Inequalities In Access To Health Care Research Articles

Structural Racism-Related State Laws and Healthcare Access Among Black, Latine, and White U.S. Adults.

Racialized healthcare inequities in the USA remain glaring, yet root causes are understudied. To address this gap, we created a state-level structural racism legal index (SRLI) using the Structural Racism-Related State Law Database and analyzed its association with racialized inequities in four outcomes (lacking health insurance coverage, lacking a personal doctor, avoiding care due to cost, lacking a routine check-up) from the 2013 Behavioral Risk Factor Surveillance System (N = 454,834). To obtain predicted probabilities by SRLI quartiles (Q1 = less structural racism, Q4 = more structural racism) and racialized group, we fit survey-weighted multilevel logistic models adjusted for individual- and state-level covariates. We found substantial healthcare access inequities across racialized groups within SRLI quartiles and less pronounced, but still meaningful, inequities within racialized groups across SRLI quartiles. For example, the predicted probabilities of lacking health insurance coverage across SRLI quartiles ranged from 13 to 20% among Black adults, 31 to 41% among Latine adults, and 8 to 11% among White adults. Across racialized groups in Q4 states, predicted probabilities ranged from 11% among White adults to 41% among Latine adults. Similar patterns were observed for lacking a personal doctor and avoiding care due to cost. Findings underscore the need to address structural racism in laws and policies to mitigate these inequities.

Insurance barriers and inequalities in health care access: evidence from dual practice

BackgroundWe investigate access disparities in pharmaceutical care among German patients with type 2 diabetes, focusing on differences between public and private health insurance schemes. The primary objectives include investigating whether patients with private health insurance experience enhanced access to antidiabetic care and analyzing whether the treatment received by public and private patients is influenced by the practice composition, particularly the proportion of private patients.MethodsWe estimate fixed effect regression models, to isolate the effect of insurance schemes on treatment choices. We utilize data from a prescriber panel comprising 681 physicians collectively serving 68,362 patients undergoing antidiabetic treatments.ResultsThe analysis reveals a significant effect of the patient's insurance status on antidiabetic care access. Patients covered by private insurance show a 10-percentage-point higher likelihood of receiving less complex treatments compared to those with public insurance. Furthermore, the composition of physicians' practices plays a crucial role in determining the likelihood of patients receiving less complex treatments. Notably, the most pronounced disparities in access are observed in practices mirroring the regional average composition.ConclusionsOur findings underscore strategic physician navigation across diverse health insurance schemes in ambulatory care settings, impacting patient access to innovative treatments.

Assessing Functional Capacity in Directly and Remotely Monitored Home-Based Settings in Individuals With Chronic Respiratory Diseases: Protocol for a Multinational Validation Study.

Pulmonary rehabilitation is widely recommended to improve functional status and as secondary and tertiary prevention in individuals with chronic pulmonary diseases. Unfortunately, access to timely and appropriate rehabilitation remains limited. To help close this inaccessibility gap, telerehabilitation has been proposed. However, exercise testing is necessary for effective and safe exercise prescription. Current gold-standard tests, such as maximal cardiopulmonary exercise testing (CPET) and the 6-minute walk test (6MWT), are poorly adapted to home-based or telerehabilitation settings. This was an obstacle to the continuity of services during the COVID-19 pandemic. It is essential to validate tests adapted to these new realities, such as the 6-minute stepper test (6MST). This test, strongly inspired by 6MWT, consists of taking as many steps as possible on a "stepper" for 6 minutes. This study aims to evaluate the metrological qualities of 6MST by (1) establishing concurrent validity and agreement between the 6MST and CPET, as well as with the 6MWT; (2) determining test-retest reliability in a home-based setting with direct and remote (videoconferencing) monitoring; and (3) documenting adverse events and participant perspectives when performing the 6MST in home-based settings. Three centers (Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec in Québec, Groupement des Hôpitaux de l'Institut Catholique de Lille in France, and FormAction Santé in France) will be involved in this multinational project, which is divided into 2 studies. For study 1 (objective 1), 30 participants (Québec, n=15; France, n=15) will be recruited. Two laboratory visits will be performed to assess anthropometric data, pulmonary function, and the 3 exercise tolerance tests (CPET, 6MWT, and 6MST). Concurrent validity (paired sample t tests and Pearson correlations) and agreement (Bland-Altman plots with 95% agreement limits) will be evaluated. For study 2 (objectives 2 and 3), 52 participants (Québec, n=26; France, n=26) will be recruited. Following a familiarization trial (trial 1), the 6MST will be conducted on 2 separate occasions (trials 2 and 3), once under direct supervision and once under remote supervision, in a randomized order. Paired sample t test, Bland-Altman plots, and intraclass correlations will be used to compare trials 2 and 3. A semistructured interview will be conducted after the third trial to collect participants' perspectives. Ethical approval was received for this project (October 12, 2023, in Québec and September 25, 2023, in France) and the first participant was recruited in February 2024. This study innovates by validating a new clinical test necessary for the development and implementation of new models of rehabilitation adapted to home and telerehabilitation contexts. This study also aligns with the United Nations Sustainable Development Goals by contributing to augmenting health care service delivery (goal 3) and reducing health care access inequalities (goal 11). ClinicalTrials.gov NCT06447831; https://clinicaltrials.gov/study/NCT06447831. DERR1-10.2196/57404.

