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Chhabra K, Rajdeo H, McGuirk M, John D, Castaldi M. Race-Conscious Learning and Sociocultural Competence in an Academic Surgery Program: Diversity, Equity, and All-Inclusion Program. J Surg Res 2024; 301:88-94. [PMID: 38917578 DOI: 10.1016/j.jss.2024.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Race-based associations in medicine are often taught and learned early in medical education. Students and residents enter training with implicit and explicit biases from their educational environments, further propagating biases in their practice of medicine. Health disparities described out of context can lead trainees to develop harmful stereotypes. Surgery leadership created a model to implement educational opportunities, resources, and outcomes in an academic Department of Surgery. METHODS An ad hoc committee of surgical faculty, residents, and medical students was assembled. Educational goals and objectives were established via Diversity, Equity & Inclusion (DEI) committee: 1) incorporate race-conscious awareness and learning into the academic surgery curriculum for residents and medical students, 2) cooperatively learn about race in clinical and surgical decision-making, 3) incorporate learning about social determinants of health that lead to racial and ethnic inequities, and 4) develop tailored learning in order to recognize and lessen health inequities. PHASE I DEI Committee formed of surgery faculty, residents, medical students, and support staff. Activities of the committee, goal development, a DEI mission statement, training, and education overview were formulated by committee members. PHASE II A strengths, weaknesses, opportunities, and threats analysis was created for assessment of diversity and inclusion, and race-conscious learning in the surgery clerkship and residency curriculum. Phase III: Baseline assessment to: 1) understand opinions on DEI in the Department of Surgery, 2) assess current representation within the department workforce, and 3) correlate workforce to the make-up of patient population served. Development and restructuring of the surgery education curriculum for medical students and residency created jointly with the Racism and Bias Task Force. RESULTS Educational programs have been implemented and delivered for: 1) appropriate inclusion of race-conscious learning such as image diversity, as well as race-based association, 2) social determinants of health in the care of patients, 3) racial disparities in surgical outcomes, 4) introduction of concepts on implicit bias, 5) opportunities for health equity rounds, and 6) inclusion in committees and leadership positions. CONCLUSIONS Awareness of clinical faculty and learners to race-conscious and antibias care is paramount to recognizing and addressing biases. Knowledge of sociocultural context may allow learners to develop a socioculturally sensitive approach for patient education, and to more broadly measure surgical outcomes. Race-conscious education should be implemented into teaching curriculum as well as professional development in attempts to close the gap in health-care equity.
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Affiliation(s)
| | - Heena Rajdeo
- New York Medical College, Surgery, Valhalla, New York
| | | | - Devon John
- New York Medical College, Surgery, Valhalla, New York
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Sakowitz S, Bakhtiyar SS, Mallick S, Porter G, Ali K, Vadlakonda A, Curry J, Benharash P. Persistent Racial Disparities in Morbidity Following Major Elective Operations. Am Surg 2024:31348241257462. [PMID: 38820594 DOI: 10.1177/00031348241257462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.
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Affiliation(s)
- Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Denver, Aurora, CO, USA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Giselle Porter
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Joanna Curry
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA, USA
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Gavin JR, Rodbard HW, Battelino T, Brosius F, Ceriello A, Cosentino F, Giorgino F, Green J, Ji L, Kellerer M, Koob S, Kosiborod M, Lalic N, Marx N, Prashant Nedungadi T, Parkin CG, Topsever P, Rydén L, Huey-Herng Sheu W, Standl E, Olav Vandvik P, Schnell O. Disparities in prevalence and treatment of diabetes, cardiovascular and chronic kidney diseases - Recommendations from the taskforce of the guideline workshop. Diabetes Res Clin Pract 2024; 211:111666. [PMID: 38616041 DOI: 10.1016/j.diabres.2024.111666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/29/2024] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
There is a mounting clinical, psychosocial, and socioeconomic burden worldwide as the prevalence of diabetes, cardiovascular disease (CVD), and chronic kidney disease (CKD) continues to rise. Despite the introduction of therapeutic interventions with demonstrated efficacy to prevent the development or progression of these common chronic diseases, many individuals have limited access to these innovations due to their race/ethnicity, and/or socioeconomic status (SES). However, practical guidance to providers and healthcare systems for addressing these disparities is often lacking. In this article, we review the prevalence and impact of healthcare disparities derived from the above-mentioned chronic conditions and present broad-based recommendations for improving access to quality care and health outcomes within the most vulnerable populations.
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Affiliation(s)
- James R Gavin
- Emory University School of Medicine, Atlanta, GA, USA
| | - Helena W Rodbard
- Endocrine and Metabolic Consultants, 3200 Tower Oaks Blvd., Suite 250, Rockville, MD 20852, USA.
| | - Tadej Battelino
- University Medical Center Ljubljana, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | - Frank Brosius
- University of Arizona College of Medicine, 1501 N. Campbell Ave, Tucson, AZ 85724-5022, USA.
| | - Antonio Ceriello
- IRCCS MultiMedica, Via Milanese 300, Sesto San Giovanni MI 20099, Italy.
| | - Francesco Cosentino
- Cardiology Unit, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Solna, Stockholm, Sweden.
| | - Francesco Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy
| | - Jennifer Green
- Duke University Medical Center, Duke Clinical Research Institute, 641 Durham Centre, Box 17969, Durham, NC 27715, USA.
| | - Linong Ji
- Peking University People's Hospital, 11 Xizhimen S St, Xicheng District, Beijing, China.
| | - Monika Kellerer
- Marienhospital Stuttgart, Böheimstraße 37, Stuttgart 70199, Germany.
| | - Susan Koob
- PCNA National Office, 613 Williamson Street, Suite 200, Madison, WI 53703, USA.
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Rd, Kansas City, MO 64111, USA; The George Institute for Global Health and University of New South Wales, Sydney, Australia.
| | - Nebojsa Lalic
- University Clinical Center of Serbia, University of Belgrade, Pasterova 2, Beograd 11000, Serbia
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University Pauwelsstraße 30, 52074 Aachen, Germany.
| | | | - Christopher G Parkin
- CGParkin Communications, Inc., 2675 Windmill Pkwy, Suite 2721, Henderson, NV 89074, USA
| | - Pinar Topsever
- Department of Family Medicine, Acıbadem Mehmet Ali Aydınlar University School of Medicine, İçerenköy, Kayışdağı Cd. No: 32, Ataşehir/İstanbul 34752, Türkiye.
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institute, Stockholm, Sweden.
| | - Wayne Huey-Herng Sheu
- Institute of Molecular and Genomic Medicine, National Research Health Institutes, Zhunan, Miaoli 350, Taiwan.
| | - Eberhard Standl
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, Neuherberg, Munich, Germany.
| | - Per Olav Vandvik
- Department of Medicine, Lovisenberg Diaconal Hospital, Institute of Health and Society, University of Oslo, Lovisenberggata 17, Oslo 0456, Norway
| | - Oliver Schnell
- Forschergruppe Diabetes e. V., Ingolstaedter Landstraße 1, Neuherberg, Munich, Germany.
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Abella MKIL, Thorne T, Hayashi J, Finlay AK, Frick S, Amanatullah DF. An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes. Orthopedics 2024; 47:e131-e138. [PMID: 38285555 DOI: 10.3928/01477447-20240122-01] [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] [Indexed: 01/31/2024]
Abstract
BACKGROUND Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties. MATERIALS AND METHODS The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics. RESULTS Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients. CONCLUSION Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].
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Gallagher KA, Mills JL, Armstrong DG, Conte MS, Kirsner RS, Minc SD, Plutzky J, Southerland KW, Tomic-Canic M. Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e232-e253. [PMID: 38095068 PMCID: PMC11067094 DOI: 10.1161/cir.0000000000001192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.
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Hamm RF, Srinivas SK, Mccoy J, Morales KH, Levine LD. Standardized Cesarean Risk Counseling with Induction: Impact on Racial Disparities in Birth Satisfaction. Am J Perinatol 2023; 40:1834-1840. [PMID: 34784614 PMCID: PMC9119147 DOI: 10.1055/s-0041-1739468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Our prior work demonstrated decreased birth satisfaction for Black women undergoing labor induction. We aimed to determine if implementation of standardized counseling around calculated cesarean risk during labor induction could reduce racial disparities in birth satisfaction. STUDY DESIGN We implemented use of a validated calculator that provides an individual cesarean risk score for women undergoing induction into routine care. This prospective cohort study compared satisfaction surveys for 6 months prior to implementation (preperiod: January 2018-June 2018) to 1 year after (postperiod: July 2018-June 2019). Women with full-term (≥37 weeks) singleton gestations with intact membranes and an unfavorable cervix undergoing induction were included. In the postperiod, providers counseled patients on individual cesarean risk at the beginning of induction using standardized scripts. This information was incorporated into care at patient-provider discretion. The validated 10-question Birth Satisfaction Scale-Revised (BSS-R) subdivided into three domains was administered throughout the study. Patients were determined to be "satisfied" or "unsatisfied" if total BSS-R score was above or below the median, respectively. In multivariable analysis, interaction terms evaluated the differential impact of the calculator on birth satisfaction by race (Black vs. non-Black women). RESULTS A total of 1,008 of 1,236 (81.6%) eligible women completed the BSS-R (preperiod: 330 [79.7%] versus postperiod: 678 [82.5%], p = 0.23), 63.8% of whom self-identified as Black. In the preperiod, Black women were 50% less likely to be satisfied than non-Black women, even when controlling for differences in parity (Black: 39.0% satisfied vs. non-Black: 53.9%, adjusted odds ratio [aOR] = 0.49, 95% confidence interval [CI]: 0.30-0.79). In the postperiod, there was no difference in satisfaction by race (Black: 43.7% satisfied vs. non-Black: 44.0%, aOR = 0.97. 95% CI: 0.71-1.33). Therefore, disparities in birth satisfaction were no longer present at postimplementation (interaction p = 0.03). CONCLUSION Implementation of standardized counseling with a validated calculator to predict cesarean risk after labor induction is associated with a decrease in racial disparities in birth satisfaction. KEY POINTS · Preintervention, Black women were less likely to have above-median birth satisfaction.. · We implemented standardized counseling around cesarean risk with labor induction.. · Implementation was associated with reduced racial disparities in birth satisfaction scores..
