Diversity in Medicine

America was already facing a critical health care workforce shortage before the COVID-19 pandemic exacerbated the problem. The American Medical Association (AMA) projects that there will be a national shortage of up to 48,000 primary care physicians and 77,100 non-primary care physicians by 2034.

The dearth is particularly striking among physicians who practice in rural areas and those who are Native American. As of 2021, fewer than 3000 physicians—of 841,322—identified as American Indian or Alaska Native, according to the latest statistics from the Physician Specialty Data Report, published by the Association of American Medical Colleges (AAMC).

The lack of Native American physicians is “nothing new, it’s been going on for decades,” says Mary Owen (Tlingit), MD, director of the Center of American Indian and Minority Health and associate dean of Native American Health at the University of Minnesota Medical School, speaking in a Native America Calling podcast in October.

“These numbers are… actually lessening—and we had paltry numbers to begin with,” said Owen. “It doesn’t take a genius to look back and figure out where it’s from. We don’t have enough students coming through the pathways in the first place. For instance, our high school graduation rate in this country is easily 10 points below that of non-Natives. In Duluth, Minnesota, the high school graduation rate is only 43%… We have to recognize that this is an area we have to work on.”

Senators Tim Kaine (D-VA) and Alex Padilla (D-CA) have introduced the Expanding Medical Education Act, legislation to get more students from underrepresented groups into the physician pipeline. The bill would provide grants through the Health Resources and Services Administration (HRSA) for colleges and universities to establish or expand allopathic (MD-granting) or osteopathic (DO-granting) medical schools in underserved areas or at institutions for underrepresented populations, including Historically Black Colleges and Universities (HBCUs).

Addressing Rural Needs

However, projections on the growth of health care professions show that supply will not meet demand over the next 10 years. The shortage is more dire in rural areas. According to the US Department of Health and Human Services (HHS), since 2010, more than 150 rural hospitals have either closed their doors entirely or stopped providing inpatient hospital services. Often, rural communities have fewer local HCPs available.

More than half (54%) of American Indian or Alaska Native people live in rural and small-town areas, and 68% live on or near their tribal homelands, according to the nonprofit First Nations Development Institute. Many live far—even hours—away from the nearest health care facility. But according to Population Health in Rural America in 2020: Proceedings of a Workshop, only 10% of primary care practitioners and < 7% of specialty care practitioners live in rural areas. About 5% of rural counties do not have any family physicians. What’s more, language and culture differ among the nearly 600 tribes across the country. The Indian Health Council, for instance, counts 9 individual reservations and tribes within a 5-mile radius in San Diego County, “all of which have their own unique customs,” which contribute to the “level of care they deem appropriate.”

“If you’re a rural impoverished community, it’s hard to recruit doctors. We’re more likely to return to our communities,” said Donald K. Warne (Oglala Lakota), MD, MPH, Associate Dean for Diversity, Equity, and Inclusion at the University of North Dakota School of Medicine and Health Sciences, during the 2019 American Indian or Alaska Native Physicians Summit, which was cosponsored by the AMA, Association of American Indian Physicians (AAIP), and the AAMC.

“Communities of color and those living in rural and underserved areas have long faced significant barriers to health care, including a lack of providers that look like them or practice close by,” said Senator Kaine in a statement. “Since research shows that physicians are more likely to practice in the areas they’re from, supporting medical schools at minority-serving institutions and HBCUs in underserved areas can help improve care in those communities.”

Where Are the Native Medical Students?

Only 9% of medical schools have more than 4 American Indian or Alaska Native students; 43% have none, says Siobhan M. Wescott, MD, MPH, chair of the AMA Minority Affairs Section (MAS), and an assistant professor at the University of North Dakota. Dr. Wescott, who hosted the AMA co-sponsored summit on behalf of the AMA-MAS, is an Alaska Native and 1 of only 3 physicians from her tribe. The AAMC has also found that less than half of MD-granting medical schools in the US have enrolled more than 5 Native students.

Among other things, the Expanding Medical Education Act would prioritize grants to institutions of higher education that propose to use the funds to establish a medical school or branch campus in an area in which no other such school is based and is a medically underserved community or “health professional shortage” area. Eligible uses for the grants include hiring diverse faculty and other staff, and recruiting students from underrepresented racial and ethnic minorities, students from rural and underserved areas, low-income students, and first-generation college students.

The legislation has been endorsed by the AAMC, American Association of Colleges of Osteopathic Medicine, Association of American Indian Physicians, Association of Clinicians for the Underserved, National Hispanic Medical Association, Society for Advancement of Chicanos/Hispanics and Native Americans in Science, and Ochsner Health.

Funding Is Key

Federal agencies are investing in funding and training. Medicare is allocating 1000 new training slots for medical residents, prioritizing rural and underserved areas. Centers for Medicare and Medicaid Services (CMS) is offering another 200 slots, at least 100 of which are specifically for psychiatry residencies in 2026. HHS awarded more than $11 million through the Rural Residency Planning and Development Program (RRPD) to help establish new rural residency programs. Accredited RRPD-funded programs are already training more than 300 resident physicians in family medicine, internal medicine, psychiatry, and general surgery. HRSA published an opportunity for $5 million in FY 2024 to develop and implement clinical rotations for physician assistant students in rural areas that will integrate behavioral health with primary care services.

The Biden-Harris Administration has already taken several steps to improve access to health care for the more than 60 million people who live in rural areas, including: building on the Affordable Care Act and Inflation Reduction Act to increase access to affordable health coverage and care for those living in rural communities; keeping more rural hospitals open to provide critical services in their communities; and bolstering the rural health workforce, including for primary care and behavioral HCPs.

The administration also has funded small rural hospitals and Medicare-certified Rural Health Clinics. Critical access hospitals and small hospitals in rural areas have a new option: to convert to a Rural Emergency Hospital (REH), a new Medicare provider type. CMS has changed the payment method for Tribal and Indian Health Services–operated REHs, to address certain barriers that may have discouraged Tribal and Indian Health Service (IHS)–operated hospitals from converting to REHs. Beginning in FY 2022, HHS, through HRSA, dedicated $5 million to provide technical assistance to rural hospitals that are considering converting to the REH designation.

HHS also has several grant opportunities to support rural communities, including $28 million to provide direct health services and expand infrastructure and $16 million to provide technical assistance to rural hospitals facing financial distress. This year, 60 rural hospitals will receive technical assistance to maintain financial viability and ensure continued access to care.

The HRSA National Health Service Corps Rural Community Loan Repayment Program has invested $80 million to support substance use disorder treatment, assist in recovery, and prevent overdose deaths. Medicare will also cover opioid use disorder treatment services delivered by mobile units of registered opioid treatment programs, which can now be accessed via telehealth or audio-only communications.

Curricula Also Lack Native Diversity

As of 2017, only 11% of MD-granting schools in the US say they have included Native American health content in their curricula. Dr. Owen notes some of the challenges indigenous students face: They are in a crowd that is primarily non-Native, far from their own family and community; unlike White students, they usually do not have mentors; they may not have the wherewithal to continue school and graduate.

A 2022 study of the association of sociodemographic characteristics with US medical student attrition, published in JAMA Internal Medicine, found that American Indian, Alaska Native, Native Hawaiian, and Pacific Islander students were more than 4 times as likely to drop out compared with White students. More than 10% of Indigenous medical students don’t graduate—the highest of any group the researchers examined.

In 1973 the University of North Dakota, for instance, launched Indians Into Medicine (INMED), a program that has since recruited, supported, and trained 250 American Indian doctors, and, in 2019, the country’s first PhD program in indigenous health. Dr. Warne, the director of INMED, calls it “by far, the most successful indigenous medical training program in the world,” having helped 228 American Indians and Alaska Natives graduate since its inception. A new cohort of 6 students has just enrolled.

Oregon Health & Science University (OHSU) received $800,000 in federal funding for its Future Leaders in Indigenous Health (FLIGHT) project, managed through OHSU’s Northwest Native American Center of Excellence (NNACoE). In 2012, just 8 Native students were enrolled in the OHSU School of Medicine; a decade later, there were 29. In 2022, the newest medical class included 12 American Indian or Alaska Native students. According to the school, it is believed to be the largest group of Natives in any single US medical school MD class in history. The number of Native faculty in the OHSU School of Medicine grew from 7 in 2014 to 13 in 2022.

America was already facing a critical health care workforce shortage before the COVID-19 pandemic exacerbated the problem. The American Medical Association (AMA) projects that there will be a national shortage of up to 48,000 primary care physicians and 77,100 non-primary care physicians by 2034.

The dearth is particularly striking among physicians who practice in rural areas and those who are Native American. As of 2021, fewer than 3000 physicians—of 841,322—identified as American Indian or Alaska Native, according to the latest statistics from the Physician Specialty Data Report, published by the Association of American Medical Colleges (AAMC).

The lack of Native American physicians is “nothing new, it’s been going on for decades,” says Mary Owen (Tlingit), MD, director of the Center of American Indian and Minority Health and associate dean of Native American Health at the University of Minnesota Medical School, speaking in a Native America Calling podcast in October.

“These numbers are… actually lessening—and we had paltry numbers to begin with,” said Owen. “It doesn’t take a genius to look back and figure out where it’s from. We don’t have enough students coming through the pathways in the first place. For instance, our high school graduation rate in this country is easily 10 points below that of non-Natives. In Duluth, Minnesota, the high school graduation rate is only 43%… We have to recognize that this is an area we have to work on.”

Senators Tim Kaine (D-VA) and Alex Padilla (D-CA) have introduced the Expanding Medical Education Act, legislation to get more students from underrepresented groups into the physician pipeline. The bill would provide grants through the Health Resources and Services Administration (HRSA) for colleges and universities to establish or expand allopathic (MD-granting) or osteopathic (DO-granting) medical schools in underserved areas or at institutions for underrepresented populations, including Historically Black Colleges and Universities (HBCUs).

Addressing Rural Needs

However, projections on the growth of health care professions show that supply will not meet demand over the next 10 years. The shortage is more dire in rural areas. According to the US Department of Health and Human Services (HHS), since 2010, more than 150 rural hospitals have either closed their doors entirely or stopped providing inpatient hospital services. Often, rural communities have fewer local HCPs available.

More than half (54%) of American Indian or Alaska Native people live in rural and small-town areas, and 68% live on or near their tribal homelands, according to the nonprofit First Nations Development Institute. Many live far—even hours—away from the nearest health care facility. But according to Population Health in Rural America in 2020: Proceedings of a Workshop, only 10% of primary care practitioners and < 7% of specialty care practitioners live in rural areas. About 5% of rural counties do not have any family physicians. What’s more, language and culture differ among the nearly 600 tribes across the country. The Indian Health Council, for instance, counts 9 individual reservations and tribes within a 5-mile radius in San Diego County, “all of which have their own unique customs,” which contribute to the “level of care they deem appropriate.”

“If you’re a rural impoverished community, it’s hard to recruit doctors. We’re more likely to return to our communities,” said Donald K. Warne (Oglala Lakota), MD, MPH, Associate Dean for Diversity, Equity, and Inclusion at the University of North Dakota School of Medicine and Health Sciences, during the 2019 American Indian or Alaska Native Physicians Summit, which was cosponsored by the AMA, Association of American Indian Physicians (AAIP), and the AAMC.

“Communities of color and those living in rural and underserved areas have long faced significant barriers to health care, including a lack of providers that look like them or practice close by,” said Senator Kaine in a statement. “Since research shows that physicians are more likely to practice in the areas they’re from, supporting medical schools at minority-serving institutions and HBCUs in underserved areas can help improve care in those communities.”

Where Are the Native Medical Students?

Only 9% of medical schools have more than 4 American Indian or Alaska Native students; 43% have none, says Siobhan M. Wescott, MD, MPH, chair of the AMA Minority Affairs Section (MAS), and an assistant professor at the University of North Dakota. Dr. Wescott, who hosted the AMA co-sponsored summit on behalf of the AMA-MAS, is an Alaska Native and 1 of only 3 physicians from her tribe. The AAMC has also found that less than half of MD-granting medical schools in the US have enrolled more than 5 Native students.

Among other things, the Expanding Medical Education Act would prioritize grants to institutions of higher education that propose to use the funds to establish a medical school or branch campus in an area in which no other such school is based and is a medically underserved community or “health professional shortage” area. Eligible uses for the grants include hiring diverse faculty and other staff, and recruiting students from underrepresented racial and ethnic minorities, students from rural and underserved areas, low-income students, and first-generation college students.

The legislation has been endorsed by the AAMC, American Association of Colleges of Osteopathic Medicine, Association of American Indian Physicians, Association of Clinicians for the Underserved, National Hispanic Medical Association, Society for Advancement of Chicanos/Hispanics and Native Americans in Science, and Ochsner Health.

Funding Is Key

Federal agencies are investing in funding and training. Medicare is allocating 1000 new training slots for medical residents, prioritizing rural and underserved areas. Centers for Medicare and Medicaid Services (CMS) is offering another 200 slots, at least 100 of which are specifically for psychiatry residencies in 2026. HHS awarded more than $11 million through the Rural Residency Planning and Development Program (RRPD) to help establish new rural residency programs. Accredited RRPD-funded programs are already training more than 300 resident physicians in family medicine, internal medicine, psychiatry, and general surgery. HRSA published an opportunity for $5 million in FY 2024 to develop and implement clinical rotations for physician assistant students in rural areas that will integrate behavioral health with primary care services.

The Biden-Harris Administration has already taken several steps to improve access to health care for the more than 60 million people who live in rural areas, including: building on the Affordable Care Act and Inflation Reduction Act to increase access to affordable health coverage and care for those living in rural communities; keeping more rural hospitals open to provide critical services in their communities; and bolstering the rural health workforce, including for primary care and behavioral HCPs.

