Electronic Health Records as Biased Tools or Tools Against Bias: A Conceptual Model.

Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy. CONTEXT: Health care delivery is now inextricably linked to the use of electronic health records (EHRs), which exert considerable influence over providers, patients, and organizations. METHODS: This article offers a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. Using structuration theory, the model demonstrates how a social structure, like an EHR, creates a cyclical relationship between the environment and people, either advancing or undermining important social values. FINDINGS: The model illustrates how the implicit bias of individuals, both developers and end-user clinical providers, influence the platform and its associated information. Biased information can then lead to inequitable outcomes in clinical care, organizational decisions, and public policy. The biased information also influences subsequent users, amplifying their own implicit biases and potentially compounding the level of bias in the information itself. The conceptual model is used to explain how this concern is fundamentally a matter of quality. Relying on the Donabedian model, it explains how elements of the EHR design (structure), use (process), and the ends for which it is used (outcome) can first be used to evaluate where bias may become embedded in the system itself, but then also identify opportunities to resist and actively challenge bias. CONCLUSIONS: Our conceptual model may be able to redefine and improve the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy. For EHRs to do this, further work is needed to develop measures that assess bias in structure, process, and outcome, as well as policies to persuade vendors and health systems to prioritize systemic equity as a core goal of EHRs.

Funding Community Health Activities: An Experiment Comparing Health Foundation's Priorities to Those of Public Health Agencies, Hospitals, and Nonprofit Organizations.

CONTEXT: Health foundations provide significant financial resources for community health. Foundation priorities, therefore, can play a key role in setting community agenda, but little is known about the criteria foundations use to prioritize projects. OBJECTIVE: To understand the priorities that guide decision makers in health foundations and compare those priorities with what is known about nonprofit hospitals, public health, and community-based nonprofits. DESIGN: An online survey with a discrete choice experiment and open-ended questions, asking respondents to choose between different types of community health projects based on project characteristics. SETTING: Survey respondents were employed by health foundations located in the United States. PARTICIPANTS: Respondents were leaders at health foundations (n = 173), the majority of which (56.2%) worked at foundations with assets greater than $50 million. These respondents were compared with an earlier survey (n = 561) from nonprofit hospitals, public health, and community-based nonprofits. MAIN OUTCOME MEASURES: A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided interpretation. A two sample t test was used to compare groups. RESULTS: Foundation decision makers placed the greatest value on programs with coalitions of community partners, programs with a growing or existing base of evidence for effectiveness, and programs that focus on social determinants of health. These priorities are similar to those of community nonprofits, public health departments, and health systems. However, foundation leaders are more willing to fund interventions with longer time horizons and interventions that are not yet fully evidence-based. Foundations are also less interested in clinical care and more interested in advocacy programs. CONCLUSION: Cooperation in funding and implementation is essential to community health improvement, and major organizations could benefit from everyone clearly articulating their priorities. There are good reasons to intentionally foster both similarities and differences in priorities across organizations.

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians.

BACKGROUND: Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care. OBJECTIVE: To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care. DESIGN: Cross-sectional survey of ACO clinicians in 2018. PARTICIPANTS: 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%. MAIN MEASURES: Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care. RESULTS: Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation. CONCLUSIONS: Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978-2017.

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in-person, semi-structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology's professional autonomy was correlatively diminished. Decision-making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.

Priorities for Investing in Community Health Improvement: A Comparison of Decision Makers in Public Health, Nonprofit Hospitals, and Community Nonprofits.

