Disparities In Quality Of Care Research Articles

Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature.

Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes. Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction. A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias. Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.

Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system

BackgroundHospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system.MethodsWe selected three hospitals from each of Mexico’s main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016.ResultsThe average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions’ largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses.ConclusionsThe direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

Differences in Receipt of Neurologist Evaluation During Hospitalization for Ischemic Stroke by Race, Sex, Age, and Region: The REGARDS Study.

Improving access to health care providers with clinical expertise in stroke care may influence the use of recommended strategies for reducing disparities in quality of care. Few studies have examined differences in the receipt of evaluation by neurologists during the hospital stay. We examined the proportion of individuals hospitalized for acute ischemic stroke who received evaluation by a neurologist during the hospital stay and characterized differences in receipt of neurologist evaluation by race (Black vs White), sex, age, and study region (Stroke Belt residence vs other) among those experiencing a stroke who were participating in a national cohort study. This cross-sectional study was conducted using medical record data abstracted from 1,042 participants enrolled in the national Reasons for Geographic and Racial Differences in Stroke cohort study (2003-2007) who experienced an adjudicated ischemic stroke between 2003 and 2016. Participants with a history of stroke before baseline, in-hospital death, hospice discharge following their stroke, or incomplete records were excluded resulting in 839 cases. Differences were assessed using modified Poisson regression adjusting for participant-level and hospital-level factors. Of the 839 incident strokes, 722 (86%) received evaluation by a neurologist during the hospital stay. There were no significant differences by age, race, or sex, yet Stroke Belt residents and those receiving care in rural hospitals were significantly less likely to receive neurologist evaluation compared with non-Stroke Belt residents (relative risk [RR] 0.95; 95% CI 0.90-1.01) and participants receiving care in urban hospitals (RR 0.74; 95% CI 0.63-0.86). Participants with a greater level of poststroke functional impairment (modified Rankin scale) and those with a greater number of risk factors were more likely to receive neurologist evaluation compared with those with lower levels of poststroke functional impairment (RR 1.04; 95% CI 1.01-1.06) and fewer risk factors (RR 1.02; 95% CI 1.00-1.04). While differences in access to neurologists during the hospital stay were partially explained by patient need in our study, there were also significant differences in access by region and urban-rural hospital status. Ensuring access to neurologists during the hospital stay in such settings may require policy-level and/or system-level changes.

Characterizing provider bias in contraceptive care in Tanzania and Burkina Faso: A mixed-methods study

Provider bias based on age, marital status, and parity may be a barrier to quality contraceptive care. However, the extent to which bias leads to disparities in care quality is not well understood. In this mixed-methods study, we used four different data sources from the same facilities to assess the extent of bias and how much it affects contraceptive care. First, we surveyed providers in Tanzania and Burkina Faso (N = 295) to assess provider attitudes about young, unmarried, and nulliparous clients. Second, mystery clients anonymously visited providers for contraceptive care and we randomly assigned the reported age, marital status, and parity of each visit (N = 306). We used data from these visits to investigate contraceptive care disparities across 3 domains: information provision and counseling quality, contraceptive method provision, and perceived treatment. Third, we complemented mystery client data with client exit surveys (N = 31,023) and client in-depth interviews (N = 36). In surveys, providers reported biased attitudes against young, unmarried, and nulliparous clients seeking contraceptives. Similarly, we found disparities according to these characteristics in the reporting of contraceptive care quality; however, we found that each characteristic affected a different quality of care domain. Among mystery clients we found age-related disparities in the provision of methods; 16/17-year-old clients were 18 and 11 percentage points less likely to perceive they could take a contraceptive method relative to 24-year-old clients in Tanzania and Burkina Faso, respectively. Unmarried mystery clients perceived worse treatment from providers compared to married clients. Nulliparous mystery clients reported lower quality contraceptive counseling than their parous counterparts. These results suggest that clients of different characteristics likely experience bias across different elements of care. Improving care quality and reducing disparities will require attention to which elements of care are deficient for different types of clients.

Using artificial intelligence to promote equitable care for inpatients with language barriers and complex medical needs: clinical stakeholder perspectives.

