Who declines to respond to the reactions to race module?: findings from the South Carolina Behavioral Risk Factor Surveillance System, 2016-2017

Chronic Conditions and Racially Biased Healthcare Experiences Impact Breast Cancer and Colorectal Cancer Screening Across Racial/Ethnic Groups

INTRODUCTION

Mammogram uptake and colorectal cancer (CRC) screening are influenced by racially biased healthcare experiences and presence of chronic conditions; moreover, there is racially/ethnically disparate uptake of each. The current study aimed to expand on extant literature by examining the association between racially biased healthcare experiences and chronic conditions across three racial/ethnic groups.

METHODS

We conducted weighted multivariable logistic regressions to examine the interaction between chronic conditions (none, cancer, other chronic conditions) and racially biased healthcare experiences (none, better, worse, other) on mammogram and CRC screening adherence across three racial/ethnic groups (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic/non-Hispanic Other [NHO]) using 2022 Behavioral Risk Factor Surveillance System data.

RESULTS

Among 42,053 and 86,033 eligible respondents for mammogram and CRC screening, most respondents had an up-to-date mammogram (77.4%) or CRC test (67.0%). In adjusted analysis, Hispanic/NHO respondents with conditions other than cancer and felt they were treated worse than other races while seeking healthcare had a decreased odds of having an up-to-date mammogram (OR 0.21, 95% CI 0.09-0.46). NHW respondents with cancer who felt they were treated better than other races while seeking healthcare had increased odds of having an up-to-date mammogram (OR 1.70, 95% CI 1.11-2.60). All significant associations (i.e., p < 0.05) between chronic conditions and CRC screening were positive, regardless of treatment while seeking healthcare across racial/ethnic groups.

CONCLUSIONS

Culturally sensitive interventions aimed at improving patient-centered communication may improve mammogram and CRC screening adherence, particularly for racially/ethnically minoritized groups.

Impact of social determinants of health in patients undergoing percutaneous coronary intervention

BACKGROUND

Social determinants of health (SDOH) influence the outcomes of patients undergoing cardiovascular procedures. The area deprivation index (ADI) is a multidimensional tool designed to evaluate SDOH at the census block level, which has received limited study in cardiology. This study evaluated the impact of the ADI on short-term clinical outcomes after percutaneous coronary intervention (PCI).

METHODS

We analyzed patients who underwent PCI at a single center between April 2018 and June 2024. ADI was calculated for socioeconomic assessment, with patients stratified into quartiles. The primary endpoint was 30-day all-cause mortality. Multivariable analysis was used to control for confounders.

RESULTS

We included 4902 patients. The cohort's mean age was 67.8 ± 11.2 years, and 23.2 % were women. Patients in the fourth (the most deprived) ADI quartile were more likely to be Hispanic/Latino, have Medicaid/Medicare as primary insurance, and had higher rates of diabetes, prior PCI, and cardiogenic shock on presentation. They also exhibited higher procedural complexity. At 30 days, patients in the most deprived ADI quartile had the highest mortality and cardiovascular death rates (p < 0.001). On multivariable analysis, belonging to the most deprived ADI quartile was independently associated with 30-day all-cause mortality (odds ratio 1.21, 95 % confidence interval 1.10-1.71, p = 0.023), after controlling for demographics, clinical, and procedural variables.

CONCLUSIONS

Patients with high socioeconomic deprivation exhibit higher clinical and procedural complexity and have a higher risk for short-term mortality after PCI, even after controlling for confounders.

Adverse Childhood Experiences Module Nonresponse: Behavioral Risk Factor Surveillance System, 2019 and 2021

INTRODUCTION

Data on adverse childhood experiences are key to understanding their burden and informing prevention programs and strategies. Population-based surveys that collect adverse childhood experiences data may be affected by item nonresponse. This study examines differences in nonresponse to the optional Behavioral Risk Factor Surveillance System adverse childhood experiences module overall, by sociodemographic characteristics, by year, and by question.

METHODS

This study used Behavioral Risk Factor Surveillance System adverse childhood experiences module data from 21 states in 2019 and 16 states in 2021. Weighted proportions and 95% CIs of responders and nonresponders to the adverse childhood experiences module by year and sociodemographic characteristics and percentages of nonresponders for each question were calculated. Chi-square tests were used to assess statistically significant (p<0.05) differences. Analyses were conducted in 2023.

RESULTS

In 2019 and 2021, 1.2% (95% CI=1.1, 1.4) and 2.4% (95% CI=2.2, 2.5) of Behavioral Risk Factor Surveillance System participants were nonresponders to the adverse childhood experiences module, respectively (p<0.01). Nonresponders were more likely to be non-Hispanic Black (p=0.01) or non-Hispanic Asian (p=0.01), to be unemployed (p<0.01), to have income <$15,000 (p<0.01), or to report poor health (p<0.01) than responders. Nonresponse by question increased as the module progressed, and nonresponse was highest for sexual abuse questions.

CONCLUSIONS

Overall, findings demonstrate that individuals are willing to respond to the adverse childhood experiences module questions. Although low, nonresponse to the module increased from 2019 to 2021. Higher nonresponse for sexual abuse questions may be due to their sensitivity or potential survey fatigue due to placement at the end of the module. Higher nonresponse among racial/ethnic minorities and economically disadvantages groups highlights opportunities to improve existing surveillance systems.