The administration also has funded small rural hospitals and Medicare-certified Rural Health Clinics. Critical access hospitals and small hospitals in rural areas have a new option: to convert to a Rural Emergency Hospital (REH), a new Medicare provider type. CMS has changed the payment method for Tribal and Indian Health Services–operated REHs, to address certain barriers that may have discouraged Tribal and Indian Health Service (IHS)–operated hospitals from converting to REHs. Beginning in FY 2022, HHS, through HRSA, dedicated $5 million to provide technical assistance to rural hospitals that are considering converting to the REH designation.

HHS also has several grant opportunities to support rural communities, including $28 million to provide direct health services and expand infrastructure and $16 million to provide technical assistance to rural hospitals facing financial distress. This year, 60 rural hospitals will receive technical assistance to maintain financial viability and ensure continued access to care.

The HRSA National Health Service Corps Rural Community Loan Repayment Program has invested $80 million to support substance use disorder treatment, assist in recovery, and prevent overdose deaths. Medicare will also cover opioid use disorder treatment services delivered by mobile units of registered opioid treatment programs, which can now be accessed via telehealth or audio-only communications.

Curricula Also Lack Native Diversity

As of 2017, only 11% of MD-granting schools in the US say they have included Native American health content in their curricula. Dr. Owen notes some of the challenges indigenous students face: They are in a crowd that is primarily non-Native, far from their own family and community; unlike White students, they usually do not have mentors; they may not have the wherewithal to continue school and graduate.

A 2022 study of the association of sociodemographic characteristics with US medical student attrition, published in JAMA Internal Medicine, found that American Indian, Alaska Native, Native Hawaiian, and Pacific Islander students were more than 4 times as likely to drop out compared with White students. More than 10% of Indigenous medical students don’t graduate—the highest of any group the researchers examined.

In 1973 the University of North Dakota, for instance, launched Indians Into Medicine (INMED), a program that has since recruited, supported, and trained 250 American Indian doctors, and, in 2019, the country’s first PhD program in indigenous health. Dr. Warne, the director of INMED, calls it “by far, the most successful indigenous medical training program in the world,” having helped 228 American Indians and Alaska Natives graduate since its inception. A new cohort of 6 students has just enrolled.

Oregon Health & Science University (OHSU) received $800,000 in federal funding for its Future Leaders in Indigenous Health (FLIGHT) project, managed through OHSU’s Northwest Native American Center of Excellence (NNACoE). In 2012, just 8 Native students were enrolled in the OHSU School of Medicine; a decade later, there were 29. In 2022, the newest medical class included 12 American Indian or Alaska Native students. According to the school, it is believed to be the largest group of Natives in any single US medical school MD class in history. The number of Native faculty in the OHSU School of Medicine grew from 7 in 2014 to 13 in 2022.

America was already facing a critical health care workforce shortage before the COVID-19 pandemic exacerbated the problem. The American Medical Association (AMA) projects that there will be a national shortage of up to 48,000 primary care physicians and 77,100 non-primary care physicians by 2034.

The dearth is particularly striking among physicians who practice in rural areas and those who are Native American. As of 2021, fewer than 3000 physicians—of 841,322—identified as American Indian or Alaska Native, according to the latest statistics from the Physician Specialty Data Report, published by the Association of American Medical Colleges (AAMC).

The lack of Native American physicians is “nothing new, it’s been going on for decades,” says Mary Owen (Tlingit), MD, director of the Center of American Indian and Minority Health and associate dean of Native American Health at the University of Minnesota Medical School, speaking in a Native America Calling podcast in October.

“These numbers are… actually lessening—and we had paltry numbers to begin with,” said Owen. “It doesn’t take a genius to look back and figure out where it’s from. We don’t have enough students coming through the pathways in the first place. For instance, our high school graduation rate in this country is easily 10 points below that of non-Natives. In Duluth, Minnesota, the high school graduation rate is only 43%… We have to recognize that this is an area we have to work on.”

Senators Tim Kaine (D-VA) and Alex Padilla (D-CA) have introduced the Expanding Medical Education Act, legislation to get more students from underrepresented groups into the physician pipeline. The bill would provide grants through the Health Resources and Services Administration (HRSA) for colleges and universities to establish or expand allopathic (MD-granting) or osteopathic (DO-granting) medical schools in underserved areas or at institutions for underrepresented populations, including Historically Black Colleges and Universities (HBCUs).

Addressing Rural Needs

However, projections on the growth of health care professions show that supply will not meet demand over the next 10 years. The shortage is more dire in rural areas. According to the US Department of Health and Human Services (HHS), since 2010, more than 150 rural hospitals have either closed their doors entirely or stopped providing inpatient hospital services. Often, rural communities have fewer local HCPs available.

More than half (54%) of American Indian or Alaska Native people live in rural and small-town areas, and 68% live on or near their tribal homelands, according to the nonprofit First Nations Development Institute. Many live far—even hours—away from the nearest health care facility. But according to Population Health in Rural America in 2020: Proceedings of a Workshop, only 10% of primary care practitioners and < 7% of specialty care practitioners live in rural areas. About 5% of rural counties do not have any family physicians. What’s more, language and culture differ among the nearly 600 tribes across the country. The Indian Health Council, for instance, counts 9 individual reservations and tribes within a 5-mile radius in San Diego County, “all of which have their own unique customs,” which contribute to the “level of care they deem appropriate.”

“If you’re a rural impoverished community, it’s hard to recruit doctors. We’re more likely to return to our communities,” said Donald K. Warne (Oglala Lakota), MD, MPH, Associate Dean for Diversity, Equity, and Inclusion at the University of North Dakota School of Medicine and Health Sciences, during the 2019 American Indian or Alaska Native Physicians Summit, which was cosponsored by the AMA, Association of American Indian Physicians (AAIP), and the AAMC.

“Communities of color and those living in rural and underserved areas have long faced significant barriers to health care, including a lack of providers that look like them or practice close by,” said Senator Kaine in a statement. “Since research shows that physicians are more likely to practice in the areas they’re from, supporting medical schools at minority-serving institutions and HBCUs in underserved areas can help improve care in those communities.”

Where Are the Native Medical Students?

Only 9% of medical schools have more than 4 American Indian or Alaska Native students; 43% have none, says Siobhan M. Wescott, MD, MPH, chair of the AMA Minority Affairs Section (MAS), and an assistant professor at the University of North Dakota. Dr. Wescott, who hosted the AMA co-sponsored summit on behalf of the AMA-MAS, is an Alaska Native and 1 of only 3 physicians from her tribe. The AAMC has also found that less than half of MD-granting medical schools in the US have enrolled more than 5 Native students.

Among other things, the Expanding Medical Education Act would prioritize grants to institutions of higher education that propose to use the funds to establish a medical school or branch campus in an area in which no other such school is based and is a medically underserved community or “health professional shortage” area. Eligible uses for the grants include hiring diverse faculty and other staff, and recruiting students from underrepresented racial and ethnic minorities, students from rural and underserved areas, low-income students, and first-generation college students.

The legislation has been endorsed by the AAMC, American Association of Colleges of Osteopathic Medicine, Association of American Indian Physicians, Association of Clinicians for the Underserved, National Hispanic Medical Association, Society for Advancement of Chicanos/Hispanics and Native Americans in Science, and Ochsner Health.

Funding Is Key

Federal agencies are investing in funding and training. Medicare is allocating 1000 new training slots for medical residents, prioritizing rural and underserved areas. Centers for Medicare and Medicaid Services (CMS) is offering another 200 slots, at least 100 of which are specifically for psychiatry residencies in 2026. HHS awarded more than $11 million through the Rural Residency Planning and Development Program (RRPD) to help establish new rural residency programs. Accredited RRPD-funded programs are already training more than 300 resident physicians in family medicine, internal medicine, psychiatry, and general surgery. HRSA published an opportunity for $5 million in FY 2024 to develop and implement clinical rotations for physician assistant students in rural areas that will integrate behavioral health with primary care services.

The Biden-Harris Administration has already taken several steps to improve access to health care for the more than 60 million people who live in rural areas, including: building on the Affordable Care Act and Inflation Reduction Act to increase access to affordable health coverage and care for those living in rural communities; keeping more rural hospitals open to provide critical services in their communities; and bolstering the rural health workforce, including for primary care and behavioral HCPs.

The administration also has funded small rural hospitals and Medicare-certified Rural Health Clinics. Critical access hospitals and small hospitals in rural areas have a new option: to convert to a Rural Emergency Hospital (REH), a new Medicare provider type. CMS has changed the payment method for Tribal and Indian Health Services–operated REHs, to address certain barriers that may have discouraged Tribal and Indian Health Service (IHS)–operated hospitals from converting to REHs. Beginning in FY 2022, HHS, through HRSA, dedicated $5 million to provide technical assistance to rural hospitals that are considering converting to the REH designation.

HHS also has several grant opportunities to support rural communities, including $28 million to provide direct health services and expand infrastructure and $16 million to provide technical assistance to rural hospitals facing financial distress. This year, 60 rural hospitals will receive technical assistance to maintain financial viability and ensure continued access to care.

The HRSA National Health Service Corps Rural Community Loan Repayment Program has invested $80 million to support substance use disorder treatment, assist in recovery, and prevent overdose deaths. Medicare will also cover opioid use disorder treatment services delivered by mobile units of registered opioid treatment programs, which can now be accessed via telehealth or audio-only communications.

Curricula Also Lack Native Diversity

As of 2017, only 11% of MD-granting schools in the US say they have included Native American health content in their curricula. Dr. Owen notes some of the challenges indigenous students face: They are in a crowd that is primarily non-Native, far from their own family and community; unlike White students, they usually do not have mentors; they may not have the wherewithal to continue school and graduate.

A 2022 study of the association of sociodemographic characteristics with US medical student attrition, published in JAMA Internal Medicine, found that American Indian, Alaska Native, Native Hawaiian, and Pacific Islander students were more than 4 times as likely to drop out compared with White students. More than 10% of Indigenous medical students don’t graduate—the highest of any group the researchers examined.

In 1973 the University of North Dakota, for instance, launched Indians Into Medicine (INMED), a program that has since recruited, supported, and trained 250 American Indian doctors, and, in 2019, the country’s first PhD program in indigenous health. Dr. Warne, the director of INMED, calls it “by far, the most successful indigenous medical training program in the world,” having helped 228 American Indians and Alaska Natives graduate since its inception. A new cohort of 6 students has just enrolled.

Oregon Health & Science University (OHSU) received $800,000 in federal funding for its Future Leaders in Indigenous Health (FLIGHT) project, managed through OHSU’s Northwest Native American Center of Excellence (NNACoE). In 2012, just 8 Native students were enrolled in the OHSU School of Medicine; a decade later, there were 29. In 2022, the newest medical class included 12 American Indian or Alaska Native students. According to the school, it is believed to be the largest group of Natives in any single US medical school MD class in history. The number of Native faculty in the OHSU School of Medicine grew from 7 in 2014 to 13 in 2022.

The Diagnosis: Cutaneous Sarcoidosis

A biopsy of a plaque on the back confirmed cutaneous sarcoidosis (CS). A chest radiograph demonstrated hilar nodes, and a referral was placed for comanagement with a pulmonologist. Histopathology was critical in making the diagnosis, with well-circumscribed noncaseating granulomas present in the dermis. The granulomas in CS often are described as naked, as there are minimal lymphocytes present and plasma cells normally are absent.¹ Because the lungs are the most common site of involvement, a chest radiograph is necessary to examine for systemic sarcoidosis. Laboratory workup is used to evaluate for lymphopenia, hypercalcemia, elevated blood sedimentation rate, and elevated angiotensin- converting enzyme levels, which are common in systemic sarcoidosis.¹

Sarcoidosis is a multisystemic granulomatous disorder with an unknown etiology. It is believed to develop in genetically predisposed individuals as a reaction to unidentified antigens in the environment.¹ Helper T cells (T_H1) respond to these environmental antigens in those who are susceptible, which leads to the disease process, but paradoxically, even with the elevation of cellular immune activity at the sites of the granulomatous inflammation, the peripheral immune response in these patients is suppressed as shown by lymphopenia.²

Cutaneous sarcoidosis is found in approximately one-third of patients with systemic sarcoidosis but can occur without systemic involvement.^1,2 Sarcoidosis is reported worldwide and affects patients of all races and ethnicities, ages, and sexes but does have a higher prevalence among Black individuals in the United States, patients younger than 40 years (peak incidence, 20–29 years of age), and females.² In 80% of patients, CS occurs before systemic sarcoidosis develops, or they may develop simultaneously.¹

Cutaneous sarcoidosis has a wide range of clinical presentations that are classified as specific and nonspecific. Specific lesions in CS contain noncaseating granulomas while nonspecific lesions in CS appear as reactive processes.² The most common specific presentation of CS includes papules that are brown in pigmentation in lighter skin tones and red to violaceous in darker skin tones (Figure). The most common nonspecific skin manifestation is erythema nodosum, which represents a hypersensitivity reaction. Cutaneous sarcoidosis can appear as hypopigmented or hyperpigmented patches or plaques.¹

Treatments for CS vary based on the individual.¹ For milder and more localized cases, topical or intralesional steroids may be used. If systemic sarcoidosis is suspected or if there is diffuse involvement of the skin, systemic steroids, antimalarials (eg, hydroxychloroquine), low-dose methotrexate, minocycline, allopurinol, azathioprine, isotretinoin, tumor necrosis factor α inhibitors, or psoralen plus long-wave UVA radiation may be used. If systemic sarcoidosis is present, referral to a pulmonologist is recommended for co-management.¹

Cutaneous sarcoidosis is known as the “great imitator,” and there are multiple diseases to consider in the differential that are distinguished by the physical findings.¹ In our case of a middle-aged Black woman with indurated plaques, a few diagnoses to consider were psoriasis, discoid lupus erythematosus (DLE), mycosis fungoides (MF), and tinea infection.