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Affiliation(s)
- Rebecca F Hamm
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sindhu K Srinivas
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer Mccoy
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lisa D Levine
- Department of Obstetrics and Gynecology, Maternal and Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Lander RD, Jones CMC, Hammert WC. Identification of Clinical and Demographic Predictors for Treatment Modality in Patients With Carpal Tunnel Syndrome. Hand (N Y) 2023; 18:758-764. [PMID: 34969298 PMCID: PMC10336806 DOI: 10.1177/15589447211060448] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. There are multiple treatment modalities for CTS. This study examines both clinical and demographic predictors for initial treatment modality of CTS. METHODS Patients diagnosed with CTS between February 2015 and October 2020 with a hand clinic visit within 6 weeks before treatment were included in our study. Patients completed Patient-Reported Outcomes Measurement Information System Pain Interference, Physical Function, and Depression and had complete data on relevant predictor variables. Primary outcomes were treatment group: (1) injection only; (2) release only; and (3) injection followed by release. Bivariate analyses and multinomial logistic regression was used to identify statistically significant variables and independent predictors associated with the treatment groups, respectively. RESULTS A total of 1409 patients fit our inclusion criteria. Sex, age, body mass index (BMI), race, ethnicity, Pain Interference, and Depression were statistically significant predictors for treatment group in bivariate analysis (P < .05). In multivariable analysis, adults older than 65 years were less likely to receive either injection only or injection followed by release (odds ratio [OR]: 0.56 and OR: 0.52, respectively; P < .01). Overweight (BMI: ≥25) individuals were less likely to receive injection only (OR: 0.45; P < .01). Women were more likely to have either injection only or injection followed by released (OR: 1.50 and 1.55; P < .01). Similarly, black, Indigenous, or Persons of Color had an increased odds of injection only and injection followed by release (OR: 1.61 and OR: 1.69, respectively; P < .05). CONCLUSIONS Sex, age, BMI, race, and ethnicity were found to be independent predictors of treatment modality for CTS.
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Rotar EP, Scott EJ, Hawkins RB, Mehaffey JH, Strobel RJ, Charles EJ, Quader MA, Joseph M, Teman NR, Yarboro LT, Ailawadi G. Changes in Controllable Coronary Artery Bypass Grafting Practice for White and Black Americans. Ann Thorac Surg 2023; 115:922-928. [PMID: 35093386 DOI: 10.1016/j.athoracsur.2021.11.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 11/07/2021] [Accepted: 11/29/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Racial disparities in outcomes after cardiac surgery are well reported. We sought to determine whether variation by race exists in controllable practices during coronary artery bypass graft surgery (CABG). We hypothesized that racial disparities exist in CABG quality metrics, but have improved over time. METHODS All patients undergoing isolated CABG (2000 to 2019) in a multiple state database were stratified into three eras by race. Analysis included propensity matched White Americans and Black Americans. Primary outcomes included left internal mammary artery use, multiple arterial grafting, revascularization completeness, and guideline-directed medication prescription. RESULTS Of 72 248 patients undergoing CABG, Black American patients (n = 10 270, 15%) had higher rates of diabetes mellitus, hypertension, prior stroke, and myocardial infarction. After matching, 19 806 patients (n = 9903 per group) were well balanced. Left internal mammary artery use was significantly different early (era 1, Black Americans 84.7% vs White Americans 86.6%; P = .03), but equalized over time. Importantly, multiarterial grafting differed between Black Americans and White Americans over the entire study (9.1% vs 11.5%, P < .001) and within each era. Black Americans had more incomplete revascularization during the study period (14% vs 12.8%, P = .02) driven by a large disparity in era 1 (9.5% vs 7.2%, P < .001). Despite similar rates of preoperative use, Black Americans were more often discharged on a regimen of β-blockers (91.8% vs 89.6%, P < .001). CONCLUSIONS Coronary artery bypass graft surgery metrics of left internal mammary artery use and optimal medical therapy have improved over time and are similar despite patient race. Black Americans undergo less frequent multiarterial grafting and greater discharge β-blocker prescription. Identifying changes in controllable CABG quality practices across races supports a continued focus on standardizing such efforts.
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Affiliation(s)
- Evan P Rotar
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Erik J Scott
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - J Hunter Mehaffey
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Raymond J Strobel
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eric J Charles
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Mark Joseph
- Division of Cardiothoracic Surgery, Virginia Tech Carillion School of Medicine, Roanoke, Virginia
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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Knoedler S, Kauke-Navarro M, Haug V, Broer PN, Pomahac B, Knoedler L, Panayi AC. Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis. Aesthet Surg J 2023; 43:433-451. [PMID: 36472232 DOI: 10.1093/asj/sjac320] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/06/2022] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction. OBJECTIVES The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care. METHODS The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed. RESULTS In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications. CONCLUSIONS This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.
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Health Inequities in Orthopaedic Trauma Surgery in the United States: A Scoping Review. J Am Acad Orthop Surg 2023; 31:e489-e503. [PMID: 36884240 DOI: 10.5435/jaaos-d-22-00710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 01/29/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Health inequities have been shown to have negative effects on patient care and the healthcare system. It is important for orthopaedic trauma surgeons and researchers to understand the extent to which patients are affected by these inequities. METHODS We conducted a scoping review as outlined by the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. We searched PubMed and Ovid Embase for articles relating to orthopaedic trauma surgery and health inequities. RESULTS After exclusion criteria were applied, our final sample consisted of 52 studies. The most frequently evaluated inequities were sex (43 of 52 [82.7]), race/ethnicity (23 of 52 [44.2]), and income status (17 of 52 [32.7]). The least frequently evaluated inequities were lesbian, gay, bisexual, transgender, and queer identity (0 of 52 [0.0]) and occupational status (8 of 52 [15.4]). Other inequities evaluated included rural/underresourced (11 of 52 [21.1]) and educational level (10 of 52 [19.2]). No trend was observed when examining inequities reported by year. CONCLUSION Health inequities exist in orthopaedic trauma literature. Our study highlights multiple inequities in the field that need further investigation. Understanding current inequities and how to best mitigate them could improve patient care and outcomes in orthopaedic trauma surgery.
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Jaramillo EA, Smith EJT, Matthay ZA, Sanders KM, Hiramoto JS, Gasper WJ, Conte MS, Iannuzzi JC. Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention. J Vasc Surg 2023; 77:848-857.e2. [PMID: 36334848 DOI: 10.1016/j.jvs.2022.10.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (Wound, Ischemia, foot Infection) stage. METHODS The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis. RESULTS Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P < .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P < .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P < .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P < .001) compared with White race. CONCLUSIONS Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.
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Affiliation(s)
- Emanuel A Jaramillo
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Katherine M Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Millis JM, Vigneswaran J, Ogunnowo S, Dorsey C. Understanding the impact of health inequities in surgical complications: Rethinking morbidity and mortality conferences. Surgery 2023; 173:553-554. [PMID: 36372571 DOI: 10.1016/j.surg.2022.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022]
Affiliation(s)
| | - Janani Vigneswaran
- Department of Surgery, University of Chicago Medicine, IL. https://twitter.com/JenVigneswaran
| | - Simi Ogunnowo
- University of Chicago Pritzker School of Medicine, IL
| | - Chelsea Dorsey
- Department of Surgery, University of Chicago Medicine, IL.
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Vilariño-Rico J, Fariña-Casanova X, Martínez-Gallego EL, Hernández-Lahoz I, Rielo-Arias F, Pértega S, Encisa JM, García-Colodro JM, Fernández-Noya J. The Influence of the Socioeconomic Status and the Density of the Population on the Outcome After Peripheral Artery Disease. Ann Vasc Surg 2023; 89:269-279. [PMID: 36404448 DOI: 10.1016/j.avsg.2022.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Low socioeconomic status (SES) and living in a rural environment are associated with poorer health and a higher number of amputations among the population at large. The purpose of this study is to determine the influence of low SES and of the degree of urbanization on the short-term and long-term results of patients after revascularization for peripheral artery disease. METHODS An observational retrospective follow-up study of 770 patients operated on for peripheral artery disease at three university centers in north-western Spain from January 2015 to December 2016. The events studied were Rutherford classification of severity upon admission, direct amputation, amputations in the follow-up period, new revascularization procedures, major adverse cardiovascular events (MACE), and overall mortality. Mean personal income and income of the household associated with the street in which each patient lived and the degree of urbanization in three areas as per Eurostat criteria: densely populated areas, intermediate density areas, and thinly populated areas. Comorbidity, surgical, and follow-up variables were also collected. Descriptive analysis and Cox regression were used. Approval was obtained from the regional ethics committee. RESULTS Median follow-up was 47.5 months. MACE occurred in 21.5% of the series and overall mortality was 47.0%. Living in a thinly populated area is associated with a lower risk of MACE (adjusted subhazard ratio = 0.60; 95% confidence interval [CI]: 0.39-0.91). Overall survival is lower in intermediate density area patients (adjusted Hazard Ratio = 1.46; 95% CI: 1.07-2.00). The third quartile of mean personal and household income is associated with a higher risk of major amputation at follow-up (adjusted Odds Ratio 1.92, 95% CI: 1.05-3.52 and adjusted Odds Ratio 1.93, 95% CI: 1.0.3-3.61, respectively). CONCLUSIONS Patients who live in a densely populated area run a higher risk of MACE. SES is neither associated with worse outcomes after surgery nor with MACE in long-term follow-up.
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Affiliation(s)
- Jorge Vilariño-Rico
- Angiology and Vascular Surgery Service, A Coruña University Hospital Complex, A Coruña, Spain.
| | | | | | | | | | - Sonia Pértega
- Clinical Epidemiology and Biostatistics Unit, A Coruña University Hospital Complex, A Coruña, Spain
| | - José Manuel Encisa
- Angiology and Vascular Surgery Service, Vigo Hospital Complex, Vigo, Spain
| | | | - Jorge Fernández-Noya
- Angiology and Vascular Surgery Service, A Coruña University Hospital Complex, A Coruña, Spain
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Analysis of Outpatient Adherence in 45,237 Patients Referred by an Emergency Department to Surgical Clinics. World J Surg 2023; 47:455-460. [PMID: 36284006 PMCID: PMC9595074 DOI: 10.1007/s00268-022-06799-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2022] [Indexed: 01/29/2023]
Abstract
INTRODUCTION This study examines referral patterns to surgical clinics from the emergency department and the impact of sociodemographic factors on adherence. METHODS Patients from 2017 to 2021 were identified who had a referral placed to surgical specialties from the ED. The primary outcome was the proportion of patients who had a referral to surgery placed during an ED visit but who showed up to surgery clinic visit within 60 days of referral placement. Univariate and multivariate analysis was performed. RESULTS Referrals were made for 45,237 patients overall and 4130 for general surgery specifically. 44% showed up to general surgery clinic visit. In univariate and multivariate analysis, those who showed up to clinic were older, tended to be female, had a lower social economic status, had Medicaid or Medicare insurance and had more comorbidities compared to those who did not show up. Asians and Hispanics were more likely to show up to clinic compared to Whites. CONCLUSIONS Assigning navigators in the ED to follow-up with patients who are younger and healthier, with private insurances who have existing PCPs to ensure they follow up as advised is a potential targeted intervention to improve clinic adherence.
