Knowledge Of Practicing Physicians About Their Legal Obligations When Caring For Patients With Disability

Internal Medicine Program Directors' Perceptions About Accommodating Residents with Disabilities: A Qualitative Study

BACKGROUND

While 26% of US adults are disabled, only 3.1 to 9.3% of practicing physicians report having a disability. Ableism within medical training and practice diminishes physician diversity and wellbeing and contributes to healthcare disparities.

OBJECTIVE

Explore physician barriers to disability equity and inclusion by examining internal medicine (IM) program directors' (PD) perspectives about recruiting and accommodating residents with disabilities (RWD).

DESIGN

Qualitative study involving semi-structured virtual interviews (conducted December 2022-September 2023; analyzed through December 2023).

PARTICIPANTS

PDs were recruited via email. Purposive sampling captured program diversity in size, location, and affiliations. Convenience sampling ensured PD diversity by gender, race/ethnicity, and age.

APPROACH

Coders analyzed thematic and discursive content of interview transcripts to characterize PD perspectives about RWDs and accommodations.

KEY RESULTS

Of the 15 programs represented, 4 had ≤ 49 and 8 had ≥ 100 total residents. Three were community-based; the rest had academic affiliations. On average, PDs had 17 (SD 8.2) years in practice. Most (11/15) identified as White race; 8/15 as female; and none as disabled. PDs characterized disability as a source of grit and empathy but also as an intrinsic deficit. They worried RWDs could have unpredictable absences and clinical incompetencies. Perceived accommodation challenges included inexperience, workload distribution, information asymmetry about accommodation needs or options, barriers to disclosure (e.g., discrimination concerns), and insufficient accommodation advertising. Perceived facilitators included advanced planning; clear, publicized processes; and access to expertise (e.g., occupational health, ombudsmen).

CONCLUSIONS

PDs held contradictory views of RWDs. PD insights revealed opportunities to alleviate PD-RWD information asymmetry in recruitment/accommodation processes, which could help align needs and improve representation and inclusion.

What some physicians say about caring for patients with disability: Responses to open-ended question to nationwide physician survey

BACKGROUND

For over 50 years, federal disability civil rights laws have mandated that patients with disability receive equitable health care. However, disabled patients continue to experience health care disparities.

OBJECTIVE

To explore physicians' views, in their own words, about caring for patients with disability.

METHODS

Review of responses to open-ended question at the end of a nationally representative survey of 714 outpatient physicians about their experiences caring for adult disabled patients. The open-ended question asked for additional comments participants wanted to share. Only 108 (15.1 %) survey participants provided responses suitable for analysis (e.g., legible, complete thought). All issues reported here reflect comments from ≥5 participants.

RESULTS

Common concerns involved high costs, too little time, insufficient space, inadequate training, and lack of adequate mental health services to care for disabled patients. Many physicians appeared frustrated by legal requirements that they cover accommodation costs. Multiple physicians described as "unfair" having to pay for sign language interpreters, especially since interpreter costs generally exceed reimbursements for patients' visits. Physicians also commented on high costs and space demands of accessible exam tables, especially for small practices, and on challenges accommodating patients with severe obesity, including concerns that patients with severe obesity could damage their exam tables. Some participants suggested that disabled patients require advocates to get good quality care.

CONCLUSIONS

Albeit limited by the small number of responses, these open-ended comments from our nationwide survey of physicians suggest some doctors view certain accessibility requirements as unfair to them or infeasible in their practice environments.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND

Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.

METHODS

Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.

RESULTS

Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial).

CONCLUSIONS

Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Self-Reported Accommodation Needs for Patients with Disabilities in Primary Care

BACKGROUND

People with disabilities experience barriers to engaging with health care due to inaccessible social and physical environments at primary care clinics. Despite legal mandates, identification and provision of necessary accommodations for this population at primary care clinics are poor. The objective of this cross-sectional study was to assess patient-reported disability status and accommodation needs among patients at a primary care clinic.

METHODS

An electronic health record-based Disability and Accommodations Questionnaire assessing disability status, types, and accommodation needs was developed by subject matter experts at Michigan Medicine and the University of Michigan Council for Disability Concerns. The questionnaire underwent multiple rounds of reviews and revisions before its use in clinical settings. A paper-based questionnaire was administered to all patients presenting for a wellness-based visit at an academic health system primary care clinic in southeast Michigan. Data were collected between March 2022 and August 2022.

