Inequalities In Care Research Articles

Comparison of pathologist and deep learning–based prostate cancer grading for prediction of metastatic outcomes in primary prostate cancer.

345 Background: Gleason grading is the most potent prognostic variable in primary prostate cancer, however inter-observer variability remains a major issue, particularly where subspecialty-trained pathologists are not available. Artificial intelligence algorithms for prostate cancer grading may improve health care equity by ensuring widespread access to standardized, high quality grading, however most algorithms have not been tested for performance with respect to oncologic outcomes. Here, we compared deep learning-based and pathologist-based Gleason grading for prediction of metastatic outcome in three large radical prostatectomy cohorts. Methods: Three previously published radical prostatectomy cohorts from Johns Hopkins were utilized for this study. The Natural History Cohort (n=318, PMID: 26058959) and Case-Cohort (n=231, PMID: 36006048) both utilized a case-cohort design on the outcome of metastasis, while the Race Cohort (n=335, PMID: 30851334) was designed for a grade-matched comparison of self-identified White and Black patients. For each cohort, a single representative H&E-stained slide from the dominant tumor nodule was scanned and Gleason Grade Group (GG) assessed by a modified deep learning-based grading algorithm (PMID: 35233002), or by a subspecialty-trained pathologist. Harrell’s C-indices based on unadjusted Cox models for time to metastasis were compared for the pathologist- and deep learning-assigned GG in each cohort. Results: The C-index for deep learning-assigned GG in the Natural History Cohort was 0.757 (95% confidence interval [CI]: 0.703-0.811) compared to 0.748 (95% CI: 0.692-0.804) for the pathologist-assigned GG. The C-index for deep learning-assigned GG in the Case-Cohort was 0.848 (95% CI: 0.727-0.969) compared to 0.843 (95% CI: 0.722-0.964) for the pathologist-assigned GG. The C-index for deep learning-assigned GG in the Race Cohort was 0.754 (95% CI: 0.697-0.810) compared to 0.780 (95% CI: 0.717-0.844) for the pathologist-assigned GG. In a combined analysis of all three cohorts, the C-index for the deep learning-assigned GG was 0.765 (95% CI: 0.725-0.805) compared to 0.772 (95% CI: 0.730-0.814) for the pathologist-assigned grade group. In the combined cohorts, the historical pathologist-assigned GG for the entire case had a C-index of 0.796 (95% CI: 0.757-0.836). Conclusions: Deep learning and subspecialty-trained pathologist grading were highly comparable for association with metastatic outcome across three large radical prostatectomy cohorts.

Abstract HUP8: Mobile Stroke Unit Management Associated With Reduction In Racial Disparities In Stroke Treatment Metrics

Background: Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported. Methods: A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality. Results: A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03). Conclusion: MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.

Abstract 88: Mobile Stroke Unit Management Associated With Reduction in Racial Disparities in Stroke Treatment Metrics

Background: Racial and ethnic disparities in stroke exist across the continuum of care, including prehospital care. The impact of Mobile Stroke Units (MSUs) on racial disparities in thrombolytic treatment metrics is not reported. Methods: A pre-specified sub-study of ischemic stroke patients enrolled in BEST-MSU was conducted. MSU and standard management (SM) groups were divided into Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (H) cohorts. Other racial groups were excluded (small n). Primary outcome was last seen normal to tPA time[GJ1] . Secondary outcomes included 90-day utility-weighted modified Rankin Scale (uw-mRS), functional independence (mRS 0-1), and mortality. Results: A total of 1420 patients were included: 557 NHW, 586 NHB, and 277 H. NHB and H groups were younger, had lower education, and higher proportions uninsured. In SM, NHB and H patients received slower care and less frequent tPA compared to NHW (Table 1). In contrast, MSU management reduced time to treatment (19 min NHW vs 46.5 min NHB vs 46 min H; p=<0.001) in NHB and H, and led to more frequent tPA (13% more NHW, 11% more NHB, 25% more H) in H. MSU management was associated with better uw-mRS across all groups (Figure 1). More functional independence was seen in NHW and NHB (adjusted OR NHW 1.79 [1.10-2.95] p=0.019; NHB 2.13 [1.38-3.33] p=0.0007). Mortality benefit was seen in H (p=0.03). Conclusion: MSUs overcome known disparities in thrombolytic utilization and treatment metrics in Non-Hispanic Black and Hispanic groups. Further studies are needed to evaluate care inequities that are overcome through integration of a MSU into the prehospital setting.

