Ernst Bertner: A Surgeon with Prescient Vision for the Largest Medical Center in the World

More than 75 years ago, surgeon Ernst Bertner envisioned the Texas Medical Center (TMC) as "breathtaking in the scope and breadth of its conception," that would be "one of the largest in the world"; a gigantic medical enterprise that would "attract the greatest scientists of the world" and would combine patient care, research, and education, on a scale that was "second to none." During the next 3 years, Bertner accomplished important pieces of the Herculean task to bring onto the campus 11 major buildings, including the University of Texas MD Anderson Hospital for Cancer Research, for which he was the interim director. This was an extraordinary accomplishment because at the outset he had only a strategic plan, the deed to 134 acres of forest, and financial support from the MD Anderson Foundation! Bertner further forecasted world-class clinical and educational programs in the TMC, stating: "We envision the time when the Medical Center will become a great magnet, drawing leaders in education, medicine, and dental professions. It will provide the physical facilities and the environment in which research will flourish and bring forth for all of us new discoveries in the field of medicine." So how did his bold vision and passionate leadership culminate in the TMC today? By any criteria of scale and program excellence, the TMC today can be regarded as the largest medical center in the world. Occupying a contiguous campus of 1345 acres (2.1 square miles), it comprises 162 buildings, 60+ member institutions, 21 hospitals (> 9200 beds), 21 academic institutions, 4 medical schools, 7 nursing schools, 3 public health schools, 2 pharmacy schools, and a dental school. More than 106,000 patients and visitors come daily to the TMC, which has more than 120,000 employees, including 5000 physicians, 5700 researchers, and 11,000 registered nurses. Ernst Bertner is credited for transforming the original vision of the TMC into a workable program, and whose dynamic devotion to the idea captured the devotion of others to accomplish this extraordinary feat. Thus, during this short interval from 1946 to 1950, Bertner transitioned the leadership of the MD Anderson Cancer Hospital to Dr. R. Lee Clark, conducted a busy general surgery and gynecologic practice, facilitated the monumental transfer of the Baylor Medical School from Dallas to Houston, helped to recruit Dr. Michael DeBakey from New Orleans, and fought a heroic battle against rhabdomyosarcoma, a very rare and aggressive cancer.

[Digital environment and population health]

Health and risk of disease are determined by exposure to the physical, socio-economic, and political environment and to this has been added exposure to the digital environment. Our increasingly digital lives have major implications for people's health and its monitoring, as well as for prevention and care. Digital health, which encompasses the use of health applications, connected devices and artificial intelligence medical tools, is transforming medical and healthcare practices. Used properly, it could facilitate patient-centered, inter-professional and data-driven care. However, its implementation raises major concerns and ethical issues, particularly in relation to privacy, equity, and the therapeutic relationship.

Measuring social determinants of health in the All of Us Research Program

To accelerate medical breakthroughs, the All of Us Research Program aims to collect data from over one million participants. This report outlines processes used to construct the All of Us Social Determinants of Health (SDOH) survey and presents the psychometric characteristics of SDOH survey measures in All of Us. A consensus process was used to select SDOH measures, prioritizing concepts validated in diverse populations and other national cohort surveys. Survey item non-response was calculated, and Cronbach's alpha was used to analyze psychometric properties of scales. Multivariable logistic regression models were used to examine associations between demographic categories and item non-response. Twenty-nine percent (N = 117,783) of eligible All of Us participants submitted SDOH survey data for these analyses. Most scales had less than 5% incalculable scores due to item non-response. Patterns of item non-response were seen by racial identity, educational attainment, income level, survey language, and age. Internal consistency reliability was greater than 0.80 for almost all scales and most demographic groups. The SDOH survey demonstrated good to excellent reliability across several measures and within multiple populations underrepresented in biomedical research. Bias due to survey non-response and item non-response will be monitored and addressed as the survey is fielded more completely.

An ensemble penalized regression method for multi-ancestry polygenic risk prediction

Great efforts are being made to develop advanced polygenic risk scores (PRS) to improve the prediction of complex traits and diseases. However, most existing PRS are primarily trained on European ancestry populations, limiting their transferability to non-European populations. In this article, we propose a novel method for generating multi-ancestry Polygenic Risk scOres based on enSemble of PEnalized Regression models (PROSPER). PROSPER integrates genome-wide association studies (GWAS) summary statistics from diverse populations to develop ancestry-specific PRS with improved predictive power for minority populations. The method uses a combination ofL 1 (lasso) andL 2 (ridge) penalty functions, a parsimonious specification of the penalty parameters across populations, and an ensemble step to combine PRS generated across different penalty parameters. We evaluate the performance of PROSPER and other existing methods on large-scale simulated and real datasets, including those from 23andMe Inc., the Global Lipids Genetics Consortium, and All of Us. Results show that PROSPER can substantially improve multi-ancestry polygenic prediction compared to alternative methods across a wide variety of genetic architectures. In real data analyses, for example, PROSPER increased out-of-sample prediction R2 for continuous traits by an average of 70% compared to a state-of-the-art Bayesian method (PRS-CSx) in the African ancestry population. Further, PROSPER is computationally highly scalable for the analysis of large SNP contents and many diverse populations.