RESULTS

Approximately 13% of the 541 patients self-reported a disability, with 54.2% indicating at least one needed accommodation. The most commonly reported disabilities were mental health and hearing-related disabilities, by 4.8% and 4.6% of patients, respectively. The most frequently requested accommodations were communication- or language-based (for example, presence of an American Sign Language interpreter, assistive listening devices), cognitive-based (for example, inclusion of a support person with care decisions), and mobility-based (for example, assistance with transfers).

CONCLUSION

The Disability and Accommodations Questionnaire helped identify the presence of a disability, its types, and any requested accommodations requested at a primary care health center.

Views on the impact of the COVID-19 pandemic on health in people with Down syndrome from diverse backgrounds

Down syndrome (DS) has a unique medical and psychological profile. To date, few studies have asked individuals with DS about their views of health, and fewer have explored the impact of COVID-19 on the health of individuals with DS and their families. We used a mixed methods approach including two studies on the health of individuals with DS and their parents conducted during the COVID-19 pandemic: (1) eight virtual focus groups, comprised of 20 parents and 8 individuals with DS to obtain participants' views of health, and (2) a 20-item questionnaire on health care experience of patients with DS who are African American or come from primarily Spanish-speaking homes. Focus group transcripts were coded using a hybrid inductive/deductive framework and thematically analyzed using the Framework Method. This questionnaire included questions regarding the impact of COVID-19 on caregivers and their loved ones with DS; responses to these questions were summarized using descriptive statistics. Individuals with DS discussed the impact of the COVID-19 pandemic on their physical and social health including masking, online learning, and online communication with friends and family. Parents of individuals with DS discussed how the COVID-19 pandemic negatively impacted their child's physical, social, and mental health, as a result of virtual schooling and decreased socialization. There were unexpected positives of the pandemic such as improved hygiene and eased scheduling with telehealth visits. Caregivers noted COVID-19 impacted their own anxiety, employment, and other domains that have potential ripple effects on the health of their children. The COVID-19 pandemic had a pervasive impact on the mental health and wellness of caregivers as well as the physical, social, and mental health of individuals with DS.

A call to action for more disability-inclusive health policy and systems research

To date, the exclusion of people with disability participating in research has limited the evidence base informing health system strengthening policy and practice more generally, and addressing disability-related inequalities in access to health services and better health outcomes more particularly. Given that more than 1 billion people, or 16% of the world's population, have a disability, we may fail to respond to the needs of a large proportion of the population unless we are purposeful with inclusion. Our research in this area indicates that online qualitative methods can be effective in engaging under-represented groups and are essential to ensure their input into health policy and systems research. This has important implications for researchers whose responsibility it is to make all health research disability inclusive, for ethical and methodological reasons, so they do not perpetuate the under-representation of people with disability in health policy and systems research. Our paper puts forward several recommendations to facilitate more people with disability participating in health policy and systems research. By critically reflecting on a health system strengthening research project, in which we purposefully aimed to support the participation of people with disability, we identify lessons learnt and issues to consider when planning and conducting accessible research. We also propose a set of actions for moving the agenda forward.

Creating an Inclusive Urology Practice

Purpose of Review

Patients seeking urologic care come from diverse backgrounds. Therefore, clinics should strive for inclusivity to make all patients feel comfortable seeing a urologist. This review aims to outline and analyze literature relevant to the care of LGTBQIA+ (lesbian, gay, transgender/transexual, queer/questioning, intersex, asexual/allies, nonbinary/genderqueer +), racial and ethnic minorities, those who have disabilities, and those with a high body mass index (BMI). Although this review article presents the care of diverse communities separately, there is an overlap of the various social axes influencing healthcare outcomes. Healthcare workers should be open-minded to learning about evolving community needs.

Recent Findings

Creating a safe space for LGTBQIA+ requires understanding terminology, awareness of community-specific challenges and health risks, and changing heteronormative behaviors built into medicine. Specific clinical care delivery structural processes and patient-physician-centered practices can make a clinic welcoming for patients from underrepresented backgrounds and with disabilities. BMI surgical requirements may pose barriers to care, and if implemented, there should be assistance to reach specified weight goals.

Summary

Creating an inclusive urology clinical practice takes time, but it can be achieved by building a collaborative team. Treating patients with consideration of their personal identities and social determinants of health will lead to better patient-center care and health outcomes.