Healthcare cost coverage inequality and its impact on hypertension and diabetes: A five-year follow-up study in a Malaysian rural community.

Inequality in health care access is a socioeconomic driver for non-communicable disease related risk factors. This study examined the inequality trend in healthcare cost coverage (HCC) compared to private health insurance (PHI) coverage, a subtype of HCC, over 5 years. The study will also determine the association between HCC (and PHI) and the status of hypertension and diabetes diagnosis. The rich-poor ratio, concentration curve and concentration index were derived to determine the level of inequality. Furthermore, logistic regression was done to determine the association between HCC and the status of hypertension and diabetes. The PHI group (rich-poor ratio: 1.4 [rich: 454, poor: 314] and 2.6 [rich: 375, poor: 142]; concentration index: 0.123 [95% confidence interval, CI: 0.093-0.153] and 0.144 [95% CI: 0.109-0.178] in 2013 and 2018, respectively) has relatively higher inequality compared with the HCC group (rich-poor ratio: 0.9 [rich: 307, poor: 337] and 1.1 [rich: 511, poor: 475]; concentration index: -0.027 [95% CI: -0.053 to -0.000] and -0.014 [95% CI: -0.033 to 0.006] in 2013 and 2018, receptively). Contrasting to the observation with the HCC group, PHI was associated with higher odds for hypertension (adjusted odds ratio [aOR] = 1.252, p = 0.01, 95% CI: 1.051-1.493) and diabetes (aOR = 1.287, p = 0.02, 95% CI: 1.041-1.590) in 2018. Over 5 years, the inequality in PHI coverage remained higher compared with HCC, which suggests that the rich enjoyed private healthcare more. Furthermore, those with PHI were more likely to report known hypertension and diabetes in 2018. It is reasonable to assume that those with PHI are more likely to have earlier diagnoses compared to others and are more likely to be aware of their condition. Policymakers need to identify strategies that can narrow the existing gap in quality and type of service between the private and public health sectors.

P018 Inequalities in healthcare access, experience and outcomes in adults with Inflammatory Bowel Disease: A scoping review

Abstract Background Inflammatory Bowel Diseases (IBD) are long-term conditions requiring lifelong access to, and interactions with health services. Accumulating evidence of inequalities in health care access, experience and outcomes for individuals with IBD is apparent. However there is no existing review that systematically maps these inequalities.The purpose of this review was to map and describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps and future research priorities in this area. Methods A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from three electronic databases (EMBASE, Medline and CINAHL). English written articles published between 2000 and 2023 were systematically searched using a search strategy. The Joanna Briggs Institute protocol for scoping reviews was followed to perform data extraction and analysis. Results 1343 records were identified. 51 studies met the criteria for inclusion. Studies addressed ethnic disparities of healthcare (33/51), inequalities driven by socioeconomic differences (12/51), rurality (7/51), gender (3/51), age (2/51), culture (2/51), literacy (1/51) and sexuality (1/51). The interrelationship of disparities relating to outcome, access and experience is illustrated in Figure 1. Poorer health outcomes (42/51 studies) were described in those from Black, Asian, and Hispanic ethnic groups in relation to hospital admission, readmission, emergency room attendance, length of stay, IBD-related complications, post-operative complications, treatment delay and length of stay. Deprivation, insurance status in US populations, rural location and age also affected outcome. Access inequalities (24/51 studies) were described to services, therapies and surgery but also to educational opportunities. Poor experience of care (8/51 studies) included appointment issues, lack of cultural understanding and fragmented care. A lack of research was found in the LGBTQIA+ community (1/51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism. Conclusion Inequality affecting a wide range of population characteristics affects outcomes, access and experience in IBD care. Services need to be organised and delivered in a way that addresses this. Further research, including qualitative methods, is particularly needed to understand health experiences of underserved patient populations with IBD. The lack of research amongst LGBTQIA+ individuals, and with learning disabilities, poses a risk of creating inequalities within inequalities.

