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Mork D, Delaney S, Dominici F. Policy-induced air pollution health disparities: Statistical and data science considerations. Science 2024; 385:391-396. [PMID: 39052789 DOI: 10.1126/science.adp1870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/13/2024] [Indexed: 07/27/2024]
Abstract
Air pollution causes premature death and disease and disproportionately harms non-white and lower-income groups in the United States. Government policies are responsible for the racial disparity in air pollution exposure and related health outcomes. Investigating complex relationships between policies, air pollution, and health requires (i) harmonized data connecting policies, environmental exposures, socioeconomic characteristics, and health at the individual and area level; (ii) interpretable estimands accounting for the complex interplay between policies and disparities in exposures and health outcomes; and (iii) data science approaches that can elucidate direct and indirect policy effects on disparities to identify effective interventions. We review statistical considerations and new data science approaches needed to scrutinize the policy impacts on disparities in air pollution exposure and health outcomes.
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Affiliation(s)
- Daniel Mork
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Scott Delaney
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Francesca Dominici
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
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Hanchate AD, Abdelfattah L, Lin MY, Lasser KE, Paasche-Orlow MK. Affordable Care Act Medicaid Expansion was Associated With Reductions in the Proportion of Hospitalizations That are Potentially Preventable Among Hispanic and White Adults. Med Care 2023; 61:627-635. [PMID: 37582292 PMCID: PMC10894451 DOI: 10.1097/mlr.0000000000001902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVE Using data on 5 years of postexpansion experience, we examined whether the coverage gains from Affordable Care Act Medicaid expansion among Black, Hispanic, and White individuals led to improvements in objective indicators of outpatient care adequacy and quality. RESEARCH DESIGN For the population of adults aged 45-64 with no insurance or Medicaid coverage, we obtained data on census population and hospitalizations for ambulatory care sensitive conditions (ACSCs) during 2010-2018 in 14 expansion and 7 nonexpansion states. Our primary outcome was the percentage share of hospitalizations due to ACSC out of all hospitalizations ("ACSC share") among uninsured and Medicaid-covered patients. Secondary outcomes were the population rate of ACSC and all hospitalizations. We used multivariate regression models with an event-study difference-in-differences specification to estimate the change in the outcome measures associated with expansion in each of the 5 postexpansion years among Hispanic, Black, and White adults. PRINCIPAL FINDINGS At baseline, ACSC share in the expansion states was 19.0%, 14.5%, and 14.3% among Black, Hispanic, and White adults. Over the 5 years after expansion, Medicaid expansion was associated with an annual reduction in ACSC share of 5.3% (95% CI, -7.4% to -3.1%) among Hispanic and 8.0% (95% CI, -11.3% to -4.5%) among White adults. Among Black adults, estimates were mixed and indicated either no change or a reduction in ACSC share. CONCLUSIONS After Medicaid expansion, low-income Hispanic and White adults experienced a decrease in the proportion of potentially preventable hospitalizations out of all hospitalizations.
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Affiliation(s)
- Amresh D. Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Lindsey Abdelfattah
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Meng-Yun Lin
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
| | - Karen E. Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - Michael K. Paasche-Orlow
- Division of General Internal Medicine, Department of Medicine, Tufts University School of Medicine, Boston, MA
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Fashaw-Walters SA, McGuire CM. Proposing A Racism-Conscious Approach To Policy Making And Health Care Practices. Health Aff (Millwood) 2023; 42:1351-1358. [PMID: 37782862 DOI: 10.1377/hlthaff.2023.00482] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Racial and ethnic health inequities are driven by multiple social and political factors. Race-neutral policies that overlook the role of racism in policy and in disparities may also contribute to inequities. In response, one broad policy-making approach has been to craft race-based policies that attempt to improve outcomes explicitly for specific racial groups. However, race-based policies can be politically infeasible. We propose a racism-conscious approach to policy making and health care practices that addresses racism and advances health equity. Using postacute and long-term care policies as a backdrop, we identify five key steps to creating racism-conscious policies that rest on continuous community engagement and policy evaluation. The proposed racism-conscious framework can be used to develop a new health policy or to redesign an existing policy, and it can work for federal, state, local, and organizational policies, practices, or both.
