National Healthcare Quality and Disparities Report
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- Access to Care (1)
- Adverse Events (1)
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- Behavioral Health (2)
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- Cancer: Breast Cancer (1)
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- Low-Income (3)
- Maternal Care (2)
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- Racial and Ethnic Minorities (5)
- Research Methodologies (2)
- Respiratory Conditions (2)
- (-) Risk (33)
- Screening (2)
- (-) Social Determinants of Health (33)
- Stroke (1)
- Surgery (1)
- Tobacco Use (1)
- U.S. Preventive Services Task Force (USPSTF) (1)
- Urban Health (2)
- Vulnerable Populations (3)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 33 Research Studies DisplayedNeerland C, Slaughter-Acey J, Behrens K
An evidence map for social and structural determinants for maternal morbidity and mortality: a systematic review.
The study aimed to identify social and structural determinants of maternal morbidity and mortality during prenatal and postpartum periods in the U.S. Out of 8,378 references screened, 118 studies were included, covering domains like identity, socioeconomic factors, violence, and trauma. Findings revealed mixed patterns between risk factors and outcomes, with notable attention to depression and mental health. Advancing the field long-term should involve developing comprehensive datasets to thoroughly investigate intersections with biological and medical risk factors.
AHRQ-funded; 75Q80120D00008.
Citation: Neerland C, Slaughter-Acey J, Behrens K .
An evidence map for social and structural determinants for maternal morbidity and mortality: a systematic review.
Obstet Gynecol 2024 Mar; 143(3):383-92. doi: 10.1097/aog.0000000000005489.
Keywords: Social Determinants of Health, Maternal Care, Mortality, Evidence-Based Practice, Risk, Women, Outcomes
Linfield GH, Patel S, Ko HJ
Evaluating the comparability of patient-level social risk data extracted from electronic health records: a systematic scoping review.
This study’s objective was to evaluate how and from where social risk data are extracted from electronic health records (EHRs) for research purposes, and how observed differences may impact study generalizability. A systematic scoping review was conducted of peer-reviewed literature that used patient-level EHR data to assess 1 ± 6 social risk domains: housing, transportation, food, utilities, safety, social support/isolation. The authors found 111 of 9022 identified articles met inclusion criteria. By domain, martial/partner status was most often included, predominantly defined by marital partner status, and extracted from structured sociodemographic data. Structured housing data was extracted most from billing codes and screening tools. Across domains, data were predominantly sourced from structured fields (n = 89/111) versus unstructured free text (n = 32/111).
AHRQ-funded; HS026383.
Citation: Linfield GH, Patel S, Ko HJ .
Evaluating the comparability of patient-level social risk data extracted from electronic health records: a systematic scoping review.
Health Informatics J 2023 Jul-Sep; 29(3):14604582231200300. doi: 10.1177/14604582231200300..
Keywords: Electronic Health Records (EHRs), Health Information Technology (HIT), Social Determinants of Health, Risk
Apathy NC, Dixit RA, Boxley CL
Variations in physician telemedicine provision.
This study’s objective was to quantify physician variation in telemedicine provisions and the extent to which telemedicine use is explainable by the individual physician, adjusting for temporal, patient, and visit factors. This cross-sectional study used data on adult primary care visits across MedStar Health, Stanford Health Care, and Intermountain Healthcare systems. Primary care physicians who conducted at least 1000 visits between March 13, 2020 and December 31, 2021 were included. Primary care visits were defined in the electronic health record and scheduling systems as completed outpatient visits with those included primary care physicians. The sample consisted of 2,410,471 visits total, with 25.6% via telemedicine seen by 729 physicians. Substantial variation in telemedicine provision was shown across physicians. At least 237 physicians (32.5%) had at least 1 high-outlier week of telemedicine provision. Patient demographics only accounted for 2.3% of the variation in telemedicine use, with the site accounting for 16.3% of the variation. Residual (unexplained) variation accounted for more than half of the explanations. Telemedicine use has slowly declined, largely due to the lack of physical examinations.
AHRQ-funded; HS028255.
Citation: Apathy NC, Dixit RA, Boxley CL .
Variations in physician telemedicine provision.
JAMA Netw Open 2023 Jul; 6(7):e2321955. doi: 10.1001/jamanetworkopen.2023.21955..