Caring for Adults With Significant Levels of Intellectual Disability in Outpatient Settings: Results of a National Survey of Physicians

Between 1% and 2% of the U.S. population has an intellectual disability (ID) and often experience disparities in health care. Communication patterns and sedation use for routine medical procedures are important aspects of care for this population. We explored physicians' communication patterns and sedation use in caring for patients with significant levels of ID through a mailed survey of 1,400 physicians among seven specialties in outpatient settings (response rate = 61.0%). Among physicians who saw at least one patient with significant levels of ID in an average month, 74.8% reported usually/always communicating primarily with someone other than the patient. Among specialists, 85.5% (95% CI: 80.5%-90.5%) reported doing so, compared to 69.9% (95% CI: 64.4%-75.4%) for primary care physicians (p < 0.001). Also, 11.4% reported sedating at least one patient with significant levels of ID for a routine procedure. Three quarters of physicians reported communicating primarily with persons other than the patient usually or always-an approach that, in some instances, may not align with best medical practice. The percentage of physicians who report sedating at least one individual is associated with significant ID and the physician's volume of patients with significant ID.

Proxy-report in individuals with intellectual disability: A scoping review

BACKGROUND

Views can be collected from individuals (self-report) or others on their behalf (proxy-report).

OBJECTIVE

We aimed to review the literature on methods and statistical approaches used to evaluate observer versus self-report responses from individuals with intellectual disability or Down syndrome.

METHODS

A series of key questions related to statistical approaches and data collection methods were formulated a priori to inform the search strategy and review process. These addressed the topics of self-report in individuals with intellectual disability, including Down syndrome. Using the National Library of Medicine database, PubMed, detailed literature searches were performed. The quality of available evidence was then evaluated, the existing literature was summarised, and knowledge gaps and research needs were identified.

RESULTS

Fifty relevant original articles were identified which addressed at least one key question. Study details, including: research design, internal validity, external validity, and relevant results are presented. Review of studies of individuals with intellectual disability which used a variety of statistical approaches showed mixed agreement between self-report and proxy-report.

CONCLUSION

Few studies identified to-date have used self-report from individuals with Down syndrome, but lessons from the existing intellectual disability literature can guide researchers to incorporate self-report from individuals with Down syndrome in the future.

Relationships at Work: Integrating the Perspectives of Disability Partners to Enhance a Peer Navigation Intervention

Objective

The Our Peers-Empowerment and Navigational Support (OP-ENS) community-based participatory research study developed, implemented, and evaluated a peer navigator intervention aimed at improving health and healthcare access among Medicaid beneficiaries with disabilities. Peer navigators are community partners with physical disabilities trained to deliver structured peer support interventions that can address barriers to care. The purpose of this paper is two-fold. First, it explicates the relational work the peer navigators do with peers in delivering the intervention. Second, it illustrates how our community-based participatory approach empowered peer navigators to share their knowledge to refine the intervention.

Methods

Clinical coordinator team meeting notes, critical incident documentation reports, peer navigator reflections (n = 20) were analyzed thematically to understand the peer navigators' relational work and intervention refinements. Following Labov's 6-stage approach to personal narratives and a collaborative writing process academic, clinical, and disability partners co-wrote descriptive exemplars to showcase these processes.

Findings

Through the manualized OP-ENS intervention process, peer navigators helped peers achieve incremental successes. Peer navigators used their training and personal experiences to engage with peers and forge deep connections and relationships of trust. As a result, peers identified a wide-range of social health concerns, including poverty, social isolation, and racial and disability related discrimination that might otherwise go unaddressed. True to the principles of community-based participatory research, by fostering an equity-focused collaboration and listening to peer navigators, the project team implemented subtle but salient refinements to the intervention. Refinements included an explicit focus on social determinants of health affecting peers' health and wellbeing and supplemental trainings to help peer navigators support peers with significant mental health needs.

Conclusion

The peer navigators were intentional and skilled at relationship building, thus complex elements which impact peers' health were addressed. Peer navigators were empowered to communicate their perspectives with the study team, who worked together to strengthen the intervention processes and infrastructure. This atmosphere of trust and collaboration amongst diverse stakeholders was instrumental to OP-ENS' successful implementation. Healthcare systems should consider implementing peer support interventions that are responsive to consumer input to address social determinants of health for persons with disabilities.

