Inequity In Delivery Of Health Care Research Articles

Can We Realize a Real State of Medical Equity?

Achieving a real state of medical equity remains a challenging and complex goal within the healthcare system. Despite efforts to address disparities in healthcare access, treatment, and outcomes, significant barriers persist for marginalized communities. Structural inequalities rooted in race, socioeconomic status, geography, and education play a critical role in perpetuating inequities in healthcare delivery. To realize true medical equity, it is imperative to address these underlying factors through innovative policies and initiatives that prioritize equitable resource allocation, culturally competent care practices, and community engagement. Collaborative efforts between policymakers, healthcare providers, researchers, and community leaders are essential to reshaping our current healthcare system and ensuring that all individuals have equal opportunities to receive high-quality, person-centered care regardless of their background or circumstances. By working together towards the common goal of achieving medical equity, we can create a more just and inclusive healthcare system for everyone.

Challenges of Using Telemedicine in Hospital Specialty Consultations during the COVID-19 Pandemic in Portugal According to a Panel of Experts.

The COVID-19 pandemic has accelerated the adoption of telemedicine as a means of reducing face-to-face contact and protecting professionals and patients. In Portugal, the number of hospital telemedicine consultations has significantly increased. However, the rapid implementation of telemedicine has also led to disparities in access to these services, resulting in inequalities in healthcare delivery. The aim of this study was to identify the main challenges to accessing hospital medical specialty consultations through telemedicine in Portugal during the COVID-19 pandemic. Additionally, this study aimed to establish a consensus on possible solutions for the challenges which were identified. This study used the nominal group technique, which involved a panel of 10 experts. The panel generated a total of 71 ideas, which were then categorized into three groups: A) challenges relating to patients, which impact access to hospital-based medical specialty consultations through telemedicine; B) challenges relating to professionals, institutions and health systems, which impact access to hospital medical specialty consultations through telemedicine; C) recommendations to overcome the challenges faced in adopting telemedicine solutions. Each of the ideas was assessed, scored and ranked based on its relevance considering the study objectives. This study identified several significant challenges that impacted the adoption of telemedicine in Portugal during the COVID-19 pandemic. The challenges that related to patients (A) that were deemed the most relevant were low digital literacy, lack of information about telemedicine processes, low familiarity with technologies and distrust about the quality of services; the challenges that impacted healthcare professionals, institutions, and health systems (B) and were deemed the most relevant were the lack of integration of telemedicine in the patient's journey, low motivation to adopt telemedicine solutions, poor interoperability between systems, and the absence of the necessary technological equipment. The most relevant recommendations (C) included investing in healthcare institutions, developing clear guidelines for the safety and quality of telemedicine practices, and incorporating telemedicine into the curricula of health professions. This study identified several challenges that impacted the adoption and implementation of telemedicine services for hospital care in Portugal during the pandemic period. These challenges were related to digital health literacy, technological and operational conditions, and reluctance in technological adoption. To overcome these challenges, training programs for healthcare professionals and patients may be necessary, along with investment in technological infrastructures, interoperability between systems, effective communication strategies and the strengthening of specific regulations.

Development of an App for Tracking Family Engagement With Early Intervention Services: Focus Groups and Pilot Evaluation Study.

Expedient access to early intervention (EI) systems has been identified as a priority for children with developmental delays, identified disabilities, and other special health care needs. Despite the mandated availability of EI, it remains challenging for families to navigate referral processes and establish appropriate services. Such challenges disproportionately affect families from traditionally underserved communities. Mobile health apps can improve clinical outcomes, increase accessibility to health services, and promote adherence to health-related interventions. Though promising, the implementation of apps within routine care is in its infancy, with limited research examining the components of what makes an effective app or how to reach families most impacted by inequities in health care delivery. In study 1, we conducted focus groups to access a broad range of perspectives on the process of navigating the EI system, with the dual goals of identifying ways in which a patient-facing app might facilitate this process and identifying barriers to use with traditionally underrepresented and underserved groups. In study 2, focus group findings informed the development of a patient-facing app, which was subsequently tested with a pilot sample of 5 families. In study 1, the focus groups included 29 participants from 4 shareholder groups. Targeted sampling was used to recruit participants from traditionally underrepresented groups. Focus group questions sought information about barriers families experience as they navigate the EI system, ideal features of a patient-facing app designed to track family engagement with the EI system, and potential barriers. Focus group procedures were informed by the Consolidated Framework for Implementation Research framework. In study 2, a pilot app was developed. The app was tested with a sample of 5 families of young children involved in the EI system. Families provided information on app functionality and usability. Qualitative analysis revealed a desire for increased communication and information about the process of accessing EI services, potential utility of an app for communication purposes, and clear recommendations for app features. Insights from focus groups were used to inform the development of the Family on Track app and related implementation supports. App features included survey customization, timing and delivery of prompts, and questions related to barriers and service satisfaction. Implementation supports include a visual guide for app installation, resources related to common family questions, and availability of study personnel to guide families through installation and provide ongoing support. Field testing provided preliminary information about app usability, including identifying future directions. The results of this study could support the development of a new way for the EI system to communicate and connect with families, provide families with a means to communicate satisfaction and frustration, and access the supports they need to be active participants in their child's care.

