons with DbCM. Baseline characteristics, echocardiographic parameters, and functional capacity were analyzed and stratified by race and ethnicity.

RESULTS

The mean age of the study participants was 67.4 years; 50% were women. Black and Hispanic patients had lower use of diabetes mellitus treatments. Black patients had poorer baseline ventricular function and more impaired global longitudinal strain. Overall, health status was preserved, based on Kansas City Cardiomyopathy Questionnaire scores, but reduced exercise capacity was present as evidenced by reduced Physical Activity Scale for the Elderly (PASE) scores. When stratified by race and ethnicity and compared with the entire cohort, Black patients had poorer health status, more reduced physical activity, and a greater impairment in exercise capacity during cardiopulmonary exercise testing, whereas Hispanic patients also displayed compromised cardiopulmonary exercise testing functional capacity. White patients demonstrated higher physical activity and functional capacity.

CONCLUSIONS

Racial and ethnic differences exist in baseline characteristics of persons affected by DbCM, with Black and Hispanic study participants demonstrating higher risk features. These insights inform the need to address differences in the population with DbCM. (Safety and Efficacy of AT-001 in Patients With Diabetic Cardiomyopathy [ARISE-HF]; NCT04083339).

"The straw that broke the camel's back": An analysis of racialized women clinicians' experiences providing diabetes care

INTRODUCTION

Racialized women clinicians (RWCs) experience the brunt of unfair racial and gendered expectations, which is a direct result of their visible identity. Our study sought to understand how these experiences intersect to impact the personal and professional well-being of RWCs, and their approach to diabetes care.

METHODS

Data were collected from 24 RWCs working within Canadian diabetes care settings, who participated in semi-structured, one-on-one interviews conducted from April 2021 to September 2021. The data were qualitatively analyzed using thematic analysis to develop emergent themes, and interactions were explored using the socioecological model (SEM), adapted to our study context.

RESULTS

We identified three themes: (1) Discordance between self-identity and relational identity impacted how RWCs interacted with others, and how others interacted with them; (2) Tokenistic, "inclusive" organizational policies/practices and inherently racist and sexist social norms permitted acts of discrimination and led to the systematic othering and exclusion of RWCs within the workplace; and (3) Differential treatment of RWCs had both positive and negative impacts on participants' relational, workplace and self-identity. Using the SEM, we also found that differential treatment of RWCs stems from upstream policies, structures, and social norms, percolating through different levels of the SEM, including work environments and communities, which eventually impacts one's relational identity, as well as one's perception of oneself.

CONCLUSION

The differential treatment of RWCs arises predominantly from macro systems of the work environment. The burden to address these disparities must be shifted to the source (i.e., namely systems) by implementing interventions that equitably value diversity efforts, institute policies of accountability and correction of implicit biases, and prioritize an inclusive culture broadly across faculty and leadership.

Food Insecurity and Diabetes Insulin Adherence Among Older Adults

Older adults in the United States continue to be impacted by food insecurity. Diabetes is on the rise in older adults and insulin therapy is often recommended as treatment. However, less is known about the relationship between food insecurity and insulin adherence among older adults. The current study utilized secondary data analysis methods to examine the 2021 National Health Interview Survey to explore the relationship between food insecurity and insulin adherence among adults aged 55 and older who are living with diabetes. Results of multivariable logistic regression suggest that participants experiencing food insecurity were more likely to take less insulin than needed and delay buying insulin in the past 12 months compared to participants who were food secure. Homeownership was inversely associated with taking less insulin than needed. Higher income-to-poverty ratio was also inversely associated with skipping insulin doses, taking less insulin than needed, and delaying the purchase of insulin. Our results showed that other racialized/ethnic groups (i.e., American Indian, Alaskan Native, Asian, biracial, and multiracial persons) compared to White were less likely to skip an insulin dose and take less insulin than needed. Suggesting food insecurity should be considered when insulin therapy is recommended for older adults with diabetes.

