The association of patient education level with outcomes after elective lumbar surgery: a Michigan Spine Surgery Improvement Collaborative study

OBJECTIVE Socioeconomic factors have been shown to impact a host of healthcare-related outcomes. Level of education is a marker of socioeconomic status. This study aimed to investigate the relationship between patient education level and outcomes after elective lumbar surgery and to characterize any education-related disparities. METHODS The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar spine operations. Primary outcomes included patient satisfaction determined by the North American Spine Society patient satisfaction index, and reaching the minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score and return to work up to 2 years after surgery. Multivariate Poisson generalized estimating equation models reported adjusted risk ratios. RESULTS A total of 26,229 lumbar spine patients had data available for inclusion in this study. On multivariate generalized estimating equation analysis all comparisons were done versus the high school (HS)/general equivalency development (GED)–level cohort. For North American Spine Society satisfaction scores after surgery the authors observed the following: at 90 days the likelihood of satisfaction significantly decreased by 11% (p < 0.001) among < HS, but increased by 1% (p = 0.52) among college-educated and 3% (p = 0.011) among postcollege-educated cohorts compared to the HS/GED cohort; at 1 year there was a decrease of 9% (p = 0.02) among < HS and increases of 3% (p = 0.02) among college-educated and 9% (p < 0.001) among postcollege-educated patients; and at 2 years, there was an increase of 5% (p = 0.001) among postcollege-educated patients compared to the < HS group. The likelihood of reaching a minimum clinically important difference of Patient-Reported Outcomes Measurement Information System Physical Function score at 90 days increased by 5% (p = 0.005) among college-educated and 9% (p < 0.001) among postcollege-educated cohorts; at 1 year, all comparison cohorts demonstrated significance, with a decrease of 12% (p = 0.007) among < HS, but an increase by 6% (p < 0.001) among college-educated patients and 14% (p < 0.001) among postcollege-educated compared to the HS/GED cohort; at 2 years, there was a significant decrease by 19% (p = 0.003) among the < HS cohort, an increase by 8% (p = 0.001) among the college-educated group, and an increase by 16% (p < 0.001) among the postcollege-educated group. For return to work, a significant increase was demonstrated at 90 days and 1 year when comparing the HS or less group with college or postcollege cohorts. CONCLUSIONS This study demonstrated negative associations on all primary outcomes with lower levels of education. This finding suggests a potential disparity linked to education in elective spine surgery.

Modeling the adoption of a garlic variety (Allium sativum L.) in Mexico through survival analysis

The objective of this research was to analyze the adoption behavior over time for the improved variety of garlic CEZAC 06, and the factors associated with the adoption process through survival analysis (SA), in North-Central Mexico. The data comes at farm level and was collected in 2019 through a questionnaire given to 40 garlic farmers in Zacatecas, Mexico. The results show that 62.5 % of the farmers who adopted CEZAC 06 carried out this process in the first two years after they were first introduced to it. The factors that played a role in the adoption process were: farmer age, how long the farmer had been in business for, number of hectares availables for garlic production, yield, number of college-educated family members, income from crop farming, income from garlic farming, agriculture-related courses taken, financial aid from the federal government, and being part of any type of organization. Improving yield and the quality of the garlic bulb requires an adequate extension system that allows farmers to receive updated and reliable information on the importance of technological innovation. Highlights The analysis also suggested that new technologies should be transmitted at higher rates to increase adoption. This can be done by implementing courses aimed at farmers with low educational backgrounds, small plots of land and low productivity levels. The factors affecting the adoption process were: farmer age, how long the farmer had been in business, yield, etc. CEZAC 06 will increase yield and rural farmers could improve the quality of the bulb as a marketable surplus. This work contributes to the scarce literature on the application of survival analysis to agricultural technologies.

