Health Screening Program to Enhance Enrollment of Women and Minorities in CREST-2.

BACKGROUND AND PURPOSE: The CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) consists of 2 parallel randomized stroke prevention trials in patients with asymptomatic high-grade stenosis of the cervical carotid artery. The purpose of this report is to detail the outcomes of a health screening effort to increase trial enrollment of women and minorities. METHODS: Life Line screening (LLS) conducts nationwide screening for vascular disease. Screenings within a 50-mile radius of each CREST-2 center were identified for participation in a joint CREST-LLS program over the course of one year (November 2018 to October 2019) whereby patients with an abnormal carotid ultrasound were referred to the local CREST-2 center for further workup, management, and potential consideration for trial enrollment. RESULTS: LLS completed the screening of 588 198 individuals in 29 732 zip codes across the United States. Of those, 230 021 individuals were screened at events occurring near a CREST-2 clinical center and 646 (0.3%) were found to have abnormal carotid ultrasound findings. Each of the 646 individuals was contacted by CREST-LLS program staff for permission to be referred to their local CREST-2 center; 200 (31%) consented to be contacted by CREST-2. Of those, 39 (19.5%) agreed to be, and were, evaluated at their local CREST-2 center. High-grade stenosis was confirmed in 27 patients. A total of 3 patients were eligible for the trial and were enrolled, one woman but no racial/ethnic minorities. CONCLUSIONS: The LLS program appears to identify community-living individuals with high-grade carotid stenosis through ultrasonography. However, the prevalence of abnormal carotid findings was low. In addition, screening and offering participation into the CREST-2 trial had no substantial impact on the proportion of women and minorities enrolled in the trial. Additional innovative strategies are needed to promote enrollment of diverse patients with carotid stenosis into stroke prevention trials.

Trends in Poor Health Indicators Among Black and Hispanic Middle-aged and Older Adults in the United States, 1999-2018.

Importance: Adults who belong to racial/ethnic minority groups are more likely than White adults to receive a diagnosis of chronic disease in the United States. Objective: To evaluate which health indicators have improved or become worse among Black and Hispanic middle-aged and older adults since the Minority Health and Health Disparities Research and Education Act of 2000. Design, Setting, and Participants: In this repeated cross-sectional study, a total of 4 856 326 records were extracted from the Behavioral Risk Factor Surveillance System from January 1999 through December 2018 of persons who self-identified as Black (non-Hispanic), Hispanic (non-White), or White and who were 45 years or older. Exposure: The 1999 legislation to reduce racial/ethnic health disparities. Main Outcomes and Measures: Poor health indicators and disparities including major chronic diseases, physical inactivity, uninsured status, and overall poor health. Results: Among the 4 856 326 participants (2 958 041 [60.9%] women; mean [SD] age, 60.4 [11.8] years), Black adults showed an overall decrease indicating improvement in uninsured status (ß = -0.40%; P < .001) and physical inactivity (ß = -0.29%; P < .001), while they showed an overall increase indicating deterioration in hypertension (ß = 0.88%; P < .001), diabetes (ß = 0.52%; P < .001), asthma (ß = 0.25%; P < .001), and stroke (ß = 0.15%; P < .001) during the last 20 years. The Black-White gap (ie, the change in ß between groups) showed improvement (2 trend lines converging) in uninsured status (-0.20%; P < .001) and physical inactivity (-0.29%; P < .001), while the Black-White gap worsened (2 trend lines diverging) in diabetes (0.14%; P < .001), hypertension (0.15%; P < .001), coronary heart disease (0.07%; P < .001), stroke (0.07%; P < .001), and asthma (0.11%; P < .001). Hispanic adults showed improvement in physical inactivity (ß = -0.28%; P = .02) and perceived poor health (ß = -0.22%; P = .001), while they showed overall deterioration in hypertension (ß = 0.79%; P < .001) and diabetes (ß = 0.50%; P < .001). The Hispanic-White gap showed improvement in coronary heart disease (-0.15%; P < .001), stroke (-0.04%; P < .001), kidney disease (-0.06%; P < .001), asthma (-0.06%; P = .02), arthritis (-0.26%; P < .001), depression (-0.23%; P < .001), and physical inactivity (-0.10%; P = .001), while the Hispanic-White gap worsened in diabetes (0.15%; P < .001), hypertension (0.05%; P = .03), and uninsured status (0.09%; P < .001). Conclusions and Relevance: This study suggests that Black-White disparities increased in diabetes, hypertension, and asthma, while Hispanic-White disparities remained in diabetes, hypertension, and uninsured status.