Psoriasis is a common disease, and 90% of patients have chronic plaquelike disease with well-demarcated erythematous plaques that have a silver-gray scale and a positive Auspitz sign (also known as pinpoint bleeding).³ Plaques often are distributed on the trunk, limb extensors, and scalp, along with nail changes. Some patients also have joint pain, indicating psoriatic arthritis. The etiology of psoriasis is unknown, but it develops due to unrestrained keratinocyte proliferation and defective differentiation, which leads to histopathology showing regular acanthosis and papillary dermal ectasia with rouleaux. Mild cases typically are treated with topical steroids or vitamin D, while more severe cases are treated with methotrexate, cyclosporine, retinoids, or biologics.³

Discoid lupus erythematosus occurs 4 times more often in Black patients than in White patients. Clinically, DLE begins as well-defined, erythematous, scaly patches that expand with hyperpigmentation at the periphery and leave an atrophic, scarred, hypopigmented center.⁴ It typically is localized to the head and neck, but in cases where it disseminates elsewhere on the body, the risk for systemic lupus erythematosus increases from 1.2% to 28%.5 Histopathology of DLE shows vacuolar degeneration of the basal cell layer in the epidermis along with patchy lymphocytic infiltrate in the dermis. Treatments range from topical steroids for mild cases to antimalarial agents, retinoids, anti-inflammatory drugs, and calcineurin inhibitors for more severe cases.⁴

Although there are multiple types of cutaneous T-cell lymphoma, the most common is MF, which traditionally is nonaggressive. The typical patient with MF is older than 60 years and presents with indolent, ongoing, flat to minimally indurated patches or plaques that have cigarette paper scale. As MF progresses, some plaques grow into tumors and can become more aggressive. Histologically, MF changes based on its clinical stage, with the initial phase showing epidermotropic atypical lymphocytes and later phases showing less epitheliotropic, larger, atypical lymphocytes. The treatment algorithm varies depending on cutaneous T-cell lymphoma staging.⁶

Tinea infections are caused by dermatophytes. In prepubertal children, they predominantly appear as tinea corporis (on the body) or tinea capitis (on the scalp), but in adults they appear as tinea cruris (on the groin), tinea pedis (on the feet), or tinea unguium (on the nails).⁷ Tinea infections classically are known to appear as an annular patch with an active erythematous scaling border and central clearing. The patches can be pruritic. Potassium hydroxide preparation of a skin scraping is a quick test to use in the office; if the results are inconclusive, a culture may be required. Treatment depends on the location of the infection but typically involves either topical or oral antifungal agents.⁷

The Diagnosis: Cutaneous Sarcoidosis

A biopsy of a plaque on the back confirmed cutaneous sarcoidosis (CS). A chest radiograph demonstrated hilar nodes, and a referral was placed for comanagement with a pulmonologist. Histopathology was critical in making the diagnosis, with well-circumscribed noncaseating granulomas present in the dermis. The granulomas in CS often are described as naked, as there are minimal lymphocytes present and plasma cells normally are absent.¹ Because the lungs are the most common site of involvement, a chest radiograph is necessary to examine for systemic sarcoidosis. Laboratory workup is used to evaluate for lymphopenia, hypercalcemia, elevated blood sedimentation rate, and elevated angiotensin- converting enzyme levels, which are common in systemic sarcoidosis.¹

Sarcoidosis is a multisystemic granulomatous disorder with an unknown etiology. It is believed to develop in genetically predisposed individuals as a reaction to unidentified antigens in the environment.¹ Helper T cells (T_H1) respond to these environmental antigens in those who are susceptible, which leads to the disease process, but paradoxically, even with the elevation of cellular immune activity at the sites of the granulomatous inflammation, the peripheral immune response in these patients is suppressed as shown by lymphopenia.²

Cutaneous sarcoidosis is found in approximately one-third of patients with systemic sarcoidosis but can occur without systemic involvement.^1,2 Sarcoidosis is reported worldwide and affects patients of all races and ethnicities, ages, and sexes but does have a higher prevalence among Black individuals in the United States, patients younger than 40 years (peak incidence, 20–29 years of age), and females.² In 80% of patients, CS occurs before systemic sarcoidosis develops, or they may develop simultaneously.¹

Cutaneous sarcoidosis has a wide range of clinical presentations that are classified as specific and nonspecific. Specific lesions in CS contain noncaseating granulomas while nonspecific lesions in CS appear as reactive processes.² The most common specific presentation of CS includes papules that are brown in pigmentation in lighter skin tones and red to violaceous in darker skin tones (Figure). The most common nonspecific skin manifestation is erythema nodosum, which represents a hypersensitivity reaction. Cutaneous sarcoidosis can appear as hypopigmented or hyperpigmented patches or plaques.¹

Treatments for CS vary based on the individual.¹ For milder and more localized cases, topical or intralesional steroids may be used. If systemic sarcoidosis is suspected or if there is diffuse involvement of the skin, systemic steroids, antimalarials (eg, hydroxychloroquine), low-dose methotrexate, minocycline, allopurinol, azathioprine, isotretinoin, tumor necrosis factor α inhibitors, or psoralen plus long-wave UVA radiation may be used. If systemic sarcoidosis is present, referral to a pulmonologist is recommended for co-management.¹

Cutaneous sarcoidosis is known as the “great imitator,” and there are multiple diseases to consider in the differential that are distinguished by the physical findings.¹ In our case of a middle-aged Black woman with indurated plaques, a few diagnoses to consider were psoriasis, discoid lupus erythematosus (DLE), mycosis fungoides (MF), and tinea infection.

Psoriasis is a common disease, and 90% of patients have chronic plaquelike disease with well-demarcated erythematous plaques that have a silver-gray scale and a positive Auspitz sign (also known as pinpoint bleeding).³ Plaques often are distributed on the trunk, limb extensors, and scalp, along with nail changes. Some patients also have joint pain, indicating psoriatic arthritis. The etiology of psoriasis is unknown, but it develops due to unrestrained keratinocyte proliferation and defective differentiation, which leads to histopathology showing regular acanthosis and papillary dermal ectasia with rouleaux. Mild cases typically are treated with topical steroids or vitamin D, while more severe cases are treated with methotrexate, cyclosporine, retinoids, or biologics.³

Discoid lupus erythematosus occurs 4 times more often in Black patients than in White patients. Clinically, DLE begins as well-defined, erythematous, scaly patches that expand with hyperpigmentation at the periphery and leave an atrophic, scarred, hypopigmented center.⁴ It typically is localized to the head and neck, but in cases where it disseminates elsewhere on the body, the risk for systemic lupus erythematosus increases from 1.2% to 28%.5 Histopathology of DLE shows vacuolar degeneration of the basal cell layer in the epidermis along with patchy lymphocytic infiltrate in the dermis. Treatments range from topical steroids for mild cases to antimalarial agents, retinoids, anti-inflammatory drugs, and calcineurin inhibitors for more severe cases.⁴

Although there are multiple types of cutaneous T-cell lymphoma, the most common is MF, which traditionally is nonaggressive. The typical patient with MF is older than 60 years and presents with indolent, ongoing, flat to minimally indurated patches or plaques that have cigarette paper scale. As MF progresses, some plaques grow into tumors and can become more aggressive. Histologically, MF changes based on its clinical stage, with the initial phase showing epidermotropic atypical lymphocytes and later phases showing less epitheliotropic, larger, atypical lymphocytes. The treatment algorithm varies depending on cutaneous T-cell lymphoma staging.⁶

Tinea infections are caused by dermatophytes. In prepubertal children, they predominantly appear as tinea corporis (on the body) or tinea capitis (on the scalp), but in adults they appear as tinea cruris (on the groin), tinea pedis (on the feet), or tinea unguium (on the nails).⁷ Tinea infections classically are known to appear as an annular patch with an active erythematous scaling border and central clearing. The patches can be pruritic. Potassium hydroxide preparation of a skin scraping is a quick test to use in the office; if the results are inconclusive, a culture may be required. Treatment depends on the location of the infection but typically involves either topical or oral antifungal agents.⁷

The Diagnosis: Cutaneous Sarcoidosis

A biopsy of a plaque on the back confirmed cutaneous sarcoidosis (CS). A chest radiograph demonstrated hilar nodes, and a referral was placed for comanagement with a pulmonologist. Histopathology was critical in making the diagnosis, with well-circumscribed noncaseating granulomas present in the dermis. The granulomas in CS often are described as naked, as there are minimal lymphocytes present and plasma cells normally are absent.¹ Because the lungs are the most common site of involvement, a chest radiograph is necessary to examine for systemic sarcoidosis. Laboratory workup is used to evaluate for lymphopenia, hypercalcemia, elevated blood sedimentation rate, and elevated angiotensin- converting enzyme levels, which are common in systemic sarcoidosis.¹

Sarcoidosis is a multisystemic granulomatous disorder with an unknown etiology. It is believed to develop in genetically predisposed individuals as a reaction to unidentified antigens in the environment.¹ Helper T cells (T_H1) respond to these environmental antigens in those who are susceptible, which leads to the disease process, but paradoxically, even with the elevation of cellular immune activity at the sites of the granulomatous inflammation, the peripheral immune response in these patients is suppressed as shown by lymphopenia.²

Cutaneous sarcoidosis is found in approximately one-third of patients with systemic sarcoidosis but can occur without systemic involvement.^1,2 Sarcoidosis is reported worldwide and affects patients of all races and ethnicities, ages, and sexes but does have a higher prevalence among Black individuals in the United States, patients younger than 40 years (peak incidence, 20–29 years of age), and females.² In 80% of patients, CS occurs before systemic sarcoidosis develops, or they may develop simultaneously.¹

Cutaneous sarcoidosis has a wide range of clinical presentations that are classified as specific and nonspecific. Specific lesions in CS contain noncaseating granulomas while nonspecific lesions in CS appear as reactive processes.² The most common specific presentation of CS includes papules that are brown in pigmentation in lighter skin tones and red to violaceous in darker skin tones (Figure). The most common nonspecific skin manifestation is erythema nodosum, which represents a hypersensitivity reaction. Cutaneous sarcoidosis can appear as hypopigmented or hyperpigmented patches or plaques.¹

Treatments for CS vary based on the individual.¹ For milder and more localized cases, topical or intralesional steroids may be used. If systemic sarcoidosis is suspected or if there is diffuse involvement of the skin, systemic steroids, antimalarials (eg, hydroxychloroquine), low-dose methotrexate, minocycline, allopurinol, azathioprine, isotretinoin, tumor necrosis factor α inhibitors, or psoralen plus long-wave UVA radiation may be used. If systemic sarcoidosis is present, referral to a pulmonologist is recommended for co-management.¹

Cutaneous sarcoidosis is known as the “great imitator,” and there are multiple diseases to consider in the differential that are distinguished by the physical findings.¹ In our case of a middle-aged Black woman with indurated plaques, a few diagnoses to consider were psoriasis, discoid lupus erythematosus (DLE), mycosis fungoides (MF), and tinea infection.

Psoriasis is a common disease, and 90% of patients have chronic plaquelike disease with well-demarcated erythematous plaques that have a silver-gray scale and a positive Auspitz sign (also known as pinpoint bleeding).³ Plaques often are distributed on the trunk, limb extensors, and scalp, along with nail changes. Some patients also have joint pain, indicating psoriatic arthritis. The etiology of psoriasis is unknown, but it develops due to unrestrained keratinocyte proliferation and defective differentiation, which leads to histopathology showing regular acanthosis and papillary dermal ectasia with rouleaux. Mild cases typically are treated with topical steroids or vitamin D, while more severe cases are treated with methotrexate, cyclosporine, retinoids, or biologics.³

Discoid lupus erythematosus occurs 4 times more often in Black patients than in White patients. Clinically, DLE begins as well-defined, erythematous, scaly patches that expand with hyperpigmentation at the periphery and leave an atrophic, scarred, hypopigmented center.⁴ It typically is localized to the head and neck, but in cases where it disseminates elsewhere on the body, the risk for systemic lupus erythematosus increases from 1.2% to 28%.5 Histopathology of DLE shows vacuolar degeneration of the basal cell layer in the epidermis along with patchy lymphocytic infiltrate in the dermis. Treatments range from topical steroids for mild cases to antimalarial agents, retinoids, anti-inflammatory drugs, and calcineurin inhibitors for more severe cases.⁴

Although there are multiple types of cutaneous T-cell lymphoma, the most common is MF, which traditionally is nonaggressive. The typical patient with MF is older than 60 years and presents with indolent, ongoing, flat to minimally indurated patches or plaques that have cigarette paper scale. As MF progresses, some plaques grow into tumors and can become more aggressive. Histologically, MF changes based on its clinical stage, with the initial phase showing epidermotropic atypical lymphocytes and later phases showing less epitheliotropic, larger, atypical lymphocytes. The treatment algorithm varies depending on cutaneous T-cell lymphoma staging.⁶

Tinea infections are caused by dermatophytes. In prepubertal children, they predominantly appear as tinea corporis (on the body) or tinea capitis (on the scalp), but in adults they appear as tinea cruris (on the groin), tinea pedis (on the feet), or tinea unguium (on the nails).⁷ Tinea infections classically are known to appear as an annular patch with an active erythematous scaling border and central clearing. The patches can be pruritic. Potassium hydroxide preparation of a skin scraping is a quick test to use in the office; if the results are inconclusive, a culture may be required. Treatment depends on the location of the infection but typically involves either topical or oral antifungal agents.⁷

Weight-loss drugs should be covered by Medicare and by other health insurance, according to a poll of US adults aged 50-80 years.

Among more than 2600 polled, 83% say that health insurance should cover prescription weight-loss drugs that have been approved by the US Food and Drug Administration (FDA), and 76% say Medicare should cover such drugs. However, only 30% would be willing to pay higher Medicare premiums to have these medications covered.

Among the 27% of respondents who say they are overweight, 63% are interested in taking such medications, as are 45% of those with diabetes, regardless of weight.

The University of Michigan (U-M) National Poll on Healthy Aging was  published online  on December 13, 2023.

High Awareness

The findings come at a time when injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs), such as Ozempic, Wegovy, Zepbound, and Mounjaro, are receiving a lot of public attention, the university noted.

Overall, 64% of survey respondents had heard of at least one prescription medication used for weight management. 

By brand name, 61% had heard of Ozempic, approved for the treatment of  type 2 diabetes  but prescribed off label for weight loss; 18% had heard of Wegovy; and 13% had heard of the anorexiant drug  phentermine .

