How Should Health Professions Educators and Organizations Desegregate Teaching and Learning Environments?

Motivating health equity requires taking deliberate steps toward desegregating health care, especially in academic health centers. One step should incorporate rigorous measurement and assessment of patients' access to health services and ongoing collection and review of patients' health outcomes data. Another step should develop, fund, incorporate and administer initiatives with community members that address social determinants of community and individual health, including academic health centers' inpatient and outpatient service delivery sites, insurance programs, and federal policy. Academic health centers must also be accountable for monitoring initiatives' successes and failures over short- and long-term trajectories and for modifying initiatives' methods as needed to achieve equity in access to health services and health outcomes.

Gender Differences in Retention and Promotion Among Generalists Who Graduated From Research-Intensive Fellowships.

BACKGROUND: Generalists who pursue research-intensive fellowships develop research skills and mentor-mentee relationships. Whether gender disparities in retention and promotion exist among this research-trained cohort is understudied. OBJECTIVE: We measured whether disparities exist among graduates of research-intensive fellowships and how mentorship influences them. METHODS: We surveyed generalists (internal medicine, pediatrics, family medicine, combined internal medicine-pediatrics) between July and August 2016 who graduated from research-intensive fellowships. Generalists ("mentees") were asked whether they remained or were promoted, and to name up to 10 influential mentors during or within 5 years of fellowship. Multivariable logistic regression estimated associations between mentee gender and retention and promotion. Next, we separately included 3 network characteristics: (1) mentee degrees (number of mentors reported per mentee); (2) mean mentor betweenness centrality (importance of each mentor within the network); and (3) largest community membership (mentee status in the largest interconnected mentor-mentee group within the network). All models adjusted for generalists' race, specialty, fellowship institution, and publications. RESULTS: One hundred sixty-two graduates (51%) representing 19 institutions responded. In adjusted analyses, compared to men, women were as likely to remain in academic medicine (odds ratio [OR] 1.88; 95% confidence interval [CI] 0.72-4.89; P = .20), but less likely to be promoted within 5 years of fellowship (OR 0.26; 95% CI 0.09-0.80; P = .018). Inclusion of network measures did not alter these associations. CONCLUSIONS: Despite remaining in academic medicine as frequently as their male counterparts, fellowship-trained women were promoted less often. Features of mentors, measured using network analysis, may not explain these observed differences.

Stress-Associated Neurobiological Pathway Linking Socioeconomic Disparities to Cardiovascular Disease.

BACKGROUND: Lower socioeconomic status (SES) associates with a higher risk of major adverse cardiac events (MACE) via mechanisms that are not well understood. OBJECTIVES: Because psychosocial stress is more prevalent among those with low SES, this study tested the hypothesis that stress-associated neurobiological pathways involving up-regulated inflammation in part mediate the link between lower SES and MACE. METHODS: A total of 509 individuals, median age 55 years (interquartile range: 45 to 66 years), underwent clinically indicated whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging and met pre-defined inclusion criteria, including absence of known cardiovascular disease or active cancer. Baseline hematopoietic tissue activity, arterial inflammation, and in a subset of 289, resting amygdalar metabolism (a measure of stress-associated neural activity) were quantified using validated 18F-fluorodeoxyglucose positron emission tomography/computed tomography methods. SES was captured by neighborhood SES factors (e.g., median household income and crime). MACE within 5 years of imaging was adjudicated. RESULTS: Over a median 4.0 years, 40 individuals experienced MACE. Baseline income inversely associated with amygdalar activity (standardized ß: -0.157 [95% confidence interval (CI): -0.266 to -0.041]; p = 0.007) and arterial inflammation (ß: -0.10 [95% CI: -0.18 to -0.14]; p = 0.022). Further, income associated with subsequent MACE (standardized hazard ratio: 0.67 [95% CI: 0.47 to 0.96]; p = 0.029) after multivariable adjustments. Mediation analysis demonstrated that the path of: ↓ neighborhood income to ↑ amygdalar activity to ↑ bone marrow activity to ↑ arterial inflammation to ↑ MACE was significant (ß: -0.01 [95% CI: -0.06 to -0.001]; p < 0.05). CONCLUSIONS: Lower SES: 1) associates with higher amygdalar activity; and 2) independently predicts MACE via a serial pathway that includes higher amygdalar activity, bone marrow activity, and arterial inflammation. These findings illuminate a stress-associated neurobiological mechanism by which SES disparities may potentiate adverse health outcomes.