Evaluation of Disability Education and Emergency Preparedness Curricula of Physician Assistant Programs

OBJECTIVE

The purpose of this pilot study was to evaluate whether physician assistant (PA) programs in the Midwest integrate both disabilities and emergency preparedness education into 1 curriculum.

METHODS

A convenience sample was utilized to survey program directors and deans of PA programs. Emails were obtained from the Physician Assistant Education Association. A 26, closed-ended question Qualtrics survey was based on an original study by Tanenhaus et al.

RESULTS

Out of 43 accredited physician assistant programs surveyed, 9 programs replied (21%), and 1 program did not complete the survey. Six of the 10 programs (66%) responded that their program provided lectures specific to emergency preparedness. All 9 programs responded they do not offer a graduate-level track or concentration in emergency/disaster preparedness, and they do not offer a dual degree or a multidisciplinary program that highlights emergency/disaster preparedness.

CONCLUSIONS

This study was conducted to bring awareness to physician assistant students' education regarding disabilities and emergency preparedness. As public health crises continue to arise, such as coronavirus disease (COVID-19), it is critical to have appropriately trained health care professionals. The study revealed that most programs lack a graduate-level track or concentrations, dual degrees, or extracurricular opportunities related to disabilities and emergency and disaster preparedness.

Why Do Patients Seek Diagnose Dis-accordance With Hierarchical Medical System Related Policies in Tertiary Hospitals? A Qualitative Study in Shanghai From the Perspective of Physicians

Background

Although the Hierarchical Medical System has been utilized in China for many years, it is inadequate for guiding patients in adopting appropriate diagnose-seeking behaviors in accordance with related policies. This study examined how patients' diagnose-seeking behavior in tertiary hospitals that is dis-accordance with Hierarchical Medical System related policy (“DSB-dis-accordance”) arise and ways to guide patients away from such behaviors, both from the perspective of physicians.

Methods

A qualitative study based on a mixed method including in-depth interviews and grounded theory. Twenty-seven physicians with more than 2 years of experience serving in tertiary hospitals of Shanghai were involved after reviewing the related purposes and requirements. Patients' “DSB-dis-accordance” was studied from the perspective of physicians.

Results

Patient-related factors (habits, trust, and knowledge), physician-related factors (conservative preference, risk avoidance), and system-related factors (accessibility, operability) affected patients' diagnose-seeking behavior.

Conclusions

Patient-related, physician-related, and system-related factors affecting patients' diagnose-seeking behaviors in tertiary hospitals should be addressed by investing more health resources in lower-level hospitals, enhancing dissemination of health-related and policy-related knowledge, refining the classification of diseases, incentivizing physicians, and developing appropriate follow-up measures. Physicians could then become more involved in guiding patients' “DSB-dis-accordance,” thereby benefitting development of the Hierarchical Medical System in China.

Institutional Accountability for Students With Disabilities: A Call for Liaison Committee on Medical Education Action

Medical educators and leaders have called for greater diversity among the physician workforce, including those with disabilities. However, many students with disabilities are precluded from entering and completing medical training due to historically restrictive technical standards and poor internal practices to protect student privacy. This limits the possibilities for growing this part of the workforce and making progress toward the ultimate goal of having a physician workforce that better represents the patients it serves. To achieve diversity among the physician workforce, medical education must create environments that allow students with disabilities to apply to, flourish in, and feel well supported in medical school. Recent additions to Accreditation Council for Graduate Medical Education requirements have helped to catalyze work in the area of disability inclusion by incorporating disability-focused mandates into graduate medical education accreditation standards. However, similar mandates for undergraduate medical education have not yet materialized. In this article, the authors call for the Liaison Committee on Medical Education (LCME) to elevate disability as a valued part of medical school diversity in its accreditation standards and to include protections for disabled students. The authors propose that the LCME can take 5 actions to promote institutional accountability toward students with disabilities: (1) define disability as diversity, (2) mandate disability support, (3) protect from conflicts of interest, (4) protect privacy, and (5) verify schools' technical standards comply with the Americans with Disabilities Act. By adopting these recommendations, the LCME would send the powerful message that students with disabilities bring welcome expertise and value to the medical community.

