State-Level Social Vulnerability Index and Healthcare Access: The Behavioral Risk Factor Surveillance System Survey

Implementation strategies to increase seasonal influenza vaccination among adults: A rapid scoping review

Many strategies have been applied to increase seasonal influenza vaccination; however, gaps in coverage remain. We synthesized the evidence on effectiveness of implementation strategies to increase seasonal influenza vaccination among U.S. adults. Studies performed from February 2010-August 2023 in the United States, focused on seasonal influenza vaccination, and measuring uptake and coverage were included. Guidance from Cochrane was followed. Interventions were mapped to Expert Recommendations for Implementing Change strategies. A total of 1,585 non-duplicate records were identified, full-text screening was performed for 353 records, and 51 studies met inclusion criteria. Among these studies, implementation strategies included those that engaged consumers, trained and educated stakeholders, and supported providers. Considerable heterogeneity was found in the study setting, populations, design, and methods. Substantial study variation limits the ability to conclude which strategies are most effective at increasing influenza vaccination uptake and coverage in U.S. adults.

Area-Level Indices and Health Care Use in a Pediatric Brain and Central Nervous System Tumor Cohort: Observational Study

Background

While survival among pediatric patients with cancer has advanced, disparities persist. Public health tools such as the Area Deprivation Index, the Child Opportunity Index (COI), and the Social Vulnerability Index (SVI) are potential proxies for social determinants of health and could help researchers, public health practitioners, and clinicians identify neighborhoods or populations most likely to experience adverse outcomes. However, evidence regarding their relationship with health care use, especially in the pediatric population with cancer, remains mixed.

Objective

We sought to evaluate the relationship between emergency department (ED) visits and hospitalizations with these area-level indices in our study population.

Methods

We conducted a cross-sectional study of pediatric patients with brain and central nervous system tumors in a single Midwestern state who were diagnosed between 2010 and 2020. We fitted zero-inflated Poisson models for counts of ED and inpatient visits to determine if any of these use measures were associated with our 3 area-level indices. Finally, we mapped index quintiles onto neighborhoods to visualize and compare how each index differentially ranks neighborhoods.

Results

Our study cohort consisted of 524 patients; 78.6% (n=412) of them had no recorded ED visit, and 39.7% (n=208) had no record of hospitalization. Moderate (coefficient=0.306; P=.01) and high (coefficient=0.315; P=.01) deprivation were associated with more ED visits. Both low child opportunity (coefficient=0.497; P<.001) and very high child opportunity (coefficient=0.328; P=.01) were associated with more ED visits. All quintiles of SVI were associated with ED visits, but the relationship was not dose-dependent. Low and very high deprivation were associated with hospitalizations, but COI and SVI were not. Additionally, by overlaying index quintiles onto census tracts and census block groups, we showed that most patients who had an ED visit lived in disadvantaged neighborhoods based on Area Deprivation Index rankings, but not necessarily COI or SVI rankings.

Conclusions

Although indices provide useful context about the environment in which our patient population resides in, we found little evidence that neighborhood conditions as measured by these indices consistently or reliably relate to health care use.

Characteristics Associated With Mental Health Treatment Prior to Suicide Among Youth in the United States

OBJECTIVE

To examine individual and contextual characteristics associated with receipt of mental health treatment prior to youth suicide.

METHOD

Data from the US National Violent Death Reporting System, Area Health Resource File, and Social Vulnerability Index were used to examine characteristics associated with receipt of mental health treatment within 2 months before death among youth suicide decedents aged 5 to 17 years from 2013 to 2020 (N = 6,229). The association between individual (demographic, precipitating circumstances, and clinical characteristics) and contextual-level variables (county health resources, Social Vulnerability Index) and mental health service use was modeled using logistic regression.

RESULTS

Mental health treatment was received by 31.6% of youth suicide decedents (n = 1,967) in the 2 months before suicide. Male individuals and youth from all racial and ethnic minority groups were less likely to receive mental health treatment in the 2 months prior to suicide, as were youth residing in non-metropolitan counties and living in counties characterized by high compared to low levels of social vulnerability. A history of family problems, a recent crisis, criminal/legal problems, and suicidal thoughts and attempts were associated with increased odds of receiving mental health services.

CONCLUSION

Youth suicide decedents who were male, members of a racial or ethnic minority group, and residing in counties that are non-metropolitan and/or socially disadvantaged were less likely to have received mental health services in the months prior to death. Suicide prevention efforts that focus on improving access to care are essential for these vulnerable populations at risk for suicide.

PLAIN LANGUAGE SUMMARY

This study used data from the US National Violent Death Reporting System, Area Health Resource File, and Social Vulnerability Index to examine characteristics associated with mental health treatment within two months of death by suicide among 6,229 youth aged 5 to 17 years from 2013 to 2020. Mental health treatment was received by 31.6% of youth suicide decedents in the 2 months before death with male decedents and those from racial and ethnic minority groups less likely to receive mental health treatment than non-Hispanic White decedents. Youth living in nonmetropolitan areas and in counties with high Social Vulnerability Index were also less likely to receive care. Suicide prevention efforts focused on improving access to care are essential for these vulnerable populations at risk for suicide.

