Equity In Health Outcomes Research Articles

7.H. Workshop: Lessons Learned Workshop from JAHEE- the importance of evaluation

Abstract Joint Action Health Equity (JAHEE) was a Joint Action financed by the Third Health Programme 2014-2020 of the European Union. It was developed in the period June 1, 2018 - November 30, 2021, and involved 24 countries. It represented an important opportunity for member states to work together to address health inequalities and achieve greater equity in health outcomes across all groups in society in all participating countries and in Europe at large. The results of JAHEE show that almost all participating countries have increased their level of action to address health inequalities and strengthened their capacities in some important policy domains. 76 actions to contrast health inequalities were started during the Joint Action and a final Consensus Policy Document was produced including a set of cross-cutting recommendations. The proposed workshop will discuss the 3-year JAHEE project in the European region and through presentations and active participation review JAHEE actions, results of internal and external evaluations and discuss the main lessons learned. The session will go beyond sharing information and disseminating results and focus on what the JAHEE evaluation has taught us and how it can help improve health equity interventions in the future. We plan to have: a) Presentations 1. Short introduction to JAHEE and Actions 2. Presentation Internal Evaluation 3. Presentation External Evaluation After the presentations there will be opportunity for interactive sessions with the participants to further explore the case studies and issues raised around evaluation and equity b) Interactive Group Discussion • What do the JAHEE evaluations findings add? • What aspects of the evaluation were missing? What could have been improved? • How can the lessons learned from the evaluation be applied to interventions in equity/ migrant health? 3) Feedback from Groups 4) Summary and Conclusions Key messages • No data no progress. • Apply an equity lens: Evaluation in health equity actions is important for the sustainability of actions and contributes to the implementation of good practices.

Illuminating Emergency Nurses’ Perceptions of Stigma, Attribution, and Caring Behaviors Toward People With Mental Illness Through the Lens of Individualized Care: A Cross-sectional Study

IntroductionEmergency nurses’ negative attitudes and lack of caring have been identified as factors affecting the experience of individuals with mental illness in emergency departments. This study examined the relationships between emergency nurses’ perceptions of stigma, attribution, caring behaviors, and individualized care toward people with mental illness. MethodsA cross-sectional study was conducted among 813 nurses working in United States emergency departments. Data were collected using a demographic questionnaire; the Mental Illness: Clinicians’ Attitudes Scale-4; the Attribution Questionnaire; 24-Item Caring Behaviors Inventory; and the Individualized Care Scale-Nurse version. Data analyses consisted of descriptive and correlation statistics and multiple linear regression. ResultsThe findings from the final regression analysis revealed that caring had a significant relationship with individualized care (version A: β = 0.70, P < .001; Version B: β = 0.73; P < .001). Stigma and attribution had significant inverse relationships with individualized care (β = −0.07, P < .01; β = −0.06, P < .05, respectively). DiscussionThe results of this study indicated that emergency nurses’ perception of individualized care toward people with mental illness is mostly associated with the nurses’ level of caring behaviors toward this population. Stigma and attribution had little to no effect. Findings from this study reinforce nurses’ altruistic and caring qualities. The findings suggest the need for a possible paradigm shift from antistigma training to trainings that prioritize caring behaviors toward mental illness. This could ultimately improve health equity, safety, and overall outcomes for people with mental illness.

Advancing Health Research Impact through a Systemic Multi-Sectoral Approach: A Protocol for Introducing Reduced-Sodium Salts and Salty Condiments in Vietnam.

Better alignment between health research organisations with the needs (and interests) of key stakeholders in the health policy and research system is critical to improving research impact. The George Institute for Global Health’s ‘Healthier Societies’ program focuses on harnessing the power of governments, markets, and communities to improve population level health equity outcomes and maximise research impact. This protocol outlines a systemic multi-sectoral approach to advance health research impact globally applied to a project to reduce population salt intake in Vietnam by introducing reduced-sodium salts and salty condiments. We defined a systemic multi-sectoral approach to be a strategy that involves engaging with government, market and communities in a deliberate and joined-up way to solve a problem in which they all have a role to play. The project objectives are to: (i) produce reduced-sodium fish sauce products and test consumer acceptability; (ii) investigate the market feasibility of introducing reduced-sodium foods (salt, bot canh and fish sauce) into the Vietnamese market; (iii) estimate the cost-effectiveness of three different government strategies to support the implementation of reduced-sodium products; and (iv) develop an advocacy roadmap to maximise potential research impact. Methods will include standard quality and safety assessments, consumer sensory testing for the locally produced reduced-sodium fish sauces, market feasibility assessment (including collating market data and semi-structured interviews with stakeholders), cost-effectiveness modelling (Markov cohort model), multi-sector stakeholder engagement, and the development of a coordinated advocacy strategy using the Kotter Plus framework. Health research organisations are increasingly seeking ways to achieve greater impact with their research. Through the application of a systemic multi-sectoral approach with governments, markets and communities, this protocol provides an example of how health research projects can achieve such impact.

