Reimagining Merit and Representation: Promoting Equity and Reducing Bias in GME Through Holistic Review.

OBJECTIVE: This study aims to evaluate the capacity of a holistic review process in comparison with non-holistic approaches to facilitate mission-driven recruitment in residency interview screening and selection, with particular attention to the promotion of race equity for applicants underrepresented in medicine (URM). METHODS: Five hundred forty-seven applicants to a psychiatry residency program from US allopathic medical schools were evaluated for interview selection via three distinct screening rubrics-one holistic approach (Holistic Review; HR) and two non-holistic processes: Traditional (TR) and Traditional Modified (TM). Each applicant was assigned a composite score corresponding to each rubric, and the top 100 applicants in each rubric were identified as selected for interview. Odds ratios (OR) of selection for interview according to URM status and secondary outcomes, including clinical performance and lived experience, were measured by analysis of group composition via univariate logistic regression. RESULTS: Relative to Traditional, Holistic Review significantly increased the odds of URM applicant selection for interview (TR-OR: 0.35 vs HR-OR: 0.84, p < 0.01). Assigning value to lived experience and de-emphasizing USMLE STEP1 scores contributed to the significant changes in odds ratio of interview selection for URM applicants. CONCLUSIONS: Traditional interview selection methods systematically exclude URM applicants from consideration without due attention to applicant strengths or potential contribution to clinical care. Conversely, holistic screening represents a structural intervention capable of critically examining measures of merit, reducing bias, and increasing URM representation in residency recruitment, screening, and selection.

American Indian Reservations and COVID-19: Correlates of Early Infection Rates in the Pandemic.

OBJECTIVE: To determine the household and community characteristics most closely associated with variation in COVID-19 incidence on American Indian reservations in the lower 48 states. DESIGN: Multivariate analysis with population weights. SETTING: Two hundred eighty-seven American Indian Reservations and tribal homelands (in Oklahoma) and, as of April 10, 2020, 861 COVID-19 cases on these reservation lands. MAIN OUTCOME MEASURES: The relationship between rate per 1000 individuals of publicly reported COVID-19 cases at the tribal reservation and/or community level and average household characteristics from the 2018 5-Year American Community Survey records. RESULTS: By April 10, 2020, in regression analysis, COVID-19 cases were more likely by the proportion of homes lacking indoor plumbing (10.83, P = .001) and were less likely according to the percentage of reservation households that were English-only (-2.43, P = .03). Household overcrowding measures were not statistically significant in this analysis (-6.40, P = .326). CONCLUSIONS: Failure to account for the lack of complete indoor plumbing and access to potable water in a pandemic may be an important determinant of the increased incidence of COVID-19 cases. Access to relevant information that is communicated in the language spoken by many reservation residents may play a key role in the spread of COVID-19 in some tribal communities. Household overcrowding does not appear to be associated with COVID-19 infections in our data at the current time. Previous studies have identified household plumbing and overcrowding, and language, as potential pandemic and disease infection risk factors. These risk factors persist. Funding investments in tribal public health and household infrastructure, as delineated in treaties and other agreements, are necessary to protect American Indian communities.

Diversity in Clinical and Biomedical Research: A Promise Yet to Be Fulfilled.

Esteban Gonzalez Burchard and colleagues explore how making medical research more diverse would aid not only social justice but scientific quality and clinical effectiveness, too.

Drivers of shared decision making in inpatient psychiatry: An exploratory survey of patients' and multi-disciplinary team members' perspectives.

OBJECTIVE: To assess the prevalence and predictors of Shared Decision Making (SDM) in an adult, inpatient psychiatric setting. METHOD: Multi-disciplinary clinician focus groups and patient pre-testing informed the development of a survey on 4 SDM and 11 factors hypothesized to interfere with SDM. The survey was administered to 89 adult inpatients (80% response rate) and their treatment team psychiatrists, nurses, and social workers (n = 338 ratings, 95% response rate). Group differences and predictors were estimated using t and F-tests. RESULTS: Patients' mean SDM score (n = 64, standardized Cronbach alpha = 0.858) was 3.35 ± 1.13 (5 = highest agreement), and correlated with overall satisfaction with care (n = 61, r = 0.399, p = 0.001). Patients' disagreement with clinician's diagnosis (44% of patients) correlated with lower SDM ratings by patients (t = 2.55, df = 62, p = 0.013) and by clinicians (t = 2.99, df = 69, p = 0.004). Psychotic diagnoses were not a significant determining factor for SDM. Overall, clinicians rated SDM more favorably than patients (t = -5.43, df = 63, p < 0.001), with nurses and social workers rating SDM higher than physicians (p < 0.001). CONCLUSIONS: Diagnostic agreement / disagreement is a key predictor of SDM for patients and clinicians, while presence of psychosis is not. SDM was rated higher by clinicians than patients. SDM ratings vary significantly between clinical disciplines.