Transforming End-of-Life Care: Impact of the "Melhor em Casa" Home-Based Palliative Care Program in Brazil

Background: Palliative care (PC) is essential for managing symptoms and improving the quality of life for cancer patients. In Brazil, the "Melhor em Casa" ("Better at Home") program offers interdisciplinary home-based care. The SAD-Caratinga Program (SAD-CP) in Minas Gerais has provided care to patients with cancer since 2013. Objectives: This study aimed to evaluate the SAD-CP, focusing on sociodemographic and clinical data of cancer patients, symptoms, survival, number of hospitalizations, and place of death. Methods: A retrospective, cross-sectional, quantitative analysis was conducted on data from 471 consecutive oncology patients who died while under the program's care between 2013 and 2023. Demographic, clinical, and service data were analyzed using descriptive statistics, Kaplan-Meier survival estimates, chi-square, and Kruskal-Wallis tests. Results: The median age was 70 years, with 52.9% male patients and stage IV (57.8%). Pain was the most reported symptom (94.7%), followed by dyspnea (77.1%) and hypersomnolence (69.2%). Median survival was 48 days, with significant variation by cancer type. Notably, 468/471 (99.4%) patients died at home. The program demonstrated effective symptom management, as only three patients (0.6%) patients were hospitalized, and there were minimal emergency visits (0.08 visits/day). Conclusion: This interdisciplinary intensive home-based PC program improved patient symptom control and dramatically reduced hospital deaths. Future research should explore scalability and long-term outcomes in diverse populations.

Area-Level socioeconomic disadvantage and access to primary care: A rapid review

Social drivers of health aggregate geographically, contributing to health inequities that primary care access may mitigate. Two area-level measures of social disadvantage are the Area Deprivation Index and Social Vulnerability Index. This rapid review aimed to assess the association between these measures and primary care access. We conducted a rapid review of US studies published through February 11, 2025. Included studies were categorized as defining primary care access by self-reported access to primary care, geographic accessibility, or utilization. We analyzed 31 studies, of which 68% (N = 9/13 Area Deprivation Index, N = 12/18 Social Vulnerability Index) found that greater area-level social disadvantage was consistently associated with reduced primary care access. This association was most consistently observed in studies measuring primary care access via self-report (N = 2/2), vaccine uptake (N = 5/7), and via a higher odds of using telephone vs audio-visual or in-person primary care in areas of high socioeconomic disadvantage (N = 5/5). These findings have implications for telemedicine payment policy and care redesign. The possible expiration of Medicare's expanded telemedicine reimbursement may disproportionately reduce access points to primary care for individuals living in high socioeconomic disadvantage areas. These findings also support the need for community-level interventions to increase access to primary care administered vaccines.

Engagement in child psychiatry department appointments: An analysis of electronic medical records in one safety-net hospital in New England, USA

OBJECTIVE

This study examined whether being scheduled in a screening clinic versus scheduled directly with a long-term provider to conduct a mental health intake (MHI) is associated with engagement in child psychiatry services in New England, USA.

METHOD

We used electronic medical record data from one safety-net hospital serving a predominantly low-income and minoritised population. The study sample included 815 youths aged 0 to 25 years, referred or scheduled for a MHI between 1 January 2016 and 31 December 2016. We used chi-square and t-tests to examine the association between referral pathways and engagement, logistic regression to understand the relationship between youth's socio-demographic characteristics and referral pathways, and logistic and Poisson regressions to assess potential moderating effects of socio-demographic characteristics on engagement.

RESULTS

The mean age of the study population was 12 years; 46% were female, and the majority had public health insurance (84%) and lived in high social vulnerability areas (65%). Less than half of the youth attended the first scheduled MHI visit. Those scheduled with the screening clinic were less likely than those scheduled with the provider to ever attend a MHI appointment. Spanish-speakers were more likely to be directly scheduled with a provider (Odds Ratio, OR 0.48; 95% CI: 0.32, 0.73), while those with public health insurance were more likely to be scheduled with the screening clinic (OR 0.56; 95% CI: 0.43, 0.96). Spanish-speaking status and areas social vulnerability scores moderated the relationship between the referral pathway and engagement in psychiatric appointments.

CONCLUSIONS

The study highlights the need for psychiatric services to evaluate how MHI referral procedures may mitigate barriers to care and facilitate engagement for youth at high risk of not attending psychiatric service appointments.

Exploring social vulnerability in National Health Safety Network surgical site infections

OBJECTIVE

To assess the association between social vulnerability index (SVI) and surgical site infections (SSIs) using National Healthcare Safety Network (NHSN) criteria.

DESIGN

Retrospective cohort study between August 1, 2022, and August 31, 2023.

SETTING

In total, 20 acute care hospitals in the Southeast United States.

PATIENTS

Totally, 23,768 total hip arthroplasty, total knee arthroplasty, abdominal hysterectomy, colon, and spinal fusion surgeries in 22,239 patients were included. Procedures with infection present at the time of surgery or incomplete geographic tracking data were excluded.

METHODS

Patient addresses as noted in the electronic health record were geocoded to determine census tract of residence and determine SVI. Demographic and clinical data were linked with SVI scores. SSIs were identified according to NHSN criteria. SVI was categorized into quartiles, and logistic regression was used to evaluate the association between SVI quartile (overall and for each SVI theme) and SSI risk. Subgroup analyses by procedure type and race were performed. Multivariable models of the association between overall SVI and SSI were adjusted for demographic and clinical factors.

RESULTS

Patients in the top SVI quartiles had significantly higher odds of developing SSIs after adjusting for other clinical and demographic factors. Increased risk was found for socioeconomic status and household characteristics themes, but not for the racial/ethnic minority theme. Association between SVI and SSI risk varied by type of surgery.

