Racial/Ethnic and Geographic Disparities in Comorbid Traumatic Brain Injury-Renal Failure in US Veterans and Associated Veterans Affairs Resource Costs, 2000-2020.

Studies have identified disparities by race/ethnicity and geographic status among veterans with traumatic brain injury (TBI) and renal failure (RF). We examined the association of race/ethnicity and geographic status with RF onset in veterans with and without TBI, and the impact of disparities on Veterans Health Administration resource costs. METHODS: Demographics by TBI and RF status were assessed. We estimated Cox proportional hazards models for progression to RF and generalized estimating equations for inpatient, outpatient, and pharmacy cost annually and time since TBI + RF diagnosis, stratified by age. RESULTS: Among 596,189 veterans, veterans with TBI progressed faster to RF than those without TBI (HR 1.96). Non-Hispanic Black veterans (HR 1.41) and those in US territories (HR 1.71) progressed faster to RF relative to non-Hispanic Whites and those in urban mainland areas. Non-Hispanic Blacks (-$5,180), Hispanic/Latinos ($-4,984), and veterans in US territories (-$3,740) received fewer annual total VA resources. This was true for all Hispanic/Latinos, while only significant for non-Hispanic Black and US territory veterans < 65 years. For veterans with TBI + RF, higher total resource costs only occurred ≥ 10 years after TBI + RF diagnosis ($32,361), independent of age. Hispanic/Latino veterans ≥ 65 years received $8,248 less than non-Hispanic Whites and veterans living in US territories < 65 years received $37,514 less relative to urban veterans. CONCLUSION: Concerted efforts to address RF progression in veterans with TBI, especially in non-Hispanic Blacks and those in US territories, are needed. Importantly, culturally appropriate interventions to improve access to care for these groups should be a priority of the Department of Veterans Affairs priority for these groups.

Mentoring strategies to support diversity in research-focused junior faculty: A scoping review.

Objective: The purpose of this scoping review is two-fold: to assess the literature that quantitatively measures outcomes of mentorship programs designed to support research-focused junior faculty and to identify mentoring strategies that promote diversity within academic medicine mentoring programs. Methods: Studies were identified by searching Medline using MESH terms for mentoring and academic medicine. Eligibility criteria included studies focused on junior faculty in research-focused positions, receiving mentorship, in an academic medical center in the USA, with outcomes collected to measure career success (career trajectory, career satisfaction, quality of life, research productivity, leadership positions). Data were abstracted using a standardized data collection form, and best practices were summarized. Results: Search terms resulted in 1,842 articles for title and abstract review, with 27 manuscripts meeting inclusion criteria. Two studies focused specifically on women, and four studies focused on junior faculty from racial/ethnic backgrounds underrepresented in medicine. From the initial search, few studies were designed to specifically increase diversity or capture outcomes relevant to promotion within academic medicine. Of those which did, most studies captured the impact on research productivity and career satisfaction. Traditional one-on-one mentorship, structured peer mentorship facilitated by a senior mentor, and peer mentorship in combination with one-on-one mentorship were found to be effective strategies to facilitate research productivity. Conclusion: Efforts are needed at the mentee, mentor, and institutional level to provide mentorship to diverse junior faculty on research competencies and career trajectory, create a sense of belonging, and connect junior faculty with institutional resources to support career success.

Feasibility, impact, and priority of key strategies to enhance diverse and inclusive training programs in clinical and translational research: A mixed methods study.

Background: Enhancing diversity in the scientific workforce is a long-standing issue. This study uses mixed methods to understand the feasibility, impact, and priority of six key strategies to promote diverse and inclusive training and contextualize the six key strategies across Clinical and Translational Science Awards (CTSAs) Program Institutions. Methods: Four breakout sessions were held at the NCATS 2020 CTSA Program annual meeting focused on diversity, equity, and inclusion (DEI) efforts. This paper focuses on the breakout session for Enhancing DEI in Translational Science Training Programs. Data were analyzed using a mixed methods convergent approach. The quantitative strand includes the online polling results. The qualitative strand includes the breakout session and the chat box in response to the training presentation. Results: Across feasibility, impact, and priority questions, prioritizing representation ranked number 1. Building partnerships ranked number 2 in feasibility and priority, while making it personal ranked number 2 for impact. Across each strategy, rankings supported the qualitative data findings in feasibility through shared experiences, impact in the ability to increase DEI, and priority rankings in comparison to the other strategies. No divergence was found across quantitative and qualitative data findings. Conclusion: Findings provide robust support for prioritizing representation as a number one strategy to focus on in training programs. Specifically, this strategy can be operationalized through integration of community representation, diversity advocates, and adopting a holistic approach to recruiting a diverse cadre of scholars into translational science training programs at the national level across CTSAs.

