Friday, June 16, 2023

Nearly 1 in 3 Black adults may develop PAD; disparities in care increase amputation risk


Routine, low-cost testing may reduce disparities and health care costs for people with peripheral artery disease (PAD), according to new American Heart Association scientific statement

Peer-Reviewed Publication

AMERICAN HEART ASSOCIATION

Statement Highlights:

  • Nearly 1 in 3 Black adults may develop peripheral artery disease (PAD), compared to about 1 in 5 Hispanic or white adults. If amputation is necessary for treatment, Black, Hispanic and American Indian adults experience lower survival rates and worse quality of life after amputation compared to white adults.
  • Multiple social, economic and health variables contribute to disparities by sex, race and ethnicity in the development, diagnosis and treatment of PAD.
  • Opportunities to address disparities include greater focus on prevention in health care systems, increasing cultural competency and diversity among the physician workforce and public health efforts to raise awareness in affected communities.
  • Implementing routine preventive strategies, such as regular blood glucose testing, ankle blood pressure monitoring and foot exams for high-risk individuals, may decrease the risk of PAD complications and improve outcomes, particularly among people from diverse racial and ethnic groups.

Embargoed until 4 a.m. CT / 5 a.m. ET, Thursday, June 15, 2023

DALLAS, June 15, 2023 — Low-cost, routine testing may help to reduce disparities and health care costs for people with peripheral artery disease (PAD), according to a new scientific statement from the American Heart Association, published today in the Association’s flagship peer-reviewed journal Circulation.

The new scientific statement, “Health Disparities in Peripheral Artery Disease,” reviews the latest research, outlines racial and ethnic disparities in PAD diagnosis and treatment, and offers potential solutions to reduce disparities and increase health equity among people with PAD. Previous studies have found that PAD and its consequences disproportionately impact individuals who are Black, American Indian or Hispanic. These demographic groups experience both higher rates of PAD and worse PAD-related outcomes, such as disability, depression, coronary artery disease, cerebrovascular disease and/or limb amputation.

PAD is a narrowing of the arteries that carry blood to the extremities, often leading to reduced blood supply to the legs. It is the result of fatty plaque buildup in the arteries and causes pain, cramping or weakness in the legs and feet when walking. Approximately 1 in 10 people with PAD may develop chronic limb-threatening ischemia, where people experience pain even when resting, and they are at increased risk for limb amputation and death from cardiovascular disease. In addition, people with PAD who also have Type 2 diabetes have a higher rate of complications, including amputation, compared to people without Type 2 diabetes. More than 12 million people in the U.S. and 200 million people worldwide have PAD, and the majority of people living with PAD are ages 40 and older.

The statement advises routine, low-cost preventive screening and monitoring for people with PAD that includes hemoglobin A1c testing (a measure of blood glucose as a 3-month average), ankle-brachial index measurements (a comparative test of blood pressure at the ankle vs. arm to monitor blood flow) and, for those with Type 2 diabetes, foot exams to check for ulcerations and neuropathy.

“This debilitating condition has devastating outcomes such as major limb amputation, which often leads to lower quality of life and increased disability, and results in social and economic burden for individuals and their families, and places an enormous financial burden on the health care system,” said statement writing group member Carlos Mena-Hurtado, M.D, an associate professor of cardiology and director of vascular medicine at Yale New Haven Hospital and Yale University in New Haven, Connecticut. ”High-risk patients should routinely receive low-cost preventive measures. Preventing problems before they occur may help to improve quality of life and reduce health care costs in the long run for people with PAD.”