All of Us Program Illustrates What Less-Diverse Genomics Studies Might Be Missing

This Medical News story discusses new findings from genomics studies involving diverse cohorts.

Comparison of phenomic profiles in the All of Us Research Program against the US general population and the UK Biobank

IMPORTANCE

Knowledge gained from cohort studies has dramatically advanced both public and precision health. The All of Us Research Program seeks to enroll 1 million diverse participants who share multiple sources of data, providing unique opportunities for research. It is important to understand the phenomic profiles of its participants to conduct research in this cohort.

OBJECTIVES

More than 280 000 participants have shared their electronic health records (EHRs) in the All of Us Research Program. We aim to understand the phenomic profiles of this cohort through comparisons with those in the US general population and a well-established nation-wide cohort, UK Biobank, and to test whether association results of selected commonly studied diseases in the All of Us cohort were comparable to those in UK Biobank.

MATERIALS AND METHODS

We included participants with EHRs in All of Us and participants with health records from UK Biobank. The estimates of prevalence of diseases in the US general population were obtained from the Global Burden of Diseases (GBD) study. We conducted phenome-wide association studies (PheWAS) of 9 commonly studied diseases in both cohorts.

RESULTS

This study included 287 012 participants from the All of Us EHR cohort and 502 477 participants from the UK Biobank. A total of 314 diseases curated by the GBD were evaluated in All of Us, 80.9% (N = 254) of which were more common in All of Us than in the US general population [prevalence ratio (PR) >1.1, P < 2 × 10-5]. Among 2515 diseases and phenotypes evaluated in both All of Us and UK Biobank, 85.6% (N = 2152) were more common in All of Us (PR >1.1, P < 2 × 10-5). The Pearson correlation coefficients of effect sizes from PheWAS between All of Us and UK Biobank were 0.61, 0.50, 0.60, 0.57, 0.40, 0.53, 0.46, 0.47, and 0.24 for ischemic heart diseases, lung cancer, chronic obstructive pulmonary disease, dementia, colorectal cancer, lower back pain, multiple sclerosis, lupus, and cystic fibrosis, respectively.

DISCUSSION

Despite the differences in prevalence of diseases in All of Us compared to the US general population or the UK Biobank, our study supports that All of Us can facilitate rapid investigation of a broad range of diseases.

CONCLUSION

Most diseases were more common in All of Us than in the general US population or the UK Biobank. Results of disease-disease association tests from All of Us are comparable to those estimated in another well-studied national cohort.

Inadequate Use of Newer Treatments and Glycemic Control by Cardiovascular Risk and Sociodemographic Groups in US Adults with Diabetes in the NIH Precision Medicine Initiative All of Us Research Program

PURPOSE

Data are limited on sodium glucose co-transport 2 inhibitors (SGLT2-is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) among real-world cohorts of underrepresented patients. We examined these therapies and glycemic control in US adults with diabetes mellitus (DM) by atherosclerotic cardiovascular disease (ASCVD) risk and sociodemographic factors.

METHODS

In the NIH Precision Medicine Initiative All of Us Research Program, we categorized DM as (1) moderate risk, (2) high risk, and (3) with ASCVD. We examined proportions on DM therapies, including SGLT2-i or GLP-1 RA, and at glycemic control by sociodemographic factors and CVD risk groups.

RESULTS

Our 81,332 adults aged ≥ 18 years with DM across 340 US sites included 22.3% non-Hispanic Black, 17.2% Hispanic, and 1.8% Asian participants; 31.1%, 30.3%, and 38.6% were at moderate risk, high risk, or with ASCVD, respectively. Those with DM and ASCVD were most likely on SGLT2-i (8.6%) or GLP-1 RA (11.9%). SGLT2-i use was < 10% in those with heart failure or chronic kidney disease. The odds (95% CI) of SGLT2-i use were greater among men (1.35 [1.20, 1.53]) and Asian persons (2.31 [1.78, 2.96]), with GLP-1 RA being less common (0.78 [0.70, 0.86]) in men. GLP-1 RA use was greater among those with health insurance, and both GLP-1 RA and SGLT2-i greater within lower income groups. 72.0% of participants had HbA1c < 7%; Hispanic persons were least likely at glycemic control.

CONCLUSIONS

Treatment with SGLT2-is and GLP-1 RAs remains low, even among higher ASCVD risk persons with DM and use is even lower among underserved groups.

Post stroke pain: Is there under-diagnosis in Black versus White patients?

