Search

Introduction: Ischemic stroke is common complication among heart failure patients. Community-level socio-economic distress has been linked to adverse clinical outcomes in prior research. However, few to no studies have examined the relationship between neighborhood level socio-economic distress and stroke within a population of heart failure patients exclusively. Hypothesis: Odds of stroke among patients with heart failure are higher in neighborhoods with increased socio-economic distress, controlling for patient demographic and clinical comorbidities. Methods: Two separate cohorts of heart failure patients were assembled using ICD9/10 codes to identify all patients with a heart failure diagnosis seen at West Virginia University Hospital Systems (WVU Medicine) between 2008 and 2020 and Charleston Area Medical Center (CAMC) between 2017 and 2020. Cases were defined as heart failure patients with a diagnosis of ischemic stroke. Controls were defined as heart failure patients without a diagnosis of stroke and were matched to cases 4:1 on five-year age grouping and sex at birth. Distressed communities index (DCI) was linked to clinical data by patient zip code of residence. Neighborhoods with a DCI above 75 were classified as distressed, while those below were noted as non-distressed. Multivariable conditional logistic regression was used to identify significant associations at the 95% confidence level within each cohort separately. Results: In total there were 26,532 unique heart failure patients in the WVU Medicine cohort and 20,070 in the CAMC cohort. Of these, 10.3% (n=2,741) of the WVU Medicine cohort and 4.5% (n=900) of the CAMC cohort met the case definition of having had a diagnosis of stroke. Among patients in the WVU Medicine cohort with heart failure who experienced a stroke, 47.1% (n=1,291) were male and had an average age of 72.4 (± 12.9). In the CAMC cohort, among heart failure patients who experienced a stroke, 51.1% (n=460) were male and the average age was 70.9 (± 11.8). After controlling for demographics and clinical comorbidities, conditional logistic regression analyses identified a statistically significant association between neighborhood-level socio-economic distress in both the WVU Medicine cohort (OR = 1.31; 95% CI = 1.20 - 1.44) and the CAMC cohort (OR = 1.29; 95% CI = 1.027 - 1.454). Conclusion: Neighborhood-level socio-economic distress was associated with prevalence of stroke among heart failure patients. This is a critical finding for rural states, such as West Virginia, as it has the ability to inform placement of new satellite clinics among large hospital systems, or government funded clinics, such as federally qualified health centers, to address inequities in care for patients living in medically underserved communities.

Objective: Implicit bias is an unconscious bias that may influence behavior, cognitive processes and decision-making. In clinical settings, implicit bias present in clinicians may influence the treatment that people receive and may be a root cause of health disparities. Our study measured implicit bias among vascular surgeons who participate in the management of individuals with peripheral artery disease (PAD). Methods: Our sampling frame included all vascular surgeons that contribute to the Vascular Quality Initiative (VQI) registry. We invited these individuals to take the race implicit association test (IAT) used to measure level of unconscious bias. The IAT asks participants to classify items presented on a computer by quickly pressing computer keys. The underpinning of the IAT is that people will match a representative group (images of African American or European American faces) to an attribute (good and bad words, such as excellent and angry) more quickly if there is already an implicit connection. Based on the differences in reaction time from several trials, participants are classified as having a no preference between African American and European Americans or a preference for one or the other. The level of preference can be slight, moderate, or strong. We stratified implicit findings by physician race/ethnicity. Results: Among 2765 vascular surgeons that participate in the VQI, 338 (12%) completed the IAT. Most participants (70%) showed an automatic preference for European Americans over African Americans, with more than half of participants (51%) showing a moderate or strong automatic preference. Of 195 participants who identified as Non-Hispanic White, 25% showed a slight automatic preference for European Americans, 41% showed a moderate automatic preference, and 34% showed a strong automatic preference. Of 16 participants who identified as Non-Hispanic Black, 38% showed an automatic preference for European Americans over African Americans and 31% showed an automatic preference for African Americans. We also found that participants were often unaware of their biases: More than two-thirds (n=64) of the 94 participants who disagreed with a statement asking if they are biased (“I am biased”) had an automatic preference upon testing. Conclusions: Implicit bias was found among vascular surgeons. The next step in our research will focus on the ability of implicit bias scores to predict a surgeon’s actual delivery of guideline care. Pending our findings, training and clinical support tools offer techniques to mitigate the impact of implicit biases on PAD-related health care.