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Byrd JN, Cichocki MN, Chung KC. Plastic Surgeons and Equity: Are Merit-Based Incentive Payment System Scores Impacted by Minority Patient Caseload? Plast Reconstr Surg 2023; 152:534e-539e. [PMID: 36917743 DOI: 10.1097/prs.0000000000010406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services introduced the Merit-based Incentive Payment System (MIPS) in 2017 to extend value-based payment to outpatient physicians. The authors hypothesized that the MIPS scores for plastic surgeons are impacted by the existing measures of patient disadvantage, minority patient caseload, and dual eligibility. METHODS The authors conducted a retrospective cohort study of plastic surgeons participating in Medicare and MIPS using the Physician Compare national downloadable file and MIPS scores. Minority patient caseload was defined as nonwhite patient caseload. The authors evaluated the characteristics of participating plastic surgeons, their patient caseloads, and their scores. RESULTS Of 4539 plastic surgeons participating in Medicare, 1257 participated in MIPS in the first year of scoring. The average patient caseload is 85% white, with racial/ethnicity data available for 73% of participating surgeons. In multivariable regression, higher minority patient caseload is associated with a lower MIPS score. CONCLUSIONS As minority patient caseload increases, MIPS scores decrease for otherwise similar caseloads. The Centers for Medicare and Medicaid Services must consider existing and additional measures of patient disadvantage to ensure equitable surgeon scoring.
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Affiliation(s)
- Jacqueline N Byrd
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
- Center for Health Outcomes and Policy, University of Michigan
- Department of Surgery, University of Texas Southwestern Medical School
| | - Meghan N Cichocki
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Kevin C Chung
- From the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
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Khera R, Kondamudi N, Liu M, Ayers C, Spatz ES, Rao S, Essien UR, Powell-Wiley TM, Nasir K, Das SR, Capers Q, Pandey A. Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study. Am J Prev Cardiol 2023; 14:100493. [PMID: 37397263 PMCID: PMC10314135 DOI: 10.1016/j.ajpc.2023.100493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Objective To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. Methods We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. Results A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. Conclusion Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Mengni Liu
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, United States
| | - Shreya Rao
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, United States
| | - Utibe R Essien
- Department of Medicine, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, United States
| | - Tiffany M Powell-Wiley
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, National Heart, Lung, and Blood Institute, NIH, 3131 Center Drive, Bethesda, MD, United States
- Intramural Research Program, National Institute on Minority Health and Health Disparities, NIH, 6707 Democracy Boulevard, Suite 800, Bethesda, MD, United States
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist, 6565 Fannin St, Houston, TX, United States
| | - Sandeep R Das
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Quinn Capers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, United States
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Holston D, Greene M. The LSU AgCenter Healthy Communities Initiative: Community-Participatory Policy, Systems, and Environmental Change. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2023; 55:381-386. [PMID: 37164553 DOI: 10.1016/j.jneb.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Denise Holston
- School of Nutrition and Food Sciences, Louisiana State University Agriculture Center, Baton Rouge, LA
| | - Matthew Greene
- School of Nutrition and Food Sciences, Louisiana State University Agriculture Center, Baton Rouge, LA.
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Khazanchi R, Soled DR, Yearby R. Racism-Conscious Praxis: A Framework to Materialize Anti-Oppression in Medicine, Public Health, and Health Policy. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:31-34. [PMID: 37011342 DOI: 10.1080/15265161.2023.2186521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Affiliation(s)
- Rohan Khazanchi
- Harvard Internal Medicine-Pediatrics Residency Program at Brigham & Women's Hospital, Boston Children's Hospital, and Boston Medical Center
- Harvard Medical School
| | - Derek R Soled
- Harvard Internal Medicine-Pediatrics Residency Program at Brigham & Women's Hospital, Boston Children's Hospital, and Boston Medical Center
- Harvard Medical School
| | - Ruqaiijah Yearby
- Moritz College of Law, The Ohio State University
- Kirwan Institute for the Study of Race and Ethnicity, The Ohio State University
- The Institute for Healing Justice & Equity
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Greene M, Holston D, Freightman J, Briley C. African American Perceptions of Service Provided by Supplemental Nutrition Assistance Program-Education: A Qualitative Exploration. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2023; 55:125-134. [PMID: 36764794 DOI: 10.1016/j.jneb.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/30/2022] [Accepted: 10/20/2022] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To assess African Americans' satisfaction with Supplemental Nutrition Assistance Program-Education (SNAP-Ed) in Louisiana. METHODS African American facilitators conducted 5 focus group discussions with 25 African American SNAP-Ed participants according to issues identified by African American SNAP-Ed implementers in Louisiana. Focus group discussion transcripts were coded independently using inductive and in vivo coding by 2 members of the research team. RESULTS Participants viewed lessons as race-neutral and thought they should include more information about African American history and culture. Participants also noted a lack of engagement with the African American community and stressed the need for the program to employ African American staff. However, participants thought the information was important for African Americans in the context of medical issues faced by their community. CONCLUSIONS AND IMPLICATIONS Findings indicate that SNAP-Ed in Louisiana be modified to address African American food history and culture, additional African American staff and better engagement with the African American community.
