Ethnic inequalities among NHS staff in England: workplace experiences during the COVID-19 pandemic

OBJECTIVES

This study aims to determine how workplace experiences of National Health Service (NHS) staff varied by ethnicity during the COVID-19 pandemic and how these experiences are associated with mental and physical health at the time of the study.

METHODS

An online Inequalities Survey was conducted by the Tackling Inequalities and Discrimination Experiences in Health Services study in collaboration with NHS CHECK. This Inequalities Survey collected measures relating to workplace experiences (such as personal protective equipment (PPE), risk assessments, redeployments and discrimination) as well as mental health (Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder 7 (GAD-7)), and physical health (PHQ-15) from NHS staff working in the 18 trusts participating with the NHS CHECK study between February and October 2021 (N=4622).

RESULTS

Regression analysis of this cross-sectional data revealed that staff from black and mixed/other ethnic groups had greater odds of experiencing workplace harassment (adjusted OR (AOR) 2.43 (95% CI 1.56 to 3.78) and 2.38 (95% CI 1.12 to 5.07), respectively) and discrimination (AOR 4.36 (95% CI 2.73 to 6.96) and 3.94 (95% CI 1.67 to 9.33), respectively) compared with white British staff. Staff from black ethnic groups also had greater odds than white British staff of reporting PPE unavailability (AOR 2.16 (95% CI 1.16 to 4.00)). Such workplace experiences were associated with negative physical and mental health outcomes, though this association varied by ethnicity. Conversely, understanding employment rights around redeployment, being informed about and having the ability to inform redeployment decisions were associated with lower odds of poor physical and mental health.

CONCLUSIONS

Structural changes to the way staff from ethnically minoritised groups are supported, and how their complaints are addressed by leaders within the NHS are urgently required.

Factors associated with bacterial sexually transmitted infections among people of South Asian ethnicity in England

OBJECTIVES

Despite being the largest ethnic minority group in England, South Asians have historically had low levels of utilisation of sexual health services (SHS) and sexually transmitted infection (STI) diagnoses, although recent data suggests this may be changing. This study aimed to investigate factors associated with a bacterial STI diagnosis among South Asians attending SHS in England.

METHODS

Using data from the GUMCAD STI Surveillance system, a descriptive analysis of South Asians attending SHS in England in 2019 was carried out. Factors associated with a bacterial STI diagnosis were examined using univariate and multivariable logistic regression models adjusted for age, Asian ethnic subgroup, HIV status, patient's region of residence and Index of Multiple Deprivation quintile. Analyses were stratified by gender and sexual orientation (heterosexual male versus gay, bisexual and other men who have sex with men (GBMSM) versus women of any sexual orientation). Crude and adjusted associations were derived using binary logistic regression.

RESULTS

There were 121 842 attendances by South Asians to SHS in England in 2019. Compared with heterosexual South Asian men, GBMSM had a higher odds of being diagnosed with a bacterial STI (adjusted odds ratio (aOR) 2.32, 95% CI 2.19 to 2.44) and South Asian women had a lower odds (aOR 0.83, 95% CI 0.78 to 0.87). For women and heterosexual South Asian men, a diagnosis was associated with younger age, being of any other Asian background other than Bangladeshi, Indian or Pakistani and not being HIV positive. For heterosexual South Asian men, there was an association with increasing socioeconomic deprivation. For GBMSM, a bacterial STI diagnosis was associated with known HIV-positive status and living in London.

CONCLUSION

People of South Asian ethnicity in England are heterogeneous with regard to their sexual health needs, which should be explored further through focused research and policy.

Association of urinary albumin-to-creatinine ratio with cardiometabolic risk markers and pre-diabetes in adults with normoglycemia, normoalbuminuria, and normotension with parental type 2 diabetes

INTRODUCTION

This is a post hoc analysis of urinary albumin-to-creatinine ratio (uACR) within the normoalbuminuric range in relation to cardiometabolic risk factors among initially normoglycemic, normotensive participants in the Pathobiology of Prediabetes in a Biracial Cohort (POP-ABC) Study.

RESEARCH DESIGN AND METHODS

308 healthy African American (AA) and European American (EA) participants in the POP-ABC Study underwent baseline assessments, including oral glucose tolerance test, anthropometry, urinary albumin-to-creatinine ratio (uACR), lipids, adipocytokines, insulin sensitivity and secretion. Participants were followed quarterly for 5.5 years (mean 2.62 years) for the primary outcome of incident pre-diabetes.

RESULTS

The cohort's mean fasting glucose was 92.1±6.90 mg/dL, 2-hour plasma glucose was 123±25.0 mg/dL, systolic blood pressure was 123±15.9 mm Hg, and diastolic blood pressure was 74±8.80 mm Hg. Baseline uACR levels (range 1-29 mg/g) were similar in AA versus EA participants (6.40 mg/g±4.80 vs 6.80±5.40 mg/g, p=0.52), higher in women than men (7.30 mg/g±5.30 vs 4.60±3.90 mg/g, p<0.0001), and showed significant associations with cardiometabolic risk factors, including age, insulin sensitivity, high-density lipoprotein cholesterol, and adiponectin levels (p=0.03-0.004). During 5.5 years of follow-up, 104 participants developed pre-diabetes and 204 maintained normoglycemia. Baseline uACR quartiles were associated with incident pre-diabetes (r=0.19, p=0.0011).

CONCLUSIONS

Baseline uACR levels were associated with cardiometabolic risk markers and incident pre-diabetes risk among adults with normoglycemia, normoalbuminuria and normotension with parental diabetes.

Coverage, completion and outcomes of COVID-19 risk assessments in a multi-ethnic nationwide cohort of UK healthcare workers: a cross-sectional analysis from the UK-REACH Study

INTRODUCTION

There are limited data on the outcomes of COVID-19 risk assessment in healthcare workers (HCWs) or the association of ethnicity, other sociodemographic and occupational factors with risk assessment outcomes.

METHODS

We used questionnaire data from UK-REACH (UK Research study into Ethnicity And COVID-19 outcomes in Healthcare workers), an ethnically diverse, nationwide cohort of UK HCWs. We derived four binary outcomes: (1) offered a risk assessment; (2) completed a risk assessment; (3) working practices changed as a result of the risk assessment; (4) wanted changes to working practices after risk assessment but working practices did not change.We examined the association of ethnicity, other sociodemographic/occupational factors and actual/perceived COVID-19 risk variables on our outcomes using multivariable logistic regression.

RESULTS

8649 HCWs were included in total. HCWs from ethnic minority groups were more likely to report being offered a risk assessment than white HCWs, and those from Asian and black ethnic groups were more likely to report having completed an assessment if offered. Ethnic minority HCWs had lower odds of reporting having their work change as a result of risk assessment. Those from Asian and black ethnic groups were more likely to report no changes to their working practices despite wanting them.Previous SARS-CoV-2 infection was associated with lower odds of being offered a risk assessment and having adjustments made to working practices.

DISCUSSION

We found differences in risk assessment outcomes by ethnicity, other sociodemographic/occupational factors and actual/perceived COVID-19 risk factors. These findings are concerning and warrant further research using actual (rather than reported) risk assessment outcomes in an unselected cohort.

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study

INTRODUCTION

Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

RESEARCH DESIGN AND METHODS

This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

RESULTS

Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

CONCLUSIONS

A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.

Ethnic differences in 25-year risk of incident chronic kidney disease among people with type 2 diabetes in New Zealand

INTRODUCTION

Insights into ethnic differences in the natural history of chronic kidney disease (CKD) among people with type 2 diabetes mellitus (T2DM) might inform clinical strategies to address disparities in hospitalization and mortality. Risks of CKD II-V stages over a 25-year period between New Zealand Europeans (NZEs), Māori and Pasifika, and with T2DM in Auckland, New Zealand (NZ) were compared.

RESEARCH DESIGN AND METHODS

As a primary care audit program in Auckland, the Diabetes Care Support Service was linked with national registration databases. People with existing CKD II-V were ruled out. To balance potential confounders, we applied a tapered matching method . 'Quasi-trial'-matched cohorts were set up separately between Māori and NZE and between Pasifika and NZE. Ethnic population differences in risk of any and each stage of CKD over 1994-2018 were examined by weighted Cox regression model.

RESULTS

The HRs for developing any CKD, CKD stages II-V for Māori (n=2215) versus NZE (n=2028) were 1.18 (95% CI 0.99 to 1.41), 1.10 (95% CI 0.91 to 1.32), 1.70 (95% CI 1.19 to 2.43), 3.93 (95% CI 2.16 to 7.14), and 3.74 (95% CI 1.74 to 8.05), respectively. Compared with NZE (n=2474), the HRs for developing any CKD, CKD stages II-V for Pasifika (n=3101) were 1.31 (95% CI 1.09 to 1.57), 1.26 (95% CI 1.05 to 1.52), 1.71 (95% CI 1.14 to 2.57), 3.75 (95% CI 1.40 to 10.05), and 4.96 (95% CI 1.56 to 15.75), respectively.

