Factors Associated With, and Mitigation Strategies for, Health Care Disparities Faced by Patients With Headache Disorders

Systematic Review of Racial, Socioeconomic, and Insurance Status Disparities in the Treatment of Pediatric Neurosurgical Diseases in the United States

Racism in Pain Medicine: We Can and Should Do More

Racial and Ethnic Disparities in the Quality of Pain Care

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

This review provides an overview of the current and future role of artificial intelligence (AI) and virtual reality (VR) in addressing the complexities inherent to the diagnosis, classification, and management of headache disorders. Through machine learning and natural language processing approaches, AI offers unprecedented opportunities to identify patterns within complex and voluminous datasets, including brain imaging data. This technology has demonstrated promise in optimizing diagnostic approaches to headache disorders and automating their classification, an attribute particularly beneficial for non-specialist providers. Furthermore, AI can enhance headache disorder management by enabling the forecasting of acute events of interest, such as migraine headaches or medication overuse, and by guiding treatment selection based on insights from predictive modeling. Additionally, AI may facilitate the streamlining of treatment efficacy monitoring and enable the automation of real-time treatment parameter adjustments. VR technology, on the other hand, offers controllable and immersive experiences, thus providing a unique avenue for the investigation of the sensory-perceptual symptomatology associated with certain headache disorders. Moreover, recent studies suggest that VR, combined with biofeedback, may serve as a viable adjunct to conventional treatment. Addressing challenges to the widespread adoption of AI and VR in headache medicine, including reimbursement policies and data privacy concerns, mandates collaborative efforts from stakeholders to enable the equitable, safe, and effective utilization of these technologies in advancing headache disorder care. This review highlights the potential of AI and VR to support precise diagnostics, automate classification, and enhance management strategies for headache disorders.

A headache is defined as “pain found in the head above the orbito-meatal line and or nuchal ridge” and widely affects both males and females globally. Chiropractic treatment and the management of headaches is substantial, with one in five new patients’ chief complaint being a headache and, thus, the use of chiropractic care in the management and treatment of headaches is popular. The term “self-perceived preparedness” refers to how people view themselves in terms of confidence and competency with regard to certain skills. Self-perceived preparedness is essential as it relates to one’s confidence and the ability to accurately diagnose and manage headache disorders. There is a definite scarcity in South African literature as to the self-perceived preparedness of students in the diagnosis and management of headache disorders. In a South African chiropractic context, the literature, with regard to students’ confidence, awareness and self-assessment of skills is lacking. There are a number of advantages that can come from exploring the concept of self-perceived preparedness. The benefits include, but are not limited to, the assessment of whether or not the curricula goals have been achieved, the readiness of chiropractic students to confidently and correctly diagnose and manage patients sufficiently, and the different aspects that can lead to one feeling unprepared. Aim The aim of this study was to explore and describe the self-perceived preparedness of the chiropractic students’ in the diagnosis and management of headache disorders. Methodology This study design employed a qualitative, explorative and descriptive design. Purposeful sampling was utilised and individual, semi-structured interviews were conducted with 13 Master’s degree students in the chiropractic programme. These interviews took place “in person” and an interview guide was utilised in each interview. The interviews were conducted over a week from the 18th to the 23rd of September 2023. The questions surrounded the topics of self-perceived preparedness, confidence, challenges (whether educational or personal) and the effect of clinical exposure on one’s confidence and skills. The interviews were analysed and themes were extracted utilising Tesch’s eight-step approach of data analysis. Results The chief themes that emerged from the data collection included the level of preparedness, educational and environmental challenges, as well as the positive role that clinical exposure had on students’ views of their self-perceived preparedness. The participants felt largely unprepared to deal clinically with headache disorders. This stemmed from the feeling of isolation within academia, lack of support from staff and clinicians, lack of practical aspects within the curriculum and the COVID-19 pandemic, which resulted in a lack of in-person interaction. Conclusion The findings of this study highlighted the lack of confidence and feeling of under-preparedness to deal with headache disorders within a clinic setting by chiropractic Master’s students. This was mainly attributed to educational and environmental challenges. However, the exposure students gained within a clinical environment greatly improved their feeling of overall self-perceived preparedness

