Equity Considerations Research Articles

Reproductive options and genetic testing for patients with an inherited cardiac disease.

In the past decade, genetic testing for cardiac disease has become part of routine clinical care. A genetic diagnosis provides the possibility to clarify risk for relatives. For family planning, a genetic diagnosis provides reproductive options, including prenatal diagnosis and preimplantation genetic testing, that can prevent an affected parent from having a child with the genetic predisposition. Owing to the complex genetic architecture of cardiac diseases, characterized by incomplete disease penetrance and the interplay between monogenic and polygenic variants, the risk reduction that can be achieved using reproductive genetic testing varies among individuals. Globally, disparities, including regulatory and financial barriers, in access to reproductive genetic tests exist. Although reproductive options are gaining a prominent position in the management of patients with inherited cardiac diseases, specific policies and guidance are lacking. Guidelines recommend that prenatal diagnosis and preimplantation genetic testing are options that should be discussed with families. Health-care professionals should, therefore, be aware of the possibilities and feel confident to discuss the benefits and challenges. In this Review, we provide an overview of the reproductive options in the context of inherited cardiac diseases, covering the genetic, technical, psychosocial and equity considerations, to prepare health-care professionals for discussions with their patients.

Equity considerations for the implementation of health insurance benefit package in Ethiopia: result of expert Delphi exercise

BackgroundEfficiency, equity and financial risk protection are key health systems objectives. Equitable distribution of health care is among the priority strategic initiative of the government of Ethiopia. However, data on the distribution of interventions benefits or on disease burden disaggregated by subpopulations to guide health care priority setting is not available in Ethiopia.MethodsAligned with policy documents, we identified the following groups to be the worse off in the Ethiopian context: under-five children, women of reproductive age, the poor, and rural residents. We used the Delphi technique by a panel of 28 experts to assign a score for 253 diseases/conditions over a period of two days, in phases. The expert panel represented different institutes and professional mix. Experts assigned a score 1 to 4; where 4 indicates disease/condition predominantly affecting the poor and rural residents and 1 indicates a condition more prevalent among the wealthy and urban residents. Subsequently, the average equity score was computed for each disease/condition.ResultsThe average scores ranged from 1.11 (for vitiligo) to 3.79 (for obstetric fistula). We standardized the scores to be bounded between 1 and 2; 1 the lowest equity score and 2 the highest equity score. The scores for each disease/condition were then assigned to their corresponding interventions. We used these equity scores to adjust the CEA values for each of the interventions. To adjust the CEA values for equity, we multiplied the health benefits (the denominator of the cost-effectiveness value) of each intervention by the corresponding equity scores, resulting in equity adjusted CEA values. The equity adjusted CEA was then used to rank the interventions using a league table.ConclusionsThe Delphi method can be useful in generating equity scores for prioritizing health interventions where disaggregated data on the distribution of diseases or access to interventions by subpopulation groups are not available.

Quality Indicators for Transition from Pediatric to Adult Care for Youth With Chronic Conditions: Proposal for an Online Modified Delphi Study.

The transition from pediatric to adult care poses a significant health system-level challenge impeding the delivery of quality health services for youth with chronic health conditions. In Canada and globally, the transition to adult care is regarded as a top priority in adolescent health in need of readily applicable, adaptable, and relevant national metrics to evaluate and benchmark transition success across disease populations and clinical care settings. Unfortunately, existing literature fails to account for the lack of engagement from youth and caregivers in developing indicators, and its applicability across chronic conditions, primary care involvement, and health equity considerations. Our proposed study aims to establish a consensus-driven set of quality indicators for the transition to adult care that are universally applicable across physical, developmental, and mental health conditions, clinical care settings, and health jurisdictions. Using an integrated knowledge translation (iKT) approach, a panel comprising youth, caregivers, interdisciplinary health care providers, and health system leaders will be established to collaborate with our research team to ensure that the study methodology, materials, and knowledge dissemination are suitable and reflect the perspectives of youth and their families. We will then conduct an iterative 3-round Online Modified Delphi (OMD) study (n=160) to (1) compare and contrast the perspectives of youth, caregivers, health care providers, and health system leaders on quality indicators for transition; and (2) prioritize a key set of quality indicators for transition applicable across disease populations that are the most important, useful, and feasible in the Canadian context. Using the RAND/UCLA Appropriateness Method (RAM) multistage analytic approach, data from each panel and stakeholder group will be examined separately and compared to establish a key set of indicators endorsed by both panels. The study is funded by the Canadian Institutes of Health Research and Physicians Services Incorporated. This study will produce quality indicators to evaluate and inform action equitably to improve transition from pediatric to adult care for youth and their families in Canada. PRR1-10.2196/60860.

