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Shilling DM, Manz CR, Strand JJ, Patel MI. Let Us Have the Conversation: Serious Illness Communication in Oncology: Definitions, Barriers, and Successful Approaches. Am Soc Clin Oncol Educ Book 2024; 44:e431352. [PMID: 38788187 DOI: 10.1200/edbk_431352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Serious illness communications are crucial elements of care delivery for patients with cancer. High-quality serious illness communications are composed of open, honest discussions between patients, caregivers, and clinicians regarding patient's communication preferences, expected illness trajectory, prognosis, and risks and benefits of any recommended care. High-quality communication ideally starts at the time of a patients' cancer diagnosis, allows space for and response to patient emotions, elicits patients' values and care preferences, and is iterative and longitudinal. When integrated into cancer care, such communication can result in improved patient experiences with their care, care that matches patients' goals, and reduced care intensity at the end of life. Despite national recommendations for routine integration of these communication into cancer care, a minority of patients with cancer receive such communication. In this chapter, we describe elements of high-quality serious illness communication, patient-, clinician-, institution-, and payer-level barriers, and successful strategies that can routinely integrate such communication into cancer care delivery.
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Affiliation(s)
- Danielle M Shilling
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Christopher R Manz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Jacob J Strand
- Division of Community Internal Medicine, Geriatrics & Palliative Care, Mayo Clinic, Rochester, MN
| | - Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
- VA Palo Alto Health Care System, Palo Alto, CA
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Liu X, Berkman C. Hospice Knowledge, Attitudes, and Preference among Older Chinese Immigrants in the United States. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024; 20:201-216. [PMID: 38557360 DOI: 10.1080/15524256.2024.2330920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Racial disparities in hospice use are a longstanding concern in the U.S. Asian Americans are among the least likely to receive hospice care and to be included in studies on this topic. This study examined the knowledge, attitudes, and preferences related to hospice care among older Chinese immigrants and associated factors. A sample of 262 Chinese immigrants age 60+ was recruited from six older adult centers in NYC. In-person interviews were conducted in Mandarin and Cantonese. Non-English-speaking older Chinese immigrants had very limited knowledge about hospice care. Only 26% of respondents had heard of hospice, and a few could correctly define any components. After receiving a comprehensive definition of hospice care, study participants expressed a positive attitude and a strong willingness to use hospice if near the end of life. Notably, some respondents still held misconceptions about hospice and were less positive in their attitude and preference for hospice care. These findings underscore the necessity for clear and accessible information about hospice among this population throughout the trajectory from good health to end of life. Further research is needed to identify the range of factors that influence the attitudes and preferences of older Chinese immigrants toward hospice care.
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Affiliation(s)
- Xiaofang Liu
- Columbia Population Research Center, Columbia University, New York, New York, USA
| | - Cathy Berkman
- Graduate School of Social Service, Fordham University, New York, New York, USA
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Brown CE, Marshall AR, Cueva KL, Snyder CR, Kross EK, Young BA. Physician Perspectives on Addressing Anti-Black Racism. JAMA Netw Open 2024; 7:e2352818. [PMID: 38265801 PMCID: PMC10809013 DOI: 10.1001/jamanetworkopen.2023.52818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 12/01/2023] [Indexed: 01/25/2024] Open
Abstract
Importance Uncertainty remains among clinicians regarding processes to address and resolve conflict around anti-Black racism. Objective To elicit clinicians' perceptions of their role in addressing concerns about anti-Black racism among Black patients with serious illness as well as their families. Design, Setting, and Participants In this qualitative study, one-on-one semistructured interviews were conducted with 21 physicians at an academic county hospital between August 1 and October 31, 2022. Participants were provided clinical scenarios where anti-Black racism was a concern of a patient with serious illness. Participants were asked open-ended questions about initial impressions, prior similar experiences, potential strategies to address patients' concerns, and additional resources to support these conversations. A framework based on restorative justice was used to guide qualitative analyses. Main Outcomes and Measures Perspectives on addressing anti-Black racism as described by physicians. Results A total of 21 medical subspecialists (mean [SD] age, 44.2 [7.8] years) participated in the study. Most physicians were women (14 [66.7%]), 4 were Asian (19.0%), 3 were Black (14.3%), and 14 were White (66.7%). Participants identified practices that are normalized in clinical settings that may perpetuate and exacerbate perceptions of anti-Black racism. Using provided scenarios and personal experiences, participants were able to describe how Black patients are harmed as a result of these practices. Last, participants identified strategies and resources for addressing Black patients' concerns and facilitating conflict resolution, but they stopped short of promoting personal or team accountability for anti-Black racism. Conclusions and Relevance In this qualitative study, physicians identified resources, skills, and processes that partially aligned with a restorative justice framework to address anti-Black racism and facilitate conflict resolution, but did not provide steps for actualizing accountability. Restorative justice and similar processes may provide space within a mediated setting for clinicians to repair harm, provide accountability, and facilitate racial healing.
