Equitable Health Care Delivery Research Articles

Reducing the pressures of outpatient care: the potential role of patient-reported outcomes.

The global demand for hospital treatment exceeds capacity.The COVID-19 pandemic has exacerbated this issue, leading to increased backlogs and longer wait times for patients. The amount of outpatient attendances undertaken in many settings is still below pre-pandemic levels and this, combined with delayed referrals, means that patients are facing delays in treatment and poorer health outcomes. Use of digital health technologies, notably the use of remote symptom monitoring systems based on patient-reported outcomes (PROs), may offer a solution to reduce outpatient waiting lists and tailor care to those in greatest need. Drawing on international examples, the authors explore the use of electronic PRO systems to triage clinical care. We summarise the key benefits of the approach and also highlight the challenges for implementation, which need to be addressed to promote equitable healthcare delivery.

Assessment of San Antonio refugee health clinic telehealth response and refugees’ needs during the COVID-19 pandemic

In March of 2020, Texas declared a statewide public health emergency in response to the rapidly spreading COVID-19 virus, forcing the shutdown of many critical operations across the state. The pandemic has had a massive impact on the refugee population worldwide, increasing displacement and limiting opportunities for resettlement, work, and aid. In an effort to evaluate and address the holistic needs of the San Antonio's vulnerable refugee community during the pandemic, the San Antonio Refugee Health Clinic (SARHC) created a COVID-19 response team that screened and triaged the population, collected data, and provided telemedicine and other urgent teleservices.The SARHC clinic has served the mostly uninsured and underserved refugee population of San Antonio, Texas for over 10 years as a Student-Faculty Collaborative Practice (SFCP). With the collaboration of the Center for Refugee Services in San Antonio, the clinic utilizes the site of a local church on a weekly basis to serve refugees via teams of nursing, dental, and medical students and faculty.At the height of the COVID-19 lockdown, teams of student and faculty volunteers conducted a cross-sectional study of patients’ needs by systematically calling and screening patients. Qualitative data on COVID-19 risk, mental wellness, financial needs, food security, dental needs, and medical needs was collected. Quantitative data on number of patients contacted, country of origin, interpreter use, insurance access, internet access, referrals, appointments, and prescriptions carried out was also collected and analyzed.Of the patients called (N = 216), 57% (n = 123) were successfully reached and completed the survey. 61% (n = 75) required language interpreter services. Only 9% (n = 11) of individuals had health insurance. 46% (n = 52) expressed the need for telemedicine services, and 34% (n = 42) reported access to WiFi. 41% (n = 50) reported a medical concern, 18% (n = 22) reported dental concerns, 41% (n = 51) reported social needs, and 11% (n = 14) reported mental health concerns. 24% (n = 30) of patients requested medication refills.Our snapshot of the San Antonio refugee community during the COVID-19 pandemic captures their social, mental, and physical struggles; the pandemic left many families without access to medications, health services, social services, job, and food security. The telemedicine campaign proved to be an effective method of assessing and addressing a variety of patient needs in a virtual setting. Of concern is the high rates of uninsured families and limited Internet access. These findings reveal important considerations for equitable healthcare delivery to vulnerable populations in the face of prolonged unforeseen events, like the COVID-19 pandemic.

Abstract 15142: Consistent Improvement in Utilization of Guideline Directed Medical Therapy Race for Traditionally Underserved Populations Using a Remote Intervention