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Butterfield JT, Golzarian S, Johnson R, Fellows E, Dhawan S, Chen CC, Marcotte EL, Venteicher AS. Racial disparities in recommendations for surgical resection of primary brain tumours: a registry-based cohort analysis. Lancet 2022; 400:2063-2073. [PMID: 36502844 DOI: 10.1016/s0140-6736(22)00839-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/12/2022] [Accepted: 04/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Disparities in treatment and outcomes disproportionately affect minority ethnic and racial populations in many surgical fields. Although substantial research in racial disparities has focused on outcomes, little is known about how surgeon recommendations can be influenced by patient race. The aim of this study was to investigate racial and socioeconomic disparities in the surgical management of primary brain tumors. METHODS In this registry-based cohort study, we used data from the Surveillance, Epidemiology, and End Results (SEER) database (1975-2016) and the American College of Surgeons National Cancer Database (NCDB) in the USA for independent analysis. Adults (aged ≥20 years) with a new diagnosis of meningioma, glioblastoma, pituitary adenoma, vestibular schwannoma, astrocytoma, and oligodendroglioma, with information on tumour size and surgical recommendation were included in the analysis. The primary outcome of this study was the odds of a surgeon recommending against surgical resection at diagnosis of primary brain neoplasms. This outcome was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors. FINDINGS This study included US national data from the SEER (1975-2016) and NCDB (2004-17) databases of adults with a new diagnosis of meningioma (SEER n=63 674; NCDB n=222 673), glioblastoma (n=35 258; n=104 047), pituitary adenoma (n=27 506; n=87 772), vestibular schwannoma (n=11 525; n=30 745), astrocytoma (n=5402; n=10 631), and oligodendroglioma (n=3977; n=9187). Independent of clinical and demographic factors, including insurance status and rural-urban continuum code, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (adjusted odds ratio 1·13, 95% CI 1·06-1·21, p<0·0001), glioblastoma (1·14, 1·01-1·28, p=0·038), pituitary adenoma (1·13, 1·05-1·22, p<0·0001), and vestibular schwannoma (1·48, 1·19-1·84, p<0·0001) when compared with White patients in the SEER dataset. Additionally, patients of unknown race had significantly higher odds of recommendation against surgical resection for pituitary adenoma (1·80, 1·41-2·30, p<0·0001) and vestibular schwannoma (1·49, 1·10-2·04, p=0·011). Performing a validation analysis using the NCDB dataset confirmed these significant results for Black patients with meningioma (1·18, 1·14-1·22, p<0·0001), glioblastoma (1·19, 1·12-1·28, p<0·0001), pituitary adenoma (1·21, 1·16-1·25, p<0·0001), and vestibular schwannoma (1·19, 1·04-1·35, p=0·0085), and indicated and indicated that the findings are independent of patient comorbidities. When further restricted to the most recent decade in SEER, these inequities held true for Black patients, except those with glioblastoma (meningioma [1·18, 1·08-1·28, p<0·0001], pituitary adenoma [1·20, 1·09-1·31, p<0·0001], and vestibular schwannoma [1·54, 1·16-2·04, p=0·0031]). INTERPRETATION Racial disparities in surgery recommendations in the USA exist for patients with primary brain tumours, independent of potential confounders including clinical, demographic, and select socioeconomic factors. Further studies are needed to understand drivers of this bias and enhance equality in surgical care. FUNDING None.
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Affiliation(s)
- John T Butterfield
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Sina Golzarian
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Reid Johnson
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Emily Fellows
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Erin L Marcotte
- Division of Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Andrew S Venteicher
- Center for Skull Base and Pituitary Surgery, University of Minnesota, Minneapolis, MN, USA; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.
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Chesley CF, Anesi GL, Chowdhury M, Schaubel D, Liu VX, Lane-Fall MB, Halpern SD. Characterizing Equity of Intensive Care Unit Admissions for Sepsis and Acute Respiratory Failure. Ann Am Thorac Soc 2022; 19:2044-2052. [PMID: 35830576 PMCID: PMC9743468 DOI: 10.1513/annalsats.202202-115oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022] Open
Abstract
Rationale: Patients who identify as from racial or ethnic minority groups who have sepsis or acute respiratory failure (ARF) experience worse outcomes relative to nonminority patients, but processes of care accounting for disparities are not well-characterized. Objectives: Determine whether reductions in intensive care unit (ICU) admission during hospital-wide capacity strain occur preferentially among patients who identify with racial or ethnic minority groups. Methods: This retrospective cohort among 27 hospitals across the Philadelphia metropolitan area and Northern California between 2013 and 2018 included adult patients with sepsis and/or ARF who did not require life support at the time of hospital admission. An updated model of hospital-wide capacity strain was developed that permitted determination of relationships between patient race, ethnicity, ICU admission, and strain. Results: After adjustment for demographics, disease severity, and study hospital, patients who identified as Asian or Pacific Islander had the highest adjusted ICU admission odds relative to patients who identified as White in both the sepsis and ARF populations (odds ratio, 1.09; P = 0.006 and 1.26; P < 0.001). ICU admission was also elevated for patients with ARF who identified as Hispanic (odds ratio, 1.11; P = 0.020). Capacity strain did not modify differences in ICU admission for patients who identified with a minority group in either disease population (all interactions, P > 0.05). Conclusions: Systematic differences in ICU admission patterns were observed for patients that identified as Asian, Pacific Islander, and Hispanic. However, ICU admission was not restricted from these groups, and capacity strain did not preferentially reduce ICU admission from patients identifying with minority groups. Further characterization of provider decision-making can help contextualize these findings as the result of disparate decision-making or a mechanism of equitable care.
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Affiliation(s)
- Christopher F. Chesley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
| | - Doug Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Meghan B. Lane-Fall
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennslyvania, Philadelphia, Pennsylvania; and
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Simko S, Dallas K, Molina AL, Siedhoff MT, Wright KN, Anger JT, Truong MD. Rates of Complications and Reoperation after Myomectomy-the Impact of Surgical Approach: A Statewide Population-based Cohort Study from 2005-2018. J Minim Invasive Gynecol 2022; 29:1157-1164. [PMID: 35781056 DOI: 10.1016/j.jmig.2022.06.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE To assess rates of and factors associated with complications and reoperation after myomectomy. DESIGN Population-based cohort study. SETTING All non-Veterans Affairs facilities in the state of California from January 1, 2005, to December 31, 2018. PARTICIPANTS Women undergoing abdominal or laparoscopic myomectomy for myoma disease were identified from the Office of Statewide Health Planning and Development datasets using appropriate International Classification of Diseases, Ninth and Tenth Revision and Current Procedural Terminology codes. INTERVENTIONS Demographics, surgery facility type, facility surgical volume, and surgical approach were identified. Primary outcomes included complications occurring within 60 days of surgery and reoperations for myomas. Patients were followed up for over an average of 7.3 years. Univariate and multivariable associations were explored between the above factors and rates of complications and reoperation. All odds ratios (ORs) are adjusted ORs. MEASUREMENTS AND MAIN RESULTS Of the 66 012 patients undergoing myomectomy, 5265 had at least one complication (8.0%). Advanced age, black, Asian race, MediCal and Medicare payor status, academic facility, and medical comorbidities were associated with increased odds of a complication. Minimally invasive myomectomy (MIM) was associated with decreased complications compared with abdominal myomectomy (AM) (OR, 0.29; 95% confidence interval [CI], 0.25-0.33; p <.001). Overall, 17 377 patients (26.3%) underwent reoperation. Medicare and MediCal payor status and medical comorbidities were associated with increased odds of a repeat surgery. Reoperation rates were higher in the MIM group over the entire study period (OR, 2.33; 95% CI, 1.95-2.79; p <.001). However, the odds of reoperation after MIM decreased each year (OR, 0.93; 95% CI 0.92-0.95; p <.001), with the odds of reoperation after AM surpassing MIM in 2015. CONCLUSION This study identifies outcome disparities in the surgical management of myomas and describes important differences in the rates of complications and reoperations, which can be used to counsel patients on surgical approach. These findings suggest that MIM can be considered a lasting and safe approach in properly selected patients.
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Affiliation(s)
- Sarah Simko
- Department of Obstetrics and Gynecology, Adventist Health White Memorial Medical Center (Dr. Simko), University of California San Diego, Los Angeles, California.
| | - Kai Dallas
- Division of Urology, Department of Surgery, City of Hope Medical Center (Dr. Dallas), University of California San Diego, Los Angeles, California
| | - Andrea L Molina
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Matthew T Siedhoff
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Kelly N Wright
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
| | - Jennifer T Anger
- Division of Urology, Department of Surgery, University of California San Diego (Dr. Anger), Los Angeles, California
| | - Mireille D Truong
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center (Drs. Molina, Siedhoff, Wright, and Truong), University of California San Diego, Los Angeles, California
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Brown NJ, Jammal OA, Himstead A, Shahrestani S, Yang C, Patel NA, Gendreau JL, Sahyouni R, Diaz-Aguilar LD, Pham MH. Demographic Predictors of Treatment and Complications for Adult Spinal Deformity: An Analysis of the National Inpatient Sample. Clin Neurol Neurosurg 2022; 222:107423. [PMID: 36063642 DOI: 10.1016/j.clineuro.2022.107423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To examine the role of demographics on surgical management and inpatient complications in patients with spinal deformity between 2010 and 2014 via retrospective analysis. METHODS Data were obtained from the National Inpatient Sample (NIS). International Classification of Diseases 9th revision codes were used to identify patients with a primary diagnosis of adult spinal deformity (ASD). Multivariable Poisson regression analyses were used to determine whether any individual demographic variables were predictive of surgical management, surgical complexity, postoperative complications and revision operations. RESULTS 17,433 patients were identified for analysis. Surgical intervention was performed for 94.5% of patients with a primary diagnosis of ASD. Patients at urban teaching hospitals were the most likely to receive surgery (OR= 2.13; 95% CI 1.51-2.95; p < 0.001) relative to rural patients. Female patients were the majority undergoing surgery and were more likely to receive a complication or require a revision when controlling for surgical complexity. Medicare patients were the least likely to undergo surgery and the most likely to receive complex fusion when undergoing an operation. Medicare patients were the least likely to experience complications (OR=0.89; 95% CI 0.80-0.98; p = 0.022) after adjusting for surgical complexity. With regards to race and ethnicity, Hispanics had a decreased likelihood of receiving a revision surgery. CONCLUSION There were substantial differences in rates of surgical management, postoperative complications, and revisions among individuals of different demographics including sex, insurance status, ethnicity and hospital teaching status. Further research evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient outcomes.