CONCLUSIONS

Living in an area with a higher SVI is associated with increased SSI risk. Targeted interventions are needed to mitigate these disparities and improve outcomes.

Utilizing an Educational Intervention to Enhance Influenza Vaccine Literacy and Acceptance Among Minoritized Adults in Southern Californian Vulnerable Communities in the Post-COVID-19 Era

BACKGROUND/OBJECTIVES

Since the COVID-19 pandemic began, vaccination rates for preventable diseases, including influenza, have significantly dropped among racially and ethnically minoritized (REM) individuals in the United States. This study explored the effects of a community-based educational intervention designed to improve influenza vaccine literacy and acceptance among vulnerable REM individuals.

METHODS

The intervention included four 45 min interactive educational sessions on the influenza vaccine. The session attendees (18+) were invited to participate in a pre-/post-intervention study where an anonymous survey measured their post-COVID-19 pandemic attitudes, knowledge, and behaviors regarding the influenza virus and vaccine. To assess the effect of the intervention on vaccine literacy, we used a Mann-Whitney U test to test for differences between the pre-/post-intervention survey responses to seven knowledge-based questions. Descriptive statistics were employed to assess the impact of intervention on vaccine acceptance.

RESULTS

A total of 116 participants completed the pre-intervention survey, and 90 (78%) completed the post-intervention survey. All (100%) identified as REM, and 99% lived in highly vulnerable areas. Only 43% believed they were at risk for viral infection before the intervention, but 60% said the intervention helped them reassess their risk. We found significant differences in vaccine literacy when comparing the pre-/post-intervention survey responses, particularly regarding guideline-based vaccine recommendations (p < 0.05). Before the intervention, 65% of the participants indicated a high likelihood of receiving the influenza vaccine. In contrast, after the intervention, 81% of respondents indicated a high likelihood of being vaccinated, and 72% indicated that they were "extremely likely" to receive the immunization.

CONCLUSIONS

Community-based educational interventions can have a positive impact on influenza vaccine literacy and acceptance among vulnerable REM populations in the post-COVID-19 era.

Association of Social Determinants of Health With Brain MRI Outcomes in Individuals With Pediatric Onset Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Accumulating evidence points to worse clinical outcomes among adults with multiple sclerosis (MS) belonging to minority or poverty-affected groups. By contrast, little is known about the outcomes of these populations with pediatric-onset MS (POMS). Individuals with POMS represent 5% of the MS population and are more racially diverse yet have been understudied regarding socioeconomic environment or characteristics. In this study, we investigated the association between childhood social determinants of health (SDOH) and brain MRI outcomes in patients with POMS.

METHODS

This is a retrospective single-site cohort study of patients with POMS with brain MRI quantitatively analyzed using icobrain software to yield total white matter lesion, black hole, whole brain, white matter, and gray matter volumes. All patients with POMS evaluated at New York University Langone MS Center and who underwent high-quality volumetric MRI scans were included in this study. SDOH indicators of race, ethnicity, health insurance type, parental education, and childhood neighborhood social vulnerability index (SVI) were examined for association with MRI outcomes using linear least absolute shrinkage selection operator penalized regression modeling. Disease-modifying therapy (DMT) timing and DMT efficacy were compared for each SDOH category.

RESULTS

A total of 138 patients with POMS (70% female) were included with a mean age of 19.86 years and median disease duration of 4 years at time of scan. Public health insurance, Black race, Hispanic ethnicity, low parental education, and high SVI (greater neighborhood disadvantage) were each associated with white matter lesion and black hole volume. SVI was the strongest individual predictor of total white matter lesion (β = 4.63, p = 0.002) and black hole volume (β = 2.91, p = 0.003). In models incorporating all SDOH variables, public health insurance was the strongest predictor of total lesion (β = 2.48, p = 0.01) and black hole volume (β = 1.50, p = 0.02), attenuating the effect of SVI (β = 1.66, p = 0.33 and β = 1.00, p = 0.39). There were no differences in DMT timing or efficacy between categories of social disadvantage.

DISCUSSION

Individual-level and neighborhood-level indicators of social disadvantage are associated with worse brain MRI outcomes in POMS. Further investigation of race, ethnicity, and childhood disadvantage as risk factors of MS susceptibility and severity is needed to reduce MS health disparities.

Mpox Vaccination and the Role of Social Vulnerability in Durham County, North Carolina, USA

BACKGROUND

Disparities in vaccine coverage among groups in the USA is common, possibly due to higher vaccine hesitancy in certain populations, difficulty accessing vaccines, and underlying social vulnerability.

METHODS

The aim of this study was to investigate the association between mpox vaccine administration, social determinants of health, and social vulnerability index (SVI) in Durham County, North Carolina, USA. Random forest regression (RFE) and min-max scaling preprocessing were used to predict mpox vaccinations in Durham County at the census tract level. The top eleven most influential features and their correlations with mpox vaccination were calculated.

RESULTS

Non-Hispanic white individuals, males, and those between the ages of 20 and 40 years were overrepresented in mpox vaccine reception in Durham County. Surprisingly, lacking a high school diploma, lacking health insurance, lacking a household vehicle, and living below the poverty line were all positively associated with receiving the mpox vaccine. Being a Black or African American and Hispanic or Latino individual was also positively associated with receiving the mpox vaccine.

