The effects of social determinants of health on anterior cruciate ligament injury recovery.

Context: Over 200,000 anterior cruciate ligament (ACL) injuries occur in the United States each year. While many patients choose to pursue ACL reconstruction (ACLR), the impact of social determinants of health (SDOH) on outcomes is unclear. Objective: The purpose of this study was to review and synthesize current literature to determine the impact of SDOH on outcomes following ACL reconstruction. Data sources: A systematic search of PubMed, CINAHL, Medline, PsychINFO, and Scopus was completed. Study selection: Articles reporting outcomes following ACLR were included if they discussed at least one SDOH and provided ACLR failure rates. Study design: Systematic review. Level of evidence: Level I. Results: After screening 712 studies, 13 were found that met inclusion criteria and were analyzed. Studies commonly examined the correlations between race, income, location, education, and insurance on outcomes following ACLR. Three studies found that the ACL revision risk for Black patients compared to White patients ranged from 0.23 to 0.78, while the revision risk for Hispanic patients compared to White patients ranged from 0.7 to 0.83. One study reported finding that the odds ratio of revision for the White patients was 1.32. Another study reported no difference in revision risk based on race. Patients living in urban areas were found to have improved outcomes compared to rural areas (Mean IKDC (Urban 85.3 vs Rural 81.87) and Tegner-Lysholm (Urban 88.26 vs Rural 84.82)). Lower socioeconomic status was correlated with decreased post-operative functional scores (KOOS, Marx and IKDC). Conclusion: Several SDOH such as White race, rural location, and low socioeconomic status may be independently correlated with worse ACLR outcomes in the form of increased revision rates or worse post-operative functional scores. However, further research is needed to better elucidate the degree of impact and interconnectedness of SDOH domains on ACLR patient outcomes.

[Promoting Equity, Diversity, and Inclusion in Healthcare: An Example of the COVID-19 Pandemic].

Healthcare systems must embody equity, diversity, and inclusion (EDI) and, in the event of unfairness, appropriate policies / countermeasures should be enacted. The healthcare system response to the COVID-19 pandemic not only highlighted how socioeconomic disparities affect mortality risk but also posed significant challenges to the successful practice of EDI in healthcare. In light of this, this article was written to provide an overview of EDI, analyze the international efforts to promote it, and suggest strategies for promoting EDI in infectious disease healthcare using COVID-19 as an example. In healthcare settings, equity centers on ensuring patients receive fair treatment regardless of race, gender, age, or socioeconomic status; diversity centers on healthcare providers understanding the uniqueness of patients from different cultural backgrounds and the health barriers they face; and inclusion centers on ensuring patients are treated with respect and given the attention they deserve. During pandemics, social determinants of health (SDOH) greatly impact patient health outcomes and hinder the practice of EDI. Reflecting on the impact of COVID-19, healthcare systems can actively apply EDI in clinical practice to provide to all patients equitable access to healthcare opportunities and outcomes. Practical strategies include establishing EDI committees within healthcare systems, monitoring relevant data, conducting staff training, and continuously addressing the SDOH and needs of marginalized groups to achieve EDI in healthcare.

Open versus Minimally Invasive Partial Nephrectomy: Trends and Outcomes from a Wide National Population-Based Database.

Objectives: To investigate temporal trends and overall complication rates among open partial nephrectomy (OPN) and minimally invasive partial nephrectomy (MIPN), including the impact of social determinants of health (SDOH) on postoperative outcomes. Methods: Patients who underwent OPN or MIPN between 2011 and 2021 were retrospectively analyzed by using PearlDiver-Mariner, an all-payer insurance claims database. The International Classification of Diseases diagnosis and procedure codes were used to identify the type of surgical operation, patient's characteristics (age, sex, region, insurance plan), postoperative complications and SDOH, categorized in education, healthcare, environmental, social, and economic domains. Outcomes were compared using multivariable regression models. Results: Overall, 65,325 patients underwent OPN (n = 23,377) or MIPN (n = 41,948). OPN adoption declined over the study period, whereas that of MIPN increased from 24% to 34% (p = 0.001). The 60-day postoperative complication rate was 15% for the open and 9% for the minimally invasive approach. Approximately 16% and 11% of patients reported at least one SDOH at baseline for OPN and MIPN, respectively. SDOH were associated with higher odds of postoperative complications (OPN = OR: 1.11, 95% CI: 1.01-1.25; MIPN = OR: 1.31, 95% CI: 1.18-1.46). The open approach showed a significantly higher risk of postoperative complications (OR: 1.62, 95% CI: 1.54-1.70) compared to the minimally invasive one. Conclusions: Our findings confirm that MIPN is gradually replacing OPN, which carries a higher risk of complications. SDOH are significant predictors of postoperative complications following PN, regardless of the approach.