Background: Heart failure (HF) disproportionately affects populations traditionally underserved in medicine. Remote healthcare delivery expands the reach of health care systems and providers, however some fear new models may pose challenges to equitable health care delivery. By building a remote HF clinic we aimed to increase equitable access to guideline-directed medical therapy (GDMT) optimization for HF. Methods: Patients with HF and a left ventricular ejection fraction < 40% were identified by health record screening. Patients’ cardiologist was approached to participate in the remote intervention (RI) program, and those who declined their patient’s involvement served as a reference ‘usual care’ (UC) group. HF medications in the RI group were adjusted by pharmacists and patient navigators according to a GDMT titration algorithm. We examined differences in the efficacy of the intervention by race and separately by area deprivation index (ADI) - a validated method of stratifying neighborhood-level health determinants (higher scores indicate fewer resources). Results: Of 1131 eligible patients, 196 completed the 3-month follow-up in the RI group. The RI group included 16.8% Black individuals, 59.2% of patients in the low (1-5) ADI category and 29.6% in the high (6-10) ADI category. The UC group included 831 patients: 9.9% Black individuals, 54.0% in the low ADI category and 25.6% in the high ADI category. When compared to Black patients in UC, Black patients who participated in the RI program saw more medication titrations and rates of reaching target dosage for both ACE/ARB/ARNI & beta-blockers (BB). When compared across ADI, the RI group had increased rates of ACE/ARB/ARNI & BB titration and target dose achieved in the low and high ADI categories compared the UC group (Figure 1). Conclusion: A remote HF program was able to improve utilization of GDMT regardless of race and ADI. This care model may improve access to HF care for traditionally underserved populations.

LUNG TRANSPLANTATION IN THE UNITED STATES: COMPARISON OF SOCIODEMOGRAPHIC TRENDS BETWEEN 2001 AND 2021

LUNG TRANSPLANTATION IN THE UNITED STATES: COMPARISON OF SOCIODEMOGRAPHIC TRENDS BETWEEN 2001 AND 2021

IMPACT OF CARDIOVASCULAR DISEASE: A LITERATURE REVIEW OF THE ALL OF US RESEARCH PROGRAM - AN NIH PRECISION MEDICINE INITIATIVE

The homogeneity of cardiovascular (CV) clinical studies involving populations limits the generalizability of results and compounds health inequities faced by women, older adults and people of color. The All of Us Research Program is part of the NIH Precision Medicine Initiative that aims to enroll 1 million underrepresented persons in the U.S. to increase the inclusion of diverse populations, accelerate biomedical research, and achieve equitable healthcare delivery.The objective of this project is to perform a literature review of the All of Us Research Program and provide an overview of the cardiovascular risk profiles of participants enrolled in the program based on gender, race and ethnicity.Studies were identified through a database search from 2017 to 2022 using PubMed and Google Scholar and 3 broad search term categories: (1) White, Black, Hispanic, Asian, (2) Heart disease, (3) All of Us Research Program.Figure 1 shows how the average percentage of participants from underrepresented racial and ethnic groups reported in our literature review is representative of the U.S. population by the higher Simpson's Diversity Index score compared to the data reported by the US Census Bureau. Table 1 demonstrates a higher CV risk profile among White participants, due to the higher percentage of White population in all reviewed sources. Also, among underrepresented populations, participants that identify as Black have higher rates of all CV diseases and female participants have ≥ 50% of all CV diseases compared to male participants.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The homogeneity of cardiovascular (CV) clinical studies involving populations limits the generalizability of results and compounds health inequities faced by women, older adults and people of color. The All of Us Research Program is part of the NIH Precision Medicine Initiative that aims to enroll 1 million underrepresented persons in the U.S. to increase the inclusion of diverse populations, accelerate biomedical research, and achieve equitable healthcare delivery. The objective of this project is to perform a literature review of the All of Us Research Program and provide an overview of the cardiovascular risk profiles of participants enrolled in the program based on gender, race and ethnicity. Studies were identified through a database search from 2017 to 2022 using PubMed and Google Scholar and 3 broad search term categories: (1) White, Black, Hispanic, Asian, (2) Heart disease, (3) All of Us Research Program. Figure 1 shows how the average percentage of participants from underrepresented racial and ethnic groups reported in our literature review is representative of the U.S. population by the higher Simpson's Diversity Index score compared to the data reported by the US Census Bureau. Table 1 demonstrates a higher CV risk profile among White participants, due to the higher percentage of White population in all reviewed sources. Also, among underrepresented populations, participants that identify as Black have higher rates of all CV diseases and female participants have ≥ 50% of all CV diseases compared to male participants.