DISCUSSION

Vaccine outreach efforts in Durham County, North Carolina, had success in reaching at-risk individuals, including socially vulnerable individuals. Future research should focus more specifically on how social vulnerability relates to vaccine reception for vaccine-preventable diseases.

Search interest in alleged COVID-19 treatments over the pandemic period: the impact of mass news media

Background

Understanding how individuals obtain medical information, especially amid changing guidance, is important for improving outreach and communication strategies. In particular, during a public health emergency, interest in unsafe or illegitimate medications can delay access to appropriate treatments and foster mistrust in the medical system, which can be detrimental at both individual and population levels. It is thus key to understand factors associated with said interest.

Methods

We obtained US-based Google Search Trends and Media Cloud data from 2019-2022 to assess the relationship between Internet search interest and media coverage in three purported COVID-19 treatments: hydroxychloroquine, ivermectin, and remdesivir. We first conducted anomaly detection in the treatment-specific search interest data to detect periods of interest above pre-pandemic baseline; we then used multilevel negative binomial regression-controlling for political leaning, rurality, and social vulnerability-to test for associations between treatment-specific search interest and media coverage.

Findings

We observed that interest in hydroxychloroquine and remdesivir peaked early in 2020 and then subsided, while peak interest in ivermectin occurred later but was more sustained. We detected significant associations between media coverage and search interest for all three treatments. The strongest association was observed for ivermectin, in which a single standard deviation increase in media coverage was associated with more than double the search interest (164%, 95% CI: 148, 180), compared to a 109% increase (95% CI: 101, 118) for hydroxychloroquine and a 49% increase (95% CI: 43, 55) for remdesivir.

Interpretation

Search interest in purported COVID-19 treatments was significantly associated with contemporaneous media coverage, with the highest impact on interest in ivermectin, a treatment demonstrated to be ineffectual for treating COVID-19 and potentially dangerous if used inappropriately.

Funding

This work was funded in part by the US National Institutes of Health and the US National Science Foundation.

Peripartum Cardiomyopathy and Social Vulnerability: An Epidemiological Analysis of Mortality Outcomes

BACKGROUND

Peripartum cardiomyopathy (PPCM) outcomes have been previously linked to demographic and social factors. The social vulnerability index (SVI) is a measure of social vulnerability in the United States. We explored PPCM disparities and the impact of SVI on PPCM mortality.

METHODS AND RESULTS

Mortality from 1999 to 2020, SVI, and demographic data were obtained from CDC databases. County-specific SVI rankings were linked to PPCM age-adjusted mortality rates (AAMRs), allowing for a comparative analysis of AAMRs across both cumulative populations and subpopulations to identify disparities. All US counties were then stratified into low- and high-SVI groups, facilitating comparison of SVI rankings by estimation of excess-deaths per 1 000 000 person-years attributable to greater social vulnerability and rate ratios (RR) through univariable Poisson regression. We identified a total of 1026 deaths related to PPCM between 1999 and 2020. Overall AAMR increased from 0.180 in 1999 to 0.326 in 2020. Black populations (AAMR: 1.081) and Southern US counties (AAMR: 0.444) had the highest AAMRs compared with other racial and US census groups, respectively. Higher SVI accounted for 0.172 excess deaths per 1 000 000 person-years (RR=1.800). Among Black and White populations, higher SVI also accounted for 0.248 and 0.071 excess deaths per 1 000 000 person-years, respectively. Similar impacts of greater social vulnerability were observed when comparing the US census regions (Northeast RR=1.609, Midwest RR=1.819, South RR=1.934, West RR=1.776).

CONCLUSIONS

PPCM mortality disparities exist across racial and geographic populations in the United States. A greater burden of social vulnerability is associated with higher PPCM mortality on a national level.

Social Vulnerability, Intervention Utilization, and Outcomes in US Adults Hospitalized With Influenza

Importance

Seasonal influenza is associated with substantial disease burden. The relationship between census tract-based social vulnerability and clinical outcomes among patients with influenza remains unknown.

Objective

To characterize associations between social vulnerability and outcomes among patients hospitalized with influenza and to evaluate seasonal influenza vaccine and influenza antiviral utilization patterns across levels of social vulnerability.

Design, Setting, and Participants

This retrospective repeated cross-sectional study was conducted among adults with laboratory-confirmed influenza-associated hospitalizations from the 2014 to 2015 through the 2018 to 2019 influenza seasons. Data were from a population-based surveillance network of counties within 13 states. Data analysis was conducted in December 2023.

Exposure

Census tract-based social vulnerability.

Main Outcomes and Measures

Associations between census tract-based social vulnerability and influenza outcomes (intensive care unit admission, invasive mechanical ventilation and/or extracorporeal membrane oxygenation support, and 30-day mortality) were estimated using modified Poisson regression as adjusted prevalence ratios. Seasonal influenza vaccine and influenza antiviral utilization were also characterized across levels of social vulnerability.