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Al Jammal OM, Shahrestani S, Delavar A, Brown NJ, Gendreau JL, Lien BV, Sahyouni R, Diaz-Aguilar LD, Shalakhti OS, Pham MH. Demographic predictors of treatments and surgical complications of lumbar degenerative diseases: An analysis of over 250,000 patients from the National Inpatient Sample. Medicine (Baltimore) 2022; 101:e29065. [PMID: 35356929 PMCID: PMC10513212 DOI: 10.1097/md.0000000000029065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/24/2022] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT This was a national database study.To examine the role of comorbidities and demographics on inpatient complications in patients with lumbar degenerative conditions.Degenerative conditions of the lumbar spine account for the most common indication for spine surgery in the elderly population in the United States. Significant studies investigating demographic as predictors of surgical rates and health outcomes for degenerative lumbar conditions are lacking.Data were obtained from the National Inpatient Sample from 2010 to 2014 and International Classification of Diseases, 9th revision, Clinical Modification codes were used to identify patients with a primary diagnosis of degenerative lumbar condition. Patients were stratified based on demographic variables and comorbidity status. Multivariate regression analyses were used to determine whether any individual demographic variables, such as race, sex, insurance, and hospital status predicted postoperative complications.A total of 256,859 patients were identified for analysis. The rate of overall complications was found to be 16.1% with a mortality rate of 0.10%. Female, Black, Hispanic, and Asian/Pacific Islander patients had lower odds of receiving surgical treatment compared to White patients (P<.001). Medicare and Medicaid patients were less likely to be surgically managed than patients with private insurance (OR = 0.75, 0.37; P<.001, respectively). Urban hospitals were more likely to provide surgery when compared to rural hospitals (P < .001). Patients undergoing fusion had more complications than decompression alone (P < .001). Females, Medicare insurance status, Medicaid insurance status, urban hospital locations, and certain geographical locations were found to predict postoperative complications (P < .001).There were substantial differences in surgical management and postoperative complications among individuals of different sex, races, and insurance status. Further investigation evaluating the effect of demographics in spine surgery is warranted to fully understand their influence on patient complications.
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Affiliation(s)
- Omar M Al Jammal
- Department of Neurosurgery, University of California San Diego School of Medicine, San Diego, CA,Keck School of Medicine of the University of Southern California, Los Angeles, CA,Department of Medical Engineering, California Institute of Technology, Pasadena, CA,University of California Irvine School of Medicine, Irvine, CA,Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, MD
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Dhawan S, Alattar AA, Bartek J, Ma J, Bydon M, Venteicher AS, Chen CC. Racial disparity in recommendation for surgical resection of skull base chondrosarcomas: A Surveillance, Epidemiology, and End Results (SEER) analysis. J Clin Neurosci 2021; 94:186-191. [PMID: 34863436 DOI: 10.1016/j.jocn.2021.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/09/2021] [Accepted: 09/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION There is increased appreciation of racial disparities in the delivery of neurosurgical care. Here, we explore whether race influences surgical recommendations in the management of skull base chondrosarcomas. METHODS We identified 493 patients with skull base chondrosarcoma using the Surveillance, Epidemiology, and End Results (SEER) registry (November 2017 submission). Regression analyses were performed to identify demographic variables associated with recommendation against surgery. Univariate and multivariate cox proportional hazards models were used for survival analysis. RESULTS In a univariate analysis, we found that the African-American race was associated with an increased likelihood of surgeon recommendation against surgery (OR = 4.416, 95% CI = 1.893-10.302, p = 0.001). This association remained robust in the multivariate model that controlled for other covariates, including age of diagnosis (OR = 5.091, 95% CI = 2.127-12.187, p < 0.001). For patients who received a recommendation against surgery, the likelihood of dying from non-chondrosarcoma causes was comparable between Caucasian and African-American patients, suggesting that the prevalence and severity of medical conditions that increase the risk of death were comparable between these cohorts (HR = 0.466, 95% CI = 0.057-3.802, p = 0.475). The likelihood of dying from chondrosarcoma was comparable between Caucasian and African-American patients who underwent surgery (HR = 0.982, 95% CI = 0.353-2.732, p = 0.973), suggesting absence of race-specific surgical benefits. CONCLUSION We identified a racial disparity against African-Americans in recommendations for surgical resection of skull base chondrosarcomas.
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Affiliation(s)
- Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Ali A Alattar
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience and Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jun Ma
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.
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Teaching what matters: Integrating health equity education into the core surgery clerkship. Surgery 2021; 171:1505-1511. [PMID: 34857383 DOI: 10.1016/j.surg.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Significant disparities in surgical outcomes exist. It is imperative to prepare future doctors to eliminate disparities. Our team of senior medical students developed a surgical clerkship module examining equity in prostate cancer. Student attitudes before and after a facilitated teaching session were assessed. METHODS A surgical equity pilot module was integrated into the core surgical clerkship starting in July 2020. This module was composed of (1) asynchronous preparatory material and (2) a synchronous interactive case discussion regarding disparities in prostate cancer. Discussion sessions were facilitated by upper-level medical students. Participants answered optional anonymous Likert-style and open-ended survey questions before and after the session. Pre- and post-responses were compared. RESULTS One hundred and sixteen students completed the module between July 2020 and January 2021. Pre- and post-survey response rates were 66% and 29%, respectively. At baseline, almost all students (95%) agreed knowledge of disparities would make them a better physician. However, the majority (95%) described their general knowledge of surgical disparities as "nonexistent," "poor," or "average." Most students did not have a framework for assessing causes of surgical disparities (86%) and were not aware of interventions for reducing disparities (90%). After intervention, the majority rated their knowledge of surgical disparities as "good" or "excellent" (71%; P < .001). Most students indicated they had a framework 79%; P < .001) and were aware of effective interventions (62%; P < .001). CONCLUSION We demonstrated a successful pilot of an equity-focused clerkship module. Student attitudes after a single session reflected significant improvement in knowledge of causes and interventions related to surgical disparities. Equity-focused teaching can be incorporated into the surgical clerkship.
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Parikh PP, Kipfer SC, Crawford TN, Cochran A, Falls G. Unmasking bias and perception of lead surgeons in the operating room: A simulation based study. Am J Surg 2021; 223:58-63. [PMID: 34373086 DOI: 10.1016/j.amjsurg.2021.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Perception of a surgeon based on physical attributes in the operating room (OR) environment has not been assessed, which was our primary goal. METHODS A common OR scenario was simulated using 8 different actors as a lead surgeon with combinations of age (<40 vs. >55), race (white vs. black), and gender (male vs. female). One video scenario with a survey was electronically distributed to surgeons, residents, and OR nurses/staff. The overall rating, assessment, and perception of the lead surgeon were assessed. RESULTS Of 974 respondents, 64.5% were females. There were significant differences in the rating and assessment based upon surgeon's age (p = .01) favoring older surgeons. There were significant differences in the assessments of surgeons by the study group (p = .03). The positive assessments as well as perceptions trended highest towards male, older, and white surgeons, especially in the stressful situation. CONCLUSION While perception of gender bias may be widespread, age and race biases may also play a role in the OR. Inter-professional education training for OR teams could be developed to help alleviate such biases.
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Affiliation(s)
- Priti P Parikh
- Department of Surgery, Wright State University, Dayton, OH, USA
| | | | - Timothy N Crawford
- Department of Population and Community Health, Wright State University, Dayton, OH, USA
| | | | - Garietta Falls
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
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Wellesley Wesley E, Patel I, Kadra-Scalzo G, Pritchard M, Shetty H, Broadbent M, Segev A, Patel R, Downs J, MacCabe JH, Hayes RD, de Freitas DF. Gender disparities in clozapine prescription in a cohort of treatment-resistant schizophrenia in the South London and Maudsley case register. Schizophr Res 2021; 232:68-76. [PMID: 34022618 DOI: 10.1016/j.schres.2021.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gender disparities in treatment are apparent across many areas of healthcare. There has been little research into whether clozapine prescription, the first-line treatment for treatment-resistant schizophrenia (TRS), is affected by patient gender. METHODS This retrospective cohort study identified 2244 patients with TRS within the South London and Maudsley NHS Trust, by using a bespoke method validated against a gold-standard, manually coded, dataset of TRS cases. The outcome and exposures were identified from the free-text using natural language processing applications (including machine learning and rules-based approaches) and from information entered in structured fields. Multivariable logistic regression was carried out to calculate the odds ratios for clozapine prescription according to patients' gender, and adjusting for numerous potential confounders including sociodemographic, clinical (e.g., psychiatric comorbidities and substance use), neutropenia, functional factors (e.g., problems with occupation), and clinical monitoring. RESULTS Clozapine was prescribed to 77% of the women and 85% of the men with TRS. Women had reduced odds of being prescribed clozapine as compared to men after adjusting for all factors included in the present study (adjusted OR: 0.66; 95% CI 0.44-0.97; p = 0.037). CONCLUSION Women with TRS are less likely to be prescribed clozapine than men with TRS, even when considering the effects of multiple clinical and functional factors. This finding suggests there could be gender bias in clozapine prescription, which carries ramifications for the relatively poorer care of women with TRS regarding many outcomes such as increased hospitalisation, mortality, and poorer quality of life.