Very few respondents (3% for each) had heard of the GLP-1 RA Saxenda, Qsymia (phentermine plus the anticonvulsant  topiramate ), and the opiate antagonist Contrave. 

Zepbound, the  obesity -specific form of the diabetes drug Mounjaro, received FDA approval after the poll was taken and was not included in survey questions.

Among respondents who had heard of at least one prescription medication used for weight management, 58% had heard about them through the news (eg, TV, magazines, newspapers) and 53% had heard about them from an advertisement on TV, the Internet, or radio. Only 11% heard about them from their healthcare providers.

Respondents more likely to be interested in taking a prescription medication for weight management included women, those aged 50-64 years, Black persons, Hispanic persons, those with household incomes of less than $60,000 annually, those with lower levels of education, those in fair or poor physical or mental health, and those with a health problem or disability limiting their daily activities.

Spotty Coverage

The GLP-1 RAs can cost more than $12,000 a year for people who pay out of pocket, the university noted. 

A  Medicare Part D law  passed in 2003 prohibits Medicare from covering medications for weight loss, although currently it can cover such drugs to help people with type 2 diabetes manage their weight. 

Medicaid covers the cost of antiobesity drugs in some states. 

Most private plans and the  Veterans Health Administration  cover them, but with restrictions due to high monthly costs for the newer medications.

The American Medical Association recently  called on insurers  to cover evidence-based weight-loss medications.

The strong demand for these medications, including for off-label purposes by people willing to pay full price, has created major shortages, the university noted. 

“As these medications grow in awareness and use, and insurers make decisions about coverage, it’s crucial for patients who have obesity or diabetes, or who are overweight with other health problems, to talk with their healthcare providers about their options,” said poll director Jeffrey Kullgren, MD, MPH, MS, a primary care physician at the VA Ann Arbor Healthcare System and associate professor of internal medicine at U-M.

Other weight-management strategies that respondents think should be covered by health insurance include sessions with a registered dietitian or nutritionist (85%);  weight-loss surgery  (73%); gym or fitness facility memberships (65%); apps or online programs to track diet, exercise, and/or behavior change (58%); and sessions with a personal trainer (53%).

The randomly selected nationally representative household survey of 2657 adults was conducted from July 17 to August 7, 2023, by NORC at the University of Chicago for the U-M Institute for Healthcare Policy and Innovation. The sample was subsequently weighted to reflect population figures from the US Census Bureau. The completion rate was 50% among those contacted to participate. The margin of error is ±1 to 5 percentage points for questions asked of the full sample and higher among subgroups.

The poll is based at the U-M Institute for Healthcare Policy and Innovation and supported by AARP and Michigan Medicine, the University of Michigan’s academic medical center.
 

A version of this article appeared on Medscape.com.

Weight-loss drugs should be covered by Medicare and by other health insurance, according to a poll of US adults aged 50-80 years.

Among more than 2600 polled, 83% say that health insurance should cover prescription weight-loss drugs that have been approved by the US Food and Drug Administration (FDA), and 76% say Medicare should cover such drugs. However, only 30% would be willing to pay higher Medicare premiums to have these medications covered.

Among the 27% of respondents who say they are overweight, 63% are interested in taking such medications, as are 45% of those with diabetes, regardless of weight.

The University of Michigan (U-M) National Poll on Healthy Aging was  published online  on December 13, 2023.

High Awareness

The findings come at a time when injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs), such as Ozempic, Wegovy, Zepbound, and Mounjaro, are receiving a lot of public attention, the university noted.

Overall, 64% of survey respondents had heard of at least one prescription medication used for weight management. 

By brand name, 61% had heard of Ozempic, approved for the treatment of  type 2 diabetes  but prescribed off label for weight loss; 18% had heard of Wegovy; and 13% had heard of the anorexiant drug  phentermine .

Very few respondents (3% for each) had heard of the GLP-1 RA Saxenda, Qsymia (phentermine plus the anticonvulsant  topiramate ), and the opiate antagonist Contrave. 

Zepbound, the  obesity -specific form of the diabetes drug Mounjaro, received FDA approval after the poll was taken and was not included in survey questions.

Among respondents who had heard of at least one prescription medication used for weight management, 58% had heard about them through the news (eg, TV, magazines, newspapers) and 53% had heard about them from an advertisement on TV, the Internet, or radio. Only 11% heard about them from their healthcare providers.

Respondents more likely to be interested in taking a prescription medication for weight management included women, those aged 50-64 years, Black persons, Hispanic persons, those with household incomes of less than $60,000 annually, those with lower levels of education, those in fair or poor physical or mental health, and those with a health problem or disability limiting their daily activities.

Spotty Coverage

The GLP-1 RAs can cost more than $12,000 a year for people who pay out of pocket, the university noted. 

A  Medicare Part D law  passed in 2003 prohibits Medicare from covering medications for weight loss, although currently it can cover such drugs to help people with type 2 diabetes manage their weight. 

Medicaid covers the cost of antiobesity drugs in some states. 

Most private plans and the  Veterans Health Administration  cover them, but with restrictions due to high monthly costs for the newer medications.

The American Medical Association recently  called on insurers  to cover evidence-based weight-loss medications.

The strong demand for these medications, including for off-label purposes by people willing to pay full price, has created major shortages, the university noted. 

“As these medications grow in awareness and use, and insurers make decisions about coverage, it’s crucial for patients who have obesity or diabetes, or who are overweight with other health problems, to talk with their healthcare providers about their options,” said poll director Jeffrey Kullgren, MD, MPH, MS, a primary care physician at the VA Ann Arbor Healthcare System and associate professor of internal medicine at U-M.

Other weight-management strategies that respondents think should be covered by health insurance include sessions with a registered dietitian or nutritionist (85%);  weight-loss surgery  (73%); gym or fitness facility memberships (65%); apps or online programs to track diet, exercise, and/or behavior change (58%); and sessions with a personal trainer (53%).

The randomly selected nationally representative household survey of 2657 adults was conducted from July 17 to August 7, 2023, by NORC at the University of Chicago for the U-M Institute for Healthcare Policy and Innovation. The sample was subsequently weighted to reflect population figures from the US Census Bureau. The completion rate was 50% among those contacted to participate. The margin of error is ±1 to 5 percentage points for questions asked of the full sample and higher among subgroups.

The poll is based at the U-M Institute for Healthcare Policy and Innovation and supported by AARP and Michigan Medicine, the University of Michigan’s academic medical center.
 

A version of this article appeared on Medscape.com.

Weight-loss drugs should be covered by Medicare and by other health insurance, according to a poll of US adults aged 50-80 years.

Among more than 2600 polled, 83% say that health insurance should cover prescription weight-loss drugs that have been approved by the US Food and Drug Administration (FDA), and 76% say Medicare should cover such drugs. However, only 30% would be willing to pay higher Medicare premiums to have these medications covered.

Among the 27% of respondents who say they are overweight, 63% are interested in taking such medications, as are 45% of those with diabetes, regardless of weight.

The University of Michigan (U-M) National Poll on Healthy Aging was  published online  on December 13, 2023.

High Awareness

The findings come at a time when injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs), such as Ozempic, Wegovy, Zepbound, and Mounjaro, are receiving a lot of public attention, the university noted.

Overall, 64% of survey respondents had heard of at least one prescription medication used for weight management. 

By brand name, 61% had heard of Ozempic, approved for the treatment of  type 2 diabetes  but prescribed off label for weight loss; 18% had heard of Wegovy; and 13% had heard of the anorexiant drug  phentermine .

Very few respondents (3% for each) had heard of the GLP-1 RA Saxenda, Qsymia (phentermine plus the anticonvulsant  topiramate ), and the opiate antagonist Contrave. 

Zepbound, the  obesity -specific form of the diabetes drug Mounjaro, received FDA approval after the poll was taken and was not included in survey questions.

Among respondents who had heard of at least one prescription medication used for weight management, 58% had heard about them through the news (eg, TV, magazines, newspapers) and 53% had heard about them from an advertisement on TV, the Internet, or radio. Only 11% heard about them from their healthcare providers.

Respondents more likely to be interested in taking a prescription medication for weight management included women, those aged 50-64 years, Black persons, Hispanic persons, those with household incomes of less than $60,000 annually, those with lower levels of education, those in fair or poor physical or mental health, and those with a health problem or disability limiting their daily activities.

Spotty Coverage

The GLP-1 RAs can cost more than $12,000 a year for people who pay out of pocket, the university noted. 

A  Medicare Part D law  passed in 2003 prohibits Medicare from covering medications for weight loss, although currently it can cover such drugs to help people with type 2 diabetes manage their weight. 

Medicaid covers the cost of antiobesity drugs in some states. 

Most private plans and the  Veterans Health Administration  cover them, but with restrictions due to high monthly costs for the newer medications.

The American Medical Association recently  called on insurers  to cover evidence-based weight-loss medications.

The strong demand for these medications, including for off-label purposes by people willing to pay full price, has created major shortages, the university noted. 

“As these medications grow in awareness and use, and insurers make decisions about coverage, it’s crucial for patients who have obesity or diabetes, or who are overweight with other health problems, to talk with their healthcare providers about their options,” said poll director Jeffrey Kullgren, MD, MPH, MS, a primary care physician at the VA Ann Arbor Healthcare System and associate professor of internal medicine at U-M.

Other weight-management strategies that respondents think should be covered by health insurance include sessions with a registered dietitian or nutritionist (85%);  weight-loss surgery  (73%); gym or fitness facility memberships (65%); apps or online programs to track diet, exercise, and/or behavior change (58%); and sessions with a personal trainer (53%).

The randomly selected nationally representative household survey of 2657 adults was conducted from July 17 to August 7, 2023, by NORC at the University of Chicago for the U-M Institute for Healthcare Policy and Innovation. The sample was subsequently weighted to reflect population figures from the US Census Bureau. The completion rate was 50% among those contacted to participate. The margin of error is ±1 to 5 percentage points for questions asked of the full sample and higher among subgroups.

The poll is based at the U-M Institute for Healthcare Policy and Innovation and supported by AARP and Michigan Medicine, the University of Michigan’s academic medical center.
 

A version of this article appeared on Medscape.com.

You’re familiar with DIY and DUI, but what associations do the initials DEI trigger in your thought processor? Your college is probably influenced by it. So is your medical school, as are many of the businesses whose advertisements bombard you on television and the internet. Your professional association is definitely involved with it.

In the words of one newspaper columnist, DEI is an “ideological framework” whose most recognizable buzz words are “diversity,” “equity,” and “inclusion.” In the case of the American Academy of Pediatrics (AAP), DEI has taken the form of a hiring philosophy that accepts and respects its responsibility to create a workplace “where each person can fully contribute to the shared mission without discrimination or intimidation and each person is respected, supported, and provided the equal opportunity, regardless of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity, or expression age, veteran status, immigration status, or disability.”.

As an organization representing its members, the AAP has issued a statement: “Celebrating the diversity of children and families and promoting nurturing, inclusive environments means actively opposing intolerance, bigotry, bias and discrimination” Further, the AAP says it is committed to using policy, advocacy, and education to encourage inclusivity and cultural effectiveness for all.”. Included in its recommendations to fulfill this commitment are efforts to diversify the pediatric workforce and eliminate race-based medicine.

For the AAP, its commitment to diversity, equity, and inclusion seems to be a good fit. The first line of its mission statement — “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” — is well focused and one that its members can agree upon. However, we are beginning to see and hear that on some college and university campuses DEI has worn out its welcome.

In academia, the decision to include a broad mix of students and faculty with diverse backgrounds and at the same time provide opportunities equitably has hit some serious bumps in the road. It’s unclear how much the chaos in the Middle East is to blame, However, for several years there have been unfortunate campus incidents when the invitation of controversial guest speakers has laid bare the widely different interpretations of exactly what “free speech” means.

From its hazy inception, DEI has been missing one key ingredient — commonality. If we are going to actively seek to include individuals from a variety of backgrounds, encourage them to celebrate their diversity, and offer them equitable opportunities, then at the same time we must make it clear that our overriding goal is to seek and encourage the civil discussion of what we all have in common. Neglecting this additional step of promoting commonality is a grave mistake.

One mustn’t be surprised that a group of individuals from diverse backgrounds will have differing opinions. Finding common ground will predictably be a challenge, but it can be done. It requires compromise and a commitment to civil discussion. Regrettably, DEI as a framework places so much emphasis on the individual and diversity that the critical concept of commonality has been lost. Ironically, true inclusion and equity can’t occur without a reverence for commonality.

The AAP has done a good job of folding DEI into fulfilling the first sentence of its mission statement. However, it must not lose sight of the critical ingredient of commonality as it seeks to “support the professional needs of its members” (the second sentence of its mission). Despite a general agreement on the goal of providing care for all children, there are differences of opinion among its members when it comes to some of the details. The confusing topic of gender-affirmative care comes to mind. I am confident that as a group of thoughtful professionals, even in the face of wide differences, we can see the way to civil and productive discussions in the search for commonality.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You’re familiar with DIY and DUI, but what associations do the initials DEI trigger in your thought processor? Your college is probably influenced by it. So is your medical school, as are many of the businesses whose advertisements bombard you on television and the internet. Your professional association is definitely involved with it.

In the words of one newspaper columnist, DEI is an “ideological framework” whose most recognizable buzz words are “diversity,” “equity,” and “inclusion.” In the case of the American Academy of Pediatrics (AAP), DEI has taken the form of a hiring philosophy that accepts and respects its responsibility to create a workplace “where each person can fully contribute to the shared mission without discrimination or intimidation and each person is respected, supported, and provided the equal opportunity, regardless of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity, or expression age, veteran status, immigration status, or disability.”.

As an organization representing its members, the AAP has issued a statement: “Celebrating the diversity of children and families and promoting nurturing, inclusive environments means actively opposing intolerance, bigotry, bias and discrimination” Further, the AAP says it is committed to using policy, advocacy, and education to encourage inclusivity and cultural effectiveness for all.”. Included in its recommendations to fulfill this commitment are efforts to diversify the pediatric workforce and eliminate race-based medicine.