Gender-related self-reported mental health inequalities in primary care in England: a cross-sectional analysis using the GP Patient Survey

Transgender, non-binary, and gender diverse people face discrimination and barriers to accessing health care. Existing evidence suggests higher rates of mental health conditions among these groups compared with binary and cisgender groups. However, information is limited by poor gender recording in health records and surveys. We aimed to provide the first national estimates of gender-related inequalities in self-reported mental health conditions and mental health support across 15 gender groups in England. We used changes to the 2021 and 2022 nationally representative cross-sectional English General Pracitioner (GP) Patient Surveys and used age-adjusted logistic regression to predict probabilities of two outcomes: first, self-reporting a mental health condition and second, self-reporting unmet mental health needs. We report results for 15 exposure groups: five gender groups (female, male, non-binary, prefer to self-describe, and prefer not to say), within three cisgender or transgender identity groups (cisgender, transgender, or prefer not to say). We explored potential mediation by adding covariates. Of the 1 520 457 respondents in the estimation sample, 861 017 (51·4%) were female, 645 300 (47·4%) were male, 2600 (0·3%) were non-binary, 2277 (0·2%) self-described their gender, and 9263 (0·7%) preferred not to state their gender. 1 499 852 (98·3%) respondents were cisgender, 7994 (0·7%) were transgender, and 12 611 (1·0%) preferred not to say their cisgender or transgender identity. We found wide gender-related inequalities in the probability of self-reporting a mental health condition, with the highest probabilities among non-binary patients who were transgender (47·21% [95% CI 42·86-51·60]) or preferred not to say their cisgender or transgender identity (32·90% [26·50-40·00]), and among transgender patients who self-described their gender (35·03% [27·39-43·53]). With the exception of non-binary patients in each case, probabilities were lowest among cisgender patient groups (ranging from male at 8·80% [8·69-8·92] to female at 11·97% [11·86-12·07]) and patients who preferred not to say their cisgender or transgender identity (ranging from female 7·15% [6·06-8·42] to prefer to self-describe 10·37% [7·13-14·86]). Inequalities in other health conditions and socioeconomic factors might mediate some of these inequalities. Probabilities of self-reported unmet mental health needs were lowest among cisgender male (15·55% [15·33-15·76]) and female (15·93% [15·76-16·10]) patients with increased probabilities among all other groups, ranging from 19·95% (17·57-22·57) in transgender male patients to 28·64% (26·23-31·17) among patients who preferred not to say their gender or their cisgender or transgender identity. Inequalities in interactions with health-care professionals may mediate much of these inequalities. Together with existing evidence, our findings showed large gender-related inequalities in self-reported mental health outcomes in England. Given the existence of self-reported unmet mental health needs, we suggest that better health care system inclusivity and health-care professional training are needed, alongside broader improvements in the social and legal environment for transgender, non-binary, and gender diverse people. National Institute for Health and Care Research.

Missed care and equitable breastfeeding support: An integrative review of exposure to in-hospital care by patient characteristics and breastfeeding outcomes.