Some of the disparities identified in the statement include:

  • Nearly 1 in 3 Black adults may develop PAD, compared to about 1 in 5 Hispanic or white adults.
  • When seeking medical care, Black adults are more likely to have more advanced PAD and are more likely to undergo leg or foot amputation in comparison to peers who are white adults.
  • Compared to white adults, Black, Hispanic and American Indian adults experience lower survival rates and worse quality of life after amputation. People in these demographic groups are also less likely to use a prosthesis to regain the ability to walk and more likely to live in a nursing home.
  • People from underrepresented racial and ethnic groups also have an increased risk of death after amputation, with the rate of death within five years ranging from 45%–60%, depending on the location of the amputation.
  • Limited access to health care resources may play a role in differences in outcomes for patients with PAD. Underrepresented, rural and low-income adults are at greater risk of being uninsured and are more likely to seek care at a more advanced stage of the disease compared with white, urban and higher-income adults, which increases the risk for amputation.

Mena-Hurtado added, “Even after controlling for traditional cardiovascular risk factors, we were surprised to find that higher PAD prevalence persists among Black adults. However, we now know that social determinants of health, such as access to nutritious foods, walkable neighborhoods and structural inequities, have a profound impact on an individual’s health status.”

Disparities in Risk Factors for PAD

Smoking is the most important risk factor for PAD. According to the statement, people who are of American Indian and Alaska Native descent have higher rates of smoking than people from other racial and ethnic groups. Although smoking rates have decreased in the U.S. overall, the decline has been lower among Black and American Indian adults.

Other risk factors for PAD include Type 2 diabetes, high blood pressure, high cholesterol and obesity. People who are Black or Hispanic have higher rates of obesity compared with white adults in the U.S. In addition, Black adults with PAD also have higher rates of Type 2 diabetes, high blood pressure and chronic obstructive pulmonary disease (COPD) than white adults.

Differences in vascular health may also contribute to higher rates of PAD among Black adults. Social determinants of health have been linked to alterations in blood vessel function and increased blood vessel aging and stiffness, which, in turn, increase the risk of PAD. Several studies have found Black adults are more likely to have accelerated vascular aging, reduced endothelial function, increased arterial stiffness and elevated biomarkers of systemic inflammation, which are associated with an increased risk of cardiovascular disease.

Potential Solutions to Reduce Disparities

The statement suggests opportunities to reduce disparities in PAD care from three perspectives:

  • a system-wide approach that integrates PAD screening into routine care;
  • improving cultural competence and increasing diversity of clinicians and physicians; and
  • improving community education and support programs.

The writing group suggests that emerging advances in telehealth appointments and remote patient monitoring may help to expand access to routine and preventive care. Broader implementation of telehealth and remote monitoring may help to reduce the disproportionately high number of amputations throughout the U.S., in general, and especially among people from diverse racial and ethnic groups.

Community health efforts aimed at increasing public awareness and knowledge about PAD may also help improve patient outcomes. As an example, the statement cites novel approaches to deliver health care and raise awareness among Black men, such as barbershop-based screening and follow-up. Studies have shown that community-based care and support programs are effective to lower blood pressure and raise awareness of PAD.

Quitting smoking, improving diet and exercise therapy are critical to reducing cardiovascular risk, mortality and amputation rates in people with PAD. Interventions that increase access to healthy foods, and ensure sensitivity to diverse cultural eating patterns may help to reduce hospital admissions and health care costs. Examples include programs that partner with food banks and implement community gardens.

For people with established PAD, medications to manage blood pressure, lower cholesterol and reduce blood clotting may be considered to reduce the risk of heart attack, stroke, amputation and cardiovascular death. Surgical revascularization procedures that restore blood flow in blocked arteries, such as lower extremity arterial bypass, were found to be less likely to be offered in certain regions of the U.S., especially among Black, Hispanic and American Indian populations. Greater access to these procedures and follow-up care may also help to reduce disparities.

 “It is essential that health care professionals understand the disparities in PAD prevalence and outcomes in order to provide appropriate, evidence-based care and bridge the gaps in the treatment of this diverse patient population. Health care systems need to optimize cost-effective interventions at every step,” Mena-Hurtado.

The American Heart Association and 25 other organizations have developed the PAD National Action Plan to increase public awareness and understanding of PAD, prevent complications, address health barriers and improve quality of life for people living with the condition.