Stroke incidence is higher and stroke outcomes are poorer in Black patients compared to White patients. Poststroke pain, however, is not a well understood stroke outcome. Using the National Institutes of Health All of Us Research Program database, we hypothesized that the dataset would demonstrate proportionately higher relative risk of poststroke pain in the Black poststroke patient population compared to the White poststroke patient population. However, our analysis showed that Black stroke patients were diagnosed with poststroke pain at a similar rate as White stroke patients. As our results are not consistent with other poststroke outcomes in the literature, this study identifies a potentially underdiagnosed patient population, highlighting the need for further research.

A scoping study on the social determinants of health and sugar consumption in the context of policy approaches for improving population health

OBJECTIVES

To conduct a scoping review of existing research on the social determinants of health, sugar consumption and public health policy responses to address or improve health outcomes.

METHODS

A total of 13 categories were developed to reflect the authors' interest in the overall focus on the social determinants of health, sugar as an independent risk factor, upstream policy action ('whole populations'), downstream policy action ('targeted') and two contemporary policy strategies (namely 'Vulnerable populations' and 'Proportionate Universalism'). The search strategy was then performed on MEDLINE (via Ovid) and Web of Science, and was limited to the English language. No time limits prior to when the database search was conducted in 2022 were set to explore the full extent of the literature in this field.

RESULTS

Five hundred and sixty articles were retrieved, of which 181 met the criteria for review. When all categories were applied, the findings showed that 76% of papers focusing on sugar consumption as a risk factor for non-communicable diseases (NCDs) mentioned the social determinants of health. The majority of studies (60%) recommended downstream interventions, with 40% recommending 'upstream' interventions. A limited proportion (12%) of research work was published in dental journals. Research had been done using predominantly quantitative methods (66% of articles), with 24% of studies adopting a mixed methods approach, and 8% being exclusively qualitative. Research on contemporary strategies for sugar reduction were focused on the 'Global North' and 98% of papers used individual level data focused on targeted approaches, highlighting that there is little direct evidence for contemporary strategies aimed at reducing sugar consumption.

CONCLUSIONS

Whilst the majority of public and dental health research argues that there is a need to address the social determinants of health, the findings from this study highlight that very few empirical studies have been designed to directly inform contemporary strategies for sugar reduction. More research is therefore needed that can directly assess the evidence for contemporary strategies in public health policy.

Urban environment and health: a cross-sectional multiregional project based on population health surveys in Spain (DAS-EP project) - study protocol

INTRODUCTION

The European Environment Agency estimates that 75% of the European population lives in cities. Despite the many advantages of city life, the risks and challenges to health arising from urbanisation need to be addressed in order to tackle the growing burden of disease and health inequalities in cities. This study, Urban environment and health: a cross-sectional multiregional project based on population health surveys in Spain (DAS-EP project), aims to investigate the complex association between the urban environmental exposures (UrbEEs) and health.

METHODS AND ANALYSIS

DAS-EP is a Spanish multiregional cross-sectional project that combines population health surveys (PHS) and geographical information systems (GIS) allowing to collect rich individual-level data from 17 000 adult citizens participating in the PHS conducted in the autonomous regions of the Basque Country, Andalusia, and the Valencian Community, and the city of Barcelona in the years 2021-2023. This study focuses on the population living in cities or metropolitan areas with more than 100 000 inhabitants. UrbEEs are described by objective estimates at participants' home addresses by GIS, and subjective indicators present in PHS. The health outcomes included in the PHS and selected for this study are self-perceived health (general and mental), prevalence of chronic mental disorders, health-related quality of life, consumption of medication for common mental disorders and sleep quality. We aim to further understand the direct and indirect effects between UrbEEs and health, as well as to estimate the impact at the population level, taking respondents' sociodemographic and socioeconomic characteristics, and lifestyle into consideration.

ETHICS AND DISSEMINATION

The study was approved by the regional Research Ethics Committee of the Basque Country (Ethics Committee for Research Involving Medicinal Products in the Basque Country; PI2022138), Andalusia (Biomedical Research Ethics Committee of the Province of Granada; 2078-N-22), Barcelona (CEIC-PSMar; 2022/10667) and the Valencian Community (Ethics Committee for Clinical Research of the Directorate General of Public Health and Center for Advanced Research in Public Health; 20221125/04). The results will be communicated to the general population, health professionals, and institutions through conferences, reports and scientific articles.

Chatbots and COVID-19: Taking Stock of the Lessons Learned

While digital innovation in health was already rapidly evolving, the COVID-19 pandemic has accelerated the generation of digital technology tools, such as chatbots, to help increase access to crucial health information and services to those who were cut off or had limited contact with health services. This theme issue titled "Chatbots and COVID-19" presents articles from researchers and practitioners across the globe, describing the development, implementation, and evaluation of chatbots designed to address a wide range of health concerns and services. In this editorial, we present some of the key challenges and lessons learned arising from the content of this theme issue. Most notably, we note that a stronger evidence base is needed to ensure that chatbots and other digital tools are developed to best serve the needs of population health.

