Advancing health disparities research within the health care system: a conceptual framework

Anti-racism, Heterosexism, and Transphobia: Strategies for Adolescent Health Promotion Post-Coronavirus Disease 2019

Anti-Black racism, heterosexism, and transphobia are significant public health concerns contributing to poor adolescent health outcomes. The authors introduce the health-equity adapted STYLE framework to increase knowledge and awareness of Black and lesbian, gay, bisexual, transgender, non-binary, queer, questioning, asexual, or intersex (LGBTQ) + intersectionality. Guided by case examples, the authors identify key strategies to promote anti-racist, anti-heterosexist, and anti-transphobic practices. Utilization of this framework by adolescent health providers could promote the health and well-being of Black and LGBTQ + adolescents.

Disparities in the treatment of primary hyperparathyroidism: A scoping review and conceptual model

BACKGROUND

Primary hyperparathyroidism is underdiagnosed and surgical treatment is underutilized and inequitably distributed. We present a review of the current literature on disparities in the treatment of hyperparathyroidism, with a focus on gaps in knowledge and paths forward.

METHODS

We searched PubMed and Scopus for abstracts related to disparities in hyperparathyroidism.

RESULTS

16 articles (of 1541) met inclusion criteria. The most commonly examined disparity was race. Notably, Black, Hispanic, and Asian patients were less likely to undergo surgery after diagnosis, face delays in obtaining treatment, and less likely to see a high-volume surgeon. Similar disparities in care were noted among those without insurance, older patients, and patients with limited English proficiency.

CONCLUSION

There are clear inequities in the treatment of hyperparathyroidism. Current research is in an early "identification" phase of disparities research; a new conceptual model based on established socioecological frameworks is provided to help move the field forward to "understanding" and "intervening" in surgical disparities.

Improving Diabetes Equity and Advancing Care (IDEA) to optimize team-based care at a safety-net health system for Black and Latine patients living with diabetes: study protocol for a sequential, multiple assignment, randomized trial

BACKGROUND

Diabetes is the eighth leading cause of death in the USA. Inequities driven by structural racism and systemic oppression have led to racial/ethnic disparities in diabetes prevalence, diagnosis, and treatment. Diabetes-self management training (DSMT), remote glucose monitoring (RGM), and tailored support from a community health worker (CHW) have the potential to improve outcomes. This study will examine the implementation of these interventions in a safety-net healthcare setting.

METHODS

Using implementation science and racial equity principles, this study aims to (1) evaluate the appropriateness; (2) measure fidelity; and (3) compare the effectiveness of varying the combination and sequence of three interventions. An exploratory aim will measure sustainability of intervention adherence and uptake. This mixed-methods trial employs a sequential, multiple assignment randomized trial (SMART) design, patient focus group discussions, and staff interviews. Eligible Black/Latine patients will be recruited using patient lists extracted from the electronic medical record system. After a detailed screening process, eligible patients will be invited to attend an in-person enrollment appointment. Informed consent will be obtained and patients will be randomized to either DSMT or RGM. At 6 months, patients will complete two assessments (diabetes empowerment and diabetes-related distress), and HbA1c values will be reviewed. "Responders" will be considered those who have an HbA1c that has improved by at least one percentage point. "Responders" remain in their first assigned study arm. "Nonresponders" will be randomized to either switch study arms or be paired with a CHW. At 6 months participants will complete two assessments again, and their HbA1c will be reviewed. Twelve patient focus groups, two for each intervention paths, will be conducted along with staff interviews.

DISCUSSION

This study is the first, to our knowledge, that seeks to fill critical gaps in our knowledge of optimal sequence and combinations of interventions to support diabetes management among Black and Latine patients receiving care at a safety-net hospital. By achieving the study aims, we will build the evidence for optimizing equitable diabetes management and ultimately reducing racial and ethnic healthcare disparities for patients living in disinvested urban settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06040463. Registered on September 7, 2023.

Systematic review and meta analysis of psychological interventions to prevent or treat pediatric chronic disease in rural communities

OBJECTIVE

The purpose of this systematic review and meta-analysis was to examine the effectiveness of psychological interventions at improving physical or mental health outcomes for youth living in rural communities who have, or are at-risk for, any chronic medical condition in comparison to control interventions conducted in rural communities.

METHODS

Following prospective registration (OSF.IO/7TDQJ), 7 databases were searched through July 1, 2023. Studies were included if they were a randomized control trial of a psychological intervention conducted with youth living in a rural area who had, or were at-risk for, a chronic medical condition. Risk of bias was assessed with the Cochrane risk of bias version 2 tool. A qualitative synthesis and meta-analysis were conducted.

RESULTS

15 studies met inclusion criteria. Obesity studies (n = 13) primarily focused on body mass index metrics, with limited significant findings across studies. Asthma treatment interventions (n = 2) showed no impact on hospitalizations. 3 studies evaluated mental health outcomes with no significant group differences observed. We meta-analytically analyzed 9 studies that evaluated body mass index z-scores and identified an overall null effect (Hedge's g = 0.01, 95% CI [-0.07, 0.09], p = .85).

CONCLUSIONS

Most included studies focused on pediatric obesity, and there was a limited range of health outcomes reported. Compared to controls, minimal significant improvements in health outcomes were identified for psychological interventions for youth living in rural communities. Future efforts may benefit from situating this work more systematically within a health disparities framework with a focus on understanding mechanisms of disparities and translating this work into interventions and policy changes.

Leveraging the health equity implementation framework to foster an equity focus in medical education

Teaching equitable clinical practice is of critical importance, yet how best to do so remains unknown. Educators utilize implementation science frameworks to disseminate clinical evidence-based practices (EBP). The Health Equity Implementation Framework (HEIF) is one of these frameworks, and it delineates how health equity may be concomitantly assessed and addressed in planning the implementation of an EBP. The HEIF therefore lays a strong foundation to understand and explain barriers and facilitators to implementation through an equity lens, making it well-suited for use by medical educators. Three equity-focused frames of reference within the model include (1) the clinical encounter, (2) societal context, and (3) culturally relevant factors, herein referred to as domains. The HEIF provides a structure for prospective and retrospective assessment of how EBP are taught and ultimately incorporated into clinical practice by trainees, with specific attention to delivering equitable care. We present three examples of common topics in internal medicine, contextualized by the three equity domains of the HEIF. We additionally acknowledge the limitations of this framework as a research tool with complex features that may not be suitable for brief teaching in the clinical environment. We propose a 360-degree learner assessment to ensure implementation of this framework is successful. By encouraging trainees to explore the narrative experiences of their patients and examine their own implicit biases, the HEIF provides a structure to address gaps in knowledge about delivering equitable care.

Consistent Factors Influence Body Mass Index Thresholds for Total Joint Arthroplasty Across Health-Care Systems: A Qualitative Study

BACKGROUND

Body mass index (BMI) thresholds are used as eligibility criteria to reduce complication risk in total joint arthroplasty (TJA). This approach oversimplifies preoperative risk assessment and inadvertently restricts access to effective surgical treatment for osteoarthritis. A prior survey of orthopaedic surgeons in the United States identified complex underlying factors that influence BMI considerations. To understand whether similar factors exist and influence surgeons in a different health-care system setting, we investigated Canadian surgeons' views and use of BMI criterion thresholds for TJA access.