Results

Among 57 964 sampled cases, the median (IQR) age was 71 (58-82) years; 55.5% (95% CI, 51.5%-56.0%) were female; 5.2% (5.0%-5.4%) were Asian or Pacific Islander, 18.3% (95% CI, 18.0%-18.6%) were Black or African American, and 64.6% (95% CI, 64.2%-65.0%) were White; and 6.6% (95% CI, 6.4%-68%) were Hispanic or Latino and 74.7% (95% CI, 74.3%-75.0%) were non-Hispanic or Latino. High social vulnerability was associated with higher prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support (931 of 13 563 unweighted cases; adjusted prevalence ratio [aPR], 1.25 [95% CI, 1.13-1.39]), primarily due to socioeconomic status (790 of 11 255; aPR, 1.31 [95% CI, 1.17-1.47]) and household composition and disability (773 of 11 256; aPR, 1.20 [95% CI, 1.09-1.32]). Vaccination status, presence of underlying medical conditions, and respiratory symptoms partially mediated all significant associations. As social vulnerability increased, the proportion of patients receiving seasonal influenza vaccination declined (-19.4% relative change across quartiles; P < .001) as did the proportion vaccinated by October 31 (-6.8%; P < .001). No differences based on social vulnerability were found in in-hospital antiviral receipt, but early in-hospital antiviral initiation (-1.0%; P = .01) and prehospital antiviral receipt (-17.3%; P < .001) declined as social vulnerability increased.

Conclusions and Relevance

In this cross-sectional study, social vulnerability was associated with a modestly increased prevalence of invasive mechanical ventilation and/or extracorporeal membrane oxygenation support among patients hospitalized with influenza. Contributing factors may have included worsened baseline respiratory health and reduced receipt of influenza prevention and prehospital or early in-hospital treatment interventions among persons residing in low socioeconomic areas.

Functional Capacity, Functional Performance, and Symptoms in People With Heart Failure: An Integrative Review

BACKGROUND

Heart failure (HF) is a clinical syndrome that has a negative effect on functional status, a multidimensional concept characterizing one's ability to provide for the necessities of life. Symptoms might be associated with different aspects of functional status in HF. However, the terms functional capacity and performance have been misused interchangeably, and no previous review has focused on the extent to which symptoms contribute to functional capacity and performance among people with HF.

OBJECTIVE

The aim of this study was to comprehensively review and synthesize the existing literature on the relationship between symptoms, functional capacity, and functional performance in people with HF.

METHODS

We conducted an integrated review of observational studies in which authors examined the relationship between at least 1 symptom and at least 1 aspect of functional capacity or performance in people with HF 18 years or older. The Joanna Briggs Institute's critical appraisal tools were used to analyze the quality of studies.

RESULTS

We included 23 studies with 7219 participants and an age range of 40 to 86 years. Fifteen symptom measures were used to measure dyspnea, fatigue, pain, insomnia symptoms, depressive symptoms, and anxiety symptoms. Three functional capacity measures were assessed in 9 studies, and 7 functional performance measures were assessed in 17 studies. As often measured with the Six-Minute Walk Test, functional capacity was inversely associated with pain/discomfort, insomnia symptoms, and psychological symptoms. Functional performance, often measured by the New York Heart Association functional class and Medical Outcome Scale Short Form 36, was associated with sleep difficulties, fatigue, depressive symptoms, and anxiety. Four studies combined functional capacity and performance measures to elicit functional status. Depressive symptoms, fatigue, pain, and insomnia symptoms are associated with decreased functional performance and capacity.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Commonly, symptoms experienced in HF are associated with declining functional status. However, this finding depends on the measures or metrics used to assess symptoms, functional capacity, and performance. The observed dissimilarities in the relationship between symptoms and functional capacity and performance highlight the conceptual distinctions, suggesting that authors of future studies should judiciously select appropriate dimensions and measures of functional status based on the study's purposes, design, and available resource.

The Most Socially Vulnerable Patients Benefit the Most Following Gender Affirming Facial Surgery

OBJECTIVE

While studies have shown that access to facial feminization surgery can be restricted by financial and geographic limitations, there is a lack of information on the impact of surgery on the most vulnerable patients. Therefore, this study assessed the impact of social vulnerability and neighborhood socioeconomic disadvantage on patient-reported outcomes after facial feminization surgery.

METHODS

Patients were surveyed pre and postoperatively using the FACE-Q Aesthetics Questionnaire and geo-coded using home addresses to obtain social vulnerability index (SVI) and Area Deprivation Index scores. Two sets of Pearson correlation values were calculated: (1) between SVI scores and each of the pre and postoperative FACE-Q modules and (2) between SVI scores and differences between pre and postoperative FACE-Q modules. Univariate linear regression analyses were performed for the latter. All analyses were repeated for Area Deprivation Index scores.

RESULTS

Twenty patients participated in this study. Postoperative facial appearance satisfaction positively correlated with total SVI (r = 0.48, P = 0.031), socioeconomic status theme (r=0.47, P=0.037), and racial and ethnic minority theme (r = 0.48, P = 0.031) scores. The difference between pre and postoperative facial appearance satisfaction positively correlated with total SVI (coefficient = 37.40, r = 0.47, P = 0.035), racial and ethnic minority theme (coefficient = 44.00, r = 0.46, P = 0.040), and housing type and transportation theme (coefficient = 46.97, r = 0.46, P = 0.042) scores.

CONCLUSION

Patients impacted by greater social vulnerability disproportionally experience the greatest benefit from gender-affirming facial surgery.

Social Vulnerability Index and All-Cause Mortality After Acute Ischemic Stroke, Medicare Cohort 2020-2023

Background

Inequities in stroke outcomes have existed for decades, and the COVID-19 pandemic amplified these inequities.

Objectives

This study examined the association between social vulnerability and all-cause mortality among Medicare beneficiaries hospitalized with acute ischemic stroke (AIS) during COVID-19 pandemic periods.

