New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Leveraging Health Services Research to Address Aging Health Equity

To achieve optimal, equitable health outcomes for all older adults, the United States desperately needs equity in access to, quality of, and cost of aging care. To illustrate these needs, we discuss the current inequitable state of frailty care. Frailty disproportionately affects marginalized populations, yet these populations struggle to access high-quality geriatrics care and long-term care services and supports (LTSS) that mitigate frailty, leading to accelerated frailty trajectories. Health services research can provide the data needed to document, elucidate, and address health inequities in frailty care, including early identification and referral of frail adults to specialized care and financing LTSS.

Global Barriers to Accessing Off-Patent Endocrine Therapies: A Renaissance of the Orphan Disease?

CONTEXT

Clinical endocrinology encompasses many diseases requiring long-term drug therapy. Prohibitive pricing of some endocrine drugs classified as essential by the World Health Organization has created suboptimal care of patients with endocrine disorders.

EVIDENCE ACQUISITION

This review is based on evidence obtained from several databases and search engines including PubMed, Google, and Google Scholar; reference searches; manual searching for web pages of international regulatory bodies; and the authors' experience from different healthcare settings.

EVIDENCE SYNTHESIS

After the expiry of a patent, generic versions with the opportunity for increased availability and a price reduction are expected. There are access barriers worldwide for many off-patent endocrine drugs. The high price is the main issue for several medicines including insulin, hydrocortisone, testosterone, and gonadotropins. This is caused by several factors including the market monopoly due to the lack of registered generics or suppliers limiting the benefit of competition and a complex supply chain. Additionally, the lack of some medicines has been concerning due to market factors such as the relatively small number of patients, making it less attractive for the manufacturers. Commissioning of nonprofit manufacturers and state manufacturing as well as strict price control measures could alleviate this situation.

CONCLUSION

Lack of availability and disproportionate price inflation affecting essential off-patent endocrine therapies is common due to several interrelated factors. Global collaboration among healthcare organizations with the support of policymaking bodies might be needed to mitigate this.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

BACKGROUND

Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease.

OBJECTIVE

Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes.

DESIGN

Observational cohort study.

PARTICIPANTS

One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021.

INTERVENTIONS

Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support).

MAIN MEASURES

Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations).

KEY RESULTS

Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months.

CONCLUSIONS

CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Integrated Interventions to Bridge Medical and Social Care for People Living with Diabetes

Social drivers of health impact health outcomes for patients with diabetes, and are areas of interest to health systems, researchers, and policymakers. To improve population health and health outcomes, organizations are integrating medical and social care, collaborating with community partners, and seeking sustainable financing with payors. We summarize promising examples of integrated medical and social care from the Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care initiative. The initiative funded eight organizations to implement and evaluate integrated medical and social care models, aiming to build a value case for services that are traditionally not eligible for reimbursement (e.g., community health workers, food prescriptions, patient navigation). This article summarizes promising examples and future opportunities for integrated medical and social care across three themes: (1) primary care transformation (e.g., social risk stratification) and workforce capacity (e.g., lay health worker interventions), (2) addressing individual social needs and structural changes, and (3) payment reform. Integrated medical and social care that advances health equity requires a significant paradigm shift in healthcare financing and delivery.

Financial Sustainability for Complex Care Models Serving Low-Income Patients: a New Role for Philanthropy

This paper shares lessons learned from providing planning and technical assistance to the grantees of the Merck Foundation's 5-year, $16 million initiative, Bridging the Gap: Reducing Disparities in Diabetes Care, designed to improve access to high-quality diabetes care and reduce disparities in health outcomes among vulnerable and underserved U.S. populations with type 2 diabetes. Our objective was to co-create, with the sites, financial sustainability plans to sustain their work once the initiative had ended and to improve and/or expand it to serve more patients, better. Financial sustainability is an unfamiliar concept in this context, largely because the current payment system inadequately compensates providers for the value their care models provide to patients and to insurers. Our assessment and recommendations are based on our experiences working with each of the sites on sustainability plans. The sites were diverse in terms of their approaches to clinical transformation and integration of SDOH interventions, geography, organizational context, external environment, and populations served. These factors influenced the sites' capacity to build and implement viable financial sustainability strategies and the eventual plans themselves. Philanthropy has a critical role in investing in providers' capacity to develop and implement financial sustainability plans.

Critical Theory, Culture Change, and Achieving Health Equity in Health Care Settings

Achieving optimal health for all requires confronting the complex legacies of colonialism and white supremacy embedded in all institutions, including health care institutions. As a result, health care organizations committed to health equity must build the capacity of their staff to recognize the contemporary manifestations of these legacies within the organization and to act to eliminate them. In a culture of equity, all employees-individually and collectively-identify and reflect on the organizational dynamics that reproduce health inequities and engage in activities to transform them. The authors describe 5 interconnected change strategies that their medical center uses to build a culture of equity. First, the medical center deliberately grounds diversity, equity, and inclusion efforts (DEI) in critical theory, aiming to illuminate social structures through critical analysis of power relations. Second, its training goes beyond cultural competency and humility to include critical consciousness, which includes the ability to critically analyze conditions in the organizational and broader societal contexts that produce health inequities and act to transform them. Third, it works to strengthen relationships so they can be change vehicles. Fourth, it empowers an implementation team that models a culture of equity. Finally, it aligns equity-focused culture transformation with equity-focused operations transformation to support transformative praxis. These 5 strategies are not a panacea. However, emerging processes and outcomes at the medical center indicate that they may reduce the likelihood of ahistorical and power-blind approaches to equity initiatives and provide employees with some of the critical missing knowledge and skills they need to address the root causes of health inequity.

Standup comedy principles and the personal monologue to explore interpersonal bias: experiential learning in a health disparities course

BACKGROUND

Interpersonal biases between clinicians and patients contribute to disparities in health care and outcomes by race, ethnicity, and socioeconomic status. We used standup comedy principles and exercises to help medical students recognize how others perceive them and how they perceive others, and engage in difficult discussions around implicit biases and interpersonal racism.

METHODS

90 min Zoom workshop with 40 first-year medical students in urban medical school. Intervention consisted of three exercises: Naming icebreaker, Rant and Rave (communicate strong perspective clearly), and Personal Monologue about how others perceive you and how you perceive yourself. Discussion debriefed the personal monologue exercise. Likert scale questions on post-session survey evaluated workshop overall, whether workshop increased skills, and safety of learning environment. Open-ended questions included what trainees liked about the module, what could be improved, and what impact the module had on them?

RESULTS

Seventeen (42.5%) students responded to survey. Six respondents identified as white, 4 as Asian, 1 as Black, 1 as multiracial, and 5 did not identify. Seventy-six percent rated the module as "very good" or "excellent", and 94% would recommend the module to others. Most respondents reported the workshop helped them become better listeners (75%) and more observant (82%). Eighty-three percent reported the training could help them take better care of patients with lived experiences different than their own. All respondents believed the learning environment was safe, and 94% reported that instructors created an atmosphere in which they could take risks. Thirty-six percent felt stressed. Students reported the workshop helped them recognize their own identities, others' perceptions, and bidirectional biases, and inspired them to strive for more accurate, authentic interactions with patients.

CONCLUSIONS

Standup comedy principles show promise for engaging students in meaningful, safe discussions about perceptions and interpersonal biases rooted in their own personal experiences and those of their classmates.