La perspectiva de personas migrantes sobre el acceso a la atención sanitaria en el contexto de políticas de austeridad en Andalucía / The perspective of migrants on access to health care in the context of austerity policies in Andalusia (Spain)

OBJETIVO: Conocer la valoración de personas migrantes sobre su acceso al sistema sanitario tras la entrada en vigor del Real Decreto-Ley16/2012 y sobre el efecto que han podido producir los recortes económicos en dicho acceso. MÉTODO: Estudio cualitativo fenomenológico con entrevistas semiestructuradas, realizado en Andalucía, en dos fases (2009-2010 y 2012-2013), con 36 participantes. Se segmentó la muestra por tiempo de estancia, nacionalidad y ámbito de residencia. Las nacionalidades de las personas migrantes son Bolivia, Marruecos y Rumanía. RESULTADOS: Como elementos facilitadores del acceso en ambas fases se identifican la situación administrativa regular, la posesión de tarjeta sanitaria individual, el conocimiento del idioma, las redes sociales y la información. Los resultados muestran diferencias en el acceso a la atención sanitaria de las personas migrantes antes y después de la aplicación del RDL 16/2012, en el marco de las políticas de austeridad. En la segunda fase se agravan algunas barreras de acceso, como los tiempos de espera y la incompatibilidad de horarios, y empeoran las condiciones socioeconómicas y administrativas de las personas participantes. CONCLUSIONES: El diseño de políticas económicas y de regulación de la atención sanitaria debería tener en cuenta las barreras y los facilitadores de acceso como ejes fundamentales de la protección de la salud de las personas migrantes y, por ende, de la población general

OBJECTIVE: To conduct an assessment of migrant people regarding their access to the health system following entry into force of Royal Decree-Law 16/2012 along with the impact of economic cuts on such access. METHOD: Qualitative phenomenological study with semi-structured interviews, conducted in Andalusia (Spain), in two phases (2009-2010 and 2012-2013), with 36 participants. The sample was segmented by length of stay, nationality and area of residence. The nationalities of origin are Bolivia, Morocco and Romania. RESULTS: Elements facilitating access in both periods: regular administrative situation, possession of Individual Health Card, knowledge of the language, social networks and information. The results show differences in access to health care for migrants before and after the enforcement of the RDL 16/2012, within austerity policies. In the second period, access barriers such as waiting times or incompatibility of schedules are aggravated and the socio-economic and administrative conditions of participants worsen. CONCLUSIONS: The design of policies, economic and regulatory health care, should take into account barriers and facilitators of access as fundamental main points of health protection for migrants and, therefore, for the general population

Young Adults With Pancreatic Cancer: National Trends in Treatment and Outcomes.

OBJECTIVES: The treatment and outcomes of patients younger than 50 years (young adults [YAs]) with pancreatic cancer are largely unknown. We evaluated the presentation, treatment, and outcomes of these patients. METHODS: The National Cancer Database was analyzed. Univariate and multivariate Cox proportional hazards models were performed to identify variables associated with overall survival. RESULTS: A total of 124,442 patients with pancreatic cancer were identified, with 9657 between 18 and 50 years of age. Mean age was 45.4 years (standard deviation, 4.6 years). About 30.9% of YA patients and 25% of patients older than 50 years underwent resection of the primary tumor. Survival advantage was seen for patients 18 to 39 years (hazard ratio, 1.14; 95% confidence interval, 1.07-1.23; P < 0.001). This age advantage was similar across all the racial groups. Overall, YAs treated between 2009 and 2013 had higher survival rates compared with 2004 to 2008 (hazard ratio, 0.85; 95% confidence interval, 0.81-0.89; P < 0.001). This survival improvement was highest in American Indians and Asian/Pacific Islanders (16.6% vs 6.5%), African Americans (10.6% vs 8.5%), and Hispanics (14.5% vs 12.6%). CONCLUSIONS: Survival of YAs with pancreatic cancer patients is superior to older patients and has improved over time, especially in minority populations.

