Category Archives: Infectious disease
CDC Identifies Rare U.S. Case of Lassa Fever
A severe viral disease common in West Africa has been confirmed in a person returning to the United States from the region, according to the U.S. Centers for Disease Control and Prevention (CDC) and the Minnesota Department of Health (MDH). The patient was admitted to a Minnesota hospital for Lassa fever on March 31, with the CDC confirming diagnosis on April 3 and the patient now recovering and in stable condition. The last case of Lassa fever in the United States, of which there have been seven confirmed and all related to travel, was in Pennsylvania in 2010. The virus is not transmitted through direct contact with a sick person’s blood of bodily fluids and cannot by transmitted by casual contact; there are up to 300,000 cases and 5,000 deaths each year in West Africa. “This imported case is a reminder that we are all connected by international travel. A disease anywhere can appear anywhere else in the world within hours,” said CDC Director Tom Frieden, MD, MPH. Read more on infectious disease.
Public Health Officials in Developing Countries Use Social Marketing to Promote Health Behaviors
Public health officials in developing countries are successfully using social marketing strategies to educate people about the importance of behaviors related to water and sanitation, according to a new study in the journal Social Science & Medicine. In a systematic review of 32 studies, researchers led by W. Douglas Evans, PhD, a professor of prevention and community health at Milken Institute School of Public Health at the George Washington University, looked at how public health officials utilized social marketing tools such as door-to-door visits and public education campaigns for school children to promote behaviors such as regular hand washing and water purification. Read more on global health.
Depression, Anxiety Linked to Poor Diabetes Management
Depression and anxiety can be significant impediments to proper management of diabetes, according to a new study in the journal BioMed Central. Researchers from The University of Texas School of Public Health examined 500 Mexican-American adults from the Cameron County Hispanic Cohort in Brownsville, Texas, each of whom had been diagnosed diabetes and were taking medication for diabetes. Each t was interviewed about symptoms of depression and anxiety, and researchers also took measurements for body mass index (BMI), waist circumference, physical activity, fasting glucose and average blood sugar levels over time. “Unfortunately, greater depression and anxiety are associated with higher BMI and greater waist circumference, both indicators of obesity, as well as engaging in less physical activity and having less favorable indicators of glycemic control,” said Darla Kendzor, PhD, principal investigator and assistant professor at the School of Public Health Dallas Regional Campus, part of The University of Texas Health Science Center at Houston. Eighty one percent of Mexican-Americans are obese or overweight nationwide, with a nationwide diabetes rate of 16.3 that climbs to 30 percent for those who live along the U.S.-Mexico border. Read more on obesity.
Tomorrow, March 25, the day after World Tuberculosis Day, the Public Broadcasting Program Frontline will present TB Silent Killer a new documentary that looks at tuberculosis in Swaziland, the country with the highest incidence of the disease.
While many people, especially in the United States, think tuberculosis has long since been eradicated, there are in fact more than 8 million new infections every year, many of them virulent new drug-resistant strains that are passed—throughout the world—through a cough or a sneeze. According to the World Health Organization, tuberculosis has become the second-leading cause of death from an infectious disease on the planet.
Jezza Neumann, the filmmaker who created TB Silent Killer, tells the story of several people in Swaziland suffering daily from the disease, including ten-year-old Nokubegha, whose mother recently died of a multidrug resistant strain of tuberculosis and whose 17-year-old brother cares for her.
“In Swaziland, a quarter of all adults are HIV-positive, which means their immune systems are compromised and especially susceptible to TB infection,” said Neumann, “But globalization and international travel mean that these infections have the potential to spread all over the world.”
NewPublicHealth spoke by phone with Jezza Neumann a few days before the documentary was scheduled to air on Frontline (Check local PBS schedules here.)
NewPublicHealth: Why did you choose tuberculosis as your topic?
Jezza Neumann: The idea being to make films that make a difference and give voice to the voiceless. In doing so, we’ve made and kept relationships with nonprofits and NGOs and other organizations and look to find the issue that’s hidden in the background that no one is hearing about, that’s not getting the platform that it needs.