To synthesize the literature on breastfeeding outcomes associated with exposure to internationally recognized best practices, such as the Baby-Friendly Hospital Initiative, for patients in the United States during the postpartum period, contextualized within the Missed Care Model. The authors employed Whittemore and Knafl's integrative review framework and the 2020 PRISMA guidelines for data extraction, synthesis, reporting and assessment. Five electronic databases were searched for articles published between 2007 and 2023. Eligible articles reported on exposure to breastfeeding best practices and outcomes or the experiences, views, perceptions and attitudes of parents, nurses or lactation consultants regarding hospital breastfeeding support. Extracted data were compared to identify in-hospital exposure to breastfeeding best practices and breastfeeding outcomes, and differences in exposure and outcomes based on patient and provider characteristics. Twenty-one quantitative, qualitative and mixed methods articles met inclusion criteria. A higher reported adherence to best practices was associated with greater odds of breastfeeding; some practices demonstrated greater effects overall or for specific groups. Higher exposures to best practices and higher breastfeeding rates were found for non-Hispanic white patients, and those with more education, private insurance and who live in urban areas. Disparities in support and outcomes were related to patients' race/ethnicity, language, weight and age. Qualitative findings reflected missed care concepts, such as internal processes related to habits and group norms, relevant to breastfeeding support. Review findings also include an adapted Missed Care Model specific to breastfeeding support, which can inform future research related to providers' internal processes that may influence breastfeeding or equitable breastfeeding care. Missed care can be influenced by a variety of factors, including providers' internal values and beliefs. Study findings suggest the existence of inequities in breastfeeding care and underscore the need to address and eliminate breastfeeding disparities. This study addressed how patient exposure to best practices in breastfeeding support relates to breastfeeding outcomes and whether exposure and outcomes differ by patient or provider characteristics, connecting this to the Missed Care in Breastfeeding Support Model. The main findings were that higher reported exposure to best practices in breastfeeding support related to improved breastfeeding outcomes; inequities exist in exposure to best practices; and patients and providers identify the importance of providers' internal processes in the delivery of breastfeeding support, which aligns with the Missed Care in Breastfeeding Support Model. Study findings will have the potential to impact how nurses, lactation consultants and other providers who deliver breastfeeding support in the postpartum hospital setting. The authors adhered to relevant 2020 PRISMA reporting guidelines. No patient or public contribution.

Technology and health inequities in diabetes care: How do we widen access to underserved populations and utilize technology to improve outcomes for all?

Digital health technologies are being utilized increasingly in the modern management of diabetes. These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps). Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide. In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.

Experiences of healthcare practitioners providing nutrition care to people with cancer in New Zealand: A qualitative study.

Aim: To explore the perspectives and experiences of healthcare practitioners in providing nutrition care to people with cancer in New Zealand. Methods: Semi-structured interviews were conducted with 16 New Zealand healthcare professionals (HCPs) practicing in specialist secondary and tertiary cancer care (both public and private) who had previously completed an online survey about nutrition in cancer care. Interviews were recorded and transcribed verbatim, and thematic analysis was undertaken. Results: Participants identified nutrition as important in cancer care, from diagnosis to survivorship, in order to maximise recovery and ongoing health. While participants reported that the best person to provide high-quality individualised nutrition care is a dietitian, other HCPs also have a role in nutrition care. Limited nutrition care is currently available, especially for those in rural areas, which impacts health and equity in cancer care. Participants identified a need for increased dietitian capacity in the workforce as well as a need for nutrition resources that were accessible and appropriate. Conclusion: The perspective of participants was that more must be done to provide nutrition care as part of cancer care in New Zealand to improve health and wellbeing among people with cancer.

P889 Facilitating equitable IBD care trust-wide: a need for treatment targets in IBD?

