Inequalities In Health Care Research Articles

Development and Validation of the IDS-TILDA FI; A Novel Frailty Instrument for People with Intellectual Disability

Abstract Background Adults with Intellectual Disabilities (ID) are a vulnerable population, experiencing higher rates of multimorbidity, polypharmacy and healthcare inequities. Pre-existing functional disability and dependency complicates frailty measurement in ID. This study aimed to develop an ID-specific Frailty Index (FI), and compare frailty measurements between adults with and without ID. Methods This cross-sectional study was conducted using the Intellectual Disability Supplement to The Irish Longitudinal Database of Aging (IDS-TILDA). A 31-item IDS-TILDA FI was developed. Markers of functional dependence were excluded avoid disability bias. The index was applied to 745 adults with ID, with results compared to the general population. Statistical analysis included multivariate regression on frailty controlling for age, sex, level of ID and presence of Down syndrome (DS). Multivariate logistic regression on Mortality controlling for age, Level of ID and DS was also conducted. Predictive validity was tested using receiver operating characteristic (ROC) curves and evaluated the area under the curve (AUC). Results FI scores ranged from 0.00 to 0.59; median 0.16 and mean 0.19. These scores are lower than in other studies of frailty in ID, but higher than seen in the general population. Increasing frailty score was associated with older age (p<0.05), female sex (p<0.05) and severe/profound ID (p<0.05). Increasing frailty was associated with mortality, even when controlling for age (p<0.05). This association was lost when ID severity was included in analysis. FI score demonstrated moderate predictive validity for mortality (controlling for age, sex and Level of ID) with an AUC of 0.6101 (p<0.05, 95% CI: 0.564-0.656). Conclusion It is possible to measure frailty without measuring functional dependence. Frailty is more prevalent among adults with ID compared to the general population. The IDS-TILDA FI is associated with age and mortality, though the impact of severe ID could not be overcome highlighting the complexity of medical needs for adults with ID.

Use of biomarkers in the diagnosis of Alzheimer's disease in adults with intellectual disability.

People with intellectual disability are a vulnerable cohort who face challenges accessing health care. Compared with the general population, people with intellectual disability have an elevated risk of developing dementia, which often presents at a younger age and with atypical symptoms. The lifelong cognitive and functional difficulties faced by people with intellectual disability further complicate the diagnostic process. Specialised intellectual disability memory services and evaluation using reliable biomarkers of neurodegeneration are needed to improve diagnostic and prognostic certainty in this group. Inadequate specialist services and paucity of research on biomarkers in this population hinders progress and impedes the delivery of adequate health care. Although cerebrospinal fluid-based biomarkers and radiological biomarkers are used routinely in the evaluation of Alzheimer's disease in the general population, biological variation within the clinically heterogenous group of people with intellectual disability could affect the clinical utility of existing biomarkers. As disease-modifying therapies become available for the treatment of early Alzheimer's disease, and hopefully other neurodegenerative conditions in the future, biomarkers will serve as gatekeepers to establish the eligibility for such therapies. Inadequate representation of adults with intellectual disability in biomarker research will result in their exclusion from treatment with disease-modifying therapies, thus perpetuating the inequity in health care that is already faced by this group. The aim of this Series paper is to summarise current evidence on the application of biomarkers for Alzheimer's disease in a population with intellectual disability (that is not attributable to Down syndrome) and suspected cognitive decline.

Impact of Health Access on Hospitalization of Children and Youth with Cerebral Palsy and Paralytic Syndromes in Brazilian Regions.

In 2021, 28.16% of Brazilians were aged 0-19 years, highlighting the critical need for medical care in diagnosing and treating cerebral palsy (CP). In developing countries, CP prevalence reaches 7/1000 live births, emphasizing the importance of healthcare access, which influences diagnosis and prognosis. This study aimed to analyze the correlation between health infrastructure across different Brazilian regions and its impact on hospitalization and mortality rates among children with CP and other paralytic syndromes. An ecological time-series design was used, analyzing secondary population-based data from DATASUS, covering January 2018 to December 2021. The data included healthcare facilities, physicians, hospitalizations, and deaths for individuals aged 0-19 years, with analysis conducted using Microsoft Excel. The results revealed significant disparities in healthcare infrastructure, particularly in the northern and northeastern regions. A notable correlation was found between healthcare inequalities and hospitalizations and mortality rates, with the northern region showing significant results (p = 0.03 for hospitalizations and p = 0.02 for mortalities). This study underscores significant regional disparities in healthcare access in Brazil, contributing to variations in hospitalization rates for children and adolescents, especially in the northern region.