BackgroundPeople undergoing revascularization for symptomatic peripheral artery disease (PAD) have a high incidence of major limb amputation in the year following their surgical procedure. The incidence of limb amputation is particularly high in patients from racial and ethnic minority groups. The purpose of our study was to investigate the role of sub-optimal prescription of preoperative antiplatelets and statins in producing disparities in risk of major amputation following revascularization for symptomatic PAD.MethodsWe used data from adult (≥18 years old) patients in the Vascular Quality Initiative (VQI) registry who underwent a revascularization procedure from 2011-2018. Patients were categorized as non-Hispanic Black, non-Hispanic White, and Hispanic. We estimated the crude probability of a patient being prescribed a preoperative antiplatelet and preoperative statin. We calculated one year risk incidence of amputation by prescription groups and by race/ethnicity. We estimated the amputation risk difference between race/ethnicity groups (the proportion of disparity) that could be eliminated under a hypothetical intervention where a pre-operative antiplatelet and statin was provided to all patients.ResultsAcross 100,579 revascularizations recorded in the Vascular Quality Initiative, a vascular procedure-based registry in the United States and Canada, 1-year risk of amputation was 2.5% (95% CI: 2.4%,2.6%) in White patients, 5.3% (4.9%,5.6%) in Black patients and 5.3% (4.7%,5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive recommended antiplatelet and statin therapy prior to their procedures. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received the appropriate guideline recommended medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (−2.9%,21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (−0.7%,38.6%).ConclusionsEven though guideline-based care appeared evenly distributed by race/ethnicity, increasing access to such care may still decrease health care disparities in major limb amputation.

Background Attention-deficit hyperactivity disorder is a common disorder that affects both children and adults. However, for adults, little is known about ADHD-attributable medical expenditures. Objective To estimate the medical expenditures associated with ADHD, stratified by age, in the US adult population. Design Using a two-part model, we analyzed data from Medical Expenditure Panel Survey for 2015 to 2019. The first part of the model predicts the probability that individuals incurred any medical costs during the calendar year using a logit model. The second part of the model estimates the medical expenditures for individuals who incurred any medical expenses in the calendar year using a generalized linear model. Covariates included age, sex, race/ethnicity, geographic region, Charlson comorbidity index, insurance, asthma, anxiety, and mood disorders. Participants Adults (18 +) who participated in the Medical Expenditure Panel Survey from 2015 to 2019 (N = 83,776). Main Measures Overall and service specific direct ADHD-attributable medical expenditures. Key Results A total of 1206 participants (1.44%) were classified as having ADHD. The estimated incremental costs of ADHD in adults were $2591.06 per person, amounting to $8.29 billion nationally. Significant adjusted incremental costs were prescription medication ($1347.06; 95% CI: $990.69–$1625.93), which accounted for the largest portion of total costs, and office-based visits ($724.86; 95% CI: $177.75–$1528.62). The adjusted incremental costs for outpatient visits, inpatient visits, emergency room visits, and home health visits were not significantly different. Among older adults (31 +), the incremental cost of ADHD was $2623.48, while in young adults (18–30), the incremental cost was $1856.66. Conclusions The average medical expenditures for adults with ADHD in the US were substantially higher than those without ADHD and the incremental costs were higher in older adults (31 +) than younger adults (18–30). Future research is needed to understand the increasing trend in ADHD attributable cost.

Objective: Claudication is an early-stage subtype of peripheral artery disease that may result in surgical intervention. The purpose of this study was to compare the types of elective bypass in a population of Black and White patients with claudication and to identify actionable areas that may explain the higher limb amputation rates observed in Black patients. Methods: We identified Black and White patients undergoing elective infrainguinal bypass for claudication using data from the Vascular Quality Initiative registry (2011-2018). Distal bypass target was classified as 1) at or above the popliteal artery (above-knee) or 2) below the popliteal, including all tibial, peroneal, dorsalis pedis and tarsal/plantar arteries (below-knee). Graft conduit was categorized as vein or prosthetic. We calculated one-year risk of major lower limb amputation with 95% confidence intervals (CI) for all combinations of target and conduit, stratified by race. We then forced an intervention on the data to estimate the post-intervention incidence of amputation and the proportion of racial disparity eliminated and 95% CI if everyone received the gold standard treatment (above-knee, vein). Results: We identified 8,401 infrainguinal bypass revascularizations for claudication (12% Black/88% White); 82% were performed above-knee and 44% of those used a vein conduit. The remaining 18% of bypasses were to below-knee arteries, of which 78% used a vein conduit. The remaining 1,534 (18.3%) bypasses were to below-knee arteries, including 1,197 (78.4%) using vein and 330 (21.6%) using prosthetic material. One-year incidence of major limb amputation was 1.6% (1.3%,1.9%) among all grafts, 1.2% (1.0%,1.5%) in above-knee grafts, and 3.3% (2.4%,4.2%) in below-knee grafts. Black patients had higher incidence of amputation across bypass target/conduit groups compared to White patients; the difference was greatest for below-knee revascularizations (8.9%, 95% CI: 4.8%,12.3% v 2.1%, 95% CI: 0.9%,2.9%). Pre-intervention amputation incidence was 1.3% (1.0%,1.5%) in White patients and 3.6% (1.9%,5.2%) in Black patients. Overall amputation incidence decreased significantly after our gold standard intervention was applied for both White (1.0%; 0.7%,1.2%) and Black (2.0%; 0.7%,3.2%) patients. The risk difference (i.e. the disparity gap) between Black and White patients was lessened post-intervention by 56.8% (31.9%,116.3%). Conclusions: We observed risk of amputation higher than would be expected based on other studies of the natural history of claudication without bypass surgery; future work should identify the mechanisms that alter the natural history of claudication via open bypass surgery. Interventions below-knee or using a prosthetic graft were particularly harmful and their harm was concentrated in Black patients.