Abstract Background Timely biological therapy in IBD is associated with reduced disease progression, especially in CD (Berg et al 2019). However, there are no clear UK standards detailing the timescale in which IBD care should be delivered. We evaluated the time between initial consideration of therapy and first dose in a district general hospital and tertiary referral centre in Barts Health NHS Trust. Methods Details of patients receiving biologics for IBD at Newham (NUH) and Royal London Hospital (RLH) (between 2018 – 2022) were obtained from infusion clinics; electronic records were reviewed for 50 recent referrals. The following information was collected: demographics, phenotype, drug, first documentation of consideration of biologic, completion of funding application, onset of therapy. Results Demographics: NUH: Age (median(IQR)) = 43.5(30.3 – 50.56) Gender (F:M) = 26:24, CD:UC = 34:16, Biologic: infliximab:vedolizumab:ustekinumab:adalimumab: 29:5:11:5, First biologic: n=34 RLH: Age (median(IQR)) = 31.6 (24.6 – 41.1) Gender (F:M) = 27:23 CD:UC = 23:27, Biologic: infliximab:vedolizumab:ustekinumab:adalimumab: 34:12:3:1, First biologic: n=25 There was substantially longer time between initial consideration of therapy and first dose delivered at NUH 94.5 days (44 – 174) compared with RLH 35.5 days (23.75 –69) (p<0.01). However, time from completion of funding application to first dose did not differ significantly between sites (43.5 days (30.3 – 50.6) vs 31.6 (24.6 – 41.1), p=0.42). In patients receiving first biologic, there was a trend towards a longer time since diagnosis at NUH (3.2 years (1.0 – 9.1) vs 1.7 years (0.5 – 4.3), p=0.08). Conclusion Patients treated in a tertiary referral centre started biologics sooner after consideration, and earlier in disease course. This does not appear due to availability of infusion services, but due to time to complete initial investigations and finalise escalation. This may reflect differences in service set-up; in particular, NUH manages IBD care with a single IBD nurse, and fewer options for fast-track clinic follow up. A clear UK IBD standards framework identifying recommended time frames for establishing biologics is indicated, to ensure equity in care across tertiary and DGH settings.

P286 Variation of outcomes in inflammatory bowel disease at ten Australasian centres - Crohn's Colitis Cure (CCC) Data Insights Program

Abstract Background Inflammatory bowel disease (IBD) is a global health issue with Australia having amongst the highest prevalence rates worldwide. Our study examined the quality, safety and equity of care amongst ten Australasian centres using Crohn’s Colitis Care electronic management record. The aim was to describe current care delivery at each centre for a range of performance indicators to provide a baseline from which to engage in a regional care quality benchmarking initiative Methods Deidentified data prospectively entered by clinicians during routine clinical practice throughout 2022 were retrospectively analysed. Only centres with >100 eligible people with IBD and an assessment during the trial period were included. Sites from Australia and New Zealand were a mixture of public and private IBD referral centres Results The cohort included 7172 people with IBD from 10 centres; 58.6% with Crohn’s disease (CD), 39.1% ulcerative colitis (UC) and 2.3% IBD-unclassified (IBDU). Mean age was 44.3 (SD +/- 18.0) with an even gender balance (50.7% female). The number of people with IBD per centre ranged from 201 to 2151 (median 566). In the total cohort, 38.3% were currently on advanced IBD therapy (biologics or new small molecules), with centre variation from 30.8% to 43.5% (p<0.001). Of those on advanced therapy, 42% were on dose escalated therapy which varied between centres substantially from 18% to 64%. Current steroid use ranged from 0.3% to 6.1% (median 1.6%; p<0.001). Documented IBD surgical rates varied from 0.1% to 7.2% (median 2.0; p<0.001). IBD admission rates ranged from 0.1% to 13.6% (median 1.2; p<0.001) while current smokers comprised 1.7% to 12.5% (p<0.001) of the cohort with a mean of 6.0% across all ten centres. A total of 3,379 faecal calprotectin’s (FCP) with an overall remission rate (< 250μg/g) of 71% varying from 63.4% to 83.1% (median 69.1; p=0.001); 2,616 lower endoscopies were performed with an observed remission rate of 56%; this varied between sites from 0% to 69%. Recorded Influenza vaccination rates varied from 6.3% to 54.4% (median 19.8) and Covid vaccination rates from 14% to 78.5% (median 43.4). Skin care check completion rates ranged from 16.3% to 32.3% (median 22.9). The centre with the highest documented healthcare maintenance completion rate across all three domains was private. Conclusion Despite advances in treatment and much literature addressing care guidelines and targets, significant disparity in care documentation and outcomes remains for people with IBD in routine care. CCCare as an IBD-specific EMR supports easy, serial examination of these measures at scale and is therefore a useful tool to measure and drive efforts to improve these deficiencies and reduce unwarranted care variation

Strategies to decrease inequalities in cancer therapeutics, care and prevention: Proceedings on a conference organized by the Pontifical Academy of Sciences and the European Academy of Cancer Sciences, Vatican City, February 23-24, 2023.