CONTEXT: As a result of additional requirements for tax exemption, many nonprofit hospitals have become more actively involved in community health improvement. There is an open question, however, as to how decision makers in hospitals decide which kind of improvement projects should receive priority and how hospital managers' priorities compare with those of decision makers in public health agencies and community-based nonprofits. OBJECTIVE: To understand the priorities that guide decision makers in public health, nonprofit hospitals, and community nonprofits when allocating resources to community health projects. DESIGN: We conducted an online survey with a discrete choice experiment, asking respondents to choose between different types of community health projects, which varied along several project characteristics. Respondents included managers of community health and community benefit at nonprofit hospitals (n = 225), managers at local public health departments (n = 200), and leaders of community nonprofits (n = 136). Respondents were located in 47 of 50 US states. A conditional logit model was used to estimate how various project characteristics led to greater or lesser support of a given health project. Open-ended questions aided in interpretation of results. RESULTS: Respondents from all 3 groups showed strong agreement on community health priorities. Projects were more likely to be selected when they addressed a health issue identified on community health needs assessment, involved cross-sector collaboration, or were supported by evidence. Project characteristics that mattered less included the time needed to measure the project's impact and the project's target population. CONCLUSION: Elements often considered central to community health, such as long-term investment and prioritizing vulnerable populations, may not be considered by decision makers as important as other aspects of resource allocation. If we want greater priority for ideas such as health equity and social determinants of health, it will take a concerted effort from practitioners and policy makers to reshape expectations.

The Good and Evil of Health Policy: Medicaid Expansion, Republican Governors, and Moral Intuitions.

Using moral foundations theory (MFT), this study analyzes how Republican governors employed moral concepts to either build support or opposition to Medicaid expansion. The study examined statements about Medicaid expansion made by all Republican governors as reported in two large newspapers in each governor's state from 28 June 2012 to 31 December 2018. A slight majority of the statements (183 or 58.5%) used moral arguments in support of Medicaid expansion. Governors from both policy camps most frequently used the moral foundations shared by liberals and conservatives: care/harm and fairness/cheating. Those supporting expansion also used loyalty/betrayal, authority/subversion, and sanctity/degradation. Those opposing expansion used liberty/oppression. Policymakers recognize that activating the public's moral intuitions can be an effective way to advance a policy of interest. Those interested in advancing health policies would do well to better understand the kind of moral arguments that are used with potential supporters and arguments that may be used by opponents.

Nonprofit Hospital Community Benefit in the U.S.: A Scoping Review From 2010 to 2019.

Background: U.S. nonprofit hospital community benefit recently underwent significant regulatory revisions. Starting in 2009, the Internal Revenue Service (IRS) required hospitals to submit a new Schedule H that provided greater detail on community benefit activities. In addition, the Affordable Care Act (ACA), which became law in 2010, requires hospitals to conduct community health needs assessments (CHNA) and develop community health implementation plans (CHIP) as a response to priority needs every 3 years. These new requirements have led to greater transparency and accountability and this scoping review considers what has been learned about community benefit from 2010 to 2019. Methods: This review identified peer-reviewed literature published from 2010 to 2019 using three methods. First, an OvidSP MEDLINE search using terms suggested previously by community benefit researchers. Second, a PubMed search using keywords frequently found in community benefit literature. Third, a SCOPUS search of the most frequently cited articles in this topic area. Articles were then selected based on their relevance to the research question. Articles were organized into topic areas using a qualitative strategy similar to axial coding. Results: Literature appeared around several topic areas: governance; CHNA and CHIP process, content, and impact; community programs and their evaluation; spending patterns and spending influences; population health; and policy recommendations. The plurality of literature centered on spending and needs assessments, likely because they can draw upon publicly available data. The vast majority of articles in these areas use spending data from 2009 to 2012 and the first cycle of CHNAs in 2013. Policy recommendations focus on accountability for impact, enhancing collaboration, and incentivizing action in areas other than clinical care. Discussion: There are several areas of community benefit in need of further study. Longitudinal studies on needs assessments and spending patterns would help inform whether organizations have changed and improved operations over time. Governance, program evaluation, and collaboration are some of the consequential areas about which relatively little is known. Gaps in knowledge also exist related to the operational realities that drive community benefit activities. Shaping organizational action and public policy would benefit from additional research in these and other areas.

Nonprofit Hospitals' Process for Community Health Improvement: A Qualitative Study of Leading Practices and Missing Links.