Access to healthcare among transgender women living with and without HIV in the United States: associations with gender minority stress and resilience factors

BackgroundTransgender women (TW) experience significant inequities in healthcare access and health disparities compared to cisgender populations. Access to non-transition related healthcare is understudied among TW. We aimed to assess the association between access to care and gender minority stress and resilience factors among TW living with and without HIV in eastern and southern United States.MethodsThis study was a cross-sectional analysis of baseline data drawn from a cohort of 1613 adult TW from the LITE Study. The cohort permitted participation through two modes: a site-based, technology-enhanced mode and an exclusively online (remote) mode. Exploratory and confirmatory factor analyses determined measurement models for gender minority stress, resilience, and healthcare access. Structural equation modeling was used to assess the relationships between these constructs. Models were evaluated within the overall sample and separately by mode and HIV status.ResultsHigher levels of gender minority stress, as measured by anticipated discrimination and non-affirmation were associated with decreased access to healthcare. Among TW living with HIV, higher levels of anticipated discrimination, non-affirmation, and social support were associated with decreased healthcare access. Among TW living without HIV in the site-based mode, resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. Among TW living without HIV in the online mode, anticipated discrimination was associated with barriers to healthcare access; resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access.ConclusionsGender minority stress was associated with increased barriers to healthcare access among TW in the US, regardless of HIV status. Resilience factors did not mediate this effect. Interventions aiming to increase healthcare access among TW can be aided by efforts to mitigate drivers of gender minority stress and improve patient experiences in healthcare facilities.

Effect of an Education Intervention on Nursing Students' Knowledge of and Attitudes Toward Caring for Transgender and Nonbinary People.

Transgender and nonbinary (TGNB) people experience inequities in health care access, quality, and outcomes. Health care professionals' lack of knowledge and biased attitudes toward gender minorities contribute to inequitable care. This study examined the effect of TGNB health education on nursing students' knowledge and attitudes about caring for TGNB clients. A quasi-experimental study using a one-group pretest/posttest design was conducted with 46 nursing students at 2 private baccalaureate nursing programs. A paired-samples t test found a significant increase in knowledge about caring for TGNB clients at posttest ( P = .02). Attitudes toward caring for TGNB clients showed a significant improvement in the Sex and Gender Beliefs subscale at posttest ( P = .014). The findings suggest that TGNB health education is effective for inclusion in nursing curricula to better prepare nurses to care for gender-diverse clients.

Disparities in Healthcare-Seeking Behavior and Decision Preference Among Hispanics: A Comparative Study Across Races/Ethnicities, SES, and Provider Types.

Hispanics, the largest minority in America, have increased risk of several medical issues and face noteworthy health disparities. This study compares care-seeking behaviors and choice experience among Hispanics, Asians, Blacks, and Whites, considering SES (income, education, and insurance status) and across five healthcare provider (HCP) types. Concurrent analysis provides a comprehensive view of how and where inequity manifests in healthcare. A cross-sectional online survey assessed 1485 adults (Hispanic=314, Asian=313, Black=316, White=542, recruited through a panel agency) of the frequency of visiting primary care providers, dentists, optometrists, gynecologists, and specialists for chronic conditions. Participants also rated the importance of self-selecting a HCP and difficulty in finding one. Whites visited each HCP most regularly. Compared to Asians, more Hispanics saw specialists regularly (45.1% vs 56.5%, p=0.042), and Blacks saw dentists less (47.0% vs 38.3%, p=0.028) and gynecologists more often (21.2% vs 33.1%, p=0.024). No other frequency differences were observed among minorities. Low-income participants across four races saw dentists and gynecologists with comparable infrequency. Hispanics and Asians assigned similarly significantly lower self-choice importance and experienced more difficulty relative to Whites or Blacks. Participants with lower income or education visited HCPs less regularly yet perceived the same choice importance as higher-SES peers (p>0.05). Notably, discrepancies in visit frequency between Whites and minorities were more pronounced in higher-SES than lower-SES group. Differences in experiencing care-seeking difficulty were associated with income (p=0.029) and insurance type (p=0.009) but not education (p>0.05). Higher income and education increase healthcare utilization; however, racial disparities persist, particularly among higher-SES groups. Despite similarities among minorities, the extent of disparities varied by SES and provider type. The findings help explain evident inequity in healthcare access and health outcomes. Tailored patient education, culturally-specific navigation support, and more inclusive services are needed to address barriers faced by minorities and disadvantaged populations.