One of the organizations we’d worked a lot with is MSF, Medecins Sans Frontieres, or Doctors Without Borders as it’s known over here. The press officer at the U.K. office knew that Doctors Without Borders had been struggling to get the issue of tuberculosis out on the mainstream. People had done small reports but she knew there was a big impact possible with a documentary because the reality is if you combine the facts, stats and figures in documents with a film that has a human face and a human cost of those facts, stats and figures, it becomes something so much bigger. The documentary becomes a platform that has a life far further reaching than just the transmission.
HHS: Common Sports Injuries Mean High Costs for People Without Insurance
The ASPE Office of Health Policy, part of the U.S. Department of Health and Human Services (HHS), has released a new issue brief analyzing the incidence and average health care charges associated with common sports injuries. The injuries range from minor sprains and strains to more serious injuries such as broken bones and concussions, where direct medical bills can be significant, placing an especially heavy burden on people without health insurance. Such individuals could be made to pay not just out-of-pocket costs, but also providers’ full stated charges. Breaking down health care costs by age and sometimes gender, the brief found, for example, that the average cost to fix a leg fracture for a person 10-19 years old was $4,689 and for those ages 25-40 was $3,403. Read more on injury prevention.
CDC: Drexel Meningitis Death Linked to Princeton Outbreak
Researchers at the U.S. Centers for Disease Control and Prevention have confirmed through “genetic fingerprinting” that a Drexel University student who died March 10 from meningitis died from the same serogroup B meningococcal strain that previously caused an outbreak at Princeton University. Health department officials confirmed that the Drexel student had been in close contact with Princeton students a week before becoming ill, indicating that the strain may still be present in the Princeton University community. Health officials have already administered antibiotic prophylaxis to prevent additional cases of meningococcal disease in people who had been close to the Drexel student. No new cases have since been reported. Read more on infectious diseases.
Study: ICU Survivors Face Heightened Risk for Mental Health Problems
Critically ill people who survive a stay in a hospital intensive care unit (ICU) are at heightened risk for mental health problems such as depression and anxiety in the following months, according to a new study in the Journal of the American Medical Association. Examining the records of more than 24,000 Danish ICU patients, researchers found that in the three months post-discharge that about 0.5 percent had a new diagnosis—which was 22 times higher than the rate in the general population. Approximately 13 percent received a new prescription for a psychiatric medication, including antidepressants and drugs for anxiety and insomnia, during that period. Researchers said the findings indicate that as doctors become better at saving the lives of critically ill patients, more people will also be at risk for problems beyond their physical health. Read more on mental health.
CDC: Reducing High-risk Antibiotic Prescriptions Could Also Reduce Deadly Infections
The most recent Vital Signs report from the U.S. Centers for Disease Control and Prevention (CDC) finds that if prescriptions of high-risk antibiotics in hospitals were reduced by just 30 percent, then there could be as many as 26 fewer cases of deadly diarrhea infections with Clostridium difficile. “Improving antibiotic prescribing can save today’s patients from deadly infections and protect lifesaving antibiotics for tomorrow’s patients,” said CDC Director Tom Frieden, MD, MPH. “Health care facilities are an important part of the solution to drug resistance and every hospital in the country should have a strong antibiotic stewardship program.” As part of its ongoing efforts to improve antibiotic prescribing, the CDC has release a checklist of seven core elements for hospitals:
- Leadership commitment: Dedicate the necessary human, financial, and IT resources.
- Accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role.
- Drug expertise: Appoint a single pharmacist leader to support improved prescribing.
- Act: Take at least one prescribing improvement action, such as requiring reassessment of prescriptions within 48 hours to check drug choice, dose, and duration.
- Track: Monitor prescribing and antibiotic resistance patterns.
- Report: Regularly report prescribing and resistance information to clinicians.
- Educate: Offer education about antibiotic resistance and improving prescribing practices.
Read more on infectious diseases.
Poorer Women Most Likely to Be Caught in ‘Vicious’ Caregiving, Financial Well-being Cycle
Low-income women are at increased risk of finding themselves caught in a “vicious cycle” of parental caregiving and financial well-being, according to a new study in The Journals of Gerontology. While women of better financial means can afford additional caregiver assistance and better health care for aging parents, poorer women lack those options. "People who had less household income and less financial resources were more likely to take care of their parents so there is this cycle that they cannot get out of—they are poor, then taking care of parents, then being poor and taking care of their parents—there's this kind of cycle," said lead author Yeonjung Lee, a researcher and professor at the Faculty of Social Work at the University of Calgary in Alberta, Canada, according to Reuters. Read more on aging.