CONCLUSIONS

Among people with T2DM in NZ, significant ethnic differences exist in the risk of progressing to each stage of CKD (stage V in particular). Mechanism studies underlying these differences, as well as the need for identification of biomarkers to predict the early onset renal lesion, are warranted.

Systematic scoping review of occupational health injuries and illnesses among Indigenous workers

Indigenous populations in the USA, Australia, New Zealand (NZ) and Canada total more than 13 million, but continue to be marginalised in their respective regions. The goal of this comprehensive review of all studies evaluating adverse occupational health outcomes among Indigenous populations in these countries was to identify gaps in the literature and future research directions. A systematic scoping review of research published between 1970 and 2020 was undertaken using the methodological framework initially proposed by Arksey and O'Malley. Country, Indigenous participants, study type, exposure, adverse health outcome, occupation and industry were identified for each paper. Of the 1272 research papers identified, only 51 articles met the inclusion criteria of this scoping review. Almost half of the studies (n=24, 47.1%) were published after 2010. Only 13 (25.5%) studies specifically focused on Indigenous persons at the time of the study design, and less than half of the studies (47.1%) included more than 100 Indigenous participants. Most studies used the following general terms without mention of specific indigenous groups: Indigenous (Australia), Māori (NZ), Aboriginal (Canada) and American Indian or Alaskan Native (USA). Only one study acknowledged asking respondents their preferred terminology. Over the past 50 years, there has been a paucity of research directly or indirectly evaluating occupational health outcomes of Indigenous populations in these four countries. There is a need for better sampling strategies and inclusion of demographic questions that capture Indigenous status in surveys, workers' compensation data and other commonly used data sources to develop adequate baseline data for targeted future interventions.

Pandemic priorities: the impact of the COVID 19 pandemic on ethical leadership in the healthcare profession

PURPOSE

The COVID 19 pandemic has brought into sharp focus the importance of leadership and the ethics of health-care leadership. The purpose of this study is to investigate the impact of COVID 19 on ethical leadership principles using a validated quantitative survey of NHS leaders to compare pre- and post-pandemic ethical leadership principles.

DESIGN/METHODOLOGY/APPROACH

This study involved a quantitative survey of NHS "leaders". Inclusion criteria included consultants and registrars leading clinical teams, or NHS managers, senior nurses and matrons. The survey was designed as a modification of the Ethical Leadership Questionnaire proposed by Langlois et al. (2013). A modification was made to ask questions from the questionnaire pertaining to before the pandemic and presently. This allowed a comparison of responses and measures of ethical leadership qualities before and after the pandemic. Twenty-three questions were on attitudes pre-pandemic, and 23 were post-pandemic.

FINDINGS

A total of 79 responses were received. Responses were divided for analysis into those related to an ethics of care dimension, those related to ethics of justice and those related to the ethics of critique. This study has found significant changes in attitudes of health-care leaders with regards to the ethics of critique. Leaders were more likely post-pandemic to speak out against injustice and unfair practices. Leaders were also more concerned with matters of human dignity as well as understanding how some groups may be privileged. Other ethical principles showed no statistical difference.

ORIGINALITY/VALUE

This paper highlights the changes the COVID-19 pandemic has had on leaders' attitudes to ethics.

Key considerations when involving children in health intervention design: reflections on working in partnership with South Asian children in the UK on a tailored Management and Intervention for Asthma (MIA) study

Participatory research is an empowering process through which individuals can increase control over their lives, and allows researchers/clinicians to gain a clearer understanding of a child's needs. However, involving children in participatory research is still relatively novel, despite national and international mandates to engage children in decision making. This paper draws on the learnings from designing the Management and Intervention for Asthma (MIA) study, which used a collaborative participatory method to develop an intervention-planning framework for South Asian children with asthma. There are currently 1 million children in the UK receiving treatment for asthma, making it one of the most prevalent chronic childhood illnesses. Symptoms of asthma are often underrecognized in children from South Asian communities in the UK, contributing to increased disease severity and increased attendance at the emergency department compared to White British children. Despite this, ethnic minorities are often excluded from research and thus absent from the 'evidence base', making it essential to hear their perspectives if health inequalities are to be successfully addressed. We worked alongside healthcare professionals, community facilitators, parents, and children to identify the key concerns and priorities they had and then designed the framework around their needs. Reflecting on the process, we identified several key considerations that need to be addressed when co-developing interventions with children. These include the power dynamics between the parent/researcher and child; navigating the consent/assent process; how parental involvement might affect the research; establishing a convenient time and location; how to keep children engaged throughout the process; tailoring activities to different levels of ability; and accounting for cultural differences. These factors were considered by the researchers when designing the study, however, implementing them was not without its challenges and highlighted the need for researchers to develop expertise in this field. Tailoring existing research methods allowed us to explore children's perceptions, priorities, and experiences of illness more effectively. However, involving children in participatory research is a complex undertaking, and researchers need to ensure that they have the expertise, time, and resources necessary to be able to fully support the needs of child participants before deciding to commit to this approach.

The American Board of Family Medicine's 8 Years of Experience with Differential Item Functioning

INTRODUCTION

Differential item functioning (DIF) procedures flag examination questions in which examinees from different subpopulations who are of equal ability do not have the same probability of answering it correctly. Few medical certification boards employ DIF procedures because they do not collect the needed data on the examinee's race or ethnicity. This article summarizes the American Board of Family Medicine's (ABFM) combined use of DIF procedures and an expert panel to review certification questions for bias.

METHODS

ABFM certification examination data from 2013 to 2020 were analyzed using a DIF procedure to flag questions with possible ethnic or racial bias. The flagged questions were reviewed by a racially and ethnically diverse panel of content experts. If the panel judged the source of the DIF was not clinically relevant for the practice of family medicine, the question was removed from the examination.

RESULTS

Out of the 3487 questions analyzed, 374 unique questions (11%) were flagged by DIF procedures as potentially biased. Of the flagged questions, the review panel felt 4 should be removed for fairness.

DISCUSSION

Using DIF procedures and panel review can improve the quality of the board certification questions and demonstrate the organization's commitment to avoid racial or ethnic bias.

Racial/Ethnic Representation Among American Board of Family Medicine Certification Candidates from 1970 to 2020

BACKGROUND

Because improved patient outcomes and experiences have been associated with health care workforce diversity, efforts to create a diverse family physician workforce have increased. However, a metric that could properly measure family physician representation in various contexts has seldom been studied.

OBJECTIVE

The goal of this study is to propose a new metric logRQ and use it to examine the diversification progress of American Board of Family Medicine (ABFM) certification candidates relative to national, state, and historic populations, as well as medical school matriculants.

METHODS

We obtained race/ethnicity for certification candidates from the 2014 to 2020 ABFM Certification Examination Registration questionnaire and examined racial/ethnic representation relative to various populations via logRQs.

RESULTS

The total sample comprised 26,368 initial certification candidates and 55,347 continuing certification candidates. Asian, Hispanic, and Black's logRQ increased by 0.51, 0.42, and 0.41, respectively, in initial certification candidates compared with continuing certification candidates. In addition, logRQ standard deviation ranged from 0.19 to 0.87 across States, indicating state-level variation. Although Black and Hispanic remained underrepresented, the degree of underrepresentation had improved substantially across the past 5 decades, with logRQ increasing from -2.12 (Black) and -1.16 (Hispanic) in the 1970s to -0.46 (Black) and -0.68 (Hispanic) in the 2010s. The race/ethnicity logRQs of 2020 initial certification candidates relative to 2013 to 2014 medical school matriculants were all near 0, reflecting equitable representation.

CONCLUSION

We utilized the proposed metric logRQ to quantify the advancement in representation among ABFM certification candidates in different contexts. The proposed logRQ may serve as a useful tool to monitor representation progress systematically.

Uses of Theory in Racial Health Disparities Research: A Scoping Review and Application of Public Health Critical Race Praxis

Given the persistence of racial health disparities, scholars have called for investigations into structural origins of health inequity and deeper engagement with theory. We systematically assessed uses of theory-including theory-informed conceptualizations of race and ethnicity, social structure, and racial hierarchy-in epidemiology and other quantitative population health literature on racial health disparities. We conducted a scoping review of systematically identified original research articles (n=650) that sought to explain racial health disparities; articles were published in 17 high-impact epidemiology, public health, and social science journals. Trained coders abstracted data from each article. We applied Public Health Critical Race Praxis and an iterative data-charting method to identify key themes. Only 63 (9.7%) of 650 racial health disparities articles explicitly used theory. Among studies that engaged theory, one third (n=21/63) clearly conceptualized race and/or ethnicity, and a minority theorized social structure (n=19/63; 30%) and/or racial hierarchy as a structural relation (n=4/63; 6%). There is a pressing need for racial health disparities researchers to unambiguously use theory to conceptualize race and ethnicity in social and historical contexts and explain relational aspects of racial hierarchy. These approaches can better elucidate and inform action on structural determinants of both racial inequity and racial health inequity.