Keywords: Low-Income, Social Determinants of Health, Outcomes, Risk
Rogstad TL, Gupta S, Connolly J
Social risk adjustment In the hospital readmissions reduction program: a systematic review and implications for policy.
Investigators reviewed fourteen studies of social risk adjustment in Medicare's Hospital Readmissions Reduction Program (HRRP). They concluded that their findings support the use of social risk adjustment to improve provider payment equity and highlight opportunities to enhance social risk adjustment in value-based payment programs.
AHRQ-funded; HS026727.
Citation: Rogstad TL, Gupta S, Connolly J .
Social risk adjustment In the hospital readmissions reduction program: a systematic review and implications for policy.
Health Aff 2022 Sep;41(9):1307-15. doi: 10.1377/hlthaff.2022.00614..
Keywords: Social Determinants of Health, Hospital Readmissions, Risk, Policy
Bucholz EM, Toomey SL, McCulloch CE EM, Toomey SL, McCulloch CE
Adjusting for social risk factors in pediatric quality measures: adding to the evidence base.
The purpose of this study was to evaluate a method for incorporating social risk variables into a pediatric measure of utilization from the Pediatric Quality Measures Program (PQMP). The researchers utilized data from California Medicaid claims (2015-16) and Massachusetts All Payer Claims Database (2014-2015) to assess health plan performance using the Pediatric Asthma Emergency Department Use measure. The study found that of 133 health plans serving 404,649 pediatric patients with asthma, 7% to 13% changed performance categories after social risk adjustment. Health plans that shifted to higher performance categories cared for lower socioeconomic status (SES) patients, while those that shifted to lower performance categories cared for higher SES patients. The study concluded that adjustment for social risk factors shifted performance rankings on the PQMP Pediatric Asthma Emergency Department Use measure for a large number of health plans.
AHRQ-funded; HS025297; HS025299.
Citation: Bucholz EM, Toomey SL, McCulloch CE EM, Toomey SL, McCulloch CE .
Adjusting for social risk factors in pediatric quality measures: adding to the evidence base.
Acad Pediatr 2022 Apr;22(3s):S108-s14. doi: 10.1016/j.acap.2021.09.023..
Keywords: Children/Adolescents, Quality Measures, Quality of Care, Risk, Social Determinants of Health
Frehn JL, Brewster AL, Shortell SM
Comparing health care system and physician practice influences on social risk screening.
This study examined the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. A secondary analysis of the 2018 National Survey of Healthcare Organizations and Systems data was conducted. Five social risks were used as measures for physician and system screening: food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs. System-owned practices screened an average of 1.7 of the 5 social risks assessed. The differences were 16% attributable to practice variation between their health system owners, and 84% attributable to differences between individual practices. Practices owned by hospital systems screened for an additional 0.44 social risks relative to practices of systems without hospitals. Characteristics associated with more social risk screening included health information technology capacity, innovation culture, and patient engagement strategies.
AHRQ-funded; HS024075; HS022241.
Citation: Frehn JL, Brewster AL, Shortell SM .
Comparing health care system and physician practice influences on social risk screening.
Health Care Manage Rev 2022 Jan-Mar;47(1):E1-e10. doi: 10.1097/hmr.0000000000000309..
Keywords: Health Systems, Social Determinants of Health, Screening, Risk
Davidson KW, Krist AH, Tseng CW
AHRQ Author: Mills J, Borsky A
Incorporation of social risk in US Preventive Services Task Force Recommendations and identification of key challenges for primary care.
The authors assessed how social risks have been considered in USPSTF recommendation statements and identified current gaps in evidence needed to expand the systematic inclusion of social risks in future recommendations. They concluded that their report serves as a benchmark and foundation for ongoing work to advance the goal of ensuring that health equity and social risks are incorporated into USPSTF methods and recommendations.
AHRQ-authored.
Citation: Davidson KW, Krist AH, Tseng CW .
Incorporation of social risk in US Preventive Services Task Force Recommendations and identification of key challenges for primary care.
JAMA 2021 Oct 12;326(14):1410-15. doi: 10.1001/jama.2021.12833..