Advancing diversity, equity, and inclusion within clinical and translational science training programs: A qualitative content analysis of the training breakout session at the national CTSA program meeting.

Background: Diversity, equity, and inclusion (DEI) in clinical and translational science (CTS) are paramount to driving innovation and increasing health equity. One important area for improving diversity is among trainees in CTS programs. This paper reports on findings from a special session at the November 2020 Clinical and Translational Science Award (CTSA) national program meeting that focused on advancing diversity and inclusion within CTS training programs. Methods: Using qualitative content analysis, we identified approaches brought forth to increase DEI in KL2 career development and other training programs aimed at early-stage CTS investigators, beyond the six strategies put forth to guide the breakout session (prioritizing representation, building partnerships, making it personal, designing program structure, improving through feedback, and winning endorsement). We used an inductive qualitative content analysis approach to identify themes from a transcript of the panel of KL2 program leaders centered on DEI in training programs. Results: We identified four themes for advancing DEI within CTS training programs: 1) institutional buy-in; 2) proactive recruitment efforts; 3) an equitable application process; and 4) high-quality, diverse mentorship. Conclusion: Implementing these strategies in CTS and other training programs will be an important step for advancing DEI. However, processes need to be established to evaluate the implementation and effectiveness of these strategies through continuous quality improvement, a key component of the CTSA program. Training programs within the CTSA are well-positioned to be leaders in this critical effort to increase the diversity of the scientific workforce.

Association of Social Risk Domains With Poor Cardiovascular Risk Factor Control in US Adults With Diabetes, From 2006 to 2016.

Importance: Few studies have examined the association between social risk factors and poor control of cardiovascular disease (CVD) risk factors. Objective: To examine the sequential association between social risk domains and CVD risk control over time in older adults with diabetes. Design, Setting, and Participants: This cohort study analyzed core interviews from 4877 US adults with diabetes who were participating in the Health and Retirement Study, a national longitudinal survey of US adults. Participants were older than 50 years, completed the social risk domain questions, and had data on CVD risk factor measures from January 2006 to December 2016. Data were analyzed from June to July 2022. Exposures: Five social risk domains were created: (1) economic stability, (2) neighborhood or built environment, (3) education access, (4) health care access, and (5) social or community context. Main Outcomes and Measures: The 4 primary outcomes were (1) poor glycemic control (hemoglobin A1c [HbA1c] level ≥8.0%), (2) poor blood pressure (BP) control (systolic BP≥140 mm Hg and diastolic BP ≥90 mm Hg), (3) poor cholesterol control (total cholesterol/high-density lipoprotein ratio ≥5), and (4) a composite of poor CVD risk control (≥2 poorly controlled glucose level, BP, or cholesterol level). Results: Among this cohort of 4877 older adults with diabetes (mean [SD] age, 68.6 [9.8] years; 2715 women [55.7%]), 890 participants (18.3%) had an HbA1c level of 8% or higher, 774 (15.9%) had systolic BP of 140 mm Hg or higher and diastolic BP of 90 mm Hg or higher, 962 (19.7%) had total cholesterol/high-density lipoprotein ratio of 5 or higher, and 437 (9.0%) had at least 2 poorly controlled CVD risk factors. Neighborhood or built environment (ie, adverse social support) was independently associated with poor glycemic control (odds ratio [OR], 1.31; 95% CI, 1.06-1.63), whereas economic stability (ie, medication cost-related nonadherence) (OR, 1.40; 95% CI, 1.04-1.87) and health care access (ie, lack of health insurance) (OR, 1.58; 95% CI, 1.20-2.09) were independently associated with poor BP control after full adjustment. Education access (ie, lack of education) (OR, 1.24; 95% CI, 1.01-1.52) and health care access (ie, lack of health insurance) (OR, 1.31; 95% CI, 1.02-1.68) were independently associated with poor cholesterol control. Health care access (ie, lack of health insurance) was the only social risk domain that was independently associated with having at least 2 poorly controlled CVD risk factors (OR, 1.72; 95% CI, 1.26-2.37). Conclusions and Relevance: Results of this study suggest that certain social risk domains are associated with control of CVD risk factors over time. Interventions targeting domains, such as neighborhood or built environment, economic stability, and education access, may be beneficial to controlling CVD risk factors in older adults with diabetes.