Objective: Peripheral artery disease (PAD) is a common atherosclerotic disorder that reduces blood flow to the lower extremities. There are significant racial disparities in the outcomes of patients with PAD. Ideally, understanding the result of inadequate implementation of proven interventions on health disparities might provoke a policy and culture shift in the provision of care for minoritized persons. We demonstrate a method that leverages knowledge of interventions that we know should be implemented to optimize care for people with PAD, to identify the extent to which disparities might be mitigated by more universal uptake of those interventions. Methods: We compare racial disparities as they exist currently with disparities that would exist under complete uptake of interventions to improve PAD and vascular care. This counterfactual world is modeled by upweighting people who received the proposed interventions to represent the study population at the start of follow-up. It relies on the assumption that we have measured (and adjusted for) all confounders of the intervention (a hypothesized mediator of the observed health disparities) and the outcome. A unique feature of the application of this method to this problem is our ability to demonstrate how, even when guideline-based care appears evenly distributed by race/ethnicity, increasing access to such care may still decrease health disparities. This method was previously proposed for estimating potential reductions in racial disparities for people with HIV. Results: Across 100,579 infrainguinal revascularizations among Black (n=15,442), Hispanic (n=5,506) and White (n=67,651) patients treated for symptomatic PAD, Black (56.5%) and Hispanic patients (57.6%) were slightly less likely than White patients (59.8%) to receive Class I recommended aspirin and statin therapy prior to their procedures. One-year risk of amputation was 2.7% (95% CI: 2.6%,2.8%) in White patients, 5.8% (5.4%,6.2%) in Black patients and 5.6% (5.0%,6.2%) in Hispanic patients. Had all patients received the appropriate anti-ischemic medications, amputation risk would have been lower across all three race-ethnicity groups. However, specifically, the risk difference (RD) for Black vs White patients would have reduced by 8% (-3%,20%) and the RD for Hispanic vs White patients would have reduced by 18% (-1%,36%). Conclusions: Not only is provision of aspirin and statin for infrainguinal revascularization good for all PAD patients, it is also a social justice imperative.

Readmissions constitute a major health care burden among peripheral artery disease (PAD) patients. This study aimed to 1) estimate the zip code tabulation area (ZCTA)-level prevalence of readmission among PAD patients and characterize the effect of covariates on readmissions; and (2) identify hotspots of PAD based on estimated prevalence of readmission. Thirty-day readmissions among PAD patients were identified from the South Carolina Revenue and Fiscal Affairs Office All Payers Database (2010–2018). Bayesian spatial hierarchical modeling was conducted to identify areas of high risk, while controlling for confounders. We mapped the estimated readmission rates and identified hotspots using local Getis Ord (G*) statistics. Of the 232,731 individuals admitted to a hospital or outpatient surgery facility with PAD diagnosis, 30,366 (13.1%) experienced an unplanned readmission to a hospital within 30 days. Fitted readmission rates ranged from 35.3 per 1000 patients to 370.7 per 1000 patients and the risk of having a readmission was significantly associated with the percentage of patients who are 65 and older (0.992, 95%CI: 0.985–0.999), have Medicare insurance (1.013, 1.005–1.020), and have hypertension (1.014, 1.005–1.023). Geographic analysis found significant variation in readmission rates across the state and identified priority areas for targeted interventions to reduce readmissions.