Strategies for inclusion of lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) education throughout pharmacy school curricula

Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others (LGBTQIA+) patients face stigma and barriers to health care, including a lack of health care professionals' knowledge and confidence in treating this patient population. Pharmacists are in prime position to decrease this health disparity. United States pharmacy schools have limited LGBTQIA+ content, continuing the concern of recent graduates without knowledge and confidence. This commentary discusses potential barriers to introducing LGBTQIA+ content into school of pharmacy curricula and presents five strategies currently in use by nursing, medical, and pharmacy schools. Schools of Pharmacy should consider proactive incorporation of this content to graduate practitioners able to provide quality care to LGBTQIA+ patients

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Asistencia sanitaria a migrantes en alta mar. El caso de la operación EUNAVFOR MED Sophia / Healthcare for migrants on the high seas. The case of the operation EUNAVFOR MED "Sophia"

Desde 2015, la Armada española participa en la operación EUNAVFOR MED Sophia, una operación naval de la Unión Europea contra el tráfico de seres humanos en el Mediterráneo, en la que nuestros buques realizan una importante labor humanitaria en el rescate y asistencia de migrantes en la mar. La atención y asistencia sanitaria de estos migrantes recae principalmente en el Grupo de Sanidad militar, y se basa en una serie de principios y procedimientos entre los que destacan la aplicación de un triaje adaptado a las especiales condiciones del rescate y asistencia en alta mar, así como en el diagnóstico y tratamiento de diversas patologías presentes entre los migrantes. En este sentido, este trabajo proporciona una serie de datos epidemiológicos, incidiendo en las patologías más frecuentes entre los migrantes rescatados, y destacando la importancia de la adopción de una serie de medidas para prevenir la transmisión de patologías infecciosas poco frecuentes o ya erradicadas en nuestro país

Since 2015, the Spanish Navy participates in the Operation EUNAVFOR MED Sophia, a naval operation of the European Union against the trafficking of human beings in the Mediterranean in which our ships carry out an important humanitarian work in the rescue and assistance of migrants on the sea. The attention and health care of these migrants lies mainly in the military Health Group and it is based on a series of principles and procedures among which the application of a triage adapted to the special conditions of rescue and assistance on the sea and in the diagnosis and treatment of various pathologies present among migrants. In this context, a series of epidemiological data is provided, especially the most frequent pathologies attended by rescued migrants and emphasizing the importance of adopting a series of measures to prevent the transmission of infectious pathologies that are rare or already eradicated in our country

Fragmentation or Diversification? Ethnoracial Change and the Social and Economic Heterogeneity of Places.

Our study investigates the diversification and fragmentation theses, fueled by claims that greater diversity is reshaping the social fabric of American life and that the United States is an increasingly fragmented nation. We take a multidimensional view of heterogeneity that considers whether growing ethnoracial diversity within U.S. communities (i.e., incorporated and unincorporated places) has resulted in the consolidation or differentiation of demographic, sociocultural, and economic distinctions between 1980 and 2010. As communities have become more ethnoracially diverse, they have become more heterogeneous in language and nativity-two characteristics tied closely to Latino and Asian population growth. However, ethnoracial diversity within communities is only weakly associated with household, age, educational, occupational, or income heterogeneity despite large racial/ethnic differences in these characteristics nationally. This trend does not apply to all forms of ethnoracial diversity equally: Hispanic and especially Asian population growth is more likely to generate community sociodemographic and economic heterogeneity than is black population growth. Consistent with the fragmentation hypothesis, we also find that broader geographic context matters, with more ethnoracially diverse metropolitan and micropolitan areas experiencing reduced social and economic heterogeneity inside their constituent places. We conclude by discussing the social implications of these patterns for intergroup relations, spatial exclusion, and ethnoracial inequality.

Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities.

Multilevel interventions can be uniquely effective at addressing minority health and health disparities, but they pose substantial methodological, data analytic, and assessment challenges that must be considered when designing and applying interventions and assessment. To facilitate the adoption of multilevel interventions to reduce health disparities, we outline areas of need in filling existing operational challenges to the design and assessment of multilevel interventions. We discuss areas of development that address overarching constructs inherent in multilevel interventions, with a particular focus on their application to minority health and health disparities. Our approach will prove useful to researchers, as it allows them to integrate information related to health disparities research into the framework of broader constructs with which they are familiar. We urge researchers to prioritize building transdisciplinary teams and the skills needed to overcome the challenges in designing and assessing multilevel interventions, as even small contributions can accelerate progress toward improving minority health and reducing health disparities. To make substantial progress, however, a concerted and strategic effort, including work to advance analytic techniques and measures, is needed.

