Inequalities In Access To Health Care Research Articles

Applications of digital medicine to care pathways: taxonomy, methods, impact on patients, barriers to overcome.

Digital health represents an important step in the management of chronic diseases also in light of the reform of proximity care that is intended to be implemented as part of the Recovery Plan (PNRR). For this purpose, the inclusion of digital health tools in the care pathways is strategic. A specific Working Group of the MaCroScopio Project defined a taxonomic, methodological and cultural framework within which the development of digital health can be promoted. This would ensure that the introduction of this type of technological innovation addresses not only the need for a more efficient health system but also the real patients' healthcare requirements. At the same time it fosters the reduction of healthcare access inequalities, instead of their exacerbation.

Informing Equity & Diversity in Primary Care Policy and Practice: Introducing a New Series of Policy Briefs, Commentaries, and Voices in JABFM.

Recent events remind us that deeply embedded inequities in health care access and health outcomes are rooted in historically white, and male, systems of power.[1][1],[2][2] Authors have documented how, in the United States, medicine was built on racist and patriarchal foundations that excluded and

Grand Challenges in global eye health: a global prioritisation process using Delphi method

SummaryBackgroundWe undertook a Grand Challenges in Global Eye Health prioritisation exercise to identify the key issues that must be addressed to improve eye health in the context of an ageing population, to eliminate persistent inequities in health-care access, and to mitigate widespread resource limitations.MethodsDrawing on methods used in previous Grand Challenges studies, we used a multi-step recruitment strategy to assemble a diverse panel of individuals from a range of disciplines relevant to global eye health from all regions globally to participate in a three-round, online, Delphi-like, prioritisation process to nominate and rank challenges in global eye health. Through this process, we developed both global and regional priority lists.FindingsBetween Sept 1 and Dec 12, 2019, 470 individuals complete round 1 of the process, of whom 336 completed all three rounds (round 2 between Feb 26 and March 18, 2020, and round 3 between April 2 and April 25, 2020) 156 (46%) of 336 were women, 180 (54%) were men. The proportion of participants who worked in each region ranged from 104 (31%) in sub-Saharan Africa to 21 (6%) in central Europe, eastern Europe, and in central Asia. Of 85 unique challenges identified after round 1, 16 challenges were prioritised at the global level; six focused on detection and treatment of conditions (cataract, refractive error, glaucoma, diabetic retinopathy, services for children and screening for early detection), two focused on addressing shortages in human resource capacity, five on other health service and policy factors (including strengthening policies, integration, health information systems, and budget allocation), and three on improving access to care and promoting equity.InterpretationThis list of Grand Challenges serves as a starting point for immediate action by funders to guide investment in research and innovation in eye health. It challenges researchers, clinicians, and policy makers to build collaborations to address specific challenges.FundingThe Queen Elizabeth Diamond Jubilee Trust, Moorfields Eye Charity, National Institute for Health Research Moorfields Biomedical Research Centre, Wellcome Trust, Sightsavers, The Fred Hollows Foundation, The Seva Foundation, British Council for the Prevention of Blindness, and Christian Blind Mission.TranslationsFor the French, Spanish, Chinese, Portuguese, Arabic and Persian translations of the abstract see Supplementary Materials section.

Association of community-level social vulnerability with US acute care hospital intensive care unit capacity during COVID-19

The COVID-19 pandemic has placed unprecedented stress on US acute care hospitals, leading to overburdened ICUs. It remains unknown if increased COVID-19 ICU occupancy is crowding out non-COVID-related care and whether hospitals in vulnerable communities may be more susceptible to ICUs reaching capacity. Using facility-level hospitalization data, we conducted a retrospective observational cohort study of 1753 US acute care hospitals reporting to the US Department of Health and Human Services Protect database from September 4, 2020 to February 25, 2021. 63% of hospitals reached critical ICU capacity for at least two weeks during the study period, and the surge of COVID-19 cases appeared to be crowding out non-COVID-19-related intensive care needs. Hospitals in the South (OR = 3.31, 95% CI OR 2.31–4.78) and West (OR = 2.28, 95% CI OR 1.51–3.46) were more likely to reach critical capacity than those in the Northeast, and hospitals in areas with the highest social vulnerability were more than twice as likely to reach capacity as those in the least vulnerable areas (OR = 2.15, 95% CI OR 1.41–3.29). The association between social vulnerability and critical ICU capacity highlights underlying structural inequities in health care access and provides an opportunity for policymakers to take action to prevent strained ICU capacity from compounding COVID-19 inequities.