Cross-Sector Collaborations Between Health Care Systems and Community Partners That Target Health Equity/Disparities in Diabetes Care.

Evidence shows that social determinants of health (SDOH) are key drivers of diabetes outcomes and disparities in diabetes care. Targeting SDOH at the individual, organizational, and policy levels is an essential step in improving health equity for individuals living with diabetes. In addition, there is increasing recognition of the need to build collaboration across the health care system and the communities experiencing inequities to improve health equity. As a result, partnerships between health and nonhealth sectors have emerged as a crucial component for increasing health equity in diabetes care and achieving health equity. The purpose of this article is to discuss cross-sector collaborations between health care systems and nonhealth partners that target health equity in diabetes care.

Nonmedical Interventions For Type 2 Diabetes: Evidence, Actionable Strategies, And Policy Opportunities.

This systematic review identified studies of nonmedical interventions designed to reduce risk for and improve clinical outcomes for type 2 diabetes. Specifically, this review sought to identify interventions that target structural racism and social determinants of health. To be included, studies were published in English; published between database initiation and January 2022; conducted in the United States; measured an intervention effect using a clinical trial, quasi-experimental, or pre-post design; included a population of adults at risk for or with type 2 diabetes; and targeted hemoglobin A1c levels, blood pressure, lipids, self-care, or quality of life as outcomes. The findings of our review indicate that interventions with targeted, multicomponent designs that combine both medical and nonmedical approaches can reduce risk for and improve clinical outcomes for type 2 diabetes. HbA1c levels improved significantly with the use of food supplementation with referral and diabetes support; the use of financial incentives with education and skills training; the use of housing relocation with counseling support; and the integration of nonmedical interventions into medical care using the electronic medical record. Our findings demonstrate that the literature on nonmedical interventions designed to address relevant social factors and target structural racism is limited. The article offers actionable strategies and identifies policy opportunities for targeting structural inequalities and decreasing social risk among adults with type 2 diabetes.

A Lifestyle Intervention to Delay Early Chronic Kidney Disease in African Americans With Diabetic Kidney Disease: Pre-Post Pilot Study.

BACKGROUND: Behavioral factors, such as lifestyle, have been shown to explain approximately 24% of the excess risk of chronic kidney disease (CKD) among African Americans. However, there are limited intervention studies culturally tailored to African Americans with type 2 diabetes mellitus and CKD. OBJECTIVE: The main objective of this study was to examine the feasibility and preliminary efficacy of a culturally tailored lifestyle intervention among African Americans with type 2 diabetes mellitus and CKD. METHODS: A pre-post design was used to test the feasibility of a lifestyle intervention in 30 African American adults recruited from the Medical University of South Carolina between January 2017 and February 2017. A research nurse delivered the manualized study intervention weekly for 6 weeks. Clinical outcomes (hemoglobin A1c, blood pressure, and estimated glomerular filtration rate [eGFR]) were measured at baseline and postintervention. Disease knowledge, self-care, and behavior outcomes were also measured using validated structured questionnaires at baseline and postintervention. Descriptive statistics and effect sizes were calculated to determine clinically important changes from baseline. RESULTS: Significant pre-post mean differences and decreases were observed for hemoglobin A1c (mean 0.75%, 95% CI 0.16-1.34; P=.01), total cholesterol (mean 16.38 mg/dL, 95% CI 5.82-26.94; P=.004), low-density lipoprotein (mean 13.73 mg/dL, 95% CI 3.91-23.54; P=.008), and eGFR (mean 6.73 mL/min/1.73m2, 95% CI 0.97-12.48; P=.02). Significant pre-post mean differences and increases were observed for CKD self-efficacy (mean -11.15, 95% CI -21.55 to -0.75; P=.03), CKD knowledge (mean -2.62, 95% CI -3.98 to -1.25; P<.001), exercise behavior (mean -1.21, 95% CI -1.96 to -0.46; P=.003), and blood sugar testing (mean -2.15, 95% CI -3.47 to -0.83; P=.003). CONCLUSIONS: This study provides preliminary data for a large-scale appropriately powered randomized controlled trial to examine a culturally tailored lifestyle intervention in African Americans with type 2 diabetes mellitus and CKD in order to improve clinical, knowledge, self-care, and behavior outcomes in this population.