Integrating Catholic Social Teaching with AI Ethics to Address Inequity in AI Healthcare

Integrating Catholic Social Teaching with AI Ethics to Address Inequity in AI Healthcare

Comprehensive approach used to help youth with MH, SU issues

Focusing on the specific needs of youth with mental health and substance use issues while also addressing health care inequities are the objectives behind a program developed by Horizon Blue Cross Blue Shield of New Jersey.

The activism of David Dennis

In 2019, Canadian First Nations activist David Dennis challenged the 6-month alcohol abstinence requirement when he was denied placement on the liver transplant list. While Mr. Dennis was eventually placed on the waitlist, he passed away before receiving a transplant. As Canadian transplant programs seek to reduce healthcare inequities experienced by Indigenous patients—First Nations, Métis, and Inuit—this analysis sheds much needed light on the inconvenient truths of settler colonialism and the need for impactful reconciliation in Canadian healthcare. This analysis examines Dennis’ activism and his argument about the inequities in transplant medicine experienced by Indigenous patients. Dennis’ activism highlighted how the Canadian healthcare systems underserve Indigenous populations, including in transplant medicine; fails to address racial biases within healthcare; and does little to consider and address negative inter-generational determinants of health that perpetuate poor health outcomes for Indigenous populations. This analysis provides direction to decision makers in transplant and additions medicine, to Ministries of Health, and to First Nations, Métis, and Inuit healthcare leaders for improved healthcare for Indigenous patients living with alcohol-related liver disease. Without concerted and coordinated efforts to address the needs of this patient population, we will continue to see rapid deterioration of their health status and high rates of mortality will persist among this patient population.

The geography of healthcare: Mapping patient flow and medical resource allocation in China

The misallocation of medical resources leads to interregional patient flow in search of better healthcare. Using out-of-pocket medical expenditure data and a delineating method, this paper identifies spatial clusters of medical services in China based on patient flow across cities. Our findings indicate that healthcare resources are more concentrated in northern China, while southern China is divided into several large healthcare clusters at the same threshold. The provincial capital and economically significant cities are more likely to serve as medical cluster centers. We further apply the gravity model to examine the effects of healthcare disparity on cross-city medical expenditure. The results reveal that geographic disparities in high-quality medical resources encourage remote healthcare-seeking behavior, and the shorter the distance between locations, the higher the level of medical consumption. Patients are inclined to seek medical services within their own province and within specific medical clusters identified through delineation methods. This effect is more pronounced among patients from non-central cities. This study highlights healthcare inequality by examining cross-regional medical expenditure, providing valuable insights for future healthcare policy.

The unfairness of place: A cultural history of the UK's ‘postcode lottery’

The 'postcode lottery' has become a dominant political framing for place-based health inequalities in Britain, used by patient groups, politicians and in media coverage of regional health and healthcare inequalities. Using newspapers, parliamentary material and health policy documents, this paper traces how this term has changed and expanded from its origins as a protest about access to new pharmaceutical treatments, to a broader commentary about geographical variations in the quality of NHS and other public services, health outcomes, and deprivation. It traces this emergence and evolution from its origins in the 1989-91 introduction of the 'internal market' and the 1994 reintroduction of the National Lottery, through to New Labour health reforms, the introduction of austerity, and the Levelling Up programme in the present day. This paper finds that the term's concern with unfairness has enabled its incorporation into a range of political positions, both as a defence of universalism against market-based reforms in the NHS, and to rationalise distinctions between 'unequal' and 'unfair' disparities in health outcomes. We conclude that understanding and addressing place based differences and inequalities in health, healthcare, and health outcomes may be aided through investigation of cultural ideas and values as well as the deep histories of place and local services.