Identifying community-level disparities in access to driver education and training: Toward a definition of driver training deserts

Objective Obtaining a license may be challenging for teens due to access to driving instruction; in some states, behind-the-wheel (BTW) instruction is required to secure a license before age 18. We investigate spatial accessibility to BTW centers, and how this geographic distribution intersects with metrics of social disparity at the metropolitan level, toward identifying Driver Training Deserts (DTDs): geographic areas of disconnection to driver training. Methods For the Columbus OH region, we collect socioeconomic variables at the Census tract unit of analysis and geocoded locations of public and private BTW training centers and estimate travel time to the nearest BTW training center. We define travel time as either the mean or the maximum travel time to BTW centers across all 1 km × 1 km grid cells within a Census tract. We employ spatial statistical approaches, including homogeneous/inhomogeneous K functions, to determine whether BTW training centers are clustered. Next, we define DTDs as Census tracts with a poverty rate and travel time to BTW centers larger than the 75th percentile values across the region. Results BTW training centers are spatially clustered across the region; the magnitude of this clustering is so great that BTW centers exhibit statistically significant patterns of clustering, even when considering the underlying spatial distribution of socio-economic characteristics. We find that 11–27 Census tracts are identified as DTDs depending on the definition of travel time. DTDs contain a disproportionate percent of the high poverty population (8.7–23.5%) and, depending on the definition of travel time, a disproportionately large African American population. Conclusions Methodologically, defining DTDs necessitates a fine-grained spatial approach as suburban and rural Census tracts tend to be large and thus can be poorly represented by travel times averaged over the Census tract. Defining DTDs as a measure of individual-specific variables – income and impedance – allows DTDs to be addressed with policy interventions. The findings motivate future research correlating DTDs with licensure rates, enrollment in driver training, and safe driving outcomes to understand if DTDs can help explain health equity outcomes related to young driver safety.

The Role of Health Equity and Improving Care and Outcomes From a Coordinated Approach.

Vickers, Selwyn M. MD*; Lee, Vivian S. MD, PhD, MBA†; Love, Ted W. MD‡; Randall, David PhD§; Pawlik, Timothy M. MD, MPH, PhD∥ Author Information

Ethical and Policy Implications of Financial Burden in Family Caregivers.

Palliative care nurses are key members of the health care team and provide support to patients and their families navigating chronic and life-limiting illness. Financial burden is an issue inherent to chronic illness, yet has not been fully addressed in family caregivers. The purpose of this article is to (1) provide a case study of a family caregiver navigating chronic illness with her daughter and the associated financial and employment consequences and (2) review the nursing ethical, policy, and practice implications of financial burden for family caregivers. The ethical implications of financial burden in family caregivers relate to health equity and health outcomes for both the patient and family caregiver in treatment access and quality. The policy implications include state and federal policies related to caregiver compensation and support and family medical leave. Palliative care nurses play an integral role in addressing caregiver financial burden through assessment, education, referral, and policy support. Family caregivers are essential to the palliative care team, and palliative care nurses have the opportunity to lead initiatives to support the financial well-being of family caregivers in practice, research, and policy settings.