Problem Statement: Stigmatizing language—written and verbal—can fuel implicit bias among health care professionals, leading to unintentional negative effects in how they care for patients. To provide equitable care, health care professionals and systems must become aware of the language they use and learn to replace biased language with inclusive language. Background: The medical field strives to treat all patients equally, yet disparities in health care persist. These disparities are due, in part, to implicit bias that affects how health care professionals and systems care for patients. Although reports recommend developing education programs that address implicit bias, these programs fail to address an important contributor: stigmatizing language used among health care professionals. With guidance, health care professionals and institutions can recognize and replace their biased language to foster more inclusive communication that promotes equitable health care. Application: The AMA Manual of Style outlines standardized inclusive language that health care professionals can use to address bias in their writing, as well as in their clinical practice, teaching, and research. The guide recommends using person-first language, avoiding generalizations and labeling, describing specific details, and being sensitive to the preferences of individuals or groups. The guide also provides detailed recommendations for using inclusive language regarding race/ethnicity, physical or mental condition, sex or gender, sexual orientation, age, and socioeconomic status. With these guidelines, health care providers can replace stigmatizing language to reduce implicit bias and comprehensively address disparities in health care.

Reducing Implicit Bias in Maternity Care: A Framework for Action

BackgroundAdolescent idiopathic scoliosis (AIS) is a common spinal deformity. Previous studies have demonstrated that healthcare disparities affect the initial presentation of AIS patients. However, studies have utilized various socioeconomic status (SES) indices with no previous study assessing the congruency of these indices.MethodsA single-center, retrospective review of adolescent patients presenting for initial evaluation of scoliosis was performed at a tertiary care pediatric hospital based in the central United States. Patient demographic data were recorded in addition to radiographic data consisting of coronal curve magnitude at presentation and skeletal maturity indices. Socioeconomic variables were collected, including geographic area of residence (urban vs rural), distance from the treating hospital, and SES indices using the Childhood Opportunity Index (COI), Index of Concentration at the Extremes (ICE), and Area Deprivation Index (ADI) based on home address. SES indices were based on national standards and were subdivided into quintiles. Socioeconomic status (SES) disparity was defined as the two worst quintile scores. Socioeconomic status indices were compared for correlation, as well as significant differences in the definition of SES disparity.ResultsA total of 368 patients presenting for initial evaluation of scoliosis were identified (mean 15.0 ±1.6 years, 75.8% female). The mean curve magnitude at presentation was 25.9±12.3° (range 10–81.0°). Using the three SES indices, disparity was present in between 5% and 36% of patients. There were significant differences (P < .001) in the definition of SES disparity between the indices: ADI 36.4% (N = 134), COI 19.8% (N = 73), and ICE 5.4% (N = 20). Overall, there was a 52.2% rate of loss to follow-up (N = 192), which was significantly associated with disparity as defined by COI (23.9% vs 15.3%, P = .038) but not ADI (33.1% vs 39.6%, P = .2) or ICE (6.8% vs 3.9%, P = .2).ConclusionsSignificant differences exist in the definition of SES disparity using the COI, ICE, and ADI indices. Although these indices are all significantly correlated, ICE produces a more conservative estimate of disparity, whereas COI is more responsive and may be more advantageous in identifying patients at risk for SES disparity as it pertains to the management of spinal deformity.Key Concepts(1)Previous studies have shown that healthcare disparities influence how AIS patients initially present. However, these studies have used various socioeconomic status (SES) indices, and no previous research has evaluated the consistency of these measures indices.(2)Socioeconomic status indices may not be predictive of coronal curve magnitude at initial presentation.(3)The increased Childhood Opportunity Index disparity was correlated with higher rates of loss to follow-up.(4)ICE produces a more conservative estimate of disparity. In contrast, COI and ADI are more responsive. They may be more advantageous in identifying patients at risk for SES disparity as it pertains to the management of spinal deformity, with COI providing a less extreme assessment for SES disparity.(5)Future studies should aim to determine how SES indices can help prospectively identify patients at risk for loss to follow-up, facilitating targeted resource allocation for these individuals.Level of EvidenceIII, Retrospective Review and Analysis