Vulnerable migrants’ access to healthcare in the early stages of the COVID-19 pandemic in the UK

ObjectivesTo understand the living conditions, changes in the service user profile, and needs of vulnerable migrants trying to access healthcare in the early stages of the COVID-19 pandemic. Study designMixed methods study; using quantitative questionnaire data collected from migrant service users of Doctors of the World UK (DOTW UK) with qualitative data from free-text notes. MethodsDOTW UK provides drop-in clinics to vulnerable migrants. Consultations switched to remote during the UK's first lockdown. We compared patient profile, well-being, healthcare access and reason for consultations of individuals attending the virtual clinic between March and September 2020 to those of the prepandemic periods between 2011 and 2018. ResultsDuring the pandemic, consultations dropped to under half of the prepandemic numbers, with the shift to remote consultations attracting more users outside of London. DOTW UK's user base changed to include a greater proportion of asylum seekers, younger adults (18–34) and individuals reporting good health. Socio-economic conditions and housing stability deteriorated for the majority of users. Those in the greatest need of healthcare appeared to be less able to access remote services. General practitioner (GP) registration remained the most common reason for contacting the virtual clinic with a lack of knowledge of the healthcare system being the main barrier to access. ConclusionThe shift to virtual consultations may have exacerbated existing inequalities in healthcare access for vulnerable migrants. Given that many clinical services continue to operate remotely, it is important to consider the impact such actions have on vulnerable migrants and find ways to support access.

Epidemiology of pre-existing multimorbidity in pregnant women in the UK in 2018: a cross-sectional study

BackgroundAlthough maternal death is rare in the UK, 90% (510 of 566 deaths) of women who died during or within a year after pregnancy in 2016–18 had multiple health and social problems (MBRRACE-UK). This study aims to estimate the prevalence of pre-existing multimorbidity in pregnant women in the UK. MethodsPregnant women aged 15–49 years with a conception date between Jan 1 and Dec 31, 2018, were included in this cross-sectional study, using routine health-care datasets: Clinical Practice Research Datalink (CPRD) GOLD (UK, n=37 641), Secure Anonymised Information Linkage (SAIL) databank (Wales, n=27 782), and Scottish Morbidity Records (SMR, secondary care) with linked community prescribing data (Tayside and Fife, n=6099). We defined pre-existing multimorbidity (two or more morbidities) preconception from 79 long-term physical and mental health conditions. This definition was identified from the literature and prioritised by the multidisciplinary research advisory group, including patient representatives. The association of women's characteristics preconception with multimorbidity was examined with logistic regression. The University of St Andrews School of Medicine Ethics Committee approved this project. Participant consent was not required as the data used are anonymised. InterpretationPrevalence of multimorbidity was 44·2% (95% CI 43·7–44·7) in CPRD, 46·2% (45·6–46·8) in SAIL, and 19·8% (18·8–20·8) in SMR. Mental health conditions were highly prevalent and involved 70% of multimorbidity (CPRD: prevalence of multimorbidity with one or more mental health conditions 31·3% [30·8–31·8]). Pregnant women with conditions that were leading causes of maternal deaths had a high prevalence of multimorbidity (CPRD: 745 [2·0%] of 37 641 women had cardiovascular disease, of whom 597 [80·1%] had multimorbidity). Higher maternal age (CPRD: adjusted odds ratio 1·81 [95% CI 1·04–3·17] for 45–49 years vs 15–19 years), gravidity (1·68 [1·50–1·89] for ≥5 vs 1), BMI (1·59 [1·44–1·76], for ≥30 vs 18·5–24·9) and smoking (1·61 [1·46–1·77] for smoker vs non-smoker) were significantly associated with multimorbidity. Ethnicity and deprivation were not significantly associated with multimorbidity. InterpretationA significant proportion of women enter pregnancy with pre-existing multimorbidity, especially mental health conditions. Pregnant women with multimorbidity were more likely to smoke and have a raised BMI and support may be required to address this. There may be health-care access inequalities for some health conditions, especially mental health conditions in pregnant women from deprived or ethnic minority groups. Secondary care and linked community prescription dataset captured severe conditions and might underestimate the prevalence of multimorbidity. Urgent research is needed to quantify the consequences of maternal multimorbidity for mother and child. FundingThis work was supported by the joint UKRI-NIHR Strategic Priorities Fund consolidator grant (grant number MR/V005243/1). BT was funded by the National Institute for Health Research (NIHR) West Midlands Applied Research Collaboration. AA and SIL were funded as NIHR Academic Clinical Fellows. The views expressed are those of the author and not necessarily those of the funders, the NIHR or the UK Department of Health and Social Care.