Abstract 1020: Cancer health awareness through screening and education (CHANGE): Understanding community experience accessing cancer care

Abstract INTRODUCTION. Incidence and mortality rates for breast, prostate, and colorectal cancers all exceed national rates in Georgia and are higher among African Americans (AAs). Ensuring culturally competent and equitable health care delivery relies on creating an educated and engaged health care team. Patient stories are powerful examples of community-learned experiences and can be used to educate better providers and health care students who serve diverse populations, particularly when communicating risk and prevention of cancer. The goal of the CHANGE project is to provide a sustainable model of evidence-based cancer awareness through education - with an emphasis on prevention and early detection behaviors. We will develop a health disparities and culturally competent cancer care e-Learning curriculum for health care professionals, hematology-oncology fellows, residents, and medical students at the Medical College of Georgia. METHODS. Thirty community members and stakeholders (93% AA, 76% female, all adults) were recruited through public housing, healthcare clinics and providers, and community organizations. Vignettes describing patient access and care interactions were used in semi-structured interviews to guide conversations about experiences accessing care, attitudes towards cancer prevention, and community cancer beliefs. Interviews were recorded, professionally transcribed, and content analyzed using NVivo 12.0 by two independent raters. RESULTS. Three common themes emerged: accessibility of healthcare (transportation, finances, and difficulties in scheduling were primary barriers); cancer myths and cultural norms (no interpersonal discussion of cancer, seen as “taboo,” cancer will spread if cut into and cancer is contagious); and experience of racial bias in health care (historical racial bias and systemic racism; receipt of treatment and care perceived to be different due to race; lack of AA providers). CONCLUSION. This sample adequately represented those most at risk for cancer in Augusta, GA area. Their shared experiences will be used to design and inform an e-learning curriculum, in conjunction with education on health disparities across the state and specific to the local community. This will provide a comprehensive approach to provider education that will begin to improve patient care satisfaction and health outcomes. Citation Format: Marlo M. Vernon, Samantha Jones, Justin X. Moore, Steve S. Coughlin, Vahe Heboyan, Shakirah Clarke, Barbara Idun, Martha S. Tingen. Cancer health awareness through screening and education (CHANGE): Understanding community experience accessing cancer care [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1020.

Prioritization versus rationing of healthcare – elective surgery is not optional surgery

Prioritization versus rationing of healthcare – elective surgery is not optional surgery

Health care seeking behaviour and financial protection of patients with hypertension: A cross-sectional study in rural West Bengal, India.

BackgroundElevated blood pressure or hypertension is responsible for around 10 million annual deaths globally, and people residing in low and middle-income countries are disproportionately affected by it. India is no exception, where low rate of treatment seeking for hypertension coupled with widespread out-of-pocket payments (OOPs) have been a challenge. This study assessed the pattern of health care seeking behaviour and financial protection along with the associated factors among hypertensive individuals in rural West Bengal, India.Method and findingsA cross-sectional study was conducted in Birbhum district of the state of West Bengal, India, during 2017–2018, where 300 individuals were recruited randomly from a list of hypertensives in a population cohort. Healthcare seeking for hypertension and related financial protection in terms of–OOPs and expenses relative to monthly per-capita family expenditure, were analysed. Findings indicated that 47% of hypertensives were not on treatment. Among those under treatment, 80% preferred non-public facilities, and 91% of them had wide-spread OOPs. Cost of medication was a major share of expenses followed by transportation cost to access public health care facility. Multivariable logistic regression analysis indicated longer duration of disease (adjusted odds ratio (aOR): 5.68, 95% Confidence Interval (CI) 1.24–25.99) and health care seeking from non-public establishment (aOR: 34.33, CI: 4.82–244.68) were associated with more incident of OOPs. Linear regression with generalized linear model revealed presence of co-morbidities (adjusted coefficient (aCoeff)10.28, CI: 4.96,15.61) and poorer economic groups (aCoeffpoorest 11.27, CI 3.82,18.71; aCoefflower-middle 7.83, CI 0.65,15.00 and aCoeffupper-middle 7.25, CI: 0.80,13.70) had higher relative expenditure.ConclusionThis study suggests that individuals with hypertension had poor health care seeking behaviour, preferred non-public health facilities and had suboptimal financial protection. Economically poorer individuals had higher burden of health expenditure for treatment of hypertension, which indicated gaps in equitable health care delivery for the control of hypertension.

