United States

Objective: Idiopathic inflammatory myopathies (IIMs) have heterogeneous presentations and require multiple lines of testing, some of which are invasive, to diagnose. Additionally, treatment is chronic and can be costly. Delays in diagnosis are known to occur and can lead to significant morbidity. This study aims to investigate the influence of socioeconomic status (SES) on time to diagnosis, treatment, and improvement in disease status of IIMs. 

Methods: This is a retrospective study patients from 2011-2021 from a university hospital and a county safety-net hospital. Salient clinicopathologic and demographic data including race, ethnicity, sex, zip code, median household income, and insurance data were abstracted. Patients with ICD codes for polymyositis, dermatomyositis, inclusion body myositis, other inflammatory or immune-mediated myositis were included. The modeling of time-to-event and binary outcomes incorporated covariates such as median household income, race, ethnicity, sex, insurance status (Charity vs. Medicare/Medicaid vs. Other), and inpatient status (Inpatient = 1, Outpatient = 0). Time-to-event data were analyzed using Cox proportional hazards models through the survival package in R.

Results: Our study included 2,258 subjects, of which 1,734 were from the academic hospital and 524 were from the safety-net hospital. After filtering for patients with the proper diagnosis, there were 46 from the academic and 143 from the safety-net hospital. There is no significant difference in time from first abnormal muscle enzyme level (creatine kinase, CK) to diagnosis between race, median household income, ethnicity, and initial presentation in the inpatient vs. outpatient setting. However, those receiving charity had a 4.58-fold increase in the instantaneous probability of being diagnosed after first positive CK after 230 days (p = 0.009). Those on Medicare/Medicaid had a 62% decrease in the instantaneous probability of being diagnosed after first positive CK within the first 94 days (p = 0.02) but a 4.60-fold increase in the instantaneous probability of being diagnosed after first positive CK after 230 days (p = 0.006). There is no significant difference in the probability of a muscle biopsy being order or the time to disease improvement between races, ethnicities, sexes, income, or insurance status.

Conclusions: Our findings showed that there could be delays in diagnosis for those with Medicare/Medicaid or those receiving charity to finance their care. There was no impact detected from race, ethnicities, or sexes. While income did not clearly correlate with insurance status, income is limited by zip-code level data rather than individual data. Our study sheds light on populations that may have delays in diagnosis and treatment, which could lead to increased disease morbidity. Unfortunately, increased morbidity in the population identified will only perpetuate the cycle of poverty and add greater burden to the healthcare system. Future studies will seek to examine impact of SES and disease outcomes.


AMA Research Challenge 2024 

Impact of socioeconomic factors on time to myositis diagnosis and treatment


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Background
Universal helmeting has been shown to decrease fatalities associated with motorcycle accidents, and helmeting may reduce the incidence of traumatic brain injury, facial fractures, and injury severity for the head and neck. Enhancing rider knowledge of safe riding practices and effective helmeting are approaches that may improve motorcycle safety.

Methods
The dissemination of a motorcycle safety toolkit in areas frequented by riders, or in proximity to vulnerable populations could provide a means for teaching about educational offerings and safety resources. Our team utilized the graphic design platform Canva to create a concise handout highlighting New Jersey helmeting laws, tiers of helmet safety, and crash statistics, among other topics. We utilized quick-response (QR) codes so viewers can interact with the toolkit from their phones. Leaders in roadway safety from across New Jersey were consulted in developing these resources. Collaborators included rider safety educators, injury prevention professionals, and authorities in public safety and policy.

Results
Strong positive feedback was received by the New Jersey Trauma Injury Prevention Council. Several organizations stated they plan to use the toolkit in their community outreach efforts, including:

· New Jersey's Governor's Office
· New Jersey Division of Highway Traffic Safety
· New Jersey Brain Injury Alliance Motorcycle Safety Committee
· AAA - New Jersey Division
· Monmouth and Ocean Traffic Safety Officers Committee.

The toolkit has been received favorably by a cohort of patients hospitalized with motorcycle-related injuries. These individuals received the toolkit together with motivational interviewing emphasizing safe riding.