Racial and ethnic disparity in clinical outcomes among patients with confirmed COVID-19 infection in a large US electronic health record database

BACKGROUND

Racial and ethnic minority groups have been disproportionately affected by the US coronavirus disease 2019 (COVID-19) pandemic; however, nationwide data on COVID-19 outcomes stratified by race/ethnicity and adjusted for clinical characteristics are sparse. This study analyzed the impacts of race/ethnicity on outcomes among US patients with COVID-19.

METHODS

This was a retrospective observational study of patients with a confirmed COVID-19 diagnosis in the electronic health record from 01 February 2020 through 14 September 2020. Index encounter site, hospitalization, and mortality were assessed by race/ethnicity (Hispanic, non-Hispanic Black [Black], non-Hispanic White [White], non-Hispanic Asian [Asian], or Other/unknown). Associations between racial/ethnic categories and study outcomes adjusted for patient characteristics were evaluated using logistic regression.

FINDINGS

Among 202,908 patients with confirmed COVID-19, patients from racial/ethnic minority groups were more likely than White patients to be hospitalized on initial presentation (Hispanic: adjusted odds ratio 1·690, 95% CI 1·620-1·763; Black: 1·810, 1·743-1·880; Asian: 1·503, 1·381-1·636) and during follow-up (Hispanic: 1·700, 1·638-1·764; Black: 1·578, 1·526-1·633; Asian: 1·391, 1·288-1·501). Among hospitalized patients, adjusted mortality risk was lower for Black patients (0·881, 0·809-0·959) but higher for Asian patients (1·205, 1·000-1·452).

INTERPRETATION

Racial/ethnic minority patients with COVID-19 had more severe disease on initial presentation than White patients. Increased mortality risk was attenuated by hospitalization among Black patients but not Asian patients, indicating that outcome disparities may be mediated by distinct factors for different groups. In addition to enacting policies to facilitate equitable access to COVID-19-related care, further analyses of disaggregated population-level COVID-19 data are needed.

Use of Zip Code Based Aggregate Indicators to Assess Race Disparities in COVID-19

Objective

In the first six months of the pandemic, information on race and ethnicity was missing for half of the US COVID-19 cases. Combining case ascertainment with census-based zip code indicators may identify COVID-19 race-ethnicity disparities in the absence of individual-level data.

Design

Ecological retrospective study for the period March-July 2020.

Setting

Population-based investigation, Allegheny County, Pennsylvania.

Participants

All COVID-19 cases, adjusted for zip code area population, in the early period of the pandemic.

Main Outcome Measures

Monthly COVID-19 incidence and requests for human services by zip code level indicators of race-ethnicity and poverty.

Results

In the early period of the pandemic, COVID-19 incidence was higher in zip codes with a greater proportion of racial and ethnic minorities. Zip codes with the highest quartile of minority residents (>25.1% of population) had a COVID-19 incidence of 60.1 (95% CI: 51.7-68.5) per 10,000 in this period; zip codes with the lowest quartile of minority residents (<6.3%) had an incidence of 31.3 (95% CI: 14.4-48.2). Requests for human services during this period (volume of 211 calls and county services) confirm these disparities.

Conclusion

Use of census-defined race-ethnicity proportions by zip code offers a way to identify disparities when individual race-ethnicity data are unavailable.

Examining the Prevalence of Peripartum Depressive Symptoms in a Border Community

Introduction: Depression is one of the most common complications in pregnancy, affecting 10% to 20% of women. Untreated peripartum depression increases the risk of adverse life events, more considerable distress, homelessness, and illness later in life. This study explored the prevalence of peripartum depression and associated demographic characteristics in a population of low-income, Healthy Start program participants in one New Mexico county along the U.S.-Mexico border where knowledge of depression prevalence is lacking. Materials and Methods: Healthy Start caseworkers routinely administered the 10-item Edinburgh Postnatal Depression Scale (EPDS) to all pregnant and recently pregnant program participants between 2009 and 2017. Scores for the first prenatal screen, first postpartum screen, and all screens for 1453 women were studied. A score of >10 points out of a possible 30 indicated a positive screen. Screening outcome was examined in relation to age, race, ethnicity, primary language, and trimester of the prenatal screen. Crude and adjusted odds ratios were generated from logistic regression models. Results: Overall, 16.4% of women screened positive for depression. English-speaking women, non-Hispanic white women, and those ages >35 years were more likely to screen positive. Women >35 years also had higher odds of reporting thoughts of self-harm than younger women. Conclusion: In this low-income border population, non-Hispanic white, English-speaking women over the age of 35 were at the greatest risk of peripartum depression. These findings underscore the need for peripartum depression screening in this population.

Bridging health disparities: a national survey of ambulatory care pharmacists in underserved areas

Background

There is a shortage of primary care medical providers, particularly in rural communities and communities of racial and ethnic minority groups. Clinical pharmacists can help fill gaps in care among these vulnerable populations.

Objective

To identify characteristics of ambulatory care pharmacists that pursue and maintain employment within underserved areas.

Methods

An original survey was distributed nationwide to ambulatory care clinical pharmacists in underserved settings. Respondent characteristics were analyzed using descriptive statistics.

Results

Of the 111 completed surveys, a majority of respondents were White, non-Hispanic, female, with English as their only spoken language. A majority of pharmacists completed a clinical experience or specialized training focused on underserved care prior to their position. The top three motivators for pharmacists accepting their clinical position as well as staying at their job were passion for caring for underserved populations, the presence of a faculty appointment, or the freedom and flexibility of advanced clinical roles.

Conclusions

With a large majority of our respondents identifying as White and unilingual, there remains a large opportunity to increase diversity in the clinical pharmacy ambulatory care workforce caring for underserved populations. There is an observed correlation between early experiential or specialized training in underserved care and pharmacists pursuing employment in these areas. Thus, one potential long-term strategy to diversify and grow the ambulatory care clinical pharmacist workforce in underserved settings is for clinical practice sites to partner with colleges of pharmacy to recruit and maintain quality individuals who can meet the needs of diverse patient populations as well as expand student and resident training opportunities in underserved settings.

Mithun (Bos frontalis): the neglected cattle species and their significance to ethnic communities in the Eastern Himalaya - A review

Objective

This review consolidates the available information on the socio-economic and ecological significance of Mithun in the lives of ethnic communities in the Eastern Himalaya.

Methods

Standard guidelines were followed for the review and data collection was carried out at three stages; literature search, literature screening, and literature review and analysis.

Results

Records indicate a long association of Mithun with the ethnic groups. Mithun serves as a symbol of pride and local currency for barter trade in the ethnic society. Its utilities range from being used as a bride price to settling legal disputes. Several cultural festivals and local ceremonies are celebrated around this bovine. Due to its semi-wild nature, this animal also has an ecological role to conserve broad leaf sub-tropical forests. However, it remains neglected and has not received policy attention, leading to a stagnated growth. The institutions for Mithun research and development are also weak. Furthermore, the species is under threat from new diseases and habitat alteration triggered by climate change.

Conclusion

Founded on the current state of knowledge, there is a need for institutional development, strengthening institutional linkages, and promoting regional cooperation among Mithun rearing countries for further research and development of this unique cattle.

Prevalence of Pre-existing Conditions Among Community Health Center Patients With COVID-19: Implications for the Patient Protection and Affordable Care Act

BACKGROUND

Short- and long-term effects of COVID-19 will likely be designated pre-existing conditions. We describe the prevalence of pre-existing conditions among community health center patients overall and those with COVID-19 by race/ethnicity.

MATERIALS AND METHODS

This cross-sectional study used electronic health record data from OCHIN, a network of 396 community health centers across 14 states.

RESULTS

Among all patients with COVID-19, 33% did not have a pre-existing condition before the pandemic. Up to half of COVID-19-positive non-Hispanic Asians (51%), Hispanic (36%), and non-Hispanic black (28%) patients did not have a pre-existing condition before the pandemic.

CONCLUSIONS

The future of the Patient Protection and Affordable Care Act is uncertain, and the long-term health effects of COVID-19 are largely unknown; therefore, ensuring people with pre-existing conditions can acquire health insurance is essential to achieving health equity.

Uterine clear cell carcinoma risk in White versus non-White US subpopulations: does race matter?

OBJECTIVE

To determine incidence rates of uterine clear cell carcinoma among non-White US subpopulations.

METHODS

Data from the United States Cancer Statistics and National Cancer Database from 2004 to 2016 were analyzed using descriptive statistics.

RESULTS

A total of 488,811 women were diagnosed with uterine cancer from 2004-2016. Of these, 73.3% were endometrioid, 6.6% were serous, 5.3% were carcinosarcoma, 1.4% were clear cell, and 13.4% were other. Blacks had the highest incidence rate of uterine clear cell compared with Whites, Asian/Pacific Islanders, and American Indian/Alaska Natives (0.59 vs. 0.31, 0.29, and 0.24, respectively). Overall mean age at diagnosis was 68.6 years, with the youngest age in Asian/Pacific Islanders compared to Whites, Blacks, and American Indian/Alaska Natives (65.9 vs. 68.7, 68.6, and 66.3 years, respectively). Analysis of the Asian subpopulation revealed significantly younger age at diagnosis in Vietnamese women (55.8 years) compared with 72.4 years in Japanese, 68.6 years in Pacific Islander, 66.6 years in Indian/Pakistani, 65.9 years in Filipino, 65.8 years in Chinese, 65.2 years in Korean, and 63.7 years in other Asians.

