Nevin Manimala

JAMA Oncol. 2025 Apr 10. doi: 10.1001/jamaoncol.2025.0473. Online ahead of print.

ABSTRACT

IMPORTANCE: Approximately 29.9 million cancer cases and 15.3 million deaths are anticipated by 2040 globally, necessitating cancer system strengthening. A greater understanding of health system factors that can be leveraged to improve cancer control may guide health system planning.

OBJECTIVE: To evaluate predictors of improved cancer outcomes globally.

DESIGN, SETTING, AND PARTICIPANTS: This pan-cancer ecological study used the most recent available national health system metrics and cancer statistics, spanning the breadth of global income levels across 185 countries. Estimates of age-standardized mortality to incidence ratios were derived from GLOBOCAN 2022 for patients with cancer of all ages. The analysis took place on November 27, 2024.

MAIN OUTCOMES AND MEASURES: Health spending as a percent of gross domestic product (GDP), physicians per 1000 population, nurses and midwives per 1000 population, surgical workforce per 1000 population, GDP per capita, Universal Health Coverage (UHC) service coverage index, availability of pathology services, human development index, gender inequality index (GII), radiotherapy centers per 1000 population, and out-of-pocket expenditure as percentage of current health expenditure were collected. The association between the mortality to incidence ratio (MIR) and each metric was evaluated using univariable linear regressions (α = .0045), which were used to construct multivariable models (α = .05). Variation inflation factor allowed exclusion of variables with significant multicollinearity. R2 measured goodness of fit.

RESULTS: On univariable analysis, all metrics were significantly associated with MIR of cancer (P < .001 for all), including UHC index (β, -0.0076 [95% CI, -0.0083 to -0.0068]), GDP per capita (β, -5.10 × 10-6 [95% CI, -5.75 × 10-6 to -4.46 × 10-6]), clinical and workforce capacity, radiotherapy capacity (β, -88.25 [95% CI, -100.43 to -76.06]), and gender inequality index (β, 0.63 [95% CI, 0.57-0.70]). After including metrics significant on univariable analysis and correcting for multicollinearity, on multivariable analysis, greater UHC index and GDP per capita were independently associated with lower (improved) MIR for cancer. The multivariable model had R2 of 0.87. On multivariable analysis stratified by sex, greater UHC index and greater GDP per capita were independently associated with improved MIR for all cancers. R2 for the multivariable models was 0.87 for females and 0.85 for males.

CONCLUSIONS: This study found that global health system metrics related to progress toward universal health care, greater health care spending and GDP per capita, strengthened clinical workforce and capacity, and increased gender equity were associated with improved pan-cancer outcomes at a population level on univariable analysis. The degree of UHC and GDP per capita were independently associated with improved cancer outcomes in multivariable models with good explanatory power. These exploratory findings merit further validation and may guide health system planning and prioritization.

PMID:40208599 | DOI:10.1001/jamaoncol.2025.0473

JAMA Netw Open. 2025 Apr 1;8(4):e254439. doi: 10.1001/jamanetworkopen.2025.4439.

ABSTRACT

IMPORTANCE: Measures of childhood adiposity merit investigation, particularly in individuals of South Asian descent.

OBJECTIVE: To investigate prenatal and childhood factors associated with the trajectory of adiposity in South Asian children, and the cumulative contribution of modifiable factors, such as diet and physical activity, on this trajectory.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a prospective analysis of the South Asian Birth Cohort (START; 2011-2015) for discovery; and the Family Atherosclerosis Monitoring In Early Life (FAMILY; 2002-2009) in Ontario, Canada, and the Born in Bradford (BiB; 2008-2009) cohort in Bradford, UK, for validation. Mother-child pairs included 903 South Asian individuals (START), 675 White European individuals (FAMILY), and 1593 individuals (BiB), of which 52% were South Asian. Analysis was conducted from March 2020 to September 2024.