Psychosocial and Physical Activity Outcomes Among Group Lifestyle Balance Program Participants With Arthritis

Background Weight loss and physical activity (PA) are recommended for arthritis management. The Group Lifestyle Balance (GLB) Program(TM) is an evidence-based, lifestyle change program for weight loss in individuals with prediabetes, but hasn’t been evaluated in people with arthritis. Purpose The purpose of this study was to evaluate the effectiveness of an adapted version of the GLB program on PA and psychosocial outcomes related to weight loss among overweight (Body Mass Index &gt;27) individuals with arthritis. Methods A single-group, quasi-experimental design was used to examine the effects of the adapted GLB program on measures of PA and psychosocial outcomes. All participants (N=15) received the GLB program and completed the following surveys: CHAMPS PA, Self-Efficacy for PA (SE), Social Support for PA (SS), Weight Loss Efficacy (WEL) and Barriers to Healthy Eating (BHE) at baseline, 12-weeks, 6 months, and 12 months. Repeated measures ANOVA and the Friedman Test were used to examine changes over time. Results Participants (aged 53-79 years) were primarily female (82%), white (94%), and college educated (94%). Significant improvements were found in BHE subsections of self-control and motivation (p=0.002), daily mechanics (p=0.042), and WEL subsections of availability (p=0.049), social pressure (p=0.010), physical discomfort (p=0.011), and positive activities (p=0.007). Weekly caloric expenditure (p=0.004), metabolic equivalent minutes (p=0.022) for all activities, and moderate-intensity activities (p=0.019) also showed significant improvements. However, most improvements were seen in the short-term. Conclusions The GLB program should be further evaluated for its effectiveness in people with arthritis.

Video Chat Use and Mealtime Behaviors in Older Adults Before and During the COVID-19 Pandemic

Video chat allows people to connect when not physically together. Using video chat while sharing a meal (VideoDining) may decrease loneliness and improve older adults' nutritional intake. We conducted a cross-sectional online survey study using Amazon Mechanical Turk in June 2020. The objectives were to learn about eating with others, the use of video chat, and interest in VideoDining in older adults during the pandemic. There were 1331 survey attempts with 167 responses meeting the criteria for age (65 years of age or older), U.S. residency, and quality. Participants were 64% male, 77% white, 65% college-educated, and a median age of 67 years (IQR=2 years). Few participants lived alone (17%), yet 76% reported feeling isolated. Eating with others regularly, defined as several times a week or more, declined in the pandemic (44% vs. 59% pre-pandemic, p=0.0002). The use of video chat and eating when video chatting increased during the pandemic versus pre-pandemic (82% vs. 74%, p=0.003; 47% vs. 37%, p=0.0005). The majority of participants said they would VideoDine (50%) or consider trying it (37%). Interest in VideoDining did not vary by age, race, or gender. Participants who used video chat were more likely to say they would VideoDine than participants who had never used video chat (OR=3.1; 95% CI=1.25, 8.35; p=0.02). This data suggests most adults 65 years of age and older, already using the Internet, are experiencing isolation and decreased mealtime commensality during the pandemic. The vast majority are using video chat and are interested in trying VideoDining.

Dementia Caregiver Surrogate Decision Making Self-Efficacy:Distress, and Quality of Life

We assessed the relationship between caregiver self-efficacy and caregivers’ ratings of care recipient’s health-related quality of life, the severity of neuropsychiatric symptoms, and associated caregiver distress for persons with Alzheimer’s dementia (AD). Methods: The 31-item DEMQOL-Proxy, Neuropsychiatric Inventory (NPI-Q), and the Self-Efficacy for Surrogate Decision-Making scale (SDM-SES) were collected from 26 family caregivers of people with AD expressing care resistant behaviors. We used Spearman correlations to assess relationships between SDM-SES, NPI-Q severity, and NPI-distress and DEMQOL-proxy. Among enrolled caregivers, 14 (54%) were women; mean age was 64.5 years, and 24 (92%) were college-educated. Their care recipients were 61% women, 77 % white, with a mean age of 76 years, and mostly college-educated (88%). Mean scores were DEMQOL-Proxy 91.27 (+/- 14.16), SDM-SES 16.38 (+/- 2.74), NPI-Q Severity score 14.23 (+/- 6.04), and NPI-distress 17.42 (+/-6.90). There were moderate correlations between DEMQOL-Proxy and SDM-SES (r=0.54), NPI severity (r= -0.42) and NPI-distress (r= -0.49). Secondary analysis showed a moderate correlation between SDM-SES and NPI-distress (r= -0.40). We identified associations between caregiver self-efficacy, quality of life, and caregiver distress. A higher baseline SDM-SES was associated with greater health-related quality of life for the care recipient. Lower self-efficacy scores were related to more caregiver distress related to neuropsychiatric symptoms. Higher NPI severity and caregiver distress were associated with lower quality of life for the care recipient. Interventions targeting self-efficacy may promote improved QOL and decrease caregiver distress in AD dyads.