Grand Challenges in Pharmaceutical Research Series: Ridding the Cold Chain for Biologics.

Biologics are complex pharmaceuticals that include formulated proteins, plasma products, vaccines, cell and gene therapy products, and biological tissues. These products are fragile and typically require cold chain for their delivery and storage. Delivering biologics, while maintaining the cold chain, whether standard (2°C to 8°C) or deepfreeze (as cold as -70°C), requires extensive infrastructure that is expensive to build and maintain. This poses a huge challenge to equitable healthcare delivery, especially during a global pandemic. Even when the infrastructure is in place, breaches of the cold chain are common. Such breaches may damage the product, making therapeutics and vaccines ineffective or even harmful. Rather than strengthening the cold chain through building more infrastructure and imposing more stringent guidelines, we suggest that money and effort are best spent on making the cold chain unnecessary for biologics delivery and storage. To meet this grand challenge in pharmaceutical research, we highlight areas where innovations are needed in the design, formulation and biomanufacturing of biologics, including point-of-care manufacturing and inspection. These technological innovations would rely on fundamental advances in our understanding of biomolecules and cells.

Aboriginal patient and interpreter perspectives on the delivery of culturally safe hospital‐based care

Improving equitable delivery of health care for Aboriginal people in northern Australia is a priority. This study sought to gauge patient experiences of hospitalisation and to identify strategies to improve equity in health care for Aboriginal patients. Aims were to validate an experience of care survey and document advice from Aboriginal interpreters. Medical charts of Aboriginal patients were audited for documentation of language and interpreter use. Aboriginal inpatients were surveyed using an adapted Australian Hospital Patient Experience Question Set. Multiple-choice responses were compared with free-text comments to explore validity. Semi-structured interviews were conducted with Aboriginal interpreter staff. In 68 charts audited, primary language was documented for only 30/68 (44%) people. Of 73 patient experience survey respondents, 49/73 (67%) indicated satisfaction with overall care; 64/73 (88%) indicated hospital staff communicated well in multiple-choice responses. Respondents who gave positive multiple-choice ratings nevertheless reported in free text responses concerns relating to social-emotional support, loneliness, racism and food. Key themes from interviews included the benefits to patients from accessing interpreters, benefits of hospital-based support for interpreters and the need for further service redesign. Multiple-choice questions in the survey were of limited utility; respondents' free comments were more informative. Social and emotional wellbeing must be addressed in future experience-of-care evaluations. Aboriginal patients' language and cultural needs can be better met by improved systems approaches. Aboriginal interpreters are uniquely placed to advise on this. SO WHAT?: Improving health communication is critical to equitable and effective health care. Interventions must be driven by Aboriginal perspectives.

The Quality of Healthcare System of Level 1 Hospitals in Northern Negros Occidental

Healthcare is a primary concern of everyone. The United Nations Sustainable Development Goals recognize the importance of healthcare, ensuring healthy lives for all. Hence, healthcare organizations worldwide are interested in achieving better quality and performance. The Philippines supports this thrust towards achieving universal health coverage. The Philippine Health Agenda for 2016 to 2022 focus on recognizing the advancement and protection of public health. It has to discourse not just the universal and equitable delivery of health care but also the economic, social, and environmental dimensions of health concerns. The enactment of the Local Government Code provided that local government units deliver public health services with the national government's technical assistance through the Department of Health (DOH). Thus, this study describes and compares the level of quality of hospital healthcare system of Level 1 Hospitals in Northern Negros Occidental in the areas of hospital management, patient care management, and service delivery as assessed by implementers and patients' folks when they are taken as a whole and when grouped according to their designation. Likewise, it identified the challenges encountered by implementers and recommendations of patients' folks to improve the healthcare system of hospitals.