Assessing psychometric of the perceived stress scale and identifying stress-associated factors in a sample of Ukrainian female refugees in the Czech Republic

IntroductionThe full-scale Russian war has caused refugees to experience many stressful events, which may have a long-term adverse impact on their physical and mental health. Understanding the factors associated with increasing/decreasing stress is essential for the psychosocial support services for refugees. The Perceived Stress Scale (PSS) is a popular tool for assessing life stress perception through self-reporting. The purposes of the study were: 1) to examine the psychometric qualities of the Ukrainian versions of the PSS-14 and PSS-10; 2) to determine the level of perceived stress; 3) to reveal factors associated with perceived stress in the sample of Ukrainian female refugees in the Czech Republic (N = 919). MethodsPerceived stress was measured by the Ukrainian versions of the Perceived Stress Scale (PSS-14 and PSS-10) which were validated by applying exploratory and confirmatory factor analysis. Linear regressions were run to understand associations between self-reported physical health conditions, the barriers to adaptation in the host country, the determinants of social health and perceived stress. ResultsBoth PSS-14 and PSS-10 scales had a high level of internal consistency. Two factors (involving positive and negative items) were extracted based on exploratory factor analysis. The external consistency was confirmed by analysing correlations of the PSS-14/PSS-10 and coping strategies as well as self-reported physical and mental health. Ukrainian female refugees in the Czech Republic experienced moderate to high levels of perceived stress. The study found that on the one hand, a decrease in self-reported physical and mental health statuses, worsening health due to the war, low housing quality, financial disadvantages, experience of cultural differences issues and discrimination, healthcare access inequalities, lack of Czech language skills, failure to integrate into social activities within Ukrainian community, lack of social support, and applying an avoidant coping strategy are factors associated with forced migration that could increase perceived stress in the sample of Ukrainian female refugees. On the contrary, the level of perceived stress of participants could decrease with increasing social support, including such factors as regular communication with relatives and friends who are staying in Ukraine, and having good relations with loved ones, friends, and locals. ConclusionsThe Ukrainian version of PSS-10 has good psychometric properties and can be relied upon to measure perceived stress. The study revealed factors associated with the perceived stress in the sample of Ukrainian female refugees in the Czech Republic and emphasised the necessity of psychosocial support services and developing interventions to help cope with stress among Ukrainian female refugees in the host country.

Advancing Equitable Ambulatory Telehealth Through Dashboard Development.

Telehealth has the potential to improve access to health care by mitigating barriers related to geography, time, and finances. However, the increased adoption of ambulatory telehealth has inadvertently widened access gaps for socially disadvantaged and marginalized populations. Quality improvement approaches are a valuable strategy to address health care access inequities and disparities, involving data-driven implementation, assessment, and adaptation of tests of change over time. Because these iterative changes and interventions are data-driven, a critical element of quality improvement requires ongoing data collection and monitoring. This perspective describes the development and validation processes of a telehealth equity dashboard. This dashboard is currently available for use by our health system leaders, providers, and clinic staff. The overall objective of this dashboard is to identify and track inequities and to improve equitable ambulatory telehealth access across diverse patient groups. Lessons learned from creating this dashboard can inform other health care systems of how to develop and validate telehealth data feedback systems to promote quality improvement efforts to advance telehealth equity and accessibility.