Assessing Social Determinants of Health During Critical Illness: Implications and Methodologies.

A growing body of literature has identified social determinants of health (SDoH) as potential contributors to health disparities in pediatric critical illness. Pediatric critical care providers should use validated screening tools to identify unmet social needs and ensure appropriate referral through multisector partnerships. Pediatric critical care researchers should consider factors outside of race and insurance status and explore the association between neighborhood-level factors and disparate health outcomes during critical illness. Measuring and addressing the SDoH at the individual and neighborhood level are important next steps in mitigating health disparities for critically ill pediatric patients.

Association Between Postpartum Depression Symptoms and Social Determinants of Health in Outpatient Pediatric Clinic.

INTRODUCTION: We aimed to (1) identify the prevalence of postpartum depression (PPD) symptoms using the Patient Health Questionnaire-2 (PHQ-2) and the Edinburgh Postnatal Depression Scale (EPDS), and (2) analyze the relationship between PPD symptoms and social determinants of health (SDoH). METHOD: We obtained data from 1327 infant/mother dyads at 1 and 6-month well-child checks. We used Chi-square and T-tests to compare social determinants between PPD screening groups and logistical regression to construct predictive models for PPD. RESULTS: The prevalence of positive PPD screens was 5-7%, but only 1.85% screened positive at both periods. Although the EPDS and PHQ-2 were correlated (Pearson 0.66), the PHQ-2 missed 65% of those identified by the EPDS. Positive PPD screens were associated with greater SDoH concerns. DISCUSSION: Our study highlights the importance of repeated PPD screening. The EPDS detected more mothers at risk than the PHQ-2. Multiple SDoH were associated with PPD symptoms.

Leverage pre-requisite courses to teach bachelor of science in nursing students about social determinants of health.

BACKGROUND: Nurses have frequent opportunities to address social determinants of health (SDOH) in practice. However, many nurses graduate without completing coursework in SDOH, and there remain barriers to incorporating SDOH content into nursing curricula. PURPOSE: We propose the revision of nursing pre-requisites to include substantive, introductory coursework on SDOH. METHOD: We explored the history and professional context surrounding nursing's current pre-requisite course expectations. We also performed an assessment of the credit hour requirements and pre-requisite course titles for the nation's 100 top-ranked nursing programs. FINDINGS: Our assessment revealed that the allocation of credit hour requirements for most programs leaves little room for SDOH-focused credits once nursing coursework starts; also, based on title analyses, foundational coursework on SDOH may be missing from most programs' pre-requisite listings. DISCUSSION: Nursing pre-requisites should include SDOH content for reasons including the limited availability of credit hours for SDOH-focused electives and the importance of students developing a strong foundation in SDOH before their nursing coursework begins.

Social Determinants of Health Impact Complications Following Free-Flap Reconstruction for Head and Neck Cancer.