Increasing doctors working in specific rural regions through selection from and training in the same region: national evidence from Australia

Background‘Grow your own’ strategies are considered important for developing rural workforce capacity. They involve selecting health students from specific rural regions and training them for extended periods in the same regions, to improve local retention. However, most research about these strategies is limited to single institution studies that lack granularity as to whether the specific regions of origin, training and work are related. This national study aims to explore whether doctors working in specific rural regions also entered medicine from that region and/or trained in the same region, compared with those without these connections to the region. A secondary aim is to explore these associations with duration of rural training.MethodsUtilising a cross-sectional survey of Australian doctors in 2017 (n = 6627), rural region of work was defined as the doctor’s main work location geocoded to one of 42 rural regions. This was matched to both (1) Rural region of undergraduate training (< 12 weeks, 3–12 months, > 1 university year) and (2) Rural region of childhood origin (6+ years), to test association with returning to work in communities of the same rural region.ResultsMultinomial logistic regression, which adjusted for specialty, career stage and gender, showed those with > 1 year (RRR 5.2, 4.0–6.9) and 3–12 month rural training (RRR 1.4, 1.1–1.9) were more likely to work in the same rural region compared with < 12 week rural training. Those selected from a specific region and having > 1-year rural training there related to 17.4 times increased chance of working in the same rural region compared with < 12 week rural training and metropolitan origin.ConclusionThis study provides the first national-scale empirical evidence supporting that ‘grow your own’ may be a key workforce capacity building strategy. It supports underserviced rural areas selecting and training more doctors, which may be preferable over policies that select from or train doctors in ‘any’ rural location. Longer training in the same region enhances these outcomes. Reorienting medical training to selecting and training in specific rural regions where doctors are needed is likely to be an efficient means to correcting healthcare access inequalities.

Drawbacks and Aftermath of the Affordable Care Act: Ex-Ante Moral Hazard and Inequalities in Health Care Access

Background: Following the introduction of the Affordable Care Act, various studies have tried to identify the effects of the reform, without reaching a clear consensus. The aim of this study was to investigate whether expansion of the Medicaid program has led to less inequality in access to health care and to a higher level of ex-ante moral hazard.Design and Methods: The analysis was conducted on two-year longitudinal data (2014-2015) regarding a cohort of 15,898 individuals from a Medical Expenditure Panel Survey (MEPS). After a data cleaning procedure, a sample of 9,255 individuals was selected for the inequality part of the study and 2,307 for the exante moral hazard analysis. Propensity score matching with nearest- neighbour and kernel matching algorithms, difference-in-difference models and concentration index, corrected according to Erreygers methodology, were adopted.Results: The analysis showed that disparities were reduced between social classes although the ex-ante moral hazard is a real problem with the Affordable Care Act since individuals covered by public insurance tended to abuse the public service. Among those who benefited from the Act, a reduction in preventive behaviours was observed: there was an increase in smoking and a decrease in level of physical activity. As far as concerns access to health care, there was a decrease in inequality in emergency visits, inability to get care and getting care when needed among beneficiaries of the reform.Conclusions: This study demonstrates that the extension of Medicaid has had a dual effect of reducing disparities in access to health care but, at the same time, it seems to have induced people to take less care of themselves. Significance for public health In the last years, the debate about the Affordable Care Act has been vigorous. For the first time, the US health system experienced a strong and revolutionary change with the introduction of a public programme into a previously totally private system. The debate about the consequences of this policy is open since the effects are unclear. The recent US presidential election proved the relevance of the debate. The analysis reported here is an attempt to add another piece to the puzzle, highlighting some critical aspects from a different point of view in a field that is still controversial.

