Have Almost Fifty Years Of Disability Civil Rights Laws Achieved Equitable Care?

New Rules Requiring Accessible Medical Diagnostic Equipment-Updates to Section 504 Disability Civil Rights Regulations

This Viewpoint reviews the history of mandates governing access to medical diagnostic equipment in Section 504 of the Rehabilitation Act of 1973 and reviews the new rules.

Reducing Disparities Through Online Accessibility Information

This Viewpoint describes the need for more health care organizations to include disability accessibility information on their websites and to improve physical access for patients with disabilities.

Disability Mortality Disparity: Risk Of Mortality For Disabled Adults Nearly Twice That For Nondisabled Adults, 2008-19

After years of advocacy by the disability community and allied organizations, on September 26, 2023, the National Institute on Minority Health and Health Disparities (NIMHD) designated disabled people as a health disparities population in the US. During its deliberations, the NIMHD emphasized that there was not sufficient empirical evidence on health disparities between disabled and nondisabled adults. My study addressed this gap by examining 2008-19 data from the National Health Interview Survey Linked Mortality Files on people ages eighteen and older to identify, categorize, and quantify disparities in mortality risk among disabled and nondisabled adults. The risk of mortality during the study period was 1.9 times higher overall for disabled compared with nondisabled adults. The risk increased with the number of reported disabilities and varied by disability category. These findings underscore the need to improve access to high-quality, evidence-based health care among disabled people. To gain a full understanding of the scope of disparity and the interventions needed to mitigate it, it is critical to develop more equitable and inclusive measures of disability and ableism for use in population health surveys.

A New Process Model for Relationship-Centred Shared Decision-Making in Physical Medicine and Rehabilitation Settings

INTRODUCTION

We present a relationship-centred shared-decision-making (RCSDM) process model to explicate factors that shape decision-making processes during physical medicine and rehabilitation (PMR) encounters among patients, their care partners and practitioners. Existing shared decision-making (SDM) models fall short in addressing the everyday decisions routinely made regarding persons with chronic disabilities who require high levels of support, their care partners and rehabilitation practitioners. In PMR, these everyday decisions are small scale, immediate and in service to a larger therapeutic goal. They can be thought of as micro-decisions and involve multiple practitioners, care partners and patients. How micro-decisions are made in this context is contingent on multiple roles and relationships among these relevant parties. Our model centres on micro-decisions among patients, their care partners and practitioners based on our disorders of consciousness (DoC) research.

METHODS

To develop our model, we examined peer-reviewed literature in SDM in PMR, chronic disability and person-centeredness; formed collaborations and co-created our constructs with rehabilitation practitioners and with care partners who have lived experience of caring for persons with DoC; analysed emerging empirical data and vetted early versions with expert scientific and clinical audiences. Our model builds from the core tenets of relational autonomy, and scholarship and activism of disability advocates.

FINDINGS

Our model conceptualizes four non-hierarchical levels of analysis to understand the process of micro-decision-making in chronic disability and medical rehabilitation: social forces (historical and sociological); roles and relationships (multiple and intersecting); relational dimensions (interactional and contextual) and micro-decision moments (initiation, response and closure).

DISCUSSION

Relationships among patients, their care partners and practitioners are the intersubjective milieu within which decisions are made. Our conceptual model explicates the process of micro-decision-making in PMR.

PATIENT OR PUBLIC CONTRIBUTION

Care partners (or caregivers) and rehabilitation practitioners are active members of our team. We work together to develop research projects, collect, analyse and disseminate data. The conceptual model we present in this manuscript was co-created-input from care partners and practitioners on previously collected data became the impetus to develop the RCSDM process model and share co-authorship in this manuscript.

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.

Older adults with communication disabilities and their use of communication support at doctor's visits: a nationally representative study

PURPOSE

Older adults with communication disabilities (CDs) experience barriers to receiving care and face a paucity of accommodations for their disability. Utilizing someone that supports communication with healthcare providers (communication support persons) may be a way that this group self-supports their disability. We examined if this utilization was independently associated with CDs among older adults. We also sought to understand if socioeconomic factors were associated with utilization.

METHODS

We used the 2015 National Health and Aging Trends Survey (NHATS) to conduct a cross-sectional analysis of Medicare beneficiaries (n = 5954) with functional hearing, expressive, or cognitive difficulties. We calculated a weighted, population prevalence and an adjusted prevalence ratio (APR) controlling for sociodemographic, health and other disability factors.