METHODS

A cross-sectional online qualitative survey was conducted with orthopaedic surgeons performing TJA in the Canadian health-care system. Responses were anonymous and questions were open-ended to allow for candid perspectives. Survey data were coded and a systematic process was followed to identify major themes. Findings were compared with U.S. surgeon perspectives.

RESULTS

Sixty-nine respondents had a mean age of 49.0 ± 11.4 years (range, 33 to 79 years), with a mean surgical experience duration of 15.7 ± 11.4 years (range, 2 to 50 years). Surgeons reported variable use of BMI thresholds in practice. Twelve interconnected factors that influence BMI considerations were identified: (1) variable evidence interpretation, (2) surgical challenge, (3) surgeon beliefs and biases, (4) hospital differences, (5) access to resources, (6) health system bias, (7) patient health status, (8) patient body fat distribution, (9) patient decisional burden (to lose weight or accept risk), (10) evidence gaps and uncertainties, (11) need for innovation, and (12) societal views. Nine themes matched with findings from U.S. surgeons.

CONCLUSIONS

Parallel to the United States, complex, interconnected factors influence Canadian orthopaedic surgeons' variable use of BMI restrictions for TJA eligibility. Despite different health-care systems and reimbursement models, similar technical and personal factors were identified. With TJA practice guidelines advising against hard BMI criteria, attention regarding access to resources, surgical training, and innovations to address TJA complexity in patients with large bodies are critically needed. Future advancements in this sphere must balance barrier removal with risk reduction to ensure safe and equitable surgical care.

CLINICAL RELEVANCE

This study may influence surgeon behaviors with regard to hard BMI cutoffs for TJA and encourage critical thought about factors that influence decisions about surgical eligibility for patients with high BMI.

Improving equity in diabetes technology use: Voices of youth and their parents

AIMS

There are marked inequities in clinical outcomes and rates of diabetes technology use among youth with type 1 diabetes (T1D). The quantitative data from our mixed methods cohort study identified significant improvements in glycaemia and quality of life in participants. We aimed to use qualitative methods to provide further insight into our quantitative findings in the setting of underlying health disparities.

METHODS

Fifteen publicly insured, insulin pump-naïve non-Hispanic Black youth aged 6-21 years with T1D and baseline haemoglobin A1c (HbA1c) ≥86 mmol/mol (10%) and their parents participated in a mixed methods cohort study. Semi-structured interviews were conducted separately with parents and youth after completion of 6 months of HCL use. Three topic areas were explored: (1) Experience using HCL, (2) barriers to HCL and (3) facilitators to accessing HCL. Semantic content analysis and consensus coding involving two team members were used to generate themes. Thematic saturation was achieved.

RESULTS

Youth (Medianage 14.9 years, 67% female) and parents (92% female) were interviewed. Youth and their parents reported that access to HCL provides a new outlook on living with T1D, although managing T1D is still hard. They felt that diabetes technology is most helpful for those struggling with management. Participants experienced barriers to access including misconceptions of HCL systems, clinician bias and systemic racism. They suggested these barriers can be overcome by offering diabetes technology education for all people with T1D, increasing awareness of HCL in the community and providing resources to overcome barriers created by social determinants of health.

CONCLUSIONS

The voices of historically minoritised youth with suboptimal T1D control and their parents provide important, previously unreported experiences and perspectives on barriers and facilitators to using HCL that will shape interventions to improve equity in access to diabetes technology.

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

Receipt of Medications for Alcohol Use Disorder in the Veterans Health Administration: Comparison of Rates at the Intersections of Racialized and Ethnic Identity With Both Sex and Transgender Status

OBJECTIVES

Medications for alcohol use disorder (MAUDs) are recommended for patients with alcohol use disorder yet are underprescribed. Consistent with Minority Stress and Intersectionality theories, persons with multiple sociodemographically marginalized identities (eg, Black women) often experience greater barriers to care and have poorer health outcomes. We use data from the Veterans Health Administration to assess disparities in Federal Drug Administration (FDA)-approved MAUDs and all effective MAUDs between the following groups: racialized and ethnic identity, sex, transgender status, and their intersections.

METHODS

Among all Veterans Health Administration outpatients between August 1, 2015, and July 31, 2017, with documented alcohol screenings and an International Classification of Diseases diagnosis for alcohol use disorder in the 0-365 days prior (N = 308,238), we estimated the prevalence and 95% confidence intervals of receiving FDA-approved MAUDs and any MAUDs in the following year and compared them using χ2 or Fisher's exact test. Analyses are unadjusted to present true prevalence and group differences.

RESULTS

The overall prevalence for MAUDs was low (FDA-MAUDs = 8.7%, any MAUDs = 20.0%). Within sex, Black males had the lowest rate of FDA-MAUDs (7.3%, [7.1-7.5]), whereas American Indian/Alaskan Native females had the highest (18.4%, [13.8-23.0]). Among those identified as transgender, Asian and Black transgender persons had the lowest rates of FDA-MAUDs (0%; 4.3%, [1.8-8.5], respectively), whereas American Indian/Alaskan Native transgender patients had the highest (33.3%, [2.5-64.1]). Similar patterns were observed for any MAUDs, with higher rates overall.

CONCLUSIONS

Substantial variation exists in MAUD prescribing, with marginalized veterans disproportionately receiving MAUDs at lower and higher rates than average. Implementation and quality improvement efforts are needed to improve MAUD prescribing practices and reduce disparities.

Veterans Affairs Medical Center Racial and Ethnic Composition and Initiation of Anticoagulation for Atrial Fibrillation

Importance

Racial and ethnic disparities exist in anticoagulation therapy for atrial fibrillation (AF). Whether medical center racial and ethnic composition is associated with these disparities is unclear.

Objective

To determine whether medical center racial and ethnic composition is associated with overall anticoagulation and disparities in anticoagulation for AF.

Design, Setting, and Participants

Retrospective cohort study of Black, White, and Hispanic patients with incident AF from 2018 to 2021 at 140 Veterans Health Administration medical centers (VAMCs). Data were analyzed from March to November 2023.

Exposure

VAMC racial and ethnic composition, defined as the proportion of patients from minoritized racial and ethnic groups treated at a VAMC, categorized into quartiles. VAMCs in quartile 1 (Q1) had the lowest percentage of patients from minoritized groups (ie, the reference group).

Main Outcomes and Measures

The odds of initiating any anticoagulant, direct-acting oral anticoagulant (DOAC), or warfarin therapy within 90 days of an index AF diagnosis, adjusting for sociodemographics, medical comorbidities, and facility factors.