EXPOSURE: Maternal, infancy, and early childhood exposures.

MAIN OUTCOMES AND MEASURES: Adiposity, assessed by the sum of subscapular and triceps skinfold thicknesses (SSF) from birth to 3 years, aggregated to a single measure as total area under the growth curve (AUC for SSF); multivariable linear regression models to identify determinants of AUC for SSF; and a cumulative score to assess joint contribution of modifiable risk factors to AUC for SSF.

RESULTS: START included 903 children (456 female [50.5%]; mean [SD] maternal age, 30.2 [4.0] years; maternal mean [SD] prepregnancy body mass index [BMI], 23.8 [4.50]). Maternal sum of skinfold thicknesses (β = 0.80 [95% CI, 0.30-1.30] per 10 mm), gestational weight gain (β = 0.38 [95% CI, 0.02-0.74] per 5 kg), a health-conscious diet score (β = -0.68 [95% CI, -1.26 to -0.10] per 1 SD), and infant breastfeeding for the first year (β = -1.68 [95% CI, -2.94 to -0.42), as well as physical activity (β = -0.33 [95% CI, -0.57 to -0.09] per 30-min/d) and screen time (β = 0.49 [95% CI, 0.18-0.81] per 30-min/d) were each independently associated with AUC for SSF. These 6 early-life modifiable factors combined into a single score had a direct, graded association between number of factors and AUC for SSF (P for trend < .001). In the validation cohorts, maternal BMI, breastfeeding, and child physical activity were replicated and showed a similar graded association with AUC for SSF (P for trend < .001) when combined.

CONCLUSIONS AND RELEVANCE: In this cohort study of South Asian children, 6 modifiable factors were associated with lower adiposity and combined into a single score. This score may be useful in clinical and public health settings to help mitigate childhood obesity in South Asian individuals and beyond.

PMID:40208595 | DOI:10.1001/jamanetworkopen.2025.4439

JAMA Netw Open. 2025 Apr 1;8(4):e254462. doi: 10.1001/jamanetworkopen.2025.4462.

ABSTRACT

IMPORTANCE: Influenza vaccination is a safe, effective way to mitigate influenza infection but remains underused by some groups, including older Black and Hispanic adults. There is concern that changing attitudes toward vaccination during the COVID-19 pandemic could decrease influenza vaccination rates.

OBJECTIVE: To examine national patterns of influenza vaccination among older adults with Medicare, including analyses stratified by race and ethnicity, educational attainment, and rurality.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective, cross-sectional survey study of responses to the 2019 and 2022 Medicare Consumer Assessment of Healthcare Providers and Systems surveys used cross-sectional analysis for data from a weighted sample of 285 265 community-dwelling Medicare Advantage and Medicare Fee-for-Service enrollees aged 65 years or older living in the 50 US states and Washington, DC, who answered a survey question about influenza immunization.

EXPOSURES: Race and ethnicity, educational attainment, and rurality of survey respondents.

MAIN OUTCOMES AND MEASURES: The primary outcome was self-reported influenza vaccination.

RESULTS: The weighted sample combining both years of data for 285 265 individuals included 54.5% women. A total of 4.2% were Asian American, Native Hawaiian, and Other Pacific Islander; 8.0% were Black; 6.9% were Hispanic; and 76.2% were White. Between 2019 and 2022, overall influenza vaccination rates for older adults increased by 0.7 percentage points (95% CI, 0.2-1.1 percentage points), from 76.3% to 77.0%. Whereas influenza vaccination rates for Asian American, Native Hawaiian, and Other Pacific Islander older adults (from 81.2% to 83.1%) and White older adults (from 77.7% to 77.9%) were essentially unchanged between 2019 and 2022, they increased by 3.8 percentage points (95% CI, 1.8-5.7 percentage points) for Black older adults (from 66.9% to 70.7%) and 2.3 percentage points (95% CI, 0.5-4.0 percentage points) for Hispanic older adults (from 72.7% to 75.0%). Black and Hispanic older adults living in rural areas had the largest increases during this period (Black, 7.0 percentage points [95% CI, 0.3-13.8 percentage points]; Hispanic, 8.2 percentage points [95% CI, 0.8-15.5 percentage points]), while White older adults with lower educational attainment and/or living in rural areas had decreases in vaccination rates (White with lower educational attainment, -1.9 percentage points [95% CI, -2.8 to -1.0 percentage points]; White living in rural areas, -2.0 percentage points [95% CI, -3.2 to -0.8 percentage points]; White with lower educational attainment and living in rural areas, -3.7 percentage points [95% CI, -5.5 to -1.9 percentage points]).