OBJECTIVE: Head and neck cancers (HNCs) have increased in prevalence and often require free-flap reconstruction (FFR) after tumor ablation. Postoperative complications following FFR can be high, occurring in as many as 48% and 71% of cases. HNC patients also have many disparities in Social Determinants of Health (SDOH), but the potential impact of SDOH disparities on postoperative complications following FFR has not been formally assessed. STUDY DESIGN: Retrospective cohort review. SETTING: Academic Tertiary Care Institution in Northeast United States. METHODS: Patients that underwent head and neck FFR between January 2018 and December 2021 were analyzed to determine associations between quartiles of the national Area Deprivation Index (ADI), a proxy for SDOH disparity, and various medical and surgical postoperative complications. Associations were assessed using χ2 analysis. RESULTS: Two hundred four patients were included in the study, and 61 patients had 97 complications. Significant associations between higher national ADI quartile and incidence of several postoperative complications were identified, including any surgical complication (P = .0419), wound dehiscence (P = .0494), myocardial infarction (MI) (P = .0215), and sepsis (P = .0464). CONCLUSION: There are significant associations between SDOH disparities and postoperative surgical complications, wound dehiscence, MI, and sepsis following head and neck FFR. Addressing SDOH disparities in HNC is pivotal to enhance postoperative outcomes and promote holistic patient care.

Racial and Ethnic Disparities Within Social Determinants of Health Amongst Patients With Systemic Lupus Erythematosus.

Introduction This study aims to identify the influence of social determinants of health (SDoH) on patients with systemic lupus erythematosus (SLE), emphasizing racial and ethnic disparities in healthcare. Methods A cross-sectional study used the National Institute of Health's (NIH) All of Us Research Program (AoU). From 727,000 patients, SLE patients were categorized by race, ethnicity, and responses to the Social Determinants of Health survey from May 2018 until March 2023. Survey questions addressed transportation access, neighborhood safety, provider biases, and food insecurity. JMP Pro 16.0 and R 4.2.2 were used for statistical analysis. Results Significant racial disparities were evident amongst SLE patients for transportation access, neighborhood safety, food security, and respect from healthcare providers (p-value < 0.001). African Americans, Asians, and White participants showed different perceptions regarding neighborhood crime, healthcare provider courtesy, and feeling unheard by providers, with respective p-values of 0.001, 0.010, and 0.023. Hispanic participants perceived higher neighborhood crime rates, felt unsafe during nighttime walks, felt unheard by healthcare providers, and reported worrying about food security compared to non-Hispanic participants, with respective p-values of 0.003, 0.003, 0.009, and <0.001.  Discussion SLE is affected by access to care, treatments, stress, and lifestyle habits. Therefore, identifying SDoH for SLE patients is critical as it impacts disease progression, leading to delays in diagnosis, improper management, and worsening morbidity.  Conclusion Targeted social and community-based interventions may improve access to care, identify implicit biases among providers, and alleviate food insecurity.

Engaging Community Health Workers in the Centers for Disease Control and Prevention's COVID-19 Public Health Response to Address Health Disparities and Build Community Resilience.

In 2021, the Centers for Disease Control and Prevention's (CDC) National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) funded community health workers (CHWs) for COVID Response and Resilient Communities (CCR). CCR is a 3-year, $350 million initiative to implement CHW strategies aimed at reducing COVID-19 impacts, building resilience, and improving health equity by addressing health-related social needs. This paper describes the CCR initiative and experiences to date, underscoring CHWs' critical role in CDC's pandemic response. CCR funds 67 recipients to reach communities who are disproportionately affected by long-standing health disparities (hereafter, priority populations). CCR aims to decrease the impact of COVID-19 and increase community resilience to respond to COVID-19 and future public health emergencies. Recipients implement three strategies: train CHWs to support the COVID-19 response, increase the workforce of CHWs to manage the spread of the disease, and improve utilization of community and clinical resources to engage CHWs to help strengthen communities' resilience to mitigate the impact of COVID-19. We funded three additional organizations to provide technical assistance to CCR recipients and collaborate with us on a national evaluation of the program. CCR recipients hired about 950 CHWs and integrated these CHWs into over 1,000 organizations and care teams. At the end of the second program year, CHWs made over 250,000 referrals to social services and over 150,000 referrals to address specific health conditions. CCR demonstrates that CHWs can be quickly mobilized to participate in a public health emergency and reach those most affected by COVID-19.

A Review of COVID-19 Hotels in New York City During the Early 2020 Outbreak: An Alternative Care Model.