27. Understanding Exposure to Plastic Surgery at the Undergraduate University Level

Background: A diverse workforce in medicine has been shown to improve health equity and patient outcomes. Despite this, minority populations are underrepresented among physicians, particularly among surgical specialties such as plastic and reconstructive surgery. Current research investigates where along the medical school-to-residency pathway (aka, “the pipeline”) students of color are lost. This study aims to target students earlier in the pipeline, during undergraduate university, to determine if and how students are exposed to the field of plastic surgery and if exposures differ by demographic variables. Methods: Data was collected via an IRB-approved survey distributed via Qualtrics to one institution’s undergraduate students self-identified as pursuing a career as a physician. Descriptive statistics and logistic regression were conducted to determine odds of exposure to plastic surgery when considering variables such as race and academic factors (e.g., year in school, involvement in research). Results: Of 136 completed surveys, 54 met inclusion criteria and were analyzed: 75.9% (n=41) were women, 25.9% (n=14) were college juniors, and 9.3% (n=5) were college seniors. The majority of respondents were East Asian (33.3%, n=18), followed by multiracial (18.5%, n=10), and South Asian (14.8%, n=8). Women had a lower odds of exposure to plastic surgery than men (OR: 0.913, 95% CI: 0.3-3.2) and Black/African American and Hispanic/Latinx students had a higher odds of exposure than White students (OR: 1.3 and 3.3, respectively; CI: 0.4-30.7 and 0.1-15.7, respectively). Odds of exposure increased with each increasing year of age (OR: 1.63, CI: 1.0-2.7) and were higher for students involved in research than those who were not (OR: 4.7, CI: 0.9-24.4). Conclusion: Our preliminary survey of undergraduate students at one academic institution demonstrates that men, African American, and Latinx students were more likely to have had previous exposure to plastic surgery than women or White students. Additionally, older students or those with research experience were increasingly likely to have had exposure to the field. We are currently expanding the study to include other undergraduate universities to confirm or disprove these data in order to better design potential interventions to support underrepresented students pursuing plastic and reconstructive surgery.

Exploring theoretical mechanisms of community-engaged research: a multilevel cross-sectional national study of structural and relational practices in community-academic partnerships

BackgroundCommunity-Based Participatory Research (CBPR) is often used to address health inequities due to structural racism. However, much of the existing literature emphasizes relationships and synergy rather than structural components of CBPR. This study introduces and tests new theoretical mechanisms of the CBPR Conceptual Model to address this limitation.MethodsThree-stage online cross-sectional survey administered from 2016 to 2018 with 165 community-engaged research projects identified through federal databases or training grants. Participants (N = 453) were principal investigators and project team members (both academic and community partners) who provided project-level details and perceived contexts, processes, and outcomes. Data were analyzed through structural equation modeling and fuzzy-set qualitative comparison analysis.ResultsCommitment to Collective Empowerment was a key mediating variable between context and intervention activities. Synergy and Community Engagement in Research Actions were mediating variables between context/partnership process and outcomes. Collective Empowerment was most strongly aligned with Synergy, while higher levels of Structural Governance and lower levels of Relationships were most consistent with higher Community Engagement in Research Actions.ConclusionsThe CBPR Conceptual Model identifies key theoretical mechanisms for explaining health equity and health outcomes in community-academic partnerships. The scholarly literature’s preoccupation with synergy and relationships overlooks two promising practices—Structural Governance and Collective Empowerment—that interact from contexts through mechanisms to influence outcomes. These results also expand expectations beyond a “one size fits all” for reliably producing positive outcomes.

Databases for Gastrointestinal Clinical and Public Health Research: Have Database, Will Research

Databases for Gastrointestinal Clinical and Public Health Research: Have Database, Will Research

We can do better.

