Differences In Health Care Outcomes Research Articles

Racial/Ethnic Residential Segregation, Neighborhood Health Care Provision, and Choice of Pediatric Health Care Provider Across the USA.

Much research has been conducted that demonstrates a link between racial/ethnic residential segregation and health care outcomes. We suggest that minority segregated neighborhoods may have diminished access to organizations and that this differential access may contribute to differences in health care outcomes across communities. We analyze this specifically using the case of pediatric health care provider choice. To examine this association, we estimate a series of multinomial logistic regression models using restricted data with ZIP code level geoidentifiers from the 2011-2012 National Survey of Children's Health (NSCH). We find that racial/ethnic residential segregation is related to a greater reliance on non-ideal forms of health care, such asclinics, and hospital outpatient departments, instead of pediatric physician's offices. This association is at least partially attenuated by the distribution of health care facilities in the local area, physician's offices, and health care practitioners in particular. Additionally, families express greater dissatisfaction with these other forms of care compared to physician's offices, demonstrating that the lack of adequate health care provision is meaningful for health care outcomes. This study expands the literature by examining how the siting of health organizations has consequences for individuals residing within these areas.

Regional Variation in Health Care Utilization Among Adults With Inadequate Cardiovascular Health in the USA.

Background Prior evidence of region-level differences in health outcomes and specialized healthcare services in the US poses questions of whether there are differences in utilization of healthcare that may account for regional differences in healthcare outcomes. This study aimed to examine regional differences in healthcare utilization for individuals with poor cardiovascular health (CVH) compared to those with ideal/intermediate CVH. Methods In this cross-sectional analytical study, two 3-year periods (2008-2010 and 2018-2020) were pooled and analyzed using multivariate Poisson's regression of region on counts of healthcare utilization, while controlling for relevant covariates. The interaction of the non-southern regions with recent years was to reveal how the regional dispersion in healthcare usage was changing over time for the non-southern regions compared to the south. Results The results showed significant regional variation in healthcare usage for individuals with poor CVH, with lower health utilization rates observed primarily in southern states, consistent with higher rates of coronary heart disease in those regions. The impact of a unit improvement on CVH score was to reduce the level of healthcare utilization by 15.7% ([95% CI, 15 - 17%; p < 0.001]) for individuals with poor CVH and 19.1% ([95% CI, 19 - 20%; p < 0.001]) for the intermediate and ideal subgroups, with the Northeast exhibiting the highest level of healthcare usage. Conclusion Our results suggest that there is a need for public health interventions to reduce regional disparities in access to healthcare for the people at greatest risk of cardiovascular events by considering individual factors as well as the broader regional and policy contexts where these people live.

Abstract #1407267: In-hospital Outcomes of Myxedema Coma in Teaching Vs Non-teaching Hospitals

Many studies have analyzed current data on outcomes at teaching vs non-teaching hospitals, and the results have been found to be dissimilar in certain hospitalizations in the United States. this study set out to examine the differences in healthcare outcomes between teaching and non-teaching hospitals in patients who were admitted for myxedema coma using a nationally representative sample. We reviewed data from the National Inpatient Sample (NIS) of patients between 2016-2019. Using ICD-10 diagnosis codes, we identified patients who were admitted due to myxedema coma within the study period. We further categorized our study population into 2 groups based on teaching vs non-teaching status. Multivariate analysis was done to investigate the in-hospital outcomes between both groups and adjust for confounders. During the study period, 3,839 myxedema coma admissions were identified. Teaching hospitals received 70.7% (2,715) of these admissions, while non-teaching hospitals received 29.3% (1,124). The mean age of the cohort was 66 years, 70% were females and 69% were white. The mean length of stay (LOS) was 9.4 days and the average total hospital charge was 89,068 $. There was no significant difference in in-hospital mortality in both groups (OR 1.23, 95% CI 0.66 -2.27, p=0.507). The teaching hospital group had increased odds of acute respiratory failure (OR 1.6, 95% CI 1.07 – 2.4, p = 0.021), acute kidney injury (OR 1.48, 95% CI 1.04 – 2.1, p = 0.028), and bradycardia (OR 1.67, 95% CI 1.06 – 2.6, p = 0.025). No significant risk difference between the two groups in terms of hyponatremia (OR 0.91, 95% CI 0.6 – 1.36, p= 0.66), pericardial effusion (OR 0.87, 95% CI 0.41 – 1.8, p= 0.719) or sepsis (OR 1.38, 95% CI 0.69 – 2.7, p= 0.353). Hospital teaching status was associated with an increased mean LOS (10 vs 7.9 days, p=0.002) and mean total hospital charges (93,122 vs 79,336 $, p=0.035). The study clearly showed that patients admitted with myxedema coma in teaching hospitals have an increased risk of in-hospital outcomes including acute respiratory failure, acute kidney injury, and bradycardia compared to non-teaching hospitals. Teaching hospital status was not associated with increased in-hospital mortality in myxedema coma admissions.

