Blacks' Diminished Health Returns of Educational Attainment: Health and Retirement Study

Chimeric Antigen Receptor T-Cell Access in Patients with Relapsed/Refractory Large B-Cell Lymphoma: Association of Access with Social Determinants of Health and Travel Time to Treatment Centers

BACKGROUND

Large B-cell lymphoma (LBCL) is the most common type of non-Hodgkin lymphoma. Chimeric antigen receptor T-cell (CAR T) therapy represents a novel treatment with curative potential for relapsed or refractory (R/R) LBCL, but there are access barriers to this innovative therapy that are not well-studied.

OBJECTIVES

(1) Assess the impact of geographic factors and social determinants of health (SDOH) on access to treatment with CAR T in a sample of patients with R/R LBCL and ≥ 2 prior lines of treatment (LOT). (2) Compare and contrast patient characteristics, SDOH, and travel time between patients with R/R LBCL who received CAR T and those who did not.

STUDY DESIGN

An observational, nested case-control study of patients with R/R LBCL, ≥ 2 prior LOT, not in a clinical trial, identified using 100% Medicare Fee-For-Service and national multi-payer claims databases. Patients were linked to near-neighborhood SDOH using 9-digit ZIP-code address. Driving distance and time between residence and nearest CAR T treatment center (TC) was calculated. Patients were stratified based on treatments received upon 3rd LOT initiation (Index Date) or later: 1) received CAR T and 2) did not receive CAR T. Multivariable logistic regression was used to evaluate factors associated with CAR T.

RESULTS

5,011 patients met inclusion criteria, with 628 (12.5%) in the CAR T group. Regression models found the likelihood of receiving CAR T decreased with patient age (OR=0.96, p<.001), and males were 29% more likely to receive CAR T (OR=1.29, p=.02). Likelihood of CAR T increased with Charlson Comorbidity Index (CCI; OR=1.07, P<.001) indicating patients with more comorbidities were more likely to receive CAR T. Black patients were less than half as likely to receive CAR T than White patients (OR=0.44, p=.01). Asian patients did not significantly differ from White patients (OR=1.43, p=.24), and there was a trend for Hispanic patients to have a slightly lower likelihood of CAR T (OR=0.50, p=0.07). Higher household income was associated with receipt of CAR T, with the lowest income group more than 50% less likely to receive CAR T than the highest (OR=0.44, p=.002), and the second lowest income group more than 30% less likely (OR=0.68, p=.02). Finally, likelihood of CAR T therapy was reduced when the driving time to the nearest TC was 121 to 240 minutes (reference group: ≤ 30 minutes; OR=0.64, p=.04). Travel times between 31 and 121 or greater than 240 minutes were not significantly different from ≤ 30 minutes. Payer type was collinear with age and could not be included in the regression analysis, but patients with commercial insurance were 1.5-3 times more likely to receive CAR T than other payers on an unadjusted basis.

CONCLUSIONS

We identified significant disparities in access to CAR-T related to demographics and SDOH. Patients who were older, female, low income, or Black were less likely to receive CAR-T. The positive association of CCI with CAR T requires further research. Given the promising outcomes of CAR T, there is urgent need to address identified disparities and increase efforts to overcome access barriers.

Race/ethnicity and socioeconomic position in emergency department utilization in patients with hepatocellular carcinoma

Aim: Evaluate the association of race/ethnicity and socioeconomic position (SEP) on emergency department (ED) visits for patients with hepatocellular carcinoma (HCC), which may reflect access to and quality of cancer care. Materials & methods: Patients with HCC identified from a commercial multi-payer claims database between 2015 and 2018 were matched to near-neighborhood social determinants of health (SDOH) and stratified by race/ethnicity and SEP (proxied by annual household income). Analyses evaluated the effect of race/ethnicity and SEP on ED utilization, adjusting for SDOH, demographic and clinical characteristics using multivariable regression methods. Results: A total of 22,247 patients were included. Black and Hispanic patients had 43 and 18% higher ED utilization than White patients at higher-income levels (p < 0.01); these differences were nonsignificant at lower-income. Regardless of income level, Asian patients had lower ED utilization. Conclusion: Further research on the intersectionality between race/ethnicity, SEP and other SDOH may guide structural-level interventions to address health inequities.