Shifting COVID-19 Vaccine Intentions in New Zealand: Next Steps in the Vaccination Campaign.

Shifting COVID-19 Vaccine Intentions in New Zealand: Next Steps in the Vaccination Campaign.

Disparities in Telehealth Use during COVID‐19 across Federally Qualified Health Centers: Findings from National Survey Data

Research ObjectiveFederally Qualified Health Centers (FQHCs) provide primary care services to 28.4 million low‐income patients across the US. In 2019, less than 1 in 4 FQHCs across the US were using any type of telehealth to provide real‐time virtual care directly to patients. The COVID‐19 pandemic transformed the landscape of primary care with rapid shifts to telehealth. The extent to which telehealth was implemented across FQHCs, and for whom, has significant implications for access to and equity of care for this population. Thus, our objective was to use a novel, nationally representative data set to evaluate differential trends in telehealth use across urban vs. rural areas; racial/ethnic groups; linguistic groups; and states during COVID‐19.Study DesignOur primary data source was weekly HRSA Health Center COVID‐19 Survey data (April through June 2020), which included an average response rate of 71% per week. Our secondary data source was the 2019 Uniform Data System. Using generalized estimating equations with exchangeable correlation structures, we evaluated temporal week‐to‐week rates of telehealth visits (% of all visits that were virtual) across urban vs. rural areas; racial/ethnic groups; linguistic groups; and states. Models adjusted for the percent change in average weekly visits relative to the pre‐COVID time period, used state fixed effects, and clustered errors at the FQHC‐level.Population Studied100% sample of FQHCs across the US (N = 1349), serving >28 million low‐income patients. Our analytic sample included 11,169 FQHC‐weeks.Principal FindingsFrom April through June of 2020, 96% of FQHCs across the US were using some telehealth and 47% of all FQHC visits were virtual—from 52% of visits in early April to 37% of visits by the end of June. However, there was significant heterogeneity in these trends. For instance, while urban and rural FQHCs had statistically similar rates of virtual visits in April 2020, over time, rural areas were increasingly less likely to be using telehealth (39% of visits in urban areas vs. 29% of visits in rural areas by late June 2020, p < 0.001). FQHCs serving a high proportion (>25%) of Black patients, Hispanic patients, or non‐English speaking patients experienced a significantly lesser rate of decline in virtual visits over time relative to all other FQHCs (p < 0.001 for all). Finally, telehealth utilization varied widely by state over our study period, including highest rates of use in CT (80%), RI (78%), and MA (76%) and lowest rates of use in SD (14%), KS (18%), GA (21%), AR (23%), TN (24%), ID (26%), and SC (26%).ConclusionsAs FQHCs across the US reach a steady state of integrating telehealth into care delivery, there are significant differences in telehealth utilization that may be mitigating existing inequities in health care access, particularly for FQHCs that disproportionately serve Black, Hispanic, or non‐English speaking patients. However, geographic inequities in telehealth utilization are vast.Implications for Policy or PracticePermanently expanding coverage and reimbursement of telehealth services may help to address racial/ethnic and linguistic inequities in access to care. Wide across‐state variation in telehealth highlights the potential importance of state‐level policy, leadership, and investment in telehealth in enabling, or hindering, its implementation and reach.Primary Funding SourceThe Robert Wood Johnson Foundation.

The door is open, but not everyone may enter: racial inequities in healthcare access across three Brazilian surveys.

Health policies in Brazil have sought to expand healthcare access and mitigate inequities, but recent revisions of their content have weakened the Brazilian Unified Health System. This study estimates three healthcare indicators across three national surveys conducted in 2008, 2013, and 2019 to assess the impact of changes to the National Primary Care Policy on racial inequities in healthcare. Considering the survey design and sampling weights, we estimated the prevalence of each outcome among both whites and Blacks for the whole country, and according to the Brazilian regions. We test the following hypotheses: compared to whites, Blacks showed higher frequency of coverage by the Family Health Strategy, lower frequency of health insurance coverage, and higher frequency of perceived difficulty accessing health services (H1); Racial inequities decreased in the ten-year period but remained constant between 2013-2019 (H2); Racial gaps have widened among regions with lower proportions of Blacks (H3). Our findings fully support H1, but not H2 and H3. Racial inequities either remained constant or decreased in the 2013-2019 period. By downplaying the importance of the universality and equity principles, the latest revision of the National Primary Care Policy has contributed to the persistence of racial inequities in healthcare.

Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures

There are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs. To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare. Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity. Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment. Six patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening). The final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures. In this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were significantly more likely to experience worse outcomes for most access and quality measures than White or multiracial beneficiaries in both programs.

The importance of addressing social inequalities and targeting the undecided to promote vaccination against COVID-19.

The importance of addressing social inequalities and targeting the undecided to promote vaccination against COVID-19.

COVID-19 Vaccine Hesitancy and Acceptance in a Cohort of Diverse New Zealanders.

BackgroundNew Zealand's Immunisation Programme is an important pillar in the war against COVID-19, making high vaccine uptake essential. This study sought to: (1) identify potential vaccine uptake rates among New Zealanders prior to programme rollout; (2) understand reasons for unlikelihood/likelihood of vaccine uptake; and, (3) explore sociodemographic differences in risk of and reasons for vaccine hesitancy.MethodsData were collected in March 2021 (n = 1,284) via a web-based survey. Respondents were a diverse sample of New Zealanders who were part of a large, pre-existing social research sampling frame. Multinomial and logit regressions were estimated to examine sociodemographic predictors of vaccine hesitancy and reasons for likelihood/hesitancy.FindingsOverall, 70% reported they would likely take the vaccine once available (i.e., very likely or somewhat likely). Being younger and less educated were correlated with greater vaccine hesitancy risk (i.e., very unlikely, somewhat likely, or unsure). Women were more likely than men to say they were unsure (Relative Risk Ratio = 1.60) vs. either likely or unlikely and to identify concerns regarding personal health, such as potential side effects, as a reason. Men identified concerns surrounding trust in vaccines and the perceived exaggerated risk of COVID-19 to them and the population.InterpretationAlthough a majority intend to take the COVID-19 vaccine once available, a sizeable minority who were more likely to be young, female, and less educated, were unsure about or unlikely to get the vaccine, primarily due to perceptions of unknown future side effects. Ethnicity was not statistically associated with vaccine hesitancy, suggesting that public health efforts aimed at increasing vaccine acceptance among Māori and Pacific peoples—subgroups most at-risk of COVID-19 infection and morbidity—should focus on inequities in health care access to increase uptake.

Cream skimming by health care providers and inequality in health care access: Evidence from a randomized field experiment

Using a randomized field experiment, we show that health care specialists cream-skim patients by their expected profitability. In the German two-tier system, outpatient reimbursement rates for both public and private insurance are centrally determined but are significantly higher for the privately insured. In our field experiment, following a standardized protocol, the same hypothetical patient called 991 private practices in 36 German counties to schedule appointments for allergy tests, hearing tests and gastroscopies. Practices were 4% more likely to offer an appointment to the privately insured. Conditional on being offered an appointment, wait times for the publicly insured were twice as long than for the privately insured. We also find smaller access differences when reimbursement rate differences are smaller. Our findings show that structural differences in reimbursement rates lead to structural differences in health care access.