Conclusion
Efforts may be made to share the toolkit in a variety of settings and to better understand factors contributing to motorcycle-related injury. Our collaborators can broaden the reach of the toolkit, incorporating it into safety courses, sharing it on social media, or using it to guide conversation with survivors. We can track use of the toolkit through analytical tools measuring viewership. A retrospective cohort study investigating the relationship between helmeting and injury severity scores and health outcomes among victims of motor-vehicle collisions locally could identify areas of focus for further education. It remains to be seen where this toolkit will reach the most motorcyclists and whether education is a limiting factor in the prevention of motorcycle-related injury and fatality. A better understanding of the financial and social factors that complicate the use of safe and effective helmets is imperative in reducing fatalities.

Implementing a Motorcycle Safety Toolkit: A Resource for Riders and Providers

Background
Medical Students Making Change (MSMC), led by University of South Carolina School of Medicine Columbia students in collaboration with The Free Medical Clinic in Columbia, SC, aims to improve diabetic control in South Carolina. Approximately 13.2% of South Carolina’s adult population has diabetes. With serious complications such as heart disease, stroke, and amputation, diabetes costs South Carolina an estimated $5.9 billion each year. By pairing medical student volunteers with diabetic patients for routine check-ins, MSMC seeks to strengthen patient understanding of their health and lifestyle trends with the goal of improving patient glycemic control as measured by A1C levels. A new recruitment method was implemented where medical student volunteers went to The Free Medical Clinic weekly to participate in A1C screening and patient recruitment aiming to increase MSMC patient enrollment and A1C screening capabilities.
Methods
MSMC implemented a weekly A1C screening and enrollment clinic starting in January 2024. During this session, medical student volunteers reviewed A1Cs from the previous week, contacted eligible patients, screened eligible patients in the clinic, and attempted to enroll those meeting the inclusion criteria: adults (≥18 years old), diagnosed type 2 diabetes, access to a phone, and an A1C ≥6.5%. MSMC volunteers screen patients for diabetes using A1C test kits. The Free Clinic providers provide MSMC with patients current BMI and glucose to assist with goals. Patients are then paired with a trained medical student volunteer and provided educational materials regarding T2DM management. Phone calls between volunteers and
patients focus on assessing goals related to diet, exercise, sleep, and hydration. Volunteers address barriers to achieving goals and navigate solutions. HbA1C and fasting blood glucose are measured every 3 months to monitor glycemic control.
Results
Fourteen patients were enrolled in the MSMC program between January-April 2024. The average BMI was 38.7. The average base A1C was 9.6%, and the average fasting blood glucose was 246. Of the patients enrolled in the MSMC program with 3-month A1C values, there has been an average decrease in A1C of 1.7%.
Conclusion
The clinic’s high A1C average highlights a need for lifestyle and therapeutic interventions within this demographic. This preliminary data further emphasizes the need for patient education and intervention to improve glycemic control and thereby attenuate the complications associated with insulin resistance/type 2 diabetes.

Improving Diabetic Patient Enrollment & A1C Screening Capabilities at South Carolina Free Clinics: A 6-month progress update

Background:
Addressing health disparities in U.S. border states requires overcoming linguistic barriers that disproportionately affect the Hispanic/Latino population. This review critically evaluates the potential of Medical Spanish Certification (MSC) in medical school curricula as a strategy to advance health equity by improving communication between healthcare providers and patients with Limited English Proficiency (LEP).

Methods:
This review was conducted by systematically searching PubMed, Scopus, and Embase databases for literature published up to 2023. The search focused on studies, policy documents, and educational materials related to MSC, language concordance in healthcare, and the feasibility of MSC implementation in medical education. Selection criteria were established to include articles that directly address the debate on MSC in border states, its implications for healthcare delivery, and educational challenges. The review concentrated on analyzing arguments for and against MSC, evaluating evidence on the benefits of language concordance, and identifying barriers to MSC program implementation. Quality assessment and thematic analysis were performed to ensure a balanced evaluation of the available evidence.

Results:
Evidence highlights that language concordance through MSC significantly enhances patient care outcomes, satisfaction, and access. Proponents argue MSC bridges communication gaps, potentially reducing medical errors and improving care engagement. The growing demand for Medical Spanish courses mirrors the urgent need for bilingual healthcare skills amid demographic shifts. However, challenges such as curriculum constraints, resource allocation, and the potential for ethical dilemmas and tokenism raise concerns about mandating MSC. While the demand for Medical Spanish courses is rising among medical schools, there is variability in program implementation and a lack of standardized assessment methods.