Food Delivery Apps and Their Potential to Address Food Insecurity in Older Adults: A Review.

The proportion of older adults is increasing globally, yet many of them experience food insecurity. Technological innovations, such as increased access to internet- and mobile-based food delivery apps (FDAs), may help mitigate food insecurity. However, this topic has been understudied. This scoping review searched for publications and online technical reports from around the world using interdisciplinary databases like ScienceDirect and internet sources like government websites, respectively. Eligible references were published recently (2019-present) and focused on general technology use, including apps, among older adults (≥50 years) or FDAs for food insecurity or nutritional health generally or specifically among older adults. The search identified 19 studies from 10 countries and extracted relevant information for summary tables. A limited number of studies supported the idea that FDAs can help address food insecurity, but there are important equity considerations for older adults living in rural areas or with constrained physical abilities. Consistently, customized app features and functions increased the intention to use FDAs. In addition, FDAs may have health and environmental impacts, such as food waste and increased access or promotion of ultraprocessed foods. Additional research is needed to elucidate the potential of FDAs to address food insecurity generally and specifically among older adults.

The Paige Prostate Suite: Assistive Artificial Intelligence for Prostate Cancer Diagnosis

What Is the Paige Prostate Suite? The Paige Prostate Suite is a set of artificial intelligence (AI) applications that works alongside pathologists reviewing prostate biopsy samples. The suite is not available in Canada as of this writing (June 2024), but international counterparts have authorized it for clinical use. The system requires pathology slides to be digitized for the suite to be able to highlight areas of suspicion for pathologist review. Pathologists can use Paige Prostate Detect as a “second set of eyes” on biopsy slides scanned into the digital system. What Issue Does the Paige Prostate Suite Intend to Address? In Canada, prostate cancer accounted for 20% of new cancers in 2022. It is the most common cancer found in people who have a prostate. Unlike many other cancers, the disease progresses slowly and early diagnosis results in a 5-year survival rate close to 100%. However, health systems are faced with more cancer cases without an increased capacity in pathology. What Is the Potential Impact? Paige Prostate aims to improve pathologists’ ability to detect prostate cancer in less time by allowing pathologists to focus on positive cases. However, the time-saving benefits of the suite require further validation that reflects real world settings and applications. The Paige Prostate Suite has the potential to optimize pathology workflow and prevent delays in diagnosis. Pathologists can use the suite to supplement their review instead of sending biopsy slides to the lab for additional staining or to experts for a second consultation. It does, however, require the added the step of digitizing slides to the workflow. The Paige Prostate Suite aims to improve consistency by helping pathologists grade tumours. What Else Do We Need to Know? Canada is in the early stages of implementing technology to produce digital images of biopsies. To adapt to the uptake of AI, pathology departments will need to adopt new digital workflows and processes. They could leverage this infrastructure for telepathology to improve access in rural and remote areas. Clinicians expect the Paige Prostate Suite to cost more than current practice. Costs will vary depending on the case load, system readiness for AI, and use case for the suite. Cost-effectiveness of the suite requires in-depth investigation that considers the cost-benefit from productivity changes. Upcoming prospective studies will assess the benefits of the Paige Prostate Suite from a clinical utility and cost impact perspective. It is also important to further understand the diagnostic performance and impact of Paige Prostate in the context of race, ethnicity, and other equity considerations, as those in equity-deserving groups may be underrepresented in algorithm development and trials, or have different levels of prostate cancer risk.

Opportunities to Advance Equity Through Implementation Strategy Design.