Inpatients with language barriers and complex medical needs suffer disparities in quality of care, safety, and health outcomes. Although in-person interpreters are particularly beneficial for these patients, they are underused. We plan to use machine learning predictive analytics to reliably identify patients with language barriers and complex medical needs to prioritize them for in-person interpreters. This qualitative study used stakeholder engagement through semi-structured interviews to understand the perceived risks and benefits of artificial intelligence (AI) in this domain. Stakeholders included clinicians, interpreters, and personnel involved in caring for these patients or for organizing interpreters. Data were coded and analyzed using NVIVO software. We completed 49 interviews. Key perceived risks included concerns about transparency, accuracy, redundancy, privacy, perceived stigmatization among patients, alert fatigue, and supply-demand issues. Key perceived benefits included increased awareness of in-person interpreters, improved standard of care and prioritization for interpreter utilization; a streamlined process for accessing interpreters, empowered clinicians, and potential to overcome clinician bias. This is the first study that elicits stakeholder perspectives on the use of AI with the goal of improved clinical care for patients with language barriers. Perceived benefits and risks related to the use of AI in this domain, overlapped with known hazards and values of AI but some benefits were unique for addressing challenges with providing interpreter services to patients with language barriers. Artificial intelligence to identify and prioritize patients for interpreter services has the potential to improve standard of care and address healthcare disparities among patients with language barriers.

Collaborative Learning Among Health Care Organizations to Improve Quality and Advance Racial Equity.

The study examined stakeholder experiences of a statewide learning collaborative, sponsored and led by Blue Cross Blue Shield of Massachusetts (BCBSMA) and facilitated by the Institute for Healthcare Improvement (IHI) to reduce racial and ethnic disparities in quality of care. Interviews of key stakeholders (n=44) were analyzed to assess experiences of collaborative learning and interventions to reduce racial and ethnic disparities in quality of care. The interviews included BCBSMA, IHI, provider groups, and external experts. Breast cancer screening, colorectal cancer screening, hypertension management, and diabetes management were focal areas for reducing disparities. Collaborative learning methods involved expert coaching, group meetings, and sharing of best practices. Interventions tested included pharmacist-led medication management, strategies to improve the collection of race, ethnicity, and language (REaL) data, transportation access improvement, and community health worker approaches. Stakeholder experiences highlighted three themes: (1) the learning collaborative enabled the testing of interventions by provider groups, (2) infrastructure and pilot funding were foundational investments, but groups needed more resources than they initially anticipated, and (3) expertise in quality improvement and health equity were critical for the testing of interventions and groups anticipated needing this expertise into the future. BCBSMA's learning collaborative and intervention funding supported contracted providers in enhancing REaL data collection, implementing equity-focused interventions on a small scale, and evaluating their feasibility and impact. The collaborative facilitated learning among groups on innovative approaches for reducing racial disparities in quality. Concerns about sustainability underscore the importance of expertise for implementing initiatives to reduce racial and ethnic disparities.

Health inequalities: the unintended consequences of private healthcare policy?

Our Political Editor looks at the disparity in quality of care between private and public-funded healthcare and how this affects patients.

Experiences of in-hospital care among dementia caregivers in the context of high neighborhood-level disadvantage.

Persons living with dementia (PLWD) experience high rates of hospitalization and rehospitalization, exposing them to added risk for adverse outcomes including delirium, hastened cognitive decline, and death. Hospitalizations can also increase family caregiver strain. Despite disparities in care quality surrounding hospitalizations for PLWD, and evidence suggesting that exposure to neighborhood-level disadvantage increases these inequities, experiences with hospitalization among PLWD and family caregivers exposed to greater levels of neighborhood disadvantage are poorly understood. This study examined family caregiver perspectives and experiences of hospitalizations among PLWD in the context of high neighborhood-level disadvantage. We analyzed data from the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) study, an in-depth, multisite qualitative study examining hospitalization and rehospitalization of PLWD in the context of high neighborhood disadvantage, to identify caregiver perspectives and experiences of in-hospital care. Data were analyzed using rapid identification of themes; duplicate transcript review was used to enhance rigor. Data from N = 54 individuals (47 individual interviews, 2 focus groups with 7 individuals) were analyzed. Sixty-three percent of participants identified as Black/African American, 35% as non-Hispanic White, and 2% declined to report. Caregivers' experiences were largely characterized by PLWD receiving suboptimal care that caregivers viewed as influenced by system pressures and inadequate workforce competencies, leading to communication breakdowns and strain. Caregivers described poor collaboration between clinicians and caregivers with regard to in-hospital care delivery, including transitional care. Caregivers also highlighted the lack of person-focused care and the exclusion of the PLWD from care. Caregiver perspectives highlight opportunities for improving hospital care for PLWD in the context of neighborhood disadvantage and recognition of broader issues in care structure that limit their capacity to be actively involved in care. Further work should examine and develop strategies to improve caregiver integration during hospitalizations across diverse contexts.