Keywords: U.S. Preventive Services Task Force (USPSTF), Primary Care, Social Determinants of Health, Risk, Evidence-Based Practice, Research Methodologies, Guidelines
Javalkar K, Robson VK, Gaffney L
Socioeconomic and racial and/or ethnic disparities in multisystem inflammatory syndrome.
Researchers characterized the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C). They found that lower socioeconomic status or higher social vulnerability index, Hispanic ethnicity, and Black race independently increased risk for MIS-C. They recommended additional studies to target interventions to improve health equity for children.
AHRQ-funded; HS000063.
Citation: Javalkar K, Robson VK, Gaffney L .
Socioeconomic and racial and/or ethnic disparities in multisystem inflammatory syndrome.
Pediatrics 2021 May;147(5). doi: 10.1542/peds.2020-039933..
Keywords: Children/Adolescents, Social Determinants of Health, Disparities, Racial and Ethnic Minorities, Risk
Brewster AL, Fraze TK, Gottlieb LM
The role of value-based payment in promoting innovation to address social risks: a cross-sectional study of social risk screening by US physicians.
The authors studied the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks. Their results indicated that implementation of social risk screening was not associated with overall exposure to value-based payment for physician practices. They recommended expanding social risk screening in order to reduce the level of innovative capacity required.
AHRQ-funded; HS024075.
Citation: Brewster AL, Fraze TK, Gottlieb LM .
The role of value-based payment in promoting innovation to address social risks: a cross-sectional study of social risk screening by US physicians.
Milbank Q 2020 Dec;98(4):1114-33. doi: 10.1111/1468-0009.12480..
Keywords: Payment, Social Determinants of Health, Practice Patterns, Vulnerable Populations, Screening, Risk, Nutrition
Oates GR, Baker E, Rowe SM
Tobacco smoke exposure and socioeconomic factors are independent predictors of pulmonary decline in pediatric cystic fibrosis.
This longitudinal study evaluates the effects of tobacco smoke exposure and socioeconomic factors on pulmonary decline in pediatric cystic fibrosis (CF). Data from the CF Foundation Patient Registration was obtained for patients who were 6-18 years old at the end of 2016. Lung function measures (ppFEV(1)) for 10,895 individuals was calculated at each attained age. At age 6, lung function was 4.7% lower among smoke-exposed children than among unexposed with this deficit continuing through age 18. Smoke exposure and socioeconomic factors had independent, additive associations with lung function. Factors that declined ppFEV(1) include smoke exposure (2.4%), lower paternal education (4.9%), public insurance (0.3%), and increased 0.2% with each $10,000 annual household income.
AHRQ-funded; HS023009.
Citation: Oates GR, Baker E, Rowe SM .
Tobacco smoke exposure and socioeconomic factors are independent predictors of pulmonary decline in pediatric cystic fibrosis.
J Cyst Fibros 2020 Sep;19(5):783-90. doi: 10.1016/j.jcf.2020.02.004..
Keywords: Children/Adolescents, Respiratory Conditions, Tobacco Use, Social Determinants of Health, Risk
Chen DW, Reyes-Gastelum D, Wallner LP
Disparities in risk perception of thyroid cancer recurrence and death.
The authors studied risk perception among survivors of thyroid cancer. Patients diagnosed with differentiated thyroid cancer from the Surveillance, Epidemiology, and End Results registries were surveyed and an analytic cohort defined by a 5% or greater risk of disease recurrence and mortality. The authors found that less educated patients and Hispanic patients were more likely to report inaccurate risk perceptions, which were associated with worry and a decreased quality of life.
AHRQ-funded; HS024512.
Citation: Chen DW, Reyes-Gastelum D, Wallner LP .
Disparities in risk perception of thyroid cancer recurrence and death.
Cancer 2020 Apr 1;126(7):1512-21. doi: 10.1002/cncr.32670..
Keywords: Disparities, Cancer, Risk, Quality of Life, Social Determinants of Health, Racial and Ethnic Minorities
Heller CG, Parsons AS, Chambers EC
Social risks among primary care patients in a large urban health system.
The objective of this study was to understand the variability in the number and types of social risks overall and in population subgroups among primary care patients routinely screened in a large urban health system. Participants across nineteen ambulatory sites in the Bronx, New York, completed a 10-item screener. Findings showed that there were important differences in the prevalence of overall and individual social risks by subgroup. These findings should be considered to inform clinical care and social risk screening and interventions.