Social disparities and inequalities in healthcare access and expenditures among Iranians exposed to sulfur mustard: a national study using spatio-temporal analysis

Background Sulfur Mustard (SM) is a chemical warfare agent that has serious short-term and long-term effects on health. Thousands of Iranians were exposed to SM during the eight-year Iran-Iraq conflict and permanently injured while the socioeconomic imbalance in their healthcare utilization (HCU) and health expenditures remains. This study aims to describe the HCU of SM-exposed survivors in Iran from 2018 to 2021; identify high-risk areas; and apply an inequality analysis of utilization regarding the socioeconomic groups to reduce the gap by controlling crucial determinants.Methods From Oct 2018 to June 2021, the Veterans and Martyrs Affairs Foundation (VMAF) recorded 58,888 living war survivors with eye, lung, and skin ailments. After cleaning the dataset and removing junk codes, we defined 11 HCU-related variables and predicted the HCU for the upcoming years using Bayesian spatio-temporal models. We explored the association of individual-level HCU and determinants using a Zero-inflated Poisson (ZIP) model and also investigated the provincial hotspots using Local Moran’s I.ResultsWith ≥ 90% confidence, we discovered eleven HCU clusters in Iran. We discovered that the expected number of HCU 1) rises with increasing age, severity of complications in survivors' eyes and lungs, wealth index (WI), life expectancy (LE), and hospital beds ratio; and 2) decreases with growing skin complications, years of schooling (YOS), urbanization, number of hospital beds, length of stay (LOS) in bed, and bed occupancy rate (BOR). The concentration index (CInd) of HCU and associated costs in age and wealth groups were all positive, however, the signs of CInd values for HCU and total cost in YOS, urbanization, LOS, and Hospital beds ratio groups were not identical.ConclusionsWe observed a tendency of pro-rich inequity and also higher HCU and expenditures for the elderly population. Finally, health policies should tackle potential socioeconomic inequities to reduce HCU gaps in the SM-exposed population. Also, policymakers should allocate the resources according to the hotspots of HCU.

Cancer care and economic burden-A narrative review.

Cancer care poses a significant economic burden in India, where noncommunicable diseases contribute to a large number of deaths and disability-adjusted life-years. Despite economic growth, equitable wealth distribution remains a challenge, leading to inequalities in healthcare access. India's healthcare system is primarily privatized, financed through out-of-pocket expenditure (OOPE), and lacks coverage for a majority of the population. As a result, individuals without financial means face catastrophic health consequences when seeking necessary healthcare. OOPE in India's healthcare system is a major concern, with medicines accounting for a significant portion of expenses, followed by diagnostic tests and consultation fees. Nonmedical expenses also contribute to the financial burden. Cancer care specifically faces substantial financial challenges, with high treatment costs, reduced workforce participation, and the need for distress financing. Cancer-related OOPE is predominantly borne by patients and their families, leading to significant financial strain. The lack of comprehensive health insurance coverage and limited access to publicly funded healthcare services exacerbate the problem. Catastrophic health expenditure (CHE) in cancer care is prevalent, pushing households into financial distress and potentially impoverishment. Efforts have been made to address this issue, such as increasing public spending on healthcare and implementing health insurance schemes. However, challenges remain in ensuring their effectiveness and reach. The role of family care physicians is crucial in supporting patients and their families during catastrophic health expenditures related to cancer-related palliative care. They coordinate care, provide advocacy, emotional support, symptom management, and facilitate end-of-life discussions. Comprehensive measures are needed to strengthen healthcare infrastructure, improve access to affordable cancer care, enhance health insurance coverage, and implement supportive measures for cancer patients. Additionally, promoting preventive measures and early detection can help reduce the need for expensive treatments and decrease the risk of catastrophic health expenditures.

Factors influencing nursing and allied health recent graduates' rural versus urban preferred principal place of practice: A cross-sectional data linkage study.

Disparities between metropolitan and non-metropolitan health workforce must be addressed to reduce inequities in health care access. Understanding factors affecting early career practitioners' choice of practice location can inform workforce planning. To investigate influences on rural practice location preferences of recent graduates. Cross-sectional analysis linked university enrolment, Graduate Outcomes Survey (GOS) and Australian Health Professional Regulation Agency (Ahpra) principal place of practice (PPP) for 2018 and 2019 nursing and allied health graduates from two Australian universities. Chi-squared tests and logistic regression compared rural versus urban PPP and locational preference. Of 2979 graduates, 1295 (43.5%) completed the GOS, with 63.7% (n = 825) working in their profession and 84.0% of those (n = 693) in their preferred location. Ahpra PPP data were extracted for 669 (81.1%) of those working in their profession. Most reported influences were 'proximity to family/friends' (48.5%), 'lifestyle of the area' (41.7%) and 'opportunity for career advancement' (40.7%). Factors most influential for rural PPP were 'cost of accommodation/housing' (OR = 2.26, 95% CI = 1.23-4.17) and 'being approached by an employer' (OR = 2.10, 95% CI = 1.12-3.92). Having an urban PPP was most influenced by 'spouse/partners employment/career' (OR = 0.53, 95% CI = 0.30-0.93) and 'proximity to family/friends' (OR = 0.41, 95% CI = 0.24-0.72). While the findings add strength to the understanding that graduates who originated from a rural area are most likely to take up rural practice in their preferred location, varied social and professional factors are influential on decision-making. It is imperative to recruit students from non-metropolitan regions into health professional degrees, as well as addressing other influences on choice of practice location.