Association between atopic dermatitis and inflammatory bowel disease among US adults in the All of Us Research Program

Our study investigated the association between atopic dermatitis (AD) and inflammatory bowel disease using the All of Us Research Program, a US National Institutes of Health database providing health information on over 300 000 Americans. This cross-sectional study demonstrated that individuals with AD have an approximately twofold increase in odds of having inflammatory bowel disease, Crohn disease and ulcerative colitis, compared with individuals without AD.

Psychiatric comorbidities associated with rosacea: a propensity score-matched case-control study in the All of Us database

Using the ethnically diverse All of Us dataset, this study investigated the association between rosacea and various psychiatric disorders. The analysis identified a significant prevalence of major psychiatric conditions, most notably phobic disorder, OCD, dysthymia and generalized anxiety disorder in participants with rosacea. This association highlights the importance of addressing the psychological wellbeing of people with rosacea and calls for further research into the underlying pathophysiological connections.

The Digital Therapeutics Real-World Evidence Framework: An Approach for Guiding Evidence-Based Digital Therapeutics Design, Development, Testing, and Monitoring

Digital therapeutics (DTx) are a promising way to provide safe, effective, accessible, sustainable, scalable, and equitable approaches to advance individual and population health. However, developing and deploying DTx is inherently complex in that DTx includes multiple interacting components, such as tools to support activities like medication adherence, health behavior goal-setting or self-monitoring, and algorithms that adapt the provision of these according to individual needs that may change over time. While myriad frameworks exist for different phases of DTx development, no single framework exists to guide evidence production for DTx across its full life cycle, from initial DTx development to long-term use. To fill this gap, we propose the DTx real-world evidence (RWE) framework as a pragmatic, iterative, milestone-driven approach for developing DTx. The DTx RWE framework is derived from the 4-phase development model used for behavioral interventions, but it includes key adaptations that are specific to the unique characteristics of DTx. To ensure the highest level of fidelity to the needs of users, the framework also incorporates real-world data (RWD) across the entire life cycle of DTx development and use. The DTx RWE framework is intended for any group interested in developing and deploying DTx in real-world contexts, including those in industry, health care, public health, and academia. Moreover, entities that fund research that supports the development of DTx and agencies that regulate DTx might find the DTx RWE framework useful as they endeavor to improve how DTxcan advance individual and population health.

Identifying Frailty in Older Adults in Rural Victoria, Australia: A Secondary Analysis of Population Health Data

Objectives: To determine the prevalence of frailty among community-dwelling older adults in regional Victoria, Australia. Methods: Frailty status of 376 participants from the Crossroads II cross-sectional study was assessed by selected markers of frailty. The selected variables were psychometrically tested. Associations between frailty and socio-demographic, environmental and health factors were analysed using chi-square, ANOVA and binary logistic regression (BLR). Results: Estimated prevalence of frailty was 39.4%. BLR indicated that frailty decreased with higher educational attainment, (OR = .23; 95% CI: .10-.51) increased for divorced/separated participants (OR = 2.68; 95% CI: 1.29-5.56) and when having three (OR = 3.27; 95% CI: 1.07-9.98), four (OR = 7.20; 95% CI: 2.22-23.31) or five or more chronic conditions (OR = 9.18; 95% CI: 2.83-29.72). Discussion: Frailty in this Australian regional community-dwelling sample was higher than other studies conducted in urban areas of Australia. Present results highlight the importance of exploring the multidimensionality of the frailty construct to have a better understanding which factors are associated with the development of this syndrome.

Climate Change Adaptation Methods for Public Health Prevention in Australia: an Integrative Review

PURPOSE OF REVIEW

Climate change poses a serious threat to human health and well-being. Australia is not immune to the public health impacts and continues to be underprepared, putting the population health at risk. However, there is a dearth in knowledge about how the Australian public health system will address the impacts of climate change.

RECENT FINDINGS

This integrative review synthesises tools, frameworks, and guidance material suitable for climate change adaptation from a preventive public health perspective. The literature search was conducted in electronic databases MEDLINE, PubMed, CINAHL, and Web of Science. Of 4507 articles identified, 19 articles met the inclusion criteria that focused on operational methods in public health and excluded the clinical context and reactive disaster response approaches. This review revealed that Australia is ill-prepared to manage climate change adverse health impacts due to ineffective adaptation strategies. The review highlights that Australia urgently requires effective adaptation strategies such as undertaking a National Adaptation Plan process and an improved understanding in managing complex health risks. Taking this action will strengthen the public health system and build health resilience especially for vulnerable populations. These findings will help understand and develop of the necessary adaptive strategies in Australia.