Has the quality of health care for the immigrant population changed during the economic crisis in Catalonia (Spain)? Opinions of health professionals and immigrant users / ¿Ha cambiado la calidad de la atención a la población inmigrante durante la crisis económica en Cataluña (España)? Opinión de profesionales e inmigrantes

Objective: To analyse changes in health professionals' and immigrant users' perceptions of the quality of care provided to the immigrant population during the crisis. Methods: A qualitative descriptive-interpretative and exploratory study was conducted in two areas of Catalonia. Semi-structured individual interviews were used with a theoretical sample of medical (n=24) and administrative (n=10) professionals in primary care (PC) and secondary care (SC), and immigrant users (n=20). Thematic analysis was conducted and the results were triangulated. Results: Problems related to technical and interpersonal quality emerged from the discourse of both professionals and immigrants. These problems were attributed to cutbacks during the economic crisis. Regarding technical quality, respondents reported an increase in erroneous or non-specific diagnoses, inappropriate use of diagnostic tests and non-specific treatments, due to reduction in consultation times as a result of cuts in human resources. With regard to interpersonal quality, professionals reported less empathy, and users also reported worse communication, due to changes in professionals' working conditions and users' attitudes. Finally, a reduction in the resolution capacity of the health services emerged: professionals described unnecessary repeated PC visits and limited responses in SC, while young immigrants reported an insufficient response to their health problems. Conclusion: The results indicate a deterioration in perceived technical and interpersonal quality during the economic crisis, due to cutbacks mainly in human resources. These changes affect the whole population, but especially immigrants

Objetivo: Analizar los cambios en la calidad percibida de la atención a la población inmigrante durante la crisis económica, desde la perspectiva de profesionales e inmigrantes. Métodos: Estudio cualitativo descriptivo-interpretativo y exploratorio en dos áreas de Cataluña, mediante entrevistas individuales semiestructuradas a una muestra teórica de médico/as (n=24) y administrativas (n=10) de atención primaria (AP) y secundaria (AS), e inmigrantes (n=20). Se realizó un análisis temático de contenido y se triangularon los resultados. Resultados: Del discurso de profesionales e inmigrantes emergen problemas en la calidad técnica e interpersonal, que relacionan con la reducción de recursos durante la crisis. Respecto a la calidad técnica, los/las informantes describen un aumento de diagnósticos erróneos o inespecíficos, un uso inadecuado de pruebas y tratamientos inespecíficos, debido a la disminución del tiempo de consulta por la reducción de recursos humanos. Respecto a la calidad interpersonal, los/las profesionales señalaron menor empatía, mientras que los/las inmigrantes, además, una peor comunicación, que atribuyeron al cambio en las condiciones laborales de los/las profesionales y en la actitud de los/las inmigrantes. Finalmente, emergió la disminución de la capacidad resolutiva de los servicios: según los/las profesionales, por la repetición de consultas innecesarias en AP y limitadas en AS; según los/las inmigrantes jóvenes, por respuestas limitadas a sus problemas de salud. Conclusiones: Los resultados apuntan a un empeoramiento de la calidad técnica e interpersonal durante la crisis, por reducción de recursos, principalmente humanos, que afectan al conjunto de la población, pero en especial a las personas inmigrantes

Population Health, Ethnicity, and Rate of Living Donor Kidney Transplantation.