COVID-19 inpatient mortality in Brazil from 2020 to 2022: a cross-sectional overview study based on secondary data

BackgroundIn Brazil, the COVID-19 pandemic found the universal and public Unified Health System (SUS) with problems accumulated over time, due, among other reasons, to low investments, and disparities in resource distribution. The preparedness and response of the healthcare system, involving the SUS and a private sector, was affected by large socioeconomic and healthcare access inequities. This work was aimed at offering an overview of COVID-19 inpatient mortality during the pandemic in Brazil, exploring factors associated with its variations and, specifically, differences across public, private (for-profit) and philanthropic (private non-profit) inpatient healthcare units, providers, and non-providers of services to the SUS.MethodsThis cross-sectional study used public secondary data. The main data source was the SIVEP-Gripe, which comprises data on severe acute respiratory illness records prospectively collected. We also employed the National Record of Health Establishments, the SUS’ Hospitalization Information System and municipalities' data from IBGE. We considered adult COVID-19 hospitalizations registered in SIVEP-Gripe from February 2020 to December 2022 in inpatient healthcare units with a minimum of 100 cases in the period. Data analyses explored the occurrence of inpatient mortality, employing general linear mixed models to identify the effects of patients', health care processes', healthcare units' and municipalities' characteristics on it.ResultsAbout 70% of the COVID-19 hospitalizations in Brazil were covered by the SUS, which attended the more vulnerable population groups and had worse inpatient mortality. In general, non-SUS private and philanthropic hospitals, mostly reimbursed by healthcare insurance plans accessible for more privileged socioeconomic classes, presented the best outcomes. Southern Brazil had the best performance among the macro-regions. Black and indigenous individuals, residents of lower HDI municipalities, and those hospitalized out of their residence city presented higher odds of inpatient mortality. Moreover, adjusted inpatient mortality rates were higher in the pandemic peak moments and were significantly reduced after COVID-19 vaccination reaching a reasonable coverage, from July 2021.ConclusionsCOVID-19 exposed socioeconomic and healthcare inequalities and the importance and weaknesses of SUS in Brazil. This work indicates the need to revert the disinvestment in the universal public system, a fundamental policy for reduction of inequities in the country.

DISP-01. THE IMPACT OF COVID-19 PANDEMIC ON THE HEALTHCARE DELIVERY OF RACIAL/ETHNIC MINORITIES WITH BRAIN METASTASIS BY FACILITY TYPE

Abstract OBJECTIVES Brain metastases (BM) are the most common form of adult brain cancer and one of the most devastating complications of cancer. We propose to characterize the effect of the pandemic on health care delivery for racial/ethnic underserved populations on BM care in general and stratifying by facility type. METHODS We utilized two national-scale datasets - the National Cancer Database (NCDB) and one of the largest COVID-19 real-time centralized data in the world - the National COVID Cohort Collaborative (N3C) database. Multivariable binary logistic regression models were performed to determine whether the pandemic (three-dimensional measures: pre-pandemic vs. during-pandemic, COVID-19 positivity, and density of COVID-19 prevalence) influence BM care delivery [including stereotactic radiosurgery (SRS), chemotherapy, and immunotherapy], especially for race/ethnicity minorities and patients receiving treatments at non-academic centers (NACs). RESULTS Compared to pre-pandemic years, the proportions of receiving BM care significantly decreased across all racial/ethnic groups during the pandemic using two nationwide datasets (NCDB: N=5238; N3C: N=13106), but non-white patients were still significantly less likely to undergo SRS than non-Hispanic whites (NHW) in N3C (total: aOR-0.76, p< 0.001; Black: aOR-0.78, p< 0.001, Hispanic: aOR-0.75, p=0.013; APAA: aOR-0.62, p=0.002) and NCDB (Black: aOR-0.78, p=0.006). Similarly, the odds of receiving chemotherapy for race/ethnicity minorities BM patients were significantly lower than NHW in N3C (Black: aOR-0.71, Hispanic: aOR-0.63, APAA: aOR-0.46, all p< 0.001) and NCDB (Black: aOR-0.86, p=0.028). Furthermore, such inequality in SRS receipt by race/ethnicity was exacerbated during the pandemic at NACs over academic centers (ACs) (esp. Hispanic vs. NHW at NACs: aOR-0.58, p=0.004; Hispanic vs. NHW at ACs: aOR-0.88, p=0.380) in NCDB. CONCLUSION Our study suggests that BM healthcare delivery has been significantly reduced in general during the pandemic, but racial/ethnic disparities in BM care and inequality in healthcare access by facility type still exist and have been even exacerbated.