RESULTS

Among community dwelling older adults, having CDs was associated with higher utilization of a communication support person at medical visits (APR: 1.41 [CI: 1.27 - 1.57]). Among adults with CDs, Black adults and women had lower levels of utilization as compared to White adults and men, respectively.

CONCLUSION

Communication support persons may be a way that older adults with CDs self-support their disability. However, not all older adults with CDs bring someone and variation by social factors could suggest that unmet support needs exist.

The study of ableism in population health: a critical review

Over the past three decades, health equity has become a guiding framework for documenting, explaining, and informing the promotion of population health. With these developments, scholars have widened public health's aperture, bringing systems of oppression sharply into focus. Additionally, some researchers in disability and health have advocated for utilizing socially grounded frameworks to investigate the health of disabled people. Yet, naming ableism, much less operationalizing it for the empirical study of health, remains scant. This paper critically reviews the study of ableism as a social determinant of disabled people's health within population health research. First, we provide an orientation to the present state of this literature by looking to the past. We briefly trace a history of traditional approaches to studying disability and health and alternatives that have emerged from critiques of the individualized lens that has dominated this work. Next, we delineate the operation of ableism across social levels. We characterize how ableism has been studied in population health in terms of levels of analysis (intrapersonal, interpersonal, institutional, and structural) and measures of interest. To conclude, we discuss hinderances to and promising avenues toward population health research that advances health equity for disabled people.

Nurse practitioner education: Uniting the 2021 essentials with The Core Competencies on Disability Health Care Education

ABSTRACT

People with disabilities (PWD) are the largest minority group in the world, making up 16% of the world's population, an estimated 1.3 billion people. People with disabilities die earlier, have poorer health outcomes, and are more affected by emergencies and natural disasters. Factors contributing to health inequities can be characterized as socioeconomic, political, involve social determinants of health, include higher risk factors, and display a wide spectrum of health system barriers. Too often, health care training programs exclude specific standards for disability training. By mapping the new American Association of Colleges of Nursing (AACN) The Essentials: Core Competencies for Professional Education with The Core Competencies for Disability Health Care Education , we can provide a synergistic relationship that will prepare future advanced practice nurses to provide effective care to people with disabilities across the lifespan and in every delivery care system.

Enhancements to a Telewellness Program for People With Physical Disabilities: Mindfulness, Exercise, and Nutrition To Optimize Resilience (MENTOR 2.0)

Introduction

This study evaluated the National Center on Health, Physical Activity and Disability (NCHPAD) Mindfulness, Exercise, and Nutrition To Optimize Resilience (MENTOR) program for people with physical disabilities.

Methods

This retrospective evaluation of MENTOR 2.0, an 8-week online group health promotion program, was based on improvements from its first implementation (MENTOR 1.0). Baseline and postassessments included the Godin Leisure-Time Exercise Questionnaire (GLTEQ), NCHPAD Wellness Assessment (NWA), Connor-Davidson Resilience Scale, and Mindfulness Attention Awareness Scale. Estimates and corresponding 95% CIs from linear mixed models were provided to compare baseline and postassessment scores and effect sizes using Cohen d.

Results

Among 116 participants (mean age, 53 y; 63% female), postassessment scores increased significantly in the overall NWA and in all 15 NWA domains (effect size, 0.30-0.69). The overall NWA score was 7.59 (95% CI, 5.63-9.56) units higher at postassessment compared with baseline. Scores for GLTEQ health contribution increased significantly among participants with low baseline scores (31.37 [95% CI, 12.97-49.77]) (effect size, 0.50). Mindfulness and resilience scores both showed improvement (0.16 [95% CI, 0.01-0.31]; effect size, 0.15) and (0.72 [95% CI, -0.25 to 1.68]; effect size 0.09), respectively, but only the change in mindfulness was significant.

Conclusion

MENTOR 2.0 advanced the evaluation of this online telewellness program for people with physical disabilities by demonstrating consistent results with MENTOR 1.0. We reported improvements in GLTEQ, especially among those with lower baseline scores; in multiple areas of wellness, including physical, mental, and emotional/spiritual health; and in mindfulness and resilience, although the improvements in these 2 constructs were small.

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.

Documentation of Disability Status and Accommodation Needs in the Electronic Health Record: A Qualitative Study of Health Care Organizations' Current Practices

BACKGROUND

This qualitative study aimed to understand how early adopting health care organizations (HCOs) implement the documentation of patients' disability status and accommodation needs in the electronic health record (EHR).

