Indigenous Leadership and Advocacy in Pro-Equity Eligibility Criteria for New Diabetes Medicines in Aotearoa New Zealand [Policy Report]

Addressing Social Determinants of Mental Health in Pediatrics During the Coronavirus Disease 2019 Pandemic.

Background: Mexican Americans (MAs) have worse outcomes after stroke than non-Hispanic Whites (NHWs). We investigated ethnic differences in the quality of inpatient stroke care between MAs and NHWs to determine if quality differences may contribute to the observed outcome disparity. Methods: Cases of ischemic stroke were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project (February 2009- June 2012). Quality of inpatient stroke care was assessed with seven quality metrics based on the 2008 Joint Commission Primary Stroke Center definitions. Two summary measure of overall quality were also created (binary defect-free care and a continuous composite score: proportion of achieved eligible measures). Multilevel generalized linear regression models were used to assess ethnic differences in quality of care, both unadjusted and then adjusting for hospital-level effects, demographics and confounders. Results: A total of 757 individuals were included (480 MAs and 277 NHWs). MAs were less likely than NHWs to receive tPA (RR: 0.71, 95% confidence interval (CI) 0.53, 0.96, p=0.026), and MAs with atrial fibrillation were less likely to receive anticoagulant medications at discharge (RR 0.71, 95% CI 0.55, 0.91, p=0.008). There were no ethnic differences in the other individual quality measures, or in the two overall summary measures. Adjustment for hospital clustering, demographics, and other confounders (summary measures only) resulted in little to no change in the association between ethnicity and quality (Table). Conclusions: There were no ethnic differences in the overall quality of stroke care between MAs and NHWs, though ethnic differences were seen in indicators for tPA and anticoagulant at discharge for atrial fibrillation. Since less than 20% of the population were eligible for these two measures, factors other than quality are likely to be primarily responsible for ethnic differences in stroke outcome.

Healthcare Effectiveness Data and Information Set (HEDIS) quality measures have long been used to compare care across health plans and to study racial/ethnic and socioeconomic disparities among Medicare Advantage (MA) beneficiaries. However, possible gender differences in seniors' quality of care have received less attention. To test for the presence and nature of any gender differences in quality of care across MA Plans, overall and by domain; to identify those most at risk of poor care. Cross-sectional analysis of individual-level HEDIS measure scores from 23.8 million records using binomial mixed-effect models to estimate the effect of gender on performance. For each measure, we assess variation in gender gaps and their correlation with plan performance. Beneficiaries from 456 MA plans in 2011-2012 HEDIS data. Performance on 32 of 34 HEDIS measures which were available in both measurement years. The two excluded measures had mean performance scores below 10%. Women experienced better quality of care than men for 22/32 measures, with most pertaining to screening or treatment. Men experienced better quality on nine measures, including four related to cardiovascular disease and three to potentially harmful drug-disease interactions. Plans varied substantially in the magnitude of gender gaps for 21/32 measures; in general, the gender gap in quality of care was least favorable to men in low-performing plans. Women generally experienced better quality of care than men. However, women experienced poorer care for cardiovascular disease-related intermediate outcomes and potentially harmful drug-disease interactions. Quality improvement may be especially important for men in low-performing plans and for cardiovascular-related care and drug-disease interactions for women. Gender-stratified reporting could reveal gender gaps, identify plans for which care varies by gender, and motivate efforts to address faults and close the gaps in the delivery system.

Patient gender influences the quality of medical care whilst the role of physician gender is not well established. To investigate the influence of physician gender on quality of care in patients with type 2 diabetes. Cross-sectional study in 51 053 outpatients (48.6% male), treated by 3096 office-based physicians (66.3% male; 74.0% general practitioners, 21.8% internists and 4.2% diabetologists). Outcome measures included processes of care, intermediate outcomes and medical management. Quality of care measures were based on current ADA guidelines. Hierarchical regression models were used to avoid case-mix bias and to correct for physician-level clustering. Adjusted odds ratios were calculated controlling for age, gender, disease duration and presence of atherosclerotic disease. The patients of female physicians were more often women, more obese, older and had more often atherosclerotic disease (34% in the total cohort). The patients of female physicians more often reached target values in glycaemic control (HbA1c < 6.5%; OR 1.14; 1.05-1.24, P = 0.002), blood lipoproteins (LDL-C < 100 mg dL(-1); OR 1.16; 1.06-1.27, P = 0.002), and blood pressure (systolic values < 130 mmHg; OR 1.11; 1.02-1.22, P = 0.018). They were more likely to receive antihypertensive drug therapy in general (OR 1.35; 1.24-1.46, P < 0.0001) and angiotensin converting enzyme (ACE) inhibitors in particular (OR 1.17; 1.09-1.25, P < 0.0001). The patients of female physicians less often performed glucose self-monitoring (OR 0.83; 0.76-0.91, P < 0.0001) and less often received oral hypoglycaemic agents (OR 0.88; 0.82-0.95, P = 0.001). Physician gender influences quality of care in patients with type 2 diabetes. Female physicians provide an overall better quality of care, especially in prognostically important risk management.

