Epidemiological approaches to multivariable models of health inequity: A study of race, rurality, and occupation during the COVID-19 pandemic

PURPOSE

Methods for assessing the structural mechanisms of health inequity are not well established. This study applies a phased approach to modeling racial, occupational, and rural disparities on the county level.

METHODS

Rural counties with disparately high rates of COVID-19 incidence or mortality were randomly paired with in-state control counties with the same rural-urban continuum code. Analysis was restricted to the first six months of the pandemic to represent the baseline structural reserves for each county and reduce biases related to the disruption of these reserves over time. Conditional logistic regression was applied in two phases-first, to examine the demographic distribution of disparities and then, to examine the relationships between these disparities and county-level social and structural reserves.

RESULTS

In over 200 rural county pairs (205 for incidence, 209 for mortality), disparities were associated with structural variables representing economic factors, healthcare infrastructure, and local industry. Modeling results were sensitive to assumptions about the relationships between race and other social and structural variables measured at the county level, particularly in models intended to reflect effect modification or mediation.

CONCLUSIONS

Multivariable modeling of health disparities should reflect the social and structural mechanisms of inequity and anticipate interventions that can advance equity.

Diabetes care in the pandemic era in the Midwestern USA: a semi-structured interview study of the patient perspective

OBJECTIVES

To understand patients' experiences with diabetes care during the COVID-19 pandemic, with an emphasis on rural, medically underserved, and/or minoritised racial and ethnic groups in the Midwestern USA.

DESIGN

Community-engaged, semi-structured interviews were conducted by medical student researchers trained in qualitative interviewing. Transcripts were prepared and coded in the language in which the interview was conducted (English or Spanish). Thematic analysis was conducted, and data saturation was achieved.

SETTING

The study was conducted in communities in Eastern and Western Iowa.

PARTICIPANTS

Adults with diabetes (n=20) who were fluent in conversational English or Spanish were interviewed. One-third of participants were residents of areas designated as federal primary healthcare professional shortage areas and/or medically underserved areas, and more than half were recruited from medical clinics that offer care at no cost.

RESULTS

Themes across both English and Spanish transcripts included: (1) perspectives of diabetes, care providers and care management; (2) challenges and barriers affecting diabetes care; and (3) participant feedback and recommendations. Participants reported major constraints related to provider availability, costs of care, access to nutrition counselling and mental health concerns associated with diabetes care during the pandemic. Participants also reported a lack of shared decision-making regarding some aspects of care, including amputation. Finally, participants recognised systems-level challenges that affected both patients and providers and expressed a preference for proactive collaboration with healthcare teams.

CONCLUSIONS

These findings support enhanced engagement of rural, medically underserved and minoritised groups as stakeholders in diabetes care, diabetes research and diabetes provider education.

A Scoping Review of Wearable Technologies for Use in Individuals With Intellectual Disabilities and Diabetic Peripheral Neuropathy

BACKGROUND

Individuals with intellectual disabilities (IDs) are at risk of diabetes mellitus (DM) and diabetic peripheral neuropathy (DPN), which can lead to foot ulcers and lower-extremity amputations. However, cognitive differences and communication barriers may impede some methods for screening and prevention of DPN. Wearable and mobile technologies-such as smartphone apps and pressure-sensitive insoles-could help to offset these barriers, yet little is known about the effectiveness of these technologies among individuals with ID.

METHODS

We conducted a scoping review of the databases Embase, PubMed, and Web of Science using search terms for DM, DPN, ID, and technology to diagnose or monitor DPN. Finding a lack of research in this area, we broadened our search terms to include any literature on technology to diagnose or monitor DPN and then applied these findings within the context of ID.

RESULTS

We identified 88 articles; 43 of 88 (48.9%) articles were concerned with gait mechanics or foot pressures. No articles explicitly included individuals with ID as the target population, although three articles involved individuals with other cognitive impairments (two among patients with a history of stroke, one among patients with hemodialysis-related cognitive changes).

CONCLUSIONS

Individuals with ID are not represented in studies using technology to diagnose or monitor DPN. This is a concern given the risk of DM complications among patients with ID and the potential for added benefit of such technologies to reduce barriers to screening and prevention. More studies should investigate how wearable devices can be used among patients with ID.

Retrospective review of intermittent and continuous infusion vancomycin for methicillin-resistant Staphylococcus aureus bacteremia

PURPOSE

Vancomycin is commonly administered as an intermittent infusion (IIV), although vancomycin's stability at room temperature permits administration continuously over 24 h (CIV). At our institution, CIV has been the preferred infusion method for over 20 years due to ease of administration and simplicity of therapeutic drug monitoring. The purpose of this study was to examine the outcomes associated with IIV compared to CIV.