CONCLUSIONS AND RELEVANCE: In this cross-sectional survey study, although overall influenza vaccination rates changed little from 2019 to 2022, they increased substantially for Black and Hispanic older adults, particularly those in rural areas, and decreased for some groups of White older adults. Determining the reasons for these divergent changes in influenza vaccination rates is a high priority for future research.

PMID:40208594 | DOI:10.1001/jamanetworkopen.2025.4462

JAMA Netw Open. 2025 Apr 1;8(4):e254470. doi: 10.1001/jamanetworkopen.2025.4470.

ABSTRACT

IMPORTANCE: The relationship of neighborhood environmental and socioeconomic factors with mental health across childhood and adolescence remains unclear.

OBJECTIVE: To investigate the associations of neighborhood characteristics with mental health at various developmental stages, from early childhood to late adolescence.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study used data from the Millennium Cohort Study, including approximately 19 000 children born in the UK from 2000 to 2002. This analysis included individuals in England with complete data on neighborhood exposures at ages 3, 5, 7, 11, 14, and 17 years. Data were analyzed from January to December 2023.

EXPOSURES: Neighborhood-level air pollution, green space, and socioeconomic status.

MAIN OUTCOMES AND MEASURES: Strengths and Difficulties Questionnaire (SDQ) scores linked with exposure to air pollution, green space, and socioeconomic status, measured at participants’ residential addresses, were analyzed using a hierarchical bayesian regression model. Hypotheses were formulated after data collection.

RESULTS: The sample included 3595 children and adolescents, with 1826 (50.5%) female; 3012 participants (83.8%) were White and 583 participants (16.2%) were another ethnicity. The mean (SD) SDQ score was 7.1 (5.1). After adjusting for individual and household factors, neighborhood socioeconomic status emerged as the strongest factor associated with mental health. Residing in affluent neighborhoods was associated with improved mental health, with this association magnifying through adolescence. For children of the same age, those in the most affluent neighborhoods had log-transformed SDQ scores 0.73 (95% credible interval [CrI], 0.58 to 0.88) lower at age 17 years compared with their peers in the most deprived areas; at age 5 years, scores were 0.31 (95% CrI, 0.17 to 0.45) lower. Exposure to particulate matter with diameter less than 2.5 μm was associated with poorer mental health during early childhood (age 3 years), with an effect size of 0.15 (95% CrI, 0.08 to 0.22). While green space was not directly associated with improved mental health, a sex-based difference was observed, with males showing more favorable associations (interaction, -0.10 [95% CrI, -0.17 to -0.03]).

CONCLUSIONS AND RELEVANCE: In this cohort study of children and adolescents, associations between neighborhood characteristics and mental health evolved from childhood through adolescence. These findings suggest that targeted interventions in disadvantaged neighborhoods and strategies to protect young children from air pollution are essential. A comprehensive approach is recommended to incorporate air pollution, green space, and socioeconomic status not only in residential neighborhoods but also in other settings, such as schools.

PMID:40208593 | DOI:10.1001/jamanetworkopen.2025.4470

JAMA Netw Open. 2025 Apr 1;8(4):e254508. doi: 10.1001/jamanetworkopen.2025.4508.