Results

The cohort comprised 89 791 patients with a mean (SD) age of 73.0 (10.1) years; 87 647 (97.6%) were male, 9063 (10.1%) were Black, 3355 (3.7%) were Hispanic, and 77 373 (86.2%) were White. Overall, 64 770 individuals (72.1%) initiated any anticoagulant, 60 362 (67.2%) initiated DOAC therapy, and 4408 (4.9%) initiated warfarin. Compared with White patients, Black and Hispanic patients had lower rates of any anticoagulant and DOAC therapy initiation but higher rates of warfarin initiation across all quartiles of VAMC racial and ethnic composition. Any anticoagulant therapy initiation was lower in Q4 than Q1 (69.8% vs 74.9%; adjusted odds ratio [aOR], 0.80; 95% CI, 0.69-0.92; P < .001). DOAC and warfarin initiation were also lower in Q4 than in Q1 (DOAC, 69.4% vs 65.3%; aOR, 0.85; 95% CI, 0.74-0.97; P < .001; warfarin, 5.4% vs 4.5%; aOR, 0.82; 95% CI, 0.67-1.00; P < .001). In adjusted models, patients in Q4 were significantly less likely to initiate any anticoagulant therapy than those in Q1 (aOR, 0.88; 95% CI, 0.78-0.99). Patients in Q3 (aOR, 0.75; 95% CI, 0.60-0.93) and Q4 (aOR, 0.69; 95% CI, 0.55-0.87) were significantly less likely to initiate warfarin therapy than those in Q1. There was no significant difference in the adjusted odds of initiating DOAC therapy across racial and ethnic composition quartiles. Although significant Black-White and Hispanic-White differences in initiation of any anticoagulant, DOAC, and warfarin therapy were observed, interactions between patient race and ethnicity and VAMC racial composition were not significant.

Conclusions and Relevance

In a national cohort of VA patients with AF, initiation of any anticoagulant and warfarin, but not DOAC therapy, was lower in VAMCs serving more minoritized patients.

Influence of socioeconomic status on rates of advanced heart failure therapies

BACKGROUND

Socioeconomic deprivation is associated with a lower likelihood of referral for advanced heart failure (HF) evaluation, but it is not known whether it influences rates of advanced HF therapies independently of key hemodynamic measures and comorbidity following advanced HF evaluation in a universal healthcare system.

METHODS

We linked data from a single-center Danish clinical registry of consecutive patients evaluated for advanced HF with patient-level information on socioeconomic status. Patients were divided into groups based on the level of education (low, medium, and high), combined degree of socioeconomic deprivation (low, medium, and high), and household income quartiles. Rates of the combined outcome of left ventricular assist device implantation or heart transplantation (advanced HF therapy) with death as a competing risk were estimated with cumulative incidence functions, and Cox proportional hazards models adjusted for age, sex, central venous pressure, cardiac index, and comorbidities.

RESULTS

We included 629 patients, median age 53 years, of whom 77% were men. During a median follow-up of 5 years, 179 (28%) underwent advanced HF therapy. The highest level of education was associated with higher rates (high vs low, adjusted HR 1.81 95% CI 1.14-2.89, p = 0.01), whereas household income quartile groups (Q4 vs Q1, adjusted HR 1.37 95% CI 0.76-2.47, p = 0.30) or groups of combined socioeconomic deprivation (high vs low degree of deprivation, adjusted HR 0.86 95% CI 0.50-1.46, p = 0.56) were not significantly associated with rates of advanced HF therapy.

CONCLUSIONS

Patients with a lower level of education might be disfavored for advanced HF therapies and could require specific attention in the advanced HF care center.

Gender, racial-ethnic, and socioeconomic disparities in the development of social-emotional competence among elementary school students

Social-emotional competence (SEC) has been demonstrated to be a crucial factor for student mental health and is malleable through the high-quality implementation of effective school-based social and emotional learning (SEL) programs. SEL is now widely practiced in the United States as a Tier 1 strategy for the entire student body, yet it remains unclear whether disparities exist in the development of SEC across socio-culturally classified subgroups of students. Also, despite the field's widespread concern about teacher bias in assessing SEC within diverse student bodies, little evidence is available on the measurement invariance of the SEC assessment tools used to explore and facilitate SEC development. Based on a sociocultural view of student SEC development, this study aimed to measure and examine the extent to which gender, racial-ethnic, and socioeconomic disparities exist in SEC developmental trajectories during elementary school years. Specifically, using 3 years of SEC assessment data collected from a districtwide SEL initiative (N = 5452; Grades K-2 at baseline; nine measurement occasions), this study (a) tested the measurement invariance of a widely-used, teacher-rated SEC assessment tool (DESSA-Mini) across student gender, race and ethnicity, and socioeconomic status (SES); and (b) examined the extent to which multiyear SEC growth trajectories differed across these subgroups under a routine SEL practice condition. The invariance testing results supported strict factorial invariance of the DESSA-Mini across all the examined subgroups, thereby providing a foundation for valid cross-group comparisons of student SEC growth. The piecewise latent growth modeling results indicated that boys (vs. girls), Black students (vs. White students), Hispanic students (vs. White students), and low-income students (vs. middle-to-high-income students) started with a lower level of SEC, with these gaps being sustained or slightly widened throughout 3 elementary school years. Based on these findings, this study calls for future research that can inform practice efforts to ensure equitable SEC assessments and produce more equitable SEL outcomes, thereby promoting equity in school mental health.

Diversity of Research Participant Gender, Race, and Ethnicity in Communication Sciences and Disorders: A Systematic Review and Quantitative Synthesis of American Speech-Language-Hearing Association Publications in 2020

Purpose

One manifestation of systemic inequities in communication sciences and disorders (CSD) is the chronic underreporting and underrepresentation of sex, gender, race, and ethnicity in research. The present study characterized recent demographic reporting practices and representation of participants across CSD research.

Methods

We systematically reviewed and extracted key reporting and participant data from empirical studies conducted in the United States (US) with human participants published in the year 2020 in journals by the American Speech-Language-Hearing Association (ASHA; k = 407 articles comprising a total n = 80,058 research participants, search completed November 2021). Sex, gender, race, and ethnicity were operationalized per National Institutes of Health guidelines (National Institutes of Health, 2015a, 2015b).

Results

Sex or gender was reported in 85.5% of included studies; race was reported in 33.7%; and ethnicity was reported in 13.8%. Sex and gender were clearly differentiated in 3.4% of relevant studies. Where reported, median proportions for race and ethnicity were significantly different from the US population, with underrepresentation noted for all non-White racial groups and Hispanic participants. Moreover, 64.7% of studies that reported sex or gender and 67.2% of studies that reported race or ethnicity did not consider these respective variables in analyses or discussion.

Conclusion

At present, research published in ASHA journals frequently fails to report key demographic data summarizing the characteristics of participants. Moreover, apparent gaps in representation of minoritized racial and ethnic groups threaten the external validity of CSD research and broader health care equity endeavors in the US. Although our study is limited to a single year and publisher, our results point to several steps for readers that may bring greater accountability, consistency, and diversity to the discipline.