Lost in recessions: youth employment and earnings in Spain

Young workers in Spain face the unprecedented impact of the Great Recession and the COVID-19 crisis in short sequence. Moreover, they have also experienced a deterioration in their employment and earnings over the last three decades. In this paper, we document this evolution and adopt a longitudinal approach to show that employment and earnings losses suffered by young workers during recessions are not made up in the subsequent expansions. We also estimate the size of the scarring effects of entering the job market in a recession for college-educated workers during their first decade in the labor market. Our empirical estimates indicate that while there is some evidence of scarring effects, the driving force is a trend worsening of youth labor market outcomes.

The Interplay of Race/Ethnicity and Education in Fertility Patterns

This study examines the racial/ethnic and educational disparities in fertility for U.S. women born during 1960–80. Using data from the National Survey of Family Growth from 2006 to 2017, we apply a regression-based approach to estimate 1) cohort total fertility rates, 2) parity progression ratios, and 3) parity-specific probability of having a birth by age, for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics by educational attainments. We find that compared to their White counterparts, Black and Hispanic women with less than a high school education have higher fertility. However, among college educated women, Blacks have the lowest fertility levels, whereas Hispanics have the highest. The difference in fertility between Black and White college educated women is mainly driven by the smaller proportion of Black mothers having second births. We find little evidence that the observed racial disparities in fertility levels across educational levels are driven by differences in fertility timing.

Mitigating Patient and Consumer Safety Risks When Using Conversational Assistants for Medical Information: Exploratory Mixed Methods Experiment

Background Prior studies have demonstrated the safety risks when patients and consumers use conversational assistants such as Apple’s Siri and Amazon’s Alexa for obtaining medical information. Objective The aim of this study is to evaluate two approaches to reducing the likelihood that patients or consumers will act on the potentially harmful medical information they receive from conversational assistants. Methods Participants were given medical problems to pose to conversational assistants that had been previously demonstrated to result in potentially harmful recommendations. Each conversational assistant’s response was randomly varied to include either a correct or incorrect paraphrase of the query or a disclaimer message—or not—telling the participants that they should not act on the advice without first talking to a physician. The participants were then asked what actions they would take based on their interaction, along with the likelihood of taking the action. The reported actions were recorded and analyzed, and the participants were interviewed at the end of each interaction. Results A total of 32 participants completed the study, each interacting with 4 conversational assistants. The participants were on average aged 42.44 (SD 14.08) years, 53% (17/32) were women, and 66% (21/32) were college educated. Those participants who heard a correct paraphrase of their query were significantly more likely to state that they would follow the medical advice provided by the conversational assistant (χ21=3.1; P=.04). Those participants who heard a disclaimer message were significantly more likely to say that they would contact a physician or health professional before acting on the medical advice received (χ21=43.5; P=.001). Conclusions Designers of conversational systems should consider incorporating both disclaimers and feedback on query understanding in response to user queries for medical advice. Unconstrained natural language input should not be used in systems designed specifically to provide medical advice.

Patriotism, Competition, Nationalism, and Respect for the Military in U.S. Sports: Public recognition of American Institutionalized Sports Nationalism

Using new data from the National Sports and Society Survey (N = 3,993), this study first examines the extent to which U.S. adults recognize that sports teach love of country, competition as a way of life, respect for the military, and that U.S. sports teach how to be American. We characterize this sport and society process as American Institutionalized Sports Nationalism (AISN). Then, multiple regression analyses are used to assess the extent to which dominant statuses, indicators of traditionalism, and sports fandom are associated with beliefs about American Institutionalized Sports Nationalism and its component values. Results suggest that U.S. adults commonly agree that sports teach love of country, competition as a way of life, respect for the military, and how to be American; they are especially likely to agree that sports teach competition as a way of life and love of country. Many U.S. adults also recognize sports as teaching respect for the military and how to be American, but most do not. In addition, as expected, identifying as male, heterosexual, Christian, Republican, and as more of a sports fan are consistently and positively associated with agreeing that sports teach patriotic, capitalistic, militaristic, and nationalistic values. In contrast to expectations, we find evidence that White adults are less likely than Black and Latinx adults to recognize AISN and its component values; college educated adults are also less likely than those with a high school education or less to agree that sports teach patriotism, capitalism, militarism, and nationalism. This may be because sports have traditionally been perceived to offer more inclusive and fairer social and economic opportunities, for Nonwhites and the less educated. Regardless, it is important to continue to research which cultural messages are promoted through sports, why, and to what effect. The present study advances this research initiative.

