1
|
Chen J, Khazanchi R, Bearman G, Marcelin JR. Racial/Ethnic Inequities in Healthcare-associated Infections Under the Shadow of Structural Racism: Narrative Review and Call to Action. Curr Infect Dis Rep 2021; 23:17. [PMID: 34466126 PMCID: PMC8390539 DOI: 10.1007/s11908-021-00758-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 02/03/2023]
Abstract
Purpose of Review The purpose of this study is to review racial and ethnic inequities in the incidence and prevention of healthcare-associated infections (HAIs) in the USA, identify gaps in the literature, and recommend future directions to mitigate these inequities. Recent Findings While some existing literature has identified the presence of racial/ethnic inequities in HAI incidence and outcomes, few studies to date have evaluated whether HAI prevention efforts have mitigated these inequities. Factors contributing to inequities in HAI prevention may include unconscious bias of healthcare professionals towards minoritized patients; socioeconomic and structural inequities disparately affecting minoritized communities; the racial segregation of quality healthcare through hospital price discrimination; divergent reimbursement rates between public and private insurers; policies or performance metrics which underfund and financially penalize safety-net hospitals; and insufficient research evaluating and addressing HAI inequities. Summary Expansion of the literature is needed to further interrogate root causes and evaluate the impact of interventions on racial/ethnic inequities in HAI incidence. Measures to mitigate inequities might include teaching healthcare workers how to recognize and mitigate unconscious biases, expanding community resources which address the social and structural determinants of health, increasing access to preventive health services, reforming federal and institutional policies to better support safety-net hospitals and disincentivize price discrimination, and improving diversity and inclusion within the health workforce.
Collapse
Affiliation(s)
- Jiabi Chen
- School of Medicine, Virginia Commonwealth University, Richmond, VA USA
| | - Rohan Khazanchi
- College of Medicine, University of Nebraska Medical Center, Omaha, NE USA.,School of Public Health, University of Minnesota, Minneapolis, MN USA
| | - Gonzalo Bearman
- Department of Internal Medicine, Division of Infectious Disease, Virginia Commonwealth University, Richmond, VA USA
| | - Jasmine R Marcelin
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE USA
| |
Collapse
|
2
|
Development of a Clinical Prediction Model for Central Line-Associated Bloodstream Infection in Children Presenting to the Emergency Department. Pediatr Emerg Care 2020; 36:e600-e605. [PMID: 30985631 PMCID: PMC6788929 DOI: 10.1097/pec.0000000000001835] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE The majority of the children with a central line who present to the emergency department with fever or other signs of bacteremia do not have a central line-associated bloodstream infection (CLABSI). Our objective was to develop a clinical prediction model for CLABSI among this group of children in order to ultimately limit unnecessary hospital admissions and antibiotic use. METHODS We performed a nested case-control study of children with a central line who presented to the emergency department of an urban, tertiary care children's hospital between January 2010 and March 2015 and were evaluated for CLABSI with a blood culture. RESULTS The final multivariable model developed to predict CLABSI consisted of 12 factors: age younger than 5 years, black race, use of total parenteral nutrition, tunneled central venous catheter, double-lumen catheter, absence of other bacterial infection, absence of viral upper respiratory tract infection symptoms, diarrhea, emergency department temperature greater than 39.5°C, fever prior to presentation, neutropenia, and spring/summer season. The clinical prediction score had good discrimination for CLABSI with a c-statistic of 0.81 (confidence interval, 0.77-0.85). A cut point less than 6 was associated with a sensitivity of 98.5% and a negative predictive value of 99.2% for CLABSI. CONCLUSIONS We were able to identify risk factors and develop a clinical prediction model for CLABSI in children presenting to the emergency department. Once validated in future study, this clinical prediction model could be used to assess the need for hospitalization and/or antibiotics among this group of patients.