[The analysis of dynamics of indicator of mortality of population of the Siberian Federal Okrug resulted from toxic impact of alcohol in 2011-2020]

The purpose of the study is to investigate dynamics of mortality of population of the Siberian Federal Okrug resulted from toxic impact of alcohol in 2011-2020 and to comparatively analyze mortality of population of the regions of the Siberian Federal Okrug with general Okrug values. The study uses statistical data of the Federal State Statistics Service of the Russian Federation. The analysis was applied to mortality of population of the Russian Federation, the Siberian Federal Okrug and the regions of the Siberian Federal Okrug (the Republic of Altai, the Republic of Tuva, the Republic of Khakassia, the Altai Kray, the Krasnoyarsk Kray, Irkutsk, Kemerovo, Novosibirsk, Omsk and Tomsk Oblast) resulted from toxic impact of alcohol. The comparative analysis of regional and general Okrug indicators of mortality was implemented. The statistical processing of data included common methods of calculating extensive and intensive indicators, indicator average error and evaluation of reliability of differences. It was established that in 2011-2020, mortality of population of the Siberian Federal Okrug resulted from toxic impact of alcohol decreased by 3.3 times. The decrease of mortality of the population was registered in all regions of the Siberian Federal Okrug. The fastest decreasing of mortality of population occurred in the Altai Kray (7.7 times), the Republic of Tuva (7.0 times), the Krasnoyarsk Kray (6.4 times). The investigation of dynamics of mortality of population in the regions of the Siberian Federal Okrug resulted from toxic impact of alcohol permits to identify characteristics of toxicological situation at the regional level and to determine strategic directions of the regional policy of chemical safety and population health protection.

Rethinking Data Collection Methods During the Pandemic: Development and Implementation of CATI for the All of Us Research Program

The All of Us Research Program is a longitudinal cohort study aiming to build a diverse database to advance precision medicine. The COVID-19 pandemic hindered the ability of participants to receive in-person assistance at enrollment sites to complete digital surveys. Therefore, the program implemented Computer-Assisted Telephone Interviewing (CATI) to facilitate survey completion remotely to combat the disrupted data collection procedures. In January 2021, All of Us implemented a 1-year CATI Pilot supporting 9399 participants and resulting in 16 337 submitted surveys. The pilot showed that CATI was successful in increasing survey completion and retention activities for the All of Us Research Program, given the additional remote support offered to participants. Given the success of the CATI Pilot, multimodal survey administration will continue.

Structural Sexism and Preventive Health Care Use in the United States

Preventive health care use can reduce the risk of disease, disability, and death. Thus, it is critical to understand factors that shape preventive care use. A growing body of research identifies structural sexism as a driver of population health, but it remains unknown if structural sexism is linked to preventive care use and, if so, whether the relationship differs for women and men. Gender performance and gendered power and resource allocation perspectives lead to competing hypotheses regarding these questions. This study explores the relationship between structural sexism and preventive care in gender-stratified, multilevel models that combine data from the Behavioral Risk Factor Surveillance System with state-level data (N = 425,454). We find that in states with more structural sexism, both men and women were less likely to seek preventive care. These findings support the gender performance hypothesis for men and the gendered power and resource allocation hypothesis for men and women.

Precision Medicine for Whom? Public Health Outputs from "Genomics England" and "All of Us" to Make Up for Upstream and Downstream Exclusion

This paper problematizes the precision medicine approach embraced by the All of Us Research Program (US) and by Genomics England (UK) in terms of benefits distribution, by arguing that current "diversity and inclusion" efforts do not prevent exclusiveness, unless the framing and scope of the projects are revisited in public health terms. Grounded on document analysis and fieldwork interviews, this paper analyzes efforts to address potential patterns of exclusion upstream (from participating in precision medicine research) and downstream (from benefitting from precision medicine outputs). It argues that efforts for inclusion upstream are not corresponded downstream, and this unbalance jeopardizes the equitable capacities of the projects. It concludes that enhanced focus on socio-environmental determinants of health and aligned public health interventions as precision medicine outputs would be to the benefit of all and especially of those who are most at risk of (upstream as well as downstream) exclusion.

Personhood as projection: the value of multiple conceptions of personhood for understanding the dehumanisation of people living with dementia

We examine the concept of personhood in relation to people living with dementia and implications for the humanity of care, drawing on a body of ethnographic work. Much debate has searched for an adequate account of the person for these purposes. Broad contrasts can be made between accounts focusing on cognition and mental faculties, and accounts focusing on embodied and relational aspects of the person. Some have suggested the concept of the person is critical for good care; others suggest the vexed debates mean that the concept should be abandoned. We argue instead that the competing accounts illuminate the very tensions in personhood which are manifest for all of us, but especially for people living with dementia, and argue that our account has explanatory power in shedding light on how precisely dehumanisation and constraints on agency may arise for people living with dementia, and for staff, within an institutional context.