ABSTRACT

IMPORTANCE: Multiarterial coronary bypass procedures offer improved clinical outcomes compared with single arterial grafting with supplementary saphenous vein grafts. However, the survival advantage of multiarterial grafting across varying levels of left ventricular impairment remains uncertain.

OBJECTIVE: To compare long-term survival outcomes of patients undergoing multiple vs single arterial grafting, stratified by preoperative ejection fraction.

DESIGN, SETTING, AND PARTICIPANTS: A complete-case retrospective cohort study was conducted using data from a multicenter population-based cardiac registry established by the Australian & New Zealand Society of Cardiac & Thoracic Surgeons with linkage to the National Death Index. Participants were individuals who underwent primary isolated coronary bypass surgery between June 1, 2001, and January 31, 2020. Exclusion criteria were nonadults, reoperations, concomitant or previous cardiac surgical procedures, single-graft procedure, and cases without any arterial grafts. Statistical analyses were conducted in September 2024.

EXPOSURES: Patients underwent either multiple or single arterial grafting, stratified by their preoperative left ventricular ejection fraction.

MAIN OUTCOMES AND MEASURES: Long-term all-cause mortality.

RESULTS: The study included 59 641 patients (mean [SD] age at the time of surgery, 65.8 [10.2] years; 48 321 men [81.0%]). The median follow-up duration was 5.0 years (IQR, 2.3-8.6 years). Multiarterial grafting was associated with a 19.0% relative reduction in all-cause mortality compared with single arterial grafting among patients with a normal left ventricular ejection fraction (hazard ratio [HR], 0.81; 95% CI, 0.75-0.87; P < .001). Similar survival benefits were observed among patients with mild (HR, 0.83; 95% CI, 0.77-0.90; P < .001), moderate (HR, 0.82; 95% CI, 0.74-0.90; P < .001), and severe left ventricular impairment (HR, 0.82; 95% CI, 0.71-0.96; P = .01). A multivariable Cox proportional hazards regression interaction-term analysis indicated no significant differences in the multiarterial survival benefit by ejection fraction stratification (P = .75). Multiarterial grafting with exclusively arterial conduits was associated with enhanced survival benefits compared with other multiarterial procedures with saphenous vein grafts, except when the left ventricular ejection fraction was below 30% (HR, 0.87; 95% CI, 0.67-1.13; P = .30).

CONCLUSIONS AND RELEVANCE: In this retrospective cohort study using data from a binational database, multiarterial procedures were associated with reduced long-term mortality risk compared with single arterial grafting across the spectrum of preoperative left ventricular ejection fractions. Total arterial revascularization was associated with incrementally improved survival, particularly among patients with preserved ejection fraction. Because most coronary surgery practice continues to use single arterial grafting, consideration to alter grafting strategy to multiarterial procedures may be indicated.

PMID:40208590 | DOI:10.1001/jamanetworkopen.2025.4508

JAMA Netw Open. 2025 Apr 1;8(4):e254715. doi: 10.1001/jamanetworkopen.2025.4715.

ABSTRACT

IMPORTANCE: Health-related social needs (HRSNs) contribute to appointment nonadherence. Childcare needs are an underrecognized HRSN that particularly affect women.

OBJECTIVE: To determine whether self-reported childcare barriers were associated with appointment nonadherence among women.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used linked survey and electronic health record (EHR) data. Survey data were collected from November 2023 to May 2024 and EHR data were extracted for the 1 year prior to the survey date for each participant. Data were analyzed between June and September 2024. This single-center study was conducted in a safety-net health system in Dallas County, Texas. EHR data included ambulatory care encounters. Eligible participants included women aged 18 years or older referred to gynecology for abnormal cervical cancer screening who reported having childcare responsibilities.

EXPOSURE: Self-reported childcare barriers to appointments in the past year.