The relationship between financial hardship and incident diabetic kidney disease in older US adults - a longitudinal study.

BACKGROUND: Financial hardship is associated with poor health, however the association of financial hardship and incident diabetic kidney disease (DKD) is unknown. This study aimed to examine the longitudinal relationship between financial hardship and incident DKD among older adults with diabetes. METHODS: Analyses were conducted in 2735 adults age 50 or older with diabetes and no DKD using four waves of data (2006-2012) from the Health and Retirement Study, a national longitudinal cohort. The primary outcome was incident DKD. Financial hardship was based on three measures: 1) difficulty paying bills; 2) food insecurity; and 3) cost-related medication non-adherence using validated surveys. A dichotomous financial hardship variable (0 vs 1 or more) was constructed based on all three measures. Cox regression models were used to estimate the association between financial hardship, change in financial hardship experience and incident DKD adjusting for demographics, socioeconomic status, and comorbidities. RESULTS: During the median follow-up period of 4.1 years, incident DKD rate was higher in individuals with versus without financial hardship (41.2 versus 27/1000 person years). After adjustment, individuals with financial hardship (HR 1.32, 95% CI 1.04-1.68) had significantly increased likelihood of developing DKD compared to individuals without financial hardship. Persistent financial hardship (adjusted HR 1.52 95% CI 1.06-2.18) and negative financial hardship (adjusted HR 1.54 95% CI 1.02-2.33) were associated with incident DKD compared with no financial hardship experience. However, positive financial hardship was not statistically significant in unadjusted and adjusted (adjusted HR 0.89 95% CI 0.55-1.46) models. Cost-related medication non-adherence (adjusted HR 1.43 95% CI 1.07-1.93) was associated with incident DKD independent of other financial hardship measures. CONCLUSIONS: Financial hardship experience is associated with a higher likelihood of incident DKD in older adults with diabetes. Future studies investigating factors that explain the relationship between financial hardship and incident DKD are needed.

Preferences in trust regarding the provision of cancer information among adults.

BACKGROUND: Disparities associated with trust in health information exist warranting a need for research assessing this relationship among adults. Therefore, the aim of this study was to assess trust of cancer information among U.S. adults. METHODS: A weighted sample of 237,670,167 adults from the Health Information National Trends Survey (HINTS) from 2011-2014 was used for the analyses. Dependent variables were dichotomized answers to whether individuals trusted information from family/friends, the internet, or a doctor. Independent variables included age, sex, region, race/ethnicity, and cancer diagnosis to investigate associations between demographic factors and differences in trust. Logistic regression was run using R survey package. RESULTS: There were statistically significant differences in trust based on race/ethnicity, age, and cancer diagnosis. Minorities were less likely to trust information from a doctor, with Hispanics more likely to trust information from the internet (OR=1.8 (95% CI 1.36,2.43)), and Non-Hispanic Blacks trusting information from family and friends (OR=1.5 (95% CI 1.06, 2.13)). Adults ≥45 years of age were less likely to trust the doctor 'a lot' (45-64 years: OR=0.6 (95% CI 0.50, 0.83); 65+ years (OR=0.7 (95% CI 0.54, 0.92)), but more likely to not trust information from family and friends or the internet. Patients with cancer were more likely to trust information from a doctor 'a lot' (78%; p=0.01). DISCUSSION: Significant differences in preferences regarding trust in cancer information occurred based on sociodemographic characteristics. CONCLUSION: These finding suggest targeting specific population subgroups for information from sources they trust could be helpful in reducing disparities in trust.