Building the Roadmap to Health Equity Research: Extracorporeal Membrane Oxygenation Health Disparities.

Sex-related differences in quality of acute stroke care are an important concern with limited data available, specifically regarding stroke unit (SU) setting. We used the prospective nationwide Austrian SU registry to address this issue. Our analysis covered an 8-year time period (January 2005 to December 2012) during which all patients with transient ischemic attack or ischemic stroke admitted to 1 of 35 Austrian SU had been captured in the registry. These data were analyzed for age-adjusted preclinical and clinical characteristics and quality of acute stroke care in men and women. In addition, we assessed the outcome at 3 months in multivariate analysis. A total of 47 209 individuals (47% women) had received SU care. Women were significantly older (median age: 77.9 versus 70.3 years), had higher pre-existing disability and more severe strokes. Correcting for age, no significant sex-related differences in quality of care were identified with comparable onset-to-door times, times to and rates of neuroimaging, as well as door-to-needle times and rates of intravenous thrombolysis (14.5% for both sexes). Despite equal acute stroke care and a comparable rate of neurorehabilitation, women had a worse functional outcome at 3-month follow-up (modified Rankin scale 3-5: odds ratio, 1.26; 95% confidence interval [1.17-1.36]), but a lower mortality (odds ratio, 0.70; 95% confidence interval [0.78-0.88]) after correcting for confounders. We identified no disproportions in quality of care in the acute SU setting between men and women, but the outcome was significantly different. Further studies on the poststroke period including socioeconomic aspects are needed to clarify this finding.

To determine the influence of ethnic differences in diabetes care on inequalities in mortality and prevalence of end-stage complications among diabetic patients. The following questions were examined: 1) Are there ethnic differences among diabetic patients in mortality and end-stage complications and 2) are there ethnic differences among diabetic patients in quality of care? A review of the literature on ethnic differences in the prevalence of complications and mortality among diabetic patients and in the quality of diabetes care was performed by systematically searching articles on Medline published from 1987 through October 2004. A total of 51 studies were included, mainly conducted in the U.S. and the U.K. In general, after adjusting for confounders, diabetic patients from ethnic minorities had higher mortality rates and higher risk of diabetes complications. After additional adjustment for risk factors such as smoking, socioeconomic status, income, years of education, and BMI, in most instances ethnic differences disappear. Nevertheless, blacks and Hispanics in the U.S. and Asians in the U.K. have an increased risk of end-stage renal disease, and blacks and Hispanics in the U.S. have an increased risk of retinopathy. Intermediate outcomes of care were worse in blacks, and they were inclined to be worse in Hispanics. Likewise, ethnic differences in quality of care in the U.S. exist: process of care was worse in blacks. Given the fact that there are ethnic differences in diabetes care and that ethnic differences in some diabetes complications persist after adjustment for risk factors other than diabetes care, it seems the case that ethnic differences in diabetes care contribute to the more adverse disease outcomes of diabetic patients from some ethnic minority groups. Although no generalizations can be made for all ethnic groups in all regions for all kinds of complications, the results do implicate the importance of quality of care in striving for equal health outcomes among ethnic minorities.

Ten years have passed since the release of the final report of the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH),1 a landmark document that provided a global blue‐print for the health promotion community and the stakeholders we work with. Three overarching recommendations were outlined, improving daily living conditions; tackling the inequitable distribution of power, money and resources; and measuring and understanding the problem and assessing the impact of action.1 The extent to which progress has been, and continues to be, made is contested. This editorial briefly reflects on what has been achieved over the past decade—in broad terms—about action on the social determinants of health (SDH) in Australia. We deliberately take a balanced view by highlighting the weaknesses and strengths in what has been achieved by governments, non‐government organisations, research institutions, peak bodies and civil society. We also reflect on the ongoing role that the Australian Health Promotion Association (AHPA) has played in advancing our understanding about, and action on, the SDH.

Nurse work environment and quality of care by unit types: A cross-sectional study

Gender differences in inpatient quality of care are well known. However, whether men and women receive equivalent ambulatory care is less well understood. To study gender differences in quality of care for patients receiving primary care in the Veterans Affairs (VA) Health Care System. Cross-sectional samples of VA enrollees during fiscal years 1999 to 2000. Samples of 6,442 to 86,405 men and women treated at VA facilities for whom at least 1 of 9 quality measures was available. Appropriate general preventive services (pneumococcal vaccination, influenza vaccination, colorectal cancer screening), and specific services for diabetes (annual hemoglobin A1c [HbA1c] testing, good glycemic control, annual diabetic eye exam), hypertension (good blood pressure control), or prior myocardial infarction (use of beta-blockers or aspirin). In adjusted analyses, there were no substantial gender differences in rates of appropriate care. For women compared with men, the adjusted relative risk for appropriate care ranged from 0.96 for blood pressure control (95% confidence interval: 0.93 to 0.99; P=.02) to 1.05 for HbA1c< or =8.0% (95% confidence interval: 1.03 to 1.07; P<.01). Analyses stratified by age demonstrated equivalent care between men and women in 9 of the 14 subgroups evaluated. In this large national health care system that predominantly serves men, the quality of ambulatory care is equivalent for women and men on numerous measures.