Intersectionality and Caregiving: The Exclusion Experience and Coping Resources of Immigrant Women Caring for a Family Member With Severe Mental Illness.

Intersectionality has become a central analytical framework in the study of exclusion and empowerment experiences among women from marginalized communities. However, the relevance of intersectionality to informal caregiving in mental healthcare has hardly been explored to date. The purpose of the current study is to examine the exclusion experiences and coping resources of immigrant women caring for a family member with a severe mental illness (SMI) through the lens of intersectionality theory. Semi-structured in-depth interviews were conducted with 26 informal female immigrant caregivers from the former Soviet Union residing in Israel. The interviews were analyzed using a qualitative content approach. The findings revealed that the participants experienced stigma and exclusion in several intersecting categories: economic marginalization of immigrant single mothers, ethnic and gender-based stigma of Russian-speaking women, gender-based domestic violence, and mental health stigma by professionals. The participants' coping resources included spirituality and religious faith, support groups, and social activism. The study provides insights into the burdens and rewards experienced by female immigrant caregivers of family members with SMI through the lens of intersectionality theory. Implications for adapting services to the contextual characteristics of female immigrant caregivers and minimizing intersectional stigma and inequities in informal healthcare are discussed.

How Can Newborn Toxicology Testing Be More Equitable? An Interactive Ethics Workshop.

Practice variation in newborn toxicology testing during the birth hospitalization exists across institutions and legal jurisdictions. While testing can provide benefits, indiscriminate testing has been shown to perpetuate health care inequities. In the backdrop of an opioid epidemic and a charged medicolegal landscape, this workshop guides participants to reexamine newborn toxicology testing through a shared ethical lens. We conducted a live, 90-minute workshop in English at an international pediatric conference. Physicians, residents, and fellows participated in large- and small-group breakout sessions to learn relevant clinical and bioethical frameworks, share their own local context and expertise, and explore ethical applications through case-based discussions. We administered two anonymous online follow-up surveys to assess self-perceived impact on participant knowledge, behavior, and clinical practice. Seven facilitators and 45 individuals participated in the workshop. Eighteen participants completed survey 1 immediately following workshop conclusion, and six participants completed survey 2 after 3 months had elapsed. Immediately following the workshop, 94% of respondents reported that they had been introduced to a new idea, and 82% were considering practice change. A low response rate to survey 2 limited interpretation, but some respondents reported self-perceived change following workshop attendance. This workshop facilitated conversation between physician participants on a complex pediatric health care inequity issue using an ethical framework.

Wealth disparities in maternal health service utilization among women of reproductive age in Ethiopia: findings from the mini-EDHS 2019

BackgroundEthiopia has made strides in reducing maternal mortality, but significant discrepancies in maternal health service utilization exist across socioeconomic levels. According to studies, women from higher-income households are far more likely to use essential services such as antenatal care, delivery care, and postnatal care than poorer women. This wealth disparity is a primary contributor to persistently high maternal mortality, particularly among poor populations. The study’s goal was to assess wealth disparities in maternal health service uptake and identify contributing factors.Methods and materialsWe used the Ethiopian Mini Demographic Health Survey (EMDHS), conducted in 2019 on women aged 15–49 living in selected census areas, with a weighted sample size of 3,909. The Erreygers Concentration Index (ECI) was used to measure wealth inequalities in maternal health care, and the ECI decomposition was used to identify factors contributing to inequality in maternal health services.ResultsMaternal health service utilization was pro-rich among women in Ethiopia. The prevalence of antenatal care service (ANC), delivery, and postnatal care (PNC) service utilization showed a pro-rich distribution among Ethiopian women, with ECI = 0.115 (95% CI: 0.091–0.137), ECI = 0.223 (95% CI: 0.191–0.276), and ECI = 0.121 (95% CI: 0.041-0.200), respectively. The ECI indices were decomposed to examine the contributing factors to disparities in maternal service utilization in Ethiopia. Mother’s current age, household family size, region, birth order, and parity were contributors to maternal health service utilization.ConclusionThe ANC service, delivery service and PNC service utilization showed a pro-rich distribution among Ethiopian women. Mother’s current age, household family size, region, birth order, and parity are important contributors of maternal health service inequality. To improve access and usage among low-income women, policymakers can develop programs including increasing the number of free or subsidized services and providing transportation.