METHODS

This was a retrospective study of patients who received vancomycin for MRSA bacteremia. The primary outcomes were the time to therapeutic goal and frequency of adverse drug reactions on IIV compared to CIV. Secondary outcomes evaluated all-cause readmission, relapse, and mortality 30 days after completion of therapy.

RESULTS

Sixty-three patients were included. Significantly fewer patients were able to achieve a therapeutic goal on IIV compared to CIV (52.4% vs. 82.5%, p < 0.01). Patients on IIV took 3.6 days, on average, to reach the target goal, compared to 1.9 days when patients were switched to CIV (95% confidence interval, 0.48-3.04, p < 0.01). Six patients experienced adverse events on IIV, and 15 patients experienced adverse events on CIV (IIV 9.5%, CIV 23.8%, p = 0.035). One patient experienced relapse of infection, and six patients (9.5%) were readmitted 30 days after completion of therapy. There were no deaths in the cohort.

CONCLUSION

For MRSA bacteremia, CIV enabled patients to achieve the AUC/MIC goal significantly faster than when patients received IIV. Furthermore, patients who were unable to achieve a therapeutic trough on IIV became therapeutic once switched to CIV.

Visualizing complex healthcare disparities: proof of concept for representing a cyclical continuum of care model for a retrospective cohort of patients with musculoskeletal infections

Background

Care continuum models (also known as care cascade models) are used by researchers and health system planners to identify potential gaps or disparities in healthcare, but these models have limited applications to complex or chronic clinical conditions. Cyclical continuum models that integrate more complex clinical information and that are displayed using circular data visualization tools may help to overcome these limitations. We performed proof-of-concept cyclical continuum modeling for one such group of conditions—musculoskeletal infections—and assessed for racial and ethnic disparities across the complex care process related to these infections.

Methods

Cyclical continuum modeling was performed in a diverse, retrospective cohort of 1648 patients with musculoskeletal infections, including osteomyelitis, septic arthritis, and/or infectious myositis, in the University of New Mexico Health System. Logistic regression was used to estimate the relative odds of each element or outcome of care in the continuum. Results were visualized using circularized, map-like images depicting the continuum of care.

Results

Racial and ethnic disparities differed at various phases in the care process. Hispanic/Latinx patients had evidence of healthcare disparities across the continuum, including diabetes mellitus [odds ratio (OR) 2.04, 95% confidence interval (CI): 1.61, 2.60 compared to a white non-Hispanic reference category]; osteomyelitis (OR 1.28, 95% CI: 1.01, 1.63); and amputation (OR 1.48; 95% CI: 1.10, 2.00). Native American patients had evidence of disparities early in the continuum (diabetes mellitus OR 3.59, 95% CI: 2.63, 4.89; peripheral vascular disease OR 2.50; 95% CI: 1.45, 4.30; osteomyelitis OR 1.43; 95% CI: 1.05, 1.95) yet lower odds of later-stage complications (amputation OR 1.02; 95% CI: 0.69, 1.52). African American/Black non-Hispanic patients had higher odds of primary risk factors (diabetes mellitus OR 2.70; 95% CI: 1.41, 5.19; peripheral vascular disease OR 4.96; 95% CI: 2.06, 11.94) and later-stage outcomes (amputation OR 2.74; 95% CI: 1.38, 5.45) but not intervening, secondary risk factors (osteomyelitis OR 0.79; 95% CI: 0.42, 1.48).

Conclusions

By identifying different structural and clinical barriers to care that may be experienced by groups of patients interacting with the healthcare system, cyclical continuum modeling may be useful for the study of healthcare disparities.

Improving Emergency Access to Human Immunodeficiency Virus Prophylaxis for Patients Evaluated After Sexual Assault

INTRODUCTION

Patients evaluated after sexual assault may benefit from nonoccupational postexposure prophylaxis (nPEP) to prevent infection with HIV, yet multiple barriers may prohibit nPEP delivery. The IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice) project was designed to improve access to HIV screening and prevention for patients evaluated in the emergency department (ED) of our academic hospital after a sexual assault.

METHODS

The IN-STEP team identified and addressed four key areas for improvement: (1) training of ED providers to perform nPEP assessments; (2) access to HIV testing in the ED; (3) provision of nPEP medications, using a patient-centered approach; and (4) continuity of care between the ED and follow-up sites in the community. Improvements were implemented using parallel plan-do-study-act cycles corresponding to these four key areas.