Intersectional Differences in Health Care Outcomes among Patients with Musculoskeletal Disorders in Germany

In all regions of the world, musculoskeletal disorders are a significant contributor to the burden of chronic illnesses. The effectiveness of treatments, such as rehabilitation, may vary intersectionally across demographic and other categories. The present study examines this intersectionality with respect to a lack of improvement in health conditions after rehabilitation of patients in Germany. Routine data from 298,617 patients aged 18–65 years residing in Germany who received rehabilitation because of arthropathies, dorsopathies, or soft tissue disorders during 2006–2016 were included in the analysis. Odds of the outcome were compared across demographic groups and across diagnostic sub-groups by means of multivariable logistic regression. Interaction terms were included to examine intersectional differences across these groups and over time. Women were more likely than men to have an impairment despite treatment (adjusted odds ratio [aOR] = 1.11; 95%-CI = 1.08, 1.13). In addition, patients in semi-skilled/unskilled employment were at higher odds of a poor outcome compared to patients in skilled positions (aOR = 1.13; 95%-CI = 1.10–1.17). Nationality also affected health care outcomes, with Turkish nationals and nationals from a Yugoslav successor state having higher odds of a poor outcome than Germans (aOR = 1.56; 95%-CI = 1.45–1.67 and aOR = 1.52; 95%-CI = 1.41–1.65, respectively). The findings highlight the importance of an intersectional perspective in health research and practice and can support the development of strategies and measures that aim to reduce disparities in health care.

Investigating real-world consequences of biases in commonly used clinical calculators.

To evaluate whether one summary metric of calculator performance sufficiently conveys equity across different demographic subgroups, as well as to evaluate how calculator predictive performance affects downstream health outcomes. We evaluate 3 commonly used clinical calculators-Model for End-Stage Liver Disease (MELD), CHA2DS2-VASc, and simplified Pulmonary Embolism Severity Index (sPESI)-on the cohort extracted from the Stanford Medicine Research Data Repository, following the cohort selection process as described in respective calculator derivation papers. We quantified the predictive performance of the 3 clinical calculators across sex and race. Then, using the clinical guidelines that guide care based on these calculators' output, we quantified potential disparities in subsequent health outcomes. Across the examined subgroups, the MELD calculator exhibited worse performance for female and White populations, CHA2DS2-VASc calculator for the male population, and sPESI for the Black population. The extent to which such performance differences translated into differential health outcomes depended on the distribution of the calculators' scores around the thresholds used to trigger a care action via the corresponding guidelines. In particular, under the old guideline for CHA2DS2-VASc, among those who would not have been offered anticoagulant therapy, the Hispanic subgroup exhibited the highest rate of stroke. Clinical calculators, even when they do not include variables such as sex and race as inputs, can have very different care consequences across those subgroups. These differences in health care outcomes across subgroups can be explained by examining the distribution of scores and their calibration around the thresholds encoded in the accompanying care guidelines.

The effect of socioeconomic factors on patient outcomes in cardiac surgery.

Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures. We utilized the National Inpatient Sample,Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseasesprocedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors. Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR. These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.