Trustworthy and ethical AI-enabled cardiovascular care: a rapid review

BackgroundArtificial intelligence (AI) is increasingly used for prevention, diagnosis, monitoring, and treatment of cardiovascular diseases. Despite the potential for AI to improve care, ethical concerns and mistrust in AI-enabled healthcare exist among the public and medical community. Given the rapid and transformative recent growth of AI in cardiovascular care, to inform practice guidelines and regulatory policies that facilitate ethical and trustworthy use of AI in medicine, we conducted a literature review to identify key ethical and trust barriers and facilitators from patients’ and healthcare providers’ perspectives when using AI in cardiovascular care.MethodsIn this rapid literature review, we searched six bibliographic databases to identify publications discussing transparency, trust, or ethical concerns (outcomes of interest) associated with AI-based medical devices (interventions of interest) in the context of cardiovascular care from patients’, caregivers’, or healthcare providers’ perspectives. The search was completed on May 24, 2022 and was not limited by date or study design.ResultsAfter reviewing 7,925 papers from six databases and 3,603 papers identified through citation chasing, 145 articles were included. Key ethical concerns included privacy, security, or confidentiality issues (n = 59, 40.7%); risk of healthcare inequity or disparity (n = 36, 24.8%); risk of patient harm (n = 24, 16.6%); accountability and responsibility concerns (n = 19, 13.1%); problematic informed consent and potential loss of patient autonomy (n = 17, 11.7%); and issues related to data ownership (n = 11, 7.6%). Major trust barriers included data privacy and security concerns, potential risk of patient harm, perceived lack of transparency about AI-enabled medical devices, concerns about AI replacing human aspects of care, concerns about prioritizing profits over patients’ interests, and lack of robust evidence related to the accuracy and limitations of AI-based medical devices. Ethical and trust facilitators included ensuring data privacy and data validation, conducting clinical trials in diverse cohorts, providing appropriate training and resources to patients and healthcare providers and improving their engagement in different phases of AI implementation, and establishing further regulatory oversights.ConclusionThis review revealed key ethical concerns and barriers and facilitators of trust in AI-enabled medical devices from patients’ and healthcare providers’ perspectives. Successful integration of AI into cardiovascular care necessitates implementation of mitigation strategies. These strategies should focus on enhanced regulatory oversight on the use of patient data and promoting transparency around the use of AI in patient care.

How Do We Better Serve Excluded Populations When Delivering Digital Health Technology? Inclusion Evaluation of a Digital Musculoskeletal Self-Management Solution.

Digital self-management platforms have been proposed as a solution to better support people manage their musculoskeletal (MSK) condition. However, research studies often explicitly exclude people who can't access internet connected devices. An important consideration is that digital exclusion (for people without access to an internet connected device) from these new digital options will worsen already existing inequality and inequity in healthcare. To evaluate the acceptability and potential causes of digital exclusion of the South West London (SWL) MSK self-management app. (1) Explore why some patients are not using the app and any barriers they have. Explore why some clinicians are not prescribing the app. (2) Make recommendations, based on these findings, to improve digital inclusion. An explanatory sequential mixed method service evaluation that consisted of initial questionnaires to identify suitable collaborators, followed by structured interviews of patients and clinicians. Following a comprehensive data analysis, 10 sub-themes were grouped into four main themes: (1) Beliefs: Importance of understanding the role of digital; face to face consultation is still valued and needed. (2) Barriers: Lack of digital literacy; lack of physical examination/contact with a clinician. (3) Enablers: Immediate access to advice and information; perceived better control over health; ease of use; no appointment needed. (4) Solutions: Support and training; greater awareness. As digital health technology develops, strategies must change, requiring deliberate work and investments to improve inclusion. Our findings highlight how digital technology design and delivery can be adapted to address the causes of digital exclusion.

Assessing Healthcare Equity in Orthopaedic Surgery: An Analysis of Over 24,000 Surgical Cases.