Collapse
|
3
|
The role of the built environment and private rooms for reducing central line-associated bloodstream infections. PLoS One 2018; 13:e0201002. [PMID: 30052672 PMCID: PMC6063409 DOI: 10.1371/journal.pone.0201002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 07/06/2018] [Indexed: 11/24/2022] Open
Abstract
Private hospital rooms are believed to offer some protective effect against hospital-acquired infections, including central line-associated bloodstream infections. Yet a recent meta-analysis found the evidence-base to be lacking from a policy perspective. We sought to determine whether private rooms were associated with a lower risk of central-line infections. We examined the discharge records of more than one million inpatients from 335 Texas hospitals to determine patients that stayed in private rooms. Patients who stayed in bay rooms had 64 percent more central line infections than patients who stayed in private rooms. Even after adjusting for relevant covariates, patients assigned to bay rooms had a 21 percent greater relative risk of a central line infection (p = 0.005), compared with patients assigned to private rooms. At the hospital level, a 10% increase in private rooms was associated with an 8.6% decrease in central line infections (p<0.001), regardless of individual patients' room assignment. This study demonstrates and validates the use of private rooms as a structural measure and independent predictor of hospital quality.
Collapse
|
4
|
Stein A. Race and ethnicity as predictors of hospital-acquired conditions after total hip arthroplasty and total knee arthroplasty. Int J Orthop Trauma Nurs 2017; 27:16-22. [PMID: 28673450 DOI: 10.1016/j.ijotn.2017.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/22/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Anne Stein
- Northern Michigan University, 1401 Presque Isle Ave, Marquette, MI 49855, United States.
| |
Collapse
|
5
|
Rosenberg BL, Kellar JA, Labno A, Matheson DHM, Ringel M, VonAchen P, Lesser RI, Li Y, Dimick JB, Gawande AA, Larsson SH, Moses H. Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment. PLoS One 2016; 11:e0166762. [PMID: 27973617 PMCID: PMC5156342 DOI: 10.1371/journal.pone.0166762] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/03/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite numerous studies of geographic variation in healthcare cost and utilization at the local, regional, and state levels across the U.S., a comprehensive characterization of geographic variation in outcomes has not been published. Our objective was to quantify variation in US health outcomes in an all-payer population before and after risk-adjustment. METHODS AND FINDINGS We used information from 16 independent data sources, including 22 million all-payer inpatient admissions from the Healthcare Cost and Utilization Project (which covers regions where 50% of the U.S. population lives) to analyze 24 inpatient mortality, inpatient safety, and prevention outcomes. We compared outcome variation at state, hospital referral region, hospital service area, county, and hospital levels. Risk-adjusted outcomes were calculated after adjusting for population factors, co-morbidities, and health system factors. Even after risk-adjustment, there exists large geographical variation in outcomes. The variation in healthcare outcomes exceeds the well publicized variation in US healthcare costs. On average, we observed a 2.1-fold difference in risk-adjusted mortality outcomes between top- and bottom-decile hospitals. For example, we observed a 2.3-fold difference for risk-adjusted acute myocardial infarction inpatient mortality. On average a 10.2-fold difference in risk-adjusted patient safety outcomes exists between top and bottom-decile hospitals, including an 18.3-fold difference for risk-adjusted Central Venous Catheter Bloodstream Infection rates. A 3.0-fold difference in prevention outcomes exists between top- and bottom-decile counties on average; including a 2.2-fold difference for risk-adjusted congestive heart failure admission rates. The population, co-morbidity, and health system factors accounted for a range of R2 between 18-64% of variability in mortality outcomes, 3-39% of variability in patient safety outcomes, and 22-70% of variability in prevention outcomes. CONCLUSION The amount of variability in health outcomes in the U.S. is large even after accounting for differences in population, co-morbidities, and health system factors. These findings suggest that: 1) additional examination of regional and local variation in risk-adjusted outcomes should be a priority; 2) assumptions of uniform hospital quality that underpin rationale for policy choices (such as narrow insurance networks or antitrust enforcement) should be challenged; and 3) there exists substantial opportunity for outcomes improvement in the US healthcare system.