Abstract 11111: In-Hospital Outcomes of Coronary Atherectomy in Teaching vs Non-Teaching Hospitals

INTRODUCTION: Studies have analyzed contemporary data on outcomes at teaching vs non-teaching hospitals with the results found to be dissimilar in certain procedures in the United States. Coronary Atherectomy (CA) is a minimally invasive procedure that involves the opening of obstruction from heavily calcified blocked coronaries to improve blood flow to the heart. This study is set out to examine the differences in health care outcomes between teaching and non-teaching hospitals in patients who underwent CA using a nationally representative sample. METHODS: We reviewed data from the National Inpatient Sample (NIS) of patients admitted between 2016-2019. Using ICD-10 procedural codes, we identified patients who underwent CA (Rotational or Orbital) within the study period. We further categorized our study population into 2 groups based on teaching vs non-teaching status. Multivariate analysis was done to investigate the in-hospital outcomes between both groups and adjust for confounders. RESULTS: A total of 171,740 CA procedures were performed within the study period. 75% (129,585) vs 25% (42,155) of these procedures were performed in teaching vs non-teaching hospitals respectively. The mean age of patients who underwent the procedure was 65 years, with a higher preponderance in males (71.4%). There was no significant difference in in-hospital mortality in both groups (AOR 1.06, 95% CI 0.93 -1.21, p=0.372). There was also no observed difference in the odds of coronary perforation or cardiac tamponade (AOR 1.26, 95% CI 0.89-1.28 p=0.19) and (AOR 1.23, 95% CI 0.82-1.87, p=0.31) respectively. However, the teaching hospital groups had an increased odds of Coronary dissection (AOR 1.34, 95% CI 1.05 - 1.71, p=0.017) and heart Block (AOR 1.22, 95% CI 1.11-1.34, p&lt; 0.001). We also noticed an increased odds of septic shock (AOR 1.24, 95% CI 1.05-1.80, p= 0.018), AKI (AOR 1.12, 95% CI 1.07-1.22, p=0.005) and a higher hospitalization duration (Adjusted coefficient 0.43, 95% CI 0.30-0.56, p&lt; 0.001) in the teaching hospital group . CONCLUSION: CA performed at teaching hospitals is found to be associated with an increased risk of cardiac (coronary dissection and heart block) and non-cardiac (septic shock and AKI) outcomes.

Research on Disparities in Primary Health Care in Rural versus Urban Areas: Select Perspectives

Much of the differences in health care outcomes can be attributed to the differential rates of primary health care utilization and resource allocation across population subgroups [...].

¿Qué hay del efecto fin de semana? Impacto del día de ingreso sobre la mortalidad intrahospitalaria, la duración de la estancia y el coste de la hospitalización

IntroductionThere is no agreement on the existence of the weekend effect in healthcare or, if it exists, on its possible causes. The objective of the study was to evaluate the differences in healthcare outcomes between patients admitted on weekdays or weekends in a high-complexity hospital. MethodsObservational and retrospective study of patients admitted between 2016 and 2019 in a public hospital with more than 1300 beds. Hospitalization episodes were classified according to whether admission took place between Friday at 3:00 p.m. and the following Monday at 8:00 a.m. (weekend admission) or not (admission on weekdays). Mortality, length of stay and associated costs were compared, applying their respective risk-adjustment models. ResultsOf the total 169,495 hospitalization episodes analyzed, 48,201 (28.44%) corresponded to the weekend, presenting an older age (54.9 years vs. 53.9; P<.001), a higher crude mortality rate (5.22% vs. 4.59%; P<0.001), and a longer average length of stay (7.42 days vs. 6.74; P<.001), than those admitted on weekdays. The median crude cost of stay was lower (€731.25 vs. €850.88; P<0.001). No significant differences were found when applying the adjustment models, with a risk-adjusted mortality ratio of 1.03 (0.99–1.08) vs. 0.98 (0.95–1.01), risk-adjusted length of stay of 1.002 (0.98–1.005) vs. 0.999 (0.997–1.002) and risk-adjusted cost of stay of 0.928 (0.865–0.994) vs. 0.901 (0.843–0.962). ConclusionThe results of the study reveal that the assistance provided during the weekends does not imply worse health outcomes or increased costs. Comparing the impact between hospitals will require a future homogenization of temporal criteria and risk adjustment models.