Background Racial and ethnic disparities in outcomes following lower limb revascularization for peripheral artery disease have been ascribed to disease severity at presentation for surgery. Methods and Results We calculated 1‐year risk of major adverse limb events (MALEs), major amputation, and death for patients undergoing elective revascularization for claudication or chronic limb‐threatening ischemia in the Vascular Quality Initiative data (2011–2018). We report hazard ratios according to race and ethnicity using Cox (death) or Fine and Gray subdistribution hazards models (MALE and major amputation, treating death as a competing event), adjusted for patient, treatment, and anatomic factors associated with disease severity. Among 88 599 patients (age, 69 years; 37% women), 1‐year risk of MALE (major amputation and death) was 12.8% (95% CI, 12.5–13.0) in 67 651 White patients, 16.5% (95% CI, 5.8–7.8) in 15 442 Black patients, and 17.2% (95% CI, 5.6–6.9) in 5506 Hispanic patients. Compared with White patients, we observed an increased hazard of poor limb outcomes among Black (MALE: 1.17; 95% CI, 1.12–1.22; amputation: 1.52; 95% CI, 1.39–1.65) and Hispanic (MALE: 1.22; 95% CI, 1.14–1.31; amputation: 1.45; 95% CI, 1.28–1.64) patients. However, Black and Hispanic patients had a hazard of death of 0.85 (95% CI, 0.79–0.91) and 0.71 (95% CI, 0.63–0.79) times the hazard among White patients, respectively. Worse limb outcomes were observed among Black and Hispanic patients across subcohorts of claudication and chronic limb‐threatening ischemia. Conclusions Black and Hispanic patients undergoing infrainguinal revascularization for chronic limb‐threatening ischemia and claudication had worse limb outcomes compared with White patients, even with similar disease severity at presentation. Additional investigation aimed at eliminating disparate limb outcomes is needed.

The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes.This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients.This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at37 weeks of gestation and low birthweight of2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned.A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34).There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

ObjectivesGroup prenatal care (GPC), an alternative to individual prenatal care (IPC), is becoming more prevalent. This study aimed to describe the attendance and reasons of low attendance among pregnant women who were randomly assigned to receive GPC or IPC and explore the maternal characteristics associated with low-attendance.MethodsThis study was a descriptive study among Medically low risk pregnant women (N = 992) who were enrolled in an ongoing prospective study. Women were randomly assigned to receive CenteringPregnany GPC (N = 498) or IPC (N = 994) in a single clinical site The attendance frequency and reason for low-attendance (i.e. ≤ 5/10 sessions in GPC or ≤ 5 visits in IPC) were described separately in GPC and IPC. Multivariable logistic regressions were performed to explore the associations between maternal characteristics and low-attendance.ResultsOn average, women in GPC attended 5.32 (3.50) sessions, with only 6.67% attending all 10 sessions. Low-attendance rate was 34.25% in GPC and 10.09% in IPC. The primary reasons for low-attendance were scheduling barriers (23.19%) and not liking GPC (16.43%) in GPC but leaving the practice (34.04%) in IPC. In multivariable analysis, lower perceived family support (P = 0.01) was positively associated with low-attendance in GPC, while smoking in early pregnancy was negatively associated low-attendance (P = 0.02) in IPC.Conclusions for practiceScheduling challenges and preference for non-group settings were the top reasons for low-attendance in GPC. Changes may need to be made to the current GPC model in order to add flexibility to accommodate women's schedules and ensure adequate participation.Trial registrationNCT02640638 Date Registered: 12/20/2015.

Objectives: Acute ischemic stroke is one of the leading causes of death. Patient outcomes, such as in-patient mortality, may be impacted by the time of arrival to the hospital. Telestroke networks have been found to be effective and safe at treating acute ischemic strokes. This paper investigated the association between mortality and time of arrival and hospital's participation in a telestroke network. Methods: Data were collected on ischemic stroke patients who arrived at 15 nonteaching hospitals in Georgia's Paul Coverdell Acute stroke registry from 2009 to 2016. After controlling for patient and hospital characteristics, multivariate logistic regression was conducted to assess whether time of arrival and telestroke participation was associated with in-hospital mortality. Subgroup analysis was conducted based on hospital bed size. Results: Overall, a total of 19,759 admissions for acute ischemic stroke were included in this analysis. The odds of dying in the hospital when arriving during the nighttime are 1.22 times the odds of dying when arriving during the day (95% CI: 1.04-1.45) and the odds of dying at a telestroke hospital are 53% lower than at a nontelestroke hospital (OR .47, 95% CI .31-.71). The associations were more prominent in large hospitals. Conclusions: Our study found that the hour of arrival for acute ischemic stroke is linked with in-hospital mortality in large hospitals, with patients more likely to die if they arrive during the nighttime hours as compared to the daytime hours. Telestroke participation is linked with lower odds of hospital mortality in all hospitals.