Data aggregation hides Pacific Islander health disparities

Site-specific patterns of early-stage cancer diagnosis during the COVID-19 pandemic

The COVID-19 pandemic caused widespread disruptions in cancer care. We hypothesized that the greatest disruptions in diagnosis occurred in screen-detected cancers. We identified patients (≥18 years of age) with newly diagnosed cancer from 2019 to 2020 in the US National Cancer Database and calculated the change in proportion of early-stage to late-stage cancers using a weighted linear regression. Disruptions in early-stage diagnosis were greater than in late-stage diagnosis (17% vs 12.5%). Melanoma demonstrated the greatest relative decrease in early-stage vs late-stage diagnosis (22.9% vs 9.2%), whereas the decrease was similar for pancreatic cancer. Compared with breast cancer, cervical, melanoma, prostate, colorectal, and lung cancers showed the greatest disruptions in early-stage diagnosis. Uninsured patients experienced greater disruptions than privately insured patients. Disruptions in cancer diagnosis in 2020 had a larger impact on early-stage disease, particularly screen-detected cancers. Our study supports emerging evidence that primary care visits may play a critical role in early melanoma detection.

Racial Disparities in 30-day Readmissions after Surgery for Head and Neck Cancer

BACKGROUND

Native Hawaiians and other Pacific Islanders (NHPI) patients with head and neck cancer are often aggregated with Asian individuals despite evidence of heterogeneous health outcomes and mortality. The aim of this study was to determine the association of race with unplanned 30-day hospital readmission rate after head and neck surgery across the five federally recognized racial categories.

METHODS

This retrospective cohort study used a national hospital-based database and included patients ≥18 years old with diagnostically confirmed, nonmetastatic head and neck cancer of any subsite treated surgically between 2004 and 2017. The primary endpoint was unplanned readmission within 30 days of discharge after primary surgery.

RESULTS

A total of 365,834 patients were included who were predominantly White (87%), treated at academic cancer centers (47%), lower income (63%), with early-stage disease (60%), and with thyroid (47%) or oral cavity (23%) cancers. Median follow-up duration was 47 months. Of the 10,717 (3%) readmissions, 5,845 (1.6%) were unplanned. Adjusted for confounders and compared with White patients, NHPI patients had the highest likelihood of unplanned (aOR 2.07, 95%CI 1.16-3.40, p = 0.008) readmissions. Within the NHPI group, patients with lower income (aOR 4.27, 95%CI 1.28-20.4, p = 0.035) and those residing in an urban or rural area (aOR 7.42, 95%CI 1.14-49.5, p = 0.034) were more likely to be readmitted.

CONCLUSIONS

NHPI patients with head and neck cancers experience significantly higher 30-day readmissions following definitive surgical treatment. These results highlight the importance of racial disaggregation in clinical studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1282-1287, 2024.

Demographic and Socioeconomic Trends in Cervical Fusion Utilization from 2004 Through 2021 and the COVID-19 Pandemic

BACKGROUND

Cervical fusion rates increased in the U.S. exponentially 1990-2014, but trends leading up to/during the COVID-19 pandemic have not been fully evaluated by patient socioeconomic status (SES). Here, we provide the most recent, comprehensive characterization of demographic and SES trends in cervical fusions, including during the pandemic.

METHODS

We collected the following variables on adults undergoing cervical fusions, 1/1/2004-3/31/2021, in Optum's Clinformatics Data Mart: age, Charlson Comorbidity Index, provider's practicing state, gender, race, education, and net worth. We performed multivariate linear and logistic regression to evaluate associations of cervical fusion rates with SES variables.

RESULTS

Cervical fusion rates increased 2004-2016, then decreased 2016-2020. Proportions of Asian, Black, and Hispanic patients undergoing cervical fusions increased (OR = 1.001,1.001,1.004, P < 0.01), with a corresponding decrease in White patients (OR = 0.996, P < 0.001) over time. There were increases in cervical fusions in higher education groups (OR = 1.006, 1.002, P < 0.001) and lowest net worth group (OR = 1.012, P < 0.001). During the pandemic, proportions of White (OR = 1.015, P < 0.01) and wealthier patients (OR ≥ 1.015, P < 0.01) undergoing cervical fusions increased.

CONCLUSIONS

We present the first documented decrease in annual cervical surgery rates in the U.S. Our data reveal a bimodal distribution for cervical fusion patients, with racial-minority, lower-net-worth, and highly-educated patients receiving increasing proportions of surgical interventions. White and wealthier patients were more likely to undergo cervical fusions during the COVID-19 pandemic, which has been reported in other areas of medicine but not yet in spine surgery. There is still considerable work needed to improve equitable access to spine care for the entire U.S.