American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations.

Members of the writing group and disclosures are listed in the manuscript.

The Association receives funding primarily from individuals. Foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers, and the Association’s overall financial information are available here.

Additional Resources:

About the American Heart Association

The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations, and powered by millions of volunteers, we fund innovative research, advocate for the public’s health and share lifesaving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us on heart.org, Facebook, Twitter or by calling 1-800-AHA-USA1.

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JOURNAL

Circulation

DOI

10.1161/CIR.0000000000001153 

ARTICLE TITLE

Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Study of former NFL players reveals racial disparities in chronic pain


Mass General Brigham researchers found that Black players experience pain that is both more intense and more disruptive to day-to-day life compared to their white counterparts


Peer-Reviewed Publication

MASS GENERAL BRIGHAM

A new study by researchers from Mass General Brigham and Harvard Medical School found that among participants in the Football Players Health Study at Harvard University, Black players experienced more intense and higher levels of pain that interfered with daily activities than white players. The findings, published in the journal Pain, represent one of the largest studies on pain in racial and ethnic minorities, and lend support to similar findings of race-related disparities in chronic pain in general populations.

“We've known for quite a while that there are large racial and ethnic differences in pain outcomes around the world, just like there are for most other medical outcomes,” said corresponding author Robert R. Edwards, PhD, a clinical psychologist in the Pain Management Center at Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system. “It's only recently we've been studying some of the contributors to these sorts of effects in the U.S.”

Chronic pain is estimated to affect over 100 million American adults, and it is among the leading global causes of reduced quality of life. The annual cost of chronic pain approaches one trillion dollars in the United States. However, the burden of this pain is not distributed equally.  

There are many factors that likely drive the racial disparities in chronic pain that we found in elite athletes, such as discrimination in medical settings, early life socioeconomic disadvantages, and more,” said senior author Rachel Grashow, PhD, director of epidemiological research initiatives for the Football Players Health Study at Harvard University and a research scientist at the Harvard T. H. Chan School of Public Health.

Edwards worked with Mass General Brigham colleagues from the Brigham, Massachusetts General Hospital, and Spaulding Rehabilitation Hospital, and the Football Players Health Study, to conduct the study. The team analyzed extensive data which surveyed 3,995 former NFL players on their playing positions, demographics, exposure to injury during their football careers, pain outcomes, and various other health and psychosocial factors.

The researchers found that Black players, though significantly younger than white players, reported more pain intensity and that their pain more greatly impacted their day-to-day life. The disparities were consistent across several statistical models that controlled for confounding factors such as age, body mass index, other health conditions including hypertension, diabetes, and sleep apnea, and football-related factors, such as the frequency of concussion symptoms. They also found that Black players experienced more severe fatigue, a higher frequency of smoking, and lower frequencies of exercise. Psychosocial factors, including depression, anxiety, and lack of social support, were more strongly associated with pain among Black players compared to white players.

While the study included too many conflicting variables to implicate any one cause of these disparities, the findings demonstrate that racial disparities in chronic pain are more complex than previously understood. The authors conclude that understanding this complexity will prove critical when it comes to correcting these disparities.

“This study is a microcosm of the racial and ethnic disparities in pain that we’ve observed over the years, and reminds us that elite athletic status is not sufficient to eliminate these differences,” said principal investigator of the Football Players Health Study, Ross Zafonte, DO. Zafonte is president of Spaulding Rehabilitation Network, a Mass General Brigham sports medicine physician, and the Earle P. and Ida S. Charlton Professor and Chair of the Harvard Medical School Department of Physical Medicine and Rehabilitation. “By exploring other factors that are closely associated with differences in pain outcomes, we can help identify therapeutic interventions to improve disparities and facilitate a personalized pain medicine approach that maximizes treatment benefits for populations most acutely impacted by pain.”