Young Skin Cancer Survivors at Heightened Risk for Other Cancers
Younger skin cancer survivors are at increased risk for additional cancer types later in life, according to a new study in the journal Cancer Epidemiology, Biomarkers & Prevention. A review of data of more than 500,000 people with a history of nonmelanoma skin cancer found that while all age groups were at heightened risk for melanoma and other types of cancers, the increase was especially significant for people under the age of 25, who were 23 times more likely to develop cancer than people who had never had nonmelanoma cancer. The risk was 3.5 times higher for nonmelanoma survivors ages 25-44, 1.74 times higher for those ages 45-59 and 1.32 times higher for those older than 60. The types of cancer they are at risk for include melanoma skin cancer, and cancers of the breast, colon, bladder, liver, lung, brain, prostate, stomach and pancreas. Read more on cancer.
FDA Proposes New ‘Nutrition Facts’ Food Labels
The U.S. Food and Drug Administration (FDA) has put forth a new proposed Nutrition Facts label for packaged foods. The updated design would reflect scientific information not available when the current label was designed two decades ago. For example, it would replace out-of-date serving sizes and feature a design that highlights key parts of the label, such as calories and serving sizes. “For 20 years consumers have come to rely on the iconic nutrition label to help them make healthier food choices,” said FDA Commissioner Margaret A. Hamburg, MD. “To remain relevant, the FDA’s newly proposed Nutrition Facts label incorporates the latest in nutrition science as more has been learned about the connection between what we eat and the development of serious chronic diseases impacting millions of Americans.” Read more on nutrition.
Study: One in Five U.S. Health Facilities Don’t Provide Hand Sanitizer Everywhere Needed
One in five U.S. health facilities don’t make hand sanitizer available everywhere necessary, needlessly increasing the risk for health-care associated infections, according to a new study in the American Journal of Infection Control. In addition, approximately half of the hospitals, ambulatory care facilities and long-term care facilities included in their budgets funds for proper hand hygiene training. The study examine compliance with the World Health Organization’s hand hygiene guidelines at 168 facilities in 42 states and Puerto Rico. "When hospitals don't focus heavily on hand hygiene, that puts patients at unnecessary risk for preventable health care-associated infections," said by Laurie Conway, RN, MS, CIC, PhD student at Columbia Nursing, in a release. "The tone for compliance with infection control guidelines is set at the highest levels of management, and our study also found that executives aren't always doing all that they can to send a clear message that preventing infections is a priority." Read more on infectious disease.
CDC Foundation Expands Safe Injection Campaign
The CDC Foundation and Eli Lilly are partnering to expand the U.S. Centers for Disease Control and Prevention’s (CDC) Safe Injection Practices Coalition—a safety awareness campaign that provides information for health providers and patients. According to CDC data, more than 150,000 patients have been notified of potential exposure to hepatitis and HIV because of unsafe injection practices in U.S. health care settings since 2001, and CDC researchers have found that medical injections are an overlooked source of infections and outbreaks. Planned actives of the partnership include:
- Expand the One & Only Campaign to new audiences such as individual and group-owned physician practices
- Educate health care providers through new and enhanced training and communication materials to address emerging issues
- Improve the Safe Injection Practices Coalition website and social media platforms to share resources and toolkits with new audiences
- Engage new and existing Safe Injection Practices Coalition partners
Read more on prevention.
What’s that cute blue thing shining its lights in the patient rooms and hallways of the National Institutes of Health’s (NIH) clinical center in Bethesda, Md.? A literal life saver.
Tru-D, a new robot now gainfully employed at the NIH, shoots beams of ultraviolet (UV) light. The rays kill a range of pathogens, including many of the bacterial strains—such as MRSA and C.diff—that have been linked to 90,000 health system deaths each year, according to the U.S. Centers for Disease Control and Prevention (CDC).
Manual disinfecting rids surfaces of about half of the bacteria in an area. Limitations of human cleaning squads include the probability they can miss a few—or many—spots and that disinfectants must remain wet on a surface for a full ten minutes to fully do their job and then be rinsed away. That time commitment is often very costly for hospitals that typically need to turn over patient rooms quickly. But incomplete disinfection can leave a lot of disease. MRSA, for example, can remain on surfaces for as long as nine months.