Diversity, Equity, and Inclusion in the Multiple Sclerosis Community: A Call to Action.

Many medical organizations have begun to confront the longstanding problem of inequalities in health care delivery and the undeniable effect of disparities on health outcomes. The Consortium of Multiple Sclerosis Centers (CMSC) recognizes that disparities affect the lives of many people with multiple sclerosis (MS) and acknowledges the need to address this as an organization. The CMSC recently (1) appointed a task force, (2) conducted a survey of its membership, (3) commissioned this review article and call to action, and (4) formulated a mission statement on diversity, equity, and inclusion (DEI), which was adopted by the CMSC's Board of Governors in March 2023. This paper summarizes recent literature on health care disparities in MS, particularly those relating to race/ethnicity, sexual orientation, and gender identity. It presents findings from CMSC's survey of members' awareness of DEI issues, the need for education and resources for MS care providers, and existing institutional policies on DEI in the members' practice settings. It also presents the task force's recommendations for next steps, which includes the goal of greater diversity in the MS workforce of the future. The CMSC will continue to revisit DEI policies and practices over time with the goal of motivating greater awareness, momentum, and positive changes within the MS community.

(275) Health Care Disparities in the Transgender Population

Abstract Introduction The transgender population has largely been marginalized by society, causing inequities in health care delivery. The dearth of provider knowledge on transgender health issues further exacerbates these disparities. Objective A survey of the transgender population was conducted to help call attention to the often-overlooked aspect of care: fertility preservation prior to hormone therapy or gender affirmation surgery. Methods A survey of 65 transgender individuals was conducted, with participants recruited through Reddit transgender groups and local transgender associations, to assess their knowledge regarding fertility preservation and their experience with healthcare providers. Results were compiled and analysis was performed. Results Out of the 65 individuals who responded to the survey, approximately 88% were between the ages of 18 and 39. Seventy-four percent were assigned male gender at birth and 26% female. Sixty-two percent of individuals identified as female, 20% as male, and 18% as gender non-conforming. Only 35% of individuals had ever been cared for in a multidisciplinary transgender clinic. Interestingly, while 100% of surveyed individuals were aware that fertility would be irreversibly lost after hormonal or surgical affirmation surgery and 43% believed this to be an important issue, only 46% had any health care providers discuss fertility preservation options with them. Conclusions Hormonal therapy and gender affirming procedures affect the long-term reproductive potential of transgender individuals. While oncofertility is a prominent area of discussion, transgender care is still lagging. With an increase in medical and surgical therapy in younger individuals, health care providers must discuss fertility preservation options prior to affirmation therapy. Disclosure No

Race and Ethnicity Influences Outcomes of Adult Burn Patients.

Outcomes of burn survivors is a growing field of interest; however, there is little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any inequities in burn outcomes by racial and ethnic groups. A retrospective chart review of an ABA Certified burn center at a large urban safety net hospital identified adult inpatient admissions from 2015 to 2019. A total of 1142 patients were categorized by primary ethnicity: 142 black or African American, 72 Asian, 479 Hispanic or Latino, 90 white, 215 other, and 144 patients whose race or ethnicity was unrecorded. Multivariable analyses evaluated the relationship between race and ethnicity and outcomes. Covariate confounders were controlled by adjustment of demographic, social, and prehospital clinical factors to isolate differences that might not be explained by other factors. After controlling for covariates, black patients had 29% longer hospital stays (P = .043). Hispanic patients were more likely to be discharged to home or to hospice care (P = .005). Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (P = .022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P = .041, P = .011 respectively). The causes of these inequities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery.