Racial Differences in Nursing Home Quality of Life Among Residents Living With Alzheimer's Disease and Related Dementias.

ObjectivesAmong nursing home (NH) residents with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD), racial/ethnic disparities in quality of care exist. However, little is known about quality of life (QoL). This study examines racial/ethnic differences in self-reported QoL among NH residents with AD/ADRD. Methods: Validated, in-person QoL surveys from 12,562 long-stay NH residents with AD/ADRD in Minnesota (2012-2015) were linked to Minimum Data Set assessments and facility characteristics. Hierarchical linear models assessed disparities in resident-reported mean QoL score (range, 0-100 points), adjusting for case-mix and facility factors. Results: Compared to White residents, racially/ethnically minoritized residents reported significantly lower total mean QoL scores (75.53 points vs. 80.34 points, p < .001). After adjustment for resident- and facility-level characteristics, significant racial/ethnic differences remained, with large disparities in food enjoyment, attention from staff, and engagement domains. Discussion: Policy changes and practice guidelines are needed to address racial/ethnic disparities in QoL of NH residents with AD/ADRD.

Is being a refugee associated with increased 30-day mortality after visiting the emergency department? A register-based cohort study using Danish data.

Refugees face many challenges that could lead to disparity in quality of care from the health-care system compared with native Danes. These challenges could be language barriers, cultural differences, mental health co-morbidities and socio-economic status (SES). The aim of this study was to compare the 30-day mortality of refugees and native Danes after visiting the emergency department (ED) at Aarhus University Hospital, Denmark. In this register-based cohort study linking clinical and socio-demographic data, we included all visits to a major Danish ED from 1 January 2016 to 31 December 2018. According to the predefined analysis plan, we present non-parametric Kaplan-Meier plots and propensity score-weighted analysis. We included 29,257 eligible unique patients of whom 631 were refugees. In the 30-day time period after discharge from the ED, 11 deaths occurred in the group of refugees, resulting in a Kaplan-Meier estimate of 1.8% (95% confidence interval (CI) 0.7-2.8), and 1638 deaths occurred in the group of Danes, resulting in a Kaplan-Meier estimate of 5.9% (95% CI 5.6-6.1). The adjusted 30-day mortality risk difference was 1.6 percentage points (95% CI -2.0 to -1.2 percentage points) lower for refugees compared to native Danes. The 30-day mortality risk difference decreased from approximately 4 to 1.6 percentage points in the adjusted analysis. Thus, there were 16 fewer deaths among refugees within 30 days per 1000 discharged from the ED compared with native Danes when adjusting for age, sex, SES and co-morbidities. This study shows that refugees had a lower 30-day mortality after visiting the ED compared with native Danes.

Racial Disparity in Outcomes Among Prostate Cancer Patients in the Post-Affordable Care Act Period.

Our objective was to assess whether Medicaid expansion is associated with reduced racial disparity in quality of care measured as 30-day mortality, 90-day mortality, and 30-day readmission in prostate cancer patients receiving surgery. We used the National Cancer Database to extract a cohort of African American and White men diagnosed with prostate cancer between 2004 and 2015 and surgically treated. We used 2004-2009 data to observe preexisting racial disparity in outcomes. We used 2010-2015 data to assess racial disparity in outcomes and the interaction of race and Medicaid expansion status. Between 2004 and 2009, 179,762 men met our criteria. In this period, African American patients reported higher hazard of 30- and 90-day mortality and higher odds of 30-day readmission compared to White patients. Between 2010 and 2015, 174,985 men met our criteria. Of these 84% were White and 16% were African American. Main effects models showed that compared to White men, African American men had higher odds of 30-day mortality (OR=1.96, 95% CI = 1.46, 2.67), 90-day mortality (OR=1.40, 95% CI = 1.11, 1.77), and 30-day readmission (OR=1.28, 95% CI = 1.19, 1.38).The interactions between race and Medicaid expansion were not significant (P = .1306, .9499, and .5080, respectively). Improved access to care via Medicaid expansion may not translate into reduced racial disparity in quality-of-care outcomes in prostate cancer patients treated surgically. System-level factors such as availability of and referrals to care, and complex socioeconomic structure may also play a role in improving quality of care and reducing disparities.