The cumulative impact of social determinants of health factors on mortality in adults with diabetes and chronic kidney disease.

BACKGROUND: A growing body of evidence supports the potential role of social determinants of health on health outcomes. However, few studies have examined the cumulative effect of social determinants of health on health outcomes in adults with chronic kidney disease (CKD) with or without diabetes. This study examined the cumulative impact of social determinants of health on mortality in U.S. adults with CKD and diabetes. METHODS: We analyzed data from National Health and Nutrition Examination Surveys (2005-2014) for 1376 adults age 20 and older (representing 7,579,967 U.S. adults) with CKD and diabetes. The primary outcome was all-cause mortality. CKD was based on estimated glomerular filtration rate and albuminuria. Diabetes was based on self-report or Hemoglobin A1c of ≥6.5%. Social determinants of health measures included family income to poverty ratio level, depression based on PHQ-9 score and food insecurity based on Food Security Survey Module. A dichotomous social determinant measure (absence vs presence of ≥1 adverse social determinants) and a cumulative social determinant score ranging from 0 to 3 was constructed based on all three measures. Cox proportional models were used to estimate the association between social determinants of health factors and mortality while controlling for covariates. RESULTS: Cumulative and dichotomous social determinants of health score were significantly associated with mortality after adjusting for demographics, lifestyle variables, glycemic control and comorbidities (HR = 1.41, 95%CI 1.18-1.68 and HR = 1.41, 95%CI 1.08-1.84, respectively). When investigating social determinants of health variables separately, after adjusting for covariates, depression (HR = 1.52, 95%CI 1.10-1.83) was significantly and independently associated with mortality, however, poverty and food insecurity were not statistically significant. CONCLUSIONS: Specific social determinants of health factors such as depression increase mortality in adults with chronic kidney disease and diabetes. Our findings suggest that interventions are needed to address adverse determinants of health in this population.

Team Science, Population Health, and COVID-19: Lessons Learned Adapting a Population Health Research Team to COVID-19.

Our multidisciplinary research team is composed of 6 faculty with expertise in internal medicine, nephrology, maternal/fetal medicine, health services research, statistics, and community-based research, and 36 program staff including biostatisticians, nurses, program coordinators, program assistants, and medical assistants/phlebotomists. With the emergence of the COVID-19 pandemic and the impact it was having on our community, especially the ethnic minority population in inner-city Milwaukee, we felt it was critical to stay engaged and figure out how to ask meaningful research questions that are important to the community, are relevant to the times, and will lead to lasting change. While navigating this unprecedented challenge, our research team made difficult decisions but were able to engage our staff and respond to community needs. We organized our lessons learned to serve as a perspective on how to effectively remain committed to vision and serve our communities, while collecting evidence that can inform policy in difficult times.

The Association of Paternal Race and Ethnicity with Adverse Pregnancy Outcomes in a Contemporary U.S. Cohort.