ObjectivesTo examine hospital variation in crude and risk-adjusted rates of intrapartum-related perinatal mortality among caesarean births.DesignSecondary analysis of data from the DECIDE (DECIsion for caesarean DElivery) cluster randomised trial postintervention...

Social determinants of racial health inequities

The increasing global migration has made migrants' health a pertinent topic. This article aimed to examine whether migrants were less likely than Danish-born residents to receive guideline recommended care when hospitalized for major depressive disorder (MDD) and potential differences in clinical outcomes, including all-cause mortality, suicidal behavior, and readmissions during 1-year follow-up after first-time admission. A national cohort study was performed, including all adult MDD inpatients at mental care units in the period 2011-2017. Migrants and two migrant subgroups (non-Western and Western) were compared with Danish-born patients. Quality of care was examined using multivariable Poisson and linear regression models. Clinical outcomes were examined using Cox proportional hazards regression analysis. Migrant-status was associated with a non-significantly lower chance of receiving high-quality care (relative risk [RR]=0.93, confidence interval [CI] 0.86:1.01) and lower readmission rates for depression (hazard rate ratio [HR]=0.93, CI 0.86:1.01), and significantly higher all-cause mortality (HR=1.55, CI 1.19:2.01) and lower all-cause readmission rate (HR=0.88, CI 0.83:0.94). No clear association was found regarding suicidal behavior. While associations were comparable for migrant subgroups regarding readmission, the associations with low quality of care and of all-cause mortality appeared strongest among Western migrants. Among inpatients with MDD in a universal tax-financed healthcare system, being a migrant was associated with a potential lower quality of in-hospital care and worse clinical outcomes. These results warrant further investigation to clarify the underlying explanation for these inequalities and to develop and test interventions to ensure better quality of care and clinical outcomes for migrant patients.

SummaryBackgroundIn India, men are more likely than women to have active tuberculosis but are less likely to be diagnosed and notified to national tuberculosis programmes. We used data from standardised patient visits to assess whether these gender differences occur because of provider practice.MethodsWe sent standardised patients (people recruited from local populations and trained to portray a scripted medical condition to health-care providers) to present four tuberculosis case scenarios to private health-care providers in the cities of Mumbai and Patna. Sampling and weighting allowed for city representative interpretation. Because standardised patients were assigned to providers by a field team blinded to this study, we did balance and placebo regression tests to confirm standardised patients were assigned by gender as good as randomly. Then, by use of linear and logistic regression, we assessed correct case management, our primary outcome, and other dimensions of care by standardised patient gender.FindingsBetween Nov 21, 2014, and Aug 21, 2015, 2602 clinical interactions at 1203 private facilities were completed by 24 standardised patients (16 men, eight women). We found standardised patients were assigned to providers as good as randomly. We found no differences in correct management by patient gender (odds ratio 1·05; 95% CI 0·76–1·45; p=0·77) and no differences across gender within any case scenario, setting, provider gender, or provider qualification.InterpretationSystematic differences in quality of care are unlikely to be a cause of the observed under-representation of men in tuberculosis notifications in the private sector in urban India.FundingGrand Challenges Canada, Bill & Melinda Gates Foundation, World Bank Knowledge for Change Program.

Patient characteristics (case-mix bias) and physician-level variation (clustering) are often overlooked in profiling the quality of care provided by different groups of physicians, such as specialties. To examine the effect of case-mix bias and physician-level clustering on differences in quality of diabetes care between specialty groups participating in the American Diabetes Association's Provider Recognition Program. Retrospective record review of both process and outcome measures over 1 year and a cross-sectional patient survey. The sample included 29 solo and group practice sites in diverse regions of the United States. Of the 29 sites, 15 were endocrinology sites and 14 were primary care sites. 1750 adults with diabetes. Process measures included frequency of hemoglobin A(1c), lipid, and urine protein testing; blood pressure measurement; and foot and eye examinations. Outcome measures included A(1c)level, blood pressure, lipid levels, and patient satisfaction. Patient case-mix variables included age, sex, health status, level of education, ethnic minority status, and duration of diabetes. Unadjusted differences between endocrinologists and generalists were statistically significant for most process and outcome measures. Inclusion of patient case-mix variables reduced the statistical significance of specialty differences for some quality measures. After accounting for the substantial physician-level clustering, observed differences between specialties were no longer statistically significant for any of the quality measures except patient satisfaction. The findings underscore the importance of designing physician profiling studies with sufficient power to account for physician-level variation (clustering) as well as patient case-mix. Studies that are not designed with both sufficient numbers of physicians and patients per physician may distort differences in quality of care between physician groups.