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Affiliation(s)
- Emma Wellesley Wesley
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - India Patel
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Megan Pritchard
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Hitesh Shetty
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Aviv Segev
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Shalvata Mental Health Center, Hod Hasharon, Israel
| | - Rashmi Patel
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Johnny Downs
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - James H MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK
| | - Richard D Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Beach MC, Saha S, Park J, Taylor J, Drew P, Plank E, Cooper LA, Chee B. Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women. J Gen Intern Med 2021; 36:1708-1714. [PMID: 33754318 PMCID: PMC8175470 DOI: 10.1007/s11606-021-06682-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Black Americans and women report feeling doubted or dismissed by health professionals. OBJECTIVE To identify linguistic mechanisms by which physicians communicate disbelief of patients in medical records and then to explore racial and gender differences in the use of such language. DESIGN Cross-sectional. SETTING/PARTICIPANTS All notes for patients seen in an academic ambulatory internal medicine practice in 2017. MAIN MEASURES A content analysis of 600 clinic notes revealed three linguistic features suggesting disbelief: (1) quotes (e.g., had a "reaction" to the medication); (2) specific "judgment words" that suggest doubt (e.g., "claims" or "insists"); and (3) evidentials, a sentence construction in which patients' symptoms or experience is reported as hearsay. We used natural language processing to evaluate the prevalence of these features in the remaining notes and tested differences by race and gender, using mixed-effects regression to account for clustering of notes within patients and providers. KEY RESULTS Our sample included 9251 notes written by 165 physicians about 3374 unique patients. Most patients were identified as Black (74%) and female (58%). Notes written about Black patients had higher odds of containing at least one quote (OR 1.48, 95% CI 1.20-1.83) and at least one judgment word (OR 1.25, 95% CI 1.02-1.53), and used more evidentials (β 0.32, 95% CI 0.17-0.47), compared to notes of White patients. Notes about female vs. male patients did not differ in terms of judgment words or evidentials but had a higher odds of containing at least one quote (OR 1.22, 95% CI 1.05-1.44). CONCLUSIONS Black patients may be subject to systematic bias in physicians' perceptions of their credibility, a form of testimonial injustice. This is another potential mechanism for racial disparities in healthcare quality that should be further investigated and addressed.
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Affiliation(s)
- Mary Catherine Beach
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, USA
| | - Somnath Saha
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd. (P3HSRD), Portland, OR, 97239, USA.
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA.
| | - Jenny Park
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Janiece Taylor
- School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Drew
- Department of Language and Linguistic Science, University of York, York, UK
| | | | - Lisa A Cooper
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior & Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, USA
| | - Brant Chee
- Applied Physics Laboratory, Johns Hopkins University, Baltimore, MD, USA
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Pierz KA. CORR Insights®: Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children? Clin Orthop Relat Res 2021; 479:835-837. [PMID: 33394762 PMCID: PMC8083909 DOI: 10.1097/corr.0000000000001620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/07/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Kristan A Pierz
- K. A. Pierz, Associate Professor, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Center for Motion Analysis; Orthopaedics, Hartford, CT, USA
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Gopal DP, Chetty U, O'Donnell P, Gajria C, Blackadder-Weinstein J. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J 2021; 8:40-48. [PMID: 33791459 DOI: 10.7861/fhj.2020-0233] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Bias is the evaluation of something or someone that can be positive or negative, and implicit or unconscious bias is when the person is unaware of their evaluation. This is particularly relevant to policymaking during the coronavirus pandemic and racial inequality highlighted during the support for the Black Lives Matter movement. A literature review was performed to define bias, identify the impact of bias on clinical practice and research as well as clinical decision making (cognitive bias). Bias training could bridge the gap from the lack of awareness of bias to the ability to recognise bias in others and within ourselves. However, there are no effective debiasing strategies. Awareness of implicit bias must not deflect from wider socio-economic, political and structural barriers as well ignore explicit bias such as prejudice.
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Affiliation(s)
- Dipesh P Gopal
- Barts and The London School of Medicine and Dentistry, London, UK
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Anastasio AT, Niu S, Kim EJ, Rhee JM. Evaluating Single-Surgeon Bias Toward Recommending Corrective Procedures for Cervical Spondylotic Myelopathy Based on Demographic Factors and Comorbidities in a 484-Patient Cohort. Global Spine J 2021; 11:167-171. [PMID: 32875846 PMCID: PMC7882819 DOI: 10.1177/2192568219896296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES An increasing focus has been placed on removing implicit (unconscious) bias from the surgical selection process. In spine surgery, there is the potential for implicit bias to affect the decision to either operate on a patient or not, given lack of definitive surgical indications for many elective procedures. The objective of this study was to analyze the surgical decision making of a single spine surgeon in an effort to understand surgical decision-making trends based on certain demographic factors. METHODS This was a retrospective study of 484 patients who had undergone a corrective procedure for cervical myelopathy by an orthopedic spine surgeon at our institution. The preoperative modified Japanese Orthopaedic Association score served as the metric of severity of disease for cervical myelopathy. The factors that have been associated with implicit bias that were evaluated were smoking status, narcotic use status, gender, body mass index, and age. RESULTS Multivariate linear regression analysis showed that even after controlling for comorbidities and confounders, the only variable which predicted likelihood to operate on a patient of a milder symptomology was age (odds ratio [OR] = -0.138; (confidence interval [CI] = -0.034 to -0.006). The other factors (smoking status, narcotic use status, gender, and body mass index) were not associated with surgical decision making. CONCLUSIONS Our study demonstrates absence of association between commonly studied areas of implicit bias and the decision to operate on a patient with milder symptomology at initial presentation of cervical spondylotic myelopathy.
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Affiliation(s)
| | - Shuo Niu
- Emory University Hospital, Atlanta, GA, USA
| | | | - John M. Rhee
- Emory University Hospital, Atlanta, GA, USA,John M. Rhee, Department of Orthopaedic Surgery, Emory University, Emory Spine Center, 59 Executive Park South, Atlanta, GA 30329, USA.
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McGinigle KL, Minc SD. Disparities in amputation in patients with peripheral arterial disease. Surgery 2021; 169:1290-1294. [PMID: 33648767 DOI: 10.1016/j.surg.2021.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND To describe peripheral arterial disease-related amputation as a marker for health disparities.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Samantha D Minc
- Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, West Virginia University, Morgantown, WV; Department of Occupational and Environmental Health Sciences, School of Public Health, West Virginia University, Morgantown, WV. https://twitter.com/SamanthaMinc
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Azin A, Hirpara DH, Doshi S, Chesney TR, Quereshy FA, Chadi SA. Racial Disparities in Surgery: A Cross-Specialty Matched Comparison Between Black and White Patients. ANNALS OF SURGERY OPEN 2020; 1:e023. [PMID: 37637447 PMCID: PMC10455216 DOI: 10.1097/as9.0000000000000023] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
Objective To determine if Black race is associated with worse short-term postoperative morbidity and mortality when compared to White race in a contemporary, cross-specialty-matched cohort. Background Growing evidence suggests poorer outcomes for Black patients undergoing surgery. Methods A retrospective analysis was conducted comprising of all patients undergoing surgery in the National Surgical Quality Improvement Program dataset between 2012 and 2018. One-to-one coarsened exact matching was conducted between Black and White patients. Primary outcome was rate of 30-day morbidity and mortality. Results After 1:1 matching, 615,118 patients were identified. Black race was associated with increased rate of all-cause morbidity (odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.08-1.13, P < 0.001) and mortality (OR = 1.15, 95% CI 1.01-1.31, P = 0.039). Black race was associated with increased risk of re-intubation (OR = 1.33, 95% CI 1.21-1.48, P < 0.001), pulmonary embolism (OR = 1.55, 95% CI 1.40-1.71, P < 0.001), failure to wean from ventilator for >48 hours (OR = 1.14, 95% CI 1.02-1.29, P < 0.001), progressive renal insufficiency (OR = 1.63, 95% CI 1.43-1.86, P < 0.001), acute renal failure (OR = 1.39, 95% CI 1.16-1.66, P < 0.001), cardiac arrest (OR = 1.47, 95% CI 1.24-1.76 P < 0.001), bleeding requiring transfusion (OR = 1.39, 95% CI 1.34-1.43, P < 0.001), DVT/thrombophlebitis (OR = 1.24, 95% CI 1.14-1.35, P < 0.001), and sepsis/septic shock (OR = 1.09, 95% CI 1.03-1.15, P < 0.001). Black patients were also more likely to have a readmission (OR = 1.12, 95% CI 1.10-1.16, P < 0.001), discharge to a rehabilitation center (OR = 1.73, 95% CI 1.66-1.80, P < 0.001) or facility other than home (OR = 1.20, 95% CI 1.16-1.23, P < 0.001). Conclusion and Relevance This contemporary matched analysis demonstrates an association with increased morbidity, mortality, and readmissions for Black patients across surgical procedures and specialties.
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Affiliation(s)
- Arash Azin
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Princess Margaret Hospital and University Health Network, Toronto, Ontario, Canada
| | - Dhruvin H. Hirpara
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sachin Doshi
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Tyler R. Chesney
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Surgery, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Fayez A. Quereshy
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Princess Margaret Hospital and University Health Network, Toronto, Ontario, Canada
- Colorectal Cancer Program, Princess Margaret Hospital and University Health Network, Toronto, Ontario, Canada
| | - Sami A. Chadi
- From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Surgical Oncology, Princess Margaret Hospital and University Health Network, Toronto, Ontario, Canada
- Colorectal Cancer Program, Princess Margaret Hospital and University Health Network, Toronto, Ontario, Canada
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Slakey DP, George JS, Anderson E, Willeumier D, Guglielmi K. Applying international organization for standards 9001 to create an effective surgical quality committee. Am J Surg 2020; 221:598-601. [PMID: 33189310 DOI: 10.1016/j.amjsurg.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/23/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Efforts to improve surgical safety are limited by several factors and no consensus exists regarding the most effective way to improve surgical quality. The use of ISO 9001 quality standards within healthcare is recognized but has not been widely applied for improving surgical outcomes. METHODS A surgical quality committee was created using ISO 9001:2015 standards. Quality objectives were assessed to understand how any suggested changes will be impacted due to risks and opportunities inherent in the system. RESULTS The initial quality focus was on surgical site infections in 5 services. Change in surgical infection ratio from 2018 to 2019 showed significant improvement: coronary bypass 1.288 vs. 0.901; Colon 1.359 vs. 0.589; Hysterectomy 2.119 vs. 1.022; Knee 1.391 vs. 0.306; Hip 0 vs. 0.302. CONCLUSIONS This is one of the first studies using ISO 9001 to improve surgical quality. The results indicate both acceptance and success of applying continual improvement strategies.
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Affiliation(s)
- Douglas P Slakey
- Department of Surgery, CMC, Advocate Aurora Health, Chicago IL, 60611, United States.
| | - James S George
- Department of Surgery, CMC, Advocate Aurora Health, Chicago IL, 60611, United States
| | - Edwin Anderson
- Department of Surgery, CMC, Advocate Aurora Health, Chicago IL, 60611, United States
| | - Donna Willeumier
- Department of Surgery, CMC, Advocate Aurora Health, Chicago IL, 60611, United States
| | - Kelly Guglielmi
- Department of Surgery, CMC, Advocate Aurora Health, Chicago IL, 60611, United States
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Abstract
Until recently, thyroid cancer was one of the most rapidly increasing cancers in the United States. Disparities exist in many aspects of thyroid cancer care as a result of the multifactorial interplay of systemic, patient, and physician factors. To better understand the management of thyroid cancer in populations at risk for health disparities and subsequently implement changes that will lead to health equity for all patients with thyroid cancer, health services research with innovative approaches is necessary.