[The personnel maintenance of primary health care physicians in condition of challenges from menaces to population health]

In condition of challenges from menaces to health due to COVID-19 the role of primary health care physicians increases that requires development of management decisions at the regional level. The purpose of the study. On the basis of analysis of medical demographic indicators and data concerning provision of primary health care personnel in the Russian Federation, proposals were made related to reforming of primary health care system in conditions of implementation of general medical practice with purpose to counteract menaces to population health. The analytical and statistical methods were applied. The official statistics data from the Minzdrav of the Russian Federation and Rosstat, results of original researches with content analysis and interpretation were used. The COVID-19 pandemic negatively impacted population health. The indicator of newly detected morbidity in the Russian Federation in 2020 decreased as compared to 2019 from 78024.3 to 75989.7‰oo (by 2.6%). This is the result of decreasing of dispensary and preventive activities among population. In next COVID-19 year (2021), as compared to 2020, indicator of primary morbidity increased to 85531.6‰oo that 12.6% higher than in 2020. The increase occurred in all classes of diseases that caused necessity of rehabilitation of these patients. The COVID-19 morbidity increased up to 2.4 times i.e. from 3391.1 in 2020 to 8085.7‰oo in 2021. The provision of physicians in the Russian Federation was 37.7‰o in 2021. Across the Federal Okrugs differences in indicators made up to 1.3 times and in subjects of the Russian Federation - up to 2.7 times. In conditions of COVID-19 significance of menaces to population health worsened. The situation requires both enhancement of primary health care and implementation of physicians of new formation - general practitioners responsible for patient health. The general practice (GP) widely developed in Russia in the 1990s during last ten years loses its significance in most subjects of the Russian Federation. In 2021, provision of general practitioners in the Russian Federation made up to 0.67‰o. In the Federal Okrugs, difference between indicators made up to 5.6 times. In the subjects of the Russian Federation the difference is enormous - 141.5 times. The article presents and scientifically substantiates prospective functional organizational models of general practice. The established situation with COVID-19 infection requires development of management decisions and measures at the regional level concerning improvement of organization of primary health care and implementation of general practice in conditions of counteracting risks of menaces to population health and health preservation.

Prostate-specific antigen testing rates in high-risk populations: results from the All of Us Research Program

BACKGROUND

Early detection of prostate cancer using prostate-specific antigen (PSA) remains controversial and disparities in the receipt of prostate cancer screening persist in the US. We sought to examine disparities in PSA testing rates among groups with higher prostate cancer risk and differential access to healthcare.

METHODS

We identified a cohort of 37,706 males within the All of Us Research Program without a history of prostate cancer between the ages of 40 and 85 at time of enrollment (2017-2021). Incidence rate ratios (IRR) for the number of PSA tests received during follow-up through December 2021 were estimated using age- and multivariable-adjusted negative binomial regression models. PSA testing frequencies in the cohort were compared with population-based estimates from the 2020 Behavioral Risk Factor Surveillance System (BRFSS).

RESULTS

A total of 6,486 males (17.2%) received at least one PSA test over the course of follow-up. In multivariable-adjusted models, non-Hispanic Black males received PSA tests at a 17% lower rate (IRR = 0.83, 95% CI 0.76, 0.90) than non-Hispanic White males. Higher educational attainment, higher annual income, having self-/employer-purchased insurance, having a spouse or domestic partner, and having a family history of prostate cancer were all associated with higher rates of PSA testing. The proportion of males ages 55 to 69 who received a PSA test within two years was lower in All of Us (12.4%, 95% CI 11.8-13.0%) relative to population-based estimates from the BRFSS (35.2%, 95% CI 34.2-36.3%).

CONCLUSION

Absolute PSA testing rates in All of Us were lower than population-based estimates, but associations with PSA testing in the cohort mirrored previously reported disparities in prostate cancer screening. These findings highlight the importance of addressing barriers to care in order to reduce disparities in cancer screening.

Indigenous approaches to health assessment: a scoping review protocol

BACKGROUND

Health assessment tools developed using mainstream or Western concepts have been widely used in clinical practice worldwide. However, even culturally adapted or culturally based tools may not be relevant in other social contexts if they are grounded in Western beliefs and perspectives. The application of mainstream assessment tools, when used in Indigenous populations, can lead to the inappropriate application of normative data and inaccurate or biased diagnosis of conditions as Indigenous concepts of health differ from Western biomedical concepts of health. Thus, considering the need for culturally meaningful, sensitive, safe, and unbiased health assessment approaches and instruments over recent years, tools have been developed or adapted by and with Indigenous populations in Australia, Aotearoa/New Zealand, Canada, and the United States. However, there is no existing systematic or scoping review to identify the methods and approaches used in adapting or developing health assessment tools for use with the Indigenous population in Australia, Aotearoa/New Zealand, Canada, and the United States.

METHODS

In response to these gaps, we are working with a First Nations Community Advisory Group in Northern Ontario, Canada, to undertake a scoping review following the 2020 JBI methodology for scoping reviews. A systematic search will be conducted in PubMed, APA PsychINFO, CINAHL, MEDLINE, Web of Science, Bibliography of Native North Americans, Australian Indigenous Health info data set, and Indigenous Health Portal. Two reviewers will independently screen all abstracts and full-text articles for inclusion using criteria co-developed with an advisory group. We will chart the extracted information and summarize and synthesize the data. The summarized findings will be presented to a Community Advisory Group, including First Nations community partners, an Elder, and community members, and their feedback will be incorporated into the discussion section of the scoping review.