New York City (NYC) was the epicenter of the early US COVID-19 pandemic. From March to May 2020, overburdened healthcare centers precipitated an emergent need for non-traditional facilities to meet patient care demands. Given travel restrictions and NYC's underutilized tourist infrastructure, hotels were available to support emergency response needs. This article describes the process by which NYC's non-medical COVID-19 hotel programs were selected, mobilized, and operated, including lessons learned. NYC agencies and organizations collaborated, creating an interagency initiative that activated hotels to provide safe isolation and quarantine spaces for those diagnosed with or exposed to COVID-19, aiming to reduce community spread, increase capacity for NYC's strained healthcare system, and mitigate interagency redundancy. Interagency groups addressed hotel challenges, including infection prevention and control; behavioral health, intellectual, and developmental disorders; social determinants of health; and coordination, operations, and planning. NYC's COVID-19 hotel program successfully supported overburdened hospitals by providing alternate locations for non-inpatient COVID-19 individuals. Community engagement required a methodical approach, balancing quality assurance with efficient access. An interagency coordinating body developed and shared clinical criteria for hotel admissions, infection prevention and control (IPC) procedures, and discharge plans, enhancing the program's ability to scale and address complex needs. Lessons learned from this program can be applied for smoother implementation of similar programs in the future.

Improving Pathways to Care for Ethnic Minority Communities.

It is well established that the COVID-19 pandemic has had a substantial impact on ethnic minority communities and has worsened existing health inequalities experienced by these populations globally. Individuals from ethnic minority backgrounds have not only been more likely to become infected with COVID-19 throughout the pandemic, but they have also higher risk of adverse symptoms and death following infection. Factors responsible for these discrepancies are wide reaching and encompass all aspects of the social determinants of health (SDoH). Although always an area of concern among healthcare professionals, barriers to health care experienced by ethnic minority populations became a more pertinent issue during the COVID-19 pandemic when all individuals required sufficient and sustained access to a healthcare system (whether this be for COVID-19 testing, vaccination or treatment). These healthcare barriers exacerbated the increased COVID-19 burden experienced by minority populations and will continue to detrimentally impact the health of these populations during future COVID-19 waves or indeed, future novel pandemics. This chapter aims to summarise the major healthcare barriers experienced by minority populations throughout the COVID-19 pandemic, including COVID-19 prevention, vaccine rollout, care during hospitalisation and post-COVID care for long COVID patients. To end, this chapter will summarise lessons learned and future directions that need to be taken to improve health disparities and healthcare access for minority populations in relation to the COVID pandemic and beyond.

Retrospective Analysis of Dog Bite Injuries in Children with Autism Spectrum Disorder.

PURPOSE: Children with autism spectrum disorder (ASD) may suffer a dog bite injury, but the frequency and its clinical impact is unknown. We sought to evaluate the (1) subject characteristics; (2) injury type; (3) clinical care provided; and (4) mortality in children with ASD who suffer a dog bite injury. We hypothesized that children with ASD have higher mortality and require more clinical care than children without ASD. METHODS: This is a retrospective observational cohort study utilizing the TriNetX ® EHR database of subjects aged 0 to 18 years with dog bite diagnostic codes. Data were analyzed for demographics, diagnostic, medication, procedural codes, and mortality. RESULTS: We analyzed 38,337 subjects (n, %) coded for a dog bite injury [619 (1.6%) with ASD and 37718 (98.4%) without ASD]. Children with ASD had a higher odds of a traumatic injury to the head [1.34 (1.15, 1.57), p < 0.0001] compared to those without. There was no difference in critical care services, hospitalization, mechanical ventilation, and rabies vaccine administration. All-cause mortality at 1 year was low with no deaths reported within the ASD cohort and 37 (0.1%) deaths reported within the no ASD cohort. CONCLUSIONS: Children with ASD that suffer dog bite injuries have similar clinical needs to children without ASD but are more likely to suffer a traumatic injury to the head. Future studies are needed to better understand inciting factors for injuries in this population.

Achieving Equitable Cardiovascular Care for All: ACC Board of Trustees Health Equity Task Force Action Plan.