Ovarian cancer afflicts approximately 204,000 women worldwide, with ∼125,000/year deaths. In the United States more than 22,000 new cases of ovarian cancer diagnosed with over 14,000 disease-related deaths.[1] The standard of care in ovarian cancer includes expedient access to the health care system, consultation with a gynecologic oncologist, surgical intervention, and multiagent platinum-based chemotherapy. Prognostic factors for improved survival in women with ovarian cancer include younger age; early stage; low-grade and serous histology; good performance status; disease biology (BRCA1 and 2 mutation carriers have a better prognosis); and low volume of residual disease at the time of cytoreductive surgery. In contrast, African-American race, low socioeconomic status (SES), geographic location, and insurance status have been associated with worse survival and increased probability of not receiving appropriate standard of care treatment.[2-7] These differences in ovarian cancer outcomes linked to race, social, and economic factors indicate that health care disparities exist in the treatment of this gynecologic cancer. In this presentation, we will (1) review the standard of care for epithelial ovarian cancer treatment, (2) discuss the variables affecting the outcome for patients with epithelial ovarian cancer, (3) describe the factors contributing to healthcare disparities, and (4) discuss the evidence for clinical disparities in epithelial ovarian cancer care and outcomes. Causes of healthcare disparities are complex and include differences in race/ethnicity, SES, insurance status, education level, geographic location, culture, healthcare system factors (adherence to treatment guidelines, and access to care), and disease biology.[2-7] The following are highlighted in this presentation: Population-based studies have demonstrated that African-American women are at increased risk of ovarian cancer death compared to non-Hispanic Caucasian women.Population-based studies have demonstrated that African-American women are less likely to undergo site-specific surgery or surgical staging for ovarian cancer compared to Caucasian women.African-American women were less likely to seek care at high-volume hospitals or be operated on by high-volume surgeons.African-American women and those with Medicaid/Medicare payer status are less likely to receive standard of care therapy based on National Comprehensive Cancer Network (NCCN) guidelines.Geographic location away from a high-volume hospital is associated with increased risk of non-adherent ovarian cancer care.Geographic barriers to standard treatment disproportionately affect racial minorities and women of low-SES.In contrast to population-based studies, retrospective single academic institution studies and ancillary analysis of large cooperative group phase III trials in advanced ovarian cancer have demonstrated no difference in overall survival in women of African-American and Caucasian descent. The reported research in ovarian cancer indicates that unequal delivery of quality care, obstacles to the delivery of recommended care, and limited access to expert care may account for the disparities seen in ovarian cancer care. The U.S. Department of Health and Human Services has targeted disparities in access to health care as the centerpiece of the Healthy People 2020 campaign and the Department of Health and Human Services (HHS) has unveiled an action plan to reduce racial and ethnic Health disparities.[8, 9] The 5 goals of the HHS Disparities Action Plan are: (1) transform health care; (2) strengthen the nation's Health and Human Services infrastructure and workforce; (3) advance the health, safety, and well-being of the American people; (4) advance scientific knowledge and innovation; and (5) increase the efficiency, transparency, and accountability of HHS programs. The HHS Disparities initiative will specifically target programs to increase knowledge of, access to, and utilization of biomedical and behavioral procedures to reduce cancer disparities.[9] Listed below are future research objectives that will reduce and potentially eliminate health care disparities in ovarian cancer in the United States: Improve our knowledge of the interaction between race, ethnicity, SES, geographic location and ovarian cancer health care disparities across the United States to harmonize existing data and identify opportunities for intervention.Improve our knowledge regarding cultural barriers to care.Promote community-based participatory research to increase ovarian cancer awareness and review standards of care.Develop interventions to provide expedient access to expert care by trained specialists in Gynecology Oncology, cytoreductive surgery, and administration of multiagent platinum-based chemotherapy in order to increase the likelihood of NCCN adherent standard of care therapy.

See article on page 1519–1526, in this issue

From Intention to Action: Operationalizing AGA Diversity Policy to Combat Racism and Health Disparities in Gastroenterology

Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future. We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers. A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care. Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable. Level IV-narrative review.

Measuring Trends in Mental Health Care Disparities, 2000 2004

Diagnosis and management of headache disorders in osteopathic practice: A qualitative study