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Muirhead L, Echt KV, Alexis AM, Mirk A. Social Determinants of Health: Considerations for Care of Older Veterans. Nurs Clin North Am 2022; 57:329-345. [PMID: 35985723 DOI: 10.1016/j.cnur.2022.04.002] [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] [Indexed: 10/15/2022]
Abstract
Social determinants of health (SDOH), the environments and circumstances in which people are born, grow, live, work and age, are potent drivers of health, health disparities, and health outcomes over the lifespan. Military service affords unique experiences, exposures, and social and health vulnerabilities which impact the life course and may alter health equity and health outcomes for older veterans. Identifying and addressing SDOH, inclusive of the military experience, allows person-centered, more equitable care to this vulnerable population. Nurses and other health professionals should be familiar with how to identify and address health-related social needs and implement interdiciplinary, team-based approaches to connect patients with resources and benefits specifically available to veterans.
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Affiliation(s)
- Lisa Muirhead
- Emory University, Nell Hodgson Woodruff School of Nursing, 1520 Clifton Road, Atlanta, GA 30322, USA.
| | - Katharina V Echt
- Veterans Affairs Birmingham/ Atlanta Geriatric Research, Education and Clinical Center (GRECC), Atlanta VA Health Care System, 3101 Clairmont Road Northeast, Brookhaven, GA 30329-1044, USA; Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrea M Alexis
- Atlanta VA Health Care System, Nursing Education, 1M-116A, 1670 Clairmont Road, Decatur, GA 30033, USA
| | - Anna Mirk
- Veterans Affairs Birmingham/ Atlanta Geriatric Research, Education and Clinical Center (GRECC), Atlanta VA Health Care System, 3101 Clairmont Road Northeast, Brookhaven, GA 30329-1044, USA; Division of Geriatrics and Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Kornblith E, Bahorik A, Boscardin WJ, Xia F, Barnes DE, Yaffe K. Association of Race and Ethnicity With Incidence of Dementia Among Older Adults. JAMA 2022; 327:1488-1495. [PMID: 35438728 PMCID: PMC9020215 DOI: 10.1001/jama.2022.3550] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The racial and ethnic diversity of the US, including among patients receiving their care at the Veterans Health Administration (VHA), is increasing. Dementia is a significant public health challenge and may have greater incidence among older adults from underrepresented racial and ethnic minority groups. OBJECTIVE To determine dementia incidence across 5 racial and ethnic groups and by US geographical region within a large, diverse, national cohort of older veterans who received care in the largest integrated health care system in the US. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study within the VHA of a random sample (5% sample selected for each fiscal year) of 1 869 090 participants aged 55 years or older evaluated from October 1, 1999, to September 30, 2019 (the date of final follow-up). EXPOSURES Self-reported racial and ethnic data were obtained from the National Patient Care Database. US region was determined using Centers for Disease Control and Prevention (CDC) regions from residential zip codes. MAIN OUTCOMES AND MEASURES Incident diagnosis of dementia (9th and 10th editions of the International Classification of Diseases). Fine-Gray proportional hazards models were used to examine time to diagnosis, with age as the time scale and accounting for competing risk of death. RESULTS Among the 1 869 090 study participants (mean age, 69.4 [SD, 7.9] years; 42 870 women [2%]; 6865 American Indian or Alaska Native [0.4%], 9391 Asian [0.5%], 176 795 Black [9.5%], 20 663 Hispanic [1.0%], and 1 655 376 White [88.6%]), 13% received a diagnosis of dementia over a mean follow-up of 10.1 years. Age-adjusted incidence of dementia per 1000 person-years was 14.2 (95% CI, 13.3-15.1) for American Indian or Alaska Native participants, 12.4 (95% CI, 11.7-13.1) for Asian participants, 19.4 (95% CI, 19.2-19.6) for Black participants, 20.7 (95% CI, 20.1-21.3) for Hispanic participants, and 11.5 (95% CI, 11.4-11.6) for White participants. Compared with White participants, the fully adjusted hazard ratios were 1.05 (95% CI, 0.98-1.13) for American Indian or Alaska Native participants, 1.20 (95% CI, 1.13-1.28) for Asian participants, 1.54 (95% CI, 1.51-1.57) for Black participants, and 1.92 (95% CI, 1.82-2.02) for Hispanic participants. Across most US regions, age-adjusted dementia incidence rates were highest for Black and Hispanic participants, with rates similar among American Indian or Alaska Native, Asian, and White participants. CONCLUSIONS AND RELEVANCE Among older adults who received care at VHA medical centers, there were significant differences in dementia incidence based on race and ethnicity. Further research is needed to understand the mechanisms responsible for these differences.