US Physicians' Knowledge About The Americans With Disabilities Act And Accommodation Of Patients With Disability

More than thirty years since the enactment of the Americans with Disabilities Act (ADA), people with disability continue to experience health care disparities. The ADA mandates that patients with disability receive reasonable accommodations. In our survey of 714 US physicians in outpatient practices, 35.8 percent reported knowing little or nothing about their legal responsibilities under the ADA, 71.2 percent answered incorrectly about who determines reasonable accommodations, 20.5 percent did not correctly identify who pays for these accommodations, and 68.4 felt that they were at risk for ADA lawsuits. Physicians who felt that lack of formal education or training was a moderate or large barrier to caring for patients with disability were more likely to report little or no knowledge of their responsibilities under the law and were more likely to believe that they were at risk for an ADA lawsuit. To achieve equitable care and social justice for patients with disability, considerable improvements are needed to educate physicians and make health care delivery systems more accessible and accommodating.

Engaging Disability Rights Law to Address the Distinct Harms at the Intersection of Race and Disability for People with Substance Use Disorder

This article examines the unique disadvantages experienced by Black people and other people of color with substance use disorder in health care, and argues that an intersectional approach to enforcing disability rights laws offer an opportunity to ameliorate some of the harms of oppression to this population.

Use of Accessible Weight Scales and Examination Tables/Chairs for Patients with Significant Mobility Limitations by Physicians Nationwide

BACKGROUND

Mobility limitations are the most common disability type among the 61 million Americans with disability. Studies of patients with mobility limitations suggest that inaccessible medical diagnostic equipment poses significant barriers to care.

METHODS

The study team surveyed randomly selected US physicians nationwide representing seven specialties about their reported use of accessible weight scales and exam tables/chairs when caring for patients with mobility limitations. A descriptive analysis of responses was performed, and multivariable logistic regression was used to examine associations between accessible equipment and participants' characteristics.

RESULTS

The 714 participants (survey response rate = 61.0%) were primarily male, White, and urban, and had practiced for 20 or more years. Among those reporting routinely recording patients' weights (n = 399), only 22.6% (standard error [SE] = 2.2) reported always or usually using accessible weight scales for patients with significant mobility limitations. To determine weights of patients with mobility limitations, 8.1% always, 24.3% usually, and 40.0% sometimes asked patients. Physicians practicing ≥ 20 years were much less likely than other physicians to use accessible weight scales: odds ratio (OR) = 0.51 (95% confidence interval [CI] = 0.26-0.99). Among participants seeing patients with significant mobility limitations (n = 584), only 40.3% (SE = 2.2) always or usually used accessible exam tables or chairs. Specialists were much more likely than primary care physicians to use accessible exam tables/chairs: OR = 1.96 (95% CI = 1.29-2.99).

CONCLUSION

More than 30 years after enactment of the Americans with Disabilities Act, most physicians surveyed do not use accessible equipment for routine care of patients with chronic significant mobility limitations.

Effects of the Medicaid expansion under the Affordable Care Act on health insurance coverage, health care access, and use for people with disabilities

BACKGROUND

People with disabilities have higher health care needs, service utilization, and expenditures. They are also more likely to lack insurance and experience unmet need for medical care. There has been limited research on the effects of the Affordable Care Act Medicaid expansion on people with disabilities.

OBJECTIVE

To examine the effects of the Medicaid expansion on health insurance coverage, access, and service use for working-age adults with disabilities.

METHODS

A retrospective study using 11 years (2007-2017) of data from the Medical Expenditure Panel Survey - Household Components, linked to Area Health Resource Files and Local Area Unemployment Statistics (N = 40,995). Difference-in-differences multinomial logistic and linear probability models with state and year fixed-effects were used to estimate the effects.

RESULTS

We found strong evidence of increased Medicaid coverage in expansion states (3.2 to 5.0 percentage points), reasonably strong evidence of reduced private insurance coverage (-2.2 to -2.5 percentage points), and some evidence of reduced uninsured rate (from no effect to -3.7 percentage points). Results suggest that the increase in Medicaid coverage was due at least in part to the "crowd-out" of private insurance in expansion states. No statistically significant effects were detected for access and use outcomes.

CONCLUSIONS

Findings suggest that state Medicaid expansions led to an increase in Medicaid coverage and a decrease in private insurance coverage as well as the uninsured. However, no evidence was found for health care access and use outcomes. Further research into access and use is needed when more data become available for the post-expansion period.

Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study

BACKGROUND

Patients with disabilities often require healthcare accommodations in order to access high-quality, equitable healthcare services. While attention has been paid to accommodation needs in specific disability populations, limited research to date has explored healthcare accommodations that cross-cut diverse disability populations.

OBJECTIVE

To identify a deeper understanding regarding accommodations in healthcare settings that could apply across disability populations and promote equitable healthcare.

DESIGN

We conducted qualitative focus groups with patients with disabilities and caregivers to understand their experiences and preferences for healthcare accommodations.

PARTICIPANTS

We recruited patients and caregivers across all major disability categories to participate in focus groups. Participants were recruited through advocacy organizations and healthcare settings in Southeastern Minnesota.

APPROACH

A total of eight focus groups were conducted with 56 participants. Participants described their healthcare experiences and desires for healthcare accommodations. The multidisciplinary research team recorded, transcribed verbatim, and coded all focus groups. The team thematically coded transcripts using content analysis within and across focus groups to identify major themes.

KEY RESULTS

Patients identified four challenges and corresponding steps healthcare team could take to promote equitable care: (1) consistent documentation of disabilities and needed accommodations in the medical record; (2) allowance for accommodations to the environment, including adapting physical space, physical structures, and scheduling and rooming processes; (3) provide accommodations for administrative tasks, such as completing paper or electronic forms; and (4) adapt communication during interactions, such as speaking slower or using terms that patients can easily understand.

CONCLUSION

These identified themes represent specific opportunities for healthcare teams to effectively provide accessible care to patients with disabilities. Many of the accommodations require minimal financial investment, but did require behavioral changes by the healthcare team to ensure equitable healthcare.

Equal Access to Organ Transplantation for People with Disabilities

People with disabilities are often denied equal access to organ transplantation despite long-standing federal nondiscrimination mandates. Under the Americans with Disabilities Act and the Rehabilitation Act, people cannot be excluded from consideration for organ transplantation because of disability itself, or because of stereotypes or assumptions about the value or quality of life with a disability. Instead, decisions concerning whether an individual is a candidate for organ transplantation should be based on an individualized assessment of the patient and on objective medical evidence. Recent legal developments underscore these basic guarantees and signal a new focus on the policies, practices, and attitudes that continue to compromise equal access to life-saving organ transplants for people with disabilities.

Physicians' Perceptions Of People With Disability And Their Health Care

More than sixty-one million Americans have disabilities, and increasing evidence documents that they experience health care disparities. Although many factors likely contribute to these disparities, one little-studied but potential cause involves physicians' perceptions of people with disability. In our survey of 714 practicing US physicians nationwide, 82.4 percent reported that people with significant disability have worse quality of life than nondisabled people. Only 40.7 percent of physicians were very confident about their ability to provide the same quality of care to patients with disability, just 56.5 percent strongly agreed that they welcomed patients with disability into their practices, and 18.1 percent strongly agreed that the health care system often treats these patients unfairly. More than thirty years after the Americans with Disabilities Act of 1990 was enacted, these findings about physicians' perceptions of this population raise questions about ensuring equitable care to people with disability. Potentially biased views among physicians could contribute to persistent health care disparities affecting people with disability.

Comparison of Access to Primary Care Medical and Dental Appointments Between Simulated Patients Who Were Deaf and Patients Who Could Hear

Importance

Primary medical and dental clinics may accept fewer people who are deaf as patients than persons who can hear, and clinics may deny requests by patients who are deaf for American Sign Language (ASL) interpretation at appointments when necessary, creating diminished access to primary medical and dental care.

Objective

To compare the rate at which patients who are deaf are offered primary care medical or dental appointments with the rate at which appointments are offered to patients who can hear in a real-world context.

Design, Setting, and Participants

This cross-sectional study used a simulated patient (SP) call audit method. Simulated patients (4 who could hear and 4 who were deaf) followed a call script in which an adult sought to establish care, requesting new patient appointments from a statewide stratified random sample of clinicians listed in the Idaho Medical and Dental Associations member databases at 445 clinics (334 primary care and 111 general dentistry) throughout Idaho. Simulated patients who were deaf also requested interpreting services at the appointment. Calls were made between June 7 and December 6, 2018. Data analysis was conducted from December 2019 to April 2020.