Advancements in cardiovascular (CV) disease management are notable, yet health inequities prevail, associated with increased morbidity and mortality noted among non-Hispanic African Americans in the United States. The 2002 Institute of Medicine Report revealed ongoing racial and ethnic health care disparities, spearheading a deeper understanding of the social determinants of health and systemic racism to develop strategies for CV health equity (HE). This article outlines the strategic HE approach of the American College of Cardiology, comprising 6 strategic equity domains: workforce pathway inclusivity, health care, data, science, and tools; education and training; membership, partnership, and collaboration; advocacy and policy; and clinical trial diversity. The American College of Cardiology's Health Equity Task Force champions the improvement of patients' lived experiences, population health, and clinician well-being while reducing health care costs-the Quadruple Aim of Health Equity. Thus, we examine multifaceted HE interventions and provide evidence for scalable real-world interventions to promote equitable CV care.

The effects of social determinants of health on rotator cuff repair utilization and outcomes: a systematic review.

Background: Since various social determinants of health (SDOH) have the potential to impact the utilization and postoperative outcomes of rotator cuff repair (RCR), a review of the literature is warranted. Therefore, the purpose of this systematic review was to evaluate the effects of SDOH on RCR utilization and postoperative outcomes in order to recognize external factors that may influence patients' access to RCR and optimal clinical outcomes. Methods: Search terms related to RCR, utilization, outcomes, and SDOH were used to identify studies that reported associations between any SDOH (as defined by the World Health Organization) and RCR utilization, access, cost, or postoperative outcomes. Articles that did not isolate RCR or did not evaluate an SDOH were excluded. Nonrandomized studies were evaluated for study quality using the Methodological Index for Nonrandomized Studies score. Due to the heterogeneity of the reported data, only qualitative analysis was possible. Results: Overall, 842 articles were considered for inclusion and 14 studies were included in qualitative analysis. The average Methodological Index for Nonrandomized Studies score of included studies was 14.1 ± 5.0. The SDOH most frequently evaluated were insurance status and race/ethnicity. Non-White race is associated with lower odds of surgery and physical therapy (PT) utilization, as well as delayed treatment. Similarly, public insurance is associated with lower PT and surgery utilization rates and decreased acceptance for postoperative PT. Postoperatively, public insurance is associated with worse patient-reported outcome scores and lower return to work rates. Conclusion: Various SDOH can influence access, utilization, and outcomes of RCR. Orthopedic surgeons should be aware of how factors of race and insurance type can influence a patient's treatment and recovery after RCR.

Model-based estimation of individual-level social determinants of health and its applications in All of Us.

OBJECTIVES: We introduce a widely applicable model-based approach for estimating individual-level Social Determinants of Health (SDoH) and evaluate its effectiveness using the All of Us Research Program. MATERIALS AND METHODS: Our approach utilizes aggregated SDoH datasets to estimate individual-level SDoH, demonstrated with examples of no high school diploma (NOHSDP) and no health insurance (UNINSUR) variables. Models are estimated using American Community Survey data and applied to derive individual-level estimates for All of Us participants. We assess concordance between model-based SDoH estimates and self-reported SDoHs in All of Us and examine associations with undiagnosed hypertension and diabetes. RESULTS: Compared to self-reported SDoHs, the area under the curve for NOHSDP is 0.727 (95% CI, 0.724-0.730) and for UNINSUR is 0.730 (95% CI, 0.727-0.733) among the 329 074 All of Us participants, both significantly higher than aggregated SDoHs. The association between model-based NOHSDP and undiagnosed hypertension is concordant with those estimated using self-reported NOHSDP, with a correlation coefficient of 0.649. Similarly, the association between model-based NOHSDP and undiagnosed diabetes is concordant with those estimated using self-reported NOHSDP, with a correlation coefficient of 0.900. DISCUSSION AND CONCLUSION: The model-based SDoH estimation method offers a scalable and easily standardized approach for estimating individual-level SDoHs. Using the All of Us dataset, we demonstrate reasonable concordance between model-based SDoH estimates and self-reported SDoHs, along with consistent associations with health outcomes. Our findings also underscore the critical role of geographic contexts in SDoH estimation and in evaluating the association between SDoHs and health outcomes.