DISCUSSION

This scoping review involves iterative consultation with the Indigenous and non-Indigenous scholars, First Nations Community Advisory Group, and community partners throughout the research process. This review aims to summarize the evidence on standard ethical approaches and practices used in Indigenous research while adapting or developing health assessment tools. It will inform the larger study focused on developing an Indigenous Functional Assessment tool. Further, it will seek whether the Indigenous ways of knowing and equitable participation of Indigenous people and communities are incorporated in the Indigenous research process.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework https://osf.io/yznwk .

Inclusion of Polypills for Prevention of Cardiovascular Disease in the 23rd World Health Organization Model List of Essential Medicines: A Significant Step Towards Reducing Global Cardiovascular Morbidity and Mortality

This commentary describes the potential impact of inclusion of polypills for prevention of cardiovascular disease in the 23rd WHO Model List of Essential Medicines, and provides a roadmap for adoption, implementation, sustainment, and scale-up. The World Health Organization's endorsement of polypills is essential for improving global access, particularly in low- and middle-income countries. The greatest health gains are expected in a primary prevention population which has a significantly higher burden of fatal and non-fatal cardiovascular disease compared with the population of individuals with prevalent cardiovascular disease. A focus on adoption, implementation, sustainment, and scale-up of polypills for prevention of cardiovascular disease is needed including increasing supply of available polypills and incorporating polypills into the World Health Organization HEARTS technical package for integration into primary care systems to realize these benefits for population health. Widespread implementation of polypills for prevention of cardiovascular disease has the potential to equitably reduce the impact of cardiovascular disease globally by simplifying treatment options and expanding accessibility across economic levels, both across and within countries.

Selective under-representation of Pacific peoples in population estimates for health indicator measurements in Aotearoa New Zealand misinforms policy making

BACKGROUND

The Census of Populations and Dwellings' is the five yearly population count of Aotearoa New Zealand. Best available populations (BAP) are subnational projections based on census data and demographic assumptions developed for healthcare planning and funding allocation but are also used as the denominator for health indicator monitoring. Pacific people are systematically undercounted, but the impact on health statistics is not well studied. For COVID-19 vaccination coverage, health service user (HSU) data were considered a more reliable denominator than BAP but introduced new biases. We aimed to understand how the choice of denominator population impacts estimates of population size and health system performance for Pacific people at a local level.

METHODS

We described how declining census response rates affected population data quality. We compared BAP and HSU data at district level. For the indicators 'access to primary care' and 'cervical cancer screening uptake' we replaced currently used BAP denominators with HSU and examined the impact for different ethnic groups in different geographic districts.

RESULTS

Overall Census 2018 response declined by 10%, but for Māori and Pacific people by 21% and 23%, respectively. This inequitably affected BAP accuracy. Census undercount was highest in the district with the largest Pacific populations, where HSU exceeded BAP most. Notably, 'access to primary care' for Pacific people in this district consistently exceeds 100%. Using BAP, both health indicators are currently estimated as highest for Pacific people compared to other ethnic groups, but when based on HSU, they dropped to lowest. Similar, but less pronounced trends occurred in other districts. Changes in trends over time for both indicators coincided mostly with adjustments in BAP, rather than changes in the numerators.

CONCLUSIONS

The current use of BAP denominators for health statistics does not enable reliable monitoring of key health indicators for Pacific people. HSU denominators are also unsuitable for monitoring health. Exploring the feasibility of a real-time population register is strongly recommended as a new, transparent, way of obtaining more reliable, timely population data to guide policymaking and underpin a more equitable health system under the health reforms. Meanwhile, reporting of ethnic specific outcomes need to include a clear assessment of the potential for bias due to inaccurate population estimates.

Ethnicity data resource in population-wide health records: completeness, coverage and granularity of diversity

Intersectional social determinants including ethnicity are vital in health research. We curated a population-wide data resource of self-identified ethnicity data from over 60 million individuals in England primary care, linking it to hospital records. We assessed ethnicity data in terms of completeness, consistency, and granularity and found one in ten individuals do not have ethnicity information recorded in primary care. By linking to hospital records, ethnicity data were completed for 94% of individuals. By reconciling SNOMED-CT concepts and census-level categories into a consistent hierarchy, we organised more than 250 ethnicity sub-groups including and beyond "White", "Black", "Asian", "Mixed" and "Other, and found them to be distributed in proportions similar to the general population. This large observational dataset presents an algorithmic hierarchy to represent self-identified ethnicity data collected across heterogeneous healthcare settings. Accurate and easily accessible ethnicity data can lead to a better understanding of population diversity, which is important to address disparities and influence policy recommendations that can translate into better, fairer health for all.