Associations between sociodemographic characteristics and neonatal length of the stay

BACKGROUND

Infants with past NICU admission have a significantly higher risk of developing neurodevelopmental disorders. Studies have demonstrated an iatrogenic effect of the NICU environment on neurodevelopmental outcomes, even while accounting for physical factors. It is, therefore, critical that an infant's LOS is driven by physical needs versus sociodemographic barriers.

METHODS

We leveraged electronic health records and a backward selection regression model to explore physical and sociodemographic predictors of infant LOS.

RESULTS

Our results demonstrated that physical predictors (birthweight and ventilator use) accounted for the majority of variance in our model but that a sociodemographic predictor, mean visits per day, was also significant.

CONCLUSIONS

Infants who were visited more frequently experienced a shorter LOS, possibly due to increased parental involvement resulting in more individualized care and directly impacting infant stability and morbidity. By supporting visitation, we can reduce the costs of lengthy NICU hospitalizations while improving infant and parent health and well-being.

Health Disparities Research in Facial Plastic and Reconstructive Surgery: A Scoping Review

OBJECTIVE

Health disparities contribute significantly to disease, health outcomes, and access to care. Little is known about the state of health disparities in facial plastic and reconstructive surgery (FPRS). This scoping review aims to synthesize the existing disparities research in FPRS and guide future disparities-related efforts.

DATA SOURCES

PubMed, Embase, Web of Science.

REVIEW METHODS

We conducted a scoping review in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. Our search included all years through March 03, 2023. All peer-reviewed primary literature of any design related to disparities in FPRS was eligible for inclusion.

RESULTS

Of the 12283 unique abstracts identified, 215 studies underwent full-text review, and 108 remained for final review. The most frequently examined topics were cleft lip and palate (40.7%), facial trauma (29.6%), and gender affirmation (9.3%). There was limited coverage of other areas. Consideration of race/ethnicity (68.5%), socioeconomic status (65.7%), and gender/sex (40.7%) were most common. Social capital (0%), religion, occupation, and features of relationships were least discussed (0.01% each). The majority of studies were published after 2018 (59.2%) and were of nonprospective designs (95.4%). Most studies focused on disparity detection (80.6%) and few focused on understanding (13.9%) or reducing disparities (0.06%).

CONCLUSION

This study captures the existing literature on health disparities in FPRS. Studies are concentrated in a few areas of FPRS and are primarily in the detecting phase of public health research. Our review highlights several gaps and opportunities for future disparities-related focus.

Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Incomes to Outcomes: A Global Assessment of Disparities in Cleft and Craniofacial Treatment

OBJECTIVE

Recent investigations focused on health equity have enumerated widespread disparities in cleft and craniofacial care. This review introduces a structured framework to aggregate findings and direct future research.

DESIGN

Systematic review was performed to identify studies assessing health disparities based on race/ethnicity, payor type, income, geography, and education in cleft and craniofacial surgery in high-income countries (HICs) and low/middle-income countries (LMICs). Case reports and systematic reviews were excluded. Meta-analysis was conducted using fixed-effect models for disparities described in three or more studies.

SETTING

N/A.

PATIENTS

Patients with cleft lip/palate, craniosynostosis, craniofacial syndromes, and craniofacial trauma.

INTERVENTIONS

N/A.

RESULTS

One hundred forty-seven articles were included (80% cleft, 20% craniofacial; 48% HIC-based). Studies in HICs predominantly described disparities (77%,) and in LMICs focused on reducing disparities (42%). Level II-IV evidence replicated delays in cleft repair, alveolar bone grafting, and cranial vault remodeling for non-White and publicly insured patients in HICs (Grades A-B). Grade B-D evidence from LMICs suggested efficacy of community-based speech therapy and remote patient navigation programs. Meta-analysis demonstrated that Black patients underwent craniosynostosis surgery 2.8 months later than White patients (P < .001) and were less likely to undergo minimally-invasive surgery (OR 0.36, P = .002).

CONCLUSIONS

Delays in cleft and craniofacial surgical treatment are consistently identified with high-level evidence among non-White and publicly-insured families in HICs. Multiple tactics to facilitate patient access and adapt multi-disciplinary case in austere settings are reported from LMICs. Future efforts including those sharing tactics among HICs and LMICs hold promise to help mitigate barriers to care.

Racial Disparities in Sacral Neuromodulation for Idiopathic Fecal Incontinence

IMPORTANCE

Sacral neuromodulation (SNM) is an effective treatment for fecal incontinence (FI). Previous studies found that Black women undergo SNM for urinary incontinence less than White women, but there is less known about racial disparities for FI.

OBJECTIVE

This study assessed differences in Black and White patients' FI treatment; SNM counseling was the primary outcome.

STUDY DESIGN

This was a retrospective cohort study of adult non-Hispanic Black and White patients who received FI treatment at an academic institution from 2011 to 2021. Medical records were queried for treatments, testing, and treating specialties for a 2:1 age-matched cohort of White:Black patients.

RESULTS

Four hundred forty-seven women were included: 149 Black women and 298 age-matched White women. A total of 24.4% (109) of patients had documented SNM counseling, significantly fewer in Black patients (14.8% vs 29.2%, P < 0.001). A total of 5.1% (23) of patients received SNM, less frequent in Black patients (2.7% vs 6.4%, P = 0.003). Among patients with SNM counseling, there was no difference between cohorts. Black patients were less likely to be referred for physical therapy (59.7% vs 77.2%, P < 0.001), sphincter imaging (0.7% vs 5.7%, P = 0.011), and defecography (8.1% vs 17.1%, P = 0.009). Different specialties managed the 2 cohorts. Black patients were less likely to see urogynecology and colorectal surgery (21.5% vs 34.6%, P = 0.004; 9.4% vs 15.4%, P = 0.077). Patients seen by these surgeons were more likely to discuss SNM (48.6% vs 8.5%, P < 0.001).

CONCLUSIONS

There were differences between Black and White patients' FI treatment, including counseling about SNM. Multidisciplinary work is needed to provide equitable education for this life-altering condition.

Buprenorphine Receipt and Retention for Opioid Use Disorder Following an Initiative to Increase Access in Primary Care

OBJECTIVES

Buprenorphine, a medication for opioid use disorder (OUD), is underutilized in general medical settings. Further, it is inequitably received by racialized groups and persons with comorbidities. The Veterans Health Administration launched an initiative to increase buprenorphine receipt in primary care. The project's objective was to identify patient-related factors associated with buprenorphine receipt and retention in primary care clinics (n = 18) participating in the initiative.

METHODS

Retrospective cohort quality improvement evaluation of patients 18 years or older with 2 or more primary care visits in a 1-year period and an OUD diagnosis in the year before the first primary care visit (index date). Buprenorphine receipt was the proportion of patients with OUD who received 1 or more buprenorphine prescriptions from primary care providers during the post-index year and retention the proportion who received buprenorphine for 180 days or longer.