“What if There's Something Wrong with Her?”‐How Biomedical Technologies Contribute to Epistemic Injustice in Healthcare

AbstractWhile there is a steadily growing literature on epistemic injustice in healthcare, there are few discussions of the role that biomedical technologies play in harming patients in their capacity as knowers. Through an analysis of newborn and pediatric genetic and genomic sequencing technologies (GSTs), I argue that biomedical technologies can lead to epistemic injustice through two primary pathways: epistemic capture and value partitioning. I close by discussing the larger ethical and political context of critical analyses of GSTs and their broader implications for just and equitable healthcare delivery.

Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory From the American Heart Association.

The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association's vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.

Gender differences in the surgical management of lumbar degenerative disease: a scoping review.

Despite efforts toward achieving gender equality in clinical trial enrollment, females are often underrepresented, and gender-specific data analysis is often unavailable. Identifying and reducing gender bias in medical decision-making and outcome reporting may facilitate equitable healthcare delivery. Gender disparity in the utilization of surgical therapy has been exemplified in the orthopedic literature through studies of total joint arthroplasty. A paucity of literature is available to guide the management of lumbar degenerative disease, which stratifies on the basis of demographic factors. The objective of this study was to systematically map and synthesize the adult surgical literature regarding gender differences in pre- and postoperative patient-reported clinical assessment scores for patients with lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis). A systematic scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. MEDLINE, Embase, and the Cochrane Registry of Controlled Trials were searched from inception to September 2018. Study characteristics including patient demographics, diagnoses, procedures, and pre- and postoperative clinical assessment scores (pain, disability, and health-related quality of life [HRQoL]) were collected. Thirty articles were identified, accounting for 32,951 patients. Six studies accounted for 84% of patients; 5 of the 6 studies were published by European groups. The most common lumbar degenerative conditions were disc herniation (59.0%), disc degeneration (20.3%), and spinal canal stenosis (15.9%). The majority of studies reported worse preoperative pain (93.3%), disability (81.3%), and HRQoL (75%) among females. The remainder reported equivalent preoperative scores between males and females. The majority of studies (63.3%) did not report preoperative duration of symptoms, and this represents a limitation of the data. Eighty percent of studies found that females had worse absolute postoperative scores in at least one outcome category (pain, disability, or HRQoL). The remainder reported equivalent absolute postoperative scores between males and females. Seventy-three percent of studies reported either an equivalent or greater interval change for females. Female patients undergoing surgery for lumbar degenerative disease (disc degeneration, disc herniation, spondylolisthesis, and spinal canal stenosis) have worse absolute preoperative pain, disability, and HRQoL. Following surgery, females have worse absolute pain, disability, and HRQoL, but demonstrate an equal or greater interval change compared to males. Further studies should examine gender differences in preoperative workup and clinical course.

Doctor retention and distribution in post-apartheid South Africa: tracking medical graduates (2007\u20132011) from one university