Conclusion:
Incorporating MSC into medical curricula presents a nuanced approach to mitigating healthcare disparities and advancing health equity in border states. A voluntary certification model, supplemented by adequate resources and a focus on cultural competency, offers a practical solution. Standardizing MSC education and conducting further research are essential steps toward leveraging language concordance as a means to enhance health equity for the Spanish-speaking LEP population.

Navigating Linguistic Barriers: The Debate on Medical Spanish Certification in Border States

Background. Vaccine hesitancy hinders the eradication of preventable illnesses. Furthermore, there are gaps in public health research on vaccine hesitancy among Muslims in heterogenous societies.
Methods. Participants were recruited through Facebook group posts. Seventy-three responses were received. Sixty-three responses met the inclusion criteria and were included in the final analysis. Participants rated their opinions on political beliefs, religious practices, trust in institutions and vaccines. Answers were compiled into the following belief scores: political leaning, religiosity, trust in public institutions, and vaccine hesitancy.
Results. From bivariate analysis, participants who were older in age, attained higher levels of education, were employed, were not married, and identified with the Sunni sect were less vaccine hesitant. From multiple regression analysis, participants with higher education levels and trust in public institutions were the least likely to express vaccine hesitancy. No belief score had a significant correlation with vaccine hesitancy. Most participants (36.5%) were more likely to receive a vaccine it had no potential safety issues. Moreover, they were hesitant with vaccines if they had safety concerns or had poor efficacy.
Conclusion. Results both align with and contradict previous studies in Muslim majority and religiously heterogenous countries. This study is the first of its kind to find an association between Islamic sect and proclivity towards vaccines. Follow up studies are necessary to gauge a larger, more diverse population of Muslim-Americans. Based on this study’s findings, healthcare professionals can better promote vaccines by addressing their patient’s trust in public institutions.

Prevalence and beliefs associated with vaccine hesitancy among Muslim-Americans

Background
Women Veterans are one of the fastest growing groups of new VA users and are younger and more racially diverse than their male counterparts. Yet services such as obstetric care continue to be purchased from the community due to concerns regarding capacity and quality given the limited demand at any one VA site. Understanding whether or not racial and ethnic disparities in reproductive health care and outcomes are evident among women Veterans is critical for ensuring that VA meets its goal of providing high quality, equitable care to all Veterans. The purpose of this scoping review was to examine the evidence with respective to racial and ethnic disparities in reproductive health care and outcomes among women Veterans.

Methods
Databases were queried for articles addressing reproductive health and health care of women Veterans between 2008 and 2023, pertinent to reproductive health care or outcomes of women Veterans that also included outcome frequencies by race or ethnicity or measures of association for race or ethnicity with the outcome of interest. Articles were sorted into six categories based on topic: contraception, infertility, pregnancy, reproductive health screenings, gynecology, menopause. Outcomes were defined as structural, process, or clinical or behavioral outcome measures.

Results
Of 438 original articles, 49 articles were included. The topics with the greatest number of articles included pregnancy (43%) and contraception (24%). In terms of types of measures, only two studies included at least one structural measure (7%) and the remainder were split nearly evenly between process measures (53%) and clinical and behavioral outcomes (57%, n=28). In nearly two thirds of the studies racial and ethnic disparities were not the primary focus of the analysis and were reported only as secondary outcomes. In terms of process measures for pregnancy, non-White Veterans were less likely than White Veterans to return to VA primary
care postpartum, but results were mixed for other measures. With respect to clinical and behavioral measures, although Black versus White Veterans were consistently found to be more likely to have a low birthweight baby, results were variable regarding preterm birth, breast feeding, prenatal smoking, and perinatal mental health.

Conclusion
This scoping review identified numerous racial and ethnic disparities in reproductive health care and outcomes among women Veterans. These findings suggest a need to ensure that Veterans receive culturally competent, patient-centered contraceptive counseling and a need to potentially address social determinants in the context of reproductive health care.