RESULTS

Of 2880 patients with OUD seen in primary care, 11.7% (95% confidence interval [CI], 10.6%-12.9%) received buprenorphine in primary care, 58.2% (95% CI, 52.8%-63.3%) of whom were retained on buprenorphine for 180 days or longer. Patients with alcohol use disorder (adjusted odds ratio [AOR], 0.39; 95% CI, 0.27-0.57), nonopioid drug use disorder (AOR, 0.64; 95% CI, 0.45-0.93), and serious mental illness (AOR, 0.60; 95% CI, 0.37-0.97) had lower buprenorphine receipt. Those with an anxiety disorder had higher buprenorphine receipt (AOR, 1.42; 95% CI, 1.04-1.95). Buprenorphine receipt (AOR, 0.55; 95% CI, 0.35-0.87) and 180-day retention (AOR, 0.40; 95% CI, 0.19-0.84) were less likely among non-Hispanic Black patients.

CONCLUSIONS

Further integration of addiction services in primary care may be needed to enhance buprenorphine receipt for patients with comorbid substance use disorders, and interventions are needed to address disparities in receipt and retention among non-Hispanic Black patients.

Relationships among race, ethnicity, and gender and whole health among U.S. veterans

Racial, ethnic, and gender health care disparities in the United States are well-documented and stretch across the lifespan. Even in large integrated health care systems such as Veteran Health Administration, which are designed to provide equality in care, social and economic disparities persist, and limit patients' achievement of health goals across multiple domains. We explore Veterans' Whole Health priorities among Veteran demographic groups. Participants who were enrolling in Veteran Health Administration provided demographics and Whole Health priorities using eScreening, a web-based self-assessment tool. Veterans had similar health care goals regardless of demographic characteristics but differences were noted in current health appraisals. Non-White and women Veterans reported worse health-relevant functioning. Black Veterans were more likely to endorse a low rating for their personal development/relationships. Multiracial Veterans were more likely to endorse a low rating of their surroundings. Asian Veterans were less likely to provide a high rating of their surroundings. Women Veterans reported lower appraisals for body and personal development but higher appraisals of professional care. Results indicated that demographic factors such as race and gender, and to a lesser extent ethnicity, were associated with health disparities. The Whole Health model provides a holistic framework for addressing these disparities. These findings may inform more culturally sensitive care and enhance Veteran Health Administration equal access initiatives. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Understanding Disparities in the Pediatric ICU: A Scoping Review

BACKGROUND AND OBJECTIVES

Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized.

METHODS

Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables.

RESULTS

The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature.

CONCLUSIONS

Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.

Exploring variations in recommended first-choice therapy for complicated urinary tract infections in males: Insights from outpatient settings across age, race, and ethnicity

INTRODUCTION

There are known disparities in the treatment of infectious diseases. However, disparities in treatment of complicated urinary tract infections (UTIs) are largely uninvestigated.

OBJECTIVES

We characterized UTI treatment among males in Veterans Affairs (VA) outpatient settings by age, race, and ethnicity and identified demographic characteristics predictive of recommended first-choice antibiotic therapy.

METHODS

We conducted a national, retrospective cohort study of male VA patients diagnosed with a UTI and dispensed an outpatient antibiotic from January 2010 through December 2020. Recommended first-choice therapy for complicated UTI was defined as use of a recommended first-line antibiotic drug choice regardless of area of involvement (ciprofloxacin, levofloxacin, or sulfamethoxazole/trimethoprim) and a recommended duration of 7 to 10 days of therapy. Multivariable models were used to identify demographic predictors of recommended first-choice therapy (adjusted odds ratio [aOR] > 1).

RESULTS

We identified a total of 157,898 males diagnosed and treated for a UTI in the outpatient setting. The average antibiotic duration was 9.4 days (±standard deviation [SD] 4.6), and 47.6% of patients were treated with ciprofloxacin, 25.1% with sulfamethoxazole/trimethoprim, 7.6% with nitrofurantoin, and 6.6% with levofloxacin. Only half of the male patients (50.6%, n = 79,928) were treated with recommended first-choice therapy (first-line drug choice and appropriate duration); 77.6% (n = 122,590) were treated with a recommended antibiotic choice and 65.9% (n = 104,070) with a recommended duration. Age 18-49 years (aOR 1.07, 95% confidence interval [CI] 1.03-1.11) versus age ≥65 years was the only demographic factor predictive of recommended first-choice therapy.

CONCLUSIONS

Nearly half of the patients included in this study did not receive recommended first-choice therapies; however, racial and ethnic disparities were not identified. Underutilization of recommended first-choice antibiotic therapy in complicated UTIs continues to be an area of focus for antimicrobial stewardship programs.

Building evidence to advance health equity: a systematic review on care-related outcomes for older, minoritised populations in long-term care homes

BACKGROUND

Advancing health equity requires more contextualised evidence.

OBJECTIVES

To synthesise published evidence using an existing framework on the origins of health disparities and determine care-related outcome disparities for residents of long-term care, comparing minoritised populations to the context-specific dominant population.

DESIGN

Systematic review.

SUBJECTS

Residents of 24-hour long-term care homes.

METHODS

The protocol was registered a priori with PROSPERO (CRD42021269489). Literature published between 1 January 2000 and 26 September 2021, was searched, including studies comparing baseline characteristics and outcomes in minoritised versus dominant populations. Dual screening, two-reviewer verification for extraction, and risk of bias assessments were conducted to ensure rigour. Studies were synthesized using a conceptual framework to contextualise evidence according to multi-level factors contributing to the development of care disparities.

RESULTS

Twenty-one of 34 included studies demonstrated disparities in care outcomes for minoritised groups compared to majority groups. Thirty-one studies observed differences in individual-level characteristics (e.g. age, education, underlying conditions) upon entry to homes, with several outcome disparities (e.g. restraint use, number of medications) present at baseline and remaining or worsening over time. Significant gaps in evidence were identified, particularly an absence of literature on provider information and evidence on the experience of intersecting minority identities that contribute to care-related outcome disparities in long-term care.

CONCLUSION

This review found differences in minoritised populations' care-related outcomes. The findings provide guidance for future health equity policy and research-supporting diverse and intersectional capacity building in long-term care.

Questions to promote child-centered care in racially discordant interactions in pediatric oncology

OBJECTIVE

To examine questioning practices in racially discordant interactions and describe how these practices engendered child-centered care.

METHODS

We used applied conversation analysis to analyze a collection of 300 questions directed to children across 10 cases involving children of color and their families in disease reevaluation appointments in pediatric oncology.

RESULTS

Our analysis generated two patterns: 1) both the pediatric oncologists' and caregivers built upon one another's talk to enable the child's conversational turn, and 2) the oncologists' reformulated requests as questions to invite the child's permission and cooperation for completing exams and understanding symptoms.

CONCLUSION

Children, pediatric oncologists, and caregivers coordinated their actions to enable children to participate as recipients of and respondents to questions. The analysis of real-time interactions illuminates practices for centering children in clinical encounters and the benefits of doing so.