MAIN OUTCOMES AND MEASURES: Regression analysis was used to evaluate the primary outcome of appointment nonadherence rate during the year prior to survey date.

RESULTS: Of 1264 women eligible for the survey, 836 were successfully reached by telephone, of whom 671 women (53.1% of eligible sample) were included in the sample. Among the 671 initial respondents, 486 women reported having childcare responsibilities (72.4%). The mean (SD) age of the study sample was 34.8 (8.6) years, 405 (83.3%) identified as Hispanic, and 349 (71.8%) preferred Spanish. Additionally, 105 women reported childcare barriers to attending appointments in the past year (21.6%). Women with self-reported childcare barriers were mean 2.9 years younger and more likely to receive Medicaid (38 [36.2%]) than women without childcare barriers (89 [23.4%]). Women with self-reported childcare barriers were more likely to care for an increased number of children and younger children than women without. The mean (SD) appointment nonadherence rate was 25.1% (21.8%) among women with self-reported childcare barriers compared with 15.2% (22.1%) among women without. The adjusted difference in appointment nonadherence was 8.8 (95% CI, 3.6-14.0) percentage points (P = .001) higher among women with self-reported childcare barriers.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of women in a safety-net health system, self-reported childcare barriers were associated with increased appointment nonadherence. Younger women with younger children were most likely to report childcare barriers to appointments. These findings highlight the importance of childcare needs as a HRSN that warrants screening and intervention.

PMID:40208589 | DOI:10.1001/jamanetworkopen.2025.4715

JAMA Netw Open. 2025 Apr 1;8(4):e258565. doi: 10.1001/jamanetworkopen.2025.8565.

ABSTRACT

IMPORTANCE: The economic value of cleaning and disinfection of shared medical equipment is currently unknown.

OBJECTIVE: To evaluate whether or not better environmental cleaning and disinfection of shared medical equipment would be cost-effective compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS: This economic evaluation study was a within-trial cost-effectiveness analysis of a stepped-wedge cluster randomized clinical trial: the Cleaning and Enhanced Disinfection (CLEEN) study. The trial included 5002 inpatients and was conducted in 10 adult acute-care wards at a tertiary hospital in Australia between March 20, 2023, and November 24, 2023. The evaluation takes a hospital costing perspective. A decision-tree model was developed to evaluate the intervention; costs are presented in Australian dollars. Statistical analysis was performed from May to October 2024.

INTERVENTIONS: A multimodal cleaning intervention was introduced during the intervention, focusing on additional cleaning hours, education, audit, and feedback. The control group received usual care, including routine cleaning by clinical staff.

MAIN OUTCOMES AND MEASURES: Incremental cost-effectiveness ratio, where the mean change to costs associated with the intervention is divided by the mean change in outcomes.

RESULTS: This study assessed 5002 patients (2478 [49.5%] male, 2524 [50.5%] female [50.5%]; mean [SD] age, 71.6 [16.1] years). For a cohort of 1000 patients at risk of health care-associated infection (HAI), the estimated total costs associated with the intervention were $1 513 300, compared with $2 155 310 for usual care. The estimated number of HAIs was 100 in the intervention group, compared with 130 for the usual care group. Compared with usual care, the intervention was associated with reduced HAIs and costs, with a 90.5% chance that intervention adoption was cost-saving. This probability increased to 99.9% if a decision-maker was willing to pay $20 000 to avoid an infection.

CONCLUSIONS AND RELEVANCE: In this economic evaluation study of enhanced cleaning and disinfection of shared medical equipment, the intervention resulted in reduced HAIs and a $642 010 reduction in costs per 1000 patients, compared with the control group. These results suggest that the CLEEN intervention is a cost-saving initiative.

PMID:40208588 | DOI:10.1001/jamanetworkopen.2025.8565

Ann Am Thorac Soc. 2025 Apr 10. doi: 10.1513/AnnalsATS.202501-087OC. Online ahead of print.