For the AAP, its commitment to diversity, equity, and inclusion seems to be a good fit. The first line of its mission statement — “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” — is well focused and one that its members can agree upon. However, we are beginning to see and hear that on some college and university campuses DEI has worn out its welcome.

In academia, the decision to include a broad mix of students and faculty with diverse backgrounds and at the same time provide opportunities equitably has hit some serious bumps in the road. It’s unclear how much the chaos in the Middle East is to blame, However, for several years there have been unfortunate campus incidents when the invitation of controversial guest speakers has laid bare the widely different interpretations of exactly what “free speech” means.

From its hazy inception, DEI has been missing one key ingredient — commonality. If we are going to actively seek to include individuals from a variety of backgrounds, encourage them to celebrate their diversity, and offer them equitable opportunities, then at the same time we must make it clear that our overriding goal is to seek and encourage the civil discussion of what we all have in common. Neglecting this additional step of promoting commonality is a grave mistake.

One mustn’t be surprised that a group of individuals from diverse backgrounds will have differing opinions. Finding common ground will predictably be a challenge, but it can be done. It requires compromise and a commitment to civil discussion. Regrettably, DEI as a framework places so much emphasis on the individual and diversity that the critical concept of commonality has been lost. Ironically, true inclusion and equity can’t occur without a reverence for commonality.

The AAP has done a good job of folding DEI into fulfilling the first sentence of its mission statement. However, it must not lose sight of the critical ingredient of commonality as it seeks to “support the professional needs of its members” (the second sentence of its mission). Despite a general agreement on the goal of providing care for all children, there are differences of opinion among its members when it comes to some of the details. The confusing topic of gender-affirmative care comes to mind. I am confident that as a group of thoughtful professionals, even in the face of wide differences, we can see the way to civil and productive discussions in the search for commonality.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

You’re familiar with DIY and DUI, but what associations do the initials DEI trigger in your thought processor? Your college is probably influenced by it. So is your medical school, as are many of the businesses whose advertisements bombard you on television and the internet. Your professional association is definitely involved with it.

In the words of one newspaper columnist, DEI is an “ideological framework” whose most recognizable buzz words are “diversity,” “equity,” and “inclusion.” In the case of the American Academy of Pediatrics (AAP), DEI has taken the form of a hiring philosophy that accepts and respects its responsibility to create a workplace “where each person can fully contribute to the shared mission without discrimination or intimidation and each person is respected, supported, and provided the equal opportunity, regardless of race, ethnicity, ancestry, national origin, religion, gender, marital status, sexual orientation, gender identity, or expression age, veteran status, immigration status, or disability.”.

As an organization representing its members, the AAP has issued a statement: “Celebrating the diversity of children and families and promoting nurturing, inclusive environments means actively opposing intolerance, bigotry, bias and discrimination” Further, the AAP says it is committed to using policy, advocacy, and education to encourage inclusivity and cultural effectiveness for all.”. Included in its recommendations to fulfill this commitment are efforts to diversify the pediatric workforce and eliminate race-based medicine.

For the AAP, its commitment to diversity, equity, and inclusion seems to be a good fit. The first line of its mission statement — “to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults” — is well focused and one that its members can agree upon. However, we are beginning to see and hear that on some college and university campuses DEI has worn out its welcome.

In academia, the decision to include a broad mix of students and faculty with diverse backgrounds and at the same time provide opportunities equitably has hit some serious bumps in the road. It’s unclear how much the chaos in the Middle East is to blame, However, for several years there have been unfortunate campus incidents when the invitation of controversial guest speakers has laid bare the widely different interpretations of exactly what “free speech” means.

From its hazy inception, DEI has been missing one key ingredient — commonality. If we are going to actively seek to include individuals from a variety of backgrounds, encourage them to celebrate their diversity, and offer them equitable opportunities, then at the same time we must make it clear that our overriding goal is to seek and encourage the civil discussion of what we all have in common. Neglecting this additional step of promoting commonality is a grave mistake.

One mustn’t be surprised that a group of individuals from diverse backgrounds will have differing opinions. Finding common ground will predictably be a challenge, but it can be done. It requires compromise and a commitment to civil discussion. Regrettably, DEI as a framework places so much emphasis on the individual and diversity that the critical concept of commonality has been lost. Ironically, true inclusion and equity can’t occur without a reverence for commonality.

The AAP has done a good job of folding DEI into fulfilling the first sentence of its mission statement. However, it must not lose sight of the critical ingredient of commonality as it seeks to “support the professional needs of its members” (the second sentence of its mission). Despite a general agreement on the goal of providing care for all children, there are differences of opinion among its members when it comes to some of the details. The confusing topic of gender-affirmative care comes to mind. I am confident that as a group of thoughtful professionals, even in the face of wide differences, we can see the way to civil and productive discussions in the search for commonality.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

As medical students, we often assume we are exempt from the diagnoses we learn about. During the first 2 years of medical school, we learn about alopecia as a condition that may be associated with stress, hormonal imbalances, nutrient deficiencies, and aging. However, our curricula do not explore the subtypes, psychosocial impact, or even the overwhelming number of Black women who are disproportionately affected by alopecia. For Black women, hair is a colossal part of their cultural identity, learning from a young age how to nurture and style natural coils. It becomes devastating when women begin to lose them. 

The diagnosis of alopecia subtypes in Black women has been explored in the literature; however, understanding the unique experiences of young Black women is an important part of patient care, as alopecia often is destructive to the patient’s self-image. Therefore, it is important to shed light on these experiences so others feel empowered and supported in their journeys. Herein, we share the experiences of 2 authors (J.D. and C.A.V.O.)—both young Black women—who navigated unexpected hair loss in medical school.

Jewell’s Story

During my first year of medical school, I noticed my hair was shedding more than usual, and my ponytail was not as thick as it once was. I also had an area in my crown that was abnormally thin. My parents suggested that it was a consequence of stress, but I knew something was not right. With only 1 Black dermatologist within 2 hours of Nashville, Tennessee, I remember worrying about seeing a dermatologist who did not understand Black hair. I still scheduled an appointment, but I remember debating if I should straighten my hair or wear my naturally curly Afro. The first dermatologist I saw diagnosed me with seborrheic dermatitis—without even examining my scalp. She told me that I had a “full head of hair” and that I had nothing to worry about. I was unconvinced. Weeks later, I met with another dermatologist who took the time to listen to my concerns. After a scalp biopsy and laboratory work, she diagnosed me with telogen effluvium and androgenetic alopecia. Months later, I had the opportunity to visit the Black dermatologist, and she diagnosed me with central centrifugal cicatricial alopecia. I am grateful for the earlier dermatologists I saw, but I finally feel at ease with my diagnosis and treatment plan after being seen by the latter.

Chidubem’s Story 

From a young age, I was conditioned to think my hair was thick, unmanageable, and a nuisance. I grew accustomed to people yanking on my hair, and my gentle whispers of “this hurts” and “the braid is too tight” being ignored. That continued into adulthood. While studying for the US Medical Licensing Examination, I noticed a burning sensation on my scalp. I decided to ignore it. However, as the days progressed, the slight burning sensation turned into intense burning and itching. I still ignored it. Not only did I lack the funds for a dermatology appointment, but my licensing examination was approaching, and it was more important than anything related to my hair. After the examination, I eventually made an appointment with my primary care physician, who attributed my symptoms to the stressors of medical school. “I think you are having migraines,” she told me. So, I continued to ignore my symptoms. A year passed, and a hair braider pointed out that I had 2 well-defined bald patches on my scalp. I remember feeling angry and confused as to how I missed those findings. I could no longer ignore it—it bothered me less when no one else knew about it. I quickly made a dermatology appointment. Although I opted out of a biopsy, we decided to treat my hair loss empirically, and I have experienced drastic improvement.

Final Thoughts

We are 2 Black women living more than 500 miles away from each other at different medical institutions, yet we share the same experience, which many other women unfortunately face alone. It is not uncommon for us to feel unheard, dismissed, or misdiagnosed. We write this for the Black woman sorting through the feelings of confusion and shock as she traces the hairless spot on her scalp. We write this for the medical student ignoring their symptoms until after their examination. We even write this for any nondermatologists uncomfortable with diagnosing and treating textured hair. To improve patient satisfaction and overall health outcomes, physicians must approach patients with both knowledge and cultural competency. Most importantly, dermatologists (and other physicians) should be appropriately trained in not only the structural differences of textured hair but also the unique practices and beliefs among Black women in relation to their hair.

Acknowledgments—Jewell Dinkins is the inaugural recipient of the Janssen–Skin of Color Research Fellowship at Howard University (Washington, DC), and Chidubem A.V. Okeke is the inaugural recipient of the Women’s Dermatologic Society–La Roche-Posay dermatology fellowship at Howard University.

As medical students, we often assume we are exempt from the diagnoses we learn about. During the first 2 years of medical school, we learn about alopecia as a condition that may be associated with stress, hormonal imbalances, nutrient deficiencies, and aging. However, our curricula do not explore the subtypes, psychosocial impact, or even the overwhelming number of Black women who are disproportionately affected by alopecia. For Black women, hair is a colossal part of their cultural identity, learning from a young age how to nurture and style natural coils. It becomes devastating when women begin to lose them. 

The diagnosis of alopecia subtypes in Black women has been explored in the literature; however, understanding the unique experiences of young Black women is an important part of patient care, as alopecia often is destructive to the patient’s self-image. Therefore, it is important to shed light on these experiences so others feel empowered and supported in their journeys. Herein, we share the experiences of 2 authors (J.D. and C.A.V.O.)—both young Black women—who navigated unexpected hair loss in medical school.

Jewell’s Story

During my first year of medical school, I noticed my hair was shedding more than usual, and my ponytail was not as thick as it once was. I also had an area in my crown that was abnormally thin. My parents suggested that it was a consequence of stress, but I knew something was not right. With only 1 Black dermatologist within 2 hours of Nashville, Tennessee, I remember worrying about seeing a dermatologist who did not understand Black hair. I still scheduled an appointment, but I remember debating if I should straighten my hair or wear my naturally curly Afro. The first dermatologist I saw diagnosed me with seborrheic dermatitis—without even examining my scalp. She told me that I had a “full head of hair” and that I had nothing to worry about. I was unconvinced. Weeks later, I met with another dermatologist who took the time to listen to my concerns. After a scalp biopsy and laboratory work, she diagnosed me with telogen effluvium and androgenetic alopecia. Months later, I had the opportunity to visit the Black dermatologist, and she diagnosed me with central centrifugal cicatricial alopecia. I am grateful for the earlier dermatologists I saw, but I finally feel at ease with my diagnosis and treatment plan after being seen by the latter.

Chidubem’s Story 

From a young age, I was conditioned to think my hair was thick, unmanageable, and a nuisance. I grew accustomed to people yanking on my hair, and my gentle whispers of “this hurts” and “the braid is too tight” being ignored. That continued into adulthood. While studying for the US Medical Licensing Examination, I noticed a burning sensation on my scalp. I decided to ignore it. However, as the days progressed, the slight burning sensation turned into intense burning and itching. I still ignored it. Not only did I lack the funds for a dermatology appointment, but my licensing examination was approaching, and it was more important than anything related to my hair. After the examination, I eventually made an appointment with my primary care physician, who attributed my symptoms to the stressors of medical school. “I think you are having migraines,” she told me. So, I continued to ignore my symptoms. A year passed, and a hair braider pointed out that I had 2 well-defined bald patches on my scalp. I remember feeling angry and confused as to how I missed those findings. I could no longer ignore it—it bothered me less when no one else knew about it. I quickly made a dermatology appointment. Although I opted out of a biopsy, we decided to treat my hair loss empirically, and I have experienced drastic improvement.

Final Thoughts

We are 2 Black women living more than 500 miles away from each other at different medical institutions, yet we share the same experience, which many other women unfortunately face alone. It is not uncommon for us to feel unheard, dismissed, or misdiagnosed. We write this for the Black woman sorting through the feelings of confusion and shock as she traces the hairless spot on her scalp. We write this for the medical student ignoring their symptoms until after their examination. We even write this for any nondermatologists uncomfortable with diagnosing and treating textured hair. To improve patient satisfaction and overall health outcomes, physicians must approach patients with both knowledge and cultural competency. Most importantly, dermatologists (and other physicians) should be appropriately trained in not only the structural differences of textured hair but also the unique practices and beliefs among Black women in relation to their hair.

Acknowledgments—Jewell Dinkins is the inaugural recipient of the Janssen–Skin of Color Research Fellowship at Howard University (Washington, DC), and Chidubem A.V. Okeke is the inaugural recipient of the Women’s Dermatologic Society–La Roche-Posay dermatology fellowship at Howard University.

As medical students, we often assume we are exempt from the diagnoses we learn about. During the first 2 years of medical school, we learn about alopecia as a condition that may be associated with stress, hormonal imbalances, nutrient deficiencies, and aging. However, our curricula do not explore the subtypes, psychosocial impact, or even the overwhelming number of Black women who are disproportionately affected by alopecia. For Black women, hair is a colossal part of their cultural identity, learning from a young age how to nurture and style natural coils. It becomes devastating when women begin to lose them. 

The diagnosis of alopecia subtypes in Black women has been explored in the literature; however, understanding the unique experiences of young Black women is an important part of patient care, as alopecia often is destructive to the patient’s self-image. Therefore, it is important to shed light on these experiences so others feel empowered and supported in their journeys. Herein, we share the experiences of 2 authors (J.D. and C.A.V.O.)—both young Black women—who navigated unexpected hair loss in medical school.