The frequency of pathogenic variation in the All of Us cohort reveals ancestry-driven disparities

Disparities in data underlying clinical genomic interpretation is an acknowledged problem, but there is a paucity of data demonstrating it. The All of Us Research Program is collecting data including whole-genome sequences, health records, and surveys for at least a million participants with diverse ancestry and access to healthcare, representing one of the largest biomedical research repositories of its kind. Here, we examine pathogenic and likely pathogenic variants that were identified in the All of Us cohort. The European ancestry subgroup showed the highest overall rate of pathogenic variation, with 2.26% of participants having a pathogenic variant. Other ancestry groups had lower rates of pathogenic variation, including 1.62% for the African ancestry group and 1.32% in the Latino/Admixed American ancestry group. Pathogenic variants were most frequently observed in genes related to Breast/Ovarian Cancer or Hypercholesterolemia. Variant frequencies in many genes were consistent with the data from the public gnomAD database, with some notable exceptions resolved using gnomAD subsets. Differences in pathogenic variant frequency observed between ancestral groups generally indicate biases of ascertainment of knowledge about those variants, but some deviations may be indicative of differences in disease prevalence. This work will allow targeted precision medicine efforts at revealed disparities.

Relative predictive value of sociodemographic factors for chronic diseases among All of Us participants: a descriptive analysis

BACKGROUND

Although sociodemographic characteristics are associated with health disparities, the relative predictive value of different social and demographic factors remains largely unknown. This study aimed to describe the sociodemographic characteristics of All of Us participants and evaluate the predictive value of each factor for chronic diseases associated with high morbidity and mortality.

METHODS

We performed a cross-sectional analysis using de-identified survey data from the All of Us Research Program, which has collected social, demographic, and health information from adults living in the United States since May 2018. Sociodemographic data included self-reported age, sex, gender, sexual orientation, race/ethnicity, income, education, health insurance, primary care provider (PCP) status, and health literacy scores. We analyzed the self-reported prevalence of hypertension, coronary artery disease, any cancer, skin cancer, lung disease, diabetes, obesity, and chronic kidney disease. Finally, we assessed the relative importance of each sociodemographic factor for predicting each chronic disease using the adequacy index for each predictor from logistic regression.

RESULTS

Among the 372,050 participants in this analysis, the median age was 53 years, 59.8% reported female sex, and the most common racial/ethnic categories were White (54.0%), Black (19.9%), and Hispanic/Latino (16.7%). Participants who identified as Asian, Middle Eastern/North African, and White were the most likely to report annual incomes greater than $200,000, advanced degrees, and employer or union insurance, while participants who identified as Black, Hispanic, and Native Hawaiian/Pacific Islander were the most likely to report annual incomes less than $10,000, less than a high school education, and Medicaid insurance. We found that age was most predictive of hypertension, coronary artery disease, any cancer, skin cancer, diabetes, obesity, and chronic kidney disease. Insurance type was most predictive of lung disease. Notably, no two health conditions had the same order of importance for sociodemographic factors.

CONCLUSIONS

Age was the best predictor for the assessed chronic diseases, but the relative predictive value of income, education, health insurance, PCP status, race/ethnicity, and sexual orientation was highly variable across health conditions. Identifying the sociodemographic groups with the largest disparities in a specific disease can guide future interventions to promote health equity.

Nativity differences in socioeconomic barriers and healthcare delays among cancer survivors in the All of Us cohort

PURPOSE

We aimed to assess whether nativity differences in socioeconomic (SES) barriers and health literacy were associated with healthcare delays among US cancer survivors.

METHODS

"All of Us" survey data were analyzed among adult participants ever diagnosed with cancer. A binary measure of healthcare delay (1+ delays versus no delays) was created. Health literacy was assessed using the Brief Health Literacy Screen. A composite measure of SES barriers (education, employment, housing, income, and insurance statuses) was created as 0, 1, 2, or 3+. Multivariable logistic regression model tested the associations of (1) SES barriers and health literacy with healthcare delays, and (2) whether nativity modified this relationship.

RESULTS

Median participant age was 64 years (n = 10,020), with 8% foreign-born and 18% ethnic minorities. Compared to survivors with no SES barriers, those with 3+ had higher likelihood of experiencing healthcare delays (OR 2.18, 95% CI 1.84, 2.58). For every additional barrier, the odds of healthcare delays were greater among foreign-born (1.72, 1.43, 2.08) than US-born (1.27, 1.21, 1.34). For every 1-unit increase in health literacy among US-born, the odds of healthcare delay decreased by 9% (0.91, 0.89, 0.94).

CONCLUSION

We found that SES barriers to healthcare delays have a greater impact among foreign-born than US-born cancer survivors. Higher health literacy may mitigate healthcare delays among US cancer survivors. Healthcare providers, systems and policymakers should assess and address social determinants of health and promote health literacy as a way to minimize healthcare delays among both foreign- and US-born cancer survivors.