Analyses of inequalities related to prevention and cancer therapeutics/care show disparities between countries with different economic standing, and within countries with high Gross Domestic Product. The development of basic technological and biological research provides clinical and prevention opportunities that make their implementation into healthcare systems more complex, mainly due to the growth of Personalized/Precision Cancer Medicine (PCM). Initiatives like the USA-Cancer Moonshot and the EU-Mission on Cancer and Europe's Beating Cancer Plan are initiated to boost cancer prevention and therapeutics/care innovation and to mitigate present inequalities. The conference organized by the Pontifical Academy of Sciences in collaboration with the European Academy of Cancer Sciences discussed the inequality problem, dependent on the economic status of a country, the increasing demands for infrastructure supportive of innovative research and its implementation in healthcare and prevention programs. Establishing translational research defined as a coherent cancer research continuum is still a challenge. Research has to cover the entire continuum from basic to outcomes research for clinical and prevention modalities. Comprehensive Cancer Centres (CCCs) are of critical importance for integrating research innovations to preclinical and clinical research, as for ensuring state-of-the-art patient care within healthcare systems. International collaborative networks between CCCs are necessary to reach the critical mass of infrastructures and patients for PCM research, and for introducing prevention modalities and new treatments effectively. Outcomes and health economics research are required to assess the cost-effectiveness of new interventions, currently a missing element in the research portfolio. Data sharing and critical mass are essential for innovative research to develop PCM. Despite advances in cancer research, cancer incidence and prevalence is growing. Making cancer research infrastructures accessible for all patients, considering the increasing inequalities, requires science policy actions incentivizing research aimed at prevention and cancer therapeutics/care with an increased focus on patients' needs and cost-effective healthcare.

The lived experience of receiving and providing antenatal care during the Covid-19 crisis in Southern Europe: An exploratory qualitative study

ObjectiveThe Covid-19 pandemic led to a reorganization of antenatal care including the cancellation or shift into telemedicine of consultations and restrictions to the presence of an accompanying person. The aim was to explore healthcare professionals’ and women’s lived experience of such reorganisation consequences on the quality of care and specific challenges they faced, with a particular emphasis on telemedicine and equity. MethodsExploratory qualitative study using semi-structured interviews and focus group discussions of women and healthcare providers in New Aquitaine (France) and in the Basque Country (Spain). We collected data from a purposive sampling of women (n = 33) and professionals (n = 19) who had received or provided antenatal care in hospitals and ambulatory facilities between March 2020 and December 2021. Participants’ narratives were thematically analysed to identify themes that were subsequently contextualised to the two territories. ResultsAntenatal care professionals and pregnant women experienced strong emotions and suffered from organizational changes that compromised the quality and equity of care. The pandemic and associated restrictions were sources of emotional distress, fear and loneliness, especially among more disadvantaged and isolated women. Among professionals, the lack of adequate means of protection and the multiple changes in caring protocols generated burnout, feeling of abandonment and emotional distress. ConclusionsThe Covid-19 experience should serve to critically consider the unexpected consequences of reorganising healthcare services and the need to meet patients’ needs, with a particular consideration for disadvantaged groups. Future scenarios of telemedicine generalisation should consider a combination of in presence and remote consultations ensuring antenatal care quality and equity.

Understanding intersectional inequality in access to primary care providers using multilevel analysis of individual heterogeneity and discriminatory accuracy.

Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection. Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income. Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.

Effect of voxelotor on murine bone marrow and peripheral blood with hematopoietic progenitor cell mobilization for gene therapy of sickle cell disease

In preparation for hematopoietic stem cell mobilization and collection, current ex vivo gene therapy protocols for sickle cell disease require patients to undergo several months of chronic red cell transfusion. For health care equity, alternatives to red cell transfusion should be available. We examined whether treatment with GBT1118, the murine analog of voxelotor, could be a safe and feasible alternative to red cell transfusion. We found that 3 weeks of treatment with GBT1118 increased the percentage of bone marrow hematopoietic stem cells and upon plerixafor mobilization, the percentage of peripheral blood hematopoietic stem cells. Our data suggest that voxelotor should be further explored for its potential safety and utility as preparation for hematopoietic stem cell mobilization and collection.