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Affiliation(s)
- Debbie W. Chen
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan R. Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Hamm RF, Srinivas SK, Levine LD. A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes. Am J Obstet Gynecol MFM 2020; 2:100148. [PMID: 33345879 DOI: 10.1016/j.ajogmf.2020.100148] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND There are marked disparities between black and nonblack women in the United States in birth outcomes. Yet, there are little data on methods to reduce these disparities. Although the cause of racial disparities in health is multifactorial, implicit bias is thought to play a contributing role. To target differential management, studies in nonobstetrical populations have demonstrated disparity reduction through care standardization. With wide variation by site and provider, labor management practices are the ideal target for standardization. OBJECTIVE In this study, we aimed to evaluate the effect of a standardized induction of labor protocol on racial disparities in cesarean delivery rate and maternal and neonatal morbidity. STUDY DESIGN We performed a prospective cohort study of women undergoing an induction from 2013 to 2015. Full-term (≥37 weeks' gestation) women carrying a singleton pregnancy with intact membranes and an unfavorable cervix (dilation ≤2 cm, Bishop score of ≤6) were included. We compared the cesarean delivery rate and maternal and neonatal morbidity between 2 groups stratified by race (black vs nonblack) as follows: (1) women induced in a randomized trial (n=491) that utilized an induction protocol with standardized recommendations for interventions such as oxytocin and amniotomy at particular time points and (2) women in an observational arm (n=364) enrolled at the same time whose induction and labor management occurred at provider discretion. Regression modeling was used to test an interaction between the induction protocol and race. RESULTS A significant reduction in cesarean delivery rate in black women managed with the induction protocol was noted when compared with those in the observational group (25.7% vs 34.2%; P=.02), whereas there was no difference in cesarean delivery rate in nonblack women (34.6% vs 29.9%; P=.41). The induction protocol reduced the racial disparity in cesarean delivery rate (interaction term, P=.04), even when controlling for parity, body mass index, indication for labor induction, and Bishop score at induction start. In addition, a significant reduction in neonatal morbidity was found in black women managed with the induction protocol (2.9% vs 8.9%; P=.001), with no difference in nonblack women (3.6% vs 5.5%; P=.55). The induction protocol did not significantly affect maternal morbidity for either race. CONCLUSION A standardized induction protocol is associated with reduced cesarean delivery rate and neonatal morbidity in black women undergoing induction. Further studies should determine whether implementation of induction protocols in diverse settings could reduce national racial disparities in obstetrical outcomes.
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Affiliation(s)
- Rebecca F Hamm
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Sindhu K Srinivas
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lisa D Levine
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Hernandez SM, Sparks PJ. Barriers to Health Care Among Adults With Minoritized Identities in the United States, 2013-2017. Am J Public Health 2020; 110:857-862. [PMID: 32298177 DOI: 10.2105/ajph.2020.305598] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To examine the relationship between minoritized identity and barriers to health care in the United States.Methods. Nationally representative data collected from the 2013 to 2017 waves of the National Health Interview Survey were used to conduct descriptive and logistic regression analyses. Men and women were placed in 1 of 4 categories: no minoritized identities, minoritized identities of race/ethnicity (MIoRE), minoritized identities of sexuality (MIoS), or minoritized identities of both race/ethnicity and sexuality (MIoRES). Five barriers to health care were considered.Results. Relative to heterosexual White adults and after controlling for socioeconomic status, adults with MIoRE were less likely to report barriers, adults with MIoS were more likely to report barriers, and adults with MIoRES were more likely to report barriers across 2 of the study measures.Conclusions. Barriers to care varied according to gender, minoritized identity, and the measure of access to health care itself.Public Health Implications. Approaching health disparities research using an intersectional lens moves the discussion from examining individual differences to examining the role of social structures such as the health care system in maintaining and reproducing inequality.
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Affiliation(s)
- Stephanie M Hernandez
- The authors are with the Department of Demography, University of Texas at San Antonio
| | - P Johnelle Sparks
- The authors are with the Department of Demography, University of Texas at San Antonio
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Liu Y, Zhang CW, Zhao XD. Long-term survival of femoral neck fracture patients aged over ninety years: Arthroplasty compared with nonoperative treatment. BMC Musculoskelet Disord 2020; 21:217. [PMID: 32268893 PMCID: PMC7140318 DOI: 10.1186/s12891-020-03249-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/27/2020] [Indexed: 02/08/2023] Open
Abstract
Background The aging of the Chinese population is expected to lead to an increase in nonagenarians and centenarians. The mortality rate in nonagenarian hip fracture patients is equivalent to the mortality rate in the average population at 5 years after injury. It is imperative to evaluate 5-year mortality in this small but very challenging subgroup of patients to optimize patient management. The primary purpose of the current retrospective study was to compare five-year survival in patients aged over 90 years who received arthroplasty or nonoperative treatment for femoral neck fracture during a 16-year period. Methods From January 1998 to December 2014, all consecutive nonagenarian and centenarian patients with femoral neck fracture admitted to our hospital were included in the evaluation. The primary outcome was defined as thirty-day, 1-year, 3-year, and 5-year mortality after injury. Survival analysis was performed with the Kaplan-Meier method. Using the log-rank test, stratified analyses were performed to compare differences in the overall cumulative mortality and mortality at three time points (1 year, 3 years, and 5 years) after injury and differences in survival distributions. Results Over the 16-year study period, the arthroplasty group and the nonoperative treatment group included 33 and 53 patients, respectively. The long-term survival probability of the arthroplasty group was significantly higher than that of the nonoperative treatment group (p = 0.002). The survival time of the arthroplasty group was significantly higher than that of the nonoperative treatment group (median (P75-P25) = 53 (59) versus median (P75-P25) = 22 (52), p = 0.001). The mortality differences, except for 30-day mortality, at five time points (1, 2, 3, 4, and 5 years) between the nonoperative group and arthroplasty group were significant. The stratified analyses of overall cumulative mortality and mortality at three time points (1, 3, and 5 years) after injury demonstrated that the nonoperative treatment group had significantly higher cumulative mortality than the arthroplasty group. Conclusions Our study demonstrates that arthroplasty is more likely to improve long-term survival in femoral neck fracture patients aged over 90 years than nonoperative treatment. It can be expected that nearly half of patients will survive more than 5 years after surgery.
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Affiliation(s)
- Yang Liu
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, P.R. China, 610041.
| | - Chong-Wei Zhang
- Department of Laboratory Medicine, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, P.R. China, 610041
| | - Xiao-Dan Zhao
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, P.R. China, 610041
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#EAST4ALL: An introduction to the EAST equity, quality, and inclusion task force. J Trauma Acute Care Surg 2020; 87:225-233. [PMID: 31058750 DOI: 10.1097/ta.0000000000002360] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Minc SD, Goodney PP, Misra R, Thibault D, Smith GS, Marone L. The effect of rurality on the risk of primary amputation is amplified by race. J Vasc Surg 2020; 72:1011-1017. [PMID: 31964567 DOI: 10.1016/j.jvs.2019.10.090] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/25/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Primary amputation (ie, without attempted revascularization) is a devastating complication of peripheral artery disease. Racial disparities in primary amputation have been described; however, rural disparities have not been well investigated. The purpose of this study was to examine the impact of rurality on risk of primary amputation and to explore the effect of race on this relationship. METHODS The national Vascular Quality Initiative amputation data set was used for analyses (N = 6795). The outcome of interest was primary amputation. Independent variables were race/ethnicity (non-Latinx whites vs nonwhites) and rural residence. Multivariable logistic regression examined impact of rurality and race/ethnicity on primary amputation after adjustment for relevant covariates and included an interaction for race/ethnicity by rural status. RESULTS Primary amputation occurred in 49% of patients overall (n = 3332), in 47% of rural vs 49% of urban patients (P = .322), and in 46% of whites vs 53% of nonwhites (P < .001). On multivariable analysis, nonwhites had a 21% higher odds of undergoing primary amputation overall (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.05-1.39). On subgroup analysis, rural nonwhites had two times higher odds of undergoing primary amputation than rural whites (AOR, 2.06; 95% CI, 1.53-2.78) and a 52% higher odds of undergoing primary amputation than urban nonwhites (AOR, 1.52; 95% CI, 1.19-1.94). In the urban setting, nonwhites had a 21% higher odds of undergoing primary amputation than urban whites (AOR, 1.21; 95% CI, 1.05-1.39). CONCLUSIONS In these analyses, rurality was associated with greater odds for primary amputation in nonwhite patients but not in white patients. The effect of race on primary amputation was significant in both urban and rural settings; however, the effect was significantly stronger in rural settings. These findings suggest that race/ethnicity has a compounding effect on rural health disparities and that strategies to improve health of rural communities need to consider the particular needs of nonwhite residents to reduce disparities.
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Affiliation(s)
- Samantha Danielle Minc
- Division of Vascular and Endovascular Surgery, West Virginia University School of Medicine, Morgantown, WV.
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Ranjita Misra
- Department of Social and Behavioral Sciences, West Virginia University School of Public Health, Morgantown, WV
| | - Dylan Thibault
- Division of Vascular and Endovascular Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Gordon Stephen Smith
- Department of Epidemiology, West Virginia University School of Public Health, Morgantown, WV
| | - Luke Marone
- Division of Vascular and Endovascular Surgery, West Virginia University School of Medicine, Morgantown, WV
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Lion KC, Zhou C, Ebel BE, Penfold RB, Mangione-Smith R. Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children. Hosp Pediatr 2020; 10:1-11. [PMID: 31801795 PMCID: PMC6931033 DOI: 10.1542/hpeds.2019-0096] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention. METHODS We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income). RESULTS Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers. CONCLUSIONS System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.