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Affiliation(s)
- Crystal E. Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Arisa R. Marshall
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kristine L. Cueva
- Department of Medicine, Center for Health Workforce Studies, School of Medicine, University of Washington, Seattle
| | - Cyndy R. Snyder
- Department of Family Medicine, University of Washington, Seattle
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Bessie A. Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Justice, Equity, Diversity, and Inclusion Center for Transformational Research, Office of Healthcare Equity, University of Washington, Seattle
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Brown CE, Marshall AR, Snyder CR, Cueva KL, Pytel CC, Jackson SY, Golden SH, Campelia GD, Horne DJ, Doll KM, Curtis JR, Young BA. Perspectives About Racism and Patient-Clinician Communication Among Black Adults With Serious Illness. JAMA Netw Open 2023; 6:e2321746. [PMID: 37405773 PMCID: PMC10323709 DOI: 10.1001/jamanetworkopen.2023.21746] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/15/2023] [Indexed: 07/06/2023] Open
Abstract
Importance Black patients with serious illness experience higher-intensity care at the end of life. Little research has used critical, race-conscious approaches to examine factors associated with these outcomes. Objective To investigate the lived experiences of Black patients with serious illness and how various factors may be associated with patient-clinician communication and medical decision-making. Design, Setting, and Participants In this qualitative study, one-on-one, semistructured interviews were conducted with 25 Black patients with serious illness hospitalized at an urban academic medical center in Washington State between January 2021 and February 2023. Patients were asked to discuss experiences with racism, how those experiences affected the way they communicated with clinicians, and how racism impacted medical decision-making. Public Health Critical Race Praxis was used as framework and process. Main Outcomes and Measures The experience and of racism and its association, as described by Black patients who had serious illness, with patient-clinician communication and medical decision-making within a racialized health care setting. Results A total of 25 Black patients (mean [SD] age, 62.0 [10.3] years; 20 males [80.0%]) with serious illness were interviewed. Participants had substantial socioeconomic disadvantage, with low levels of wealth (10 patients with 0 assets [40.0%]), income (annual income <$25 000 among 19 of 24 patients with income data [79.2%]), educational attainment (mean [SD] 13.4 [2.7] years of schooling), and health literacy (mean [SD] score in the Rapid Estimate of Adult Literacy in Medicine-Short Form, 5.8 [2.0]). Participants reported high levels of medical mistrust and high frequency of discrimination and microaggressions experienced in health care settings. Participants reported epistemic injustice as the most common manifestation of racism: silencing of their own knowledge and lived experiences about their bodies and illness by health care workers. Participants reported that these experiences made them feel isolated and devalued, especially if they had intersecting, marginalized identities, such as being underinsured or unhoused. These experiences were associated with exacerbation of existing medical mistrust and poor patient-clinician communication. Participants described various mechanisms of self-advocacy and medical decision-making based on prior experiences with mistreatment from health care workers and medical trauma. Conclusions and Relevance This study found that Black patients' experiences with racism, specifically epistemic injustice, were associated with their perspectives on medical care and decision-making during serious illness and end of life. These findings suggest that race-conscious, intersectional approaches may be needed to improve patient-clinician communication and support Black patients with serious illness to alleviate the distress and trauma of racism as these patients near the end of life.
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Affiliation(s)
- Crystal E. Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Arisa R. Marshall
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Cyndy R. Snyder
- Department of Family Medicine, Center for Health Workforce Studies, School of Medicine, University of Washington, Seattle
| | | | - Christina C. Pytel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | | | - Sherita H. Golden
- Division of Endocrinology, Diabetes, and Metabolism, John Hopkins University, Baltimore, Maryland
| | - Georgina D. Campelia
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - David J. Horne
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kemi M. Doll
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Bessie A. Young
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Justice, Equity, Diversity, and Inclusion Center for Transformational Research, University of Washington, Seattle
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Secunda KE, Kruser JM. Patient-Centered and Family-Centered Care in the Intensive Care Unit. Clin Chest Med 2022; 43:539-550. [PMID: 36116821 PMCID: PMC9885766 DOI: 10.1016/j.ccm.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Patient-centered and family-centered care (PFCC) is widely recognized as integral to high-quality health-care delivery. The highly technical nature of critical care puts patients and families at risk of dehumanization and renders the delivery of PFCC in the intensive care unit (ICU) challenging. In this article, we discuss the history and terminology of PFCC, describe interventions to promote PFCC, highlight limitations to the current model, and offer future directions to optimize PFCC in the ICU.