BackgroundDoctor emigration from low- and middle-income countries represents a financial loss and threatens the equitable delivery of healthcare. In response to government imperatives to produce more health professionals to meet the country’s needs, South African medical schools increased their student intake and changed their selection criteria, but little is known about the impact of these changes. This paper reports on the retention and distribution of doctors who graduated from the University of the Witwatersrand, South Africa (SA), between 2007 and 2011.MethodsData on 988 graduates were accessed from university databases. A cross-sectional descriptive email survey was used to gather information about graduates’ demographics, work histories, and current work settings. Frequency and proportion counts and multiple logistic regressions of predictors of working in a rural area were conducted. Open-ended data were analysed using content analysis.ResultsThe survey response rate was 51.8%. Foreign nationals were excluded from the analysis because of restrictions on them working in SA. Of 497 South African respondents, 60% had completed their vocational training in underserved areas. At the time of the study, 89% (444) worked as doctors in SA, 6.8% (34) practised medicine outside the country, and 3.8% (19) no longer practised medicine. Eighty percent of the 444 doctors still in SA worked in the public sector. Only 33 respondents (6.6%) worked in rural areas, of which 20 (60.6%) were Black. Almost half (47.7%) of the 497 doctors still in SA were in specialist training appointments.ConclusionsMost of the graduates were still in the country, with an overwhelmingly urban and public sector bias to their distribution. Most doctors in the public sector were still in specialist training at the time of the study and may move to the private sector or leave the country. Black graduates, who were preferentially selected in this graduate cohort, constituted the majority of the doctors practising in rural areas. The study confirms the importance of selecting students with rural backgrounds to provide doctors for underserved areas. The study provides a baseline for future tracking studies to inform the training of doctors for underserved areas.

Inequalities in the Age of Universal Health Coverage: Young Chileans with Diabetes Negotiating for Their Right to Health.

While universal health coverage (UHC) has been praised as a powerful means to reduce inequalities and improve access to health globally, little has been said about how patients experience and understand its implementation locally. In this article, we explore the experiences of young Chileans with type 1 diabetes when seeking care in Santiago, within Chile's UHC program, which sought to improve people's access to health care. We argue that the implementation of UHC, within a structurally fragmented health system, did not lead to the promised equitable health care delivery. Although UHC aimed to equitably provide universal care, locally it materialized in heterogeneous configurations forcing individuals into positions of precarity and generating new inequalities. Furthermore, for the young people in the study, UHC intersected with their health insurance and socioeconomic status, impacting on the health care they could access, consequently making diabetes care and management a difficult challenge.

How Biomedical Technologies Harm Patients as Knowers

While there is a steadily growing literature on epistemic injustice in healthcare, there are few discussions of the role that biomedical technologies play in harming patients in their capacity as knowers. Through an analysis of newborn and pediatric genetic and genomic sequencing technologies (GSTs), I argue that biomedical technologies can lead to epistemic injustice through two primary pathways: epistemic capture and value partitioning. I close by discussing the larger ethical and political context of critical analyses of GSTs and their broader implications for just and equitable healthcare delivery.

Incentivizing Physician Diversity in Radiology

In this article, the authors review the evolving state of diversity in the field of radiology. The authors discuss several early and recent historical legislative milestones that increased the equitable delivery of health care in the United States, such as Title VI of the Civil Rights Act of 1964, which ensured that funds for Medicare reimbursement would be available only to desegregated hospitals. Furthermore, the authors examine the current state of diversity and representation in radiology, in which underrepresented minorities represent 8.3% of training and practicing radiologists, and women represent 27.8% of radiologists. Finally, the authors present arguments for diversity in the current medical education system, analyze hurdles to increasing representation in radiology, and consider the future of diversity and inclusiveness in the field.

A health care delivery model focusing on development of a cadre of primary care physicians-Recommendations of Organized Medicine Academic Guild.

Organized medicine is the academic guild of professional medical organizations in India. It was founded at the annual conference of Indian Academy of Pediatrics (PEDICON) on January 7, 2018. Organized medicine is constituted by leading professional medical organizations and mandated to support the sustainability of health agenda of the Government of India. A group of experts on behalf of Organized Medicine Academic Guild (OMAG) of India was constituted to facilitate adequate theories and models on how to make primary care integral to participation of people and intersectoral collaboration in equitable delivery of health care. A subtle, flexible, and comprehensive approach instead of a “compartmentalized existing in silos” approach is likely to be needed. This paper is a formal recommendation on behalf of OMAG with an aspiration to deliver to the people of India, what they need, focusing on discrete objectives with long-term plans.

Public–Private Partnerships in Liver Transplantation: A Novel Approach to Equitable Health-care Delivery

Public–Private Partnerships in Liver Transplantation: A Novel Approach to Equitable Health-care Delivery