AHRQ-funded; HS026396.
Citation: Heller CG, Parsons AS, Chambers EC .
Social risks among primary care patients in a large urban health system.
Am J Prev Med 2020 Apr;58(4):514-25. doi: 10.1016/j.amepre.2019.11.011..
Keywords: Social Determinants of Health, Primary Care, Urban Health, Risk, Vulnerable Populations
Predmore Z, Hatef E, Weiner JP
Integrating social and behavioral determinants of health into population health analytics: a conceptual framework and suggested road map.
There is growing recognition that social and behavioral risk factors impact population health outcomes. Interventions that target these risk factors can improve health outcomes. This study presents a review of existing literature and proposes a conceptual framework for the integration of social and behavioral data into population health analytics platforms. The authors describe several use cases for these platforms at the patient, health system, and community levels, and align these use cases with the different types of prevention identified by the Centers for Disease Control and Prevention.
AHRQ-funded; HS000029.
Citation: Predmore Z, Hatef E, Weiner JP .
Integrating social and behavioral determinants of health into population health analytics: a conceptual framework and suggested road map.
Popul Health Manag 2019 Dec;22(6):488-94. doi: 10.1089/pop.2018.0151..
Keywords: Social Determinants of Health, Risk, Research Methodologies
Tung EL, Chua RFM, Besser SA
Association of rising violent crime with blood pressure and cardiovascular risk: longitudinal evidence from Chicago, 2014-2016.
The purpose of this study was to examine the longitudinal association between rising violent crime and elevated blood pressure (BP). They analyzed 217,816 BP measurements from 17,783 adults during a temporal surge in violent crime in Chicago (2014-2016).The investigators concluded that rising violent crime was associated with increased BP during a temporal crime surge.
AHRQ-funded; HS023007.
Citation: Tung EL, Chua RFM, Besser SA .
Association of rising violent crime with blood pressure and cardiovascular risk: longitudinal evidence from Chicago, 2014-2016.
Am J Hypertens 2019 Nov 15;32(12):1192-98. doi: 10.1093/ajh/hpz134..
Keywords: Blood Pressure, Social Determinants of Health, Risk
Qi AC, Peacock K, Luke AA
Associations between social risk factors and surgical site infections after colectomy and abdominal hysterectomy.
The purpose of this study was to determine whether social risk factors, including race/ethnicity, insurance status, and neighborhood income, were associated with higher rates of surgical site infections (SSI) after colectomy or abdominal hysterectomy, 2 surgical procedures for which SSI rates are publicly reported and included in pay-for-performance programs by Medicare and other groups. The investigators report that inconsistent associations between social risk factors and SSIs were found.
AHRQ-funded; HS019455.
Citation: Qi AC, Peacock K, Luke AA .
Associations between social risk factors and surgical site infections after colectomy and abdominal hysterectomy.
JAMA Netw Open 2019 Oct 2;2(10):e1912339. doi: 10.1001/jamanetworkopen.2019.12339..
Keywords: Healthcare Cost and Utilization Project (HCUP), Risk, Surgery, Healthcare-Associated Infections (HAIs), Injuries and Wounds, Adverse Events, Social Determinants of Health
Louisias M, Ramadan A, Naja AS
The effects of the environment on asthma disease activity.
This study discusses environmental factors that trigger or aggravate symptoms of asthma in children. Biological and physical factors include allergens, microbiome, endotoxin, genetics and pollution. Psychosocial environmental factors include stress, neighborhood safety, housing and discrimination. Control of these factors help to reduce prevalence and severity of asthma.
AHRQ-funded; HS022986.
Citation: Louisias M, Ramadan A, Naja AS .
The effects of the environment on asthma disease activity.
Immunol Allergy Clin North Am 2019 May;39(2):163-75. doi: 10.1016/j.iac.2018.12.005..
Keywords: Asthma, Children/Adolescents, Respiratory Conditions, Risk, Social Determinants of Health
Buys DR, Kennedy RE, Williams CP
Social and demographic predictors of nutritional risk: cross-sectional analyses from the UAB Study of Aging II.