A Comparative Analysis of Drug Therapy, Disease Phenotype, and Health Care Outcomes for Men and Women with Inflammatory Bowel Disease.

Sex and gender refer to biological and social differences between men and women. While well-evaluated in other disciplines, their roles in inflammatory bowel disease (IBD) are not well-defined. This study aimed to characterize differences in healthcare outcomes in men and women with IBD. A retrospective single-centre cohort study was conducted to evaluate differences between men and women receiving care for Crohn's disease (CD) and ulcerative colitis (UC) at the Western University Personalized Medicine Clinic from March 2012 to September 2019. The primary endpoint was the proportion of IBD drugs used for all drug classes. Additional outcomes in healthcare utilization and disease phenotype were assessed. Student's t test and Fisher's exact test were used to assess differences RESULTS: A total of 1015 participants were included (CD = 656; UC = 359). In UC and CD, 47.9% and 59.0% were women, respectively. Overall, women were more likely prescribed budesonide than men (23.6% vs. 13.4%; p < 0.0001), while more men were exposed to prednisone for IBD management (73.5% vs. 67.4%; p = 0.04). Immunomodulator use was higher in men with CD versus women (86.6% vs. 78.3%; p = 0.008) and of those exposed, women more commonly experienced ADRs (29.5% vs. 21.2%; p = 0.01). Though no sex-related difference was identified, age was a predictor of biologic exposure in women with CD and men with UC, with those > 55 being less likely to receive biologics. These findings highlight differences in disease course and treatment approaches between men and women with IBD and support the consideration of sex and gender when researching disease outcomes.

Impact of fragmentation on rehospitalization after bariatric surgery

The care of patients who have undergone bariatric surgery is complex and requires a multidisciplinary approach. As such, these patients may be prone to fragmentation of care and differences in healthcare outcomes. We aimed to (1) determine the incidence of fragmentation among patients after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), (2) identify risk factors for readmission, and (3) ascertain whether care fragmentation affects outcomes. This is a retrospective cohort study using the National Readmission Database 2016. Patients were included if they had primary bariatric surgery during the index hospitalization using appropriate ICD-10 CM codes. Fragmentation of care was defined as a readmission to a different hospital within 90days of the index admission. Primary outcome was incidence of fragmentation. Secondary outcomes were impact of fragmentation on (1) in-hospital mortality; (2) resource utilization (length of stay (LOS), total hospitalization charges and costs, in-hospital upper endoscopy (EGD), and abdominal imaging studies; and (3) independent predictors of readmission using multivariate regression analysis. A total of 136,536 subjects were included. 90-day readmission demonstrated a prevalence of fragmentation of 21.1%. Type of surgery was an independent predictor of fragmentation, with RYGB leading to increased risk (OR 1.90 [95% confidence interval (CI) 1.61, 2.25]; p-value < 0.0001). RYGB was associated with higher adjusted mean hospitalization costs, which was not explained by increased EGD (OR 0.95, CI 0.68, 1.32) or abdominal imaging (OR 0.52, CI 0.25, 1.06). No differences were found in mortality or LOS. Over 20% of patients following primary bariatric surgery have inpatient readmissions that are fragmented, driven by patients who have undergone RYGB surgery. This may be due to the complexity of this procedure and the need for a multispecialty approach. Additional efforts targeting fragmentation should be made to better coordinate the management of these complex patients and reduce healthcare costs.

Health outcomes and the healthcare and societal cost of optimizing pediatric surgical care in the United States