POPULATION

East is east … or is it? Racialization of Asian, Middle Eastern, and Pacific Islander persons

The conventional use of racial categories in health research naturalizes "race" in problematic ways that ignore how racial categories function in service of a White-dominated racial hierarchy. In many respects, racial labels are based on geographic designations. For instance, "Asians" are from Asia. Yet, this is not always a tenable proposition. For example, Afghanistan resides in South Asia, and shares a border with China and Pakistan. Yet, people from Afghanistan are not considered Asian, but Middle Eastern, by the US Census. Furthermore, people on the west side of the Island of New Guinea are considered Asian, whereas those on the eastern side are considered Pacific Islander. In this article, we discuss the complexity of the racial labels related to people originating from Oceania and Asia, and, more specifically, those groups commonly referred to as Pacific Islander, Middle Eastern, and Asian. We begin with considerations of the aggregation fallacy. Just as the ecological fallacy refers to erroneous inferences about individuals from group data, the aggregation fallacy refers to erroneous inferences about subgroups (eg, Hmong) from group data (ie, all Asian Americans), and how these inferences can contribute to stereotypes such as the "model minority." We also examine how group averages can be influenced merely by the composition of the subgroups, and how these, in turn, can be influenced by social policies. We provide a historical overview of some of the issues facing Pacific Islander, Middle Eastern, and Asian communities, and conclude with directions for future research.

Rising From Ruin-Revitalizing Native Hawaiian Health

This Viewpoint offers insight into the health effects of the recent fires in Hawaiʻi and what culturally conscious approaches are needed to ensure the health of Native Hawaiians going forward.

Chronic Hypertension in Pregnancy and Racial-Ethnic Disparities in Complications

OBJECTIVE

To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups.

METHODS

This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups.

RESULTS

The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively.

CONCLUSION

Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander.

Ethnic differences in respiratory disease for Native Hawaiians and Pacific Islanders: Analysis of mediation processes in two community samples

OBJECTIVE

The prevalence of asthma and chronic obstructive pulmonary disorder (COPD) is elevated for Native Hawaiians but the basis for this differential is not well understood. We analyze data on asthma and COPD in two samples including Native Hawaiians Pacific Islanders, and Filipinos to determine how ethnicity is related to respiratory disease outcomes.

METHODS

We analyzed the 2016 and 2018 Behavioral Risk Factor Surveillance Survey (BRFSS), a telephone survey of participants ages 18 and over in the State of Hawaii. Criterion variables were a diagnosis of asthma or COPD by a health professional. Structural equation modeling tested how five hypothesized risk factors (cigarette smoking, e-cigarette use, second-hand smoke exposure, obesity, and financial stress) mediated the ethnic differential in the likelihood of disease. Age, sex, and education were included as covariates.

RESULTS

Structural modeling with 2016 data showed that Native Hawaiian ethnicity was related to higher levels of the five risk factors and each risk factor was related to a higher likelihood of respiratory disease. Indirect effects were statistically significant in almost all cases, with direct effects to asthma and COPD also observed. Mediation effects through comparable pathways were also noted for Pacific Islanders and Filipinos. These findings were replicated with data from the 2018 survey.

CONCLUSIONS

Native Hawaiian and Pacific Islander ethnicity is associated with greater exposure to five risk factors and this accounts in part for the ethnic differential in respiratory disease outcomes. The results support a social-ecological model of health disparities in this population. Implications of the findings for preventive interventions are discussed.

Inequities in Patient Access to Care Among Asian American, Native Hawaiian, and Pacific Islander Adults in Medicaid

BACKGROUND

Despite decades of advocacy for disaggregated data collection and reporting for Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) people, significant gaps remain in our ability to understand AA and NHPI individuals' access to care. We assess inequities in access to care measures between non-Hispanic White and AA and NHPI adult Medicaid enrollees.

METHODS

We used the 2014-15 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems, the first-and-only nationally representative sample of Medicaid enrollees. Our main outcomes were access to needed care, access to a personal doctor, timely access to a checkup, and timely access to specialty care. Using multivariable linear probability models, we assessed the relationship between racial/ethnic group and our outcomes, both in the aggregate and disaggregated into ten racial/ethnic groups, and adjusted for enrollee-level sociodemographic characteristics, health status, and state-level Medicaid expansion status.

RESULTS

In aggregate, AA and NHPI enrollees reported worse access to care than White enrollees on all four metrics (p < 0.001). The magnitude of disparities varied across the ten AA and NHPI ethnic groups. Disparities relative to White enrollees were particularly large in magnitude, roughly 1.5 to 2 times greater, for Chinese, Korean, and Vietnamese enrollees than for the aggregated AA and NHPI group.