Social factors may disparately affect access to food and nutritional risk among older adults by race and gender. This study assesses these associations using the Mini Nutritional Assessment among 414 community-dwelling persons 75+ years of age in Alabama. Multivariable analyses indicated that social factors affect nutritional risk differently by race and gender. Nutritional risk interventions are warranted for older adults.
AHRQ-funded; HS013852.
Citation: Buys DR, Kennedy RE, Williams CP .
Social and demographic predictors of nutritional risk: cross-sectional analyses from the UAB Study of Aging II.
Fam Community Health 2018 Apr/Jun;41 Suppl 2 Suppl, Food Insecurity and Obesity:S33-s45. doi: 10.1097/fch.0000000000000180.
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Keywords: Elderly, Nutrition, Obesity, Risk, Social Determinants of Health
Tung EL, Wroblewski KE, Boyd K
Police-recorded crime and disparities in obesity and blood pressure status in Chicago.
The purpose of this study was to examine associations between several types of police-recorded crime (violent, nonviolent, and homicide) and cardiometabolic health (obesity and elevated blood pressure [BP]), and to determine if associations were modified by age and sex. It concluded that in a densely populated, high-poverty region in Chicago, recurrent exposure to high rates of violent crime was consistently associated with obesity and elevated BP, but rare exposure to homicide was not.
AHRQ-funded; HS023007.
Citation: Tung EL, Wroblewski KE, Boyd K .
Police-recorded crime and disparities in obesity and blood pressure status in Chicago.
J Am Heart Assoc 2018 Mar 24;7(7). doi: 10.1161/jaha.117.008030.
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Keywords: Blood Pressure, Disparities, Risk, Social Determinants of Health, Urban Health
Sun CJ, Sutfin E, Bachmann LH
Comparing men who have sex with men and transgender women who use Grindr, other similar social and sexual networking apps, or no social and sexual networking apps: implications for recruitment and health promotion.
This paper seeks to identify differences in men who have sex with men (MSM) and transgender women who use the Grindr app and those who use other similar apps. It found significant differences in the sociodemographic characteristics by app use, including age, race/ethnicity, sexual orientation, and outness. After adjusting for the sociodemographic characteristics associated with app use, there were significant differences in HIV risk and substance use between the groups.
AHRQ-funded; HS022981.
Citation: Sun CJ, Sutfin E, Bachmann LH .
Comparing men who have sex with men and transgender women who use Grindr, other similar social and sexual networking apps, or no social and sexual networking apps: implications for recruitment and health promotion.
J AIDS Clin Res 2018;9(2). doi: 10.4172/2155-6113.1000757.
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Keywords: Health Promotion, Human Immunodeficiency Virus (HIV), Risk, Social Determinants of Health, Vulnerable Populations
Cardet JC, Louisias M, King TS
Income is an independent risk factor for worse asthma outcomes.
The authors investigated whether low income, low education, and high perceived stress were independent risk factors for treatment failure and asthma exacerbations in the context of a randomized controlled trial. They found that participants with lower income were more likely to experience adverse asthma outcomes independent of education, perceived stress, race, and medication adherence.
AHRQ-funded; HS022986.
Citation: Cardet JC, Louisias M, King TS .
Income is an independent risk factor for worse asthma outcomes.
J Allergy Clin Immunol 2018 Feb;141(2):754-60.e3. doi: 10.1016/j.jaci.2017.04.036..
Keywords: Asthma, Chronic Conditions, Low-Income, Outcomes, Patient-Centered Outcomes Research, Risk, Social Determinants of Health
Valero-Elizondo J, Hong JC, Spatz ES
Persistent socioeconomic disparities in cardiovascular risk factors and health in the United States: Medical Expenditure Panel Survey 2002-2013.
This study aimed to describe the trends in prevalence of cardiovascular risk factors (CRFs) among US adults by SES from 2002 to 2013. It found that the proportion of individuals with obesity, diabetes and hypertension increased overall, with low-income groups representing a higher prevalence for each CRF. Of note, physical inactivity had the highest prevalence increase, with the "lowest-income" group observing a relative percent increase of 71.1 percent.
AHRQ-funded; HS023000.
Citation: Valero-Elizondo J, Hong JC, Spatz ES .