CONCLUSIONS

Black women are two times more likely to be diagnosed with uterine clear cell carcinoma compared with other races. Asians present at younger ages, with Vietnamese women most likely to be diagnosed at the youngest age.

Insurance Types, Usual Sources of Health Care, and Perceived Discrimination

INTRODUCTION

Discrimination can compromise access to and utilization of health care and lead to poorer health. As such, it is important to understand the factors associated with experiences of discrimination in health care.

METHODS

Using data from the 2015 to 2017 California Health Interview Survey (n = 63,100), this study examined whether insurance types and sites of usual sources of care were associated with reasons for perceived discrimination in health care and whether the reasons were associated with delaying health care. Odds of study outcomes were calculated among insured adults using logistic regressions. Insurance coverage types and sites of usual sources of care were the main independent variables. Six reasons for lifetime discrimination in health care were examined: 1) dissatisfaction with the health care system, 2) race or skin color, 3) age, 4) way the participant speaks English or other barrier to communication, 5) insurance status or type, and 6) income or education.

RESULTS

Adults with Medicaid perceived more discrimination due to race or skin color relative to those with employer-sponsored coverage. This association does not vary by race/ethnicity. Perceived discrimination due to 1) dissatisfaction with the health care system, 2) insurance status or type, and 3) barriers to communication were each associated with increased delays in getting needed medical care.

CONCLUSIONS

Findings highlight potential insurance types and sources of care that could contribute to perceptions of being discriminated.

Inequity in Access to Transplantation in the United Kingdom

BACKGROUND AND OBJECTIVES

Despite the presence of a universal health care system, it is unclear if there is intercenter variation in access to kidney transplantation in the United Kingdom. This study aims to assess whether equity exists in access to kidney transplantation in the United Kingdom after adjustment for patient-specific factors and center practice patterns.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this prospective, observational cohort study including all 71 United Kingdom kidney centers, incident RRT patients recruited between November 2011 and March 2013 as part of the Access to Transplantation and Transplant Outcome Measures study were analyzed to assess preemptive listing (n=2676) and listing within 2 years of starting dialysis (n=1970) by center.

RESULTS

Seven hundred and six participants (26%) were listed preemptively, whereas 585 (30%) were listed within 2 years of commencing dialysis. The interquartile range across centers was 6%-33% for preemptive listing and 25%-40% for listing after starting dialysis. Patient factors, including increasing age, most comorbidities, body mass index >35 kg/m², and lower socioeconomic status, were associated with a lower likelihood of being listed and accounted for 89% and 97% of measured intercenter variation for preemptive listing and listing within 2 years of starting dialysis, respectively. Asian (odds ratio, 0.49; 95% confidence interval, 0.33 to 0.72) and Black (odds ratio, 0.43; 95% confidence interval, 0.26 to 0.71) participants were both associated with reduced access to preemptive listing; however Asian participants were associated with a higher likelihood of being listed after starting dialysis (odds ratio, 1.42; 95% confidence interval, 1.12 to 1.79). As for center factors, being registered at a transplanting center (odds ratio, 3.1; 95% confidence interval, 2.36 to 4.07) and a universal approach to discussing transplantation (odds ratio, 1.4; 95% confidence interval, 1.08 to 1.78) were associated with higher preemptive listing, whereas using a written protocol was associated negatively with listing within 2 years of starting dialysis (odds ratio, 0.7; 95% confidence interval, 0.58 to 0.9).

CONCLUSIONS

Patient case mix accounts for most of the intercenter variation seen in access to transplantation in the United Kingdom, with practice patterns also contributing some variation. Socioeconomic inequity exists despite having a universal health care system.

Combined Effects of Race and Educational Attainment on Physician Visits Over 24 Years in a National Sample of Middle-Aged and Older Americans

Background

The literature on Minorities' Diminished Returns (MDRs) have shown worse than expected health of the members of racial and ethnic minority groups particularly Blacks. Theoretically, this effect can be in part due to weaker effects of educational attainment on preventive care and disease management in highly educated racial and ethnic minorities.

Objectives

The current study explored the racial and ethnic differences in the effect of baseline educational attainment on % adherance to the routine physician visits among middle-aged and older adults in the US.

Methods

This is a prospective study with 24 years of follow up. The Health and Retirement Study (HRS: 1992-2016) included 10 880 middle-aged and older adults who were Hispanic, non-Hispanic, Black or White. The independent variable was educational attainment. The dependent variable was adherance to the routine physician visits (%). Age, gender, marital status, income, health behaviors (smoking and drinking) and health (depression, self-rated health, and chronic diseases) were the covariates. Race and ethnicity were the focal moderators. Linear regression was used for data analysis.

Results

Overall, higher educational attainment was associated with higher % of adherance to the routine physician visits over the course of follow-up, net of all confounders. Race showed a significant statistical interaction with educational attainment suggesting of a smaller effect of high education attainment on % adherance to the routine physician visits for Black than White middle-aged and older adults. A similar interaction could not be found for the comparison of Hispanic and non-Hispanic middle-aged and older adults.

Conclusion

Educational attainment is associated with a larger increase in preventive and disease management doctor visits for White than Black middle-aged and older adults. This is a missed opportunity to improve the health of highly educated middle-aged and older adults. It is not race/ethnicity or class that shapes health behaviors but race/ethnicity and class that shape people's pro-health behaviors. At least some of the racial health disparities is not due to low SES but diminished returns of SES.

Prevalence and factors associated with type 2 diabetes mellitus in the indigenous population of Mexico: systematic review

Currently, diabetes represents a serious health problem, due to the complications it entails and because of its high mortality rate. Type 2 diabetes mellitus (T2DM) is the most prevalent and it is characterized by insulin resistance. The objective was to analyze the available scientific literature on prevalence and factors associated to T2DM in indigenous population of Mexico. Searches for articles published between 1990 and 2019 in English and Spanish were carried out in 13 electronic databases. Combinations of eight keywords were used according to the MeSH vocabulary. To select the studies, it was used the JBI’s Critical Appraisal Tools guide in Spanish for analytical prevalence studies. Out of 478, 12 cross-sectional studies reported T2DM prevalences from 12 indigenous groups located in Mexico: Huichol (0%), Mexican (0%), Tepehuano (0 and 0.83%), Mazateco (2.01%), Otomí (4.4%), Tojolabal (4.7%), Mixe (6.9%), Pima (6.9 and 9.0%), Zapoteco (8.7%), Maya (10.6%), Yaqui (18.3 and 14.8%) and Mixteco (19.0 and 26.2%). Factors associated with T2DM reported were being older, being female, less education level, presence of family history of T2DM, obesity, high blood pressure and increased waist-hip circumference. There is little evidence of the prevalence of T2DM in indigenous groups in Mexico. Studies found suggest a diversity of prevalences, ranging from lower to greater prevalences. Considering the risk factors associated with T2DM is essential to generate prevention strategies according to the context of each ethnic group, in order to improve the epidemiological landscape of diabetes in indigenous groups of Mexico.

Patient experience with clinical pharmacist services in Travis County Federally Qualified Health Centers

Background

Positive patient experiences with care have been linked to improved health outcomes. Patient experience surveys can provide feedback about the level of patient-centered care provided by clinical pharmacists and information about how to improve services.

Objectives

Study objectives are: 1) To describe patient experience with clinical pharmacist services in a federally qualified health center (FQHC). 2) To determine if demographic or health-related factors were associated with patient experience.

Methods

This cross-sectional survey included adult patients who were English or Spanish speaking, and completed a clinical pharmacist visit in March or April 2018. Patient experience was evaluated, on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree), with 10 items using four domains: pharmacist-patient interaction information provision, support for self-care, and involvement in decision making. In addition, one item was used to rate the overall experience. Demographic and health-related variables were also collected. Eligible patients completed the survey after their clinical pharmacist visit. Descriptive and inferential statistics, as well as Cronbach's alpha for scale reliability, were employed.

Results

Respondents (N=99) were 55.4 (SD=12.1) years and 53.1% were women. Overall, patients rated their experiences very high with the 10-item scale score of 4.8 (SD=0.4) out of 5 points and the overall experience rating of 4.9 (SD=0.4) out of 5 points. With the exception of race, there were no differences between patient experience and demographic and health-related variables. African Americans had significantly (p=0.0466) higher patient experience scores compared to Hispanics.

Conclusions

Patients receiving care in a FQHC highly rated their experience with clinical pharmacists. This indicates that clinical pharmacists provided a high level of patient-centered care to a diverse group.

Having a Primary Care Provider is the Strongest Predictor of Successful Follow-up of Participants in a Clinical Trial

PURPOSE

Ethnic minorities, women, and those of low socioeconomic status are widely underrepresented in clinical trials. Few studies have explored factors associated with successful follow-up in these historically difficult-to-reach patients. This study's objective was to identify patient characteristics and methods of contact that predict successful contact for follow-up in an urban, predominantly ethnic minority, majority-women, poor population to help devise strategies to improve retention.