Jewell’s Story

During my first year of medical school, I noticed my hair was shedding more than usual, and my ponytail was not as thick as it once was. I also had an area in my crown that was abnormally thin. My parents suggested that it was a consequence of stress, but I knew something was not right. With only 1 Black dermatologist within 2 hours of Nashville, Tennessee, I remember worrying about seeing a dermatologist who did not understand Black hair. I still scheduled an appointment, but I remember debating if I should straighten my hair or wear my naturally curly Afro. The first dermatologist I saw diagnosed me with seborrheic dermatitis—without even examining my scalp. She told me that I had a “full head of hair” and that I had nothing to worry about. I was unconvinced. Weeks later, I met with another dermatologist who took the time to listen to my concerns. After a scalp biopsy and laboratory work, she diagnosed me with telogen effluvium and androgenetic alopecia. Months later, I had the opportunity to visit the Black dermatologist, and she diagnosed me with central centrifugal cicatricial alopecia. I am grateful for the earlier dermatologists I saw, but I finally feel at ease with my diagnosis and treatment plan after being seen by the latter.

Chidubem’s Story 

From a young age, I was conditioned to think my hair was thick, unmanageable, and a nuisance. I grew accustomed to people yanking on my hair, and my gentle whispers of “this hurts” and “the braid is too tight” being ignored. That continued into adulthood. While studying for the US Medical Licensing Examination, I noticed a burning sensation on my scalp. I decided to ignore it. However, as the days progressed, the slight burning sensation turned into intense burning and itching. I still ignored it. Not only did I lack the funds for a dermatology appointment, but my licensing examination was approaching, and it was more important than anything related to my hair. After the examination, I eventually made an appointment with my primary care physician, who attributed my symptoms to the stressors of medical school. “I think you are having migraines,” she told me. So, I continued to ignore my symptoms. A year passed, and a hair braider pointed out that I had 2 well-defined bald patches on my scalp. I remember feeling angry and confused as to how I missed those findings. I could no longer ignore it—it bothered me less when no one else knew about it. I quickly made a dermatology appointment. Although I opted out of a biopsy, we decided to treat my hair loss empirically, and I have experienced drastic improvement.

Final Thoughts

We are 2 Black women living more than 500 miles away from each other at different medical institutions, yet we share the same experience, which many other women unfortunately face alone. It is not uncommon for us to feel unheard, dismissed, or misdiagnosed. We write this for the Black woman sorting through the feelings of confusion and shock as she traces the hairless spot on her scalp. We write this for the medical student ignoring their symptoms until after their examination. We even write this for any nondermatologists uncomfortable with diagnosing and treating textured hair. To improve patient satisfaction and overall health outcomes, physicians must approach patients with both knowledge and cultural competency. Most importantly, dermatologists (and other physicians) should be appropriately trained in not only the structural differences of textured hair but also the unique practices and beliefs among Black women in relation to their hair.

Acknowledgments—Jewell Dinkins is the inaugural recipient of the Janssen–Skin of Color Research Fellowship at Howard University (Washington, DC), and Chidubem A.V. Okeke is the inaugural recipient of the Women’s Dermatologic Society–La Roche-Posay dermatology fellowship at Howard University.

TOPLINE:

Removing race and incorporating social determinants of health (SDOH) into the pooled cohort risk equations (PCEs) for predicting atherosclerotic cardiovascular disease (ASCVD) outcomes made no difference to patients’ risk scores.

METHODOLOGY:

• Primary prevention guidelines recommend using risk prediction algorithms to assess the 10-year ASCVD risk, with the currently recommended PCEs including race.
• Researchers evaluated the incremental value of revised risk prediction equations excluding race and introducing SDOH in 11,638 participants from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort.
• Participants were aged between 45 and 79 years, had no history of ASCVD, and were not taking statins.
• Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke.

TAKEAWAY:

• Risk prediction equations performed similarly in race- and sex-stratified PCEs (C-statistic [95% CI])
• Black female: 0.71 (0.68-0.75); Black male: 0.68 (0.64-0.73); White female: 0.77 (0.74-0.80); White male: 0.68 (0.65-0.71)
• Race-free sex-specific PCEs yielded similar discrimination as race- and sex-stratified PCEs (C-statistic [95% CI]):
• Black female: 0.71 (0.67-0.75); Black male: 0.68 (0.63-0.72); White female: 0.76 (0.73-0.80); White male: 0.68 (0.65-0.71)
• The addition of SDOH to race-free sex-specific PCEs did not improve model performance (C-statistic [95% CI]):
• Black female: 0.72 (0.68-0.76); Black male: 0.68 (0.64-0.72); White female: 0.77 (0.74-0.80); White male: 0.68 (0.65-0.71)

IN PRACTICE:

“The major takeaway is we need to rethink the idea of race in cardiovascular risk prediction,” lead author Arnab Ghosh, MD, assistant professor of medicine at Weill Cornell Medical College and a hospitalist at New York-Presbyterian/Weill Cornell Medical Center, said in a press release.

“It’s essential for clinicians and scientists to consider how to appropriately address the health effects of race as a social construct, which has contributed to health disparities in cardiovascular outcomes,” Dr. Ghosh added.

SOURCE:

The study led by Dr. Ghosh was published online on December 6, 2023, in JAMA Cardiology with an Editor’s Note.

LIMITATIONS:

The study required informed consent for inclusion, which may have led to selection bias.

The REGARDS cohort’s SDOH may not have captured all social and socioeconomic influences on ASCVD outcomes.

DISCLOSURES:

The research was funded by the National Institute of Neurological Disorders and Stroke and the National Institute on Aging of the National Institutes of Health, Department of Health and Human Services, and others. Some authors declared receiving funding, grants, or personal fees from various sources.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Removing race and incorporating social determinants of health (SDOH) into the pooled cohort risk equations (PCEs) for predicting atherosclerotic cardiovascular disease (ASCVD) outcomes made no difference to patients’ risk scores.

METHODOLOGY:

• Primary prevention guidelines recommend using risk prediction algorithms to assess the 10-year ASCVD risk, with the currently recommended PCEs including race.
• Researchers evaluated the incremental value of revised risk prediction equations excluding race and introducing SDOH in 11,638 participants from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort.
• Participants were aged between 45 and 79 years, had no history of ASCVD, and were not taking statins.
• Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke.

TAKEAWAY:

• Risk prediction equations performed similarly in race- and sex-stratified PCEs (C-statistic [95% CI])
• Black female: 0.71 (0.68-0.75); Black male: 0.68 (0.64-0.73); White female: 0.77 (0.74-0.80); White male: 0.68 (0.65-0.71)
• Race-free sex-specific PCEs yielded similar discrimination as race- and sex-stratified PCEs (C-statistic [95% CI]):
• Black female: 0.71 (0.67-0.75); Black male: 0.68 (0.63-0.72); White female: 0.76 (0.73-0.80); White male: 0.68 (0.65-0.71)
• The addition of SDOH to race-free sex-specific PCEs did not improve model performance (C-statistic [95% CI]):
• Black female: 0.72 (0.68-0.76); Black male: 0.68 (0.64-0.72); White female: 0.77 (0.74-0.80); White male: 0.68 (0.65-0.71)

IN PRACTICE:

“The major takeaway is we need to rethink the idea of race in cardiovascular risk prediction,” lead author Arnab Ghosh, MD, assistant professor of medicine at Weill Cornell Medical College and a hospitalist at New York-Presbyterian/Weill Cornell Medical Center, said in a press release.

“It’s essential for clinicians and scientists to consider how to appropriately address the health effects of race as a social construct, which has contributed to health disparities in cardiovascular outcomes,” Dr. Ghosh added.

SOURCE:

The study led by Dr. Ghosh was published online on December 6, 2023, in JAMA Cardiology with an Editor’s Note.

LIMITATIONS:

The study required informed consent for inclusion, which may have led to selection bias.

The REGARDS cohort’s SDOH may not have captured all social and socioeconomic influences on ASCVD outcomes.

DISCLOSURES:

The research was funded by the National Institute of Neurological Disorders and Stroke and the National Institute on Aging of the National Institutes of Health, Department of Health and Human Services, and others. Some authors declared receiving funding, grants, or personal fees from various sources.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Removing race and incorporating social determinants of health (SDOH) into the pooled cohort risk equations (PCEs) for predicting atherosclerotic cardiovascular disease (ASCVD) outcomes made no difference to patients’ risk scores.

METHODOLOGY:

• Primary prevention guidelines recommend using risk prediction algorithms to assess the 10-year ASCVD risk, with the currently recommended PCEs including race.
• Researchers evaluated the incremental value of revised risk prediction equations excluding race and introducing SDOH in 11,638 participants from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort.
• Participants were aged between 45 and 79 years, had no history of ASCVD, and were not taking statins.
• Participants were followed up to 10 years for incident ASCVD, including myocardial infarction, coronary heart disease death, and fatal and nonfatal stroke.

TAKEAWAY:

• Risk prediction equations performed similarly in race- and sex-stratified PCEs (C-statistic [95% CI])
• Black female: 0.71 (0.68-0.75); Black male: 0.68 (0.64-0.73); White female: 0.77 (0.74-0.80); White male: 0.68 (0.65-0.71)
• Race-free sex-specific PCEs yielded similar discrimination as race- and sex-stratified PCEs (C-statistic [95% CI]):
• Black female: 0.71 (0.67-0.75); Black male: 0.68 (0.63-0.72); White female: 0.76 (0.73-0.80); White male: 0.68 (0.65-0.71)
• The addition of SDOH to race-free sex-specific PCEs did not improve model performance (C-statistic [95% CI]):
• Black female: 0.72 (0.68-0.76); Black male: 0.68 (0.64-0.72); White female: 0.77 (0.74-0.80); White male: 0.68 (0.65-0.71)

IN PRACTICE:

“The major takeaway is we need to rethink the idea of race in cardiovascular risk prediction,” lead author Arnab Ghosh, MD, assistant professor of medicine at Weill Cornell Medical College and a hospitalist at New York-Presbyterian/Weill Cornell Medical Center, said in a press release.

“It’s essential for clinicians and scientists to consider how to appropriately address the health effects of race as a social construct, which has contributed to health disparities in cardiovascular outcomes,” Dr. Ghosh added.

SOURCE:

The study led by Dr. Ghosh was published online on December 6, 2023, in JAMA Cardiology with an Editor’s Note.

LIMITATIONS:

The study required informed consent for inclusion, which may have led to selection bias.

The REGARDS cohort’s SDOH may not have captured all social and socioeconomic influences on ASCVD outcomes.

DISCLOSURES:

The research was funded by the National Institute of Neurological Disorders and Stroke and the National Institute on Aging of the National Institutes of Health, Department of Health and Human Services, and others. Some authors declared receiving funding, grants, or personal fees from various sources.
 

A version of this article appeared on Medscape.com.

CHICAGO — Among women interested in aesthetic treatments, Hispanic/Latinx women are more concerned about submental fat and under-eye hollowing, which differed from the top concerns in White women, according to the results of a study that involved a survey of almost 4000 women.

To date, the aesthetic needs of Hispanic/Latinx patients, the second largest ethnic group in the United States, have been poorly understood. “Most [aesthetic] marketing materials are gauged toward Caucasian patients,” Sabrina Fabi, MD, a dermatologist and dermatologic cosmetic surgeon in San Diego, California, said at the annual meeting of the American Society for Dermatologic Surgery (ASDS), where she presented the study results.

In addition, Dr. Fabi noted that current studies of facial and body aesthetics are limited in terms of representation. “When we look at studies, they are more Fitzpatrick type IIs and IIIs,” she said. Addressing this gap, she and her colleagues conducted the large multicenter study to learn more about cosmetic concerns unique to Hispanic/Latinx women, across different ethnic groups, and how they may differ by age.

In the study, an online survey was administered to aesthetically-inclined adults across different demographic groups in the United States. Specifically, respondents were surveyed regarding 41 facial and 31 body characteristics, identifying those they found bothersome. Maximum difference scaling was used to generate their most and least bothersome characteristics in each respective category.

Of the 3974 women surveyed, 748 self-identified as Hispanic/Latinx and female. Most participants (86%) were born in the United States and were interested in aesthetic treatments (93%). The majority of patients identified as Generation X (42-57 years, 40.0%), followed by older Millennials (31-41 years, 33.0%), Generation Z/young Millennials (under 30 years, 16.7%), and Baby Boomers and older (over 57 years, 10.3%). Participants most commonly reported Fitzpatrick skin types III (24%) and IV (56%), and BMIs of 18.5 kg/m² to <25 kg/m² (42%) and 25 to <30 kg/m² (27%).

Among Hispanic/Latinx women, the top facial concerns were related to submental fat (36%) and under-eye hollowing (35%). This is in contrast to White counterparts, who tended to find wrinkles more bothersome, according to Dr. Fabi. Among Hispanic/Latinx women, the top body concerns were related to stubborn fat involving the stomach (50%), sides (44%), and bra or the back area (40%).

Despite the shared concern of stubborn body fat across age groups, facial concerns shifted from skin quality (50%) and under-eye issues (43%) in the younger generations to upper facial lines (52%) and jowls/sagging skin (57%) in the older generations.

Dr. Fabi stated that approximately 30% of the population she sees is Hispanic/Latinx, and the results of this study substantiate what she sees in her practice. “This magnifies the things we need to be talking to them more about specifically.” The findings from this survey may aid in the customization of treatment plans to better serve this population, she said.

The study was sponsored by Allergan Aesthetics, which participated in the trial design, research, analysis, data collection, interpretation of data, and the review and approval of the publication. Dr. Fabi and three other authors are speakers, consultants, and investigators for Allergan. Other authors are on the advisory board, or are employees of Abbvie, Allergan’s parent company, and may own stock.

CHICAGO — Among women interested in aesthetic treatments, Hispanic/Latinx women are more concerned about submental fat and under-eye hollowing, which differed from the top concerns in White women, according to the results of a study that involved a survey of almost 4000 women.

To date, the aesthetic needs of Hispanic/Latinx patients, the second largest ethnic group in the United States, have been poorly understood. “Most [aesthetic] marketing materials are gauged toward Caucasian patients,” Sabrina Fabi, MD, a dermatologist and dermatologic cosmetic surgeon in San Diego, California, said at the annual meeting of the American Society for Dermatologic Surgery (ASDS), where she presented the study results.