Substance Use and College Completion Among Two-Year and Four-Year College Students From a Nationally Representative Longitudinal Study.

Young adults from disadvantaged populations access higher education through two-year colleges, but substance use research among young adults focuses on four-year colleges. Filling this research gap is important given recent policy changes that have increased marijuana availability for young adults. This study uses a subsample of college-enrolled participants from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to evaluate whether substance use predicts educational attainment seven years later, comparing 888 students attending a two-year college with 1,398 matched students attending a four-year college. Matched students were identified using a propensity score method so that students were comparable on 15 measures, including precollege grades, precollege test scores, and precollege substance use. Compared with similar four-year college students, two-year college students were more likely to use methamphetamines, cocaine, or marijuana; more likely to report problematic substance use; and less likely to use alcohol. Two-year college students who used methamphetamines in the past year (incidence rate ratio (IRR) = 1.51, 95% CI (1.12, 2.04), p = 0.007) or past month (IRR = 1.69, 95% CI (1.09, 2.61), p = 0.02) or completed alcohol abuse treatment (IRR = 1.58, 95% CI (1.21, 2.07), p < 0.001) were less likely to complete college than two-year college students without those risk factors. Among the matched four-year college students, students who reported that drugs interfered with school or work in the past year (IRR = 1.84 (1.28, 2.64), p = 0.001), used cocaine in the past year (IRR = 1.47 (1.04, 2.08), p = 0.03), and used marijuana in the past year (IRR = 1.30 (1.07, 1.57), p = 0.007), past month (IRR = 1.31 (1.07, 1.61), p = 0.01), or ≥5 times in the past month (IRR = 1.44 (1.12, 1.85) p = 0.005) were less likely to complete college than the matched four-year college students without those risk factors. Substance use interventions should target both two-year and four-year college students. Two-year colleges that better accommodate students who complete substance use treatment may improve these students' completion. Students who use marijuana or cocaine or whose drug use impairs functioning may benefit from an incremental approach of completing a two-year degree prior to transferring to a four-year degree rather than enrolling directly in a four-year program.

Illuminating Perspectives: Navigating Eye Care Access in Sub-Saharan Africa Through the Social Determinants of Health.

Ensuring access to proper eye health services is not only a fundamental human right but also crucial for preserving an individual's quality of life, preventing blindness, and promoting overall well-being. This is especially true in low-income countries like Sub-Saharan Africa (SSA) where recognizing the intricate relationship between access to healthcare and social determinants of health (SDOH ) is crucial to addressing health disparities. The goal of this study was to elucidate and highlight not only the barriers millions face in obtaining eye care but also pave the way for interventions and policies aimed at creating equitable access across diverse populations. To do this, a scoping review was conducted across the Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed databases for studies meeting the search terms and inclusion criteria. The results show that intervention strategies that increase vision care must extend beyond the healthcare sector to address the multifaceted challenges. Collaborating with stakeholders involved in addressing broader livelihood issues, such as food security, education, and SDOH, becomes imperative to ensure comprehensive and sustainable improvements in vision care accessibility in SSA.

Identifying social determinants of health in populations exposed to structural inequities: a qualitative study of the COVID-19 pandemic experiences of Black and Latinx people living with HIV and cardiovascular risks.