METHODS

We retrospectively reviewed records from a prospective randomized control trial of 400 hospitalized chest pain patients to determine which characteristics were associated with successful telephone follow-up at 1 year after enrollment. We assessed demographic variables, medical history, and social factors by using bivariate analyses. A multivariate analysis was performed using variables from the bivariate analysis with P ≤ .2.

RESULTS

The overall successful 1-year follow-up rate was 95% (381/400). Study participants who completed follow-up were significantly more likely to have a primary care physician (PCP) (88% [337/381] versus 68% [13/19]), speak English natively (52% [199/381] versus 26% [5/19]), have a higher Charlson comorbidity index score, and identify as women (64.0% [244/381] versus 42.1% [8/19]). Having a PCP and native English language remained significant at multivariate analysis. Socioeconomic status score, quantity of contact information recorded at recruitment, and insurance status were not significantly associated with successful follow-up.

CONCLUSIONS

Patients engaged with the health care system by having a PCP are significantly more likely to achieve follow-up. Successful follow-up is also associated with native English speaking. The potential of improving follow-up by facilitating connections with health care providers requires further study.

Socioeconomic Status and Current Cigarette Smoking Status: Immigrants' Diminished Returns

Introduction

Although socioeconomic status (SES) resources influence population and individual health behaviors, socially marginalized groups gain significantly less health from their SES indicators, such as education and income, compared to the socially privileged groups. This pattern is called marginalization-related diminished returns (MDRs). However, most of the MDRs literature is derived from studies that have defined marginalization based on race and ethnicity. As a result, more research is needed on MDRs due to immigration. To extend what is known about MDRs due to immigration, the current study compared a national sample of immigrants and non-immigrants for the effects of education and income on current cigarette smoking of adults in the United States.

Methods

This is a cross-sectional study. The 2015 National Health Interview Survey (NHIS) enrolled 14,149 individuals who were either immigrants (n=1977; 14.0%) or non-immigrants (n=12,166; 86.0%). The independent variables (IV) were education and income that were treated as categorical variables. The dependent variable was current cigarette smoking. Age, gender, race, ethnicity, marital status, employment, and region were confounders. Immigration was the moderator. Logistic regression was used for data analysis.

Results

High education and income were associated with lower odds of current cigarette smoking. However, immigration showed significant statistical interactions with both education and income. These interactions were suggestive of smaller protective effects of high education and income on current cigarette smoking for immigrant than non-immigrant adults.

Conclusion

In line with the MDRs, the effects of education and income on tobacco use is weaker for immigrant than non-immigrant adults.

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

BACKGROUND

Education level reduces the risk of health problems such as poor self-rated health (SRH), high body mass index (BMI), and depressive symptoms (DS). Marginalization - related Diminished Returns (MDRs), however, refer to smaller health benefits of socioeconomic status (SES) indicators particularly educational attainment for the members of racial minority groups such as non-Hispanic Blacks compared to the majority group (non-Hispanic Whites). It is not known, however, if MDRs also hold for middle-age and older adults over a long period of time.

AIMS

The current study used a nationally representative data set to explore racial variation in the predictive utility of baseline education level on protecting people against poor SRH, BMI, and DS.

METHODS

Data for this analysis were borrowed from the Health and Retirement Study (HRS 1992-ongoing), a nationally representative longitudinal study that followed 10,023 middle-aged and older adults (50+ years old) for up to 26 years. From this number, 1877 (18.7%) were non-Hispanic Black Americans, and 8,146 (81.3%) were non-Hispanic White Americans. Education level was the independent variable. We used cluster analysis to categorize individuals to low and high-risk groups (outcome) based on SRH, BMI, and DS over 26 years. Age and gender were the covariates. Race was the moderator.

RESULTS

Overall, high education level reduced the odds of poor SRH, BMI, and DS over the 26 years of follow up. Interactions were observed between race and education on all three health outcomes indicating smaller protective effects of baseline educational attainment on poor health over time, regardless of the outcome.

CONCLUSIONS

In line with the MDRs, highly educated non-Hispanic Black Americans remain at high risk for poor health across domains, a risk which is unexpected given their education. The risk of all health outcomes, however, is lowest for non-Hispanic White Americans with highest education. Policies that exclusively focus on equalizing racial gaps in SES (e.g., education) may fail to eliminate the racial and ethnic health inequalities because of the racial inequalities in the marginal health return of education. Public policies must equalize education quality and address structural and environmental barriers that are disproportionately more common in the lives of non-Hispanic Black Americans, even at high education levels. Future research should test how contextual factors, segregation, labor market practices, childhood poverty, and education quality reduces the health return of education for highly educated non-Hispanic Black Americans.

Ethnic Difference in Skin Infection Rates: An Analysis of Electronic Health Records

Diagnosis and prescription data in the electronic health records (EHR) of a New Zealand primary care clinic are analyzed to identify skin infection occurrences in support of a public health initiative. High prevalence of this disease and substantial differences in the prevalence and occurrence rates among ethnic groups are identified. The findings indicate application potential of the analysis algorithm in public health for identifying the population groups with high needs and assessing intervention impact.

Being Married Increases Life Expectancy of White but Not Black Americans

Objective: The positive effect of high socioeconomic position (SEP) on health is well established. According Minorities' Diminished Returns (MDRs) theory, however, the SEP-health link is smaller for Blacks compared to Whites. Using a 25-year follow up data of a national sample, this study tested racial differences in the effects of marital status on life expectancy among American adults. Materials and methods: The data of Americans' Changing Lives (ACL, 1986 - 2011) were used. The ACL is a nationally representative longitudinal cohort study followed 3,361 White or Blacks adults from 1986 to 2011. The predictor of interest was marital status in 1986. Confounders included demographic factors (age and gender), SEP (education and employment), health behaviors (drinking, smoking, and physical activity), and health status (depressive symptoms, chronic disease, and self-rated health) all measured at baseline. Race was the moderator variable. All-cause mortality was the main dependent variable (outcome). Cox proportional hazard modeling was applied for data analysis. Results: In the overall sample, individuals who were married at baseline had a lower risk of mortality during the 25 years of follow up. Race altered the effect of marital status on life expectancy, indicating smaller protective effect for Blacks relative to Whites. Race -specific Cox regression models showed an association between marital status and life expectancy for White but not Black Americans. Conclusion: In line with the MDRs theory, the health gain that follows marital status is diminished for Black Americans compared to White Americans. Only equalizing SEP across racial groups may not be adequate for eliminating racial/ethnic health inequalities. Policies should go beyond SEP and reduce societal and structural barriers that disproportionately hinder Blacks from translating their SEP indicators to desirable health outcomes.

Expanded Prospective Payment System and Use of and Outcomes with Home Dialysis by Race and Ethnicity in the United States

BACKGROUND AND OBJECTIVES

We investigated whether the recent growth in home dialysis use was proportional among all racial/ethnic groups and also whether there were changes in racial/ethnic differences in home dialysis outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This observational cohort study of US Renal Data System patients initiating dialysis from 2005 to 2013 used logistic regression to estimate racial/ethnic differences in home dialysis initiation over time, and used competing risk models to assess temporal changes in racial/ethnic differences in home dialysis outcomes, specifically: (1) transfer to in-center hemodialysis (HD), (2) mortality, and (3) transplantation.

RESULTS

Of the 523,526 patients initiating dialysis from 2005 to 2013, 55% were white, 28% black, 13% Hispanic, and 4% Asian. In the earliest era (2005-2007), 8.0% of white patients initiated dialysis with home modalities, as did a similar proportion of Asians (9.2%; adjusted odds ratio [aOR], 0.95; 95% confidence interval [95% CI], 0.86 to 1.05), whereas lower proportions of black [5.2%; aOR, 0.71; 95% CI, 0.66 to 0.76] and Hispanic (5.7%; aOR, 0.83; 95% CI, 0.86 to 0.93) patients did so. Over time, home dialysis use increased in all groups and racial/ethnic differences decreased (2011-2013: 10.6% of whites, 8.3% of blacks [aOR, 0.81; 95% CI, 0.77 to 0.85], 9.6% of Hispanics [aOR, 0.94; 95% CI, 0.86 to 1.00], 14.2% of Asians [aOR, 1.04; 95% CI, 0.86 to 1.12]). Compared with white patients, the risk of transferring to in-center HD was higher in blacks, similar in Hispanics, and lower in Asians; these differences remained stable over time. The mortality rate was lower for minority patients than for white patients; this difference increased over time. Transplantation rates were lower for blacks and similar for Hispanics and Asians; over time, the difference in transplantation rates between blacks and Hispanics versus whites increased.

CONCLUSIONS

From 2005 to 2013, as home dialysis use increased, racial/ethnic differences in initiating home dialysis narrowed, without worsening rates of death or transfer to in-center HD in minority patients, as compared with white patients.