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Affiliation(s)
- Katharine E Secunda
- Department of Medicine, Division of Pulmonary and Critical Care, University of Pennsylvania
| | - Jacqueline M Kruser
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA.
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Starr LT, Ulrich C, Perez GA, Aryal S, Junker P, O’Connor NR, Meghani SH. Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation. Am J Hosp Palliat Care 2022; 39:619-632. [PMID: 34318700 PMCID: PMC8795236 DOI: 10.1177/10499091211034383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities. OBJECTIVE To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs. METHODS This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital. RESULTS In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race. CONCLUSIONS Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Connie Ulrich
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - G. Adriana Perez
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration *
Consultation * Analysis) Lab, University of Pennsylvania School of Nursing,
Philadelphia, Pennsylvania
| | | | - Nina R. O’Connor
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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Marcewicz L, Kunihiro SK, Curseen KA, Johnson K, Kavalieratos D. Application of Critical Race Theory in Palliative Care Research: A Scoping Review. J Pain Symptom Manage 2022; 63:e667-e684. [PMID: 35231591 DOI: 10.1016/j.jpainsymman.2022.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/13/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Structural racism negatively impacts individuals and populations. In the medical literature, including that of palliative care, structural racism's influence on interracial differences in outcomes remains poorly examined. Examining the contribution of structural racism to outcomes is paramount to promoting equity. OBJECTIVES We examined portrayals of race and racial differences in outcomes in the palliative care literature and created a framework using critical race theory (CRT) to aid in this examination. METHODS We reviewed the CRT literature and iteratively developed a rubric to examine when and how differences between races are described. Research articles published in The Journal of Pain and Symptom Management presenting empiric data specifically including findings about racial differences were examined independently by three reviewers using the rubric. RESULTS Fifty-seven articles met inclusion criteria. Articles that specifically described racial differences were common in the topic areas of quality (75% of articles), hospice (53%), palliative care services (40%) and spirituality/religion (40%). The top three reasons posited for racial differences were patient preference (26%), physician bias (23%), and cultural barriers (21%). Using the CRT rubric we found that 65% of articles posited that a racial difference was something that needed to be rectified, while articles rarely provided narrative (5%) or other data on perspectives of people of color (11%) to explain assumptions about differences. CONCLUSION Palliative care research frequently highlights racial differences in outcomes. Articles that examine racial differences often assume that differences need to be fixed but posit reasons for differences without the narratives of those most affected by them.
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Affiliation(s)
- Lawson Marcewicz
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA; Atlanta VA Health Care System (L.M.), Decatur, Georgia, USA.
| | - Susan K Kunihiro
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Kimberly A Curseen
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Khaliah Johnson
- Division of Pediatric Palliative Medicine (K.J.), Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
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Jones KF, Laury E, Sanders JJ, Starr LT, Rosa WE, Booker SQ, Wachterman M, Jones CA, Hickman S, Merlin JS, Meghani SH. Top Ten Tips Palliative Care Clinicians Should Know About Delivering Antiracist Care to Black Americans. J Palliat Med 2022; 25:479-487. [PMID: 34788577 PMCID: PMC9022452 DOI: 10.1089/jpm.2021.0502] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Racial disparities, including decreased hospice utilization, lower quality symptom management, and poor-quality end-of-life care have been well documented in Black Americans. Improving health equity and access to high-quality serious illness care is a national palliative care (PC) priority. Accomplishing these goals requires clinician reflection, engagement, and large-scale change in clinical practice and health-related policies. In this article, we provide an overview of key concepts that underpin racism in health care, discuss common serious illness disparities in Black Americans, and propose steps to promote the delivery of antiracist PC.
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Affiliation(s)
| | - Esther Laury
- Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA.,Address correspondence to: Esther Laury, PhD, RN, Merck Sharp & Dohme Corp., US Outcomes Research, 351 N. Sumneytown Pike, North Wales, PA 19454, USA
| | - Justin J. Sanders
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren T. Starr
- New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - William E. Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Staja Q. Booker
- Department of Biobehavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Melissa Wachterman
- Section of General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Christopher A. Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Susan Hickman
- Department of Community and Health Systems, Indiana University School of Nursing, Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Jessica S. Merlin
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,New Courtland Center for Transitions and Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Starr LT, O'Connor NR, Meghani SH. Improved Serious Illness Communication May Help Mitigate Racial Disparities in Care Among Black Americans with COVID-19. J Gen Intern Med 2021; 36:1071-1076. [PMID: 33464466 PMCID: PMC7814859 DOI: 10.1007/s11606-020-06557-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Lauren T Starr
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Nina R O'Connor
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Salimah H Meghani
- NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
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