OBJECTIVE: Maternal racial and ethnic disparities exist in obstetric outcomes. The contribution of paternal race and ethnicity toward obstetric outcomes has been less well documented. The objective of this study was to investigate the association between paternal race and ethnicity and several adverse pregnancy outcomes. STUDY DESIGN: This was a retrospective cohort of birth data from the CDC National Vital Statistics, years 2013-2017. All singleton live births were included in the analysis. Records with missing paternal race and ethnicity were excluded. The primary dependent variables were the following adverse maternal and perinatal outcomes: gestational diabetes, hypertensive disorder of pregnancy, preterm birth <37 weeks, cesarean delivery, low birth weight <2,500 g, 5-minute Apgar's score <7, admission to neonatal intensive care unit (NICU), and assisted ventilation at > 6 hours of life. The main exposure was paternal race and ethnicity, which was grouped into non-Hispanic white, non-Hispanic black, Hispanic, and other. Other race and ethnicity category included: American Indian, Alaskan Native, Asian, Native Hawaiian, or other Pacific Islander. Univariable and multivariable analyses were done to determine whether paternal race and ethnicity was independently associated with adverse pregnancy outcomes. RESULTS: A total of 16,482,745 births were included. In univariable analysis, all adverse obstetric outcomes were significantly associated with paternal race and ethnicity. In multivariable analysis, controlling for maternal and paternal demographic characteristics and maternal clinical factors, paternal race and ethnicity remained significantly associated with the majority of the adverse pregnancy outcomes. The strongest association was seen with: (1) paternal non-Hispanic black race and ethnicity, and higher rates of LBW and preterm birth (Odds ratio [OR] = 1.25, 95% CI: 1.24-1.27 and OR = 1.14, 95% CI: 1.13-1.15, respectively); (2) paternal Hispanic race and ethnicity and lower rates of 5-minute Apgar's score <7, and assisted ventilation at >6 hours of life (OR = 0.78, 95% CI: 0.77-0.79, and OR = 0.77, 95% CI: 0.75-0.78, respectively); and (3) other paternal race and ethnicity and higher rates of gestational diabetes, but lower rates of hypertensive disorder of pregnancy and assisted ventilation >6 hours of life (OR = 1.26, 95% CI: 1.25-1.27; OR = 0.79, 95% CI: 0.78-0.80; and OR = 0.80, 95% CI: 0.78-0.82, respectively). All associations were in comparison to paternal non-Hispanic white race and ethnicity. CONCLUSION: Paternal race and ethnicity has an independent association with adverse obstetric outcomes. The pathway and the extent of the paternal racial influence are not fully understood and deserve additional research.

AKI in Hospitalized Patients with COVID-19 and Seasonal Influenza: A Comparative Analysis.

Background: Coronavirus disease 2019 (COVID-19) is often compared with seasonal influenza and the two diseases have similarities, including the risk of systemic manifestations such as AKI. The aim of this study was to perform a comparative analysis of the prevalence, risk factors, and outcomes of AKI in patients who were hospitalized with COVID-19 and influenza. Methods: Retrospective cohort study of patients who were hospitalized with COVID-19 (n=325) or seasonal influenza (n=433). AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Baseline characteristics and hospitalization data were collected, and multivariable analysis was performed to determine the independent predictors for AKI. Results: AKI occurred in 33% of COVID-19 hospitalizations (COV-AKI) and 33% of influenza hospitalizations (FLU-AKI). After adjusting for age, sex, and comorbidity count, the risk of stage 3 AKI was significantly higher in COV-AKI (OR, 3.46; 95% CI, 1.63 to 7.37). Pre-existing CKD was associated with a six- to seven-fold increased likelihood for FLU-AKI and COV-AKI. Mechanical ventilation was associated with a higher likelihood of developing AKI in the COVID-19 cohort (OR, 5.85; 95% CI, 2.30 to 15.63). Black race, after adjustment for comorbidities, was an independent risk for COV-AKI. Conclusions: Pre-existing CKD was a major risk factor for AKI in both cohorts. Black race (independent of comorbidities) and mechanical ventilation were associated with a higher risk of developing COV-AKI, which is characterized by a higher burden of stage 3 AKI and overall poorer prognosis.

Lowering the impact of food insecurity in African American adults with type 2 diabetes mellitus (LIFT-DM) - Study protocol for a randomized controlled trial.

BACKGROUND: There is strong evidence that disparities in the burden of diabetes exist by both race and poverty. Food insecurity, or an inability to or limitation in accessing nutritionally adequate food, is an important modifiable social determinant of health, particularly in adults with chronic disease. African Americans are more likely to be diagnosed with diabetes and more likely than whites to be food insecure. METHODS: We describe a 4-year ongoing randomized controlled trial, which will test the separate and combined efficacy of monthly food vouchers and monthly food stock boxes layered upon diabetes education in improving glycemic control in low income, food insecure, African Americans with type 2 diabetes mellitus using a 2 × 2 factorial design. Three hundred African American adults with clinical diagnosis of diabetes and HbA1c ≥ 8% will be randomized into one of four groups: 1) diabetes education alone; 2) diabetes education plus food vouchers; 3) diabetes education plus stock boxes; and 4) diabetes education plus combined food vouchers and stock boxes. Our primary hypothesis is: among low-income, food insecure, African Americans with type 2 diabetes, those receiving diabetes education enhanced with food supplementation (food vouchers alone, stock boxes alone, or combination) will have significantly greater reduction in HbA1c at 12 months compared to those receiving diabetes education only. DISCUSSION: Results from this study will yield valuable insight currently lacking on how best to design and deliver diabetes interventions to low-income, food insecure, African Americans with diabetes that takes into account both clinical and social determinants of health. TRIAL REGISTRATION: This study was registered on November 29, 2019 with the United States National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT04181424).