RESULTS

IN-STEP resulted in significant systems improvements in HIV screening, prevention, and continuity of care. This program not only improved the care of patients affected by sexual assault but also those evaluated for HIV due to other indications.

CONCLUSIONS

Involvement of a multidisciplinary leadership team, clear delineation of a patient-centered project focus, and coordination across four parallel areas for improvement were useful for completing this complex effort.

Automated Detection of Periprosthetic Joint Infections and Data Elements Using Natural Language Processing

BACKGROUND

Periprosthetic joint infection (PJI) data elements are contained in both structured and unstructured documents in electronic health records and require manual data collection. The goal of this study is to develop a natural language processing (NLP) algorithm to replicate manual chart review for PJI data elements.

METHODS

PJI was identified among all total joint arthroplasty (TJA) procedures performed at a single academic institution between 2000 and 2017. Data elements that comprise the Musculoskeletal Infection Society (MSIS) criteria were manually extracted and used as the gold standard for validation. A training sample of 1208 TJA surgeries (170 PJI cases) was randomly selected to develop the prototype NLP algorithms and an additional 1179 surgeries (150 PJI cases) were randomly selected as the test sample. The algorithms were applied to all consultation notes, operative notes, pathology reports, and microbiology reports to predict the correct status of PJI based on MSIS criteria.

RESULTS

The algorithm, which identified patients with PJI based on MSIS criteria, achieved an f1-score (harmonic mean of precision and recall) of 0.911. Algorithm performance in extracting the presence of sinus tract, purulence, pathologic documentation of inflammation, and growth of cultured organisms from the involved TJA achieved f1-scores that ranged from 0.771 to 0.982, sensitivity that ranged from 0.730 to 1.000, and specificity that ranged from 0.947 to 1.000.

CONCLUSION

NLP-enabled algorithms have the potential to automate data collection for PJI diagnostic elements, which could directly improve patient care and augment cohort surveillance and research efforts. Further validation is needed in other hospital settings.

LEVEL OF EVIDENCE

Level III, Diagnostic.

Requiring the Healer's Art Curriculum to Promote Professional Identity Formation Among Medical Students

The Healer's Art curriculum (HART) is one of the best-known educational strategies to support medical student professional identity formation. HART has been widely used as an elective curriculum. We evaluated students' experience with HART when the curriculum was required. All one hundred eleven members of the class of 2019 University of New Mexico School of Medicine students were required to enroll in HART. We surveyed the students before and after the course to assess its self-reported impact on key elements of professional identity formation such as empathy towards patients and peers, commitment to service, and burnout. A majority of students (n=53 of 92, 57.6%) reported positive effects of the course on their empathy towards other students. This finding was significantly associated with self-reported willingness to have elected the course had it not been required. One-half of respondents (n=46 of 92, 50.0%) reported positive effects on their empathy towards future patients. At least one-quarter to one-third of respondents reported positive influences on commitment to service, conceptions about being a physician, and self-perceived burnout. Students report benefits on their professional identity formation after participating in a required course on humanism. Empathy-building among peers is one valuable outcome of such curricula.

Risk of Recurrent Staphylococcus aureus Prosthetic Joint Infection in Rheumatoid Arthritis Patients-A Nationwide Cohort Study

Background

Treatment of rheumatoid arthritis (RA) often involves immune-suppressive therapies. Concern for recurrent prosthetic joint infection (PJI) in RA patients might be high and could reduce use of joint implantation in these patients. We aimed to evaluate the risk of recurrence of PJI in RA patients compared with osteoarthritis (OA) patients by utilizing a large health care system.

Methods

We conducted a retrospective cohort study of all patients admitted for a Staphylococcus aureus PJI who underwent debridement, antibiotics, and implant retention (DAIR) or 2-stage exchange (2SE) between 2003 and 2010 at 86 Veterans Affairs Medical Centers. Both RA patients and the comparison group of osteoarthritis (OA) patients were identified using International Classification of Diseases, Ninth Revision, codes. All index PJI and recurrent positive cultures for S. aureus during 2 years of follow-up were validated by manual chart review. A Cox proportional hazards regression model was used to compare the time to recurrent PJI for RA vs OA.

Results

In our final cohort of 374 veterans who had either DAIR or 2SE surgery for their index S. aureus PJI, 11.2% had RA (n = 42). The majority of the cohort was male (97.3%), and 223 (59.6%) had a methicillin-susceptible S. aureus PJI. RA patients had a similar risk of failure compared with OA patients, after adjusting for covariates (hazard ratio, 0.81; 95% confidence interval, 0.48–1.37).