The UV light units work by disrupting the DNA structure of pathogens, which destroys some and makes others harmless.
Tru-D is just one of several UV light units on the market. It has been getting some attention recently both because of the NIH purchase and because it has some especially interesting features, including a cloud-computing system that lets it link up to health system records and automatically chart which rooms have been disinfected.
UV light doesn’t come cheap. Units, which come in different sizes that determine how wide a space they can disinfect simultaneously, can range from about $60,000 to $120,000. But hospitals also consider what they’re saving by making the purchase—such as new fines under the Affordable Care Act for some hospital readmissions before thirty days after a discharge. And some of those readmissions are for infections acquired during a hospital stay.
The units won’t displace the human cleaning staff, says Steve Streed, system director of Epidemiology/Infection Control at the Lee Memorial Health System in Fort Myers, Fla. and a member of the Association for Professionals in Infection Control and Epidemiology For example, the robots can’t rid spaces of blood and other substances humans leave behind.
UV units can disinfect a space in ten or twenty minutes. One limitation on their power and cleaning time is the wattage in hospitals. Units can be made more powerful but would blow out a hospital’s circuits. Streed says one company is working on a hybrid unit that would use both electricity and battery to amp up the wattage—and likely reduce the time needed—to disinfect hospital spaces.
Streed says recent studies have found that human disinfecting still leaves 50 percent of residual bacteria and UV light gets rid of 99 percent of what remains. Another disinfecting system, fogging rooms with hydrogen peroxide, gets rid of 99.9 percent, but takes more time since air ducts have to be closed before it use and then reopened afterwards. Either option gets rid of sufficient bacteria, says Streed. What remains is generally not in high enough levels to infect a patient.
>>Bonus Link: Read a CDC Vital Signs Report on Hospital Acquired Infections.
Study: Increasing Young Men’s Knowledge of Emergency Contraception Could Increase Access, Use
Increasing young men’s knowledge of emergency contraception could increase access to the drug and help prevent unwanted pregnancies, according to a new study in Journal of Family Planning and Reproductive Health Care. Emergency contraception, commonly known as "the morning after pill," prevents pregnancy after unprotected sex or when other methods of contraception fail. Nine U.S. states allow pharmacists to dispense emergency contraception without a prescription under certain conditions. The study gauged the knowledge of 101 males and 97 females ages 18 to in 2008 and 2009. "About half of the women understood basic facts about emergency contraception, how you get it, how you use it, and the fact that male partners were also able to buy it over-the-counter for their female partners," said Sheree Schrager, a member of the study team and a researcher at Children's Hospital Los Angeles, California. “But young men had significantly lower knowledge then the young women did, and this is an opportunity for providers to reach out to young men in the hopes of reaching more young women to use emergency contraception.” According to the researchers, unplanned pregnancies are more common in poor communities, where there are also greater health and economic consequences. Read more on sexual health.
U.S., Global Partners to Joint in Prevention, Detection and Response to Infectious Disease
The United States has joined with 26 countries and other global partners to, over the next five years, work to prevent, detect and effectively respond to naturally occurring, accidental and intentional infectious disease threats. Additional partners in the Global Health Security Agenda include the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE). “While we have made great progress in fighting and treating diseases, biological threats can emerge anywhere, travel quickly, and take lives,” said Lisa Monaco, Assistant to the President for Homeland Security and Counterterrorism. “The recent outbreaks of H7N9 influenza and Middle East Respiratory Syndrome are reminders of the need to step up our efforts as a global community. The Global Health Security Agenda is about accelerating progress toward a world safe and secure from infectious disease threats.” The U.S. Centers for Disease Control and Prevention (CDC) has pledged $40 million in FY 2014 to advancing Global Health Security Agenda objectives, and its FY 2015 budget will include an additional $45 million to prevent avoidable catastrophes, detect threats early and mobilize effective responses to contain outbreaks. Read more on global health.