Care Disruption During COVID-19: a National Survey of Hospital Leaders.

The COVID-19 pandemic caused massive disruption in usual care delivery patterns in hospitals across the USA, and highlighted long-standing inequities in health care delivery and outcomes. Its effect on hospital operations, and whether the magnitude of the effect differed for hospitals serving historically marginalized populations, is unknown. To investigate the perspectives of hospital leaders on the effects of COVID-19 on their facilities' operations and patient outcomes. A survey was administered via print and electronic means to hospital leaders at 588 randomly sampled acute-care hospitals participating in Medicare's Inpatient Prospective Payment System, fielded from November 2020 to June 2021. Summary statistics were tabulated, and responses were adjusted for sampling strategy and non-response. There were 203 responses to the survey (41.6%), with 20.7% of respondents representing safety-net hospitals and 19.7% representing high-minority hospitals. Over three-quarters of hospitals reported COVID testing shortages, about two-thirds reported staffing shortages, and 78.8% repurposed hospital spaces to intensive care units, with a slightly higher proportion of high-minority hospitals reporting these effects. About half of respondents felt that non-COVID inpatients received worsened quality or outcomes during peak COVID surges, and almost two-thirds reported worsened quality or outcomes for outpatient non-COVID patients as well, with few differences by hospital safety-net or minority status. Over 80% of hospitals participated in alternative payment models prior to COVID, and a third of these reported decreasing these efforts due to the pandemic, with no differences between safety-net and high-minority hospitals. COVID-19 significantly disrupted the operations of hospitals across the USA, with hospitals serving patients in poverty and racial and ethnic minorities reporting relatively similar care disruption as non-safety-net and lower-minority hospitals.

Transforming Atrial Fibrillation Research to Integrate Social Determinants of Health

Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia's often paroxysmal nature and individuals' disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF. The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF. Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.

Inequities in Access to Structural Heart Disease Interventions

This Viewpoint discusses the structural barriers to care that exist for patients of racial and ethnic minoritized and socioeconomically disadvantaged groups and proposes solutions to address the inequities in health care delivery.

Patient Perceptions of their COVID-19 Inpatient Hospital Experience: a Survey Exploring Inequities in Healthcare Delivery.

Compared with White patients, Black and Latinx patients have higher infection, hospitalization, and mortality rates from COVID-19; yet, little is known about their perspective before, during, and after a COVID-19 hospitalization. The objective of this study conducted in White, Black, and Latinx patients was to assess perceptions of their COVID-19-related hospitalization from onset of symptoms through the post-discharge period to identify disparities in their perceived care. A cross-sectional observational study using an online survey from May 19 to June 23, 2021, was conducted by The Harris Poll in 200 White, 200 Black, and 201 Latinx patients hospitalized for COVID-19 in the US. Main measures obtained included baseline demographic variables, socioeconomic status, and social determinants of health. Survey questions were specific to key aspects of the patient experience before, during, and after a COVID-19-related hospitalization. Compared with White patients, Latinx and Black patients faced unique challenges in their healthcare journey including higher likelihood of delaying their hospitalization (10% Black vs. 4% White patients, respectively, P = 0.025), lower perceived satisfaction with care (82% Latinx vs 91% White patients, P = 0.002), and lower trust in providers following their hospitalization (85% White vs. 65% Latinx [P = 0.027] and 73% Black [P = 0.050] patients). Patient perceptions of their COVID-19 hospitalization experience revealed disparities in perceived quality of care among minority groups. These findings offer insights that health inequities still exist, and strategies need to be taken to make health care delivery more equitable.

Movement disorders in COVID-19 times: impact on care in movement disorders and Parkinson disease.