Bioethical implications of robotic surgery in urology: a systematic review

Robotic technologies are being increasingly implemented in healthcare, including urology, and holding promises for improving medicine worldwide. However, these new approaches raise ethical concerns for professionals, patients, researchers and institutions that need to be addressed. The aim of this review was to investigate the existing literature related to bioethical issues associated with robotic surgery in urology, in order to identify current challenges and make preliminary suggestions to ensure an ethical implementation of these technologies. We performed a review of the pertaining literature through a systematic search of two databases (PubMed and Web of Science) in August 2020. Our search yielded 76 articles for full-text evaluation and 48 articles were included in the narrative review. Several bioethical issues were identified and can be categorized into five main subjects: 1) robotic surgery accessibility (robotic surgery is expensive, and in some health systems may lead to inequality in healthcare access. In more affluent countries the national distribution of several robotic platforms may influence the centralization of robotic surgery, therefore potentially affecting oncological and functional outcomes in low-volume centers); 2) safety (there is a considerable gap between surgical skills and patients' perception of competence, leading to ethical consequences on modern healthcare. Published incidence of adverse events during robotic surgery in large series is between 2% and 15%, which does not significantly differ amongst open or laparoscopic approaches); 3) gender gap (no data about gap differences in accessibility to robotic platforms were retrieved from our search); 4) costs (robotic platforms are expensive but a key reason why hospitals are willing to absorb the high upfront costs is patient demand. It is possible to achieve cost-equivalence between open and robotic prostatectomy if the volume of centers is higher than 10 cases per week); and 5) learning curve (a validated, structured curriculum and accreditation has been created for robotic surgery. This allows acquisition and development of basic and complex robotic skills focusing on patient safety and short learning curve). Tech-medicine is rapidly moving forward. Robotic approach to urology seems to be accessible in more affluent countries, safe, economically sustainable, and easy to learn with an appropriate learning curve for both sexes. It is mandatory to keep maintaining a critical rational approach with constant control of the available evidence regarding efficacy, efficiency and safety.

Racial disparities in COVID-19 pandemic cases, hospitalisations, and deaths: A systematic review and meta-analysis.

BackgroundPeople from racial minority groups in western countries experience disproportionate socioeconomic and structural determinants of health disadvantages. These disadvantages have led to inequalities and inequities in health care access and poorer health outcomes. We report disproportionate disparities in prevalence, hospitalisation, and deaths from COVID-19 by racial minority populations.MethodsWe conducted a systematic literature search of relevant databases to identify studies reporting on prevalence, hospitalisations, and deaths from COVID-19 by race groups between 01 January 2020 – 15 April 2021. We grouped race categories into Blacks, Hispanics, Whites and Others. Random effects model using the method of DerSimonian and Laird were fitted, and forest plot with respective ratio estimates and 95% confidence interval (CI) for each race category, and subgroup meta-regression analyses and the overall pooled ratio estimates for prevalence, hospitalisation and mortality rate were presented.ResultsBlacks experienced significantly higher burden of COVID-19: prevalence ratio 1.79 (95% confidence interval (CI) = 1.59-1.99), hospitalisation ratio 1.87 (95% CI = 1.69-2.04), mortality ratio 1.68 (95% CI = 1.52-1.83), compared to Whites: prevalence ratio 0.70 (95% CI = 0.0.64-0.77), hospitalisation ratio 0.74 (95% CI = 0.65-0.82), mortality ratio 0.82 (95% CI = 0.78-0.87). Also, Hispanics experienced a higher burden: prevalence ratio 1.78 (95% CI = 1.63-1.94), hospitalisation ratio 1.32 (95% CI = 1.08-1.55), mortality ratio 0.94 (95% CI = 0.84-1.04) compared to Whites. A higher burden was also observed for Other race groups: prevalence ratio 1.43 (95% CI = 1.19-1.67), hospitalisation ratio 1.12 (95% CI = 0.89-1.35), mortality ratio 1.06 (95% CI = 0.89-1.23) compared to Whites. The disproportionate burden among Blacks and Hispanics remained following correction for publication bias.ConclusionsBlacks and Hispanics have been disproportionately affected by COVID-19. This is deeply concerning and highlights the systemically entrenched disadvantages (social, economic, and political) experienced by racial minorities in western countries; and this study underscores the need to address inequities in these communities to improve overall health outcomes.

Communicating Healthcare Provider Perspectives about Mi'kmaq Women's Access to Pap Smear Screening in Eastern Canada: A Qualitative Study