Gender-associated cardiometabolic risk profiles and health behaviors in patients with type 2 diabetes: a cross-sectional analysis of the Joint Asia Diabetes Evaluation (JADE) program

In Asia, diabetes-associated death due to cardiorenal diseases were 2-3 times higher in women than men which might be due to gender disparity in quality of care and health habits. Adults with type 2 diabetes (T2D) from 11 Asian countries/areas were assessed using the same protocol (2007-2015). We compared treatment target attainment (HbA1c < 7%, blood pressure [BP] < 130/80mmHg, risk-based LDL-cholesterol, lack of central obesity [waist circumference <90cm in men or <80cm in women), use of cardiorenal-protective drugs (renin-angiotensin system [RAS] inhibitors, statins), and self-reported health habits including self-monitoring blood glucose (SMBG) by gender. Analyses were stratified by countries/areas, age of natural menopause (<50 vs. ≥50 years), and comorbidities (atherosclerotic cardiovascular disease [ASCVD], heart failure, kidney impairment [eGFR < 60mL/min/1.73m2]). Among 106,376 patients (53.2% men; median (interquartile range) diabetes duration: 6.0 (2.0-12.0) years; mean±SD HbA1c 8.0±1.9%; 27% insulin-treated), women were older and less likely to receive college education than men (28.9% vs. 48.8%). Women were less likely to smoke/drink alcohol and were physically less active than men. Women had lower BP (<130/80mmHg: 29.4% vs. 25.7%), less general obesity (54.8% vs. 57.8%) but more central obesity than men (77.5% vs. 57.3%). Women were less likely to have ASCVD (12.8% vs. 17.0%) or heart failure (1.3% vs. 2.3%), but more likely to have kidney impairment (22.3% vs. 17.6%) and any-site cancer than men (2.5% vs. 1.6%). In most countries/areas, more men attained HbA1c <7% and risk-based LDL-cholesterol level than women. After adjusting for potential confounders including countries and centres, men had 1.63 odds ratio (95% CI 1.51, 1.74) of attaining ≥3 treatment targets than women. Asian women with T2D had worse quality of care than men especially in middle-income countries/areas, calling for targeted implementation programs to close these care gaps. Asia Diabetes Foundation. Nil.

Sex Disparities in Failure to Rescue After Cardiac Surgery in California and New York

Women have a higher risk of mortality than men after cardiac surgery independent of other risk factors. The reason for this may not be limited to patient-specific variables. Failure to rescue (FTR) patients from death after a postoperative complication is a nationally endorsed quality care metric. We aimed to identify whether sex disparities exist in the quality of care after cardiac surgery using FTR rates. A retrospective analysis of 30 973 men (70.4%) and 13 033 women (29.6%) aged over 18 years undergoing coronary artery bypass graft or valve surgery in New York (2016-2019) and California (2016-2018) who experienced at least one serious postoperative complication. The primary outcome was the FTR. Multivariable logistic regression was used to identify predictors of death after complication. Propensity matching was used to adjust for baseline differences between sexes and yielded 12 657 pairs. Female patients that experienced complications were older (mean age 67.8 versus 66.7, P<0.001), more frail (median frailty score 0.1 versus 0.07, P<0.001), and had more comorbidities (median Charlson score 2.5 versus 2.3, P<0.001) than male patients. The overall FTR rate was 5.7% (2524), men were less likely to die after a complication than women (4.8% versus 8%, P<0.001). Independent predictors of FTR included female sex (relative risk [RR]: 1.46 [CI, 1.30-1.62]), area-level poverty rate >20% (RR, 1.21 [CI, 1.01-1.59]), higher frailty (RR, 2.83 [CI, 1.35-5.93]), undergoing concomitant coronary artery bypass graft and valve surgeries (RR, 1.69 [CI, 1.49-1.9]), and higher number of postoperative complications (RR, 16.28 [CI, 14-18.89]). In the propensity-matched cohorts, the FTR rate remained significantly lower among men than women (6.0% versus 8.0%, P<0.001). Women are less likely to be rescued from death following postoperative complications, independent of socioeconomic and clinical characteristics. Further research is warranted to investigate the clinical practices contributing to this disparity in quality of care following cardiac surgery.