FigureFigureFigureFigureFigureFigureFigureOne of the most satisfying moments for PA educators, community providers, and clinical preceptors is watching students progress from new learners to highly skilled clinicians. We bookend these milestones of achievement with ceremonies that ask students/graduates, faculty, and alumni to reflect on, and commit to, a common set of values. In PA school, this usually is the Oath of the Physician Assistant. Importantly, this oath is a direct reflection of the Statement of Values for the PA Profession, and is a staple of white coat ceremonies and graduations alike.1 It reads as follows: “I pledge to perform the following duties with honesty and dedication: I will hold as my primary responsibility the health, safety, welfare and dignity of all human beings. I will uphold the tenets of patient autonomy, beneficence, nonmaleficence, and justice. I will recognize and promote the value of diversity. I will not discriminate. I will treat equally all persons who seek my care. I will hold in confidence the patient-specific information shared in the course of practicing medicine. I will actively seek to expand my knowledge and skills, keeping abreast of advances in medicine. I will assess my personal capabilities and limitations, striving always to improve my practice of medicine. I will work with other members of the healthcare team to provide compassionate and effective care of patients. I will use my knowledge and experience to contribute to a healthy community and the improvement of public health. I will respect my professional relationship with all members of the healthcare team. I will share and expand my clinical and professional knowledge with PAs and PA students. These duties are pledged with sincerity and upon my honor.” As we collectively reflect on the national and international events of the last couple years, we are struck by the following passages: “I will recognize and promote the value of diversity,” and “I will treat equally all persons who seek my care.” Although this oath, and the values it reflects, are ostensibly representative of the aspirations we collectively have of our graduates and trainees, we would ask: does this small nod to diversity adequately represent these aspirations? Is merely recognizing and promoting the value of diversity enough? Should we not be moving away from equality and toward equity in our pursuit of healthy people and communities? When silence in the face of oppression and injustice serves invariably to perpetuate it, are we, as a profession, content with this value, or are we failing to hold ourselves to a high enough standard? Looking across the healthcare professions, some professional oaths pay homage to the importance of diversity, equity, and inclusion (DEI), and others do not. Notably, the Hippocratic Oath, both the original and a widely accepted modern version, is silent on the issue.2,3 The Oath of the Pharmacist, on the other hand, was recently updated to describe not only the actions that will be taken to advance DEI (promote inclusion, embrace diversity, advocate for justice), but the ends this oath will achieve—advancing health equity.4 As we ask graduates to contemplate the weight, responsibility, and burden of their new office, we are missing an opportunity to them collectively contemplate and affirm, if ever so briefly, their commitment to advancing DEI. As we move forward, the language in the Oath of the Physician Assistant should align with the existing DEI statements and strategic plan pillars set forth by our collaborating PA organizations.5-9 This alignment moves the profession toward actions, instead of performative gestures, as we seek health equity, outcomes parity, and social justice. We expect that these statements will move us as a profession from rewarding intentions to celebrating health equity outcomes and greater diversity in our field. Thinking ahead beyond DEI, the next step is incorporating justice into healthcare. Words matter ... and the ones in the current oath are timid, incomplete, almost meaningless, and outdated at best, and at worst, reflect a mere perfunctory nod to what is one of many important determinants of health. In our new oath, a commitment to dismantling the racist, sexist, and oppressive behaviors of our healthcare systems should be included to ensure that we as a profession can commit to a truly equitable future. We can do better. Actually, we must do better.

Assessing and Addressing Social Determinants of Health Among Children and Youth With Special Health Care Needs.

Over several decades, a field of research has emerged to examine social and environmental factors that contribute to health inequities among children and youth with special healthcare needs (CYSHCN), with the goal of reducing inequities through identifying and mitigating these social determinants of health (SDH). The Children and Youth with Special Healthcare Needs National Research Network (CYSHCNet) national research agenda development process, described in a companion article, recognized SDH, as experienced by CYSHCN, and the effects on health inequity and child and family outcomes as a high priority area. Important gaps named included which strategies best identify and mitigate the effects of negative SDH and which outcomes are most meaningful to families receiving SDH-focused interventions. In this area, the highest priority questions were the following: 1) How can SDH be routinely addressed in the course of care for CYSHCN? 2) Which interventions most effectively integrate SDH to improve child and family outcomes? Here, we discuss the impact of SDH on CYSHCN, efforts to screen for and intervene upon SDH in this population, and gaps in the current research on SDH specific to CYSHCN. We make several recommendations for research studies that will move the field forward. This work should achieve a greater understanding of patterns and impacts of SDH experienced by CYSHCN. It will also contribute to optimizing identification of SDH and improving interventions to achieve equity in health outcomes identified by patients and families as important to them.

Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study

Overwhelming evidence that anti-Black racism is associated with health inequities is driving clinician demand for antiracism practices that promote health equity. To investigate how nonmedical professionals address personally mediated, institutional, and internalized racism and to adapt these practices for the clinical setting. Using an approach from human-centered design for this qualitative study, virtual qualitative interviews were conducted among 40 professionals from nonmedical fields to investigate antiracism practices used outside of medicine. Inductive thematic analysis was conducted to identify latent themes and practices that may be adaptable to health care, subsequently using an established theoretical framework describing levels of racism to interpret and organize themes. Convenience and purposive sampling was used to recruit participants via email, social media, and electronic flyers. Antiracism practices adapted to medicine. Among 40 professionals from nonmedical fields, most were younger than age 40 years (23 individuals [57.5%]) and there were 20 (50.0%) women; there were 25 Black or African American individuals (62.5%); 4 East Asian, Southeast Asian, or South Asian individuals (10.0%); 3 individuals with Hispanic, Latinx, or Spanish origin (7.5%); and 3 White individuals. Participants described personally mediated, institutional, and internalized antiracism practices that may be adaptable to promote health equity for Black patients. Personally mediated antiracism practices included dialogue and humble inquiry, building trust, and allyship and shared humanity; clinicians may be able to adopt these practices by focusing on patient successes, avoiding stigmatizing language in the electronic health record, and using specific phrases to address racism in the moment. Institutional antiracism practices included education, representation, and mentorship; in the health care setting, clinics may be able to develop staff affiliate groups, focus on improving racial health equity outcomes, and conduct antiracism trainings. Internalized antiracism practices centered on authenticity; clinicians may be able to write positionality statements reflecting their identity and the expertise they bring to clinical encounters. This study's findings suggest that antiracism practices from outside the health care sector may offer innovative strategies to promote health equity by addressing personally mediated, institutional, and internalized racism in clinical care.

Public Health Strategies: A Pathway for Public Health Practice to Leverage Law in Advancing Equity.

This article outlines a pathway for public health departments and practitioners to incorporate law into their efforts to advance equity in health outcomes. We assert that examining and applying law can accelerate public health efforts to mitigate structural and systemic inequities, including racism. Recent events such as the COVID-19 pandemic and the community impacts of policing have brought into sharp relief the inequities faced by many populations. These stark and explosive examples arise out of long-standing, persistent, and sometimes hidden structural and systemic inequities that are difficult to trace because they are embedded in laws and accompanying policies and practices. We emphasize this point with a case study involving a small, majority Black community in semirural Appalachia that spent almost 50 years attempting to gain access to the local public water system, despite being surrounded by water lines. We suggest that public health practitioners have a role to play in addressing these kinds of public health problems, which are so clearly tied to the ways laws and policies are developed and executed. We further suggest that public health practitioners, invoking the 10 Essential Public Health Services, can employ law as a tool to increase their capacity to craft and implement evidence-based interventions.

A typology of power in implementation: Building on the exploration, preparation, implementation, sustainment (EPIS) framework to advance mental health and HIV health equity.

Persistent inequities in HIV health are due, in part, to barriers to successful HIV-related mental health intervention implementation with marginalized groups. Implementation Science (IS) has begun to examine how the field can promote health equity. Lacking is a clear method to analyze how power is generated and distributed through practical implementation processes and how this power can dismantle and/or reproduce health inequity through intervention implementation. The aims of this paper are to (1) propose a typology of power generated through implementation processes, (2) apply this power typology to expand on the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to advance HIV and mental health equity and (3) articulate questions to guide the explicit examination and distribution of power throughout implementation. This paper draws on the work of an Intermediary Purveyor organization implementing trauma-informed care and harm reduction organizational change with HIV service organizations. The expanded framework was developed through analyzing implementation coaching field notes, grant reporting, and evaluation documents, training feedback, partner evaluation interviews, and existing implementation literature. The authors identify three types of power working through implementation; (1) discursive power is enacted through defining health-related problems to be targeted by intervention implementation, as well as through health narratives that emerge through implementation; (2) epistemic power influences whose knowledge is valued in decision-making and is recreated through knowledge generation; and (3) material power is created through resource distribution and patterns of access to health resources and acquisition of health benefits provided by the intervention. Decisions across all phases and related to all factors of EPIS influence how these forms of power striate through intervention implementation and ultimately affect health equity outcomes. The authors conclude with a set of concrete questions for researchers and practitioners to interrogate power throughout the implementation process. Over the past few years, Implementation Science researchers have committed increased attention to the ways in which the field can more effectively address health inequity. Lacking is a clear method to analyze how implementation processes themselves generate power that has the potential to contribute to health inequity. In this paper, the authors describe and define three types of power that are created and distributed through intervention implementation; discursive power, epistemic power, and material power. The authors then explain how these forms of power shape factors and phases of implementation, using the well-known EPIS (exploration, preparation, implementation, sustainment) framework. The authors draw from their experience working with and Intermediary Purveyor supporting HIV service organizations implementing trauma-informed care and harm reduction organizational change projects. This paper concludes with a set of critical questions that can be used by researchers and practitioners as a concrete tool to analyze the role of power in intervention implementation processes.