Financial Toxicity Among Patients with Multiple Myeloma

Background: Treatment-related financial burden, or financial toxicity, can detract from mental health and quality of life and can lead patients to alter their care to offset treatment costs. In doing so, these patients compromise adherence which can contribute to disparities (Zafar Oncologist 2013). Among cancers, multiple myeloma treatment is particularly costly due to use of expensive, novel agents, often in combination, and for extended durations. One study found that patients with myeloma frequently reported financial toxicity and used coping strategies, including borrowing money or prematurely stopping treatment (Huntington Lancet Haematology 2015). In this study, we aim to measure financial toxicity in a cohort of patients with myeloma and examine relationships between financial toxicity and demographic, socioeconomic, and clinical factors. We further aim to follow this cohort longitudinally to examine the course of financial toxicity. Methods: We contacted individuals with multiple myeloma who had participated in our institutional banking study between 2018 and 2021. Patients who agreed to participate were sent a questionnaire which included the 11-item Comprehensive Score for financial Toxicity (COST). Scores range from 0-44 with lower scores indicating higher financial toxicity. Follow-up surveys will be completed after 3 and 6 months. This analysis included data from the initial survey only; follow-up survey data will be available at time of presentation. Results: At time of analysis, 234 patients were contacted and 122 (52%) had returned the survey. Ninety-four completed the COST at least 6 months following myeloma diagnosis and were included in the analysis. The median age at time of survey was 68 (range 37-88). The majority were Caucasian (95%), male (70%), college-educated (62%), and had left the workforce (70%). Seventy-two percent of patients were receiving first-line treatment for MM while 28% had relapsed or refractory disease. The median time from myeloma diagnosis to survey completion was 29 months (range 7-159 months). The median COST score was 28 (range 7-44); those below the median were considered to have higher financial toxicity. Patient characteristics are detailed in Table 1. Notably, 4 of the 5 African-American participants were in the higher financial toxicity group. The mean COST score for African-Americans was 18.4 (SD 8.0) compared to 27.7 (SD 9.2) for Caucasians (p = 0.03). In addition, those in the higher financial toxicity group were less likely to be college educated (52% versus 72%; p &lt;0.05) and the mean COST score for college educated patients was 28.9 (SD 9.3) compared to 24.1 (SD 8.7) for those without (p = 0.02). Interestingly, patients off treatment (n =11) had lower COST scores than patients receiving treatment (mean 21.5 [SD 9.6] compared to 27.9 [SD 9.1]; p = 0.03). Eighty-four patients had complete data and were included in the outcome analysis. Many trends were observed although none were statistically significant. Those with private insurance were more likely to be in the higher financial toxicity group. Those with college degrees or with higher socioeconomic status, approximated using the median household income from each patient's home census tract from the 2019 American Community Survey, were less likely to be in the higher financial toxicity group. Those receiving intravenous myeloma treatment were less likely to be in the higher financial toxicity group compared to those on oral only regimens or no treatment. Results from the analysis are detailed in Table 2. Conclusion: In this study, we observed relationships between demographics, socioeconomic status, and myeloma clinical characteristics with scores on the COST. However, none were independently associated with having a score below the median. Our findings are limited by sample composition, which was skewed toward patients who were Caucasian, college educated, and retired. In addition, because there is no established threshold for financial toxicity on the COST measure, we used our sample's median score; however, our median was higher than that of prior studies and this may have impacted the results. Nevertheless, these preliminary results show financial toxicity is a complex outcome that is difficult to predict. Our longitudinal data, which will be available at time of presentation, will build on these findings to assess the trajectory of financial toxicity over time. Figure 1 Figure 1. Disclosures Vij: BMS: Research Funding; Takeda: Honoraria, Research Funding; Sanofi: Honoraria, Research Funding; BMS: Honoraria; GSK: Honoraria; Oncopeptides: Honoraria; Karyopharm: Honoraria; CareDx: Honoraria; Legend: Honoraria; Biegene: Honoraria; Adaptive: Honoraria; Harpoon: Honoraria.