CDC: States with Indoor Tanning Laws See Far Less Use by Female High School Students
States with indoor tanning laws—especially those requiring parental permission or setting age restrictions—see lower rates of indoor tanning by female high school students, according to a new study in the American Journal of Public Health. The study was conducted by the U.S. Centers for Disease Control and Prevention. Studies have connected the increased exposure to ultraviolet radiation from indoor tanning to increased risk of melanoma; each year the United States sees 60,000 new melanoma diagnoses and approximately 3.5 million treatments for nonmelanoma skin cancer. The study determined that the odds of female students engaging in indoor tanning in states with any indoor tanning laws were 30 percent less than those in states without such laws, and that the odds in states with systems access, parental permission and age restriction laws were 42 percent less than those in states without any laws. “State indoor tanning laws, especially age restrictions, may be effective in reducing indoor tanning among our nation’s youth,” said Gery Guy, PhD, health economist and the study’s lead author. “We need to address the harms of indoor tanning, especially among children. Indoor tanning laws can be part of a comprehensive effort to prevent skin cancers and change social norms around tanned skin.” Read more on cancer.
SAMHSA Disaster Distress Helpline Open 24/7 to Help People Impacted by the Severe Weather
The Substance Abuse and Mental Health Administration (SAMHSA) issued a bulletin yesterday to remind public health officials and the community that its Disaster Distress Helpline (1-800-985-5990) can provide immediate counseling to anyone who needs help in dealing with the damage caused by the winter storms in the Mid-Atlantic and Southern states. The helpline is a 24 hours-a-day, seven-days-a-week resource that responds to people who need crisis counseling after experiencing a natural or man-made disaster or tragedy. The helpline immediately connects callers to trained professionals from the closest crisis counseling center; helpline staff provide confidential counseling, referrals and other needed support services. Assistance is available in several languages. The helpline can also be accessed by texting TalkWithUs to 66746, by going here and by TTY for deaf and hearing impaired at 1-800-846-8517. Read more on disasters.
Well-Child Visits Linked to More than 700,000 Cases of Flu-Like Illness
A recent study in Infection Control and Hospital Epidemiology links well-child doctor appointments for annual exams and vaccinations with an increased risk of flu-like illnesses in children and family members within two weeks of the visit. This risk translates to more than 700,000 potentially avoidable illnesses each year, costing more than $490 million annually, according to the researchers.
"Well child visits are critically important. However, our results demonstrate that healthcare professionals should devote more attention to reducing the risk of spreading infections in waiting rooms and clinics [and] more attention should be paid to these guidelines by healthcare professionals, patients, and their families," said Phil Polgreen, MD, MPH, lead author of the study.
The researchers used data from the Agency for Healthcare Research and Quality's (AHRQ) Medical Expenditure Panel Survey to examine the health care trends of 84,595 families collected from 1996-2008. After controlling for factors including the presence of other children, insurance and demographics, the authors found that well-child visits for children younger than six years old increased the probability of a flu-like illness in these children or their families during the subsequent two weeks by 3.2 percentage points. A commentary in the journal on the study also pointed out the likelihood of some unnecessary antibiotics being prescribed for some of the illnesses.
"Even with interventions, such as the restricted use of communal toys or separate sick and well-child waiting areas, if hand-hygiene compliance is poor and potentially infectious patients are not wearing masks, preventable infections will continue to occur," said Polgreen. Read more on infectious disease.
NIH Study Seeks to Improve Asthma Therapy for African-Americans
A new study by researchers at the National Heart Lung and Blood Institute, a division of the U.S. National Institutes of Health, is enrolling about 500 African-American children and adults with asthma in a multi-center clinical trial to assess how they react to therapies and to explore the role of genetics in determining the response to asthma treatment. The study will be conducted at 30 sites in 14 states, and its goal is to determine the best approach for asthma management in African-Americans, who suffer much higher rates of serious asthma attacks, hospitalizations and asthma-related deaths than whites. “While national asthma guidelines provide recommendations for all patients with asthma, it is possible that, compared with other groups, African-Americans respond differently to asthma medications,” said Michael Wechsler, MD, principal investigator for the study and professor of medicine at National Jewish Health in Denver. “Our study is designed to specifically address how asthma should be managed in African-American asthma patients, both adults and children.” Read more on health disparities.