Methods

We analyzed data on Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with AIS between April 1, 2020, and December 31, 2021 (followed until December 31, 2023) merged with county-level data from the 2020 Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry's Social Vulnerability Index (SVI). We used a Cox proportional hazard model to examine the association between SVI quartile and all-cause mortality.

Results

Among 176,123 Medicare fee-for-service beneficiaries with AIS, 29.9% resided in the most vulnerable counties (SVI quartile 4), while 14.9% resided in counties with least social vulnerability (SVI quartile 1). AIS Medicare beneficiaries living in the most vulnerable counties had the highest proportions of adults aged 65 to 74 years, non-Hispanic Black or Hispanic, severe stroke at admission, a history of COVID-19, and more prevalent comorbidities. Compared to those living in least vulnerable counties, AIS Medicare beneficiaries living in most vulnerable counties had significantly higher all-cause mortality (adjusted HR: 1.11, 95% CI: 1.08-1.14). The pattern of association was largely consistent in subgroup analyses by age group, sex, and race and ethnicity.

Conclusions

Higher social vulnerability levels were associated with increased all-cause mortality among AIS Medicare beneficiaries. To improve outcomes and address disparities, it may be important to focus efforts toward addressing social vulnerability.

Medicare Advantage Plan Star Ratings and County Social Vulnerability

Importance

The star rating of a Medicare Advantage (MA) plan is meant to represent plan performance, and it determines the size of quality bonuses. Consumer access to MA plans with a high star rating may vary by the extent of social vulnerability in geographic regions.

Objective

To examine the association between a county's Social Vulnerability Index (SVI) and the star rating of a county's MA plans.

Design, Setting, and Participants

This cross-sectional study used 2023 Centers for Medicare & Medicaid Services data for all MA plans linked to 2020 county-level SVI data from the Centers for Disease Control and Prevention. Data were analyzed from March to October 2023.

Exposure

Quintile rank of county based on composite and theme-specific SVI scores, with quartile 1 (Q1) representing the least vulnerable counties and Q5, the most vulnerable counties. The SVI is a multidimensional measure of a county's social vulnerability across 4 themes: socioeconomic status, household characteristics (such as disability, age, and language), racial and ethnic minority status, and housing type and transportation.

Main Outcomes and Measures

County-level mean star rating and the number of MA plans with low-rated (<3.5 stars), high-rated (3.5 or 4.0 stars), and highest-rated (≥4.5 stars) plans.

Results

Across 3075 counties, the median county-level star rating was 4.1 (IQR, 3.9-4.3) in Q1 counties and 3.8 (IQR, 3.6-4.0) in Q5 counties (P < .001). The mean star rating of MA plans was lower (difference, -0.24 points; 95% CI, -0.28 to -0.21 points; P < .001), the number of low-rated plans was higher (incidence rate ratio, 1.81; 95% CI, 1.61-2.06; P < .001), and the number of highest-rated plans was lower (incidence rate ratio, 0.75; 95% CI, 0.70-0.81; P < .001) in Q5 counties compared with Q1 counties. Similar patterns were found across theme-specific SVI score quintiles and for 2022 star ratings.

Conclusions and Relevance

In this cross-sectional study, the most socially vulnerable counties were found to have the fewest highest-rated plans for MA beneficiaries. As MA enrollment grows in socially vulnerable regions, this may exacerbate regional differences in health outcomes for Medicare beneficiaries.

Mapping the Ecological Terrain of Stroke Prehospital Delay: A Nationwide Registry Study

BACKGROUND

Delays in hospital presentation limit access to acute stroke treatments. While prior research has focused on patient-level factors, broader ecological and social determinants have not been well studied. We aimed to create a geospatial map of prehospital delay and examine the role of community-level social vulnerability.

METHODS

We studied patients with ischemic stroke who arrived by emergency medical services in 2015 to 2017 from the American Heart Association Get With The Guidelines-Stroke registry. The primary outcome was time to hospital arrival after stroke (in minutes), beginning at last known well in most cases. Using Geographic Information System mapping, we displayed the geography of delay. We then used Cox proportional hazard models to study the relationship between community-level factors and arrival time (adjusted hazard ratios [aHR] <1.0 indicate delay). The primary exposure was the social vulnerability index (SVI), a metric of social vulnerability for every ZIP Code Tabulation Area ranging from 0.0 to 1.0.

RESULTS

Of 750 336 patients, 149 145 met inclusion criteria. The mean age was 73 years, and 51% were female. The median time to hospital arrival was 140 minutes (Q1: 60 minutes, Q3: 458 minutes). The geospatial map revealed that many zones of delay overlapped with socially vulnerable areas (https://harvard-cga.maps.arcgis.com/apps/webappviewer/index.html?id=08f6e885c71b457f83cefc71013bcaa7). Cox models (aHR, 95% CI) confirmed that higher SVI, including quartiles 3 (aHR, 0.96 [95% CI, 0.93-0.98]) and 4 (aHR, 0.93 [95% CI, 0.91-0.95]), was associated with delay. Patients from SVI quartile 4 neighborhoods arrived 15.6 minutes [15-16.2] slower than patients from SVI quartile 1. Specific SVI themes associated with delay were a community's socioeconomic status (aHR, 0.80 [95% CI, 0.74-0.85]) and housing type and transportation (aHR, 0.89 [95% CI, 0.84-0.94]).