Association of Health-Care System and Survival in African American and Non-Hispanic White Patients With Bladder Cancer.

African American patients with bladder cancer have inferior outcomes compared with non-Hispanic White (White) patients. We hypothesize that access to health care is a primary determinant of this disparity. We compared outcomes by race for patients with bladder cancer receiving care within the predominant hybrid-payer health-care model of the United States captured in the Surveillance, Epidemiology, and End Results (SEER) database with those receiving care within the equal-access model of the Veterans' Health Administration (VHA). African American and White patients diagnosed with bladder cancer were identified in SEER and VHA. Stage at presentation, bladder cancer-specific mortality (BCM), and overall survival (OS) were compared by race within each health-care system. The SEER cohort included 122 449 patients (93.7% White, 6.3% African American). The VHA cohort included 36 322 patients (91.0% White, 9.0% African American). In both cohorts, African American patients were more likely to present with muscle-invasive disease and metastases, but the differences between races were statistically significantly smaller in VHA. In SEER multivariable models, African American patients had worse BCM (hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.15 to 1.29) and OS (HR = 1.26, 95% CI = 1.20 to 1.31). In contrast within the VHA, African American patients had similar BCM (HR = 0.97, 95% CI = 0.88 to 1.07) and OS (HR = 0.99, 95% CI = 0.93 to 1.05). In this study of contrasting health-care models, receiving medical care in an equal-access system was associated with reduced differences in stage at presentation and eliminated disparities in survival outcomes for African American patients with bladder cancer. Our findings highlight the importance of reducing financial barriers to care to notably improve health equity and oncologic outcomes for African American patients.

Diversity, Equity, Inclusion: Crucial for Organizational Learning and Health Equity

Achieving health equity requires a diversity of perspectives, values, and insights, yet the composition of the United States’ nursing workforce does not reflect the communities where they practice. Nurse leaders can advance health equity and exemplary clinical outcomes by creating diverse, equitable, and inclusive health care teams. Such teams are well-equipped for organizational learning, a crucial process for advancing health equity. Nurse leaders advance health equity by fostering diversity, equity, inclusion, and thus organizational learning in the workplace.

Racial Disparities in Stillbirth Risk Factors among non-Hispanic Black Women and non-Hispanic White Women in the United States.

Historically, stillbirth risk factors are more prevalent among non-Hispanic Black women than non-Hispanic White women, including age < 20, lower formal educational attainment, prepregnancy obesity, smoking, hypertension, diabetes, short interpregnancy interval, small for gestational age newborn, late prenatal care, and previous cesarean birth. We examined whether these disparities have changed since 2011 and identified a group of risk factors that differed between Black women and White women when accounting for correlations among variables. In a random sample of 315 stillbirths from the National Center for Health Statistics' 2016 fetal death data, Black women and White women were compared for each risk factor using t-tests or chi-square tests. Variables with p ≤ .20 were analyzed using multivariate analysis of variance. In this sample, Black women experiencing stillbirth were less likely to have a Bachelor's degree (12.94% vs. 28.49%, p = .04), and more likely to be obese (44.5% vs. 29.1%, p = .01) than White women. Multivariate analysis accounting for correlations among variables showed a group of risk factors that differed between Black women and White women: age < 20, lower education, prepregnancy obesity, hypertension (chronic and pregnancy-associated), nulliparity before stillbirth, and earlier gestation. Less formal education, obesity, age <20, hypertension, chronic and pregnancy-associated, nulliparity, and earlier gestation are important to consider in multilevel stillbirth prevention interventions to decrease racial disparity in stillbirth. Respectfully listening to women and taking their concerns seriously is one way nurses and other health care providers can promote equity in health outcomes for childbearing women.