The purpose of this review is to outline the impact of the COVID-19 pandemic on movement disorder holistic care, particularly in the care of people with Parkinson disease (PWP). As the pandemic unfolds, a flurry of literature was published regarding the impact of COVID-19 on people with Parkinson disease including the direct impact of infection, availability of ambulatory care, loss of community-based team care, and acceptability of telemedicine. COVID-19 has impacted the care of PWP in numerous ways. Recognizing infection in PWP poses challenges. Specific long-term complications, including emerging reports of long COVID syndrome is a growing concern. Caregivers and PWP have also been impacted by COVID-19 social isolation restrictions, with radical changes to the structure of social networks and support systems globally. In a matter of weeks, the global community saw an incredible uptake in telemedicine, which brought benefits and pitfalls. As PWP adapted to virtual platforms and the changing architecture of care delivery, the pandemic amplified many preexisting inequities amongst populations and countries, exposing a new 'digital divide'.

Poverty, race, ethnicity, and survival among U.S. children with non-metastatic osteosarcoma treated on EURAMOS-1: A report from the Children’s Oncology Group.

10004 Background: Children living in poverty and those who identify as a race/ethnicity other than non-Hispanic White experience higher rates of relapse and lower overall survival across many pediatric cancers. Racial, ethnic and socioeconomic disparities have not been comprehensively investigated in osteosarcoma. We leveraged data from US-enrolled patients on the recent international EURAMOS-1 trial to investigate disparities in survival outcomes. Aim: Identify if race/ethnicity, household or neighborhood poverty exposure are associated with event-free survival (EFS) or overall survival (OS) in patients with non-metastatic osteosarcoma enrolled at a US-center on EURAMOS-1. Methods: Retrospective cohort study of US patients aged 5-21 years enrolled on EURAMOS-1 with a diagnosis of non-metastatic, primary osteosarcoma. Poverty was the primary exposure defined at the household- (sole coverage with Medicaid or CHIP public insurance versus other) and neighborhood- (Census-defined high-poverty ZIP code with >20% of residents living at <100% Federal Poverty Level vs other) levels. Race and ethnicity were categorized to reflect structural inequities and historically marginalized populations, as Hispanic, non-Hispanic Black (NHB), non-Hispanic Other (NHO), and non-Hispanic White (NHW). OS and EFS as a function of time from trial enrollment were estimated using the Kaplan-Meier method. Hypotheses of associations between risks for EFS-event, death and post-relapse death with poverty-exposures and race/ethnicity were assessed using log-rank tests. Statistical comparisons were performed excluding patients with missing values for the exposures considered. P-values <=0.05 were considered significant. Results: Among 758 patients, 27% were household poverty-exposed and 29% were neighborhood-poverty exposed. Twenty-one percent of children identified as Hispanic, 17% NHB, 5% NHO and 57% NHW. Neither household- or neighborhood-poverty, nor race/ethnicity were significantly associated with risks for EFS-event or death. Post-relapse risk for death differed significantly across race/ethnicity with NHB at greatest risk compared to others (4-Year post-relapse survival 35.7% Hispanic vs. 13.0% NHB vs. 43.8% NHO vs 38.9% NHW; p=0.0046). Conclusions: Neither poverty-exposures nor race/ethnicity were associated with EFS or OS in this COG trial-enrolled cohort, suggesting equitable outcomes following standardized therapy. Despite this, non-Hispanic Black children experienced significantly inferior post-relapse survival. Investigation of mechanisms driving these post-relapse disparities, including inequities in health care delivery and access to post-relapse trial-enrollment, are paramount to ensure equity in outcomes for all children with cancer.

Health Disparities in the Treatment of Supraventricular Tachycardia in Pediatric Patients.

Supraventricular tachycardia (SVT)is a common pediatric arrhythmia. The objective of this investigation was to investigate the existence and degree of the health disparities in the treatment of pediatric patients with supraventricular tachycardia based on sociodemographic factors. This was retrospective cohort study at a large academic medical center including children ages 5-18years old diagnosed with SVT. Patients with congenital heart disease and myocarditis were excluded. Initial treatment and ultimate treatment with either medical management or ablation were determined. The odds of having an ablation procedure were determined based on patient age, sex, race, ethnicity, and insurance status. There was a larger portion of non-White patients (p = 0.033) within the cohort that did not receive an ablation during the study period. Patients that were younger, female, American Indian/Alaskan Native, unknown race, and had missing insurance information were less likely to receive ablation therapy during the study period. In this single center, regional evaluation, we demonstrated that disparities in the treatment of pediatric SVT are present based on multiple patient sociodemographic factors. This study adds evidence to the presence of inequities in health care delivery across pediatric populations.