Health disparities have been widely studied in the primary care and surgical settings. The purpose of this study was to examine surgical access disparities for orthopaedic surgical cases performed at a large academic health center by comparing the relationship between patient demographic factors and surgical wait time. A total of 24,778 orthopaedic surgical cases from 2018 to 2022 at a public, tertiary care, Level I trauma center were retrospectively analyzed to assess for surgical timing disparities based on patient-specific factors, including race, sex, language, and socioeconomic status. Elective surgical cases were completed with an average surgical wait time of 28.11 ± 26.34 days. Urgent surgical cases were completed with an average surgical wait time of 1.23 ± 1.50 days. Patient race, sex, language, and socioeconomic status had no effect on surgical wait time for urgent case scheduling. Female patients had longer average wait times in elective cases, whereas race had a weak association with increased wait time. Two-factor interaction analysis showed no multifactorial effects of patient demographic factors on surgical wait time. Patient race and socioeconomic status were associated with increased distance from surgical sites, although increased distance did not correlate with increased surgical wait time. Patient demographic factors did not demonstrate clinically notable associations with surgical timing in this patient cohort, in contrast to previous studies demonstrating the effects of race and socioeconomic status on healthcare outcomes and access. Race and socioeconomic status did correlate with increased distance from surgical centers although distance from surgical sites did not correlate with surgical wait time. This contributes to previous literature on healthcare equity and indicates that surgical wait time may not contribute to the known healthcare inequalities seen in minority and marginalized patients.

The association between socio-economic deprivation and receipt of long-acting reversible contraception at a single clinic visit

ObjectivesTo determine the relationship between area deprivation index (ADI) and obtaining single-visit long-acting reversible contraception (LARC). Study designWe utilized Poisson regression to determine the association between area deprivation and single-visit LARC insertion within a state-wide healthcare system between 2019–2021. ResultsAmong our cohort (N = 4417), 68.60% of patients desiring LARC obtained single-visit LARC. Participants living in high deprivation areas were less likely to receive single-visit LARC (aRR 0.72, 95% CI 0.65–0.80). ConclusionsLiving in areas of high deprivation is independently negatively associated with obtaining a single-visit LARC. ImplicationsWhile access to single-visit LARC should be universally improved, reducing barriers for patientswith a higher ADI may help limit inequities in reproductive healthcare.

The Role of Telehealth in Rural Healthcare Access

This study investigates the effect of telehealth in reducing healthcare inequities in rural communities. Rural communities confront considerable challenges, including geographic isolation, provider shortages, and limited access to healthcare facilities, which exacerbate health inequities. Telehealth provides an innovative solution by allowing remote access to healthcare services, eliminating the need for travel, and improving healthcare results. This review looks at current telehealth adoption trends, successful case studies, and future potential to extend telehealth services in remote areas. Finally, telemedicine is a viable way to close the healthcare access gap in remote populations. Keywords: Telehealth, rural healthcare, healthcare disparities, geographic barriers, provider shortages.

Racial and ethnic disparities in clinical outcomes among patients with takotsubo syndrome; A nation-wide analysis

BackgroundTakotsubo syndrome (TTS), a stress-induced transient left ventricular dysfunction, remains poorly understood, with an estimated incidence of 1–2 % among acute coronary syndrome cases. This study investigates racial and ethnic disparities in hospital outcomes and clinical characteristics of TTS. MethodsWe conducted a retrospective cohort study using the National Inpatient Sample data from 2016 to 2020, identifying TTS cases through validated ICD-10 codes. Statistical analysis was performed using Stata 18, with logistic regression models adjusting for confounders to identify disparities in outcomes. ResultsThe study included 32,785 TTS hospitalizations; the majority were White (80.5 %), followed by Black (6.7 %) and Hispanic (5.8 %) patients. Minority groups, mainly Black and Hispanic patients, were younger (average age 63) and predominantly from lower-income brackets, while Asians had the highest income bracket. Length of stay (5.1 days) and Total cost ($22,707.60) were highest among Native Americans. Notable findings include Black patients showing the highest rate of stroke (4.8 %, OR 2.1, 95 % CI 1.2 to 3.4, p = 0.003). The rate of cardiogenic shock was highest among Asians (11 %, OR 2, 95 % CI 1.5 to 2.5, p < 0.001). Mortality rates were elevated in Black (2 %, OR 1.5, 95 % CI 1.3 to 1.7 p < 0.001) and Asian populations (1.8 %, OR 1.97, 95 % CI 1.5 to 2.5, p < 0.001). ConclusionSignificant racial and ethnic disparities exist in TTS outcomes, with minority groups having more in-hospital outcomes. These findings highlight the urgent need for targeted interventions and further research to reduce healthcare inequities in TTS management.