Multidimensional Healthcare Access Barriers to Prostate-Specific Antigen Testing: A Nation-Wide Panel Study in the United States From 2006 to 2020

BACKGROUND

Rising metastatic prostate cancer incidence has renewed debate regarding benefits of prostate-specific antigen (PSA) screening. Identifying barriers to accessing screening for individuals at high risk of lethal prostate cancer may slow this rise. We examined associations of access barriers with receipt of PSA testing, stratified by sociodemographic factors.

METHODS

We pooled data from male respondents to Behavior Risk Factor Surveillance Systems (BRFSS) surveys from 2006 to 2020. Questions related to affordability (insurance, cost of visits) and accommodation (regular primary care provider (PCP), physician recommending a PSA test) were considered as individual-level barriers. For availability, we linked provider density from the 2012 Area Health Resource File and estimated driving times to closest health facility within Micropolitan and Metropolitan Statistical Area (MMSA) using Google Earth Engine. These measures were used to compute a spatial accessibility index. We fit survey-weighted, covariate-adjusted logistic regression models to estimate associations of barriers with receipt of PSA within the past 2 years and examined effect modification by sociodemographic factors.

RESULTS

There were 185,643 participants, of whom 73% were White, 11% were Black, 4% were Asian, and 11% were Hispanic. Physician recommendation was the strongest predictor of having a PSA test (aOR: 14.5, 95% CI: 13.6, 15.6). Not having a regular PCP (aOR: 0.29, 95% CI: 0.27, 0.31), insurance (aOR: 0.64, 95% CI: 0.58, 0.71), and prohibitive cost of care (aOR: 0.82, 95% CI: 0.75, 0.90) were associated with lower PSA testing. Access barriers were stronger predictors of PSA testing for Asian and White participants compared to other groups (Phet < 0.004 for insurance and regular PCP) and for those with college education compared to those without (Phet < 0.05 for insurance, perceived unaffordability).

DISCUSSION

Physician recommendation was the strongest predictor of receipt of PSA testing, regardless of sociodemographic grouping. Future studies should consider access barriers jointly and across sociodemographic strata.

Association of genetic ancestry with molecular tumor profiles in colorectal cancer

BACKGROUND

There are known disparities in incidence and outcomes of colorectal cancer (CRC) by race and ethnicity. Some of these disparities may be mediated by molecular changes in tumors that occur at different rates across populations. Genetic ancestry is a measure complementary to race and ethnicity that can overcome missing data issues and better capture genetic similarity in admixed populations. We aimed to identify somatic mutations and tumor gene expression differences associated with both genetic ancestry and imputed race and ethnicity.

METHODS

Sequencing was performed with the Tempus xT NGS 648-gene panel and whole exome capture RNA-Seq for 8454 primarily late-stage CRC patients. Genetic ancestry proportions for five continental groups-Africa (AFR), American indigenous (AMR), East Asia (EAS), Europe (EUR), and South Asia (SAS)-were estimated using ancestry informative markers. To address data gaps, race and ethnicity categories were imputed, resulting in assignments for 952 Hispanic/Latino, 420 non-Hispanic (NH) Asian, 1061 NH Black, and 5763 NH White individuals. We assessed association of genetic ancestry proportions and imputed race and ethnicity categories with somatic mutations in relevant CRC genes and in 2608 expression profiles, as well as 1957 consensus molecular subtypes (CMS).

RESULTS

Increased AFR ancestry was associated with higher odds of somatic mutations in APC, KRAS, and PIK3CA and lower odds of BRAF mutations. Additionally, increased EAS ancestry was associated with lower odds of mutations in KRAS, EUR with higher odds in BRAF, and the Hispanic/Latino category with lower odds in BRAF. Greater AFR ancestry and the NH Black category were associated with higher rates of CMS3, while a higher proportion of Hispanic/Latino patients exhibited indeterminate CMS classifications.

CONCLUSIONS

Molecular differences in CRC tumor mutation frequencies and gene expression that may underlie observed differences by race and ethnicity were identified. The association of AFR ancestry with increased KRAS mutations aligns with higher CMS3 subtype rates in NH Black patients. The increase of indeterminate CMS in Hispanic/Latino patients suggests that subtype classification methods could benefit from enhanced patient diversity.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.

Integrating Racism as a Sentinel Indicator in Public Health Surveillance and Monitoring Systems

Objectives. To evaluate public health surveillance and monitoring systems' (PHSMS) efforts to collect, monitor, track, and analyze racism. Methods. We employed an environmental scan approach. We defined key questions and data to be collected, conducted a literature review, and synthesized the results by using a qualitative description approach. Results. We identified 125 PHSMS; only 3-the Behavioral Risk Factor Surveillance System, Pregnancy Risk Assessment and Monitoring System, and California Health Interview Survey-collected and reported data on individual-level racism. Structural racism was not collected in PHSMS; however, we observed evidence for linkages to census and administrative data sets or social media sources to assess structural racism. Conclusions. There is a paucity of PHSMS that measure individual-level racism, and few systems are linked to structural racism measures. Public Health Implications. Adopting a standard practice of racism surveillance can advance equity-centered public health praxis, inform policy, and foster greater accountability among public health practitioners, researchers, and decision-makers. Failure to explicitly address racism and the insufficient capacity to support a robust health equity data infrastructure severely impedes efforts to address and dismantle systemic racism. (Am J Public Health. 2023;113(S1):S80-S84. https://doi.org/10.2105/AJPH.2022.307160).