Adverse Childhood Experiences and Decreased Renal Function: Impact on All-Cause Mortality in U.S. Adults.

INTRODUCTION: Evidence suggests that individuals with a history of adverse childhood experiences have higher odds of developing kidney disease than individuals with no adverse childhood experiences. However, no study has examined the influence of coexisting adverse childhood experiences and kidney disease on mortality risk. This study uses a longitudinal survey of adults to examine the influence of coexisting adverse childhood experiences and decreased renal function on all-cause mortality in a sample of U.S. adults. METHODS: A total of 1,205 adults participating in the Midlife Development in the United States series between 1995 and 2014 were used for this analysis performed in 2019. A total of 6 types of adverse childhood experiences were available in the data set, which were combined to create a dichotomous variable with any adverse experience counted as yes. Decreased renal function was defined as an estimated glomerular filtration rate <60 milliliter/minute/1.73 m2. The main outcome was all-cause mortality. Cox proportional hazards models were performed to examine 4 combinations of adverse childhood experiences and decreased renal function associated with overall survival (neither, adverse childhood experiences only, decreased renal function only, or both) controlling for covariables. RESULTS: In fully adjusted models, adverse childhood experiences and decreased renal function were associated with increased all-cause mortality relative to neither (hazard ratio=2.85, 95% CI=1.30, 6.25). Decreased renal function only and adverse childhood experiences only were not significantly associated with all-cause mortality (hazard ratio=1.14, 95% CI=0.64, 2.04 and hazard ratio=1.55, 95% CI=0.44, 5.41, respectively). When using decreased renal function as the reference group, coexisting adverse childhood experiences and decreased renal function was associated with a 64% increased risk of all-cause mortality, though this relationship was not statistically significant. CONCLUSIONS: Coexistence of adverse childhood experiences and decreased renal function is associated with higher all-cause mortality than seen in individuals with neither adverse childhood experiences nor decreased renal function and may be associated with higher all-cause mortality than seen in individuals with decreased renal function alone. Future research is needed to better understand this potential association.

The Longitudinal Influence of Social Determinants of Health on Glycemic Control in Elderly Adults With Diabetes.

OBJECTIVE: This study aimed to understand the longitudinal relationship between financial, psychosocial, and neighborhood social determinants and glycemic control (HbA1c) in older adults with diabetes. RESEARCH DESIGN AND METHODS: Data from 2,662 individuals with self-reported diabetes who participated in the Health and Retirement Study (HRS) were used. Participants were followed from 2006 through 2014. Financial hardship, psychosocial, and neighborhood-level social determinant factors were based on validated surveys from the biennial core interview and RAND data sets. All social determinant factors and measurements of HbA1c from the time period were used and treated as time varying in analyses. SAS PROC GLIMMIX was used to fit a series of hierarchical linear mixed models. Models controlled for nonindependence among the repeated observations using a random intercept and treating each individual participant as a random factor. Survey methods were used to apply HRS weighting. RESULTS: Before adjustment for demographics, difficulty paying bills (ß = 0.18 [95% CI 0.02, 0.24]) and medication cost nonadherence (0.15 [0.01, 0.29]) were independently associated with increasing HbA1c over time, and social cohesion (-0.05 [-0.10, -0.001]) was independently associated with decreasing HbA1c over time. After adjusting for both demographics and comorbidity count, difficulty paying bills (0.13 [0.03, 0.24]) and religiosity (0.04 [0.001, 0.08]) were independently associated with increasing HbA1c over time. CONCLUSIONS: Using a longitudinal cohort of older adults with diabetes, this study found that financial hardship factors, such as difficulty paying bills, were more consistently associated with worsening glycemic control over time than psychosocial and neighborhood factors.