Shaping the future of heart health

For World Heart Day on September 24, 2024, the World Heart Federation urges nations to endorse national strategies for enhancing cardiovascular health. While advancements show promise in reducing atherosclerosis, addressing healthcare inequalities and ensuring equitable access to tools remain crucial. This collection of voices touches on the intricate relationship between type 2 diabetes and cardiovascular disease, highlights innovative treatments for rare cardiomyopathies and heart failure, and explores the potentially transformative role of artificial intelligence in cardiovascular medicine, showcasing the dedication and innovation that are shaping the future of heart health.

“My children will grow up more healthy than me because of the vaccinations they received”: Using the migrant health trajectory model to understand Vietnamese American parents’ attitudes towards vaccinations and the U.S. healthcare system

Previous studies have examined the rationales affluent white American parents give for distrusting vaccinations and the U.S. healthcare system; fewer studies have investigated the vaccine- and healthcare-related attitudes of foreign-born parents who have resettled in the U.S. Drawing on 40 in-depth interviews with Vietnamese American parents who emigrated from Vietnam and reside in Southern California, this study finds that these parents favor vaccinations and trust the U.S. healthcare system. However, contrary to the “good” refugee and “model” minority stereotypes, which racializes Asian Americans as blindly adhering to authority to assimilate, these Vietnamese Americans reported purposefully agreeing to vaccinations because they believe that vaccines are a privileged prevention strategy, ensured by the U.S. healthcare system to safeguard their and their children's livelihoods. Interview participants chronicled their social experiences as refugees, particularly their upbringing in Vietnam (where they witnessed vaccine and healthcare inequities) and their emigration to and resettlement in the U.S. (a social setting they believe has an abundance of advantageous health resources) as social factors influencing their vaccination and healthcare standpoints. By attending to Vietnamese American parents' unique emigration health trajectories, this study highlights how vaccination and healthcare attitudes are social acts shaped by interlinking socio-historical, -political, and -cultural contexts.

Performance of pulse oximeters as a function of race compared to skin pigmentation: a single center retrospective study.

Pulse oximetry (SpO2) is a critical monitor for assessing oxygenation status and guiding therapy in critically ill patients. Race has been identified as a potential source of SpO2 error, with consequent bias and inequities in healthcare. This study was designed to evaluate the incidence of occult hypoxemia and accuracy of pulse oximetry associated with the Massey-Martin scale and characterize the relationship between Massey scores and self-identified race. This retrospective single institute study utilized the Massey-Martin scale as a quantitative assessment of skin pigmentation. These values were recorded peri-operatively in patients enrolled in unrelated clinical trials. The electronic medical record was utilized to obtain demographics, arterial blood gas values, and time matched SpO2 values for each PaO2 ≤ 125 mmHg recorded throughout their hospitalizations. Differences between SaO2 and SpO2 were compared as a function of both Massey score and self-reported race. 4030 paired SaO2-SpO2 values were available from 579 patients. The average error (SaO2-SpO2) ± SD was 0.23 ± 2.6%. Statistically significant differences were observed within Massey scores and among races, with average errors that ranged from - 0.39 ± 2.3 to 0.53 ± 2.5 and - 0.55 ± 2.1 to 0.37 ± 2.7, respectively. Skin color varied widely within each self-identified race category. There was no clinically significant association between error rates and Massey-Martin scale grades and no clinically significant difference in accuracy observed between self-reported Black and White patients. In addition, self-reported race is not an appropriate surrogate for skin color.