Persistent socioeconomic disparities in cardiovascular risk factors and health in the United States: Medical Expenditure Panel Survey 2002-2013.
Atherosclerosis 2018 Feb;269:301-05. doi: 10.1016/j.atherosclerosis.2017.12.014.
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Keywords: Disparities, Cardiovascular Conditions, Medical Expenditure Panel Survey (MEPS), Risk, Social Determinants of Health
Akwo EA, Kabagambe EK, Harrell FE, Jr.
Neighborhood deprivation predicts heart failure risk in a low-income population of blacks and whites in the southeastern United States.
The researchers investigated whether neighborhood deprivation predicts risk of incident heart failure (HF) beyond individual socioeconomic status in a low-income population. They concluded that, in a low-income population from the Southern Community Cohort Study, scant neighborhood resources compounded the risk of HF above and beyond individual socioeconomic status and traditional cardiovascular risk factors.
AHRQ-funded; HS022990.
Citation: Akwo EA, Kabagambe EK, Harrell FE, Jr. .
Neighborhood deprivation predicts heart failure risk in a low-income population of blacks and whites in the southeastern United States.
Circ Cardiovasc Qual Outcomes 2018 Jan;11(1):e004052. doi: 10.1161/circoutcomes.117.004052.
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Keywords: Heart Disease and Health, Low-Income, Racial and Ethnic Minorities, Risk, Social Determinants of Health
Jutkowitz E, MacLehose RF, Gaugler JE
Risk factors associated with cognitive, functional, and behavioral trajectories of newly diagnosed dementia patients.
This study examined the effect of sociodemographic and clinical risk factors on cognitive, functional, and behavioral declines in incident dementia patients. Age of onset, region of residence, and history of hypertension and psychiatric problems predicted behaviors at diagnosis. Cognition explained changes in behavior. Sociodemographic characteristics and clinical comorbidities predicted cognitive and functional changes. Only cognitive status explained behavioral decline.
AHRQ-funded; HS024165.
Citation: Jutkowitz E, MacLehose RF, Gaugler JE .
Risk factors associated with cognitive, functional, and behavioral trajectories of newly diagnosed dementia patients.
J Gerontol A Biol Sci Med Sci 2017 Feb;72(2):251-58. doi: 10.1093/gerona/glw079.
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Keywords: Dementia, Elderly, Behavioral Health, Neurological Disorders, Risk, Social Determinants of Health
Karp DN, Wolff CS, Wiebe DJ
Reassessing the stroke belt: using small area spatial statistics to identify clusters of high stroke mortality in the United States.
The researchers identified clusters of high stroke mortality and adjacent areas of low stroke mortality for US counties and evaluated for regional differences in county-level risk factors. They found that clusters of high stroke mortality exist beyond the 8-state stroke belt, and variation exists within the stroke belt. They recommended reconsideration of the stroke belt definition and suggested increased attention to local determinants of health underlying small area regional variability to inform targeted healthcare interventions.
AHRQ-funded; HS018362.
Citation: Karp DN, Wolff CS, Wiebe DJ .
Reassessing the stroke belt: using small area spatial statistics to identify clusters of high stroke mortality in the United States.
Stroke 2016 Jul;47(7):1939-42. doi: 10.1161/strokeaha.116.012997.
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Keywords: Mortality, Risk, Stroke, Social Determinants of Health
Liu Z, Zhang K, Du XL
Risks of developing breast and colorectal cancer in association with incomes and geographic locations in Texas: a retrospective cohort study.
This study aimed to determine whether median household income was associated with the risk of developing breast and colorectal cancer in Texas and to identify higher cancer risks by race/ethnicity and geographic areas. It demonstrated that higher income was associated with an increased risk of breast cancer and a decreased risk of colorectal cancer in Texas.
AHRQ-funded; HS018956.
Citation: Liu Z, Zhang K, Du XL .
Risks of developing breast and colorectal cancer in association with incomes and geographic locations in Texas: a retrospective cohort study.
BMC Cancer 2016 Apr 26;16:294. doi: 10.1186/s12885-016-2324-z.
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Keywords: Cancer: Breast Cancer, Cancer: Colorectal Cancer, Racial and Ethnic Minorities, Risk, Social Determinants of Health