Cross-Sector Partnerships to Deliver Health Equity.

Cross-Sector Partnerships to Deliver Health Equity Wengora E. Thompson, DrPH, MPH (bio), Kelly Jean Thomas Craig, PhD (bio), Kyu B. Rhee, MD, MPP (bio), Sreekanth K. Chaguturu, Md (bio), and Joneigh S. Khaldun, Md, Mph, Facep (bio) The coronavirus disease 2019 (COVID-19) pandemic has been an awakening to the entire globe and has unveiled to the public long-standing and unaddressed social inequities in the United States (U.S.). Over one million people in the U.S. have lost their lives to this terrible disease,1 and the long-term health, economic, and psychological impacts—while still undefined in detail—are significant,2 and for many remain unaddressed. The impacts of the pandemic have been much greater among those who are historically marginalized;3 these groups include people of color, LGBTQIA+ populations, those living with a disability, immigrants, people living in rural areas, the elderly, and those with lower socioeconomic status (education, income, and occupation) including the uninsured/underinsured. In 2021, over 30 million people in the U.S. suffered from food insecurity,4 which can be a temporary or long-term condition; lack of consistent access to affordable nutritious food leaves many households hungry. Furthermore, in 2021 15% of all renters were behind on their rent payments resulting in housing insecurity and many evictions.5 These preventable conditions are inequitably distributed, falling more heavily on racial/ethnic minority groups and low socioeconomic status groups across many health conditions. For example, concerning U.S. rates of maternal morbidity and mortality, women of color face risks of pregnancy-related complications and death that are more than double those of White women.6 In other examples of health disparities, the burden of death and illness associated with chronic diseases (such as diabetes,7 hypertension,8 cardiovascular disease,8 cancer,9 sickle cell disease,10 and human immunodeficiency virus11) experienced by people of color is markedly heavier than that of White populations. Non-Hispanic Black people are twice as likely as non-Hispanic White people to die from diabetes.7 Furthermore, when compared with White people, Black people have hypertension that [End Page 1] is earlier-onset, harder to control, and associated with worse outcomes;12 the Black population has five times as many potentially preventable hospitalizations and more end-organ damage; half of the cardiovascular mortality disparity between Black and White populations is attributed to hypertension.8 These health disparities reflect harsh, longstanding inequities—often stemming from structural racism—in education, employment, housing, and health care that were exacerbated by the pandemic.2 The reasons for these inequities, and thus the solutions to address them, are complex and require input from and collaboration among multiple stakeholders, as well as genuine and sustained input and partnership with communities. Many organizations, both private (e.g., health care, technology, and private nonprofits) and public (government), are extending their reach by establishing cross-sector partnerships to initiate actions that promote health and wellness in communities, workplaces, schools, and other settings in addition to addressing social determinants of health (SDoH) for all community members. Recognizing the contributions of social and physical environment to health (i.e., SDoH) and cooperatively addressing needs—such as housing, food, safety, and transportation—have the potential to deliver a scaled and community-specific impact. Public-private partnerships can identify both the social and health needs of community members and offer the promise of improving health outcomes and reducing health care costs with tailored interventions, assistance programs, and other personalized resources. The focus of this supplemental issue is the potential of public-private partnerships to advance health equity and address unmet needs. CVS Health® has a longstanding history of identifying and addressing health disparities and inequities and using partnerships to integrate care and services based on comparable missions and complementary capacities. When Aetna®, acquired by CVS Health in 2018,13 became the first national health plan to collect race and ethnicity data in 2003,14 it was a progressive and unmatched step towards improving population health on behalf of payers. The acquisition of these standardized demographic data is key to identifying disparities in quality of care and targeting quality interventions to achieve equity. Further, the curation of an equity-centric...

Real-world racial disparities in EGFR testing and third-generation EGFR TKI use among U.S. patients with stage IV NSCLC.