CONCLUSIONS

This map of acute stroke presentation times shows areas with a high incidence of delay. Increased social vulnerability characterizes these areas. Such places should be systematically targeted to improve population-level stroke presentation times.

Understanding individual health-related social needs in the context of area-level social determinants of health: The case for granularity

Introduction

Screening for health-related social needs (HRSNs) within health systems is a widely accepted recommendation, however challenging to implement. Aggregate area-level metrics of social determinants of health (SDoH) are easily accessible and have been used as proxies in the interim. However, gaps remain in our understanding of the relationships between these measurement methodologies. This study assesses the relationships between three area-level SDoH measures, Area Deprivation Index (ADI), Social Deprivation Index (SDI) and Social Vulnerability Index (SVI), and individual HRSNs among patients within one large urban health system.

Methods

Patients screened for HRSNs between 2018 and 2019 (N = 45,312) were included in the analysis. Multivariable logistic regression models assessed the association between area-level SDoH scores and individual HRSNs. Bivariate choropleth maps displayed the intersection of area-level SDoH and individual HRSNs, and the sensitivity, specificity, and positive and negative predictive values of the three area-level metrics were assessed in relation to individual HRSNs.

Results

The SDI and SVI were significantly associated with HRSNs in areas with high SDoH scores, with strong specificity and positive predictive values (∼83% and ∼78%) but poor sensitivity and negative predictive values (∼54% and 62%). The strength of these associations and predictive values was poor in areas with low SDoH scores.

Conclusions

While limitations exist in utilizing area-level SDoH metrics as proxies for individual social risk, understanding where and how these data can be useful in combination is critical both for meeting the immediate needs of individuals and for strengthening the advocacy platform needed for resource allocation across communities.

Area-Level Socioeconomic Disadvantage and Health Care Spending: A Systematic Review

Importance

Publicly available, US Census-based composite measures of socioeconomic disadvantage are increasingly being used in a wide range of clinical outcomes and health services research. Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) are 2 of the most commonly used measures. There is also early interest in incorporating area-level measures to create more equitable alternative payment models.

Objective

To review the evidence on the association of ADI and SVI with health care spending, including claims-based spending and patient-reported barriers to care due to cost.

Evidence Review

A systematic search for English-language articles and abstracts was performed in the PubMed, Web of Science, Embase, and Cochrane databases (from inception to March 1, 2023). Peer-reviewed articles and abstracts using a cross-sectional, case-control, or cohort study design and based in the US were identified. Data analysis was performed in March 2023.

Findings

This review included 24 articles and abstracts that used a cross-sectional, case-control, or cohort study design. In 20 of 24 studies (83%), ADI and SVI were associated with increased health care spending. No association was observed in the 4 remaining studies, mostly with smaller sample sizes from single centers. In adjusted models, the increase in spending associated with higher ADI or SVI residence was $574 to $1811 for index surgical hospitalizations, $3003 to $24 075 for 30- and 90-day episodes of care, and $3519 for total annual spending for Medicare beneficiaries. In the studies that explored mechanisms, postoperative complications, readmission risk, and poor primary care access emerged as health care system-related drivers of increased spending.

Conclusions and Relevance

The findings of this systematic review suggest that both ADI and SVI can play important roles in efforts to understand drivers of health care spending and in the design of payment and care delivery programs that capture aspects of social risk. At the health care system level, higher health care spending and poor care access associated with ADI or SVI may represent opportunities to codesign interventions with patients from high ADI or SVI areas to improve access to high-value health care and health promotion more broadly.

The interruption of romosozumab treatment during COVID lockdown among US post-menopausal women enrolled in Medicare

PURPOSE

To evaluate the impact of the COVID lock-down on treatment interruptions of romosozumab, a first in class biologic therapy, administered by healthcare providers once monthly.

METHODS

We used Medicare data from 1/1/2017 to 9/30/2021 to identify women age ≥65 initiating romosozumab between 4/1/2019 and 6/30/2021. Patient demographics, provider specialty, and baseline comorbidities were identified. Romosozumab dispensations were grouped into five 6-month periods based on the dispensing date from FDA licensure to the end of the data (Period 1 to 5). "Treatment interruption" was defined as any interval gap between 2 dispensations >60 days. The numbers of treatment interruption event were aggregated per period per patient. Mixed effect Poisson regression with patient-level random effects was performed, including an interaction term between Period and number of prior doses.

RESULTS

There were 12,216 romosozumab new users identified. A total of 2724 treatment interruption events were identified among 2229 romosozumab users. After adjustment, comparing with the period immediately before the lockdown (Period 2: 2019-10-1-2020-3-30), the IRRs (95 % CI) for treatment interruption were 0.49 (0.29, 0.81), 1.65 (1.48, 1.85), 1.79 (1.60, 2.01), and 1.67 (1.49, 1.87) for periods 1, 3, 4, and 5, respectively, per 1 prior dose change (p < 0.01 for all IRRs), where Periods 3, 4, and 5 were post-lockdown.

CONCLUSION

Compared to the pre-COVID period, the lockdown negatively impacted the continuity of romosozumab treatment among Medicare beneficiaries. Prioritizing in-time assistance for patients receiving a provider-administered parenteral therapy is critical when patients' in-person access to their provider is compromised.