Developing and piloting an intervention to reduce colposcopy non-attendance and corresponding inequalities: a mixed-methods study

BackgroundCervical cancer incidence and mortality is higher in lower income populations. Non-attendance for colposcopy following cervical screening is higher in deprived areas and younger patients. Diagnostic delays reduce the benefits of screening, increasing risk of pre-cancerous cells being undetected or treated later. We aimed to better understand drivers of colposcopy non-attendance and pilot a targeted intervention. Women and people with a cervix (referred to as patients in this paper) access colposcopy services. MethodsFor the service improvement audit, we collected qualitative data from Jan 24 to April 22, 2022, via telephone calls and interviews. The sample included patients who cancelled or did not attend their appointment and patients who attended their appointment. Interviews explored attendance barriers and enablers. Data were analysed thematically and reported, aligning with Consolidated Criteria for reporting Qualitative Studies’ principles. The analysis informed development of a pilot intervention, implemented from Aug 8 to Oct 6, 2022, for all scheduled appointments. Patients were contacted by telephone pre-appointment as both a reminder and opportunity to identify and address attendance barriers. Barrier-specific pathways were developed to support attendance (eg, transport assistance). We compared descriptive non-attendance rates during the intervention period and pre-intervention. Audit permission was granted by Northumbria Clinical Audit Team and Caldicott approval obtained. FindingsData were collected from 20 of the 36 patients who did not attend between Jan 24, and April 22, 2022. Further data were gathered from 88 patients cancelling appointments and four colposcopy attendees. During the audit, ethnicity and gender identity were not routinely collected. Themes identified were administrative, forgetting, anxiety, work, childcare, and transport. During the pilot, 383 (65%) of all 595 patients with an appointment were successfully contacted. The overall non-attendance in 2022 pre-telephone intervention was 10% (195 of 1736 appointments). During the intervention, non-attendance was 8% (45 of 539 appointments). Non-attendance during the intervention was 12% (10 of 87 appointments) for patients aged 25–39 years in the 20% most deprived areas was, compared with 20% (64 of 319 appointments) before the intervention. InterpretationIdentifying and addressing attendance barriers might improve non-attendance, particularly in younger and more deprived populations. This offers the prospect of improving the effectiveness of screening programmes alongside reducing inequalities in health-care access. The findings of this small-scale study are limited to NHS trust colposcopy service in the northeast of England, thus further formalised research is necessary. FundingNone.

Strengthening community health worker program in Belize

Community health workers (CHWs) have been identified as effective workforce that can improve access to primary health care particularly for underserved and hard to reach populations. The contributions of CHWs have not been limited to low-income countries. More recently, the use of CHWs has attracted attention in some high-income countries where despite more developed health systems there are large inequities in healthcare access and outcomes amongst different population groups. Belize is an upper middle-income country located in Central America and its health system is based on a primary health care model with community health workers actively involved in health service delivery. A descriptive study through review of grey literature detailing the process for strengthening the community health worker program in the country using the Community Health Worker Assessment and Improvement Matrix (CHW AIM) tool. The results were thematically analysed based on Community Health Worker Assessment and Improvement Matrix (CHW AIM) conceptual framework on factors influencing the performance of community health worker program. Community health workers in Belize are recognized as part of the formal health system with policy and strategy in place that define their roles, tasks, relationship to the health system. They are provided with monthly financial incentives, opportunities for further studies, career advancement and employment opportunities within the health system. The study contributes to the existing literature on strengthening of community health worker program to enhance the primary health care system and build a more resilient health system for better preparedness and response for future pandemics with focus on an upper middle income country.