PRACTICAL IMPLICATIONS

This study's findings have implications for defining competencies and practices for fostering child-centered communication, creating training materials based on real-time encounters, and identifying strategies for humanizing pediatric patient experiences.

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

'God is the one who give child': An abductive analysis of barriers to postnatal care using the Health Equity Implementation Framework

Background

Postnatal care is recommended as a means of preventing maternal mortality during the postpartum period, but many women in low- and middle-income countries (LMICs) do not access care during this period. We set out to examine sociocultural preferences that have been portrayed as barriers to care.

Methods

We performed an abductive analysis of 63 semi-structured interviews with women who had recently given birth in three regions of Ethiopia using the Health Equity Implementation Framework (HEIF) and an inductive-deductive codebook to understand why women in Ethiopia do not use recommended postnatal care.

Results

We found that, in many cases, health providers do not consider women's cultural safety a primary need, but rather as a barrier to care. However, women's perceived refusal to participate in postnatal visits was, for many, an expression of agency and asserting their needs for cultural safety.

Trial registration

n/a.

Conclusions

We propose adding cultural safety to HEIF as a process outcome, so that implementers consider cultural needs in a dynamic manner that does not ask patients to choose between meeting their cultural needs and receiving necessary health care during the postnatal period.

'I don't know exactly what that means to do check-ups': understanding and experiences of primary care among resettled young adult refugees

Young adult refugees have suboptimal primary care use, including having a regular provider and engaging with a regular source of care for primary and preventive healthcare needs. Our purpose was to understand how young adult refugees (ages 18-29 years) resettled to the United States understand and experience primary care. We conducted 23 semi-structured interviews with young adult refugees and explored their ideas about and experiences of key characteristics of primary care. Emergent themes were synthesized. Young adult refugees reported a lack of an understanding of the idea of primary care. However, they also described the lack of accepted key components of primary care, such as being the first contact and providing continuity, coordination and comprehensiveness. The importance of developing an ability to ask questions, get answers and feel empowered was a facilitator of primary care successes. Young refugees lack access to healthcare that exemplifies quality primary care. Improving understanding of the primary care model and its value as well as increasing access and ease of engagement could improve primary care engagement for young adult refugees.

Arab, Middle Eastern, and North African Health Disparities Research: A Scoping Review

BACKGROUND

Research in health disparities and how they affect underserved populations continues to grow and expand. However, the experiences of Arab/Middle Eastern and North African (MENA) Americans often go unnoticed, and yet, preliminary data suggests there are significant disparities between this population and other groups. The purpose of this scoping review is to examine and synthesize the extent of available literature on health disparities and outcomes for this group.

METHODS

A scoping review was conducted to investigate the current state of research on health disparities and outcomes among Arab/MENA individuals within the USA. The PRISMA protocol for scoping reviews was utilized.

RESULTS

Through the use of PubMed and PsychInfo databases, the search identified 43 articles that were eligible for inclusion in the final review. Five themes emerged: prevalence and health outcomes, factors impacting health, comparison studies, barriers, and health literacy and beliefs. Extant data was equivocal, suggesting the need for further research.

CONCLUSIONS

Research on Arab/MENA health disparities and outcomes is in the detection phase, indicating that more research is needed to elucidate the state of Arab/MENA health in the USA. These findings can help healthcare professionals and researchers understand the emerging literature on health disparities within the Arab/MENA community and inform further research and clinical practice within this population.

Disparities Research for Pelvic Floor Disorders: A Systematic Review and Critique of Literature

IMPORTANCE

Understanding the status of pelvic floor disorder (PFD) disparities research will allow the opportunity to advance future pelvic floor equity efforts.

OBJECTIVES

The aims of the study were to (1) characterize the landscape of PFD disparities literature using the 3 phases of disparities research framework, (2) describe the characteristics of PFD disparities studies, and (3) identify critical knowledge gaps.

STUDY DESIGN

We performed a systematic review of peer-reviewed publications addressing disparities in PFDs among U.S. populations from PubMed, Embase, Scopus, or the Cochrane Database indexed between 1997 and 2022. Using the triphasic framework for advancing health disparities research by Kilbourne et al (Am J Public Health. 2006;96(12):2113-21), we categorized the included studies into the detecting phase (identifies and measures disparities in historically marginalized populations), understanding phase (establishes disparity determinants), or reducing phase (conducts interventions to alleviate inequities). All screening, coding, and quality reviews were independently performed by at least 2 authors. We used descriptive analysis and the χ2 test for comparisons.

RESULTS

The initial search identified 10,178 studies, of which 123 were included. Of the included studies, 98 (79.7%), 22 (17.9%), and 3 (2.4%) studies were detecting, understanding, and reducing phase research, respectively. The most common disparity category investigated was race and ethnicity (104 studies), and one third of these studies attributed drivers of racial and ethnic differences to structural influences. Publications of detecting phase studies outpaced the growth of understanding and reducing phase research.

CONCLUSIONS

Most PFD disparities research focused on identifying historically marginalized populations with inadequate progression to understanding and reducing phases. We recommend progressing PFD disparities research beyond the detecting phase to advance health equity in PFD care.

Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals

BACKGROUND AND OBJECTIVES

Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events.

METHODS

In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity.

RESULTS

Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children.

CONCLUSIONS

Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital.

Gender Bias in Diagnosis, Prevention, and Treatment of Cardiovascular Diseases: A Systematic Review

Cardiovascular disease (CVDs) has been perceived as a 'man's disease', and this impacted women's referral to CVD diagnosis and treatment. This study systematically reviewed the evidence regarding gender bias in the diagnosis, prevention, and treatment of CVDs. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We searched CINAHL, PubMed, Medline, Web of Science, British Nursing Index, Scopus, and Google Scholar. The included studies were assessed for quality using risk bias tools. Data extracted from the included studies were exported into Statistical Product and Service Solutions (SPSS, v26; IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. A total of 19 studies were analysed. CVDs were less reported among women who either showed milder symptoms than men or had their symptoms misdiagnosed as gastrointestinal or anxiety-related symptoms. Hence, women had their risk factors under-considered by physicians (especially by male physicians). Subsequently, women were offered fewer diagnostic tests, such as coronary angiography, ergometry, electrocardiogram (ECG), and cardiac enzymes, and were referred to less to cardiologists and/or hospitalisation. Furthermore, if hospitalised, women were less likely to receive a coronary intervention. Similarly, women were prescribed cardiovascular medicines than men, with the exception of antihypertensive and anti-anginal medicines. When it comes to the perception of CVD, women considered themselves at lower risk of CVDs than men. This systematic review showed that women were offered fewer diagnostic tests for CVDs and medicines than men and that in turn influenced their disease outcomes. This could be attributed to the inadequate knowledge regarding the differences in manifestations among both genders.

A Systematic Review of the State of Neurosurgical Disparities Research: Past, Present, and Future

BACKGROUND

The social determinants of health, which influence healthcare access, patient outcomes, and population-level burden of disease, contribute to health disparities experienced by marginalized patient populations. In the present study, we sought to evaluate the landscape of health disparities research within neurosurgery.