Development and Validation of a Cross-Cultural Heart Failure-Specific Quality of Life Questionnaire

Objectives

Heart failure (HF) is a common clinical syndrome with an enormous impact on prognosis and lifestyle. Accordingly, rehabilitation measures need to be patient-specific and consider various sociocultural factors so as to improve the patient's quality of life (QOL). This study aimed to develop and validate a HF-specific QOL (HFQOL) questionnaire within a multicultural setting.

Methods

This study took place at the National Heart Institute and Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia, between March 2013 and March 2014. A self-administered 75-item HFQOL questionnaire was designed and administrated to 164 multi-ethnic Malaysian HF patients. Exploratory factor analysis was performed to assess the instrument's construct validity. Cronbach's alpha coefficients were used to determine internal consistency.

Results

A total of 33 out of 75 items were retained in the final tool. The HFQOL questionnaire had three common factors-psychological, physical-social and spiritual wellbeing-resulting in a cumulative percentage of total variance of 44.3%. The factor loading ranges were 0.450-0.718 for psychological wellbeing (12 items), 0.394-0.740 for physical-social wellbeing (14 items) and 0.449-0.727 for spiritual wellbeing (seven items). The overall Cronbach's alpha coefficient of the questionnaire was 0.82, with coefficients of 0.86, 0.88 and 0.79 for the psychological, physical-social and spiritual wellbeing subdomains, respectively.

Conclusion

The HFQOL questionnaire was found to be a valid and reliable measure of QOL among Malaysian HF patients from various ethnic groups. Such tools may facilitate cardiac care management planning among multi-ethnic patients with HF.

Social Determinants of Polypharmacy in First Generation Mexican Immigrants in the United States

INTRODUCTION

Socioeconomic status (SES) indicators are among the main social determinants of health and illness. Less, however, is known about the role of SES in the epidemiology of polypharmacy in immigrant Latino Americans living in the United States. This research studied the association between three SES indicators, education, income, and employment, and polypharmacy in older first generation Latino American immigrant adults.

METHODS

Data was obtained from the Sacramento Area Latino Study on Aging (SALSA, 1996-2008). A total of 632 older first generation Mexican-American immigrants to the U.S. entered this analysis. The independent variables were education, income, and employment. Polypharmacy was the outcome. Age, gender, physical health, smoking, and drinking were the covariates. Binary logistic regression was used to analyze the data.

RESULTS

Employment was associated with lower odds of polypharmacy. The association between education and polypharmacy was above and beyond demographic factors, physical health, health behaviors, and health insurance. Neither education nor income were associated with polypharmacy. Other determinants of polypharmacy were poor self-rated health (SRH) and a higher number of chronic medical conditions (CMCs).

CONCLUSION

Employment appears to be the major SES determinant of polypharmacy in older foreign-born Mexican Americans. Unemployed older Mexican American immigrants with multiple chronic diseases and those who have poor SRH have the highest need for an evaluation of polypharmacy. Given the age group of this population, most of them have health insurance, which provides an opportunity for reducing their polypharmacy.

Cephalometric Norms in an Omani Adult Population of Arab Descent

Objectives

This study aimed to establish cephalometric norms for an Omani population of Arab descent and to compare these with established cephalometric values for Caucasians.

Methods

This cross-sectional study was conducted at the Military Dental Centre and Oman Dental College in Muscat, Oman, between May 2014 and October 2016. A total of 150 Omani patients between 20-29 years old seeking orthodontic treatment were included. All participants had a symmetrical face, class I molar and canine relationships, proper intercuspation, a normal overjet/overbite (<3 mm) and mild spacing/crowding of the teeth (≤3 mm). Lateral cephalography was performed in centric occlusion with the lips relaxed and the head in a natural position. Cephalometric measurements were then compared with Eastman Standard norms.

Results

The Omani subjects were found to have a slightly retrusive maxilla, an increased angle between the maxillary and mandibular planes and shorter facial heights in comparison to the Eastman Standard norms. Furthermore, incisor relations were edge-to-edge in nature and the interincisal angle was reduced, suggesting that the Omani subjects had more proclined incisors. In addition, the lips were more protrusive and the nasolabial angle was more obtuse.

Conclusion

In the Omani sample, increased proclination of the incisors was observed in comparison to Eastman Standard norms. As such, slightly more proclined incisors should be considered acceptable and natural among Omani patients of Arab descent. The cephalometric findings of this study may be helpful in the diagnosis and treatment planning of orthodontic problems among Omanis of Arab descent.

Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation

BACKGROUND AND OBJECTIVES

Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach.

RESULTS

States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons).

CONCLUSIONS

Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.

Prevalence of Self-Reported Chronic Diseases and Health Services Utilization by Ethnic Minorities in Manaus Metropolitan Region

Objectives

To assess the prevalence of, and associated factors to, self-reported chronic diseases and health care utilization by ethnicity in the Manaus Metropolitan Region.

Methods

We conducted a cross-sectional, population-based survey from May through August 2015. Using probabilistic sampling in three stages, we recruited adults aged ≥18 years. Ethnicity was self-identified as White, Black, Yellow, Brown (Brazilian mixed-race), and Indigenous. We calculated adjusted prevalence ratios (PR) and 95% CI of chronic diseases and health service utilization for each ethnic minority and compared the data using Poisson regression with data from White respondents.

Results

In this study, we interviewed 4,001 people. Of these, 15.9% were White, 7.5% Black, 3.4% Yellow, 72.1% Brown, and 1.0% Indigenous. Indigenous respondents had the highest prevalence of self-reported hypertension (29.4%), diabetes (12.3%) and hypercholesterolemia (17.0%) among the ethnic respondent groups. Compared with the White population, Browns had less health insurance coverage (PR=.76; 95% CI: .62-.93) and reported hypertension (PR=.84; 95% CI: .72-0.98) and diabetes (PR=.69; 95% CI: .51-.94) less frequently. Yellows visited the doctor more frequently than Whites (PR=1.13; 95% CI: 1.04-1.22), with no significant difference in prevalence of diseases.

Conclusions

Indigenous respondents had higher prevalence rates of the investigated diseases. Compared with Whites, Brown respondents had lower rates of self-reported arterial hypertension and diabetes, as well as lower rates of private health insurance coverage.

First Cytogenetic Profile of Omani Patients with de novo Myelodysplastic Syndromes: Comparison with data from Asia, Africa, Europe and North and South America

Clonal cytogenetic abnormalities have been reported among 30-80% of patients with myelodysplastic syndromes (MDS); however, 20-70% of patients with MDS show a normal karyotype that may nevertheless harbour a cryptic genetic alteration. Earlier reports have suggested that the distribution of specific chromosomal aberrations varies among Western and Asian countries, with geographical and ethnic differences in the frequency of specific chromosomal aberrations. This article compared the cytogenetic data of 36 adult Omani patients with MDS to previously reported data from other populations. Differences were noted between the percentages of clonal aberrations and the median age of Omani subjects at presentation in comparison to individuals of different ethnicities and from various geographical locations. To the best of the authors' knowledge, this is the first report to describe the cytogenetic data of patients with MDS from Oman.

Sleep Duration and Adiposity in Early Childhood: Evidence for Bidirectional Associations from the Born in Bradford Study

Study Objectives:

To examine independent associations of sleep duration with total and abdominal adiposity, and the bidirectionality of these associations, in a young biethnic sample of children from a disadvantaged location.

Methods:

Child sleep duration (h/day) was parent-reported by questionnaire and indices of total (body weight, body mass index, percent body fat (%BF), sum of skinfolds) and abdominal adiposity (waist circumference) were measured using standard anthropometric procedures at approximately 12, 18, 24, and 36 months of age in 1,338 children (58% South Asian; 42% White). Mixed effects models were used to quantify independent associations (expressed as standardised β-coefficients (95% confidence interval (CI)) of sleep duration with adiposity indices using data from all four time-points. Factors considered for adjustment in models included basic demographics, pregnancy and birth characteristics, and lifestyle behaviours.

Results:

With the exception of the sum of skinfolds, sleep duration was inversely and independently associated with indices of total and abdominal adiposity in South Asian children. For example, one standard deviation (SD) higher sleep duration was associated with reduced %BF by -0.029 (95% CI: −0.053, −0.0043) SDs. Higher adiposity was also independently associated with shorter sleep duration in South Asian children (for example, %BF: β = -0.10 (-0.16, -0.028) SDs). There were no significant associations in White children.

Conclusions:

Associations between sleep duration and adiposity are bidirectional and independent among South Asian children from a disadvantaged location. The results highlight the importance of considering adiposity as both a determinant of decreased sleep and a potential consequence.

Depressive Symptoms During Adolescence Predict Adulthood Obesity Among Black Females

AIM

This study aimed to investigate gender differences in the association between baseline depressive symptoms and subsequent changes in obesity in a sample of urban Black youth in the USA.