Study: School Assaults Lead to Nearly 90,000 ER Visits Annually
Assaults at school account for almost 90,000 emergency-room visits annually, according to a new study in the journal Pediatrics. In a review of data on students ages 5-19, researchers determined that an average of 92,000 annual emergency visits were a result of deliberate injury, with student-on-student assault accounting for about 88,000. About 40 percent of the injuries were bruises or scratches, with few leading to later hospitalization. "[The number of injuries] appears to be concerningly high, especially when you realize that such a substantial number of injuries are occurring in the school setting, where safety measures are already in place," said lead author Siraj Amanullah, MD, an assistant professor of emergency medicine and pediatrics at Brown University's Alpert Medical School. "There is a need to continue addressing this issue at various levels—at home, at school and in the medical care setting—and there is a need to ramp up our existing prevention and safety strategies.” Read more on violence.
WHO: India Can Now Be Declared Polio-Free
With now three years passed since its last reported cased of polio—January 13, 2011—the country of India can now be declared polio-free, according to the World Health Organization (WHO). The certification process should be completed by the end of March. The country’s last victim was a two-year-old girl in West Bengal. This now leaves Afghanistan, Pakistan and Nigeria as the only countries where polio remains endemic. As part of our recent Outbreak Week, NewPublicHealth recently spoke with Sona Bari, WHO’s senior communications officer, about the efforts underway to eradicate polio globally. Read more on infectious disease.
Translation Errors Plague ACA’s Spanish-language Site, Impede Enrollment
Problems with the Spanish-language version of the Affordable Care Act’s website are making it difficult for many of the site’s users to navigate the site and enroll for coverage. In addition to launching late and sending users to English-language forms when they are clearly looking for Spanish-language content, CuidadoDeSalud.gov is also full of grammatical and other language mistakes. "When you get into the details of the plans, it's not all written in Spanish. It's written in Spanglish, so we end up having to translate it for them," said Adrian Madriz, a health care navigator who helps with enrollment in Miami. Several states with large Hispanic populations have fallen short in their goals to enroll Spanish-speakers, with critics pointing to the website as a major impediment. For example, while it’s not know how many of California’s 4.3 million residents who only speak Spanish intend to seek coverage under the Affordable Care Act, through the end of November only 5,500 had successfully enrolled. Read more on the Affordable Care Act.
North America Sees First Death from H5N1 Bird Flu
North America has seen its first fatal case of H5N1 bird flu after a passenger on a Dec. 27 flight from Beijing to Canada first became ill. Canada’s health minister has stated it was an isolated case and the general public is at little risk. The victim, who died in Alberta, had only visited Beijing while in China, and not been to any farms or markets, which raises additional concerns. "This is the first evidence of this particular virus circulating in Beijing. Chinese authorities are going to be very interested. We've contacted them already," said Gregory Taylor, MD. According to the World Health Organization, as of mid-December there were 648 laboratory-confirmed human cases of H5N1 flu, with 384 leading to death. Read more on infectious disease.
Study: Full-service Restaurants Need Standard Definitions for ‘Health Choice’ Tags
Full-service restaurants should adopt standard definitions for ''healthy choice'' tags and for entrees, especially those that target vulnerable age groups, according to a new study in the Journal of Nutrition Education and Behavior. The study found that despite popular belief, food from full-service restaurants is not always healthier and higher in quality than food from fast-food restaurants, and can ever have much higher calorie, fat and sodium levels. The push to adopt these standards is especially significant because about one-third of all calories purchased in the United States are from food prepared away from home. "The need to educate customers about the nutritional content of restaurant foods is acute because consumers increasingly eat away from home, restaurants serve large portions of energy-dense and high-sodium foods, and obesity and the prevalence of other diet-related diseases are high," said lead researcher Amy Auchincloss, PhD, MPH, of the Drexel University School of Public Health. Read more on nutrition.
Racial Disparities in Deaths After Heart Bypass Surgery Linked to Hospital Quality
Racial disparities in the death risk after heart bypass surgery are linked to hospital quality, according to a new study in the journal JAMA Surgery. Researchers analyzed the records of more than 170,000 Medicare patients who had heart bypass surgery and found that nonwhite patients had a 33 percent higher death rate after the surgery. In hospitals with the highest rates of nonwhite patients, the death rate was 4.8 percent for nonwhite patients and 3.8 percent for white patients. The disparity is explained in part because nonwhite patients have less access to high-quality hospitals with lower death rates, as well as by factors such as regional variations in hospital quality, how close patients live to high-quality hospitals and race-based referral decisions. Read more on health disparities.