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Affiliation(s)
- Erica Kornblith
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Amber Bahorik
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Northern California Institute for Research and Education, San Francisco
| | - W John Boscardin
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Medicine, University of California, San Francisco
| | - Feng Xia
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Northern California Institute for Research and Education, San Francisco
| | - Deborah E Barnes
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kristine Yaffe
- San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
- Northern California Institute for Research and Education, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Neurology, University of California, San Francisco
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Shostak S, Bandini J, Cadge W, Donahue V, Lewis M, Grone K, Trachtenberg S, Kacmarek R, Lux L, Matthews C, McAuley ME, Romain F, Snydeman C, Tehan T, Robinson E. Encountering the social determinants of health on a COVID-19 ICU: Frontline providers' perspectives on inequality in a time of pandemic. SSM. QUALITATIVE RESEARCH IN HEALTH 2021; 1:100001. [PMID: 34870264 PMCID: PMC8459572 DOI: 10.1016/j.ssmqr.2021.100001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 11/29/2022]
Abstract
Efforts to improve health equity may be advanced by understanding health care providers' perceptions of the causes of health inequalities. Drawing on data from in-depth interviews with nurses and registered respiratory therapists (RRTs) who served on intensive care units (ICUs) during the first surge of the pandemic, this paper examines how frontline providers perceive and attribute the unequal impacts of COVID-19. It shows that nurses and RRTs quickly perceived the pandemic's disproportionate burden on Black and Latinx individuals and families. Providers attribute these inequalities to the social determinants of health, and also raise questions about how barriers to healthcare access may have made some patients more vulnerable to the worst consequences of COVID-19. Providers' perceptions of inequality and its consequences on COVID-19 ICUs were emotionally impactful and distressing, suggesting that this is a critical moment for offering clinicians practical strategies for understanding and addressing the persistent structural inequities that cause racial inequalities in health.
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Affiliation(s)
- Sara Shostak
- Brandeis University, Department of Sociology, MS 071, 415 South Street, Waltham, MA, 02453, USA
| | - Julia Bandini
- RAND Corporation, 20 Park Plaza, Boston, MA, 02116, USA
| | - Wendy Cadge
- Brandeis University, Department of Sociology, MS 071, 415 South Street, Waltham, MA, 02453, USA
| | - Vivian Donahue
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Mariah Lewis
- Brandeis University, Department of Sociology, MS 071, 415 South Street, Waltham, MA, 02453, USA
| | - Katelyn Grone
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Sophie Trachtenberg
- Brandeis University, Department of Sociology, MS 071, 415 South Street, Waltham, MA, 02453, USA
| | - Robert Kacmarek
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Laura Lux
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Cristina Matthews
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | | | - Frederic Romain
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Colleen Snydeman
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Tara Tehan
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Ellen Robinson
- The Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
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Silvernale C, Kuo B, Staller K. Racial disparity in healthcare utilization among patients with Irritable Bowel Syndrome: results from a multicenter cohort. Neurogastroenterol Motil 2021; 33:e14039. [PMID: 33263195 DOI: 10.1111/nmo.14039] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/14/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Racial disparity in healthcare is defined as differences in healthcare services received by racial groups not due to difference in needs or preferences. As irritable bowel syndrome (IBS) is highly correlated with social factors, healthcare disparities are important factors in the sociocultural model of IBS. We used healthcare utilization as a lens to examine potential racial disparities in IBS. METHODS We retrospectively matched 3823 IBS minority patients who self-identified as "Hispanic," "Black," or "Asian" to white IBS controls and examined the number of patients with gastroenterology consults, gastroenterology procedures, and IBS-related Primary Care visits within each cohort from 2003 to 2017. KEY RESULTS Minority IBS patients were less likely to receive a gastroenterology consult than white IBS controls. Both Black and Asian IBS patients were more likely to have an IBS-related Primary Care visit than white IBS controls. All 3 minority IBS cohorts received significantly more gastroenterology procedures compared to white IBS controls. CONCLUSIONS & INFERENCES Minority IBS patients are more likely to receive gastroenterology procedures than white IBS patients. Further studies are needed to determine whether increased procedure likelihood in minority IBS patients represents a communication gap between minority patients and their providers or patient preference.