Implementation strategies are potential tools for advancing equity goals in healthcare. Implementation scientists have increased attention to the integration of equity considerations into implementation research, but limited concrete guidance is available for developing implementation strategies to improve equity. In parallel to an active hybrid effectiveness-implementation trial in two large health systems, our research team explored potential inequities in implementation across four non-study clinics, developed equity focused audit and feedback procedures, examined the feasibility of our approach, and identified design insights that could be tested in future work to inform equitable program scale-up. Based on our experiences deploying these strategies in pilot format, our research team identified key complexities meriting further examination in future work. These considerations are vital given the dearth of guidance on delivering feedback to clinicians in efforts to improve equity. Key takeaways include the importance of understanding local data culture, engaging constituents in co-design for the full feedback cycle, leveraging feedback for shared discourse, and centering multi-level strategies as part of robust implementation approaches. Prioritizing health equity in implementation science requires that research teams probe, interrogate, and innovate - and in doing so, grapple with central conceptual and pragmatic considerations that arise in the design of implementation strategies. Our work emphasizes the value of bidirectional and continuous learning.

Sociodemographic inequalities in cigarette, smokeless tobacco, waterpipe tobacco, and electronic cigarette use among adolescents aged 12-16 years in 114 countries: A cross-sectional analysis.

The majority of users of tobacco and nicotine products start using them in adolescence. In order to keep equity considerations at the forefront of tobacco control, it is crucial to assess whether inequalities in prevalence of tobacco and nicotine use exist among adolescents globally. We conducted a secondary analysis of Global Youth Tobacco Survey (GYTS) data from 538644 school-based adolescents (79.3% aged 13-15 years) in 114 countries (2013-2019). Data were collected on current (past 30-day) use of cigarettes, smokeless tobacco, waterpipe tobacco and electronic cigarettes. We used weighted Poisson regression models adjusted for sex, pocket money, and age to assess differences in prevalence of current use between boys and girls, and between students with high versus low pocket money. Although there was substantial regional variation, in most countries boys were statistically significantly more likely to report current use of all assessed products (ranging from 50.0% of countries for waterpipe tobacco to 73.3% of countries for electronic cigarettes). Inequalities by sex were less pronounced in Europe compared to other regions. Inequalities by pocket money were less consistent; students with more pocket money were more likely to report current use of cigarettes (vs those with less pocket money) in 61.8% of the countries, but more likely to report current use of smokeless tobacco in only 18.3% of countries. Globally, boys and adolescents with more pocket money are generally more likely to use a range of tobacco and nicotine products. However, these patterns are not universal and local variations should be taken into consideration to design effective and equitable tobacco control policies.

A review of health equity considerations in Cochrane reviews of lifestyle interventions for cardiovascular health in adults

ObjectiveCardiovascular disease (CVD) is the leading cause of global disease burden and rising healthcare costs. Systematic reviews (SRs) rigorously evaluate evidence on health interventions' effects and guide personal, clinical, and policy decision-making. Health equity is the absence of avoidable and unfair differences in health between groups within a population. Assessing equity in lifestyle interventions for cardiovascular health is important due to persisting health inequities in CVD burden and access to interventions. We aim to explore how health equity considerations are addressed in Cochrane SRs of lifestyle interventions for cardiovascular health. Study Design and SettingThis is a methodological review of Cochrane SRs of lifestyle interventions for cardiovascular health using the PROGRESS-Plus framework. PROGRESS-Plus stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital, while “Plus” stands for additional factors associated with discrimination and exclusion such as age, disability, and comorbidity. Using predefined selection criteria, two authors independently screened all Cochrane reviews published in the Cochrane Database of Systematic Reviews between August 2017 and December 2022. PROGRESS-Plus factors in the SRs were sought in the Summary of Findings (SoF) table, Methods/Inclusion criteria, Methods/Subgroup analyses, Results/Included studies, Results/Subgroup analyses, and Discussion/Overall completeness and applicability of evidence. ResultsWe included 36 SRs published by 10 Cochrane groups, addressing 11 health conditions with mostly dietary and exercise interventions. The most common PROGRESS-Plus factors assessed were gender/sex, age, and comorbidity. PROGRESS-Plus factors were most addressed in the inclusion criteria (64%), the discussion (75%), and the included studies (92%) sections of the SRs. Only 33% of SoF tables referenced PROGRESS-Plus. Sixty-nine percent of the included SRs planned for subgroup analyses across one or more PROGRESS-Plus factors, but only 43% of SRs conducted subgroup analyses, suggesting limited reporting of PROGRESS-Plus factors in primary studies. ConclusionsEquity factors are not sufficiently addressed in Cochrane reviews of lifestyle interventions for cardiovascular health. Low reporting of PROGRESS-Plus factors in implications for practice and research sections of Cochrane SRs limit equity focused guidance for current clinical practice, public health interventions and future research.