METHODS

The current study followed 681 Black youth (335 male and 346 female) for up to 18 years from 1994 to 2012. All youth were selected from an economically disadvantaged urban area in MI, USA. The main independent variable was baseline depressive symptoms measured in 1994. The main outcome was change in body mass index (BMI) from 1999 to 2012, calculated based on self-reported height and weight. Scio-demographics (age, number of parents in the household, and parental employment) were covariates. Gender was the focal moderator. We used linear regressions to test the predictive role of baseline depressive symptoms on change in BMI (from 1999 to 2012) in the pooled sample, and also based on gender.

RESULTS

Among Black females, but not Black males, baseline depressive symptoms predicted the BMI change from 1999 to 2012. The association remained significant for Black females after controlling for covariates.

CONCLUSION

High depressive symptoms at baseline better predict BMI change over the next decade for female than male Black youth. As a result, detection and reduction of depressive symptoms may be a vital element of obesity prevention programs for Black females. Policies and programs that address determinants of psychological distress as a strategy to prevent obesity among female Black youth in disadvantaged neighborhoods may be especially useful.

A Systematic Review of the Prevalence and Associations of Limited Health Literacy in CKD

BACKGROUND AND OBJECTIVES

The self-management and decision-making skills required to manage CKD successfully may be diminished in those with low health literacy. A 2012 review identified five papers reporting the prevalence of limited health literacy in CKD, largely from United States dialysis populations. The literature has expanded considerably since.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used systematic review, pooled prevalence analysis, metaregression, and exploration of heterogeneity in studies of patients with CKD (all stages).

RESULTS

From 433 studies, 15 new studies met the inclusion criteria and were analyzed together with five studies from the 2012 review. These included 13 cross-sectional surveys, five cohort studies (using baseline data), and two using baseline clinical trial data. Most (19 of 20) were from the United States. In total, 12,324 patients were studied (3529 nondialysis CKD, 5289 dialysis, 2560 transplant, and 946 with unspecified CKD; median =198.5; IQR, 128.5-260 per study). Median prevalence of limited health literacy within studies was 23% (IQR, 16%-33%), and pooled prevalence was 25% (95% confidence interval, 20% to 30%) with significant between-study heterogeneity (I2=97%). Pooled prevalence of limited health literacy was 25% (95% confidence interval, 16% to 33%; I2=97%) among patients with CKD not on dialysis, 27% (95% confidence interval, 19% to 35%; I2=96%) among patients on dialysis, and 14% (95% confidence interval, 7% to 21%; I2=97%) among patients with transplants. A higher proportion of nonwhite participants was associated with increased limited health literacy prevalence (P=0.04), but participant age was not (P=0.40). Within studies, nonwhite ethnicity and low socioeconomic status were consistently and independently associated with limited health literacy. Studies were of low or moderate quality. Within-study participant selection criteria had potential to introduce bias.

CONCLUSIONS

Limited health literacy is common in CKD, especially among individuals with low socioeconomic status and nonwhite ethnicity. This has implications for the design of self-management and decision-making initiatives to promote equity of care and improve quality. Lower prevalence among patients with transplants may reflect selection of patients with higher health literacy for transplantation either because of less comorbidity in this group or as a direct effect of health literacy on access to transplantation.

The Relation of Serum Potassium Concentration with Cardiovascular Events and Mortality in Community-Living Individuals

BACKGROUND AND OBJECTIVES

Hyperkalemia is associated with adverse outcomes in patients with CKD and in hospitalized patients with acute medical conditions. Little is known regarding hyperkalemia, cardiovascular disease (CVD), and mortality in community-living populations. In a pooled analysis of two large observational cohorts, we investigated associations between serum potassium concentrations and CVD events and mortality, and whether potassium-altering medications and eGFR<60 ml/min per 1.73 m2 modified these associations.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 9651 individuals from the Multi-Ethnic Study of Atherosclerosis (MESA) and the Cardiovascular Health Study (CHS), who were free of CVD at baseline (2000-2002 in the MESA and 1989-1993 in the CHS), we investigated associations between serum potassium categories (<3.5, 3.5-3.9, 4.0-4.4, 4.5-4.9, and ≥5.0 mEq/L) and CVD events, mortality, and mortality subtypes (CVD versus non-CVD) using Cox proportional hazards models, adjusting for demographics, time-varying eGFR, traditional CVD risk factors, and use of potassium-altering medications.

RESULTS

Compared with serum potassium concentrations between 4.0 and 4.4 mEq/L, those with concentrations ≥5.0 mEq/L were at higher risk for all-cause mortality (hazard ratio, 1.41; 95% confidence interval, 1.12 to 1.76), CVD death (hazard ratio, 1.50; 95% confidence interval, 1.00 to 2.26), and non-CVD death (hazard ratio, 1.40; 95% confidence interval, 1.07 to 1.83) in fully adjusted models. Associations of serum potassium with these end points differed among diuretic users (Pinteraction<0.02 for all), such that participants who had serum potassium ≥5.0 mEq/L and were concurrently using diuretics were at higher risk of each end point compared with those not using diuretics.

CONCLUSIONS

Serum potassium concentration ≥5.0 mEq/L was associated with all-cause mortality, CVD death, and non-CVD death in community-living individuals; associations were stronger in diuretic users. Whether maintenance of potassium within the normal range may improve clinical outcomes requires future study.

[Plasma 25-OH Vitamin D Concentrations in Cord Blood after Summer Months, Spain]

OBJECTIVE

Plasma vitamin D (25(OH)D) levels in the newborn are dependent on maternal stores. Several studies showing a high prevalence of vitamin D deficiency in pregnant women have been published last years. The aim of the study was to analyze 25(OH)D levels in cord blood after summer month, determine whether there is a relation with different variables.

METHODS

103 pregnant women were recruited between October and early December 2014, whose gestations took place during month of maximum sun exposure. Plasmatic 25(OH)D values were measured in cord blood at birth. Clinical record data were collected and a nutritional survey was made on maternal vitamin D and calcium intake and sun exposure. Statistical analysis was performed using SPSS. Comparisons were performed using Kruskal-Wallis and Mann-Whitney U tests, and correction for multiple comparisons using Bonferroni. P value smaller than 0.05 and smaller than 0.0083 for multiple comparisons were considered sta¬tistically significant.

RESULTS

Mean 25(OH)D value in cord blood was 12.36± 7.2 ng/ml. Vitamin D deficiency was present in 83.4% of women. A statistically significant correlation was observed between lowvitamin D levels and low vitamin D intake (correlation coefficient 0.29); Ethnic group, with the highest level in caucasic group (17.9 ± 5.83 ng/ml) and the lowest in indopakistani group (6.68 ± 4.2 ng/ml); the use of traditional clothing (5.64 ± 3.09 ng/ml); low sun exposure and dark skin phototype with a correlation coefficient of 0.67 and -0.48, respectively.

CONCLUSIONS

There is a high prevalence of vitamin D deficiency in pregnant women regardless of the season and increased sun exposure. Low vitamin D levels in cord blood were significantly related to ethnicity (Indopakistan and Maghreb), low sun exposure and dark skin phototype. No statistically significant differences were found between vitamin D levels and perinatal variables studied.

Increasing Family Medicine Faculty Diversity Still Lags Population Trends

BACKGROUND

Faculty diversity has important implications for medical student diversity. The purpose of this analysis is to describe trends in racial, ethnic, and gender diversity in family medicine (FM) departments and compare these trends to the diversity of matriculating medical students, the diversity of all medical school faculty, and the population in general.

METHODS

We used the Association of American Medical Colleges Faculty Roster to describe trends in proportions of female and minorities under-represented in medicine (URM) in FM department full-time faculty in U.S. MD-granting medical schools.

RESULTS

Among FM faculty, the proportions of female and URM faculty have grown more than 2-fold between 1980 and 2015. Increasing faculty rank was associated with lower diversity across the study period. FM departments had higher female and URM proportions than the average of all other specialties, but URM representation still lagged population trends.

CONCLUSION

Although FM faculty diversity is growing over time, continued attention to URM representation should remain a priority.

Educational inequalities in hypertension: complex patterns in intersections with gender and race in Brazil

Background

Hypertension is a major public health issue worldwide, but knowledge is scarce about its patterns and its relationship to multiple axes of social disadvantages in Latin American countries. This study describes the educational inequality in the prevalence of hypertension in Brazil, including a joint stratification by gender and race.

Methods

We analyzed interview-based data and blood pressure measurements from 59,402 participants aged 18 years or older at the 2013 Brazilian National Health Survey (PNS). Sociodemographic characteristics analyzed were gender (male, female), racial self-identification (white, brown, black), age (5-years intervals), and educational attainment (pre-primary, primary, secondary, tertiary). Hypertension was defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, and/or self-reported use of antihypertensive medications in the last 2 weeks. We used logistic regression to evaluate the age-adjusted prevalences of hypertension (via marginal modeling), and pair-wise associations between education level and odds of hypertension. Further, the educational inequality in hypertension was summarized through the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). All analyses considered the appropriate sampling weights and intersections with gender, race, and education.