Racial and Ethnic Disparities in Reproductive Health Care Among Female Veterans:
A Scoping Review

Introduction: Equitable inclusion and representation of racial/ethnic groups in clinical trials is important in producing generalizable data. Disparities and mismatches between clinical trial participants trials’ enrollees and general population result in selection bias and distortion of information generated by these studies. The purpose of current study was to investigate the status of racial/ethnic disparities in the ophthalmology clinical trials conducted in the United States. 
Methods: In this retrospective cross-sectional study, we utilized demographic reports of completed phases 2/3, 3, and 4 ophthalmology clinical trials conducted in the US, using the ClincialTrials.gov database. We calculated proportional enrollments of racial/ethnic groups in the trials and compared them to the 2010 US Census data as the reference population. Using regression analysis, we examined the association between various trial features (i.e., phase of the trial, starting year, funding source, and primary condition) and rate of disclosing demographics data and inclusion of racial/ethnic minorities.
Results: Among the total of 653 completed trials, racial/ethnic background were reported in 128 trials (43.6% of the studies, comprising 3 7031 participants). Compared to the US census data, White individuals were enrolled more commonly (median 76.6%, Inter quartile range (IQR) 69.0-84.0%) and minority groups, including Asians (median 1.8%, IQR 0.4-3.8%), Hispanics (median 12.5%, IQR 6.3-17.5%), and other group (median 1.7%, IQR 0.2-4.3%) were underrepresented (p<.001). Interestingly, enrollment of African-American individuals was comparable to their population estimates (median 12.4%, IQR 6.2-20.8, p=0.44). Rate of reporting race/ethnicity data was higher among earlier phase (2/3 and 3) trials and increased over time (average increase of 11.4% annually; p<0.001). Additionally, glaucoma trials had greater enrollment of Black individuals (p=0.001). 
Conclusion: Racial/ethnic disparities in clinical trials enrollment can skew the results of these studies and compromise generalizability of findings. Ophthalmology trials suffer from significant underrepresentation of minorities. More efforts are needed to reduce disparities and ensure unbiased discoveries.

Racial and Ethnic Diversity in the US Ophthalmology Clinical Trials

Background 
Cardiovascular disease significantly impacts life expectancy and quality of life, and is responsible for the highest number of deaths in Albania, comprising 59% of all mortality cases. However, limited data exists on the influence of social determinants of health on the prevalence of cardiovascular disease in Albania. This study aims to fill the gaps in the available literature by analyzing associations between socio-economic determinants of health and cardiovascular disease prevalence to guide public health interventions in Albania.

Methods: This cross-sectional study used secondary data from the Albania Demographic and Health Survey of 2017-2018. This comprehensive survey was conducted on sample clusters proportional to each county’s population size, with 17,160 households overall. There were 15,000 women and 6,142 men successfully interviewed. SPSS and Python performed statistical analysis utilizing chi-square tests to explore the associations between the social determinants and cardiovascular disease prevalence. 

Results: 
The findings showed a significant difference (p <0.05) in cardiovascular disease prevalence between different income and education levels. The results were similar among males and females. There were no significant differences in the prevalence of cardiovascular disease in different geographic residences (p>0.05). 

Conclusion: The study findings indicate that social determinants of health may play a role in cardiovascular disease prevalence in Albania, aligning with global research that describes social determinants as critical factors in cardiovascular health. It emphasizes the need for targeted public health interventions and calls for an increase in future research to effectively identify and address economic and educational social determinants associated with cardiovascular disease in Albania. Limitations of the study include its reliance on cross-sectional data, underreporting or self-reporting bias, and the potential changes in the health of the Albanian population since the 2017 health survey.

Role of Social Determinants of Health in the 
Prevalence of Cardiovascular Disease in Albania.


Sociodemographic Profile of Depression in High School Students in Cochabamba: A Subnational Study

Background: The study aims to analyze the association between sociodemographic characteristics and the presence of depression in high school students in the city of Cochabamba. Understanding these associations is crucial for developing targeted interventions to address mental health issues among adolescents. As identified in previous studies, these factors were chosen based on their potential influence on mental health.

Methods: An observational analytical cross-sectional study was conducted involving 41,820 high school students who completed a survey based on the Beck Depression Inventory Type I. Statistical analysis included frequency distributions and 95% confidence intervals. The risk of depression was analyzed using crude and adjusted odds ratios (OR).