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Affiliation(s)
- K Casey Lion
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Chuan Zhou
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Beth E Ebel
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, Washington
| | - Robert B Penfold
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics and
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
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Furlan JC, Craven BC, Fehlings MG. Is there any gender or age-related discrepancy in the waiting time for each step in the surgical management of acute traumatic cervical spinal cord injury? J Spinal Cord Med 2019; 42:233-241. [PMID: 31573451 PMCID: PMC6781466 DOI: 10.1080/10790268.2019.1614291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Context/Objective: Prior studies indicate that patient's gender and age can influence treatment choices during spine disease management. This study examines whether individual's gender and age at injury onset influence the waiting time for each step in the surgical management of patients with acute traumatic cervical spinal cord injury (atcSCI). Design: Retrospective cohort study. Setting: Quaternary spine trauma center. Participants: This study included consecutive individuals with atcSCI admitted from August/2002 to October/2008 who were enrolled in the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS). Interventions: Spinal cord decompression. Outcome Measures: Data on the periods of time for each step in the surgical management were analyzed to explore the potential effects of gender and age at injury onset. Results: There were 64 individuals with atcSCI (17 women, 47 men; age range: 18-78 years; mean age: 50.5 ± 2.1 years). Older age was associated with longer stay in the acute spine center, but this association was cofounded by major pre-existing medical co-morbidities. Age did not significantly affect the waiting time for each step in the surgical management of these individuals with atcSCI. Women underwent surgical assessment earlier than men. Gender did not influence other key steps in the surgical management. Conclusion: The study results suggest that older age at injury onset was associated with longer stay in the acute spine care center, and women had a shorter waiting time for surgical assessment than men. Nevertheless, no other age or gender bias was identified in the waiting times for the steps in the management of atcSCI.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada,Correspondence to: Julio C. Furlan, 520 Sutherland Drive, Room 206-J, Toronto, Ontario, Canada, M4G 3V9; Ph:416-597-4322 (Ext. 6129); 416-425-9923. E-mail:
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Michael G. Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada,Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Canada
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Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, Lai CK. Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons. JAMA Netw Open 2019; 2:e196545. [PMID: 31276177 DOI: 10.1001/jamanetworkopen.2019.6545] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The Implicit Association Test (IAT) is a validated tool used to measure implicit biases, which are mental associations shaped by one's environment that influence interactions with others. Direct evidence of implicit gender biases about women in medicine has yet not been reported, but existing evidence is suggestive of subtle or hidden biases that affect women in medicine. OBJECTIVES To use data from IATs to assess (1) how health care professionals associate men and women with career and family and (2) how surgeons associate men and women with surgery and family medicine. DESIGN, SETTING, AND PARTICIPANTS This data review and cross-sectional study collected data from January 1, 2006, through December 31, 2017, from self-identified health care professionals taking the Gender-Career IAT hosted by Project Implicit to explore bias among self-identified health care professionals. A novel Gender-Specialty IAT was also tested at a national surgical meeting in October 2017. All health care professionals who completed the Gender-Career IAT were eligible for the first analysis. Surgeons of any age, gender, title, and country of origin at the meeting were eligible to participate in the second analysis. Data were analyzed from January 1, 2018, through March 31, 2019. MAIN OUTCOMES AND MEASURES Measure of implicit bias derived from reaction times on the IATs and a measure of explicit bias asked directly to participants. RESULTS Almost 1 million IAT records from Project Implicit were reviewed, and 131 surgeons (64.9% men; mean [SD] age, 42.3 [11.5] years) were recruited to complete the Gender-Specialty IAT. Healthcare professionals (n = 42 991; 82.0% women; mean [SD] age, 32.7 [11.8] years) held implicit (mean [SD] D score, 0.41 [0.36]; Cohen d = 1.14) and explicit (mean [SD], 1.43 [1.85]; Cohen d = 0.77) biases associating men with career and women with family. Similarly, surgeons implicitly (mean [SD] D score, 0.28 [0.37]; Cohen d = 0.76) and explicitly (men: mean [SD], 1.27 [0.39]; Cohen d = 0.93; women: mean [SD], 0.73 [0.35]; Cohen d = 0.53) associated men with surgery and women with family medicine. There was broad evidence of consensus across social groups in implicit and explicit biases with one exception. Women in healthcare (mean [SD], 1.43 [1.86]; Cohen d = 0.77) and surgery (mean [SD], 0.73 [0.35]; Cohen d = 0.53) were less likely than men to explicitly associate men with career (B coefficient, -0.10; 95% CI, -0.15 to -0.04; P < .001) and surgery (B coefficient, -0.67; 95% CI, -1.21 to -0.13; P = .001) and women with family and family medicine. CONCLUSIONS AND RELEVANCE The main contribution of this work is an estimate of the extent of implicit gender bias within surgery. On both the Gender-Career IAT and the novel Gender-Specialty IAT, respondents had a tendency to associate men with career and surgery and women with family and family medicine. Awareness of the existence of implicit biases is an important first step toward minimizing their potential effect.
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Affiliation(s)
- Arghavan Salles
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Michael Awad
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Laurel Goldin
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St Louis, St Louis, Missouri
| | - Kelsey Krus
- Medical student, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Jin Vivian Lee
- Medical student, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Maria T Schwabe
- Medical student, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Calvin K Lai
- Department of Psychological and Brain Sciences, Washington University in St Louis, St Louis, Missouri
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Abstract
Surgical training has focused on the development of technical competency. Interpersonal and cognitive skills are essential to working as an interdisciplinary team, which translates into safety for the patient and well-being for the surgeon and colleagues. This article offers an "alternative" surgical curriculum topic list to augment the technical skill sets traditionally taught to trainees.
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Gonzalez AA, Sutzko DC, Osborne NH. A National Study Evaluating Hospital Volume and Inpatient Mortality after Open Abdominal Aortic Aneurysm Repair in Vulnerable Populations. Ann Vasc Surg 2018; 50:154-159. [PMID: 29477676 DOI: 10.1016/j.avsg.2017.11.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a large body of evidence documenting better outcomes for abdominal aortic aneurysm (AAA) repairs performed in high-volume centers. However, it remains unknown if the strength of this volume-outcome relationship is moderated by race or socioeconomic status (SES). METHODS This is a cross-sectional retrospective cohort study evaluating 60,618 Medicare fee-for-service beneficiaries undergoing open AAA repair across 1,649 hospitals between 2005 and 2009. We selected, a priori, black race and low SES as vulnerable populations based on previous reports showing each is independently associated with higher mortality. Next, we divided hospitals into quintiles of procedural volume and used logistic regression to compare risk-adjusted rates of inpatient mortality across volume quintiles for the overall study population and separately by race (black versus nonblack) and SES (low, middle, and high). RESULTS Overall, patients treated in the lowest-volume hospitals (LVHs) had higher risk-adjusted inpatient mortality rates than patients treated in the highest-volume hospitals (HVHs) (15.3% vs. 10.6%, P < 0.001). Higher mortality was associated with black versus nonblack race (12.9% vs. 11.7%, P < 0.001) and low SES versus high SES (12.2% vs. 11.6% P < 0.001). While nonblack patients treated in LVHs had higher odds of mortality (versus HVHs, adjusted odds ratio (aOR) 1.83 [1.59-2.11]), this volume-outcome effect was greater for black patients (aOR 2.60 [1.63-4.16]). In contrast, high and low SES patients experienced similar differences in mortality when treated in LVHs (aOR 1.79 [1.49-2.12]; aOR 1.72 [1.28-2.30], respectively). CONCLUSIONS While a volume-outcome effect was observed in all patients, black patients appeared to derive a disproportionate benefit from undergoing open AAA repair in HVHs. The mechanism underlying these disparate outcomes remains unclear but warrants further evaluation of contributing hospital and patient factors.
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Affiliation(s)
- Andrew A Gonzalez
- Department of Surgery, University of Illinois Hospital & Health Sciences System, Chicago IL.
| | - Danielle C Sutzko
- Institute for Healthcare Policy and Innovation (IHPI), North Campus Research Complex (NCRC), University of Michigan, Ann Arbor, MI
| | - Nicholas H Osborne
- Institute for Healthcare Policy and Innovation (IHPI), North Campus Research Complex (NCRC), University of Michigan, Ann Arbor, MI; Section of Vascular Surgery, University of Michigan, Ann Arbor MI
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Khubchandani JA, Shen C, Ayturk D, Kiefe CI, Santry HP. Disparities in access to emergency general surgery care in the United States. Surgery 2018; 163:243-250. [PMID: 29050886 PMCID: PMC6071308 DOI: 10.1016/j.surg.2017.07.026] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/13/2017] [Accepted: 07/27/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND As fewer surgeons take emergency general surgery call and hospitals decrease emergency services, a crisis in access looms in the United States. We examined national emergency general surgery capacity and county-level determinants of access to emergency general surgery care with special attention to disparities. METHODS To identify potential emergency general surgery hospitals, we queried the database of the American Hospital Association for "acute care general hospital," with "surgical services," and "emergency department," and ≥1 "operating room." Internet search and direct contact confirmed emergency general surgery services that covered the emergency room 7 days a week, 24 hours a day. Geographic and population-level emergency general surgery access was derived from Geographic Information Systems and US Census. RESULTS Of the 6,356 hospitals in the 2013 American Hospital Association database, only 2,811 were emergency general surgery hospitals. Counties with greater percentages of black, Hispanic, uninsured, and low-education individuals and rural counties disproportionately lacked access to emergency general surgery care. For example, counties above the 75th percentile of African American population (10.2%) had >80% odds of not having an emergency general surgery hospital compared with counties below the 25th percentile of African American population (0.6%). CONCLUSION Gaps in access to emergency general surgery services exist across the United States, disproportionately affecting underserved, rural communities. Policy initiatives need to increase emergency general surgery capacity nationwide.
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Affiliation(s)
| | | | - Didem Ayturk
- Department of Surgery, University of Massachusetts Medical School, Worcester, MA; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Heena P Santry
- Department of Surgery, Ohio State University, Columbus, OH.