METHODS

Embase, Ovid-MEDLINE, Scopus, Web of Science, Cochrane Library, and ProQuest Dissertations databases were queried for original research on health disparities regarding access to, outcomes of, and/or postoperative management after neurosurgical procedures in the United States.

RESULTS

Of 883 studies screened, 196 were included, of which 144 had a neurosurgery-affiliated author. We found a significant increase in the number of neurosurgical disparities reports beginning in 2010, with only 10 studies reported before 2010. Of the included studies, 3.1% used prospective methods and 63.8% used data from national registries. The disparities analyzed were racial/ethnic (79.6%), economic/socioeconomic (53.6%), gender (18.9%), and disabled populations (0.5%), with 40.1% analyzing multiple or intersecting disparities. Of the included reports, 96.9% were in phase 1 (detecting phase of disparities research), with a few studies in phase 2 (understanding phase), and none in phase 3 (reducing phase). The spine was the most prevalent subspecialty evaluated (34.2%), followed by neuro-oncology (19.9%), cerebrovascular (16.3%), pediatrics (10.7%), functional (9.2%), general neurosurgery (5.1%), and trauma (4.1%). Senior authors with a neurosurgical affiliation accounted for 79.2% of the reports, 93% of whom were academically affiliated.

CONCLUSIONS

Although a recent increase has occurred in neurosurgical disparities research within the past decade, most studies were limited to the detection of disparities without understanding or evaluating any interventions for a reduction in disparities. Future research in neurosurgical disparities should incorporate the latter 2 factors to reduce disparities and improve outcomes for all patients.

The measurement of racism in health inequities research

There is limited literature on the measures and metrics used to examine racism in the health inequities literature. Health inequities research is continuously evolving, with the number of publications increasing over time. However, there is limited knowledge on the best measures and methods to examine the impact of different levels of racism (institutionalized, personally mediated, and internalized) on health inequities. Advanced statistical methods have the potential to be used in new ways to examine the relationship between racism and health inequities. In this review, we conduct a descriptive examination of the measurement of racism in the health inequities epidemiologic literature. We examine the study design, methods used for analysis, types of measures used (e.g., composite, absolute, relative), number of measures used, phase of research (detect, understand, solutions), viewpoint (oppressor, oppressed), and components of structural racism measures (historical context, geographical context, multifaceted nature). We discuss methods (e.g., Peters-Belson, latent class analysis, difference in differences) that have demonstrated potential for future work. The articles reviewed were limited to the detect (25%) and understand (75%) phases, with no studies in the solutions phase. Although the majority (56%) of studies had cross-sectional designs, many authors pointed to the need for longitudinal and multilevel data for further exploration. We examined study design features as mutually exclusive elements. However, racism is a multifaceted system and the measurement of racism in many studies does not fit into a single category. As the literature grows, the significance of methodological and measurement triangulation to assess racism should be investigated.

The Spanish language version of the TAPS tool: protocol for a validation and implementation study in primary care

BACKGROUND

The TAPS Tool ("Tobacco, Alcohol, Prescription drug, and illicit Substance use") is a screening and brief assessment for detecting unhealthy substance use in healthcare settings that was developed by the National Institute on Drug Abuse Clinical Trials Network and validated in a multisite study. Our team developed a Spanish language version of the TAPS Tool that supports provider- and self-administration screening using a mobile/web-based platform, the TAPS Electronic Spanish Platform (TAPS-ESP).

METHODS

This article describes the protocol and rationale for a study to validate the TAPS-ESP in a sample of Spanish-speaking primary care patients recruited from a network of community-based clinics in Texas (target N = 1,000). The TAPS-ESP will be validated against established substance use disorder diagnostic measures, alternative screening tools, and substance use biomarkers. The study will subsequently examine barriers and facilitators to screening with the TAPS-ESP from a provider workflow perspective using qualitative interviews with providers.

DISCUSSION

Validating a Spanish language version of the TAPS Tool could expand access to evidence-based, linguistically accurate, and culturally relevant substance use screening and brief assessment for an underserved health disparity population.

TRIAL REGISTRATION

The study was registered with www.

CLINICALTRIALS

gov : NCT05476588, 07/22/2022.

Race Differences in Veteran's Affairs Emergency Department Utilization

INTRODUCTION

African Americans (AAs) experience disparities in chronic pain care. This study aimed to identify the rates of emergency department (ED) utilization for visits associated with chronic pain diagnoses among AAs compared to Whites and to determine variables that accounted for any differences.

METHODS

This retrospective observational study used national Veterans Affairs (Veteran's Health Administration) administrative data to identify Veterans with chronic pain diagnoses in 2018. Race/ethnicity was self-reported and assessed to examine if differences exist in ED utilization. Differences between AAs and Whites were examined using negative binomial regression models, controlling for ethnicity. Multivariable models (including demographics, pain characteristics, psychiatric comorbidities, medical comorbidities, pain-related health care utilization, and medication utilization) were examined to determine factors that contributed to these disparities.

RESULTS

Among the 2,261,030 patients, 22% (n = 492,138) were AA. The incidence rate ratio of ED utilization for AAs, relative to Whites, was 1.58 (95% CI: 1.56-1.59). The only independent variable that produced a clinically meaningful reduction in the race effect on ED use was rurality, which was associated with reduced ED use. Post hoc model including all variables reduced the race effect to 1.37 (95% CI: 1.36-1.38).

CONCLUSION

AA Veterans had a 58% greater risk of ED utilization for visits associated with chronic pain diagnoses relative to White Veterans, which remained meaningfully elevated after adjustment for observable confounders (37%). This observation may reflect disparities in outpatient chronic pain care for AAs. Future research could focus on enhancing therapeutic alliance in primary care to improve chronic pain treatment for AAs.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

PURPOSE

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery.

METHODS

A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities.

RESULTS

The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods.

CONCLUSIONS

Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation.

CLINICAL RELEVANCE

Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

Factors associated with the utilization of diagnostic tools among countries with different income levels during the COVID-19 pandemic

BACKGROUND

Disparities in the utilization of essential medical products are a key factor contributing to inequality in health outcomes. We aimed to analyze the trends and influencing factors in using Coronavirus disease 2019 (COVID-19) diagnostic tools and disparities in countries with different income levels.

METHODS

We conducted a cross-sectional study using open and publicly available data sources. Data were mainly collected from the Foundation for Innovative New Diagnostics, "Our World in Data," and the Global Burden of Disease databases. Negative binomial regression model and generalized linear mixed model were employed to investigate into five sets of factors associated with the usage of diagnostics: severity of COVID-19, socioeconomic status, health status, medical service capacity, and rigidity of response. Dominance analysis was utilized to compare the relative importance of these factors. The Blinder-Oaxaca decomposition was used to decompose the difference in the usage of diagnostics between countries.