Results: Among the participants, 52.8% were female. At the time of data collection, 11.7% had severe depression, 9.1% had moderate depression, and 7.1% had mild depression. Males had a lower risk of experiencing any degree of depression (OR: 0.91). Age groups 15-18 years (OR: 0.78) and 19-22 years (OR: 0.80) had a lower risk compared to the 11-14 years age group. Those who spoke Spanish and Quechua had a lower risk than those who spoke Aymara (OR: 0.51 and OR: 0.91, respectively). Adolescents from the Southern Cone showed a higher risk (OR: 1.35) compared to other locations, and those with health insurance had a lower risk (OR: 0.94).

Conclusion: The prevalence of depression among adolescents in Cochabamba was 27.9%. Significant risk factors included being female, aged 11-14 years, of indigenous ethnicity, lacking health insurance, and residing in the Southern Cone. These findings suggest the need for tailored mental health interventions that focus on these high-risk groups. Implementing targeted screening programs in schools, providing culturally sensitive mental health services, and improving access to health insurance could be effective strategies to mitigate these risk factors.

Sociodemographic Profile of Depression in Secondary School Students in Cochabamba: A Subnational Study

Background: Wildfire severity and frequency have increased in the last two decades, as have their consequences and public attention toward these disasters. Wildfires have led to community evacuations, social disruptions, significant property damage, loss of life, and impacts on economic activity in communities across California. However, the effect of fires on individual healthcare facilities and the health system has received comparatively less attention. There is a lack of empirical assessments on how this risk affects the operations of healthcare facilities and the spatial trends of actual wildfire exposure. We use historical wildfire perimeter data, and inpatient healthcare facility data to assess trends by county in observed exposure to wildfire between 2001 and 2023 in California.

Methods: Inpatient facility data was collated from the California State Department of Health Care Access and Information. Data on annual wildfire perimeters was retrieved from the California Department of Forestry and Fire Protection. Inpatient facility data from the pre-2008 era did not include geospatial coordinates for facility locations. However, they included street address data which was geocoded using a Google Maps API in R, and supplemented with manual geocoding. The ‘sf’ package in R was then used to compute the nearest distance to a wildfire perimeter each year for each licensed and open facility (closed facilities were excluded from analysis). The proportion of facilities that were within ten miles of a wildfire perimeter were summarized, by year, and by county. 

Results: Between 2001 and 2023, 20 of California’s 58 counties had at least an average of 50% of inpatient facilities within ten miles of a wildfire perimeter. For three counties, Placer, Shasta, and Ventura, more than 75% of inpatient facilities experienced wildfires within ten miles of the facility site between 2001 and 2023. While all but two counties experienced a wildfire within ten miles of an inpatient facility at some point, the frequency of wildfires near inpatient facilities is not evenly distributed across the state. 

Conclusion: Addressing the threat to healthcare facilities will require action at multiple scales. Policies to address the root causes of the increase in wildfire exposure are essential; these may include policies directed at reducing wildfire ignition, improving land-use management, guiding future development decisions, and mitigating future climate change through reductions in fossil fuel use and greenhouse gas emissions. Empirical data such as the results of this study may help prioritize wildfire adaptation investments for healthcare facilities in specific California counties.



Spatial Variability of Wildfires and Inpatient Healthcare Facilities in California Counties

Background: With 8.4% of Americans uninsured, free clinics act as safety nets for those without healthcare access. The CommunityCare Clinics (CCC) operate student-run free clinics in Toledo, Ohio. This study compared the demographics of patients served within these clinics to the city’s census data to analyze health needs, barriers to care, and characteristics of the underserved population.

Methods: This retrospective survey reviewed 1,338 visits at five clinic sites from February 2023- February 2024. Parameters included race, insurance, education, sex, health insurance status, and primary language. Comparative analysis was completed using 2020 Census data for Toledo, OH.

Results: Significant differences were found between the demographic characteristics of those served in the clinic population and the population of Toledo. The clinic served 22.63% fewer White patients, 17.27% more Hispanic/Latino patients, and 5.62% fewer African American patients than the city population. Among patients under 65 years, 61.91% were uninsured compared to 8.3% in Toledo. Fewer English speakers (66.60% vs. 93.2%) and more Spanish speakers (21.72% vs. 3.2%) were treated. The clinic had slightly fewer high school graduates (82.97% vs. 87.10%) but more higher education recipients (27.10% vs. 19.6%). 

Conclusions: This study highlights the demographic differences between the clinic and the city, helping identify those benefiting from these services. The inconsistency in patient demographics across free clinics in the United States should be considered by policymakers and public health agencies.


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