Sociodemographic Disparities in Ambulatory Pediatric Telemedicine Utilization During COVID-19

Objective: Few studies have examined sociodemographic disparities in ambulatory pediatric telemedicine utilization during the coronavirus disease 2019 pandemic. We aimed to (1) assess disparities in telemedicine visit completion during the first 6 weeks of the pandemic in 2020 and (2) determine if these disparities were significantly different from those present in 2019, when all visits occurred in person. Methods: We compared sociodemographic characteristics of patients with successful versus unsuccessful telemedicine visits from March 10, 2020 to April 18, 2020, using generalized linear mixed models. We performed the same analysis for in-person visits from the same period in 2019. We tested for differences across years using interaction terms in a combined 2019-2020 model. Results: Of 3,639 telemedicine visits scheduled, 3,033 (83.3%) were successful. In 2020, Black/African American race was significantly associated with lower odds of telemedicine visit success (odds ratio 0.65 [95% confidence interval 0.49-0.87]) compared with White race, after adjusting for age, gender, ethnicity, insurance type, visit timing, visit specialty, social vulnerability index, and internet access. In 2019, racial identity other than White was significantly associated with lower odds of in-person visit success than White, as was public insurance compared with private. In the full 2019-2020 model, in-person visits (2019) had lower odds of success than telemedicine visits (2020), and neither race, insurance type, nor any other sociodemographic characteristic had significant interactions with year. Conclusions: Racial disparities were evident in telemedicine utilization early in the pandemic; however, these disparities were not significantly different from those seen in 2019, when all visits were in person. Furthermore, telemedicine may improve access to care overall, despite having no significant impact on inequity. Efforts to eliminate racial disparities in ambulatory pediatric health care utilization are necessary across visit modalities.

Public Insurance and Single-Guardian Households Are Associated with Diagnostic Delay in Slipped Capital Femoral Epiphysis

BACKGROUND

Extensive literature documents the adverse sequelae of delayed diagnosis of slipped capital femoral epiphysis (SCFE), including worsening deformity and surgical complications. Less is known about predictors of delayed diagnosis of SCFE, particularly the effects of social determinants of health. The purpose of this study was to evaluate the impact of insurance type, family structure, and neighborhood-level socioeconomic vulnerability on the delay of SCFE diagnosis.

METHODS

We reviewed medical records of patients who underwent surgical fixation for stable SCFE at a tertiary pediatric hospital from 2002 to 2021. We abstracted data on demographic characteristics, insurance status, family structure, home address, and symptom duration. We measured diagnostic delay in weeks from the date of symptom onset to diagnosis. We then geocoded patient addresses to determine their Census tract-level U.S. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI), using U.S. Census and American Community Survey data. We performed 3 separate logistic regression models to examine the effects of (1) insurance status, (2) family structure, and (3) SVI on a delay of ≥12 weeks (reference, <12 weeks). We adjusted for age, sex, weight status, number of siblings, and calendar year.

RESULTS

We identified 351 patients with SCFE; 37% (129) had a diagnostic delay of ≥12 weeks. In multivariable logistic regression models, patients with public insurance were more likely to have a delay of ≥12 weeks than patients with private insurance (adjusted odds ratio [OR], 1.83 [95% confidence interval (CI), 1.12 to 2.97]; p = 0.015) and patients from single-guardian households were more likely to have a delay of ≥12 weeks than patients from multiguardian households (adjusted OR, 1.95 [95% CI, 1.11 to 3.45]; p = 0.021). We did not observe a significant increase in the odds of delay among patients in the highest quartile of overall SVI compared with patients from the lower 3 quartiles, in both the U.S. comparison (adjusted OR, 1.43 [95% CI, 0.79 to 2.58]; p = 0.24) and the Massachusetts comparison (adjusted OR, 1.45 [95% CI, 0.79 to 2.66]; p = 0.23).

CONCLUSIONS

The delay in diagnosis of SCFE remains a concern, with 37% of patients with SCFE presenting with delay of ≥12 weeks. Public insurance and single-guardian households emerged as independent risk factors for diagnostic delay. Interventions to reduce delay may consider focusing on publicly insured patients and those from single-guardian households.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Bacterial Proteases as Potentially Exploitable Modulators of SARS-CoV-2 Infection: Logic from the Literature, Informatics, and Inspiration from the Dog

(1) Background: The COVID-19 pandemic left many intriguing mysteries. Retrospective vulnerability trends tie as strongly to odd demographics as to exposure profiles, genetics, health, or prior medical history. This article documents the importance of nasal microbiome profiles in distinguishing infection rate trends among differentially affected subgroups. (2) Hypothesis: From a detailed literature survey, microbiome profiling experiments, bioinformatics, and molecular simulations, we propose that specific commensal bacterial species in the Pseudomonadales genus confer protection against SARS-CoV-2 infections by expressing proteases that may interfere with the proteolytic priming of the Spike protein. (3) Evidence: Various reports have found elevated Moraxella fractions in the nasal microbiomes of subpopulations with higher resistance to COVID-19 (e.g., adolescents, COVID-19-resistant children, people with strong dietary diversity, and omnivorous canines) and less abundant ones in vulnerable subsets (the elderly, people with narrower diets, carnivorous cats and foxes), along with bioinformatic evidence that Moraxella bacteria express proteases with notable homology to human TMPRSS2. Simulations suggest that these proteases may proteolyze the SARS-CoV-2 spike protein in a manner that interferes with TMPRSS2 priming.

Greater spatial access to care is associated with lower mortality for emergency general surgery

BACKGROUND

Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions.

METHODS

A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity.

RESULTS

A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity.

CONCLUSION

This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.