CONCLUSIONS

Despite comparable insurance coverage, there were inequities in multiple access to care metrics between non-Hispanic White and AA and NHPI Medicaid enrollees. Collection of disaggregated health data on AA and NHPI patients reveals important variation in access to care by ethnic group.

Clinical Trajectories in Adolescents with and without a History of Non-Suicidal Self-Injury: The BRIDGES Longitudinal Study

Background

Non-suicidal self-injury (NSSI) is a highly prevalent clinical concern in adolescents and is associated with impaired functioning and suicide risk. The BRIDGES (BRain Imaging Development of Girls' Emotion and Self) study was designed to collect longitudinal clinical and neurobiological data to advance our understanding of NSSI in adolescents. The purpose of this paper is to describe the clinical data collected as part of this study, including psychiatric diagnoses, depression symptoms, episodes of non-suicidal self-injury, suicidal thoughts and behaviors, childhood trauma, and personality domains.

Methods

The baseline sample included 164 adolescents aged 12-16 assigned female at birth (Mean age = 14.97, SD = 1.20) with NSSI histories ranging from none to severe. Participants and their parent/guardian were invited to provide data at three time points spaced approximately one year apart. Descriptive analyses were conducted to provide estimates of rates and trajectories of clinical data.

Results

Of the 164 study participants, 75.61% and 57.93% completed the second and third time points, respectively. Visual inspection of the data suggests an overall trend of decreasing severity of psychopathology over time, and adolescents with a history of NSSI appeared to have higher rates of psychopathology than those without.

Conclusions

This paper describes longitudinal clinical trajectories in adolescents with a range of NSSI histories and presents readers with an overview of the rich, publicly available dataset that we hope will inspire future research to advance the understanding of the neurodevelopmental trajectories associated with NSSI, depression, and suicide risk.

Racial Disparities among Asian American, Native Hawaiian, and Other Pacific Islander Patients with Cancer Who Refuse Recommended Radiation Therapy or Surgery

Despite radiation therapy (RT) and surgery being the curative treatments, prior work demonstrated that the aggregated Asian American (AA) and Native Hawaiian and Other Pacific Islanders (NHPI) population refuse RT and surgery at a higher rates than other races. Given that AA and NHPI are distinct groups, data disaggregation is necessary to understand racial and ethnic disparities for treatment refusal. We aimed to (1) compare RT and surgery refusal rates between AA and NHPI populations, (2) assess RT and surgery refusal on overall mortality, and (3) determine predictors of refusing RT and surgery using the United States (U.S.) National Cancer Database. Adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for treatment refusal were calculated using logistic regression. Adjusted hazard ratios (aHR) were calculated for overall survival using Cox proportional hazard models among propensity score-matched groups. The overall rate of RT refusal was 4.8% and surgery refusal was 0.8%. Compared to East AA patients, NHPI patients had the highest risk of both RT refusal (aOR = 1.38, 95%CI = 1.21-1.61) and surgery refusal (aOR = 1.28, 95%CI = 1.00-1.61). RT refusal significantly predicted higher mortality (aHR = 1.17, 95%CI = 1.08-1.27), whereas surgery refusal did not. Predictors of RT and surgery refusal were older patient age, high comorbidity index, and cancer diagnosis between 2011-2017. The results show heterogenous treatment refusal patterns among AA and NHPI populations, suggesting areas for targeted intervention.

Racial Disparities in Brachytherapy Treatment among Women with Cervical and Endometrial Cancer in the United States

Brachytherapy improves clinical outcomes among women diagnosed with cervical and endometrial cancers. Recent evidence demonstrates that declining brachytherapy boosts for women with cervical cancer were associated with higher mortality. In this retrospective cohort study, women diagnosed with endometrial or cervical cancer in the United States between 2004 and 2017 were selected from the National Cancer Database for evaluation. Women ≥18 years of age were included for high intermediate risk (PORTEC-2 and GOG-99 definition) or FIGO Stage II-IVA endometrial cancers and FIGO Stage IA-IVA-non-surgically treated cervical cancers. The aims were to (1) evaluate brachytherapy treatment practice patterns for cervical and endometrial cancers in the United States; (2) calculate rates of brachytherapy treatment by race; and (3) determine factors associated with not receiving brachytherapy. Treatment practice patterns were evaluated over time and by race. Multivariable logistic regression assessed predictors of brachytherapy. The data show increasing rates of brachytherapy for endometrial cancers. Compared to non-Hispanic White women; Native Hawaiian and other Pacific Islander (NHPI) women with endometrial cancer and Black women with cervical cancer were significantly less likely to receive brachytherapy. For both NHPI and Black women, treatment at community cancer centers was associated with a decreased likelihood of brachytherapy. The data suggest racial disparities among Black women with cervical cancer and NHPI women with endometrial cancer and emphasize an unmet need for brachytherapy access within community hospitals.