Trends in Out-of-Pocket Burden in United States Adults with Kidney Disease: 2002-2011.

BACKGROUND: High out-of-pocket (OOP) cost is a barrier to healthcare access and treatment compliance. Our study examined high OOP healthcare cost and burden trends in adults with kidney disease (KD). METHODS: Using Medical Expenditure Survey 2002-2011 data, we examined the proportion of people greater than 17 years old with KD whose OOP burden was high. Trends by insurance status (private, public or none) and trends by income level (poor, low, middle or high income) were also examined in this study. RESULTS: Approximately 16% of people with KD faced high OOP burden in 2011. The proportion of adults with high OOP burden between 2002 and 2011 fell by 9.7 percentage points. The proportion of privately insured adults facing high OOP burden decreased by 4.7, those who were publicly insured 22.4, and those who were uninsured, 3.1 percentage points. The proportion of those facing high OOP burden who were poor/near poor fell by 26.5, those who had low income 13.4, and those who had middle income, 9 percentage points. CONCLUSIONS: Though high OOP burden declined between 2002 and 2011 in the US population with KD, most of the decline was among the publicly insured, so the uninsured populations with KD remain vulnerable. Providers and policy makers should be aware of the vulnerability of uninsured individuals with KD to high OOP burden.

Creating a 13-year National Longitudinal Cohort of veterans with chronic kidney disease.

BACKGROUND: The development of large-scale chronic kidney disease (CKD) cohorts within the Veterans Affairs (VA) system has been limited by several factors, including the high proportion of missing race data etc. The goal of this study is to address the limitations of prior studies by creating a large cohort utilizing robust KDIGO recommendations for identifying and staging CKD. METHODS: Multiple patient and administrative files from the Veterans Health Administration (VHA) National Patient Care were linked to create a national cohort of Veterans with chronic kidney disease (CKD) between January 2000 - December 2012; patients identified during this period were followed until 2015. CKD was defined for stages 1 through 5 if markers of kidney damage, specifically proteinuria, were present for at least 3 months. Estimated glomerular filtration rate (eGFR) values were calculated based on serum creatinine levels and the patient's age, gender, and race using both the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. RESULTS: About 50 million observations were collected that supported a CKD diagnosis during the study period; these observations corresponded to 3,051,001 unique veterans; 80.9% were non-Hispanic white (NHW), 13.4% were non-Hispanic black (NHB), 3.6% were Hispanic, and 2.0% were in other groups. The mean age 76.7, about 97% were male and 50.2% died prior to January 2016. Among those with stage 3, 12.3% progressed to stage 4, 21.6% of those with stage 4 progressed to stage 5. We found that eGFR values calculated from serum creatinine levels identified about 98% of all patients, while about 11.4% of patients could be identified through ICD-9 codes; only 6.4% could be identified through both sources. CONCLUSION: This 13-year national cohort provides an important resource for answering numerous research questions in the future such as racial/ethnic disparities questions, tracking health service utilization, medication adherence, cost and health outcomes in veterans with CKD.

Assessing the relationship between food insecurity and mortality among U.S. adults.

PURPOSE: Significant evidence supports a relationship between food insecurity and health, but little work has investigated its relationship on all-cause mortality within a high resource country, such as the United States. METHODS: Data from the 2003-2010 National Health and Nutrition Examination Survey was matched to National Death Index information. Cox models were used to study the relationship between mortality and food insecurity, adjusting for relevant covariates in a sequential manner (demographics, comorbidities, lifestyle variables, body mass index). Food insecurity was used as dichotomous and as four categories. RESULTS: Of 20,918 participants, 11.6% (representing 208,789,244 U.S. residents) were food insecure. When food insecurity was dichotomized, there was 49% higher odds of mortality after adjusting for demographics (HR, 1.49; 95% CI, 1.19-1.87). After adjusting for comorbidities, the HR remained significant, but lost significance with adjustment for lifestyle factors and body mass index (HR, 1.15; 95% CI, 0.94-1.42). However, marginal food security lost significance after adjustment for lifestyle variables. CONCLUSIONS: Food insecurity significantly impacts all-cause mortality in the United States; however, lifestyle may explain this relationship. Interventions should account for level of severity when creating targeted programs.