RESULTS

The total COVID-19 testing rate ranged from 5.13 to 22,386.63 per 1000 people from March 2020 to October 2022 and the monthly testing rate declined dramatically from January 2022 to October 2022 (52.37/1000 vs 5.91/1000).. The total testing rate was primarily associated with socioeconomic status (37.84%), with every 1 standard deviation (SD) increase in Gross Domestic Product per capita and the proportion of people aged ≥ 70, the total testing rate increased by 88% and 31%. And so is the medical service capacity (33.66%), with every 1 SD increase in health workforce density, the number increased by 38%. The monthly testing rate was primarily associated with socioeconomic status (34.72%) and medical service capacity (28.67%), and the severity of COVID-19 (21.09%). The average difference in the total testing rates between high-income and low-income countries was 2726.59 per 1000 people, and 2493.43 (91.45%) of the differences could be explained through the five sets of factors.

CONCLUSIONS

Redoubling the efforts, such as local manufacturing, regulatory reliance, and strengthening the community health workforce and laboratory capacity in low- and middle-income countries (LMICs) cannot be more significant for ensuring sustainable and equitable access to diagnostic tools during pandemic.

Racial Differences in Psychiatric Symptoms, Maladaptive Eating, and Lifestyle Behaviors After Bariatric Surgery

There are several psychological and behavioral factors associated with poorer outcomes following bariatric surgery, yet it is unknown whether and how these factors may differ by race. In this cross-sectional study, individuals who underwent bariatric surgery from 2018 to 2021 and up to 4 years post-surgery were invited to complete an online survey. Psychiatric symptoms, maladaptive eating patterns, self-monitoring behaviors, and exercise frequency were examined. Participants (N = 733) were 87% women, 63% White, with a mean age of 44 years. Analyses of covariance demonstrated that White individuals endorsed greater anxiety symptoms (p =.01) and emotional eating due to depression (p = .01), whereas Black individuals endorsed greater depression severity (p = .02). Logistic regression analyses demonstrated that White individuals were more likely to experience loss of control eating (OR= 1.7, p = .002), grazing (OR= 2.53, p <.001), and regular self-weighing (OR= 1.41, p <.001) than Black individuals, and were less likely to skip meals (OR= .61, p = .04), or partake in nighttime eating (OR= .40, p <.001). There were no racial differences in binge eating, emotional eating due to anxiety or frustration, use of a food diary, or exercise. Thus, depressive symptoms, skipping meals, and nighttime eating may be important, modifiable intervention targets to optimize the benefits of bariatric surgery and promote equitable outcomes.

A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities

BACKGROUND

Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or 'race'-related health inequities.

METHODS

A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated.

RESULTS

Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a 'hybrid' framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation.

CONCLUSIONS

This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

An Intervention-Based Approach to Achieve Racial Equity in Gynecologic Oncology

Racial inequities within gynecologic oncology exist at every step of the cancer continuum. Although the disparities have been well described, there is a significant gap in the literature focused on eliminating inequities in gynecologic cancer outcomes. The goal of this narrative review is to highlight successful, evidence-based interventions from within and outside of gynecologic oncology that alleviate disparity, providing a call to action for further research and implementation efforts within the field. These solutions are organized in the socioecologic framework, where multiple levels of influence-societal, community, organizational, interpersonal, and individual-affect health outcomes.

Unraveling non-participation in genomic research: A complex interplay of barriers, facilitators, and sociocultural factors

Although genomic research offering next-generation sequencing (NGS) has increased the diagnoses of rare/ultra-rare disorders, populations experiencing health disparities infrequently participate in these studies. The factors underlying non-participation would most reliably be ascertained from individuals who have had the opportunity to participate, but decline. We thus enrolled parents of children and adult probands with undiagnosed disorders who had declined genomic research offering NGS with return of results with undiagnosed disorders (Decliners, n = 21) and compared their data to those who participated (Participants, n = 31). We assessed: (1) practical barriers and facilitators, (2) sociocultural factors-genomic knowledge and distrust, and (3) the value placed upon a diagnosis by those who declined participation. The primary findings were that residence in rural and medically underserved areas (MUA) and higher number of barriers were significantly associated with declining participation in the study. Exploratory analyses revealed multiple co-occurring practical barriers, greater emotional exhaustion and research hesitancy in the parents in the Decliner group compared to the Participants, with both groups identifying a similar number of facilitators. The parents in the Decliner group also had lower genomic knowledge, but distrust of clinical research was not different between the groups. Importantly, despite their non-participation, those in the Decliner group indicated an interest in obtaining a diagnosis and expressed confidence in being able to emotionally manage the ensuing results. Study findings support the concept that some families who decline participation in diagnostic genomic research may be experiencing pile-up with exhaustion of family resources - making participation in the genomic research difficult. This study highlights the complexity of the factors that underlie non-participation in clinically relevant NGS research. Thus, approaches to mitigating barriers to NGS research participation by populations experiencing health disparities need to be multi-pronged and tailored so that they can benefit from state-of -the art genomic technologies.

Disparities among patients with respiratory failure

PURPOSE OF REVIEW

Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex.

RECENT FINDINGS

Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation.

SUMMARY

Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: A scoping review

BACKGROUND

An integral part of clinical practice is decision-making. Yet there is widespread acceptance that there is evidence of cognitive bias within clinical practice among nurses and physicians. However, how cognitive bias among emergency nurses and physicians' decision-making influences patient outcomes remains unclear.

AIM

The aim of this review was to systematically synthesise research exploring the emergency nurses' and physicians' cognitive bias in decision-making and its influence on patient outcomes.

METHODS

This scoping review was guided by the PRISMA Extension for Scoping Reviews. The databases searched included CINAHL, MEDLINE, Web of Science and PubMed. No date limits were applied. The Patterns, Advances, Gaps, Evidence for practice and Research recommendation (PAGER) framework was used to guide the discussion.

RESULTS

The review included 18 articles, consisting of 10 primary studies (nine quantitative and one qualitative) and eight literature reviews. Of the 18 articles, nine investigated physicians, five articles examined nurses, and four both physicians and nurses with sample sizes ranging from 13 to 3547. Six primary studies were cross-sectional and five used hypothetical scenarios, and one real-world assessment. Three were experimental studies. Twenty-nine cognitive biases were identified with Implicit bias (n = 12) most frequently explored, followed by outcome bias (n = 4). Results were inconclusive regarding the influence of biases on treatment decisions and patient outcomes. Four key themes were identified; (i) cognitive biases among emergency clinicians; (ii) measurement of cognitive bias; (iii) influence of cognitive bias on clinical decision-making; and (iv) association between emergency clinicians' cognitive bias and patient outcomes.

CONCLUSIONS

This review identified that cognitive biases were present among emergency nurses and physicians during clinical decision-making, but it remains unclear how cognitive bias influences patient outcomes. Further research examining emergency clinicians' cognitive bias is required.

RELEVANCE TO CLINICAL PRACTICE

Awareness of emergency clinicians' own cognitive biases may result to the provision of equity in care.

NO PATIENT OR PUBLIC CONTRIBUTION IN THIS REVIEW

We intend to disseminate the results through publication in a peer-reviewed journals and conference presentations.