Conclusions

Prior diagnosis of RA does not increase the risk of recurrent S. aureus PJI. Further studies are needed to evaluate the effect of different RA therapies on outcomes of episodes of PJI.

Estimating the Health and Economic Impacts of Changes in Local Air Quality

OBJECTIVES

To demonstrate the benefits-mapping software Environmental Benefits Mapping and Analysis Program-Community Edition (BenMAP-CE), which integrates local air quality data with previously published concentration-response and health-economic valuation functions to estimate the health effects of changes in air pollution levels and their economic consequences.

METHODS

We illustrate a local health impact assessment of ozone changes in the 10-county nonattainment area of the Dallas-Fort Worth region of Texas, estimating the short-term effects on mortality predicted by 2 scenarios for 3 years (2008, 2011, and 2013): an incremental rollback of the daily 8-hour maximum ozone levels of all area monitors by 10 parts per billion and a rollback-to-a-standard ambient level of 65 parts per billion at only monitors above that level.

RESULTS

Estimates of preventable premature deaths attributable to ozone air pollution obtained by the incremental rollback method varied little by year, whereas those obtained by the rollback-to-a-standard method varied by year and were sensitive to the choice of ordinality and the use of preloaded or imported data.

CONCLUSIONS

BenMAP-CE allows local and regional public health analysts to generate timely, evidence-based estimates of the health impacts and economic consequences of potential policy options in their communities.

Racial and ethnic disparities in surgical amputations following serious musculoskeletal infections in a diverse New Mexico cohort

BACKGROUND

Patients with serious musculoskeletal infections may encounter health disparities across multiple phases of prevention and treatment, including surgical intervention. The purpose of this study was to identify and compare the predictors of surgical intervention and surgical amputation among patients with septic arthritis, osteomyelitis, and infectious myositis in a diverse cohort of patients from New Mexico.

METHODS

A retrospective cohort from the University of New Mexico Health System was formed. Patients with septic arthritis, osteomyelitis, and/or infectious myositis who underwent surgical procedures or amputations were compared with those who did not, using predictive multivariable logistic regression modeling. The impact of diabetes mellitus (DM) as a predictor of surgical outcomes was evaluated.

RESULTS

DM was a predictor of both surgical procedures and amputations in a diverse cohort of patients (n = 1694). Diabetes was more common in American Indian/Alaskan Native (AI/AN) patients. However, Black non-Hispanic/African American and Hispanic patients were more likely to undergo amputations, compared to AI/AN patients, even after adjustment for diabetes severity.

CONCLUSIONS

Racial and ethnic disparities in infection-related amputation may differ from those observed for diabetes or for general access to surgical management. Interventions intended to prevent or treat serious musculoskeletal infections should consider health disparities that differ across the clinical care process.

Predictors of Clostridium difficile infection and predictive impact of probiotic use in a diverse hospital-wide cohort

BACKGROUND

Hospital-based predictive models for Clostridium difficile infection (CDI) may aid with surveillance efforts.

METHODS

A retrospective cohort of adult hospitalized patients who were tested for CDI between May 1, 2011, and August 31, 2016, was formed. Proposed clinical and sociodemographic predictors of CDI were evaluated using multivariable predictive logistic regression modeling.

RESULTS

In a cohort of 5,209 patients, including 1,092 CDI cases, emergency department location (adjusted odds ratio [aOR], 1.91; 95% confidence interval [CI], 1.51, 2.41; compared with an intensive care unit reference category, which had the lowest observed odds in the study) and prior exposure to a statin (aOR, 1.26, 95% CI, 1.06, 1.51), probiotic (aOR, 1.39; 95% CI, 1.08, 1.80), or high-risk antibiotic (aOR, 1.54; 95% CI, 1.29, 1.84), such as a cephalosporin, a quinolone, or clindamycin, were independent predictors of CDI. Probiotic use did not appear to attenuate the odds of CDI in patients exposed to high-risk antibiotics, but moderate-risk antibiotics appeared to significantly attenuate the odds of CDI in patients who received probiotics.

CONCLUSIONS

Emergency department location, high-risk antibiotics, probiotics, and statins were independently predictive of CDI. Further exploration of the relationship between probiotics and CDI, especially in diverse patient populations, is warranted.

Talking About Hepatitis C: FAQs From Young Adults Who Inject Drugs

INTRODUCTION

Young adults who inject drugs and live in rural communities are at high risk for hepatitis C virus (HCV) infection. Recent changes in HCV treatment must be communicated within these communities to improve access to care and reduce HCV transmission.