Internal dynamics within primary care teams in two Spanish regions during the COVID-19 pandemic: a qualitative study

BackgroundPandemics and epidemics have represented public health emergencies with severe consequences at a global level. Primary care teams have played a crucial role in disease surveillance and monitoring during the COVID-19 pandemic through early detection, contact tracing, and isolation of positive cases. The objective of this study was to explore the impact of the COVID-19 pandemic on primary care teams regarding their internal dynamics and their professional performance.MethodsQualitative study carried out between July and December 2020 in two large central and southern Spanish regions (Castilla la Mancha and Madrid). Semi-structured interviews and focus groups were conducted with primary care workers. Data was analysed using thematic content analysis. Participants were accessed using purposive sampling.ResultsA total of 53 primary care workers participated in the study, of which 38 were individually interviewed, and 15 participated in three focus groups.The analysis of their experiences revealed two main themes regarding the impact of the COVID-19 pandemic on primary care teams: 1) The need to reorganise traditional roles: Primary care settings closed their doors to the public and their workers restructured their roles to ensure the delivery of essential services; 2) The need to implement a new primary care delivery model: Each primary care team had to self-organise, making sure their reference population was cared for and developing resource optimisation strategies.ConclusionsPrimary care teams have quickly adapted their roles and internal dynamics to respond to the demands generated by COVID-19. In the new delivery model, some positive aspects could be highlighted – such as increased communication between professionals and the use of telemedicine for some cases. However, it is important to address the negative impact that the COVID-19 crisis has had on of the main functions of primary care. These measures are necessary to promote well-being in primary care teams, and to provide quality care that addresses the complex and individual needs of each person and reduces inequalities in healthcare delivery.

561 Ethnicity Influences Outcomes of Adult Burn Patients

IntroductionOutcomes of burn survivors is a well-studied field of research for burn providers; however, there has been little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any disparities in burn outcomes of broad ethnic groups. Adjustment was made for demographic, social and pre-hospital clinical factors to help isolate ethnic disparities that might not be explainable by other factors.MethodsA retrospective chart review of an American Burn Association verified burn center identified adult inpatient admissions from 2015 to 2019 with documented insurance status. A total of 1142 patients were categorized by recorded primary ethnicity: 142 Black (or African American), 72 Asian, 479 Hispanic (or Latinx), 90 white, 215 other, and 144 patients whose race or ethnicity was not indicated. Firth logistic regression was used to study the relationship between ethnicity and each of several binary outcomes. Zero-truncated negative binomial regression was used to examine hospital length of stay (LOS) and intensive care unit LOS. Adjustment was made for several confounders (age, gender, homelessness, primary insurance type, diabetes, inhalation injury, primary burn depth, percentage of total body surface area injured) to clarify the statistical effect of ethnicity. The specific adjustment set used depended on the outcome type or frequency.ResultsRelative to white patients, surviving Black patients had an estimated 29% higher average hospital LOS (ratio 1.29; 95% CI 1.01-1.64; unadjusted P=.04). Had the average surviving patient in this sample been Black, their hospital stay would be 2.7 days longer (95% CI 0.1-5.4). Relative to white patients, the odds of being discharged home with or without services, or to hospice care, were an estimated 123% higher for Hispanic patients (OR 2.23; 95% CI 1.28-3.88; unadjusted P=.005). Compared with non-Hispanic ethnicity, Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (OR 0.56; 95% CI 0.34-0.92; unadjusted P=.022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P=.041, P=0.011 respectively).ConclusionsEven when controlling for burn severity, age, and other factors, Black patients had longer hospital stays. Hispanic patients were more likely to be discharged to home or to hospice care. The causes of these disparities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery or insurance coverage.

Does Perceived Racism Affect Prostate Cancer Screening Rates and Patient-Provider Shared Discussions Among Black and White Men?

While Black men face a significant cancer risk burden in the United States, confronting complex historical and social issues such as racism and discrimination undermines care. This study explored associations between perceived racism, prostate screening rates, and shared medical discussions. We performed data analysis of merged Behavioral Risk Factor Surveillance System (BRFSS) survey data. Data were limited to Black and White men. We used propensity score analysis to assess the race-associated effects on outcomes. Black men were less likely than White men to receive discussions of both prostate-specific antigen (PSA) screening advantages χ2(4.54), p < .05 and disadvantages χ2(41.62), p < .001. The effects of perceived racism and its interaction with race were statistically non-significant for all PSA outcomes. Compared with their White counterparts, Black men were significantly less likely to be advised of potential PSA screening advantages and harms. This inequity in health care delivery has implications concerning disease prevention and informed decision-making.

Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism.

Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access. Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia. Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI=3.8-6.2) and double the use of SHHC (95% CI=2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR=0.32; 95% CI=0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas. Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.

Impact of Race/Ethnicity on Cancer Associated Thrombosis Among Underserved Patients with Cancer

Introduction: Cancer-associated thrombosis (CAT) is common among patients with cancer. Risk factors for CAT include type of malignancy, advanced stage, and chemotherapy treatment, but the association of CAT with race and ethnicity remains controversial. Identifying the incidence of CAT among populations susceptible to inequalities in healthcare delivery may help delineate preventive strategies.Methods: We performed a retrospective cohort study at Harris Health System (HHS), a safety-net healthcare system that provides care for underserved minorities and uninsured patients in Houston, TX. We created an integrated database that linked consecutive patients with newly diagnosed invasive cancer with structured electronic health record (EHR) data from 2011-2020 (Figure 1). We followed patients from time of cancer diagnosis to time of first VTE, death, or loss of follow-up. VTE was defined as radiologically confirmed pulmonary embolism (PE), lower extremity deep vein thrombosis (LE-DVT), catheter-related DVT (CR-DVT), or splanchnic vein thrombosis in either inpatient or outpatient setting. We used VTE ICD9/ICD10 billing codes to assess for potential events and confirmed incident, recurrent, and historical events through medical record review. VTE occurring within 30 days prior to cancer diagnosis were considered as CAT at diagnosis.Incidence rates were assessed per 100 person-year (py) within 1 year of diagnosis and stratified by race/ethnicity, cancer type, and cancer stage. Cumulative incidence of VTE was assessed through competing risk method with death as the competing cause. Multivariable Fine-Gray competing risk models were performed to determine the effect of race/ethnicity on the risk of CAT, adjusted for age, sex, body mass index, insurance, cancer site, stage, systemic therapy, recent hospitalization, and prior history of VTE.Results: A total of 9,353 cancer patients were included in the study, where 49.3% were Hispanics, 27.6% were Non-Hispanic Blacks (NHB), 15.5% were Non-Hispanic Whites (NHW), and 7.6% were Asian/Pacific Islander (PI). Most patients (74.7%) were uninsured, 35.8% were obese, 19% had recent hospitalization, and 31.9% had stage IV disease. Overall, 832 developed CAT within 1 year, including 49.4% PE, 28.1% LE-DVT, and 17.1% CR-DVT. The median onset was 69 days (IQR 20-154), but a significant proportion (n=92) was diagnosed in the month before diagnosis. The incidence of CAT was 7.3% at 6 months and 9.6% at 1 year. The overall incidence rate was 11/100 py with a similar trend from 2011 to 2020.Figure 2 shows the variation in incidence rates for different cancer types across stages. The rate increased 2- to 10-fold from stage I to IV, reaching >40/100 py among patients with pancreatic and upper gastrointestinal cancers. Figure 3 shows the impact of race/ethnicity on the incidence of CAT, with 9.3% and 8.4% for NHW and NHB at 6 months, compared to 6.5% and 3.8% for Hispanics and Asian/PI, respectively. In the adjusted multivariable analysis, the risk of CAT remained lower in Hispanics vs. NHW (SHR 0.80 [0.65-0.97]) and Asian/PI vs. NHW (SHR 0.48 [0.32-0.73]). There was no difference in NHB vs. NHW (SHR 1.04 [0.84-1.27]). Other important covariates included history of VTE (SHR 2.29 [1.32-3.97]) and prolonged hospitalization (SHR 1.53 [CI 1.31-1.80]) in addition to staging and cancer types. Compared to no systemic therapy or adjuvant endocrine only, there was a higher incidence of VTE in patients receiving chemotherapy (SHR 1.72 [1.39-2.15]), targeted therapy (SHR 1.58 [1.12-2.23]), immunotherapy (SHR 2.13 [1.30-3.48], but not non-adjuvant endocrine therapy (SHR 0.91 [0.40-2.08]).Conclusion: In the current cancer registry-linked EHR cohort with a high proportion of Hispanics and Blacks from a large safety-net healthcare system in the US, we have observed a high incidence rate of CAT at 11/100 py. This rate is much higher than 3.9-5.8/100 py reported in contemporary cancer registries in Europe (PMID 27709226, 33171494), and likely reflects advanced disease and comorbidity at the time of diagnosis due to delayed care from the lack of health insurance. Despite adjusting for patient-, cancer-, and treatment-specific confounders, we found that Hispanics and Asian/PI had ~20% and ~50% lower rate of VTE, respectively, compared to NHW or NHB. This racial/ethnicity difference should be considered in future risk assessment models for CAT. [Display omitted] DisclosuresCarrier: Sanofi Aventis: Honoraria, Membership on an entity's Board of Directors or advisory committees; LEO Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bayer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Honoraria; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees; Aspen: Membership on an entity's Board of Directors or advisory committees; Boehringer Ingelheim: Honoraria; Servier: Honoraria.