BackgroundThere is a movement to ensure that pediatric patients are treated in appropriately resourced hospitals through the ACS Children’s Surgery Verification (CSV) program. The objective of this study was to assess the potential difference in care provision, health outcomes and healthcare and societal costs after implementation of the CSV program. MethodsAll 2011 inpatient admissions for selected complex pediatric patients warranting treatment at a hospital with Level I resources were evaluated across 6 states. Multivariate regressions were used to analyze differences in healthcare outcomes (postoperative complications including death, length of stay, readmissions and ED visits within 30 days) and costs by CSV level. Recycled predictions were used to estimate differences between the base case scenario, where children actually received care, and the optimized scenario, where all children were theoretically treated at Level I centers. Results8,006 children (mean age 3.06 years, SD 4.49) met inclusion criteria, with 45% treated at Level I hospitals, 30% at Level II and 25% at Level III. No statistically significant differences were observed in healthcare outcomes. Readmissions within 30 days were higher at Level II compared to Level I centers (adjusted IRR 1.61; 95% CI 1.11, 2.34), with an estimated 24 avoidable readmissions per 1000 children if treatment were shifted from Level II to Level I centers. Overall, costs per child were not significantly different between the base case and the optimized scenario. ConclusionMany complex surgical procedures are being performed at Level II/III centers. This study found no statistically significant increase in healthcare or societal costs if these were performed instead at Level I centers under the optimized scenario. Ongoing evaluation of efforts to match institutional resources with individual patient needs is needed to optimize children’s surgical care in the United States. Level of evidenceII.

Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study.

The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized. This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium. Retrospective cohort analysis. We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed. In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care. Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.

Relationships Between Race/Ethnicity and Health Care Utilization Among Older Post-Acute Home Health Care Patients.

Few studies have explored racial/ethnic differences in health care outcomes among patients receiving home health care (HHC), despite known differences in other care settings. We conducted a retrospective cohort study examining racial/ethnic disparities in rehospitalization and emergency room (ER) use among post-acute patients served by a large northeastern HHC agency between 2013 and 2014 (N = 22,722). We used multivariable binomial logistic regression to describe the relationship between race/ethnicity and health care utilization outcomes, adjusting for individual-level factors that are conceptually related to health service use. Overall rates of rehospitalization and ER visits were 10% and 13%, respectively. African American and Hispanic patients experienced higher odds of ER visits or rehospitalization during their HHC episode. Racial/ethnic differences in utilization were mediated by enabling factors, such as caregiver availability, and illness-level factors, such as illness severity, functional status, and symptoms. Intervention targets may include early risk assessment, proactive management of clinical conditions, rehabilitative therapy, and caregiver training.

Gender and health care outcomes in patients with non-small cell lung cancer: A meta-analysis.

e18113 Background: Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. It is well known that there are differences in the outcome between genders; however the effects of the sex in the prognosis have not been previously properly defined. Our aim was to evaluate in a meta-analysis, differences in healthcare outcomes between women and men with NSCLC in terms of overall survival (OS) and progression-free survival (PFS). Methods: We searched for references of published studies of hospitalary databases indexed in PubMed/Medline. We retrieved 67 references (from 1989 to 2016), of which eleven references were eligible for data extraction. In total, 11 references were evaluable for OS. Meta-analysis for Hazard Ratios (HR) obtained from univariate and multivariate analysis were analyzed in different groups. The meta-analysis was done in the software Review Manager 5.3. Results: In total, 7 studies had information for OS univariate analysis, 7 studies for OS multivariate analysis, only, one for PFS univariate analysis and one for PFS multivariate analysis. The meta-analysis for OS univariate analysis resulted in a HR = 0.75 (P &lt; 0.00001; 95% CI: 0.71 to 0.79) for women compared to men, although there was a high statistical heterogeneity between cohorts (P &lt; 0.0001). In the meta-analysis for OS multivariate analysis was estimated a HR = 0.75 (P &lt; 0.00001; 95% CI: 0.73 to 0.78), with statistical heterogeneity between cohorts (P = 0.0005). Conclusions: Our study quantified a 25%-risk reduction of death for women with NSCLC compare with male men patients with the same diagnosis.