Nonprofit hospitals and health systems spend more than $4 billion each year on community health improvement, yet little is known about the internal process that these organizations follow when implementing these efforts. Because of laws governing tax-exempt health care organizations, both the process these hospitals use to identify community health needs and their annual expenditure of community benefit dollars are known. Yet much else about the process of community health improvement is largely unknown. This study uses data from semi-structured interviews with 38 directors of community health efforts at nonprofit hospitals and health systems to describe the internal procedures that nonprofit hospitals and health systems follow when implementing community health efforts, with the goal of identifying both leading practices and areas in need of greater attention. Interviews were analyzed using open and axial coding. Results show hospitals' community health improvement efforts have 7 distinct stages: budgeting, assessing needs, developing strategy, allocating resources, implementing programs, evaluating, and communicating results. Two of these stages, assessing needs and communicating results, are similar across most organizations - most likely a result of federal regulations. Other stages, especially budgeting, allocating resources, and evaluating programs, show high variation across organizations and often lack a formal process. Several leading practices were identified for each stage, but community health efforts currently lack structure within many organizations and are not designed for improvement over time. To better leverage the resources available from nonprofit hospitals, the less public-facing aspects of community benefit will require more study and perhaps additional regulation.

Preferences for bariatric surgery: comparing surgeons and patients using a discrete choice experiment.

BACKGROUND: Increased attention to shared decision-making is particularly important in bariatric surgery. It is unclear whether the large shift toward sleeve gastrectomy is evidence of good alignment between patient and surgeon preferences. OBJECTIVE: To identify surgeon preferences for risks, benefits, and other attributes of treatment options available for bariatric surgery and to compare results with patient preferences. SETTING: Online survey. METHODS: A discrete choice experiment of weight loss procedures. Each procedure was described by the following set of attributes: (1) treatment method, (2) recovery and reversibility, (3) years treatment has been available, (4) expected weight loss, (5) effect on other medical conditions, (6) risk of complication, (7) side effects, (8) changes to diet, (9) out-of-pocket costs. Participants chose between surgical profiles by comparing attributes. A convenience sample of providers for the online survey was recruited via LISTSERVs of professional associations. RESULTS: Respondents (n = 121) were most likely to select profiles of hypothetical procedures based on the resolution of existing medical conditions and higher expected weight loss. These results align with patient preferences. However, surgeons selected profiles based on lower risk of complications than did patients and surgeons were less sensitive to out-of-pocket costs than patients. CONCLUSIONS: Results show strong alignment between the preferences of patients and the preferences of surgeons when they are asked to stand in the place of their patients. Some differences, especially those related to sensitivity to risk of complications and out-of-pocket costs indicate that shared decision-making would benefit from providers explaining their concerns about surgical risk and from appreciating the concern many patients have about financial costs.

Patient Preferences for Bariatric Surgery: Findings From a Survey Using Discrete Choice Experiment Methodology.

Importance: Surgical options for weight loss vary considerably in risks and benefits, but the relative importance of procedure-associated characteristics in patient decision making is largely unknown. Objective: To identify patient preferences for risks, benefits, and other attributes of treatment options available to individuals who are candidates for bariatric surgery. Design, Setting, and Participants: This discrete choice experiment of weight loss procedures was performed as an internet-based survey administered to patients recruited from bariatric surgery information sessions in the State of Michigan. Each procedure was described by the following set of attributes: (1) treatment method, (2) recovery and reversibility, (3) time that treatment has been available, (4) expected weight loss, (5) effect on other medical conditions, (6) risk of complication, (7) adverse effects, (8) changes to diet, and (9) out-of-pocket costs. Participants chose between surgical profiles by comparing attributes. Survey data were collected from May 1, 2015, through January 30, 2016, and analyzed from February 1 to June 30, 2016. Main Outcomes and Measures: Estimated relative value of risks and benefits for leading weight-loss surgical options and marginal willingness to pay for procedure attributes. A latent class analysis identified respondent subgroups. Results: Among the 815 respondents (79.9% women; mean [SD] age, 44.5 [12.0] years), profiles of hypothetical procedures that included resolution of medical conditions (coefficient for full resolution, 0.229 [95% CI, 0.177 to 0.280; P < .001]; coefficient for no resolution, -0.207 [95% CI, -0.254 to -0.159; P < .001]), higher total weight loss (coefficient for each additional 20% loss, 0.185 [95% CI, 0.166 to 0.205; P < .001]), and lower out-of-pocket costs (coefficient for each additional $1000, -0.034 [95% CI, -0.042 to -0.025; P < .001]) were most likely to be selected. Younger respondents were more likely than older respondents to choose treatments with higher weight loss (coefficient for loss of 80% excess weight 0.543 [95% CI, 0.435-0.651] vs 0.397 [95% CI, 0.315-0.482]) and were more sensitive to out-of-pocket costs (coefficient for $100 out-of-pocket costs, 0.346 [95% CI, 0.221-0.470] vs 0.262 [95% CI, 0.174 to 0.350]; coefficient for $15 000 in out-of-pocket costs, -0.768 [95% CI, -0.938 to -0.598] vs -0.384 [95% CI, -0.500 to -0.268]). Marginal willingness to pay indicated respondents would pay $5470 for losing each additional 20% of excess body weight and $12 843 for resolution of existing medical conditions, the most desired procedure attributes. Latent class analysis identified the following 3 unobserved subgroups: cost-sensitive (most concerned with costs); benefit-focused (most concerned with excess weight loss and resolution of medical conditions); and procedure-focused (most concerned with how the treatment itself worked, including recovery and reversibility). Conclusions and Relevance: Candidates for bariatric surgery identified costs, expected weight loss, and resolution of medical conditions as the most important characteristics of weight loss surgery decisions. Other information, such as risk of complications and adverse effects, were important to patients but less so.