Indigenous women have higher rates of cervical cancer and lower rates of Papanicolaou (Pap) smear screening than non-Indigenous in Canada. Healthcare providers are well positioned to address the inequities in access to Pap screening that many Indigenous women continue to experience. The purpose of this study was to explore healthcare providers' experiences and perspectives about Mi'kmaq women's access to Pap smear screening in Eastern Canada, and to consider the broader historical, economic, and sociopolitical contexts that shape healthcare experiences. The methodology is a qualitative, community-based participatory action research approach that embodied Indigenous approaches to knowledge development and post-colonial theoretical perspectives in a two-eyed seeing approach. In-depth semi-structured in-person interviews were conducted with five healthcare providers twice, in two First Nations communities in Nova Scotia. Findings revealed two major overarching themes: a) Understanding the Realities of Indigenous Women's Lives; which involved recognition of the impact of history, and socioeconomic and political factors; and b) Fostering Indigenous Women's Access to Pap Smear Screening, through fostering trusting relationships, cultural safety, addressing confidentiality issues and optimizing processes to improve experiences. Conclusions indicated approaches to foster Mi'kmaq women's access to Pap screening included a social women's day, targeting youth, explaining step-by-step during screening, providing Pap results to women and having nurse practitioners perform screening. Implications for practice comprised addressing confidentiality issues in community health centres, involving the community in Pap screening decision-making, acknowledging the impact of historical trauma on access to screening and optimizing processes to address and improve inequitable access to screening. This study highlights the importance of healthcare providers' participation in understanding and encouraging Indigenous women's access to Pap smear screening. Healthcare providers need to consider a wider view of the realities of Canadian Indigenous women's lives, and acknowledge the impact of historical trauma, socioeconomic factors, and racism on women's accessing of Pap smear screening. Healthcare providers can implement collaborative and culturally safe screening approaches, while acknowledging Indigenous community strengths to improve inequities in healthcare access and health outcomes.

Abstract P082: Racial/ethnical Disparities In The Utilization Of Telehealth Services Among Medicare Beneficiaries With Atrial Fibrillation Before The Covid-19 Pandemic

Introduction: Telemedicine facilitates continued access to care for management of chronic diseases while preventing exposure to health care facilities; however, reliance on telemedicine may exacerbate disparities based on the persistent digital divide. Documenting racial variation in the uptake of telemedicine is crucial to understand the potential aggravation of health care access inequities in the era of COVID-19. We used a nationally representative sample of Medicare beneficiaries with atrial fibrillation (AF) to quantify racial disparities in telehealth utilization before the COVID-19 pandemic. Hypothesis: Black patients are less likely to be engaged with telehealth services than White patients. Methods: Using a 5% random sample of Medicare claims data, we extracted telehealth visits in 2016 using modifiers GT, 95, and GQ and place of service code 2 in medical claims. We used multivariate Poisson models to estimate incidence rate ratios (IRR) comparing the number of telehealth visits across White, Black, and patients of other races. Results: Among 135,164 patients with AF, 404 (0.3%) had a total of 1420 telehealth visits in 2016. After adjusting for age, sex, AF duration, rurality, CHA2DS2-VASc score, Alzheimer's disease, use of direct oral anticoagulants and warfarin, and receipt of low-income subsidy, Black were 60% less likely than White to receive telehealth services (IRR 0.4 [0.3, 0.5]), and the ‘others’ group were 70% less likely to receive telehealth services (0.3 [0.2, 0.5]). Among rural residents, however, the racial difference in telehealth use was only seen in Black (0.4 [0.2, 0.6]) but not in the ‘others’ group (0.9 [0.6, 1.4]). The gap in telehealth use between White and Black was larger among those with higher CHA2DS2-VASc scores ( Figure) . Conclusion: Before the COVID-19 pandemic, telehealth service use was rare overall in patients with AF. However, Black patients, especially those with increased stroke risk, were still significantly less likely to have access to telemedicine than White patients.

Analysis of OpenStreetMap Data Quality at Different Stages of a Participatory Mapping Process: Evidence from Slums in Africa and Asia

This paper examines OpenStreetMap data quality at different stages of a participatory mapping process in seven slums in Africa and Asia. Data were drawn from an OpenStreetMap-based participatory mapping process developed as part of a research project focusing on understanding inequalities in healthcare access of slum residents in the Global South. Descriptive statistics and qualitative analysis were employed to examine the following research question: What is the spatial data quality of collaborative remote mapping achieved by volunteer mappers in morphologically complex urban areas? Findings show that the completeness achieved by remote mapping largely depends on the morphology and characteristics of slums such as building density and rooftop architecture, varying from 84% in the best case, to zero in the most difficult site. The major scientific contribution of this study is to provide evidence on the spatial data quality of remotely mapped data through volunteer mapping efforts in morphologically complex urban areas such as slums; the results could provide insights into how much fieldwork would be needed in what level of complexity and to what extent the involvement of local volunteers in these efforts is required.