Impact of COVID-19 on an Urban Refugee Population.

Purpose: The COVID-19 pandemic has brought to light many systemic inequities in health care delivery. As medical communities work to address the disproportionate effects of COVID-19 on vulnerable populations, it is crucial to include refugees in the public health response. Language barriers, poor health literacy, and low socioeconomic status render refugee populations highly susceptible to negative outcomes from the COVID-19 pandemic. To better understand the refugee experience with COVID-19, we constructed and administered a survey among refugee populations in Houston, Texas.Methods: Our 49-question cross-sectional survey was administered to 44 participants in Arabic, Burmese, Dari, English, Kiswahili, Nepali, Spanish, or Urdu with the use of refugee resettlement case managers acting as translators. The survey encompassed three domains, including a general knowledge assessment of COVID-19, subjective experiences with COVID-19, and risk communication practices within refugee populations.Results: The majority of refugees surveyed admitted to worrying about the effects of COVID-19 on their community (88.6%). The negative consequences of the COVID-19 pandemic included financial adversity (65.1%) and significant disruption of children's education (62.8%). Although 50.0% of participants self-reported proficiency in English, translation services were used with 75.0% of participants to ensure full comprehension.Conclusions: The implications of our findings suggest that local refugee populations require heightened support during the COVID-19 pandemic. Tailored interventions should encompass comprehensive translation and interpretation services, financial assistance, and academic interventions for refugee youth.

Racial and Ethnic Disparities in Pain Management of Children With Limb Fractures or Suspected Appendicitis: A Retrospective Cross-Sectional Study.

Objective: To evaluate whether racial/ethnical differences in analgesia administration existed in two different cohorts of children with painful conditions: children with either limb fracture or suspected appendicitis.Methods: Retrospective cross-sectional analysis of children visiting a pediatric emergency department (Boston Children Hospital) for limb fracture or suspected appendicitis from 2011 to 2015. We computed the proportion of children that received any analgesic treatment and any opioid analgesia. We performed multivariable logistic regressions to investigate race/ethnicity differences in analgesic and opioid administration, after adjusting for pain score, demographics and visit covariates.Results: Among the 8,347 children with a limb fracture and the 4,780 with suspected appendicitis, 65.0 and 60.9% received any analgesic treatment, and 35.9 and 33.4% an opioid analgesia, respectively. Compared to White non-Hispanic Children, Black non-Hispanic children and Hispanic children were less likely to receive opioid analgesia in both the limb fracture cohort [Black: aOR = 0.61 (95% CI, 0.50–0.75); Hispanic aOR = 0.66 (95% CI, 0.55–0.80)] and in the suspected appendicitis cohort [Black: aOR = 0.75 (95% CI, 0.58–0.96); Hispanic aOR = 0.78 (95% CI, 0.63–0.96)]. In the limb fracture cohort, Black non-Hispanic children and Hispanic children were more likely to receive any analgesic treatment (non-opioid or opioid) than White non-Hispanic children [Black: aOR = 1.63 (95% CI, 1.33–2.01); Hispanic aOR = 1.43 (95% CI, 1.19–1.72)].Conclusion: Racial and ethnic disparities exist in the pain management of two different painful conditions, which suggests true inequities in health care delivery. To provide equitable analgesic care, emergency departments should monitor variation in analgesic management and develop appropriate universal interventions.