In addition, Dr. Fabi noted that current studies of facial and body aesthetics are limited in terms of representation. “When we look at studies, they are more Fitzpatrick type IIs and IIIs,” she said. Addressing this gap, she and her colleagues conducted the large multicenter study to learn more about cosmetic concerns unique to Hispanic/Latinx women, across different ethnic groups, and how they may differ by age.

In the study, an online survey was administered to aesthetically-inclined adults across different demographic groups in the United States. Specifically, respondents were surveyed regarding 41 facial and 31 body characteristics, identifying those they found bothersome. Maximum difference scaling was used to generate their most and least bothersome characteristics in each respective category.

Of the 3974 women surveyed, 748 self-identified as Hispanic/Latinx and female. Most participants (86%) were born in the United States and were interested in aesthetic treatments (93%). The majority of patients identified as Generation X (42-57 years, 40.0%), followed by older Millennials (31-41 years, 33.0%), Generation Z/young Millennials (under 30 years, 16.7%), and Baby Boomers and older (over 57 years, 10.3%). Participants most commonly reported Fitzpatrick skin types III (24%) and IV (56%), and BMIs of 18.5 kg/m² to <25 kg/m² (42%) and 25 to <30 kg/m² (27%).

Among Hispanic/Latinx women, the top facial concerns were related to submental fat (36%) and under-eye hollowing (35%). This is in contrast to White counterparts, who tended to find wrinkles more bothersome, according to Dr. Fabi. Among Hispanic/Latinx women, the top body concerns were related to stubborn fat involving the stomach (50%), sides (44%), and bra or the back area (40%).

Despite the shared concern of stubborn body fat across age groups, facial concerns shifted from skin quality (50%) and under-eye issues (43%) in the younger generations to upper facial lines (52%) and jowls/sagging skin (57%) in the older generations.

Dr. Fabi stated that approximately 30% of the population she sees is Hispanic/Latinx, and the results of this study substantiate what she sees in her practice. “This magnifies the things we need to be talking to them more about specifically.” The findings from this survey may aid in the customization of treatment plans to better serve this population, she said.

The study was sponsored by Allergan Aesthetics, which participated in the trial design, research, analysis, data collection, interpretation of data, and the review and approval of the publication. Dr. Fabi and three other authors are speakers, consultants, and investigators for Allergan. Other authors are on the advisory board, or are employees of Abbvie, Allergan’s parent company, and may own stock.

CHICAGO — Among women interested in aesthetic treatments, Hispanic/Latinx women are more concerned about submental fat and under-eye hollowing, which differed from the top concerns in White women, according to the results of a study that involved a survey of almost 4000 women.

To date, the aesthetic needs of Hispanic/Latinx patients, the second largest ethnic group in the United States, have been poorly understood. “Most [aesthetic] marketing materials are gauged toward Caucasian patients,” Sabrina Fabi, MD, a dermatologist and dermatologic cosmetic surgeon in San Diego, California, said at the annual meeting of the American Society for Dermatologic Surgery (ASDS), where she presented the study results.

In addition, Dr. Fabi noted that current studies of facial and body aesthetics are limited in terms of representation. “When we look at studies, they are more Fitzpatrick type IIs and IIIs,” she said. Addressing this gap, she and her colleagues conducted the large multicenter study to learn more about cosmetic concerns unique to Hispanic/Latinx women, across different ethnic groups, and how they may differ by age.

In the study, an online survey was administered to aesthetically-inclined adults across different demographic groups in the United States. Specifically, respondents were surveyed regarding 41 facial and 31 body characteristics, identifying those they found bothersome. Maximum difference scaling was used to generate their most and least bothersome characteristics in each respective category.

Of the 3974 women surveyed, 748 self-identified as Hispanic/Latinx and female. Most participants (86%) were born in the United States and were interested in aesthetic treatments (93%). The majority of patients identified as Generation X (42-57 years, 40.0%), followed by older Millennials (31-41 years, 33.0%), Generation Z/young Millennials (under 30 years, 16.7%), and Baby Boomers and older (over 57 years, 10.3%). Participants most commonly reported Fitzpatrick skin types III (24%) and IV (56%), and BMIs of 18.5 kg/m² to <25 kg/m² (42%) and 25 to <30 kg/m² (27%).

Among Hispanic/Latinx women, the top facial concerns were related to submental fat (36%) and under-eye hollowing (35%). This is in contrast to White counterparts, who tended to find wrinkles more bothersome, according to Dr. Fabi. Among Hispanic/Latinx women, the top body concerns were related to stubborn fat involving the stomach (50%), sides (44%), and bra or the back area (40%).

Despite the shared concern of stubborn body fat across age groups, facial concerns shifted from skin quality (50%) and under-eye issues (43%) in the younger generations to upper facial lines (52%) and jowls/sagging skin (57%) in the older generations.

Dr. Fabi stated that approximately 30% of the population she sees is Hispanic/Latinx, and the results of this study substantiate what she sees in her practice. “This magnifies the things we need to be talking to them more about specifically.” The findings from this survey may aid in the customization of treatment plans to better serve this population, she said.

The study was sponsored by Allergan Aesthetics, which participated in the trial design, research, analysis, data collection, interpretation of data, and the review and approval of the publication. Dr. Fabi and three other authors are speakers, consultants, and investigators for Allergan. Other authors are on the advisory board, or are employees of Abbvie, Allergan’s parent company, and may own stock.

Lebrikizumab, an investigational interleukin-13 inhibitor, showed significant efficacy compared with placebo across racial and ethnic subgroups in patients with moderate-to-severe atopic dermatitis.

The finding comes from an analysis of the 16-week induction periods of the phase 3 ADvocate1 and ADvocate2 trials, which Raj Chovatiya, MD, PhD, presented during a late-breaking abstract session at the Revolutionizing Atopic Dermatitis (RAD) Virtual Conference. The efficacy of lebrikizumab monotherapy to treat moderate-to-severe AD has been established in phase 3 studies, “but disease characteristic and efficacy outcomes may vary among racial and ethnic subgroups,” said Dr. Chovatiya, assistant professor in the department of dermatology at Northwestern University, Chicago. “The goal of the current study is to report the week 16 efficacy of lebrikizumab-treated patients in racial and ethnic subgroups from ADvocate1 and ADvocate2.”

Dr. Chovatiya

Key eligibility criteria for both trials included adults or adolescents with a diagnosis of AD as defined by the American Academy of Dermatology Consensus Criteria, for at least 1 year prior to screening. They had moderate-to-severe AD, were candidates for systemic therapy, and were dupilumab- and tralokinumab-naive. Outcomes of interest were the Investigator’s Global Assessment 0 or 1, with at least a 2-point improvement; and the proportions of patients who achieved Eczema Area and Severity Index (EASI75) and EASI90 responses, and an improvement of 4 points or more on the Pruritus Numeric Rating Scale (NRS).

For statistical analysis, the researchers pooled data from Advocate1 and Advocate2 and applied imputation methodology to the 16-week induction period. Subsequent data from patients who received topical or systemic rescue medication or discontinued treatment due to lack of efficacy were imputed as nonresponders. Subsequent data from patients who discontinued treatment for other reasons were set to missing, and the researchers handled missing data with multiple imputation. They used logistic regression to test the interaction between the treatment and subgroup and the Cochran-Mantel-Haenszel method to evaluate the treatment effect within each subgroup after adjusting for stratification factors.

Dr. Chovatiya reported findings from the 851 study participants in the combined studies. Of these, 542 were White, 192 were Asian, 84 were Black, and 33 were from other racial subgroups. By ethnic subgroup, 748 were not Hispanic or Latino, 91 were Hispanic or Latino, and ethnicity was unknown or not reported for 12 subjects. At baseline, the mean body mass index was slightly higher among Blacks (30.4 kg/m²) and Hispanics (29.4 kg/m²) compared with other racial and ethnic groups, “which reflects general epidemiologic data among these groups in the United States,” Dr. Chovatiya said. “You can also see a difference in the balance of IGA scores — they were a little bit more severe in the Black or African American and Hispanic groups as well.” The researchers also observed differences in the baseline EASI score across some of these groups, particularly in the Asian individuals, who had higher EASI scores. Prior use of systemic therapy was lower in the Black and “other” subgroups, compared with other racial subgroups.

At week 16, key efficacy endpoints were generally similar between the different racial subgroups. Specifically, 25.1% of Asians in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 4.1% of those in the placebo group (P < .001), while 33.2% of Blacks in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 13.2% of those in the placebo group (no P value was established because this subgroup represented less than 10% of the entire study population). In addition, 43.3% of Whites in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 14.1% of those in the placebo group (P < .001).

In other findings, 45.5% of Asians in the lebrikizumab treatment group achieved an EASI75, compared with 8.5% of those in the placebo group (P < .001), while 51.7% of Blacks in the lebrikizumab treatment group achieved an EASI75, compared with 18.8% of those in the placebo group. Among whites in the lebrikizumab treatment group, 59.7% of achieved an EASI75, compared with 20.4% of those in the placebo group (P < .001).

Dr. Chovatiya said that 26.5% of Asians in the lebrikizumab treatment group achieved an EASI90, compared with 4.3% of those in the placebo group (P < .001), while 26.9% of Blacks in the lebrikizumab treatment group achieved an EASI90, compared with 13.2% of those in the placebo group. In addition, 38.3% of Whites in the lebrikizumab treatment group achieved an EASI90, compared with 10.9% of those in the placebo group (P < .001).

Finally, 36.4% of Asians in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 5.7% of those in the placebo group (P <. 001), while 41.7% of Blacks in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 17.4% of those in the placebo group. In addition, 45.9% of Whites in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 14.8% of those in the placebo group (P < .001). Statistical analyses of efficacy endpoints conducted by ethnic group yielded similar results.

Dr. Chovatiya acknowledged certain limitations of the study, including the fact that differences in baseline demographics and disease characteristics limit direct comparison across racial and ethnic subgroups. “Due to the relatively small sample size of some racial and ethnic subgroups and the post hoc nature of this analysis, additional studies are needed to verify these results,” he concluded. But for now, he said, the data available indicate that “lebrikizumab is effective across racial and ethnic subgroups for the treatment of moderate-to-severe AD after 16 weeks of monotherapy treatment.”

The study was funded by Dermira, a wholly owned subsidiary of Eli Lilly and Company. Dr. Chovatiya disclosed that he is speaker for and/or a consult and advisory board member to many pharmaceutical companies, including Eli Lilly.

Lebrikizumab, an investigational interleukin-13 inhibitor, showed significant efficacy compared with placebo across racial and ethnic subgroups in patients with moderate-to-severe atopic dermatitis.

The finding comes from an analysis of the 16-week induction periods of the phase 3 ADvocate1 and ADvocate2 trials, which Raj Chovatiya, MD, PhD, presented during a late-breaking abstract session at the Revolutionizing Atopic Dermatitis (RAD) Virtual Conference. The efficacy of lebrikizumab monotherapy to treat moderate-to-severe AD has been established in phase 3 studies, “but disease characteristic and efficacy outcomes may vary among racial and ethnic subgroups,” said Dr. Chovatiya, assistant professor in the department of dermatology at Northwestern University, Chicago. “The goal of the current study is to report the week 16 efficacy of lebrikizumab-treated patients in racial and ethnic subgroups from ADvocate1 and ADvocate2.”

Dr. Chovatiya

Key eligibility criteria for both trials included adults or adolescents with a diagnosis of AD as defined by the American Academy of Dermatology Consensus Criteria, for at least 1 year prior to screening. They had moderate-to-severe AD, were candidates for systemic therapy, and were dupilumab- and tralokinumab-naive. Outcomes of interest were the Investigator’s Global Assessment 0 or 1, with at least a 2-point improvement; and the proportions of patients who achieved Eczema Area and Severity Index (EASI75) and EASI90 responses, and an improvement of 4 points or more on the Pruritus Numeric Rating Scale (NRS).

For statistical analysis, the researchers pooled data from Advocate1 and Advocate2 and applied imputation methodology to the 16-week induction period. Subsequent data from patients who received topical or systemic rescue medication or discontinued treatment due to lack of efficacy were imputed as nonresponders. Subsequent data from patients who discontinued treatment for other reasons were set to missing, and the researchers handled missing data with multiple imputation. They used logistic regression to test the interaction between the treatment and subgroup and the Cochran-Mantel-Haenszel method to evaluate the treatment effect within each subgroup after adjusting for stratification factors.

Dr. Chovatiya reported findings from the 851 study participants in the combined studies. Of these, 542 were White, 192 were Asian, 84 were Black, and 33 were from other racial subgroups. By ethnic subgroup, 748 were not Hispanic or Latino, 91 were Hispanic or Latino, and ethnicity was unknown or not reported for 12 subjects. At baseline, the mean body mass index was slightly higher among Blacks (30.4 kg/m²) and Hispanics (29.4 kg/m²) compared with other racial and ethnic groups, “which reflects general epidemiologic data among these groups in the United States,” Dr. Chovatiya said. “You can also see a difference in the balance of IGA scores — they were a little bit more severe in the Black or African American and Hispanic groups as well.” The researchers also observed differences in the baseline EASI score across some of these groups, particularly in the Asian individuals, who had higher EASI scores. Prior use of systemic therapy was lower in the Black and “other” subgroups, compared with other racial subgroups.

At week 16, key efficacy endpoints were generally similar between the different racial subgroups. Specifically, 25.1% of Asians in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 4.1% of those in the placebo group (P < .001), while 33.2% of Blacks in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 13.2% of those in the placebo group (no P value was established because this subgroup represented less than 10% of the entire study population). In addition, 43.3% of Whites in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 14.1% of those in the placebo group (P < .001).

In other findings, 45.5% of Asians in the lebrikizumab treatment group achieved an EASI75, compared with 8.5% of those in the placebo group (P < .001), while 51.7% of Blacks in the lebrikizumab treatment group achieved an EASI75, compared with 18.8% of those in the placebo group. Among whites in the lebrikizumab treatment group, 59.7% of achieved an EASI75, compared with 20.4% of those in the placebo group (P < .001).