Disparities in the treatment of movement disorders using deep brain stimulation

OBJECTIVE

Deep brain stimulation (DBS) is a well-established treatment for Parkinson's disease (PD) and essential tremor (ET). Although the prevalence of PD and ET can vary by sex and race, little is known about the accessibility of neurosurgical treatments for these conditions. In this nationwide study, the authors aimed to characterize trends in the use of DBS for the treatment of PD and ET and to identify disparities in the neurosurgical treatment of these diseases based on ethnic, racial, sex, insurance, income, hospital, and geographic factors.

METHODS

Using the dates January 1, 2012, to December 31, 2019, the authors queried the National Inpatient Sample database for all discharges with an ICD-9 or ICD-10 diagnosis of PD or ET. Among these discharges, the DBS rates were reported for each subgroup of race, ethnicity, and sex. To develop national estimates, all analyses were weighted.

RESULTS

Among 2,517,639 discharges with PD, 29,820 (1.2%) received DBS, and among 652,935 discharges with ET, 11,885 (1.8%) received DBS. Amid the PD cases, Black patients (n = 405 [0.2%], OR 0.16, 95% CI 0.12-0.20) were less likely than White patients (n = 23,975 [1.2%]) to receive DBS treatment, as were Hispanic patients (n = 1965 [1.1%], OR 0.76, 95% CI 0.65-0.88), whereas Asian/Pacific Islander patients (n = 855 [1.5%]) did not statistically differ from White patients. Amid the ET cases, Black (n = 230 [0.8%], OR 0.39, 95% CI 0.27-0.56), Hispanic (n = 215 [1.0%], OR 0.39, 95% CI 0.28-0.55), and Asian/Pacific Islander (n = 55 [1.0%], OR 0.51, 95% CI 0.28-0.93) patients were less likely than White patients (n = 10,440 [1.9%]) to receive DBS. Females were less likely than males to receive DBS for PD (OR 0.69, p < 0.0001) or ET (OR 0.70, p < 0.0001).

CONCLUSIONS

The authors describe significant racial and sex-based differences in the utilization of DBS for the treatment of PD and ET. Further research is required to ascertain the causes of these disparities, as well as any differences in access to specialty neurosurgical care and referral for neuromodulation approaches.

Investigation of geographic disparities of diabetes-related hospitalizations in Florida using flexible spatial scan statistics: An ecological study

BACKGROUND

Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters.

METHODS

Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables.

RESULTS

There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs.

CONCLUSIONS

This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Reasons and Risk Factors for Same-Day Discharge Following Total Joint Arthroplasty: A Systematic Review

Background

Nowadays, emphasis is being given to same-day discharge (SDD) following total joint arthroplasty. Unfortunately, despite a high degree of success, there are instances of failed SDD. Therefore, we aim to conduct a systematic review to evaluate factors contributing to failed SDD after total joint arthroplasty.

Methods

Pubmed, Scopus, Cochrane, and Google Scholar were searched. The Newcastle Ottawa score was used for the quality assessment of selected studies. All the studies were evaluated through a narrative synthesis. A total of 11 studies evaluating 157,045 patients were selected. The mean age of patients was 62.5 years.

Results

Elderly patients (odds ratio [OR] 1.01 to OR 3.13), women (OR 1.63 to OR 2.87), non-white race (OR 1.31 to OR 2.19), hypertension (OR 1.11 to OR 1.41), diabetes (OR 1.25 to OR 4.06), cardiovascular diseases (OR 1.67 to OR 12.06), chronic obstructive pulmonary disease (OR 1.30 to OR 1.96), bleeding disorders (OR 1.32 to OR 1.52), obesity (OR 1.35 to OR 3.30), steroid use (OR 1.23 to OR 1.52), late procedure start time (OR 1.22 to OR 5.16), higher postoperative pain (OR 1.93 to OR 5.85), high American Society of Anesthesiologists score (OR 0.92 to OR 3.50) were major predictors of failed SDD.