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Affiliation(s)
- Casey Silvernale
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, MA, USA
| | - Braden Kuo
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, MA, USA.,Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA, USA
| | - Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School Boston, MA, USA.,Center for Neurointestinal Health, Massachusetts General Hospital, Boston, MA, USA.,Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
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Eliacin J, Matthias MS, Cunningham B, Burgess DJ. Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication. PATIENT EDUCATION AND COUNSELING 2020; 103:1798-1804. [PMID: 32204959 DOI: 10.1016/j.pec.2020.03.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/13/2020] [Accepted: 03/17/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication. METHODS We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach. RESULTS Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication. CONCLUSION Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans. PRACTICE IMPLICATIONS We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.
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Affiliation(s)
- Johanne Eliacin
- VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VAMC; ACT Center of Indiana, Psychology Department, IUPUI, Regenstrief Institute, Inc., Indianapolis, IN, USA.
| | - Marianne S Matthias
- Center for Health Information and Communication, Richard L. Roudebush VAMC, Department of Communication Studies, IUPUI, Regenstrief Institute, Inc., Indianapolis, IN, USA.
| | - Brooke Cunningham
- Department of Family Medicine and Community Health, 420 Delaware St SE, MMC 381, Minneapolis MN, USA.
| | - Diana J Burgess
- Center for Chronic Disease Outcomes Research (a VA HSR&D Center of Excellence), Veterans Affairs Medical Center, Minneapolis, MN, USA.
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Saha S, Beach MC. Impact of Physician Race on Patient Decision-Making and Ratings of Physicians: a Randomized Experiment Using Video Vignettes. J Gen Intern Med 2020; 35:1084-1091. [PMID: 31965527 PMCID: PMC7174451 DOI: 10.1007/s11606-020-05646-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/26/2019] [Accepted: 01/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studies suggest that black patients have better interactions, on average, with physicians of their own race. Whether this reflects greater "cultural competence" in race-concordant relationships, or other effects of race unrelated to physician behavior, is unclear. It is also unclear if physician race influences patient decision-making. OBJECTIVE To determine whether physician race affects patients' ratings of physicians and decision-making, independent of physician behavior. DESIGN Randomized study using standardized video vignettes. PARTICIPANTS Primary care patients with coronary risk factors or disease. INTERVENTIONS Each participant viewed one of 16 vignettes depicting a physician reviewing cardiac catheterization results and recommending coronary artery bypass graft (CABG) surgery. Vignettes varied only in terms of physicians' race, gender, age, and communication style (high vs. low patient-centeredness). MAIN MEASURES Participants rated the video physician's communication, interpersonal style, competence, trustworthiness, likability, and overall performance (0-4 Likert scales). They also rated the necessity of CABG (0-5 scale) and whether they would undergo CABG or obtain a second opinion if they were the video patient (0-3 scales). KEY RESULTS Participants included 107 black and 131 white patients (72% participation rate). Black participants viewing a black (vs. white) video physician gave higher ratings on all physician attributes (e.g., overall rating 3.22 vs. 2.34, p < 0.001) and were more likely to perceive CABG as necessary (4.05 vs. 3.72, p = 0.03) and say they would undergo CABG if they were the video patient (2.43 vs. 2.09, p = 0.004). Patient-centered communication style reduced, but did not eliminate, the impact of race concordance. Physician race was not associated with any outcomes among white patients. CONCLUSIONS Black patients viewed the doctor in a scripted vignette more positively, and were more receptive to the same recommendation, communicated in the same way, with a black vs. white physician. Patient-centered communication reduced but did not eliminate the effect of physician race.
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Affiliation(s)
- Somnath Saha
- Section of General Internal Medicine, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd. (P3HSRD), Portland, OR, USA.
- Division of General Internal Medicine & Geriatrics, Oregon Health and Science University, Portland, OR, USA.
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