Using drivers and transmission pathways to identify SARS-like coronavirus spillover risk hotspots

The emergence of SARS-like coronaviruses is a multi-stage process from wildlife reservoirs to people. Here we characterize multiple drivers—landscape change, host distribution, and human exposure—associated with the risk of spillover of zoonotic SARS-like coronaviruses to help inform surveillance and mitigation activities. We consider direct and indirect transmission pathways by modeling four scenarios with livestock and mammalian wildlife as potential and known reservoirs before examining how access to healthcare varies within clusters and scenarios. We found 19 clusters with differing risk factor contributions within a single country (N = 9) or transboundary (N = 10). High-risk areas were mainly closer (11-20%) rather than far ( < 1%) from healthcare. Areas far from healthcare reveal healthcare access inequalities, especially Scenario 3, which includes wild mammals and not livestock as secondary hosts. China (N = 2) and Indonesia (N = 1) had clusters with the highest risk. Our findings can help stakeholders in land use planning, integrating healthcare implementation and One Health actions.

Global liver transplantation: emerging trends and ethical challenges.

Liver transplant (LT) is the only definitive treatment for end-stage liver disease (ESLD). This review aims to explore current global LT practices, with an emphasis on challenges and disparities that limit access to LT in different regions of the world. A detailed analysis was performed of present-day liver transplant practices throughout the world, including the etiology of liver disease, patient access to transplantation, surgical costs, and ongoing ethical concerns. Annually, only 10% of the patients needing a liver transplant receive an organ. Currently, the USA performs the highest volume of liver transplants worldwide, followed by China and Brazil. In both North America and Europe, nonalcoholic fatty liver disease is becoming the most common indication for LT, compared to hepatitis B and C in most Asian, South American, and African countries. While deceased donor liver transplant remains the most performed type of LT, living donor liver transplant is becoming increasingly popular in some parts of the world where it is often the only option due to a lack of well-developed infrastructure for deceased organ donation. Ethical concerns in liver transplantation fundamentally revolve around the definition of a deceased donor and the exploitation of living donor liver donation systems. Globally, liver transplant practices and outcomes are varied, with differences driven by healthcare policies, inequities in healthcare access, and ethical concerns.

Improving Patient-Reported Outcomes in Stroke Care using Remote Blood Pressure Monitoring and Telehealth

Abstract Background Inequities in health care access leads to suboptimal medication adherence and blood pressure (BP) control. Informatics-based approaches may deliver equitable care and enhance self-management. Patient-reported outcomes (PROs) complement clinical measures to assess the impact of illness on patients' well-being in poststroke care. Objectives The aim of this study was to determine the feasibility of incorporating PROs into Telehealth After Stroke Care (TASC) and to explore the effect of this team-based remote BP monitoring program on psychological distress and quality of life in an underserved urban setting. Methods Patients discharged home from a Comprehensive Stroke Center were randomized to TASC or usual care for 3 months. They were provided with a BP monitor and a tablet that wirelessly transmitted data to a cloud-based platform, which were integrated with the electronic health record. Participants who did not complete the tablet surveys were contacted via telephone or e-mail. We collected the Patient-Reported Outcomes Measurement Information System Managing Medications and Treatment (PROMIS-MMT), Patient Activation Measure (PAM), Neuro-QOL (Quality of Life in Neurological Disorders) Cognitive Function, Neuro-QOL Depression, and Patient Health Questionnaire-9 (PHQ-9). T-tests and linear regression were used to evaluate the differences in PRO change between the arms. Results Of the 50 participants, two-thirds were Hispanic or non-Hispanic Black individuals. Mechanisms of PRO submission for the arms included tablet (62 vs. 47%), phone (24 vs. 37%), tablet with phone coaching (10 vs. 16%), and e-mail (4 vs. 0%). PHQ-9 depressive scores were nominally lower in TASC at 3 months compared with usual care (2.7 ± 3.6 vs. 4.0 ± 4.1; p = 0.06). No significant differences were observed in PROMIS-MMT, PAM, or Neuro-QoL measures. Conclusion Findings suggest the feasibility of collecting PROs through an interactive web-based platform. The team-based remote BP monitoring demonstrated a favorable impact on patients' well-being. Patients equipped with appropriate resources can engage in poststroke self-care to mitigate inequities in health outcomes.