A Framework for Anti-Racist Publication in Palliative Care: Structures, Processes, and Outcomes

Systemic or structural racism describes an embedded pattern of explicit and implicit racial biases that, through policy and action, systematically confer advantage to white people and disadvantage Black, indigenous, and other people of color. Hospice and palliative care journals participate in this broader system of racial discrimination. Building on palliative care's explicit focus on patients’ goals and values, which may in and of itself comprise a form of social justice in healthcare, palliative care journals and their publishers have an opportunity to lead others in cultivating anti-racist practices and explicitly promoting equity. The publication life cycle of submission and solicitation, manuscript peer-review, and publication provide a framework for examining the structures, processes, and outcomes by which palliative care and other journals might address systemic racism. We describe the current academic publishing landscape, which diminishes the voices and experiences of racial and ethnic minority patients and undermines the careers of under-represented scholars. We then propose reforms that we believe will improve publication equity and quality as well as healthcare outcomes. These include an Equity in Publication checklist, solicitation of manuscripts on equity-relevant topics, promotion of scholars through editorial structures and peer review processes, and a standard Equity Rating for publications. Greater efforts to include non-dominant voices in every aspect of publication, through appropriate recognition of their scholarship and remuneration for their efforts, will drive equity in health outcomes. By pursuing an anti-racist and equity-focused publishing agenda, hospice and palliative medicine journals and their publishers have an opportunity to transform healthcare.

The impact of the COVID-19 pandemic on paediatric glioma patients in low, middle, and high-income countries: a multicentre, international, observational cohort study

AimsPaediatric cancer is a leading cause of non-communicable disease deaths for children worldwide, with more than 90% of deaths occurring in low-and-middle-income countries (LMICs). The COVID-19 pandemic may have exacerbated disparities in paediatric cancer outcomes between LMICs and HICs. The World Health Organization (WHO) Global Initiative for Childhood Cancer has identified gliomas as a common cancer that can act as a benchmark for assessing global paediatric cancer care. This study aims to ascertain the short and medium-term outcome across 17 countries during the COVID-19 pandemic by determining 30- and 90-day all-cause mortality rates for paediatric glioma patients who underwent treatment.MethodA multicentre, international, mixed- (retrospective and prospective), collaborative cohort study in 17 countries. Patients were recruited between March 12th 2020 and July 12th 2020.Results129 patients were recruited with the majority being histologically diagnosed as low-grade gliomas (n = 86/118, 72.9%). Seven children had a change to their planned chemotherapy treatment because of the COVID-19 pandemic. Similarly, seven children and eleven children had a change to their planned radiotherapy treatment and surgical treatment respectively because of the COVID-19 pandemic. Five patients died within the 30-day follow-up period, with all five patients being in LMICs. A sixth child, also in a LMIC, died within the 90-day follow-up period. This significant difference in mortality between LMICs and HICs was present when controlling for confounding for factors such as grade, ASA status, sex, weight, and age. ConclusionThere has been relatively minimal change to the treatment of paediatric gliomas worldwide compared to their initial planned care. There was a significant difference in mortality for childhood gliomas between LMICS and high-income countries during the COVID-19 pandemic. There needs to be a concerted effort to improve equity in health outcomes globally.

How Does Insurance Status Correlate With Trauma Mechanisms and Outcomes? A Retrospective Study at a Level 1 Trauma Center.

Studies showed that a lack of insurance is associated with worse trauma outcomes. We examine insurance status and trauma mortality in a diverse metropolitan city and hypothesize that the higher risk of mortality in uninsured patients is due to insurance status and other factors. A retrospective analysis of patients admitted to a Level 1 Trauma center for emergent surgery in a diverse metropolitan city from Jan 2016-May 2020 was conducted. Patients of different insurance statuses were analyzed for their injury mechanism and surgical intervention outcomes. Multivariate logistic regression was performed and the results were presented as odds ratio with 95% confidence intervals and P values. Statistical significance was set at P < .05. 738 patients met study criteria. Medicaid patients made up the largest proportions of injury mechanisms: 65.1% of gunshot wound cases, sharp object (41.7%), and falls (32.5%). Private insurance (OR = .13, 95% CI: .05-.35, P = .000), Medicaid (OR = .19, 95% CI: .10-.35, P = .000), Medicare (OR = .65, 95% CI: 0.28-1.51, P = .31), and other insurance (OR = .44, 95% CI 0.22-.87, P = .01) were associated with survival. Uninsured patients had the highest mortality rate resulting from trauma at 32.6% (P < .001), and the lowest mortality rate belonged to the private insurance cohort (6.3%, P < .001). Uninsured patients accounted for 10.5% of gunshot wound cases, 8.5% of motor vehicle accident cases, 25% of sharp object cases, and 6.6% of falls. Being uninsured was independently associated with mortality, while having insurance improved outcomes. Underlying mechanisms should be further elucidated to improve health equity and trauma outcomes in diverse patient populations.