Socioeconomic determinants of very frequent presentations to emergency departments in New South Wales, Australia: A state wide data linkage study

ObjectivesTo describe the clinical and longitudinal patterns of presentation, and to understand the underlying socioeconomic characteristics of different modes of presentation. DesignRetrospective state-wide data linkage analysis of emergency department (ED) presentations. Patients were included if they were 18 years of age or over and presented to the ED over twenty times within any consecutive 365-day period between January 2015 and December 2020. This analysis used routinely collected data from the Emergency Department Data Collection and Admitted Patient Data Collection. The quintile of Socioeconomic Indexes for Area (SEIFA) defined by Australian Bureau of Statistics was used for equity considerations. Main outcome measuresThe main outcomes of interest included patients’ clinical presentation, demographic information and SEIFA score as represented by Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) quintiles. ResultsThere were 417,154 presentations and 5,244 patients who met the inclusion criteria. The majority of the presentations were from SEIFA groups 1 (28.2 %) and 2 (35.6 %). The most common presentations were for drug and alcohol (17.5 %), followed by abdominal pathology (11.8 %) and mental health (11.5 %). In the lowest SEIFA group, the main presenting complaints were for drug and alcohol and administrative presentations. While in the highest SEIFA group, the main presentations were for mental health then abdominal pain, followed by drug and alcohol presentations. ConclusionPatients in the lower SEIFA groups tended to be older with lower acuity presentations and were more likely to present to the same facility, more regularly. Patients in the lower SEIFA group were also more likely to present with drug and alcohol and administrative presentations while those in the higher SEIFA groups were more likely to present with mental health presentations. System wide interventions are needed to address the needs of both groups, particularly those from lower socioeconomic backgrounds, who would benefit from improved access to primary care either through access to General Practice or Urgent Care Centres.

Special Issue on Informatics Education: < Integrating Diversity, Equity, Inclusion, and Accessibility into a Data Storytelling Model for Health Informatics Education >.

Health informatics education is pivotal in integrating diversity, equity, inclusion, and accessibility (DEIA) principles into curricula and leveraging data with equity considerations. Integrating clinically driven data with other datasets is crucial to comprehensive understanding of patient care demographics, experiences, and outcomes to create equity-minded data storytelling. Publicly available Healthy People 2030 (HP2030) resources complement academic EHRs, supporting tailored learning activities in informatics education to enhance educational utility through a DEIA lens. This case report describes the expansion of an existing DEI checklist to an updated DEIA checklist for preparing future informaticians to collect and critically evaluate DEIA features using this checklist in creating equity-minded data storytelling. An equity-minded data storytelling model and the HP2030 framework were utilized to develop the DEIA checklist. We employed an informal cognitive walkthrough to expand the DEIA checklist and evaluate the DEIA measures or characteristics within datasets from the HP2030 social determinants of health (SDOH) 5 topics using this checklist. We reviewed 76 available SDOH-related datasets and added 6 measures to "demographics" and 7 to "skills, abilities, & accessibility" of the DEIA checklist. Our evaluation of the DEIA checklist verified HP2030's inclusion of all measures, except "religions/beliefs." All DEIA measures were linked to equity and accessibility, 1 in inclusion, and the inclusion of 3 characteristics comprising the category "language" and 6 characteristics comprising the category "images." Results highlighted the accessibility and comprehensiveness of HP2030 demographic data resources, considering SDOH factors and promoting inclusive data representation to address health disparities. The DEIA checklist provides a structured tool in facilitating unbiased data collection and visualization of SDOH-related data in data storytelling through an equity-informed lens. Integrating an equity-minded data storytelling with frameworks like HP2030 enriches health informatics education, broadens students' understanding of health disparities, and supports evidence-based interventions for improved health outcomes.