Engaging Community-Academic Partnerships: A Case Study of the Influence of Social Drivers of Health on Equitable Transitions of Cancer Care in the United States.

Enduring community-academic partnerships are essential for expediting the successful dissemination and implementation of promising interventions and programs, particularly for complex public health issues such as cancer prevention and control. The purpose of this case study was to understand the combined voices of a diverse group of stakeholders to outline the essential factors needed to translate research into sustainable cancer care within communities. System dynamics group model building was used to develop system maps of the factors impacting equitable access to cancer care services among three stakeholder groups (Group A: survivors and family members, n = 20; Group B: providers and administrators in community agencies/organizations, n = 40; Group C: administrators from a cancer institute, academic universities, foundations, and healthcare facilities that coordinate care, n = 25) in central Texas, USA. The lead researcher identified factors involved in transitions of care and their linkages with each other. The analysis of this work displays these connections visually. These models represent the ripple effect of factors influencing the transition of care for stakeholders who are invested in cancer care outcomes. All three groups identified medical mistrust, a culturally sensitive and diverse provider workforce, and care coordination as three essential factors (i.e., themes). Group A also identified caregiver navigation. The groups varied in their emphasis on upstream vs. downstream social drivers of health, with Group B emphasizing the former and Group C emphasizing the latter. To achieve cancer care equity, all stakeholder groups agreed on the importance of addressing the impact of social drivers as critical gaps. Eliminating or reducing these impacts allows each stakeholder group to work more efficiently and effectively to improve cancer care for patients.

Racial disparities in breast cancer survival after treatment initiation in Brazil: a nationwide cohort study

Breast cancer is a public health priority in Brazil and ensuring equity in health care is one of the cancer control plan goals. Our aim was to present the first assessment on the influence of race or skin colour on breast cancer survival at the national level. In this nationwide cohort study, data on women who initiated treatment for breast cancer in the public health-care system (Sistema Unico de Saúde), Brazil, were assembled through record linkage of administrative and mortality information systems. The administrative information systems were the Outpatient Information System (data from high complexity procedure authorisations) and the Hospital Information System (data from hospitalisation authorisations). We included women aged 19 years or older who started treatment between Jan 1, 2008, and Nov 30, 2010; self-identified as having White, Black, or Brown race or skin colour; had tumour stage I-IV; and were treated with chemotherapy or radiotherapy, or both. Patients were followed up until Dec 31, 2015. Patients with only hormone therapy records or who underwent only surgery were excluded. The Kaplan-Meier method was used to estimate crude overall survival for race or skin colour by time since treatment initiation, and Cox regression to estimate all-cause mortality hazard ratios (HRs) before and after adjustment for other covariates. We identified 59 811 women treated for stage I-IV breast cancer. 37 318 (62·4%) women identified themselves as White, 18 779 (31·4%) as Brown, and 3714 (6·2%) as Black. 5-year overall survival probability was higher for White women (74% [95% CI 73-74]) than Black women (64% [62-65]; p<0·0001). In adjusted regression models stratified by the absence of hormone therapy, Black women had a 24% (HR 1·24 [95% CI 1·16-1·34]; p<0·0001) higher risk of all-cause death than White women, and in the presence of hormone therapy Black women had a 25% (1·25 [1·14-1·38]; p<0·0001) higher risk of all-cause death than White women. Black skin colour was identified as a statistically significant risk marker for lower 5-year survival probability and higher risk of all-cause death among women treated for breast cancer by the Sistema Unico de Saúde. Actions to understand and mitigate this unfair difference in health results are urgently needed. Conselho Nacional de Desenvolvimento Científico e Tecnológico and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior and Pró-Reitoria de Pesquisa da Universidade Federal de Minas Gerais.

Improving healthcare value: The need to explicitly address equity in high-value care.

Improving healthcare value: The need to explicitly address equity in high-value care.

Challenges and enablers to implementation of the Additional Roles Reimbursement Scheme in primary care: a qualitative study.