Dr. Chovatiya said that 26.5% of Asians in the lebrikizumab treatment group achieved an EASI90, compared with 4.3% of those in the placebo group (P < .001), while 26.9% of Blacks in the lebrikizumab treatment group achieved an EASI90, compared with 13.2% of those in the placebo group. In addition, 38.3% of Whites in the lebrikizumab treatment group achieved an EASI90, compared with 10.9% of those in the placebo group (P < .001).

Finally, 36.4% of Asians in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 5.7% of those in the placebo group (P <. 001), while 41.7% of Blacks in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 17.4% of those in the placebo group. In addition, 45.9% of Whites in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 14.8% of those in the placebo group (P < .001). Statistical analyses of efficacy endpoints conducted by ethnic group yielded similar results.

Dr. Chovatiya acknowledged certain limitations of the study, including the fact that differences in baseline demographics and disease characteristics limit direct comparison across racial and ethnic subgroups. “Due to the relatively small sample size of some racial and ethnic subgroups and the post hoc nature of this analysis, additional studies are needed to verify these results,” he concluded. But for now, he said, the data available indicate that “lebrikizumab is effective across racial and ethnic subgroups for the treatment of moderate-to-severe AD after 16 weeks of monotherapy treatment.”

The study was funded by Dermira, a wholly owned subsidiary of Eli Lilly and Company. Dr. Chovatiya disclosed that he is speaker for and/or a consult and advisory board member to many pharmaceutical companies, including Eli Lilly.

Lebrikizumab, an investigational interleukin-13 inhibitor, showed significant efficacy compared with placebo across racial and ethnic subgroups in patients with moderate-to-severe atopic dermatitis.

The finding comes from an analysis of the 16-week induction periods of the phase 3 ADvocate1 and ADvocate2 trials, which Raj Chovatiya, MD, PhD, presented during a late-breaking abstract session at the Revolutionizing Atopic Dermatitis (RAD) Virtual Conference. The efficacy of lebrikizumab monotherapy to treat moderate-to-severe AD has been established in phase 3 studies, “but disease characteristic and efficacy outcomes may vary among racial and ethnic subgroups,” said Dr. Chovatiya, assistant professor in the department of dermatology at Northwestern University, Chicago. “The goal of the current study is to report the week 16 efficacy of lebrikizumab-treated patients in racial and ethnic subgroups from ADvocate1 and ADvocate2.”

Dr. Chovatiya

Key eligibility criteria for both trials included adults or adolescents with a diagnosis of AD as defined by the American Academy of Dermatology Consensus Criteria, for at least 1 year prior to screening. They had moderate-to-severe AD, were candidates for systemic therapy, and were dupilumab- and tralokinumab-naive. Outcomes of interest were the Investigator’s Global Assessment 0 or 1, with at least a 2-point improvement; and the proportions of patients who achieved Eczema Area and Severity Index (EASI75) and EASI90 responses, and an improvement of 4 points or more on the Pruritus Numeric Rating Scale (NRS).

For statistical analysis, the researchers pooled data from Advocate1 and Advocate2 and applied imputation methodology to the 16-week induction period. Subsequent data from patients who received topical or systemic rescue medication or discontinued treatment due to lack of efficacy were imputed as nonresponders. Subsequent data from patients who discontinued treatment for other reasons were set to missing, and the researchers handled missing data with multiple imputation. They used logistic regression to test the interaction between the treatment and subgroup and the Cochran-Mantel-Haenszel method to evaluate the treatment effect within each subgroup after adjusting for stratification factors.

Dr. Chovatiya reported findings from the 851 study participants in the combined studies. Of these, 542 were White, 192 were Asian, 84 were Black, and 33 were from other racial subgroups. By ethnic subgroup, 748 were not Hispanic or Latino, 91 were Hispanic or Latino, and ethnicity was unknown or not reported for 12 subjects. At baseline, the mean body mass index was slightly higher among Blacks (30.4 kg/m²) and Hispanics (29.4 kg/m²) compared with other racial and ethnic groups, “which reflects general epidemiologic data among these groups in the United States,” Dr. Chovatiya said. “You can also see a difference in the balance of IGA scores — they were a little bit more severe in the Black or African American and Hispanic groups as well.” The researchers also observed differences in the baseline EASI score across some of these groups, particularly in the Asian individuals, who had higher EASI scores. Prior use of systemic therapy was lower in the Black and “other” subgroups, compared with other racial subgroups.

At week 16, key efficacy endpoints were generally similar between the different racial subgroups. Specifically, 25.1% of Asians in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 4.1% of those in the placebo group (P < .001), while 33.2% of Blacks in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 13.2% of those in the placebo group (no P value was established because this subgroup represented less than 10% of the entire study population). In addition, 43.3% of Whites in the lebrikizumab treatment group achieved an IGA of 0/1, compared with 14.1% of those in the placebo group (P < .001).

In other findings, 45.5% of Asians in the lebrikizumab treatment group achieved an EASI75, compared with 8.5% of those in the placebo group (P < .001), while 51.7% of Blacks in the lebrikizumab treatment group achieved an EASI75, compared with 18.8% of those in the placebo group. Among whites in the lebrikizumab treatment group, 59.7% of achieved an EASI75, compared with 20.4% of those in the placebo group (P < .001).

Dr. Chovatiya said that 26.5% of Asians in the lebrikizumab treatment group achieved an EASI90, compared with 4.3% of those in the placebo group (P < .001), while 26.9% of Blacks in the lebrikizumab treatment group achieved an EASI90, compared with 13.2% of those in the placebo group. In addition, 38.3% of Whites in the lebrikizumab treatment group achieved an EASI90, compared with 10.9% of those in the placebo group (P < .001).

Finally, 36.4% of Asians in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 5.7% of those in the placebo group (P <. 001), while 41.7% of Blacks in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 17.4% of those in the placebo group. In addition, 45.9% of Whites in the lebrikizumab treatment group achieved a 4-point or greater improvement on the NRS, compared with 14.8% of those in the placebo group (P < .001). Statistical analyses of efficacy endpoints conducted by ethnic group yielded similar results.

Dr. Chovatiya acknowledged certain limitations of the study, including the fact that differences in baseline demographics and disease characteristics limit direct comparison across racial and ethnic subgroups. “Due to the relatively small sample size of some racial and ethnic subgroups and the post hoc nature of this analysis, additional studies are needed to verify these results,” he concluded. But for now, he said, the data available indicate that “lebrikizumab is effective across racial and ethnic subgroups for the treatment of moderate-to-severe AD after 16 weeks of monotherapy treatment.”

The study was funded by Dermira, a wholly owned subsidiary of Eli Lilly and Company. Dr. Chovatiya disclosed that he is speaker for and/or a consult and advisory board member to many pharmaceutical companies, including Eli Lilly.

TOPLINE

Babies born to mothers living in disadvantaged neighborhoods have a higher risk of being diagnosed with autism spectrum disorder (ASD), but only if they are White, a population-based prospective cohort study shows. 

METHODOLOGY

• Investigators analyzed data from a large cohort of singleton children with insurance born in Kaiser Permanente Southern California hospitals between 2001 and 2014.
• They ascertained ASD diagnosis, maternal race and ethnicity, and maternal address at time of birth.
• Neighborhood disadvantage was determined by the percentage of families in the mother’s neighborhood considered to be living in poverty, unemployed, have female-headed households with children, using public assistance, less than a high school education, among other variables.

TAKEAWAY

• Among 318,300 mothers who delivered babies during the study period, 6350 children were diagnosed with ASD during follow-up, and median age at diagnosis was 3.5 years.
• Greater neighborhood disadvantage at birth was associated with a higher likelihood of ASD diagnosis (adjusted hazard ratio [aHR], 1.07; 95% CI, 1.02-1.11)
• ASD diagnoses were more likely among children of mothers who were Black (aHR, 1.13; 95% CI, 1.02-1.25), Asian/Pacific Islander (aHR, 1.11; 95% CI, 1.02-1.20), or Hispanic (aHR, 1.07; 95% CI, 1.00-1.15), even after the researchers controlled for neighborhood.
• While odds of an ASD diagnosis were higher among children from minority racial and ethnic groups, neighborhood disadvantage was significantly associated with ASD diagnosis only for children of White mothers (aHR, 1.17; 95% CI, 1.09-1.26).

IN PRACTICE

Investigators noted that they could only speculate about the factors driving the association between neighborhood disadvantage and a stronger risk for ASD diagnosis in children of White mothers. “They may be due to systemic racism, discrimination, and their impact on maternal health during pregnancy,” they wrote.

SOURCE

Xin Yu, MS, and Daniel Hackman, PhD, of the University of Southern California Los Angeles, led the study, which was published online November 15 in JAMA Psychiatry. 

LIMITATIONS

The research was limited by a lack of information on fathers and variables such as incomes, which may have confounded the findings. The authors also acknowledged that the study should be replicated in other health service settings. 

DISCLOSURES

The study was funded by the National Institutes on Environmental Health Sciences, the National Institutes of Health (NIH), and the Environmental Protection Agency. Dr. Hackman reported receiving grant funding from NIH during the conduct of the study. Other disclosures are available in the original study. 
 

A version of this article appeared on Medscape.com.

TOPLINE

Babies born to mothers living in disadvantaged neighborhoods have a higher risk of being diagnosed with autism spectrum disorder (ASD), but only if they are White, a population-based prospective cohort study shows. 

METHODOLOGY

• Investigators analyzed data from a large cohort of singleton children with insurance born in Kaiser Permanente Southern California hospitals between 2001 and 2014.
• They ascertained ASD diagnosis, maternal race and ethnicity, and maternal address at time of birth.
• Neighborhood disadvantage was determined by the percentage of families in the mother’s neighborhood considered to be living in poverty, unemployed, have female-headed households with children, using public assistance, less than a high school education, among other variables.

TAKEAWAY

• Among 318,300 mothers who delivered babies during the study period, 6350 children were diagnosed with ASD during follow-up, and median age at diagnosis was 3.5 years.
• Greater neighborhood disadvantage at birth was associated with a higher likelihood of ASD diagnosis (adjusted hazard ratio [aHR], 1.07; 95% CI, 1.02-1.11)
• ASD diagnoses were more likely among children of mothers who were Black (aHR, 1.13; 95% CI, 1.02-1.25), Asian/Pacific Islander (aHR, 1.11; 95% CI, 1.02-1.20), or Hispanic (aHR, 1.07; 95% CI, 1.00-1.15), even after the researchers controlled for neighborhood.
• While odds of an ASD diagnosis were higher among children from minority racial and ethnic groups, neighborhood disadvantage was significantly associated with ASD diagnosis only for children of White mothers (aHR, 1.17; 95% CI, 1.09-1.26).

IN PRACTICE

Investigators noted that they could only speculate about the factors driving the association between neighborhood disadvantage and a stronger risk for ASD diagnosis in children of White mothers. “They may be due to systemic racism, discrimination, and their impact on maternal health during pregnancy,” they wrote.

SOURCE

Xin Yu, MS, and Daniel Hackman, PhD, of the University of Southern California Los Angeles, led the study, which was published online November 15 in JAMA Psychiatry. 

LIMITATIONS

The research was limited by a lack of information on fathers and variables such as incomes, which may have confounded the findings. The authors also acknowledged that the study should be replicated in other health service settings. 

DISCLOSURES

The study was funded by the National Institutes on Environmental Health Sciences, the National Institutes of Health (NIH), and the Environmental Protection Agency. Dr. Hackman reported receiving grant funding from NIH during the conduct of the study. Other disclosures are available in the original study. 
 

A version of this article appeared on Medscape.com.

TOPLINE

Babies born to mothers living in disadvantaged neighborhoods have a higher risk of being diagnosed with autism spectrum disorder (ASD), but only if they are White, a population-based prospective cohort study shows. 

METHODOLOGY

• Investigators analyzed data from a large cohort of singleton children with insurance born in Kaiser Permanente Southern California hospitals between 2001 and 2014.
• They ascertained ASD diagnosis, maternal race and ethnicity, and maternal address at time of birth.
• Neighborhood disadvantage was determined by the percentage of families in the mother’s neighborhood considered to be living in poverty, unemployed, have female-headed households with children, using public assistance, less than a high school education, among other variables.

TAKEAWAY

• Among 318,300 mothers who delivered babies during the study period, 6350 children were diagnosed with ASD during follow-up, and median age at diagnosis was 3.5 years.
• Greater neighborhood disadvantage at birth was associated with a higher likelihood of ASD diagnosis (adjusted hazard ratio [aHR], 1.07; 95% CI, 1.02-1.11)
• ASD diagnoses were more likely among children of mothers who were Black (aHR, 1.13; 95% CI, 1.02-1.25), Asian/Pacific Islander (aHR, 1.11; 95% CI, 1.02-1.20), or Hispanic (aHR, 1.07; 95% CI, 1.00-1.15), even after the researchers controlled for neighborhood.
• While odds of an ASD diagnosis were higher among children from minority racial and ethnic groups, neighborhood disadvantage was significantly associated with ASD diagnosis only for children of White mothers (aHR, 1.17; 95% CI, 1.09-1.26).

IN PRACTICE

Investigators noted that they could only speculate about the factors driving the association between neighborhood disadvantage and a stronger risk for ASD diagnosis in children of White mothers. “They may be due to systemic racism, discrimination, and their impact on maternal health during pregnancy,” they wrote.

SOURCE

Xin Yu, MS, and Daniel Hackman, PhD, of the University of Southern California Los Angeles, led the study, which was published online November 15 in JAMA Psychiatry. 

LIMITATIONS

The research was limited by a lack of information on fathers and variables such as incomes, which may have confounded the findings. The authors also acknowledged that the study should be replicated in other health service settings. 

DISCLOSURES

The study was funded by the National Institutes on Environmental Health Sciences, the National Institutes of Health (NIH), and the Environmental Protection Agency. Dr. Hackman reported receiving grant funding from NIH during the conduct of the study. Other disclosures are available in the original study. 
 

A version of this article appeared on Medscape.com.