Disparate benefits of higher childhood socioeconomic status on cognition in young adulthood by intersectional social positions

OBJECTIVES

Emerging evidence supports the protective effects of higher childhood socioeconomic status (cSES) on cognition over the life course. However, less understood is if higher cSES confers benefits equally across intersecting social positions. Guided by a situational intersectionality perspective and the theory of Minority Diminished Returns (MDR), this study examined the extent to which associations between cSES and cognition in young adulthood are jointly moderated by racialized identity and region of childhood residence.

METHODS

Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), we used multilevel modeling to test associations between cSES and delayed recall and working memory 14 years later when participants were ages 25-34. Further, we examined the influence of racialized identity and region of childhood residence on these associations.

RESULTS

Higher cSES was associated with higher delayed recall and working memory scores across social positions. However, the strength of the association between higher cSES and working memory differed across racialized subgroups and region of childhood residence. We found a statistically significant three-way interaction between cSES, race and region of childhood residence. Of particular important, a small yet statistically robust association was found in all groups, but was especially strong among White Southerners and especially weak among Black participants from the South.

CONCLUSIONS

This study contributes to a growing body of research indicating that the protective effects of higher cSES on cognition are not universal across subgroups of intersecting social positions, consistent with the theory of MDR. These findings provide evidence for the importance of considering the role of systemic racism across geographic contexts as part of initiatives to promote equity in life course cognitive aging and brain health.

Early life adversity, race, and childhood socioeconomic status: intersecting drivers of later life cognition

OBJECTIVES

Research on associations between early life adversity (ELA) and later life cognition has yielded mixed results and generally have not considered how broader societal systems of stratification potentially influence associations. The current study addresses this gap by exploring if racialized identity and childhood socioeconomic status (cSES) moderate associations between ELA exposure and later life cognition.

METHODS

Using data from the Health and Retirement Study (Waves 2010-2018), we used growth curve modeling to examine if the confluence of ELA, cSES, and racialized identity is associated with cognition.

RESULTS

Among White participants, greater exposure to ELA was associated with poorer baseline cognitive functioning, and higher cSES buffered against this association. Among Black participants, exposure to ELA was not associated with baseline cognitive functioning, regardless of cSES. We did not find evidence of any associations between main predictors nor their interactions with change in cognition over time.

CONCLUSIONS

This study provides evidence that associations between ELA and later life cognition is contingent upon multiple social positions in the United States. These findings support the importance of integrating insights on intersecting social positions within life-course-oriented efforts to reduce racialized cognitive disparities.

Intersectional Effects of Race and Educational Attainment on Memory Function of Middle-Aged and Older Adults With Alzheimer's Disease

BACKGROUND

High educational attainment may protect individuals, particularly middle-aged and older adults, against a wide range of health risks, including memory decline with age; however, this protection is less clear in patients with Alzheimer's disease (AD). In addition, this effect may differ across racial groups. According to the Marginalized-Related Diminished Return (MDR) theory, for example, the protective effect of high educational attainment on mental and physical health shows a weaker protective effect for racial minority groups, particularly Black people compared to White individuals.

OBJECTIVES

This longitudinal study used data of middle-aged and older adults with AD with two aims: first, to test the association between educational attainment and memory, and second, to explore racial differences in this association in the USA.

METHODS

Data came from the Alzheimer's Disease Neuroimaging Initiative (ADNI) study. The total sample was 1673 American middle-aged and older adults. The independent variable was educational attainment measured as years of education. The main outcome was memory operationalized as Rey Auditory Verbal Learning Test (RAVLT) Verbal Forgetting percentage (VF%). Age, gender, and follow-up duration were covariates. Race was the effect modifier. Linear regression model was utilized to analyze the data.

RESULTS

Of all participants, 68 (4.1%) were Black, and the remaining were White, with a mean age of 75 years old. In the pooled sample, educational attainment did not show a significant association with memory, independent of confounders. Educational attainment showed a significant interaction with race on memory, with higher educational attainment having a different effect on memory in White patients compared to Black patients.

CONCLUSION

The effect of higher educational attainment on memory differs for Black patients with AD compared to White patients. To prevent cognitive disparities by race, we need to go beyond racial inequality in access to resources (e.g., education) and minimize diminished returns of educational attainment for racial minorities. To tackle health inequalities, social policies should not be limited to equalizing socioeconomic status but also help minority groups leverage their available resources, such as educational attainment, and secure tangible outcomes.