Conclusions

Through our review, we highlighted that elderly patients, women, non-white race, hypertension, diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, bleeding disorders, obesity, steroid use, late procedure start time, higher postoperative pain, and high American Society of Anesthesiologists score were major predictors of a failed SDD. Many factors evaluated in our study were presented in one or two studies only; therefore, high-quality studies are required to supplement our findings.

Do Racial and Ethnic Disparities Exist in Intensity of Intracranial Pressure-Directed Therapies and Outcomes Following Pediatric Severe Traumatic Brain Injury?

INTRODUCTION

Studies suggest disparities in outcomes in minoritized children after severe traumatic brain injury. We aimed to evaluate for disparities in intracranial pressure-directed therapies and outcomes after pediatric severe traumatic brain injury.

METHODS

We conducted a secondary analysis of the Approaches and Decisions for Acute Pediatric TBI (ADAPT) Trial, which enrolled pediatric severe traumatic brain injury patients (Glasgow Coma Scale score  ≤8) with an intracranial pressure monitor from 2014 to 2018. Patients admitted outside of the United States were excluded. Patients were categorized by race and ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White, and "Other"). We evaluated outcomes by assessing mortality and 3-month Glasgow Outcome Score-Extended for Pediatrics. Our analysis involved parametric and nonparametric testing.

MAIN RESULTS

A total of 671 children were analyzed. Significant associations included older age in non-Hispanic White patients (P < .001), more surgical evacuations in "Other" (P < .001), and differences in discharge location (P = .040). The "other" cohort received hyperventilation less frequently (P = .046), although clinical status during Paco2 measurement was not known. There were no other significant differences in intracranial pressure-directed therapies. Hispanic ethnicity was associated with lower mortality (P = .004) but did not differ in unfavorable outcome (P = .810). Glasgow Outcome Score-Extended for Pediatrics was less likely to be collected for non-Hispanic Black patients (69%; P = .011).

CONCLUSIONS

Our analysis suggests a general lack of disparities in intracranial pressure-directed therapies and outcomes in children after severe traumatic brain injury. Lower mortality in Hispanic patients without a concurrent decrease in unfavorable outcomes, and lower availability of Glasgow Outcome Score-Extended for Pediatrics score for non-Hispanic Black patients merit further investigation.

Associations between Diabetes-Specific Medication Regimen Complexity and Cardiometabolic Outcomes among Underserved Non-Hispanic Black Adults Living with Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) management and glycemic control in underserved non-Hispanic Black adults presents with multifaceted challenges: balancing the optimal complexity of antihyperglycemic medications prescribed, limited medication access due to socioeconomic status, medication nonadherence, and high prevalence of cardiometabolic comorbidities. This single-center, cross-sectional, retrospective chart analysis evaluated the association of Medication Regimen Complexity (MRC) with cardiometabolic outcomes (glycemic, atherogenic cholesterol, and blood pressure control) among non-Hispanic Black adults with type 2 diabetes. Utilizing 470 independent patient electronic health records, MRC and other covariates were examined to determine their associations with cardiometabolic outcomes. Chi-square tests of independence and multiple logistic regression were performed to identify associations between MRC and cardiometabolic outcomes. Our findings indicate significant negative and positive associations between MRC and glycemic control and atherogenic cholesterol control, respectively. However, there were no associations between MRC and blood pressure control. As diabetes MRC was shown to be associated with poor glycemic control and improved atherogenic cholesterol control, there is a critical need to standardize interdisciplinary diabetes care to include pharmacists and to develop more insurance policy interventions that increase access to newer, efficacious diabetes medications for historically marginalized populations.

Satisfaction with diabetes involvement: Exploring parent and adolescent perspectives

AIMS

Both parent and adolescent involvement in type 1 diabetes management are critical during adolescence. The current study sought to understand the factors associated with parent and adolescent satisfaction with their own and one another's involvement in diabetes management.