Exposures

Simulated patients who were deaf or could hear called primary care medical or dental clinics from the sampling frame and requested an appointment, supplying the same basic information. In addition, SPs who were deaf requested that an ASL interpreter be provided by the clinic for the appointment.

Main Outcomes and Measures

Rates of new appointments offered and, for SPs who were deaf, whether ASL interpreter services were confirmed for the appointment.

Results

Two male and 2 female SPs who could hear were successful on 210 occasions (64.4%) when requesting a new patient appointment compared with 2 male and 2 female SPs who were deaf who were successful on 161 occasions (49.1%) (P < .001). Simulated patients who could hear were nearly 2 times more likely to secure appointments than were SPs who were deaf (adjusted odds ratio, 1.88; 95% CI, 1.27-2.79). For SPs who were deaf, 80 unsuccessful appointment requests (48.2%) were associated with a request for interpretation.

Conclusions and Relevance

The findings suggest that in a statewide representative sample, access to primary medical and dental care for patients who are deaf is significantly reduced. Patients who are deaf may not receive an appointment if they request interpreter services, even when such services are required to provide effective communication.

Providing Equitable Access to Health Care for Individuals with Disabilities: An Important Challenge for Medical Education

In a recent national survey, over 50% of physicians reported not feeling confident in their ability to provide care to individuals with disabilities. This finding is troubling as physicians are required by the Americans with Disabilities Act (1990) to ensure their practice is accessible to individuals with disabilities. This commentary addresses the need for including disability in medical education and to provide inclusive and quality care for individuals with disabilities. We offer four recommendations to enhance medical school curricula that would educate medical students to provide equitable health services to individuals with disabilities: 1) embed disability training throughout medical education; 2) educate medical students to recognize multiple models of disability; 3) include education and experience with universal design and supported decision-making; and 4) include individuals with all types of disabilities in medical education. Including disability education for medical students should better prepare future physicians for feeling confident in their ability to provide care to individuals with disabilities.

Abortion in women with Down syndrome

BACKGROUND

Nearly two-thirds of pregnancies in women with Down syndrome (DS) end in abortion. The aim of the present study was to determine if these high abortion rates might relate to specific characteristics of women with DS, their life situation and the course of pregnancy.

METHODS

In a sample of 351 pregnancies in Switzerland (1998 to 2009), women with DS were compared with women with other forms of intellectual disability (ID) and women without ID, regarding the type of abortion, personal characteristics and pregnancy complications that might increase the probability of abortion.

RESULTS

All abortions among women with DS were medically induced. In women with DS and ID, abortions were more likely to occur due to unwanted pregnancy than in women without ID. In addition, women with DS and ID were more often diagnosed with fetal complications and maternal health problems. However, no correlation between fetal complications or maternal health problems and pregnancy outcome was found.

CONCLUSIONS

The group differences found do not directly explain the high abortion rates among women with DS. Maternal diagnosis of DS appears to be the most important predictor of abortion. Possible explanations for this finding are discussed.

Disability, Ethics, and Health Care in the COVID-19 Pandemic

This article considers key ethical, legal, and medical dilemmas arising for people with disabilities in the COVID-19 pandemic. We highlight the limited application of existing frameworks of emergency planning with and for people with disabilities in the COVID-19 pandemic, explore key concerns and issues affecting the health care of people with disabilities (i.e., access to information and clinician-patient communication, nondiscrimination and reasonable accommodations, and rationing of medical goods), and indicate possible solutions. Finally, we suggest clinical and public health policy measures to ensure that people with disabilities are included in the planning of future pandemic-related efforts.The devastation evoked by the COVID-19 pandemic raises challenging dilemmas in bioethics. It also speaks to social justice issues that have plagued historically marginalized communities in the United States.Responses to the pandemic must be bound by legal standards, principles of distributive justice, and societal norms of protecting vulnerable populations-core commitments of public health-to ensure that inequities are not exacerbated, and should provide a pathway for improvements to ensure equitable access and treatment in the future.