The Additional Roles Reimbursement Scheme (ARRS) was set up to recruit 26 000 additional staff into general practice by 2024, with the aim of increasing patient access to appointments. Despite the potential benefits of integrating ARRS practitioners into primary care, their implementation has not always been straightforward. To explore the challenges and enablers to implementation of the ARRS including its impact on primary and secondary care systems. Qualitative interview study with ARRS healthcare professionals and key professional stakeholders involved in staff education or scheme implementation across three integrated care systems in England. Participants (n = 37) were interviewed using semi-structured individual or paired interviews. Interviews were audio-recorded and transcribed. Data were analysed using framework analysis until data saturation occurred. Using framework analysis, 10 categories were identified. Three were categorised as successes: staff valued but their impact unclear; multiple and certain roles maximise impact; and training hub support. Seven were categorised as challenges: scheme inflexibility; creating a sustainable workforce with career progression; managing scope and expectations; navigating supervision and roadmap progression; infrastructure and integration challenges; ARRS roles impact on wider systems; and tensions and perspectives of existing staff. Most ARRS staff felt valued, but the scheme broadened expertise available in primary care rather than reducing GP burden, which was originally anticipated. Some PCNs, especially those in areas of high deprivation, found it difficult to meet the population's needs as a result of the scheme's inflexibility, potentially leading to greater health inequalities in primary care. Recommendations are proposed to optimise the effective implementation of the primary care workforce model. Further research is required to explore administrative role solutions, further understand the impact of health inequalities, and investigate the wellbeing of ARRS staff.

Addressing inequities in medical care

Background: Health disparities and inequities persist globally, significantly affecting marginalized racial and ethnic groups. Medical institutions and educators must address these issues to foster a more equitable healthcare system. Aim: This chapter aims to explore the definitions and implications of health disparities and inequities, emphasizing the need for a comprehensive understanding in medical education to address these challenges effectively. Methods: The chapter reviews definitions from leading health organizations and examines case studies from various countries to highlight the impact of historical, structural, and social determinants of health (SDOH) on health outcomes. Methodologies for measuring these disparities, including quantitative and qualitative approaches, are discussed. Results: Health disparities often arise from systemic and institutional biases, with historical injustices like colonialism and slavery continuing to influence modern health outcomes. Case studies from the United States, Brazil, the United Kingdom, and the Netherlands illustrate ongoing inequities in maternal mortality and other health outcomes. Conclusion: Addressing health disparities requires an understanding of historical contexts, structural factors, and SDOH. Medical education must evolve to incorporate these elements to equip future healthcare professionals with the skills to combat these disparities effectively.

Beta thalassemia: Looking to the future, addressing unmet needs and challenges.

Thalassemia management has reached new milestones, with new therapies promising the dawning of a new era. However, conventional and new approaches require accessibility, affordability, acceptability/adherence by patients, and medical expertise from healthcare providers. Current treatments still do not offer the expected duration and quality of life, and inequalities in patient care are almost a universal phenomenon. To understand the requirements to achieve improved care, including the adoption of new therapies, for the maximum number of the global patient population, it is necessary to recognize the weaknesses that are experienced in the present so that future corrective action can be taken. Deficits in service provision are due to poor political and financial support, lack of prioritization during resource rationing, and absence of epidemiological information for policy making. These system weaknesses require improved resource management and would benefit from patient support organizations, improved psychosocial support and patient welfare, and an increase in professional expertise through educational programs. Medical products and technology must also be made affordable and widely available, and the curative treatments and cheaper approaches to technology must be recognized as resource saving. Improvements in the access to innovative and quality care, and even a cure, require concerted actions by all stakeholders, including physicians and the patient community.

Call to action on diabetes care: reaching communities facing health inequalities, health inequities and deprivation.

This article presents evidence and policy on the importance of reaching out into local communities with inclusive approaches to try to reduce and prevent inequities and inequalities in diabetes care. The global emergency diabetes is causing and the risks and disproportionately high ethnic disparities are investigated. The article includes some suggestions on changing approaches to reduce health inequalities to enable diabetes care to become more accessible for those who need it the most.