Developing equity-aware safety performance functions for identifying hotspots of pedestrian-involved crashes

Crashes are frequently disproportionally observed in disadvantaged areas. Despite the evident disparities in transportation safety, there has been limited exploration of quantitative approaches to incorporating equity considerations into road safety management. This study proposes a novel concept of equity-aware safety performance functions (SPFs), enabling a distinct treatment of equity-related variables such as race and income. Equity-aware SPFs introduce a fairness distance and integrate it into the log-likelihood function of the negative binomial regression as a form of partial lasso regularization. A parameter λ is used to control the importance of the regularization term. Equity-aware SPFs are developed for pedestrian-involved crashes at the census tract level in Virginia, USA, and then employed to compute the potential for safety improvement (PSI), a prevalent metric used in hotspot identification. Results show that equity-aware SPFs can diminish the effects of equity-related variables, including poverty ratio, black ratio, Asian ratio, and the ratio of households without vehicles, on the expected crash frequencies, generating higher PSIs for disadvantaged areas. Based on the results of Wilcoxon signed-rank tests, it is evident that there are significant differences in the rankings of PSIs when equity awareness is considered, especially for disadvantaged areas. This study adds to the literature a new quantitative approach to harmonize equity and effectiveness considerations, empowering more equitable decision-making in safety management, such as allocating resources for safety enhancement.

Evaluation of public private partnerships in highways

This paper reviews and evaluates four U.S. P3 toll highways, identifying their performance and common challenges. Contrary to the conventional wisdom that federal and state governments should fund highways, this paper argues that users should bear the cost for both efficiency and equity considerations. The shift from government investment and operation of highways to Public-Private Partnerships (P3) was driven by the lack of public funding, more productive competitive business practices, and the government's desire for upfront payments to fund other unrelated public projects. However, these justifiable public benefits were accompanied by significant problems. Highways were often leased for 35 to 75 years, depending on the total equity and loans of the private partner and various risk factors.

Five Years Later: Revisiting an Applied Calculus Reform Project and Its Impact on Subsequent Calculus Reforms, Pre- and Post-Pandemic

A project to reform the teaching of Applied Calculus at the University of North Dakota (UND) is revisited. The successes and failures and current status of the project are discussed. Both pre-pandemic and post-pandemic adjustments to the course structure are presented. The extension of the ideas used in the Applied Calculus course reform to update our mainstream Calculus courses is described. Diversity and equity considerations involved with these projects and future directions of these projects are addressed.

Balancing the scales? Evaluating the impact of results-based financing on maternal health outcomes and related inequality of opportunity in Zimbabwe

This study evaluates the impact of results-based financing (RBF) on maternal health outcomes and the inequality of opportunity (IOP) in these outcomes in Zimbabwe. We employ a difference-in-differences approach that leverages the staggered implementation of the programme across 60 districts, exploiting temporal variation in the introduction of RBF and individual-level variation in birth timing. Our analysis uses nationally representative, pooled cross-sectional data from the 2005/2006, 2010/2011, and 2015 Zimbabwe demographic and health surveys. Employing the extended two-way fixed effects (ETWFE) estimator to address biases associated with staggered rollouts, we find significant positive effects of RBF on maternal health outcomes. The programme is associated with an increase in the number of prenatal care visits by 0.185 units (p < 0.01), first-trimester care by 7.7 percentage points (pp) (p < 0.01), facility births by 8.6 pp (p < 0.01), and professional delivery assistance by 3.4 pp (p < 0.01), while reducing C-section rates by 1.3 pp (p < 0.01). Additionally, RBF is associated with reductions in IOP in prenatal care visits, early prenatal care, facility births, and professional delivery assistance by 3.8, 1.3, 8.4, and 4.9 pp (p < 0.01), respectively. These findings underscore the potential of RBF to enhance maternal health outcomes and promote health equity. Integrating equity considerations into health system strengthening initiatives is essential. Policymakers should ensure that health interventions improve access and balance opportunities across various socio-economic and demographic groups. This evidence suggests that RBF schemes can improve access to and equity in healthcare services, particularly in low-income settings such as Zimbabwe.