Multi-Sector Assessment and Client-Perception of Social Need at Long-Term Follow-Up of a Group-Randomized Trial of Community-Engaged Collaborative Care for Adults with Depression.

Understanding client perceptions of need for underlying social determinant support may improve services for depression care. This secondary analysis examines perceptions of "social needs" related to housing and employment, financial, and legal (EFL) concerns among individuals with depression. Data were analyzed from Community Partners in Care, a randomized comparative effectiveness trial of multi-sector collaborative care for depression among a sample of people who were predominantly racial/ethnic minorities and low-income. Adults with depression (n = 980) in both interventions were surveyed at 36-month follow-up for (1) being asked about and (2) having social needs for housing or EFL concerns. In multivariate models, life difficulty and mental health visits in non-healthcare sectors predicted being asked about housing and EFL. Lower social determinants of health-related life satisfaction increased the odds of having unmet housing and EFL needs. These findings underscore the role of non-healthcare organizations as community resources for depression care and in screening and addressing social needs.

Community Engagement and Planning versus Resources for Services for Implementing Depression Quality Improvement: Exploratory Analysis for Black and Latino Adults.

Objective: Racial/ethnic minorities experience disparities in depression1 and there is a paucity of evidence-based interventions to improve depression care access and outcomes. Community Partners in Care (CPIC) is a community-partnered study of depression care quality improvement (QI) in under-resourced, urban communities: Community Engagement and Planning (CEP) for multi-sector coalitions, and Resources for Services (RS) for program technical assistance.2 CEP demonstrated benefits for the overall CPIC study population; effects for Black and Latino sub-populations are unknown. Methods: This sub-analysis examines outcomes for 409 Latino and 488 Black (non-Latino) adults recruited from 90 programs who completed baseline or 6-month follow-up. Regression analyses were used to estimate CEP vs RS intervention effects on primary (Mental Health Related Quality of Life [MHRQL], Patient Health Questionnaire-9 [PHQ-9]) and community-prioritized (mental wellness, physical activity, risk for homelessness) outcomes at 6-months. Results: Baseline characteristics did not differ significantly by intervention in either group. In the adjusted analysis for Black adults, CEP resulted in decreased odds of poor MHRQL (OR: .62, 95% CI=.41-.94, P=.028) with a trend for reducing homelessness risk (OR: .60, .35-1.05, P=.69). For Latino adults, CEP resulted in greater probability of mental wellness (OR: 1.81, 1.05-3.13, P=.034) and a trend for increased physical activity (OR: 1.52, .93-2.49, P=.091). Conclusions: Exploratory analyses of CEP for depression quality improvement suggests significant 6-month benefits in mental health outcomes for Black and Latino participants and trends for improvement in community-prioritized outcomes for both groups. Findings may inform research in multi-sector coalitions to promote equity in depression care.

Perceived Discrimination Associated With Asthma and Related Outcomes in Minority Youth: The GALA II and SAGE II Studies.

BACKGROUND: Asthma disproportionately affects minority populations and is associated with psychosocial stress such as racial/ethnic discrimination. We aimed to examine the association of perceived discrimination with asthma and poor asthma control in African American and Latino youth. METHODS: We included African American (n = 954), Mexican American (n = 1,086), other Latino (n = 522), and Puerto Rican Islander (n = 1,025) youth aged 8 to 21 years from the Genes-Environments and Admixture in Latino Americans study and the Study of African Americans, Asthma, Genes, and Environments. Asthma was defined by physician diagnosis, and asthma control was defined based on the National Heart, Lung, and Blood Institute guidelines. Perceived racial/ethnic discrimination was assessed by the Experiences of Discrimination questionnaire, with a focus on school, medical, and public settings. We examined the associations of perceived discrimination with each outcome and whether socioeconomic status (SES) and global African ancestry modified these associations. RESULTS: African American children reporting any discrimination had a 78% greater odds of experiencing asthma (OR, 1.78; 95% CI, 1.33-2.39) than did those not reporting discrimination. Similarly, African American children faced increased odds of poor asthma control with any experience of discrimination (OR, 1.97; 95% CI, 1.42-2.76) over their counterparts not reporting discrimination. These associations were not observed among Latino children. We observed heterogeneity of the association between reports of discrimination and asthma according to SES, with reports of discrimination increasing the odds of having asthma among low-SES Mexican American youth (interaction P = .01) and among high-SES other Latino youth (interaction P = .04). CONCLUSIONS: Perceived discrimination is associated with increased odds of asthma and poorer control among African American youth. SES exacerbates the effect of perceived discrimination on having asthma among Mexican American and other Latino youth.