Race and Ethnicity Influences Outcomes of Adult Burn Patients

Outcomes of burn survivors is a growing field of interest; however, there is little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any inequities in burn outcomes by racial and ethnic groups. A retrospective chart review of an ABA Certified burn center at a large urban safety net hospital identified adult inpatient admissions from 2015 to 2019. A total of 1142 patients were categorized by primary ethnicity: 142 black or African American, 72 Asian, 479 Hispanic or Latino, 90 white, 215 other, and 144 patients whose race or ethnicity was unrecorded. Multivariable analyses evaluated the relationship between race and ethnicity and outcomes. Covariate confounders were controlled by adjustment of demographic, social, and prehospital clinical factors to isolate differences that might not be explained by other factors. After controlling for covariates, black patients had 29% longer hospital stays (P = .043). Hispanic patients were more likely to be discharged to home or to hospice care (P = .005). Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (P = .022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P = .041, P = .011 respectively). The causes of these inequities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery.

Parental education and epigenetic aging in middle-aged and older adults in the United States: A life course perspective

Epigenetic aging is one plausible mechanism by which socioeconomic status (SES) contributes to disparities in morbidity and mortality. Although the association between SES and epigenetic aging is well documented, the role of parental education into adulthood remains understudied. We examined (1) if parental education was independently associated with epigenetic aging, (2) whether upward educational mobility buffered this association, and (3) if the benefit of parental education was differentiated by race/ethnicity. Secondary data analysis of a subsample (n = 3875) of Non-Hispanic [NH] Black, Hispanic, NH White, and NH other race participants from the Venous Blood Study within Health and Retirement Study were examined. Thirteen clocks based on DNA methylation of cytosine-phosphate-guanine sites were used to calculate epigenetic aging. Participants' education (personal) and their report of their respective parent's education (parental; mother's and/or father's) were included as independent variables; several potential confounders were also included. Direct associations and interactions between parental and personal education were estimated via survey-weighted generalized linear models; marginal means for epigenetic aging were estimated and contrasts were made between the education subcategories. Analyses were also stratified by race/ethnicity. Our results showed that higher parental education was independently associated with slower epigenetic aging among four clocks, whereas higher personal education magnified this association among four different epigenetic clocks. Participants with the lowest parental and personal education had higher marginal means (i.e., accelerated aging) compared to participants with the highest parental and personal education, and there was little evidence of upward mobility. These associations were more frequently observed among NH White participants, whereas fewer were observed for Hispanic and NH Black participants. Overall, our findings support that early-life circumstances may be biologically embedded through epigenetic aging, which may also limit the biological benefits associated with one's own education.

Intersecting Early-Life Selection Mechanisms: Socio-Historical Changes in Racially Stratified Effects of Education on Functional Limitations in the United States

OBJECTIVE

Scant research has focused on the role of sociohistorical changes in shaping intersecting early-life selection mechanisms and their impacts on racially stratified effects of education on health across cohorts.

METHOD

Drawing from the Health and Retirement Survey, this study fitted negative binomial regression models to assess the impacts of childhood socioeconomic status (SES) on the relationship between education and functional limitations for Black and White adults across birth cohorts (n = 16,269, born 1931-1959).

RESULTS

The disparities between Black adults and White adults in impacts of childhood SES on both education and functional limitations were more pronounced in recent cohorts. The racial stratification in the impacts of education on functional limitations was documented across cohorts. However, after adjusting for childhood SES, this stratification narrowed considerably in recent cohorts.

DISCUSSION

This study underscores the role of a sociohistorical context in shaping the effects of education on health at the intersection of race and cohort.

Self-Rated Health of US Older Adults in the General Social Survey (GSS) 1972-2021: Complexity of the Associations of Education and Immigration

BACKGROUND

Multiple studies have shown a link between high education and better self-rated health (SRH). However, recent studies have suggested that immigrants may experience a weaker association between education and SRH than native-born individuals.

AIM

Using a national sample of US older adults, this investigation studied whether there is an inverse association between education and SRH and whether immigration status moderates this association.