Enhancing power grid resilience to winter storms via generator winterization with equity considerations

We develop two-stage stochastic programming models for generator winterization that enhance power grid resilience while incorporating social equity. The first stage in our models captures the investment decisions for generator winterization, and the second stage captures the operation of a degraded power grid, with the objective of minimizing load shed and social inequity. To incorporate equity into our models, we propose a concept called adverse effect probability that captures the disproportionate effects of power outages on communities with varying vulnerability levels. Grid operations are modeled using DC power flow, and equity is captured through mean or maximum adverse effects experienced by communities. We apply our models to a synthetic Texas power grid, using winter storm scenarios created from the generator outage data from the 2021 Texas winter storm. Our extensive numerical experiments show that more equitable outcomes, in the sense of reducing adverse effects experienced by vulnerable communities during power outages, are achievable with no impact on total load shed through investing in winterization of generators in different locations and capacities.

Equity implications of efficient water conservation programs

Abstract Urban water management is increasingly challenged by the need to balance cost-effectiveness with equity considerations. This study presents a multi-objective approach to water conservation within the Las Vegas valley water district, analyzing a comprehensive dataset of water consumption and socioeconomic indicators across all single-family residences. We assess policy scenarios under two primary objectives: maximizing water savings to enhance economic efficiency and improving water affordability to promote equity. Our analysis reveals that while strategies focused on water savings reduce water use more efficiently, they tend to favor higher-income, predominantly white neighborhoods whereas prioritizing water affordability shifts resources towards lower-income, communities of color. The analysis of intermediate policy scenarios reveals the trade-offs and potential synergies between water savings and affordability. Our findings suggest that local water sustainability can be achieved by allocating resources to both high-demand and socioeconomically disadvantaged households. Highlighting the importance of integrating equity considerations into water management policies, this study provides insights for policymakers in crafting more inclusive and sustainable urban water management practices.

Equity considerations in clinical practice guidelines for traumatic brain injury and the criminal justice system: A systematic review.

Traumatic brain injury (TBI) is disproportionately prevalent among individuals who intersect or are involved with the criminal justice system (CJS). In the absence of appropriate care, TBI-related impairments, intersecting social determinants of health, and the lack of TBI awareness in CJS settings can lead to lengthened sentences, serious disciplinary charges, and recidivism. However, evidence suggests that most clinical practice guidelines (CPGs) overlook equity and consequently, the needs of disadvantaged groups. As such, this review addressed the research question "To what extent are (1) intersections with the CJS considered in CPGs for TBI, (2) TBI considered in CPGs for CJS, and (3) equity considered in CPGs for CJS?". CPGs were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of identified CPGs on November 2021 and March 2023 (CPGs for TBI) and May 2022 and March 2023 (CPGs for CJS). Only CPGs for TBI or CPGs for CJS were included. We calculated the proportion of CPGs that included TBI- or CJS-specific content, conducted a qualitative content analysis to understand how evidence regarding TBI and the CJS was integrated in the CPGs, and utilised equity assessment tools to understand if and how equity was considered. Fifty-seven CPGs for TBI and 6 CPGs for CJS were included in this review. Fourteen CPGs for TBI included information relevant to the CJS, but only 1 made a concrete recommendation to consider legal implications during vocational evaluation in the forensic context. Two CPGs for CJS acknowledged the prevalence of TBI among individuals in prison and one specifically recommended considering TBI during health assessments. Both CPGs for TBI and CPGs for CJS provided evidence specific to a single facet of the CJS, predominantly in policing and corrections. The use of equity best practices and the involvement of disadvantaged groups in the development process were lacking among CPGs for CJS. We acknowledge limitations of the review, including that our searches were conducted in English language and thus, we may have missed other non-English language CPGs in this review. We further recognise that we are unable to comment on evidence that is not integrated in the CPGs, as we did not systematically search for research on individuals with TBI who intersect with the CJS, outside of CPGs. Findings from this review provide the foundation to consider CJS involvement in CPGs for TBI and to advance equity in CPGs for CJS. Conducting research, including investigating the process of screening for TBI with individuals who intersect with all facets of the CJS, and utilizing equity assessment tools in guideline development are critical steps to enhance equity in healthcare for this disadvantaged group.