124 Background: Biomarker testing for EGFR mutations (EGFRm) is recommended for all newly diagnosed patients with metastatic NSCLC. Third-generation EGFR TKIs are the recommended standard-of-care therapy for patients with EGFRm+ NSCLC regardless of race, although EGFRm occur more frequently in Asian patients (Table). We investigated the association between race, EGFR testing and receipt of subsequent first-line (1L) treatment with the third-generation EGFR TKI, osimertinib. Methods: This retrospective, observational study used the nationwide Flatiron Health EHR-derived de-identified database. Adults with an initial diagnosis of stage IV NSCLC who initiated systemic 1L therapy between Apr 2018 (osimertinib approval) and Feb 2022 (data cutoff date) were eligible. Two cohorts were defined: those eligible for EGFR testing, and those EGFRm+ patients eligible for 1L osimertinib. Multivariable logistic regression was used to investigate odds of 1) EGFR testing, and 2) 1L osimertinib use, by race. Random-effects logistic regression was used as a sensitivity analysis to evaluate the impact of inter-practice variation on each outcome. Confidence intervals (CI) were calculated at 95%. Results: 9,505 patients were eligible for EGFR testing. After adjustment, Asian patients were nearly twice as likely to be tested (adjusted odds ratio [aOR]: 1.93, CI: 1.33 – 2.89, p = 0.0001), while Black patients were 25% less likely to receive testing (aOR: 0.75, CI: 0.62 – 0.90, p = 0.002), both relative to White patients. Including a random factor of practice attenuated the effect of race for Asian patients (aOR: 1.74, CI: 1.15 – 2.64, p = 0.0009) as well as Black patients (aOR: 0.8, CI: 0.65-0.97, p = 0.021). Of these patients, 1,247 were confirmed EGFRm+ and were thus eligible for 1L osimertinib. Asian patients were marginally more likely to receive 1L osimertinib, even after adjustment ( aOR: 1.51, CI: 0.958 – 2.43, p =.082). The inclusion of a random factor of practice diminished the marginal effect of race ( aOR: 1.46, CI: 0.90 – 2.36, p = 0.1). Conclusions: Retrospective analyses using real-world data revealed differences across races in EGFR testing among patients with stage IV NSCLC, suggesting disparities in quality of care. Racial disparities were also observed in 1L osimertinib use among patients with EGFRm+. Sensitivity analyses suggest that these disparities may partially be attributed to differences in care between practices. Future studies are warranted to further characterize this unexpected race-based difference in biomarker testing and treatment initiation. This work highlights the need for investigations of racial disparities in access to both biomarker testing and effective treatment options across precision oncology.[Table: see text]

Racial Disparities in Nursing Home Resident and Staff COVID-19 Vaccination Rates.

To determine whether staff and resident COVID-19 vaccination rates varied by racial heterogeneity of nursing homes, defined as proportion of residents who are White. Cross-sectional study using data from the Medicare COVID-19 Nursing Home Database and LTCFocus.org to examine facility-level resident and staff vaccination status. General linear regression models assessed analyses of variance and tests for trend on proportion of residents and staff fully vaccinated as of June 13, 2021 by proportion of White residents in each facility. Over 12,000 (n=12,278) nursing homes provided resident measures and 8,838 reported staff measures. The mean (standard deviation [SD]) resident vaccination rate of nursing homes in the lowest and highest quantiles of White residents was significantly different at 72.74% (20.59%) and 85.65% (16.70%), respectively. Staff vaccination rates of nursing homes in the lowest and highest quantiles of White residents were not significantly different at 58.34% (25.09%) and 56.06% (19.32%), respectively. A higher proportion of White residents per facility was associated with higher resident COVID-19 vaccination rates reflecting continued disparities in quality of care during the pandemic.

Institutional variation in early mortality following isolated coronary artery bypass graft surgery

Background:Thirty-day mortality following coronary artery bypass grafting (CABG) is a widely accepted marker for quality of care. Although surgical mortality has declined, the utility of this measure to profile quality has not been questioned. We assessed the institutional variation in risk-standardised mortality rates (RSMR) following isolated CABG within Australia and New Zealand (ANZ).Methods: We used an administrative dataset from all public and most private hospitals across ANZ to capture all isolated CABG procedures recorded between 2010 and 2015. The primary outcome was all-cause death occurring in-hospital or within 30-days of discharge. Hospital-specific RSMRs and 95% CI were estimated using a hierarchical generalised linear model accounting for differences in patient characteristics.Results: Overall, 60,953 patients (mean age 66.1 ± 10.1y, 18.7% female) underwent an isolated CABG across 47 hospitals. The observed early mortality rate was 1.69% (n = 1029) with 81.8% of deaths recorded in-hospital. The risk-adjustment model was developed with good discrimination (C-statistic = 0.81). Following risk-adjustment, a 3.9-fold variation was observed in RSMRs among hospitals (median:1.72%, range:0.84–3.29%). Four hospitals had RSMRs significantly higher than average, and one hospital had RSMR lower than average. When in-hospital mortality alone was considered, the median in-hospital RSMR was 1.40% with a 5.6-fold variation across institutions (range:0.57–3.19%).Conclusions: Average mortality following isolated CABG is low across ANZ. Nevertheless, in-hospital and 30-day mortality vary among hospitals, highlighting potential disparities in care quality and the enduring usefulness of 30-day mortality as an outcome measure. Clinical and policy interventions, including participating in clinical quality registries, are needed to standardise CABG care.