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Chiu AS, Jean RA, Davis KA, Pei KY. Impact of Race on the Surgical Management of Adhesive Small Bowel Obstruction. J Am Coll Surg 2017; 226:968-976.e1. [PMID: 29170020 DOI: 10.1016/j.jamcollsurg.2017.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/11/2017] [Accepted: 11/13/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Small bowel obstruction (SBO) represents roughly 15% of admissions by general surgeons. Management of SBO relies heavily on provider judgment, including decisions on how long to try nonsurgical management and whether to use a laparoscopic or open approach when surgery is needed. Given the subjective nature of these decisions, it is unknown if patient race influences management of SBO. STUDY DESIGN The National Surgical Quality Improvement Program was used to identify patients who underwent adhesiolysis or small bowel resection for adhesive SBO between 2010 and 2015 (n = 13,896). Adjusted logistic regression models incorporating patient comorbidity, American Society of Anesthesiologists (ASA) class, and emergency status were used to analyze odds of receiving surgery after 5 days from hospital admission (Eastern Association for the Surgery of Trauma guidelines) and of undergoing an open operation. RESULTS Patients who waited more than 5 days for a procedure had greater adjusted odds of postoperative complication (odds ratio [OR] 1.56 95% CI 1.37 to 1.79) compared with those waiting 5 days or less. Similarly, open procedures had higher odds of complication compared with laparoscopic (OR 2.31 95% CI 2.00 to 2.68). Regression analysis demonstrated that black patients were significantly more likely than white patients to wait more than 5 days for surgery (OR 1.31 95% CI [1.13-1.53]) and undergo open surgery (OR 1.56, 95% CI 1.36 to 1.79). There was no statistical difference for Hispanics patients waiting more than 5 days (OR 0.98, 95% CI 0.73 to 1.31) or receiving open surgery (OR 0.84, 95% CI 0.70 to 1.01) compared with white patients. CONCLUSIONS Clinical decisions regarding SBO management differ based on patient race. Future studies focusing on the surgical decision-making process and the influence of bias are needed.
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Affiliation(s)
| | - Raymond A Jean
- Department of Surgery, Yale School of Medicine, New Haven, CT; National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kimberly A Davis
- Department of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT
| | - Kevin Y Pei
- Department of Surgery, Section of General Surgery, Trauma and Surgical Critical Care, Yale School of Medicine, New Haven, CT.
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Yeung F, Yuan C, Jackson DS, Chun MBJ. Gone, But Not Forgotten? Survey of Resident Attitudes Toward a Cultural Standardized Patient Examination for a General Surgery Residency Program. Health Equity 2017; 1:150-155. [PMID: 30283842 PMCID: PMC6071888 DOI: 10.1089/heq.2017.0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Various tools have been utilized for cultural competency training in residency programs, including cultural standardized patient examinations. However, it is unknown whether residents feel the training they received has a long-term impact on how they care for patients. The purpose of this study was to assess whether surgical residents who participated in a cultural standardized patient examination view the experience as beneficial. Methods: Surgical residents who completed a standardized patient examination from Fall 2009 to Spring 2015 were asked to complete a 13-question survey assessing the following: (1) did participants feel prepared when dealing with patients from different cultural backgrounds, (2) did they feel the standardized patient experience was beneficial or improved their ability to care for patients, and (3) did they perceive that cultural competence was important when dealing with patients. Results: Sixty current/former residents were asked to participate and 24 (40%) completed the survey. All agreed cross-cultural skills were important and almost all reported daily interaction with patients from different cultural backgrounds. Sixteen participants (67%) reported the cultural standardized patient examination aided their ability to care for culturally dissimilar patients, and 13 (54%) said the training helped improve their communication skills with patients. Thirteen (54%) reported they would participate in another cultural standardized patient examination. Conclusion: Development of effective cultural competency training remains challenging. This study provides some preliminary results that demonstrate the potential lasting impact of cultural competency training. Participants found the skills gained from cultural standardized patient examinations helpful.
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Affiliation(s)
- Fanny Yeung
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Chloe Yuan
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
| | | | - Maria B J Chun
- Department of Surgery, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, Hawaii
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Affiliation(s)
- Patricia Bucknor-Ferron
- Patricia Bucknor-Ferron is an assistant nurse manager at Baptist Medical Center in Jacksonville, Fla., and Lori Zagaja is a clinical risk manager at St. Francis Hospital and Medical Center in Hartford, Conn
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Tan JY, Xu LJ, Lopez FY, Jia JL, Pho MT, Kim KE, Chin MH. Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap. LGBT Health 2016; 3:327-34. [PMID: 27158858 DOI: 10.1089/lgbt.2015.0143] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered.
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Affiliation(s)
- Judy Y Tan
- 1 Department of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California
| | - Lucy J Xu
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,3 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
| | - Fanny Y Lopez
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois
| | - Justin L Jia
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,4 The College, University of Chicago , Chicago, Illinois
| | - Mai T Pho
- 5 Section of Infectious Diseases and Global Health, Department of Medicine, University of Chicago , Chicago, Illinois
| | - Karen E Kim
- 6 Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Chicago , Chicago, Illinois.,7 Center for Asian Health Equity, University of Chicago , Chicago, Illinois
| | - Marshall H Chin
- 2 Section of General Internal Medicine, Department of Medicine, University of Chicago , Chicago, Illinois.,8 Robert Wood Johnson Foundation Finding Answers: Solving Disparities through Payment and Delivery System Reform Program Office, University of Chicago , Chicago, Illinois
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Shaw JJ, Santry HP. Who Gets Early Tracheostomy?: Evidence of Unequal Treatment at 185 Academic Medical Centers. Chest 2016; 148:1242-1250. [PMID: 26313324 DOI: 10.1378/chest.15-0576] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although the benefits of early tracheostomy in patients dependent on ventilators are well established, the reasons for variation in time from intubation to tracheostomy remain unclear. We identified clinical and demographic disparities in time to tracheostomy. METHODS We performed a level 3 retrospective prognostic study by querying the University HealthSystem Consortium (2007-2010) for adult patients receiving a tracheostomy after initial intubation. Time to tracheostomy was designated early (< 7 days) or late (> 10 days). Cohorts were stratified by time to tracheostomy and compared using univariate tests of association and multivariable adjusted models. RESULTS A total of 49,191 patients underwent tracheostomy after initial intubation: 42% early (n = 21,029) and 58% late (n = 28,162). On both univariate and multivariable analyses, women, blacks, Hispanics, and patients receiving Medicaid were less likely to receive an early tracheostomy. Patients in the early group also experienced lower rates of mortality (OR, 0.84; 95% CI, 0.79-0.88). CONCLUSIONS Early tracheostomy was associated with increased survival. Yet, there were still significant disparities in time to tracheostomy according to sex, race, and type of insurance. Application of evidence-based algorithms for tracheostomy may reduce unequal treatment and improve overall mortality rates. Additional research into this apparent bias in referral/rendering of tracheostomy is needed.
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Affiliation(s)
- Joshua J Shaw
- Department of Surgery and the Center for Outcomes Research-Surgical Research Scholars Program, University of Massachusetts Medical School, Worcester, MA
| | - Heena P Santry
- Department of Surgery and the Center for Outcomes Research-Surgical Research Scholars Program, University of Massachusetts Medical School, Worcester, MA; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.
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Hisam B, Zogg CK, Chaudhary MA, Ahmed A, Khan H, Selvarajah S, Torain MJ, Changoor NR, Haider AH. From understanding to action: interventions for surgical disparities. J Surg Res 2016; 200:560-78. [DOI: 10.1016/j.jss.2015.09.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/28/2015] [Accepted: 09/14/2015] [Indexed: 11/26/2022]
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Dy CJ, Lyman S, Boutin-Foster C, Felix K, Kang Y, Parks ML. Do patient race and sex change surgeon recommendations for TKA? Clin Orthop Relat Res 2015; 473:410-7. [PMID: 25337976 PMCID: PMC4294909 DOI: 10.1007/s11999-014-4003-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 10/06/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior investigations have suggested that physician-related factors may contribute to differential use of TKA among women and ethnic minorities. We sought to evaluate the effect of surgeon bias on recommendations for TKA. QUESTIONS/PURPOSE Using an experimental approach with standardized patient scenarios, we sought to evaluate surgeon recommendations regarding TKA, specifically to determine whether recommendations for TKA are influenced by (1) patient race, and (2) patient sex. METHODS We developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis. Patients gave an orthopaedic history of 2 years worsening pain with decreased functional status and failure of oral antiinflammatory medications and corticosteroid intraarticular injections. Orthopaedic surgeons attending the 2012 annual meetings of the New York State Society of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons were recruited for the study. Surgeons passing an open recruitment table at each meeting were asked to participate. Of the 1111 surgeons in attendance at either meeting, 113 (10.2%) participated in the study. All participants viewed the "control" patient's story (white male) and were randomized to view one of the three "experimental" scenarios (white female, black male, black female). After viewing each scenario, the participants were anonymously asked whether they would recommend TKA. An a priori power analysis showed that 112 participants were needed to detect a 15% difference in the likelihood of recommending surgery for white versus nonwhite patients in the test scenarios evaluated with 90% power at a level of significance of 0.05. RESULTS Of the 39 surgeons who viewed the white male plus black female scenario, there were 33 (85%) concordant responses (TKA offered to both patients) and six discordant responses (TKA offered to only one of the patients), with no effect of patient race and sex (p = 0.99). Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89%) concordant responses and four discordant responses, with no effect of patient race (p = 0.32). Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77%) concordant responses and seven discordant responses, with no effect of patient sex (p = 0.71). CONCLUSION After orthopaedic surgeons viewed video scenarios of patients with end-stage knee osteoarthritis, patient race and sex were not associated with a different likelihood of a surgical recommendation. Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear.
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Affiliation(s)
- Christopher J. Dy
- />Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA , />Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA , />Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8233, St. Louis, MO 63124 USA
| | - Stephen Lyman
- />Healthcare Research Institute, Hospital for Special Surgery, New York, NY USA
| | | | - Karla Felix
- />Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Yoon Kang
- />Department of Medicine, Weill Cornell Medical College, New York, NY USA
| | - Michael L. Parks
- />Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
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Krieger N. Discrimination and Health Inequities. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2014; 44:643-710. [DOI: 10.2190/hs.44.4.b] [Citation(s) in RCA: 429] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In 1999, only 20 studies in the public health literature employed instruments to measure self-reported experiences of discrimination. Fifteen years later, the number of empirical investigations on discrimination and health easily exceeds 500, with these studies increasingly global in scope and focused on major types of discrimination variously involving race/ethnicity, indigenous status, immigrant status, gender, sexuality, disability, and age, separately and in combination. And yet, as I also document, even as the number of investigations has dramatically expanded, the scope remains narrow: studies remain focused primarily on interpersonal discrimination, and scant research investigates the health impacts of structural discrimination, a gap consonant with the limited epidemiologic research on political systems and population health. Accordingly, to help advance the state of the field, this updated review article: ( a) briefly reviews definitions of discrimination, illustrated with examples from the United States; ( b) discusses theoretical insights useful for conceptualizing how discrimination can become embodied and produce health inequities, including via distortion of scientific knowledge; ( c) concisely summarizes extant evidence—both robust and inconsistent—linking discrimination and health; and ( d) addresses several key methodological controversies and challenges, including the need for careful attention to domains, pathways, level, and spatiotemporal scale, in historical context.
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