METHODS

Cross-sectional baseline data from 157 parent-adolescent dyads enrolled in an RCT were used. Adolescent ages ranged from 12 to 19 (Mage = 14.7, SD = 1.89) and were balanced by gender (50.3% male). Paired t-tests examined concordance between parent and adolescent satisfaction, bivariate correlations identified correlates, and regressions examined unique associations.

RESULTS

Roughly, 43% of adolescents and 29% of parents were very satisfied with adolescent involvement in diabetes management, whereas 71% of adolescents and 26.1% of parents were very satisfied with parent involvement. Indicators of better glycaemic health (via higher percent time-in-range and lower HbA1c and percent time in hyperglycaemia) and psychosocial functioning (less diabetes distress and depression) were correlated with higher satisfaction. Parent satisfaction with adolescent involvement was higher among older adolescents (R = 0.198, p = 0.013). Non-Hispanic white youth were more satisfied with their own involvement than youth of colour (t(149) = -2.783, p = 0.003). Both percent time-in-range and one's own diabetes distress uniquely related to parent and adolescent satisfaction with adolescent involvement. Conversely, parent satisfaction with their own involvement was only uniquely associated with parent diabetes distress.

CONCLUSION

Both adolescent and parents' satisfaction with adolescents' involvement in self-management are indicators of both glycaemic control and psychosocial well-being, whereas parents' self-evaluations are more closely tied to diabetes-specific distress.

Disparities in prevalence and treatment of diabetes, cardiovascular and chronic kidney diseases - Recommendations from the taskforce of the guideline workshop

There is a mounting clinical, psychosocial, and socioeconomic burden worldwide as the prevalence of diabetes, cardiovascular disease (CVD), and chronic kidney disease (CKD) continues to rise. Despite the introduction of therapeutic interventions with demonstrated efficacy to prevent the development or progression of these common chronic diseases, many individuals have limited access to these innovations due to their race/ethnicity, and/or socioeconomic status (SES). However, practical guidance to providers and healthcare systems for addressing these disparities is often lacking. In this article, we review the prevalence and impact of healthcare disparities derived from the above-mentioned chronic conditions and present broad-based recommendations for improving access to quality care and health outcomes within the most vulnerable populations.

The Association of Multidimensional Sleep Health With HbA1c and Depressive Symptoms in African American Adults With Type 2 Diabetes

OBJECTIVE

Sleep is important for diabetes-related health outcomes. Using a multidimensional sleep health framework, we examined the association of individual sleep health dimensions and a composite sleep health score with hemoglobin A1c (HbA1c) and depressive symptoms among African American adults with type 2 diabetes.

METHODS

Participants (N = 257; mean age = 62.5 years) were recruited through local churches. Wrist-worn actigraphy and sleep questionnaire data assessed multidimensional sleep health using the RuSATED framework (regularity, satisfaction, alertness, timing, efficiency, duration). Individual sleep dimensions were dichotomized into poor or good sleep health and summed into a composite score. HbA1c was assessed using the DCA Vantage™ Analyzer or A1CNow® Self Check. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Regression models examined the association of individual sleep dimensions and composite sleep health with HbA1c and depressive symptoms.

RESULTS

Higher composite sleep health scores were associated with a lower likelihood of having greater than minimal depressive symptoms (PHQ-9 ≥ 5) (odds ratio [OR] = 0.578, 95% confidence interval [CI] = 0.461-0.725). Several individual sleep dimensions, including irregularity (OR = 1.013, CI = 1.005-1.021), poor satisfaction (OR = 3.130, CI = 2.095-4.678), and lower alertness (OR = 1.866, CI = 1.230-2.833) were associated with a greater likelihood of having depressive symptoms. Neither composite sleep health scores nor individual sleep dimensions were associated with HbA1c.

CONCLUSIONS

Better multidimensional sleep health is associated with lower depressive symptoms among African American adults with type 2 diabetes. Longitudinal research is needed to determine the causal association between multidimensional sleep health and depressive symptoms in this population.

TRIAL REGISTRY

ClinicalTrials.gov identifier NCT04282395.