Racial and ethnic differences in the adoption of opportunistic salpingectomy for ovarian cancer prevention in the United States

Clinicians in the United States have rapidly adopted opportunistic salpingectomy for ovarian cancer prevention. However, little is known about racial and ethnic differences in opportunistic salpingectomy adoption. Surgical innovations in gynecology may be adopted differentially across racial and ethnic groups, exacerbating current disparities in quality of care. This study aimed to evaluate racial and ethnic differences in opportunistic salpingectomy adoption across inpatient and outpatient settings and assess the effect of national guidelines supporting opportunistic salpingectomy use on these differences. A sample of 650,905 women aged 18 to 50 years undergoing hysterectomy with ovarian conservation or surgical sterilization from 2011 to 2018 was identified using the Premier Healthcare Database, an all-payer hospital administrative database, including more than 700 hospitals across the United States. The association between race and ethnicity and opportunistic salpingectomy use was examined using multivariable-adjusted mixed-effects log-binomial regression models accounting for hospital-level clustering. Models included race and ethnicity by year of surgery (2011-2013 [before guideline] and 2014-2018 [after guideline]) interaction term to test whether racial and ethnic differences in opportunistic salpingectomy adoption changed with the release of national guidelines supporting opportunistic salpingectomy use. From 2011 to 2018, 82,792 women underwent hysterectomy and opportunistic salpingectomy (non-Hispanic White, 60.3%; non-Hispanic Black, 18.8%; Hispanic, 12.2%; non-Hispanic other race, 8.7%) and 23,398 women underwent opportunistic salpingectomy for sterilization (non-Hispanic White, 64.7%; non-Hispanic Black, 10.8%; Hispanic, 16.7%; non-Hispanic other race, 7.8%). The proportion of hysterectomy procedures involving an opportunistic salpingectomy increased from 6.3% in 2011 to 59.7% in 2018 (9.5-fold increase), and the proportion of sterilization procedures involving an opportunistic salpingectomy increased from 0.7% in 2011 to 19.4% in 2018 (27.7-fold increase). In multivariable-adjusted models, non-Hispanic Black (risk ratio, 0.94; 95% confidence interval, 0.92-0.97), Hispanic (risk ratio, 0.98; 95% confidence interval, 0.95-1.00), and non-Hispanic other race women (risk ratio, 0.93; 95% confidence interval, 0.90-0.96) were less likely to undergo hysterectomy and opportunistic salpingectomy than non-Hispanic White women. A significant interaction between race and ethnicity and year of surgery was noted in non-Hispanic Black compared with non-Hispanic White women (P<.001), with a reduction in differences in hysterectomy and opportunistic salpingectomy use after national guideline release (risk ratio2011-2013, 0.80 [95% confidence interval, 0.73-0.88]; risk ratio2014-2018, 0.98 [95% confidence interval, 0.95-1.01]). Moreover, non-Hispanic Black women were less likely to undergo an opportunistic salpingectomy for sterilization than non-Hispanic White women (risk ratio, 0.91; 95% confidence interval, 0.88-0.95), with no difference by year of surgery (P=.62). Stratified analyses by hysterectomy route and age at surgery revealed similar results. Although opportunistic salpingectomy for ovarian cancer prevention has been rapidly adopted in the United States, our findings suggested that its adoption has not been equitable across racial and ethnic groups. Non-Hispanic Black, Hispanic, and non-Hispanic other race women were less likely to undergo opportunistic salpingectomy than non-Hispanic White women even after adjusting for sociodemographic, clinical, procedural, hospital, and provider characteristics. These differences persisted after the release of national guidelines supporting opportunistic salpingectomy use. Future research should focus on understanding the reasons for these differences to inform interventions that promote equity in opportunistic salpingectomy use.