Human papillomavirus-associated cancer incidence by disaggregated Asian American, Native Hawaiian, and other Pacific Islander ethnicity

BACKGROUND

Asian Americans and Native Hawaiians and other Pacific Islanders have suboptimal human papillomavirus (HPV) vaccination and cancer screening rates. Asian Americans and NHPIs are often aggregated, masking disparities characterized by varying colonization and immigration patterns and cultural and religious beliefs between populations and ethnicities. We examined the incidence of HPV-associated cancers across disaggregated Asian American and NHPI ethnicities.

METHODS

Using the Surveillance, Epidemiology, and End Results Detailed Asian/Pacific Islander database, we calculated 1990 to 2014 sex-specific, age-standardized HPV-associated cancer incidence of cervical carcinoma, oropharyngeal squamous cell carcinoma (SCC), vulvar SCC, vaginal SCC, anal SCC, and penile SCC by ethnicity: Asian Indian and Pakistani, Chinese, Filipino, Japanese, Kampuchean, Korean, Laotian, Native Hawaiian, other Pacific Islander, and Vietnamese. Trends by calendar period (1990 to 1996, 1997 to 2002, 2003 to 2008, 2009 to 2014) were estimated using Joinpoint regression.

RESULTS

The most common HPV-associated cancer was cervical carcinoma in women and oropharyngeal SCC in men. During 1990 to 2014, cervical carcinoma incidence per 100 000 ranged from 4.5 (Asian Indian and Pakistani) to 20.7 (Laotian). Cervical carcinoma incidence only statistically significantly declined for Asian Indian and Pakistani, Filipino, Korean, Laotian, and Vietnamese women (range = 19.9% to 44.1% decline per period). Among men, oropharyngeal SCC incidence per 100 000 ranged from 1.1 (Chinese) to 5.1 (Native Hawaiian). Oropharyngeal SCC incidence only statistically significantly increased (31.0% increase per period) for Japanese men. Heterogeneity across ethnicities were observed for other cancer sites.

CONCLUSIONS

HPV-associated cancer incidence varied widely between Asian Americans and NHPIs and by ethnicity, underscoring the need for improved data capture of ethnic groups in research and more tailored interventions to better address health disparities between Asian American and NHPI populations.

A National Cancer Disparities Analysis of Predictors for Radiation Therapy Refusal by Race

PURPOSE

Radiation therapy (RT) refusal by patients with cancer is infrequent but is significant because it portends poor outcomes. No prior study has evaluated all five federally defined racial categories with respects to RT refusal. Here we use a large nationally representative population with cancer to determine: 1) which race of patients refuse RT the most and 2) predictive factors for RT refusal by race.

MATERIALS/METHODS

A retrospective study included patients ≥18 years old with diagnostically confirmed cancer between 2004-2017, using the National Cancer Database. All patients included were offered RT for first course treatment. Multivariable logistic regression assessed RT refusal (adjusted odds ratio [aOR]) with 95% confidence intervals (95%CI). Analyses were adjusted for patient factors (age, rurality, income, education, and comorbidities) and cancer characteristics (stage, cancer type, facility type, year of diagnosis, and region). Median overall survival was calculated using the Kaplan-Meier method.

RESULTS

Of 11,609,044 patients, 2,759,753 patients were included and recommended for RT by the treating physician. Median follow-up was 50 months. RT was refused by 139,383 patients (5.0%), varying by race: 416 NHPI (7.2%), 489 AIAN (5.8%), 118,186 Non-Hispanic White (5.0%), 17,427 Black (4.8%), and 2,865 Asian (4.8%) patients. The rates of annual RT refusal were increasing, especially among NHPI patients. The populations with the highest likelihood of refusing RT were NHPI (aOR=1.53, 95%CI=1.36-1.71), AIAN (aOR=1.24, 95%CI=1.12-1.37), and Black (aOR=1.11, 95%CI=1.09-1.14) patients, compared to Non-Hispanic White patients. Older age and higher comorbidity burden predicted RT refusal across all races. Median overall survival was 81 months and 144 months for patients who refused RT and received RT, respectively.

CONCLUSIONS

Indigenous and Black patients are more likely to refuse RT, which may contribute to inferior cancer outcomes. Understanding NHPI and AIAN patient perspectives and perceptions may elucidate interventions to mitigate these disparities.