Update on Genetic Counselor Practice and Recommendations for Pediatric Cancer Predisposition Evaluation and Surveillance.

In July 2023, the American Association for Cancer Research held the second Childhood Cancer Predisposition Workshop, at which international experts in pediatric cancer predisposition met to update the previously published 2017 consensus statements on pediatric cancer predisposition syndromes. Since 2017, advances in tumor and germline genetic testing and increased understanding of cancer predisposition in patients with pediatric cancer have led to significant changes in clinical care. Here, we provide an updated genetic counseling framework for pediatric oncology professionals. The framework includes referral indications and timing, somatic and germline genetic testing options, testing for adult-onset cancer predisposition syndromes in children with and without cancer, evolving genetic counseling models to meet the increased demand for genetic testing, barriers to cancer genetic testing and surveillance in children, and psychosocial and equity considerations regarding cancer genetic testing and surveillance in children. Adaptable genetic counseling services are needed to provide support to pediatric oncology provider teams and diverse patients with pediatric cancer, cancer predisposition, and their families.

Health Equity Considerations in Cost-Effectiveness Analysis: Insights from an Umbrella Review.

Cost-effectiveness analyses (CEA) are important in healthcare decision-making and resource allocation; however, expanding the scope of CEAs beyond the traditional clinicoeconomic concepts to also include value elements such as health equity has attracted much interest in recent years. This umbrella review aimed to synthesize evidence on how equity concepts have been considered in modified types of CEAs. Publicly available articles in MEDLINE were searched on January 25, 2024, to identify systematic reviews (SLRs) published in English since 2013 that incorporate health equity considerations in CEAs. Title/abstract, full-text article screening and data extraction were conducted by a single reviewer and validated by a second reviewer. Results were qualitatively synthesized to identify common themes. Eight SLRs were included. Distributional CEAs (DCEA), equity-based weighting, extended CEA (ECEA), mathematical programming and multi-criteria decision analysis (MCDA) were the most discussed approaches. A lack of consensus on the best approach for incorporating health equity into CEAs was highlighted, as these approaches are not currently consistently used in decision-making. Important limitations included scarcity of robust data to inform health equity indices, bias associated with commonly used health outcome metrics and the challenge of accounting for additional contextual factors such as fairness and opportunity costs. Proposals to expand CEAs to address equity issues come with challenges due to data unavailability, methods complexity, and decision-makers unfamiliarity with these approaches. Our review indicates that extended and distributional CEAs can support decision-making by capturing the impact of inequity on the clinical and cost-effectiveness assessment of treatments, although future modeling should account for additional contextual factors such as fairness and opportunity costs. Recommendations for actions moving forward include standardization of data collection for outcomes related to equity and familiarity with methodologies to account for the complexities of integrating health equity considerations in CEAs.

How to design equitable digital health tools: A narrative review of design tactics, case studies, and opportunities.

With a renewed focus on health equity in the United States driven by national crises and legislation to improve digital healthcare innovation, there is a need for the designers of digital health tools to take deliberate steps to design for equity in their work. A concrete toolkit of methods to design for health equity is needed to support digital health practitioners in this aim. This narrative review summarizes several health equity frameworks to help digital health practitioners conceptualize the equity dimensions of importance for their work, and then provides design approaches that accommodate an equity focus. Specifically, the Double Diamond Model, the IDEAS framework and toolkit, and community collaboration techniques such as participatory design are explored as mechanisms for practitioners to solicit input from members of underserved groups and better design digital health tools that serve their needs. Each of these design methods requires a deliberate effort by practitioners to infuse health equity into the approach. A series of case studies that use different methods to build in equity considerations are offered to provide examples of how this can be accomplished and demonstrate the range of applications available depending on resources, budget, product maturity, and other factors. We conclude with a call for shared rigor around designing digital health tools that deliver equitable outcomes for members of underserved populations.