BACKGROUND: Living donor kidney transplantation has declined in the United States since 2004, but the relationship between population characteristics and rate of living donation is unknown. The goal of our study was to use data on general population health and socioeconomic status to investigate the association with living donation. METHODS: This cross-sectional, ecological study used population health and socioeconomic status data from the CDC Behavioral Risk Factor Surveillance System to investigate the association with living donation. Transplant centers performing 10 or greater kidney transplants reported to the Scientific Registry of Transplant Recipients in 2015 were included. Center rate of living donation was defined as the proportion of all kidney transplants performed at a center that were from living donors. RESULTS: In a linear mixed-effects model, a composite index of health and socioeconomic status factors was negatively associated with living donation, with a rate of living donation that was on average 7.3 percentage points lower among centers in areas with more comorbid disease and poorer socioeconomic status (95% confidence interval, -12.2 to -2.3, P = 0.004). Transplant centers in areas with higher prevalence of minorities had a rate of living donation that was 7.1 percentage points lower than centers with fewer minorities (95% confidence interval, -11.8 to -2.3, P = 0.004). CONCLUSIONS: Center-level variation in living donation was associated with population characteristics and minority prevalence. Further examination of these factors in the context of patient and center-level barriers to living donation is warranted.

Perceived discrimination and self-rated health in the immigrant population of the Basque Country, Spain / Discriminación y salud percibida en la población inmigrante del País Vasco (España)

Objective: To examine the effect of perceived discrimination and self-rated health among the immigrant population in the Basque Country, Spain, and determine whether this effect varies according to region of origin, age, sex and education. Methods: Descriptive cross-sectional study. The study population included immigrants aged 18 and older residing in the Basque Country. Data from the 2014 Foreign Immigrant Population Survey (n=3,456) were used. Log-binomial regression was used to quantify the association between perceived discrimination and self-rated health before and after checking for the selected characteristics. Results:Almost 1 in 10 immigrant adults reports perceiving discrimination. In adjusted analyses, the immigrants perceiving discrimination were almost were 1.92 more likely to rate their health as poor (prevalence ratio: 1.92; 95% CI: 1.44-2.56) than those who did not report discrimination. This association did not vary according to region of origin, age, sex or educational level. Conclusions: Perceived discrimination shows a consistent relationship with perceived health. Moreover, this association did not depend on the region of origin, age, sex or educational level of immigrants. These results show the need for implementing inclusive policies to eliminate individual and institutional discrimination and reduce health inequalities between the immigrant and native populations (AU)

Objetivo: Examinar el efecto de la discriminación en la salud percibida en la población inmigrante en el País Vasco y si este efecto es explicado por las diferencias en la región de origen, la edad, el sexo y la educación. Métodos: Estudio descriptivo transversal cuya población de estudio fue la población inmigrante de 18 años y más de edad, en el País Vasco. Los datos proceden de la Encuesta de Población Inmigrante Extranjera 2014 (n=3456). Se utilizó la regresión log binomial para medir la asociación entre la discriminación y la salud percibida antes y después de controlar por las características seleccionadas. Resultados: La discriminación fue referida por casi uno de cada 10 inmigrantes. En los análisis ajustados, los inmigrantes que refirieron discriminación tuvieron 1,92 de probabilidad de tener mala salud (razón de prevalencia: 1,92; intervalo de confianza del 95%: 1,44-2,56) en comparación con quienes no la refirieron. Esta asociación no cambió según la región de origen, el sexo ni el nivel de estudios. Conclusiones: La percepción de discriminación muestra una consistente relación con la salud percibida. Además, esta relación no depende del lugar de origen, la edad, el sexo ni el nivel de estudios de los inmigrantes. Estos resultados muestran la necesidad de implementar políticas inclusivas que eliminen la discriminación, tanto individual como institucional, para reducir las desigualdades en salud entre la población inmigrante y la autóctona (AU)

Collaboration Is Key for Successful Treatment of Youth-Onset Type 2 Diabetes.

Type 2 diabetes (T2D) is increasing in U.S. adolescents, particularly those of ethnic and racial minority groups. Risk factors for youth-onset T2D include obesity, family history of T2D, poor diet, lack of exercise, and poverty. The onset of diabetes-related complications is accelerated in adolescents with T2D compared to adults, and knowledge regarding the optimal way to prevent and slow complications is lacking. Existing treatment options are limited, and research into novel pharmacologic treatments is hindered by lack of sufficient patient population for clinical trials. Health care providers and investigators should collaborate both with each other, and with patients and their communities to build networks that will allow comprehensive evaluation of this disease in order to offer optimal, comprehensive care for these adolescents.

Health-related quality of life in young people at risk of exclusion in Melilla (Spain) / Calidad de vida relacionada con la salud en jóvenes en riesgo de exclusión en Melilla

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