METHODS

Field workers in the ¡VÁLE! Hepatitis Treatment and Integrated Prevention Services study identified frequently asked questions (FAQs) posed by young-adult participants at high risk for HCV during screening and educational sessions. From 2016 to 2018, 183 young adults (44.3% women; 85.8% Latino/a) younger than 30 years who inject drugs and reside in Rio Arriba or Doña Ana counties in New Mexico were enrolled. The research team compiled deidentified questions during field enrollments.

RESULTS

FAQs were reviewed and categorized into four major domains, including risk/prevention, screening, treatment, and reinfection. FAQs were addressed by a team of medical and public health professionals, using the most current research and recommendations.

CONCLUSIONS

These FAQs address important gaps in HCV knowledge among young adults who are at high risk for infection. The FAQs also highlight the importance of risk reduction counseling provided by frontline public health providers as well as access to safe and effective HCV treatments for young adults who inject drugs.

A Cyclical Approach to Continuum Modeling: A Conceptual Model of Diabetic Foot Care

“Cascade” or “continuum” models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. These models may be used to compare care across subgroups or populations and to identify and evaluate interventions intended to improve outcomes on the population level. Previous cascade or continuum models have been limited by several factors. These models are best suited to processes with stepwise outcomes—such as screening, diagnosis, and treatment—with a single defined outcome (e.g., treatment or cure) for each member of the population. However, continuum modeling is not well developed for complex processes with non-sequential or recurring steps or those without singular outcomes. As shown here using the example of diabetic foot care, the concept of continuum modeling may be re-envisioned with a cyclical approach. Cyclical continuum modeling may permit incorporation of non-sequential and recurring steps into a single continuum, while recognizing the presence of multiple desirable outcomes within the population. Cyclical models may simultaneously represent the distribution of clinical severity and clinical resource use across a population, thereby extending the benefits of traditional continuum models to complex processes for which population-based monitoring is desired. The models may also support communication with other stakeholders in the process of care, including health care providers and patients.

A Patient-Centered Approach to Postgraduate Trainee Health and Wellness: An Applied Review and Health Care Delivery Model

Attention to the health and wellness of postgraduate medical trainees has increased considerably in recent years, yet the scholarly literature consistently indicates that, in many instances, the medical and mental health care needs of this population remain unmet or only partially met. As a result, trainee health care often falls short of the current standards of the medical profession. Combined with the prevalence of burnout and other mental health conditions among trainees, inadequate health care for this patient population may result in significant negative consequences for trainees' health, safety, and performance.Here, the authors review the scholarly literature explicating the health care needs of postgraduate trainees. They explore the patient-centered medical home model as a potentially effective solution to address the unmet and partially met health care needs of trainees. The authors describe several practical interventions to improve access to care. These include care coordination and referral support, confidential care without perceived conflicts of interest in the training environment, co-location of medical and mental health care, and accommodations for schedule constraints. Finally, the authors explore the role of the medical home in developing and supporting broader institutional efforts to promote wellness.

Differential Survival for Men and Women with HIV/AIDS-Related Neurologic Diagnoses

OBJECTIVES

Neurologic complications of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) frequently lead to disability or death in affected patients. The aim of this study was to determine whether survival patterns differ between men and women with HIV/AIDS-related neurologic disease (neuro-AIDS).

METHODS

Retrospective cohort data from a statewide surveillance database for HIV/AIDS were used to characterize survival following an HIV/AIDS-related neurologic diagnosis for men and women with one or more of the following conditions: cryptococcosis, toxoplasmosis, primary central nervous system lymphoma, progressive multifocal leukoencephalopathy, and HIV-associated dementia. A second, non-independent cohort was formed using university-based cases to confirm and extend the findings from the statewide data. Kaplan-Meier analysis was used to compare the survival experiences for men and women in the cohorts. Cox regression was employed to characterize survival while controlling for potential confounders in the study population.

RESULTS

Women (n=27) had significantly poorer outcomes than men (n=198) in the statewide cohort (adjusted hazard ratio=2.31, 95% CI: 1.22 to 4.35), and a similar, non-significant trend was observed among university-based cases (n=17 women, 154 men). Secondary analyses suggested that this difference persisted over the course of the AIDS epidemic and was not attributable to differential antiretroviral therapy responses among men and women.

CONCLUSIONS

The survival disadvantage of women compared to men should be confirmed and the mechanisms underlying this disparity elucidated. If this relationship is confirmed, targeted clinical and public health efforts might be directed towards screening, treatment, and support for women affected by neuro-AIDS.