Short-term volunteer health trips: aligning host community preferences and organizer practices.

BACKGROUND: Short-term medical missions (STMMs) are quite common and largely understood to be a response to health needs in low-income countries. Yet most information about STMM practices is anecdotal. Even less is known about the preferences of in-country host communities regarding STMMs. OBJECTIVE: We aimed to gather enough quantitative and qualitative information from both STMM organizers and host community staff to compare dominant practices of organizers as well as preferences of host community staff. We use these data to discover differences between practices and preferences and suggest ways in which STMMs can be more responsive to the communities they serve. METHODS: Researchers gathered online survey responses from 334 STMM organizers and conducted interviews to determine existing practices. Similar methods were used to collect 49 online survey responses from, and conduct 75 interviews with, host community staff. RESULTS: Organizer practices and host community staff preferences are different in several areas. Organizers admit to minimal screening and preparation of volunteers whereas host staff have clear ideas of topics that should be covered in preparation, including culture and basic language skills. Organizers prioritize provision of clinical care during trips whereas host staff prioritize capacity building. Practices and preferences also differ in relation to the length of STMMs, the nature of the partnership itself, and the type of assessment and evaluation that is needed. CONCLUSIONS: The large amount of data gathered for this study allows us to confidently say that organizer practices are often not aligned with host community staff preferences. Several concrete changes can be made to STMMs to bring practices more in line with the desires of the communities they serve.

Lactate interferes with ATP release from red blood cells.

Upon exposure to low Po(2), the red blood cells of most species, including humans, release increased amounts of ATP that ultimately serves as a regulator of vascular tone matching oxygen supply with demand. In pathological conditions such as malaria and sepsis, a maldistribution of perfusion exists with its severity often correlated with the extent of elevation of serum lactate frequently in the absence of an alteration in pH. We hypothesized that the increased levels of lactate might impair the ability of red blood cells to appropriately respond to conditions of low Po(2), thus preventing its important blood flow regulatory role. Using an in vitro system and rabbit red blood cells, we evaluated the capacity of cells incubated with lactate to release increased amounts of ATP in response to acute exposure to low Po(2). We found that in the presence of lactate, the red blood cells did not release ATP. However, when sodium dichloroacetate, a drug used clinically to lower blood lactate levels, was added, ATP release was restored to levels that were not different from that of control cells (no lactate), even though intracellular levels of ATP were not. These results support the presence of a distinct flow regulatory pool of ATP within the red blood cell that can be independently regulated, and that lactate interferes with the ATP production within this pool, thereby diminishing the amount of ATP available for release on exposure to low Po(2). Therefore, if lactate levels can be reduced, the vascular regulatory capacity of the red blood cell should be restored, thus enabling the appropriate matching of oxygen supply with oxygen demand.