ABSTRACT

BACKGROUND: Long-term exposure to air pollution has been linked with acute lower respiratory infections (ALRIs) in children, but the evidence in adults is still mixed and sparse. We aimed to examine the association between long-term exposure to air pollution and incident ALRIs in adults.

METHOD: We followed all Danish residents aged 30 or older (N=3,083,227) for the first-ever hospital contact (in-, outpatient, or emergency) for ALRIs (and pneumonia or influenza separately) from 2000 to 2018. Long-term exposure to air pollution was defined as annual mean concentrations of fine particulate matter (PM2.5), nitrogen dioxide (NO2), and black carbon (BC), which were modeled using hybrid land-use regression models and assigned to baseline residential addresses. Cox regression models were used to assess the association between air pollution and incidence of ALRIs in total, pneumonia, and influenza.

RESULTS: During 16 years’ mean follow-up, there were 322,035, 309,092 and 11,977 incident cases of ALRIs, pneumonia, and influenza, respectively. We detected positive associations of air pollution and incident ALRIs, with hazard ratios (95% confidence interval) of 1.08 (1.07, 1.09) per 10 μg/m3 for NO2, 1.07 (1.06, 1.08) per 0.5 10-5 m-1 for BC, and 1.04 (1.03, 1.04) per 2 μg/m3 for PM2.5. We detected similar associations with pneumonia, but no detected association with influenza.

CONCLUSION: Long-term exposure to air pollution may contribute to an increased risk of contracting ALRIs, particularly pneumonia, that require hospital care. Associations persisted for all major pollutants (PM2.5, NO2 and BC) even at exposure lower than the current EU limits and WHO guideline.

PMID:40208575 | DOI:10.1513/AnnalsATS.202501-087OC

Omega (Westport). 2025 Apr 10:302228251333838. doi: 10.1177/00302228251333838. Online ahead of print.

ABSTRACT

This study assessed the relationship between grief and posttraumatic growth (PTG) in 2415 individuals from six Latin American countries, and how the relationship between these variables is moderated by gender and age. The Posttraumatic Growth Inventory-Short Form and Pandemic Grief Scale were used. Moderation analysis utilized Model 2, proposed by Hayes. The findings from the analysis indicate that the proposed regression model is statistically significant in most countries. Gender moderated the relationship between grief and PTG in El Salvador and Peru; meanwhile, age moderated this relationship in Uruguay. The findings support the importance of incorporating gender and age differences into both the theory of grief and PTG and empirical studies investigating these variables in Latin America. Furthermore, mental health professionals should consider gender and age differences when planning interventions aimed at fostering PTG in individuals who have experienced the loss of a loved one in the evaluated countries.

PMID:40208570 | DOI:10.1177/00302228251333838

Multivariate Behav Res. 2025 Apr 10:1-33. doi: 10.1080/00273171.2025.2480437. Online ahead of print.

ABSTRACT

In this work, we introduce a multiple-group longitudinal IRT model that accounts for skewed latent trait distributions. Our approach extends the model proposed by Santos et al. in 2022, which introduced a general class of longitudinal IRT models. The latent traits follow a multivariate skew-normal distribution, induced by an antedependence structure with centered skew-normal errors. Additionally, latent mean trajectories are modeled using quadratic curves, while structured covariance matrices capture within-participant dependencies. A three-parameter probit model is employed for dichotomous items. Bayesian parameter estimation and model fit assessment are conducted through a hybrid MCMC algorithm, combining the FFBS sampler with Metropolis-Hastings steps. The model’s effectiveness is demonstrated through an application to real data from the Longitudinal Study of the 2005 School Generation in Brazil (GERES project), where it outperforms the normal model by better capturing asymmetry in latent traits. A simulation study further supports its robustness across various test conditions.

PMID:40208567 | DOI:10.1080/00273171.2025.2480437