METHODS

The authors conducted qualitative interviews with HCOs that had active or past initiatives to implement systematic collection of disability status in the EHR. The interviews elicited participants' current experiences, desired features of a standard EHR build, and challenges and successes. A team-based analysis approach was used to review and summarize quotations to identify themes and categorize text that exemplified identified themes.

RESULTS

Themes identified from the interviews included "why" organizations collected disability status; of "what" their EHR build consisted, including who collected, how often data were collected, and what data were collected; and "how" organizations were implementing systematic collection. The main purpose for collection of disability status and accommodation needs was to prepare for patients with disabilities. Due to this priority, participants believed collection should (1) occur prior to patients' clinical encounters, (2) be conducted regularly, (3) use standardized language, and (4) be available in a highly visible location in the EHR. Leadership support to integrate collection into existing workflows was essential for success.

CONCLUSION

Patients with disabilities experience significant disparities in the receipt of equitable health care services. To provide equitable care, HCOs need to systematically collect disability status and accommodation needs in the EHR to ensure that they are prepared to provide equitable care to all patients with disabilities.

Telehealth and digital health innovations: A mixed landscape of access

In the wake of emergent natural and anthropogenic disasters, telehealth presents opportunities to improve access to healthcare when physical access is not possible. Yet, since the beginning of the COVID pandemic, lessons learned reveal that various populations in the United States do not or cannot adopt telehealth due to inequitable access. We explored the Digital Determinants of Health (DDoHs) for telehealth, characterizing the role of accessibility, broadband connectivity and electrical grids, and patient intersectionality. In addition to its role as an existing Social Determinant of Health, Policies and Laws directly and indirectly affect these DDoHs, making access more complex for marginalized populations. Digital systems lack the flexibility, accessibility, and usability to inclusively provide the essential services patients need in telehealth. We propose the following recommendations: (1) design technology and systems using accessibility and value sensitive design principles; (2) support a range of technologies and settings; (3) support multiple and diverse users; and (4) support clear paths for repair when technical systems fail to meet users' needs. Addressing these requires change not only from providers but also from the institutions providing these systems.

Advancing healthcare equity through dissemination and implementation science

OBJECTIVE

To provide guiding principles and recommendations for how approaches from the field of dissemination and implementation (D&I) science can advance healthcare equity.

DATA SOURCES AND STUDY SETTING

This article, part of a special issue sponsored by the Agency for Healthcare Research and Quality (AHRQ), is based on an outline drafted to support proceedings of the 2022 AHRQ Health Equity Summit and further revised to reflect input from Summit attendees.

STUDY DESIGN

This is a narrative review of the current and potential applications of D&I approaches for understanding and advancing healthcare equity, followed by discussion and feedback with Summit attendees.

DATA COLLECTION/EXTRACTION METHODS

We identified major themes in narrative and systematic reviews related to D&I science, healthcare equity, and their intersections. Based on our expertise, and supported by synthesis of published studies, we propose recommendations for how D&I science is relevant for advancing healthcare equity. We used iterative discussions internally and at the Summit to refine preliminary findings and recommendations.

PRINCIPAL FINDINGS

We identified four guiding principles and three D&I science domains with strong promise for accelerating progress toward healthcare equity. We present eight recommendations and more than 60 opportunities for action by practitioners, healthcare leaders, policy makers, and researchers.

CONCLUSIONS

Promising areas for D&I science to impact healthcare equity include the following: attention to equity in the development and delivery of evidence-based interventions; the science of adaptation; de-implementation of low-value care; monitoring equity markers; organizational policies for healthcare equity; improving the economic evaluation of implementation; policy and dissemination research; and capacity building.

Disability research must be a priority for nurses to advance health equity

Disability results from an interplay between health conditions and environmental and personal factors. People with disabilities face substantial and ongoing health inequities; however, research to mitigate these inequalities is lacking. There is an urgent need for a better understanding of the multilevel factors that influence health outcomes in people with visible and invisible disabilities across all the lenses of the National Institute of Nursing Research strategic plan. Disability research must be a priority of nurses and the National Institute of Nursing Research to advance health equity for all.

It’s time for the NIH to formally designate people with disabilities as a US health disparity population

This commentary discusses the implications of the report and recommendations of the Working Group on Diversity's Subgroup on Individuals with Disabilities, recently endorsed by the full Advisory Committee to the Director (ACD) of the National Institutes of Health (NIH). We suggest that one of these recommendations, the formal designation of people with disabilities as a US health disparity population, can be enacted immediately, which would spur new federal investment in disability-based disparities research.