Evaluation of Racial Disparities in Quality of Care for Patients With Gastrointestinal Tract Cancer Treated With Surgery

Racial disparities have been demonstrated in many facets of health care, but a comprehensive understanding of who is most at risk for substandard surgical care of gastrointestinal tract cancers is lacking. To examine racial disparities in quality of care of patients with gastrointestinal tract cancers. This retrospective cohort study of patients with gastrointestinal tract cancer included the US population as captured in the National Cancer Database with a diagnosis from January 1, 2004, to December 31, 2017. Participants included 565 124 adults who underwent surgical resection of gastrointestinal tract cancers. Data were analyzed from June 21 to December 23, 2021. Race and site of cancer. Oncologic standard of care, as defined by negative resection margin, adequate lymphadenectomy, and receipt of indicated adjuvant chemotherapy and/or radiotherapy. Among 565 124 adult patients who underwent surgical resection of a gastrointestinal tract cancer, 10.9% were Black patients, 83.5% were White patients, 54.7% were men, and 50.7% had Medicare coverage. The most common age range at diagnosis was 60 to 69 years (28.5%). Longer median survival was associated with negative resection margins (87.3 [IQR, 28.5-161.9] months vs 22.9 [IQR, 8.8-69.2] months; P < .001) and adequate lymphadenectomies (80.7 [IQR, 25.6 to not reached] months vs 57.6 [IQR, 17.7-153.8] months; P < .001). After adjustment for covariates, Black patients were less likely than White patients to have negative surgical margins overall (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]) and after esophagectomy (OR, 0.71 [95% CI, 0.58-0.87]), proctectomy (OR, 0.71 [95% CI, 0.66-0.76]), and biliary resection (OR, 0.75 [95% CI, 0.61-0.91]). Black patients were also less likely to have adequate lymphadenectomy overall (OR, 0.89 [95% CI, 0.87-0.91]) and after colectomy (OR, 0.89 [95% CI, 0.87-0.92]), esophagectomy (OR, 0.72 [95% CI, 0.63-0.83]), pancreatectomy (OR, 0.90 [95% CI, 0.85-0.96]), proctectomy (OR, 0.93 [95% CI, 0.88-0.98]), proctocolectomy (OR, 0.90 [95% CI, 0.81-1.00]), and enterectomy (OR, 0.71 [95% CI, 0.65-0.79]). Black patients were more likely than White patients not to be recommended for chemotherapy (OR, 1.15 [95% CI, 1.10-1.21]) and radiotherapy (OR, 1.49 [95% CI, 1.35-1.64]) because of comorbidities and more likely not to receive recommended chemotherapy (OR, 1.68 [95% CI, 1.55-1.82]) and radiotherapy (OR, 2.18 [95% CI, 1.97-2.41]) for unknown reasons. These findings suggest that there are significant racial disparities in surgical care of gastrointestinal tract cancers. Black patients are less likely than White patients to receive standard of care with respect to negative surgical margins, adequate lymphadenectomies, and use of adjuvant therapies. Both system- and physician-level reforms are needed to eradicate these disparities in health care.

Accessibility of the Affordable Care Act (ACA) marketplace websites

ABSTRACT Background The Affordable Care Act (ACA) mandated that creation of online health insurance websites to ease the complex process of shopping for and enrolling into coverage. Ensuring that these sites are not only available but also meet digital accessibility standards is important so that individuals with disabilities are able to access healthcare services and efficiently obtain insurance coverage. Method We evaluated each of the marketplace sites in 2020 to assess whether they are digitally accessible. We employed a custom audit tool based on a subset of the Web Content Accessibility Guidelines (WCAG) 1.0 and 2.0 AA and used content analysis to compare the site’s accessibility statements with best practices. Results Nearly all of the ACA marketplace websites have significant room to improve their digital accessibility. Notable technical problem areas include lack of text equivalents for images, difficult site navigation, and lack of optimization for mobile use, particularly on those pages that provide instructions on how to get in-person help. Conclusions Given that access to health insurance is a primary predictor of access to health care – sites must be easy to use and accessible to all individuals regardless of ability. Barriers to online enrollment, such as those identified in this work, may exacerbate disparities in quality of care, treatment continuity and affordability for individuals with mental and physical disabilities. Entities providing health-related online information & engagement should be aware of actionable opportunities to improve digital accessibility to optimize the enrollment process for both maintaining coverage and assisting those that remain uninsured.