Disorders of Consciousness and Disability Law

In 2018, the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research published a systematic evidence-based review and an associated practice guideline for improved assessment, treatment, and rehabilitation of patients with disorders of consciousness. Patients with disorders of consciousness include individuals in the vegetative and minimally conscious states, as well as others with covert consciousness and cognitive motor dissociation. These landmark publications (concurrently published in Neurology and Archives of Physical Medicine and Rehabilitation) supplant the 1994 New England Journal of Medicine Multi-Society Task Force report on the vegetative state and the 2002 criteria establishing minimally conscious states. The guideline re-designates the permanent vegetative state as chronic. In our article, we consider the legal and ethical implications of the practice guideline for clinical practice and explain the vulnerability of these patients who suffer from high rates of misdiagnosis, inadequate medical surveillance, undertreatment of pain, inadequate rehabilitation, and segregation in chronic care. We argue that these deficiencies in medical care are inconsistent with our growing appreciation of the dynamic nature of these brain states and an emerging standard of care as articulated by the national guideline. These deficiencies also violate domestic and international disability law. To substantiate this latter claim, we apply disability law to this population, focusing on key Americans with Disabilities Act mandates, the relevance of the 1999 Supreme Court, Olmstead v. L.C., and the utility of Olmstead enforcement actions to integrate the care of these individuals into the medical mainstream.

Accommodating patients with obesity and mobility difficulties: Observations from physicians

BACKGROUND

Given the growing population of U.S. adults with obesity and mobility disability, physicians will need to accommodate these patients.

OBJECTIVE

To explore attitudes and practices of US physicians related to caring for patients with obesity and mobility disability.

METHODS

Three open-ended, semi-structured, web-based focus group interviews with practicing physicians in selected specialties, which reached data saturation. Interviews were video recorded and transcribed for qualitative, conventional content analysis. Measurements included commonly expressed themes around caring for patients with obesity.

RESULTS

Physicians recognized obesity as a disability that poses challenges to high quality, safe, and efficient patient care. Observations coalesced around four themes: (1) difficulty routinely tracking weight; (2) reluctance to transfer obese patients to exam tables; (3) barriers to diagnostic testing; and (4) weight stigma. Physicians described difficulties accurately assessing weight, performing complete physical examinations, arranging diagnostic imaging, and providing prenatal care for obese patients. Lack of accessible medical diagnostic equipment impeded care for patients with obesity. Other participants did not contest comments of individual participants' that suggested weight stigma.

CONCLUSIONS

Our findings suggest that important gaps may remain in providing equitable access to care for patients with obesity, requiring additional training and accessible medical diagnostic equipment to safely accommodate these patients.

The Neglect of Persons with Severe Brain Injury in the United States: An International Human Rights Analysis

Brain injury contributes more to death and disability globally than any other traumatic incident.1 While the past decade has seen significant medical advances, laws and policies remain stumbling blocks to treatment and care. The quality of life of persons with severe brain injury often declines with unnecessary institutionalization and inadequate access to rehabilitation and assistive technologies.62 This raises a host of rights violations that are hidden, given that persons with severe brain injury are generally invisible and marginalized. This article highlights the current neglect and experiences of persons with severe brain injury in the United States, analyzing the rights to life, health, benefit from scientific progress, education, freedom of expression, community, family, and equality.

Ensuring the Reproductive Rights of Women with Intellectual Disability

BACKGROUND

Women with intellectual disability experience disparities in sexual and reproductive health care services.

METHODS

To explore perceptions of caring for persons with disability, including individuals with intellectual disability, we conducted open-ended individual interviews with 20 practicing physicians and three video-based focus group interviews with an additional 22 practicing physicians, which reached data saturation. Interviews were transcribed verbatim. We used conventional content analysis methods to analyse transcripts.

RESULT

Physicians indicated that intellectual disability can pose challenges to providing sexual and reproductive health care. Observations coalesced around four themes: (1) communication; (2) routine preventive care; (3) contraception and sterilization; and (4) conception and parenthood. Observations raised concerns about equity of access to reproductive care for women with intellectual disability.

CONCLUSIONS

In our sample of physicians, we found attitudes that might compromise reproductive care for women with intellectual disability, suggesting that gaps remain in ensuring reproductive rights of women with intellectual disability.

Dementia, Healthcare Decision Making, and Disability Law

Persons with dementia often prefer to participate in decisions about their health care, but may be prevented from doing so because healthcare decision-making law facilitates use of advance directives or surrogate decision makers for persons with decisional impairments such as dementia. Federal and state disability law provide alternative decision-making models that do not prevent persons with mild to moderate dementia from making their own healthcare decisions at the time the decision needs to be made. In order to better promote autonomy and wellbeing, persons with dementia should be accommodated and supported so they can make their own healthcare decisions.