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Affiliation(s)
- Matthew Greene
- School of Nutrition and Food Sciences, Louisiana State University Agriculture Center, Baton Rouge, LA.
| | - Denise Holston
- School of Nutrition and Food Sciences, Louisiana State University Agriculture Center, Baton Rouge, LA
| | - Jamila Freightman
- School of Nutrition and Food Sciences, Louisiana State University Agriculture Center, Baton Rouge, LA
| | - Chiquita Briley
- School of Nutrition and Food Sciences, Louisiana State University Agriculture Center, Baton Rouge, LA
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Chalasani R, Krishnamurthy S, Suda KJ, Newman TV, Delaney SW, Essien UR. Pursuing Pharmacoequity: Determinants, Drivers, and Pathways to Progress. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2022; 47:709-729. [PMID: 35867522 DOI: 10.1215/03616878-10041135] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The United States pays more for medical care than any other nation in the world, including for prescription drugs. These costs are inequitably distributed, as individuals from underrepresented racial and ethnic groups in the United States experience the highest costs of care and unequal access to high-quality, evidence-based medication therapy. Pharmacoequity refers to equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions. Herein the authors describe the urgent need to prioritize pharmacoequity. This goal will require a bold and innovative examination of social policy, research infrastructure, patient and prescriber characteristics, as well as health policy determinants of inequitable medication access. In this article, the authors describe these determinants, identify drivers of ongoing inequities in prescription drug access, and provide a framework for the path toward achieving pharmacoequity.
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Rhoades CA, Whitacre BE, Davis AF. Community sociodemographics and rural hospital survival. J Rural Health 2022. [DOI: 10.1111/jrh.12728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Claudia A. Rhoades
- Department of Agricultural Economics Oklahoma State University Stillwater Oklahoma USA
| | - Brian E. Whitacre
- Department of Agricultural Economics Oklahoma State University Stillwater Oklahoma USA
| | - Alison F. Davis
- Department of Agricultural Economics University of Kentucky Lexington Kentucky USA
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Kimberly LL, Onuh OC, Thys E, Rodriguez ED. Social support criteria in vascularized composite allotransplantation versus solid organ transplantation: Should the same ethical considerations apply? Front Psychol 2022; 13:1055503. [PMID: 36483709 PMCID: PMC9723137 DOI: 10.3389/fpsyg.2022.1055503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/03/2022] [Indexed: 02/13/2024] Open
Abstract
The field of vascularized composite allotransplantation (VCA) is evolving, with some procedures poised to transition from highly experimental research toward standard of care. At present, the use of social support as an eligibility criterion for VCA candidacy is at the discretion of individual VCA programs, allowing VCA teams to consider the unique needs of each potential candidate. Yet this flexibility also creates potential for bias during the evaluation process which may disproportionately impact members of certain communities where social configurations may not resemble the model considered "optimal." We examine the extent to which ethical considerations for social support in solid organ transplantation (SOT) may be applied to or adapted for VCA, and the ethically meaningful ways in which VCA procedures differ from SOT. We conclude that VCA programs must retain some flexibility in determining criteria for candidacy at present; however, considerations of equity will become more pressing as VCA procedures evolve toward standard of care, and further empirical evidence will be needed to demonstrate the association between social support and post-operative success. The field of VCA has an opportunity to proactively address considerations of equity and justice and incorporate fair, inclusive practices into this innovative area of transplantation.
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Affiliation(s)
- Laura L. Kimberly
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, United States
- Division of Medical Ethics, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | - Ogechukwu C. Onuh
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, United States
| | - Erika Thys
- University of Nevada, Reno School of Medicine, Reno, NV, United States
| | - Eduardo D. Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, United States
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Yearby R, Clark B, Figueroa JF. Structural Racism In Historical And Modern US Health Care Policy. Health Aff (Millwood) 2022; 41:187-194. [PMID: 35130059 DOI: 10.1377/hlthaff.2021.01466] [Citation(s) in RCA: 152] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The COVID-19 pandemic has illuminated and amplified the harsh reality of health inequities experienced by racial and ethnic minority groups in the United States. Members of these groups have disproportionately been infected and died from COVID-19, yet they still lack equitable access to treatment and vaccines. Lack of equitable access to high-quality health care is in large part a result of structural racism in US health care policy, which structures the health care system to advantage the White population and disadvantage racial and ethnic minority populations. This article provides historical context and a detailed account of modern structural racism in health care policy, highlighting its role in health care coverage, financing, and quality.
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Affiliation(s)
| | - Brietta Clark
- Brietta Clark, Loyola Marymount University, Los Angeles, California
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