Factors affecting the work of physicians in rural areas of Turkey

An unbalanced geographical distribution of physicians leads to important differences in healthcare outcomes and difficulties in accessing healthcare services in rural areas. As in many other countries in the world, the geographical distribution of physicians in Turkey is unbalanced. Although there has been an increase in the number of physicians in the rural areas of Turkey since the introduction of the Health Transformation Program in 2003, health statistics indicate that significant differences still exist between regions in terms of the population-to-physician ratio. The aim of this study was to determine the factors that affect physicians' decisions about working in rural areas in Turkey. Overall, 1340 physicians working in urban areas constituted the sample group of this study. A survey method was used to collect the data. The questionnaire, which was used as a data collection tool, included nine questions to gather the opinions of physicians regarding working in rural areas. Variables such as occupational group and financial incentives affecting the physicians' willingness to work in rural areas were analyzed with descriptive statistics, and the answers given according to these variables were compared via t-test and one-way analysis of variance. Of the sample, 59.9% of the participant physicians were men, and 36.9% were specialists. Opinions of the physicians about working in the rural areas differed significantly by occupational group, marital status and income. Medical residents and general practitioners were more willing to work in rural areas than other profession groups. In addition, single physicians were more open to working in rural areas than were married physicians. An increase in physicians' income reduced their willingness to work in rural areas. The developmental level of the region where they worked was found to be a very important variable affecting their preferences. Participants working in developed regions are reluctant to work in the rural areas. Specific occupational groups, young and single physicians, and physicians working in underdeveloped regions were found to be the groups that can more easily be motivated to work in rural areas. To encourage physicians to work in rural areas, monetary and non-monetary incentives should be considered.

Disparities in vascular surgery: Is it biology or environment?

Disparities in health care are well documented for several racial, ethnic, and gender groups. In peripheral arterial disease, differences in prevalence, treatment selection, treatment outcomes, and resulting quality of life have negative effects on some minority groups and women. It may be easy to document disparities, but it is harder to understand their underlying causes. Are there biologic differences between members of racial and ethnic groups that influence disease presentation and outcomes? Or is the socioeconomic environment that surrounds them the true driver of observed differences? This article reviews the evidence for racial and gender disparities in vascular surgery and presents some potential mechanisms that may explain the disparities.

Importance of Race/Ethnicity in Clinical Trials

The United States has the most affluent and sophisticated medical community in the world, yet large population differences in healthcare outcomes among racial/ethnic populations remain an imposing challenge for the twenty-first century. Although causes of healthcare disparities are many,1–4 a significant contributor is the absence of research to clearly identify the sources of differences in outcomes in racial/ethnic groups and to distinguish among biological, environmental, or social causes of disease differences.1 Evaluation of disease differences in subsegments of the population is essential to understand the variety of mechanisms of pathophysiology, as well as to optimally target therapeutic responses. Thus, effective research that would contribute to a reduction in healthcare disparities requires collection of data on health status in racial and ethnic populations and assessment of differences in disease patterns. It also requires clinical trials with the inclusion of adequate numbers of diverse populations to probe for differences in pathophysiology (including environmental or social factors contributing to disease), and responses to treatment. Finally, where differences are observed among population segments, clinical trials focused in these population groups are essential.1–4 The recently completed African-American Heart Failure Trial (A-HeFT)5 and the African-American Study of Kidney Disease and Hypertension (AASK)6 are examples of studies focused in ethnic minorities that demonstrate the value of this research approach. In addition, the more than 40 000-participant Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)7–9 is an example of a clinical trial designed to prospectively assess ethnic differences in response to antihypertensive therapy. Each study has yielded important pathophysiological data with direct impact on the population studied, as well as data that are of great value in the general understanding of disease mechanisms. These studies also represent major advances in the knowledge base for treatment of important diseases and emphasize …

Cultural Competence in Health Care

Consequently, speech-language pathologists and audiologists working in the health care setting must be prepared to provided services that are respectful of and responsive to cultural and linguistic needs of a diverse patient population. For instance, health care disparities in racial and ethnic minorities in the United States can no longer be discounted or ignored. The Institute of Medicine (IOM) Report, Unequal Treatment, summarized a growing body of literature documenting racial or ethnic differences in health care outcomes for many different diagnoses including coronary artery disease, diabetes, cancer, and HIV. Health care providers have to overcome cultural and communication barriers that may negatively influence appropriate diagnosis and treatment, provide culturally competent health care, and create health care systems that provide equitable access to all clients/patients.

Assessing the economic burden of asthma

Assessing the economic burden of asthma