Results

Age-adjusted prevalence of hypertension was 34.0 % and 30.8 % among men and women, respectively. Black and brown women had a higher prevalence than whites (34.5 % vs. 31.8 % vs. 29.5 %), whereas no racial differences were observed among men. White and brown, but not black women, showed graded inverse associations between hypertension and educational attainment; among men, non-statistically significant associations were observed in all racial strata. The RII and SII estimated inverse gradients among white (RII = 2.5, SII = 18.1 %) and brown women (RII = 2.3, SII = 14.5 %), and homogeneous distributions of hypertension in educational subgroups among black women and among men.

Conclusion

In this representative sample of Brazilian adults, the association between educational attainment and hypertension was influenced by gender and race – a topic still poorly understood. Our findings highlight the importance of assessing intersections of multiple sociodemographic characteristics in health inequalities research. The use of comprehensive measures of inequality, such as RII and SII, provide useful insights for monitoring health inequalities in an intersectional perspective.

Association of passive and active smoking with pre-diabetes risk in a predominantly Hispanic population

Smoking is the leading cause of avoidable death and is associated with type 2 diabetes (T2D) risk. Previous studies on the impact of passive smoking have not been applied to a Hispanic-majority population. We investigated the association between active smoking, exposure to environmental tobacco smoke (ETS), and pre-diabetes risk in a New Mexico population. We hypothesized that pre-diabetes risk increases with increasing smoking status after adjustment for important covariates. We screened 219 adults from an ongoing study who were categorized according to their smoking status (never smoker, current smoker, previous smoker) and their exposure to ETS (exposed or unexposed). Glucose homeostasis status was assigned using A1c: no diabetes (A1c <5.7%), pre-diabetes (A1c 5.7-6.4%), and T2D (A1c >6.4%). Among 160 patients with complete data, 51.6% had no diabetes and 48.4% had pre-diabetes. The mean age was 44.8±13.5 years. The study population was predominantly female (64.4%), and the ethnic composition was 44.4% Hispanic, 39.4% non-Hispanic White (NHW), 10.6% American Indian, 2.5% African-American, and 3.1% other. Using a logistic model with 2-way interactions, all predicted probabilities for being at risk for pre-diabetes were significant at the 0.001 level for smoking status and ETS exposure after adjusting for age, sex, ethnicity, family history of diabetes, alcohol consumption, BMI, and blood pressure. Active or passive smoking is independently associated with pre-diabetes risk.

Supportive Care: Communication Strategies to Improve Cultural Competence in Shared Decision Making

Historic migration and the ever-increasing current migration into Western countries have greatly changed the ethnic and cultural patterns of patient populations. Because health care beliefs of minority groups may follow their religion and country of origin, inevitable conflict can arise with decision making at the end of life. The principles of truth telling and patient autonomy are embedded in the framework of Anglo-American medical ethics. In contrast, in many parts of the world, the cultural norm is protection of the patient from the truth, decision making by the family, and a tradition of familial piety, where it is dishonorable not to do as much as possible for parents. The challenge for health care professionals is to understand how culture has enormous potential to influence patients' responses to medical issues, such as healing and suffering, as well as the physician-patient relationship. Our paper provides a framework of communication strategies that enhance crosscultural competency within nephrology teams. Shared decision making also enables clinicians to be culturally competent communicators by providing a model where clinicians and patients jointly consider best clinical evidence in light of a patient's specific health characteristics and values when choosing health care. The development of decision aids to include cultural awareness could avoid conflict proactively, more productively address it when it occurs, and enable decision making within the framework of the patient and family cultural beliefs.

Ethnic Differences in Incidence and Outcomes of Childhood Nephrotic Syndrome

BACKGROUND AND OBJECTIVES

Ethnic differences in outcomes among children with nephrotic syndrome are unknown.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a longitudinal study at a single regional pediatric center comparing ethnic differences in incidence from 2001 to 2011 census data and longitudinal outcomes, including relapse rates, time to first relapse, frequently relapsing disease, and use of cyclophosphamide. Among 711 children, 24% were European, 33% were South Asian, 10% were East/Southeast Asian, and 33% were of other origins.

RESULTS

Over 10 years, the overall incidence increased from 1.99/100,000 to 4.71/100,000 among children ages 1-18 years old. In 2011, South Asians had a higher incidence rate ratio of 6.61 (95% confidence interval, 3.16 to 15.1) compared with Europeans. East/Southeast Asians had a similar incidence rate ratio (0.76; 95% confidence interval, 0.13 to 2.94) to Europeans. We determined outcomes in 455 children from the three largest ethnic groups with steroid-sensitive disease over a median of 4 years. South Asian and East/Southeast Asian children had significantly lower odds of frequently relapsing disease at 12 months (South Asian: adjusted odds ratio; 0.55; 95% confidence interval, 0.39 to 0.77; East/Southeast Asian: adjusted odds ratio; 0.42; 95% confidence interval, 0.34 to 0.51), fewer subsequent relapses (South Asian: adjusted odds ratio; 0.64; 95% confidence interval, 0.50 to 0.81; East/Southeast Asian: adjusted odds ratio; 0.47; 95% confidence interval, 0.24 to 0.91), lower risk of a first relapse (South Asian: adjusted hazard ratio, 0.74; 95% confidence interval, 0.67 to 0.83; East/Southeast Asian: adjusted hazard ratio, 0.65; 95% CI, 0.63 to 0.68), and lower use of cyclophosphamide (South Asian: adjusted hazard ratio, 0.82; 95% confidence interval, 0.53 to 1.28; East/Southeast Asian: adjusted hazard ratio, 0.54; 95% confidence interval, 0.41 to 0.71) compared with European children.

CONCLUSIONS

Despite the higher incidence among South Asians, South and East/Southeast Asian children have significantly less complicated clinical outcomes compared with Europeans.

Primary Care Patients' Willingness to Participate in Comprehensive Weight Loss Programs: From the WWAMI Region Practice and Research Network

PURPOSE

In the United States, 69% of adults are overweight or obese, as defined by a body mass index (BMI) ≥25 kg/m(2). The US Preventive Services Task Force recommends screening all adult patients for obesity and referring obese patients to intensive, multicomponent behavioral weight loss programs comprising 12 to 26 yearly sessions. The objective of this study is to determine the degree to which overweight and obese primary care patients report willingness to participate in these intensive weight loss programs and to identify the patient factors associated with reported willingness to participate.

METHODS

This 2013 cross-sectional survey was offered to all adult patients seen for an office visit at 1 of 12 primary care clinics in the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Region Practice and Research Network (WPRN). Patients self-reported both their health information and their willingness to participate in a comprehensive weight loss program. Respondents were characterized by descriptive statistics. We compared reported rates of willingness to participate by patient factors and assessed which patient factors were independently associated with reported willingness using bivariate analysis and logistic regression, respectively.

RESULTS

Of overweight and obese respondents, 63% reported willingness to participate in comprehensive weight loss programs. Age, sex, race/ethnicity, insurance status, BMI, and reason for wanting to lose weight were all significantly and independently associated with reported willingness to participate.

CONCLUSIONS

Reported willingness to participate in comprehensive weight loss programs suggests that additional resources are needed to understand strategies for disseminating and implementing effective comprehensive weight loss programs.

Ethnic Variations in Duodenal Villous Atrophy Consistent With Celiac Disease in the United States

BACKGROUND & AIMS

Celiac disease is a common disorder with a worldwide distribution, although the prevalence among different ethnicities varies. We aimed to measure the prevalence of duodenal villous atrophy among patients of different ethnicities throughout the United States.

METHODS

We performed a cross-sectional study of all patients who had duodenal biopsies submitted to a national pathology laboratory between January 2, 2008 and April 30, 2015. The prevalence of villous atrophy was calculated for the following ethnicities by using a previously published algorithm based on patient names: North Indian, South Indian, East Asian, Hispanic, Middle Eastern, Jewish, and other Americans.

RESULTS

Among all patients (n = 454,885), the median age was 53 years, and 66% were female. The overall prevalence of celiac disease was 1.74%. Compared with other Americans (n = 380,163; celiac disease prevalence, 1.83%), celiac disease prevalence was lower in patients of South Indian (n = 177, 0%; P = .08), East Asian (n = 4700, 0.15%; P ≤ .0001), and Hispanic (n = 31,491, 1.06%; P ≤ .0001) ethnicities. Celiac disease was more common in patients from the Punjab region (n = 617, 3.08%) than in patients from North India (n = 1195, 1.51%; P = .02). The prevalence of celiac disease among patients of Jewish (n = 17,806, 1.80%; P = .78) and Middle Eastern (n = 1903, 1.52%; P = .33) ethnicities was similar to that of other Americans. Among Jewish individuals (n = 17,806), the prevalence of celiac disease was 1.83% in Ashkenazi persons (n = 16,440) and 1.39% in Sephardic persons (n = 1366; P = .24).

CONCLUSIONS

Among patients undergoing duodenal biopsy, individuals from the Punjab region of India constitute the ethnic group in the United States with the highest prevalence of villous atrophy consistent with celiac disease. Compared with other Americans, villous atrophy prevalence on duodenal biopsy is significantly lower among U.S. residents of South Indian, East Asian, and Hispanic ancestry.