Collapse
Affiliation(s)
- Barry L. Rosenberg
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | - Joshua A. Kellar
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | - Anna Labno
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | | | - Michael Ringel
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | - Paige VonAchen
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | - Richard I. Lesser
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | - Yue Li
- Department of Public Health Sciences, University of Rochester Medical Center, New York City, New York, United States of America
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Atul A. Gawande
- Ariadne Labs At Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Stefan H. Larsson
- The Boston Consulting Group, Boston, Massachusetts, United States of America
| | - Hamilton Moses
- The Alerion Institute and Alerion Advisors, LLC, North Garden, Virginia, United States of America
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| |
Collapse
|
6
|
Shen JJ, Cochran CR, Mazurenko O, Moseley CB, Shan G, Mukalian R, Neishi S. Racial and Insurance Status Disparities in Patient Safety Indicators among Hospitalized Patients. Ethn Dis 2016; 26:443-52. [PMID: 27440986 DOI: 10.18865/ed.26.3.443] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To examine the association between patient race/ethnicity, insurance status, and their interaction with patient safety indicators among hospitalized patients. METHODS Cross-sectional study was conducted. Data were extracted from the 2009 National Inpatient Sample. A total of 3,052,268 patient safety indicator-related discharges were identified. Dependent variables were 11 patient safety indicators (PSI) whereas independent variables included race/ethnicity and insurance status. RESULTS As compared with White patients, African American patients were more likely to experience pressure ulcer, post-operative hemorrhage or hematoma, and post-operative pulmonary embolism (PE) or deep vein thrombosis (DVE); Asian/Pacific Islander patients were more likely to experience pressure ulcer, post-operative PE or DVT, and two obstetric care PSIs; whereas Hispanic/Latino patients were more likely to experience post-operative physiometabolic derangement and accidental puncture/laceration. As compared with patients with private insurance, Medicaid patients were more likely to experience pressure ulcer, post-operative physiological metabolic derangement, post-operative PE or DVT, post-operative respiratory failure, post-operative wound dehiscence, and death among surgeries. However, both obstetric care PSIs showed that African Americans, Hispanics, and uninsured patients were less likely to incur them in comparison with their respective counterparts. Furthermore, strong interactive effects between African American and Medicaid on PSIs were detected. CONCLUSIONS Although mixed findings in disparities in PSIs were observed in our study, Asian/Pacific Islander patients and Medicaid patients seem to be the most vulnerable. Further, interactive effects between African American and Medicaid indicate that poverty may be a key factor related to disparities in health care. Future research is merited to identify underlying factors that are related to PSIs among Asian/Pacific Islander patients. Strategies are needed to improve PSIs among Medicaid patients, especially during the current Medicaid program expansion due to the implementation of the Affordable Care Act.
Collapse
Affiliation(s)
- Jay J Shen
- Department of Health Care Administration and Policy, University of Nevada Las Vegas
| | | | - Olena Mazurenko
- Department of Health Policy and Management, Indiana University - Purdue University Indianapolis
| | - Charles B Moseley
- Department of Health Care Administration and Policy, University of Nevada Las Vegas
| | - Guogen Shan
- School of Community Health Sciences, University of Nevada Las Vegas
| | | | - Scott Neishi
- Department of Health Care Administration and Policy, University of Nevada Las Vegas
| |
Collapse
|
7
|
Chen M, Xiao Y, Liu Y, Peng Y, He J, Zhang Y, Du L. The quality analysis of literature retrievals of systematic reviews for traditional Chinese medicine. J Evid Based Med 2015; 8:42-52. [PMID: 25822779 DOI: 10.1111/jebm.12139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The literature retrievals are still the main problems which limit the quality of systematic review (SR) for traditional Chinese medicine (TCM), and there were still no comprehensive analyses for these problems. The aim of this study is to analyze these problems to guide future SRs for TCM. METHODS The Cochrane Library (Issue 2, 2009) and the Chinese BioMedical Database (CBM, 1978- 2009.7.31) were comprehensively searched to identify the SRs of TCM. The native literature retrieval rate of the first author, the characteristics of the included databases, the number of the included database, the reporting of literature retrieval strategy, and the reporting of adjuvant search for both the SRs from the CBM and Cochrane Library were analyzed. RESULTS A total of 341 SRs were included in our analyses, including 245 from the CBM and 96 from the CL. The Chinese-authored SRs ranked the first in median retrieval rate (100%). The Cochrane SRs were significantly superior than the CBM SRs: more searched databases (media: 4 vs. 6, P < 0.001), more precision of retrieval time, more conducting gray literatures searches (47.92% vs. 20.41%) and handing searches (57.29% vs. 54.69%), and more reported retrieval strategies (66.67% vs. 8.16%). CONCLUSIONS There were significant problems in the literature retrieval of SRs for TCM. In future, when performing any SRs for TCM, sufficient and proper databases, clearly searching strategies and times, proper adjuvant retrievals should be reported. Cochrane SRs might be a better choice.
Collapse
Affiliation(s)
- Min Chen
- Department of Traditional Chinese Medicine, The Third People's Hospital of Chengdu, Chengdu, China
| | | | | | | | | | | | | |
Collapse
|