 

Disclosures: Ross Zafonte reported receiving royalties from Springer/Demos publishing for serving as coeditor of the text Brain Injury Medicine; serving on the scientific advisory board of Myomo Inc., and onecare.ai Inc; evaluating patients in the Massachusetts General Hospital Brain and Body-TRUST Program, which is funded by the National Football League Players Association (NFLPA); and receiving grants from the NIH and NIDILRR. Herman A. Taylor reported receiving grants from the NFLPA outside the submitted work and grants from the NIH. Marc Weisskopf reported receiving grants from the NFLPA and the NIH during the conduct of the study. Rachel Grashow, Alicia J. Whittington and Frank E. Speizer received grant funding from the NFLPA. Julius Thomas is a member of the Society for Neurosports and serves on the FPHS Player Advisory Board. The content is solely the responsibility of the authors and does not necessarily represent the official views of HMS, Harvard University, and its affiliated academic medical centers.

The NFLPA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Funding: This work was supported by the Football Players Health Study at Harvard University, which is funded by the NFLPA. In addition, National Institutes of Health grant K24NS126570 provided support for Robert R. Edwards. This funding body had no direct role in study design, data analysis, or the writing of the manuscript.

Paper cited: Edwards, RR et al. “Race differences in pain and pain-related risk factors among former professional American-style football players: findings from the Football Players Health Study” Pain DOI: 10.1097/j.pain.0000000000002948

About Mass General Brigham

Mass General Brigham is an integrated academic health care system, uniting great minds to solve the hardest problems in medicine for our communities and the world. Mass General Brigham connects a full continuum of care across a system of academic medical centers, community and specialty hospitals, a health insurance plan, physician networks, community health centers, home care, and long-term care services. Mass General Brigham is a nonprofit organization committed to patient care, research, teaching, and service to the community. In addition, Mass General Brigham is one of the nation’s leading biomedical research organizations with several Harvard Medical School teaching hospitals. For more information, please visit massgeneralbrigham.org.

About the Football Players Health Study at Harvard University

The Football Players Health Study, launched in 2014, is a comprehensive research program dedicated to examining the multifactorial causes that impact the health of former NFL players. For more information, please visit www.footballplayershealth.harvard.edu.

 

JOURNAL

Pain

DOI

10.1097/j.pain.0000000000002948 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Race differences in pain and pain-related risk factors among former professional American-style football players: findings from the Football Players Health Study

ARTICLE PUBLICATION DATE

15-Jun-2023

COI STATEMENT

Dr. Zafonte reported receiving royalties from Springer/Demos publishing for serving as coeditor of the text Brain Injury Medicine; serving on the scientific advisory board of Myomo Inc., and onecare.ai Inc; evaluating patients in the Massachusetts General Hospital Brain and Body-TRUST Program, which is funded by the NFL Players Association; and receiving grants from the NIH and NIDILRR. Dr. Taylor reported receiving grants from the NFL Players Association outside the submitted work and grants from the NIH. Dr. Weisskopf reported receiving grants from the NFL Players Association and the NIH during the conduct of the study. Drs. Grashow and Whittington received grant funding from the NFL Players Association. Mr. Thomas is a member of the Society for Neurosports and serves on the FPHS Player Advisory Board. No other disclosures were reported.

Study finds that a small number of teachers effectively double the racial gaps among students referred for disciplinary action


Peer-Reviewed Publication

AMERICAN EDUCATIONAL RESEARCH ASSOCIATION

Washington, June 15, 2023—The top 5 percent of teachers most likely to refer students to the principal’s office for disciplinary action do so at such an outsized rate that they effectively double the racial gaps in such referrals, according to new research released today. These gaps are mainly driven by higher numbers of office discipline referrals (ODRs) issued for Black and Hispanic students, compared to White students. The study, published in Educational Researcher, a peer-reviewed journal of the American Educational Research Association, was conducted by Jing Liu at the University of Maryland, College Park, Emily K. Penner at the University of California, Irvine, and Wenjing Gao at the University of Maryland, College Park.

