Racial and ethnic minority adults experience a disproportionately elevated risk of lower extremity amputation.^1-5 Diabetic foot ulceration (DFU), which precedes more than 80% of amputations, is the leading cause of limb loss in minority individuals with diabetes.⁶ African American, Hispanic, and American Indian individuals with DFUs have a several-fold greater risk of amputation than their White counterparts.^2,5,7 One of the contributing factors may be a barrier to medical care specifically due to the lack of health insurance.¹

Advanced heart failure (AHF) therapy allocation is vulnerable to bias related to subjective assessments and poor group dynamics. Our objective was to determine whether an implementation strategy for AHF team members could feasibly contribute to organizational and culture change supporting equity in AHF allocation. Using a pretest-posttest design, the strategy included an 8-week multicomponent training on bias reduction, standardized numerical social assessments, and enhanced group dynamics at an AHF center. Evaluations of organizational and cultural changes included pretest-posttest AHF team member surveys, transcripts of AHF meetings to assess group dynamics using a standardized scoring system, and posttest interviews guided by a framework for implementing a complex strategy. Results were analyzed with qualitative descriptive methods and Brunner-Munzel tests for relative effect (RE, RE >0.5 signals posttest improvement). The majority of survey metrics revealed potential benefit with RE >0.5. REs were >0.5 for 5 of 6 group dynamics metrics. Themes for implementation included (1) promoting equitable distribution of scarce resources, (2) requiring a change in team members' time investment to correct bias and change the meeting structure, (3) slowing and then accelerating the allocation process, and (4) adaptable beyond AHF and reinforceable with semi-annual trainings. An implementation strategy for AHF equity demonstrated the feasibility for organizational and culture changes.

The hospital frailty risk score (HFRS) identifies older patients at risk of poor outcomes and may have value in cirrhosis. We compared the Charlson (CCI), Elixhauser (ECI), and cirrhosis (CirCom) comorbidity indices with the HFRS in predicting outcomes for cirrhosis hospitalisations. Using the National Inpatient Sample (quarter 4 of 2015-2019), we analysed cirrhosis hospitalisations. For each index, we described the prevalence of comorbid conditions and inpatient mortality. We compared the ability of CCI, ECI, CirCom, and HFRS to predict inpatient mortality. Raw and adjusted models predicting inpatient mortality were compared using the area under the receiver operating characteristic curve and the Akaike information criterion. The cohort's (N = 626,553) median age was 61 years (IQR 52-68 years), 60% were male, cirrhosis was caused by alcohol in 43%, and 38% had ascites. The median comorbidity scores are as follows: ECI 4 (IQR 3-6), CCI 5 (IQR 4-8), and HFRS 5.6 (IQR 3.0-8.6). The most common CirCom score was 0 + 0 (44%). Across the range of values of each index, we observed different mortality ranges: CCI 1.9-13.1%, ECI 3.2-8.7%, CirCom 4.9-13.8%, and HFRS 1.0-15.2%. An adjusted model with HFRS had the highest area under the receiver operating characteristic curve in predicting mortality (HFRS 0.782 vs. ECI 0.689, CCI 0.695, and CirCom 0.692). We observed substantial variation in mortality with HFRS within each level of CCI, ECI, and CirCom. For example, for ECI 4, mortality increased from 0.6 to 16.4%, as HFRS increased from 0 to 15. Comorbidity indices predict inpatient cirrhosis mortality, but HFRS performs better than CCI, ECI, and CirCom. HFRS is an ideal tool for measuring comorbidity burden and disease severity risk adjustment in cirrhosis-related administrative database studies. We compared commonly used comorbidity indices to a more recently described risk score (hospital frailty risk score [HFRS]) in patients with cirrhosis using a national sample of hospital records. Comorbid conditions are common in hospitalised patients with cirrhosis. There is significant variability in mortality across the range of each index. HFRS outperforms the Charlson comorbidity index, Elixhauser comorbidity index, and CirCom (cirrhosis-specific comorbidity scoring system) in predicting inpatient mortality. HFRS is a valuable index for risk adjustment in inpatient administrative database studies.

Background: Segregation index (SI) has been associated with worsened health. However, the relationship between SI within health care teams (degree of heterogeneity between teams caring for Black compared with White patients) and cardiovascular care is unclear among adequately insured populations. We sought to assess the relationship between health care team SI, patient race, receipt of care by a cardiologist, 1‐year survival, and 30‐day readmission rates for Black compared with White patients admitted with heart failure, ischemic heart disease, or valvular heart disease. Methods: Using Optum's de‐identified Clinformatics Data Mart Database (CDM) from 2009 to 2020, generalized linear mixed‐effects were used to analyze effects of patient race and SI on receipt of care by a cardiologist, and care by a cardiologist on 1‐year survival and 30‐day readmission. Results: Among 6572 patients (17.1% Black), the odds of receiving care by a cardiologist were 31.3% less for Black than White patients (adjusted odds ratio 0.687 [95% CI, 0.545–0.872]; P =0.001). However, there was no statistically significant association of SI on receipt of care by a cardiologist ( P =0.14). For those seen by a cardiologist, the adjusted odds ratio (Black‐to‐White) of 1‐year survival increased with increasing SI ( P =0.02). SI had no statistically significant effect on 30‐day readmission ( P =0.86). Conclusions: Among patients hospitalized for heart failure, ischemic heart disease, or valvular heart disease, segregation of health care teams was not associated with receipt of care by cardiologists in Indiana hospitals. When cardiologists were included, the odds of 1‐year survival increased for Black versus White patients with increasing segregation of clinicians, and segregation was not associated with 30‐day readmission.

BACKGROUND: It is unknown whether predelivery cardiology care is associated with future risk of major adverse cardiovascular events (MACE) in preeclampsia/eclampsia (PrE/E). We sought to determine the cumulative incidence of MACE by race and whether predelivery cardiology care was associated with the hazard of MACE up to 1 year post-delivery for Black and White patients with PrE/E. METHODS: Using Optum’s de-identified Clinformatics Data Mart Database, we identified Black and White patients with PrE/E who had a delivery between 2008 and 2019. MACE was defined as the composite of heart failure, acute myocardial infarction, stroke, and death. Cumulative incidence functions were used to compare the incidence of MACE by race. Regression models were used to assess the hazard of MACE by cardiology care for each race. Separate hazards were calculated for the first 14 days and the remainder of the year. RESULTS: Among 29 336 patients (83.4% White patients, 16.6% Black patients, 99.5% commercially insured, mean age: 30.9 years) with PrE/E, 11.2% received cardiology care (10.9% White patients, 13.0% Black patients). Black patients had higher incidence of MACE than White patients at 1 year post-delivery (2.7% versus 1.4%) with the majority within 14 days of delivery (Black patients: 58.7%; White patients: 67.8%). After adjusting for age and comorbidities, receipt of cardiology care was associated with a lower hazard of MACE for White patients within 14 days after delivery (hazard ratio, 0.31 [95% CI, 0.21–0.46]; P <0.001) but not Black patients (hazard ratio, 1.00 [95% CI, 0.60–1.67]; P =0.999). The effect of the interaction between race and cardiology care was significant in the first 14 days ( P <0.001) but not the remainder of the year ( P =0.56). CONCLUSIONS: Among a well-insured population of patients with PrE/E, Black patients had a higher cumulative incidence of MACE up to a year post-delivery. Cardiology care was associated with a lower hazard of MACE only for White patients during the first 14 days after delivery.