METHODS

This study is based on marginalized diminished returns (MDRs) that argues socioeconomic status (SES) resources, such as education, may generate less favorable health outcomes for marginalized groups. Data were from the General Social Survey (GSS) 1972-2021, a cross-sectional survey in the US. A total of 7999 participants who were 65+ years old were included. The independent variable was education, measured as years of schooling and treated as a continuous variable. The dependent variable was poor/fair (poor) SRH. Immigration status was the moderator. Age, sex, and race were control variables. Logistic regressions were used for data analysis.

RESULTS

We found that higher levels of education were protective against poor SRH. However, this effect was weaker for immigrants than for US-born individuals.

CONCLUSIONS

This study found that native-born US older individuals are more likely to experience the protective effect of their education against poor SRH compared to their immigrants. Eliminating health inequality between immigrant and US-born individuals needs policies that go beyond socioeconomic status (SES) equality and address barriers that hinder highly-educated immigrants.

Race, Interleukin-6, TMPRSS6 Genotype, and Cardiovascular Disease in Patients With Chronic Kidney Disease

Background Differences in death rate and cardiovascular disease (CVD) between Black and White patients with chronic kidney disease is attributed to sociocultural factors, comorbidities, genetics, and inflammation. Methods and Results We examined the interaction of race, plasma IL-6 (interleukin-6), and TMPRSS6 genotype as determinants of CVD and mortality in 3031 Chronic Renal Insufficiency Cohort study participants. The primary outcomes were all-cause mortality and a composite of incident myocardial infarction, peripheral artery disease, stroke, and heart failure. During the median follow-up of 10 years, Black patients with chronic kidney disease experienced a significantly higher mortality (34% versus 26%) and CVD composite (41% versus 28%) compared with White patients. After adjustment, TMPRSS6 genotype did not associate with the outcomes. The adjusted hazard ratio for mortality (4.11 [2.48-6.80], P<0.001) and CVD composite (2.52 [1.96-3.24], P<0.001) were higher for the highest versus lowest IL-6 quintile. The adjusted hazards for death per 1-quintile increase in IL-6 in White and Black individuals were 1.53 (1.42-1.64) versus 1.29 (1.20-1.38) (P<0.001), respectively. For CVD composite they were 1.61 (1.50-1.74) versus 1.30 (1.22-1.39) (P<0.001), respectively. In Cox proportional hazard models that included IL-6, there was no longer a racial disparity for death (1.01 [0.87-1.16], P=0.92), but significant unexplained mediation remained for CVD (1.24 [1.07-1.43]; P=0.004). Path models that included IL-6, diabetes, and urine albumin to creatinine ratio were able to identify variables responsible for racial disparity in mortality and CVD. Conclusions Racial differences in mortality and CVD among patients with chronic kidney disease could be explained by good-fitting path models that include selected mediator variables including diabetes and plasma IL-6.

Race, Childhood Socioeconomic Status, and Region of Childhood Residence as Intersectional Life Course Predictors of Cognitive Aging in the U.S

Background and Objectives

Race, childhood socioeconomic status (cSES), and region of childhood residence are each associated with later life cognition, but no studies have examined how the confluence of these factors influence later life cognitive performance. Guided by intersectionality theory, we examined individuals’ social positionality across these dimensions as a predictor of cognitive performance in later life among non-Hispanic White (NHW) and Black (NHB) older adults.

Research Design and Methods

We used data from the 2010-2016 waves of the Health and Retirement Study (HRS) with participants ages 65 and older in 2010. We employed growth curve modeling to estimate associations among race, cSES and region of childhood residence, as well as their interactions, and cognitive performance at baseline and over time.

Results

Identifying as NHB, residing in the South, and having lower cSES each were associated with poorer later life cognition at baseline. Childhood residence in the South was an especially strong risk factor for poorer cognition among NHBs. Among NHWs, higher cSES was associated with better baseline cognitive performance, especially among those from the South. NHBs from the South demonstrated a small advantage of higher cSES, but regardless of cSES, NHBs from the South had lower levels of baseline cognitive scores compared to all other subgroups. We found that Southern childhood residence predicted faster rates of change in over a 6-year period.

Discussion and Implications

Our findings suggest that intersectional social positions across race, cSES, and region of childhood residence primarily influence baseline cognition in later life. Results implicate the importance of attention to multiple social positions in the context of racism within social policies and other initiatives to promote equity in life course brain health.