Based on highly detailed school data, this first-of-its-kind study documents teachers’ use of ODRs and examines the role referrals play in racial disparities in exclusionary school discipline. Office referrals are typically the first formal step in the discipline process and precede the potential use of further formal consequences, including suspension. The authors drew on data from the 2016–2017 to 2019–2020 school years involving more than 2,900 teachers and 79,000 students in grades K–12 in 101 schools in a large, diverse urban district in California.

“We were really surprised to find this small group of teachers engaged in extensive referring and how big an impact they had on expanding racial disparities,” said Jing Liu, an assistant professor in education policy at the University of Maryland, College Park. “The positive takeaway was that the group of top referrers in our study represented a relatively manageable number of educators, who could be targeted with interventions and other supports.”

The jump in racial gaps caused by top referrers is largely driven by referrals issued for more subjective reasons such as interpersonal offenses and defiance—as opposed to more objective reasons such as violence, drug use, and class skipping. The increased ODRs also partially, but not entirely, convert to increased racial gaps in student suspensions, with a much larger conversion rate for the Black-White suspension gap compared with other racial group comparisons.

In May, the Biden administration issued a letter to school leaders indicating that schools that unfairly discipline students based on race could be in violation of Title IV of the Civil Rights Act.

Liu and his colleagues found that the top 5 percent of referring teachers issued an average of over 48 ODRs per year—roughly one ODR every four school days. That is several times greater than the rates of their average-referring colleagues, who issued less than one ODR for every two months of school. Top referrers accounted for 34.8 percent of all ODRs.

Top referrers effectively doubled the Black-White, Hispanic-White, and multiracial/other-White ODR gaps. The ratio of the Black-White gap in ODRs was about 1.6-to-1 when considering all referrers but jumped to 3.4-to-1 when including top referrers.

Prior research has shown that receiving referrals, especially frequent referrals, is a strong precursor for receiving suspensions, which can hurt student engagement, achievement, and long-run success. The body of research evidence also indicates that implicit or explicit racial bias contributes to racial disparities in exclusionary discipline.

“It is important for teachers to be aware of their referring frequency and the reasons for their referrals so they can be more aware of the potential impact of their actions on students and adjust how they approach student misbehaviors accordingly,” said Liu.

“Schools leaders need to know that they can leverage information about referring frequency to identify the top referrers and the specific school contexts where extensive referring is concentrated,” Liu said. “Targeting support and interventions to these individuals and contexts might ultimately reduce the overall use of, and racial disparities in, exclusionary discipline.”

The results from Liu and his colleagues suggested that teachers who are White, early career, and who serve middle schools are most likely to engage in extensive referring. As teachers accumulate more years of teaching experience, especially after three years, their likelihood of being a referrer or top referrer quickly drops.

“Given that top referrers tend to be teachers early in their careers, targeting professional development supports of classroom management skills for this group of teachers might also be a viable approach to reducing their referring frequency,” said Liu. “Our analysis highlights that structural supports at certain school levels are warranted.”

Study citation: Liu, J., Penner, E., & Wenjing, G. (2023). Troublemakers? The role of frequent teacher referrals in expanding racial disciplinary disproportionalities. Prepublished June 15, 2023. https://www.doi.org/10.3102/0013189X231179649.

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About AERA
The American Educational Research Association (AERA) is the largest national interdisciplinary research association devoted to the scientific study of education and learning. Founded in 1916, AERA advances knowledge about education, encourages scholarly inquiry related to education, and promotes the use of research to improve education and serve the public good. Find AERA on Facebook, Twitter, LinkedIn, and Instagram.

JOURNAL

Educational Researcher

DOI

10.3102/0013189X231179649 

ARTICLE TITLE

Troublemakers? The Role of Frequent Teacher Referrals in Expanding Racial Disciplinary Disproportionalities

ARTICLE PUBLICATION DATE

15-Jun-2023


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