Introduction: Black and Latinx communities experience inequities in the social determinants of health (SDOH) and high rates of chronic illnesses [e.g., cardiovascular disease (CVD), HIV]. The COVID-19 pandemic amplified these long-standing SDOH disparities. However, scant attention has been paid to the pandemic-related experiences of populations exposed to structural inequities. Methods: Using a semi-structured interview guide, 60 in-depth telephone interviews were conducted with Black and Latinx people living with HIV (PLWH) and CVD risks to assess: (1) perceived personal and community risk for COVID-19; (2) knowledge of and access to COVID-19 public health information; (3) barriers to COVID-19 public health recommendations and vaccine uptake; and (4) perceptions of HIV, CVD, and COVID-19. Interviews were professionally transcribed into either English or Spanish. Spanish transcripts were translated into English. Rapid qualitative analysis was used to summarize each transcript into a structured templaicte corresponding to interview guide domains. Summaries were combined into matrices for identification and comparison of themes across domains. Results: Participants reported risks for COVID-19 due to being immunocompromised and SDOH, including transportation, exposure to risks conferred by others, living in under-resourced neighborhoods, and housing insecurity. Participants engaged in protective countermeasures by adhering to public health mandates. Relationships with providers, participating in community support groups, and digital inclusion and literacy were salient with respect to dissemination of COVID-19 information and vaccine uptake. Experiences with managing a chronic illness facilitated vaccine acceptance. Participants described language barriers, experiences of discrimination, and a historical lack of trust in medical systems and vaccines. Discussion: This study provides a real-time narrative from PLWH and CVD risks who were vulnerable during the height of the COVID-19 pandemic. Implications include the need for continuity with providers and established community networks, increasing internet access and digital health literacy, and addressing historical trauma incurred in medical settings. It is critical to understand the impact of traditional SDOH on those living with chronic illness as well as other social determinants that shed light on access to public health information, adherence to public health recommendations, and vaccine uptake among populations exposed to structural inequities.

Posttraumatic Stress and Opioid Use and Pain among Individuals with Probable Posttraumatic Stress Disorder and Self-Reported Chronic Pain: The Role of Health Literacy.

BACKGROUND: Chronic pain and opioid misuse are a prevalent comorbidity with deleterious health outcomes. Growing work indicates that posttraumatic stress disorder (PTSD) can increase the risk for chronic pain and opioid misuse and dependence. However, there is little understanding of social determinants of health (SDoH) that may account for interrelations of PTSD with chronic pain and opioid misuse and dependence. Health literacy is one relevant SDoH construct, reflecting the ability to gather, process, and comprehend health-related information required to engage in a healthcare setting. OBJECTIVE: The purpose of the present cross-sectional study was to examine the indirect effect of health literacy in the association between PTSD and opioid misuse, opioid dependence, pain intensity, and pain disability. METHOD: The sample included 142 adults (Mage = 35.2, SD = 9.9; 67.4% female; 70.1% White/Caucasian) with self-reported chronic pain and probable PTSD who were using opioid medication. RESULTS: Results demonstrated that PTSD symptom severity had a small indirect effect on opioid misuse and opioid dependence via health literacy; no indirect effects were evident for pain intensity and disability. CONCLUSION: The present investigation provides evidence that health literacy may serve as an important explanatory factor in associations between PTSD symptom severity and opioid misuse and dependence among adults with co-occurring probable PTSD and chronic pain.

Social Determinants of Health and Other Predictors in Initiation of Treatment with CDK4/6 Inhibitors for HR+/HER2- Metastatic Breast Cancer.

In hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) metastatic breast cancer (MBC), cyclin-dependent kinase 4/6 inhibitors (CDK4/6is) have replaced endocrine therapy alone as the standard of care; however, several barriers to treatment initiation still exist. We assessed social determinants of health (SDOH) and other factors associated with the initiation of CDK4/6i for HR+/HER2- MBC in the Medicare population. Using a retrospective cohort design, patients aged ≥65 years and diagnosed during 2015-2017 were selected from the SEER-Medicare database. Time from MBC diagnosis to first CDK4/6i initiation was the study outcome. The effect of SDOH measures and other predictors on the outcome was assessed using the multivariable Fine and Gray hazard modeling. Of 752 eligible women, 352 (46.8%) initiated CDK4/6i after MBC diagnosis (median time to initiation: 27.9 months). In adjusted analysis, SDOH factors significantly associated with CDK4/6i initiation included high versus low median household income (HHI) (hazard ratio [HR] = 1.70; 95% CI = 1.03-2.81) and the percentage of population with high versus low Medicare-only coverage (HR = 1.54; 95% CI = 1.04-2.27). In summary, older Medicare patients with HR+/HER2- MBC residing in areas with high median HHI and a high proportion of Medicare-only coverage had higher rates of initiating CDK4/6i, suggesting inequitable access to these novel, effective treatments and a need for policy intervention.