Association of Patient Out-of-Pocket Costs With Prescription Abandonment and Delay in Fills of Novel Oral Anticancer Agents.

Purpose The number of novel oral anticancer agents is increasing, but financial barriers may limit access. We examined associations between out-of-pocket (OOP) costs and reduced and/or delayed treatment initiation. Methods This retrospective claims-based study used 2014 to 2015 data from a large, proprietary, integrated database and included Medicare and commercial insurance enrollees with a new, adjudicated prescription for any of 38 oral anticancer agents. We examined rates of claim reversal (failure to purchase approved prescription), delayed initiation (reversal with subsequent fill of same agent within 90 days after adjudication), and abandonment (reversal with no fill of same agent within 90 days after adjudication) for the index oral anticancer agent. We also examined whether patients filled any alternate oral, injectable, or infusible anticancer agent within 90 days. Logistic regressions controlled for sociodemographic, clinical, and treatment characteristics to estimate adjusted rates. Results Among the final sample (N = 38,111), risk-adjusted rates of claim reversal ranged from 13% to 67%, increasing with higher OOP costs. Although the abandonment rate was 18% overall, risk-adjusted rates were higher in greater OOP cost categories (10.0% for ≤ $10 group v 13.5% for $50.01 to $100 group, 31.7% for $100.01 to $500 group, 41.0% for $500.01 to $2,000 group, and 49.4% for > $2,000 group; P < .001 compared with ≤ $10 group). Rates remained similar after accounting for use of alternate oral, injectable, or infusible anticancer agents. Delayed initiation was also more frequent for higher OOP cost categories (3% in ≤ $10 group v 18% in > $2,000 group; P < .001). Sensitivity and subgroup analyses by insurance type, pharmacy type, sex, and indication identified similar associations. Conclusion Higher OOP costs were associated with higher rates of oral prescription abandonment and delayed initiation across cancers. Fiscally sustainable strategies are needed to improve patient access to cancer medications.

The effect of care setting in the delivery of high-value colon cancer care.

BACKGROUND: The effect of care setting on value of colon cancer care is unknown. METHODS: A Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study of 6544 patients aged ≥ 66 years with stage IV colon cancer (based on the American Joint Committee on Cancer staging system) who were diagnosed between 1996 and 2005 was performed. All patients were followed through December 31, 2007. Using outpatient and carrier claims, patients were assigned to a treating hospital based on the hospital affiliation of the primary oncologist. Hospitals were classified academic or nonacademic using the SEER-Medicare National Cancer Institute Hospital File. RESULTS: Of the 6544 patients, 1605 (25%) received care from providers affiliated with academic medical centers. The unadjusted median cancer-specific survival was 16.0 months at academic medical centers versus 13.9 months at nonacademic medical centers (P < .001). After adjustment, treatment at academic hospitals remained significantly associated with a reduced risk of death from cancer (hazard ratio, 0.87; 95% confidence interval [95% CI], 0.82-0.93 [P < .001]). Adjusted mean 12-month Medicare spending was $8571 higher at academic medical centers (95% CI, $2340-$14,802; P = .007). The adjusted median cost was $1559 higher at academic medical centers; this difference was not found to be statistically significant (95% CI, -$5239 to $2122; P = .41). A small percentage of patients who received very expensive care skewed the difference in mean cost; the only statistically significant difference in adjusted costs in quantile regressions was at the 99.9th percentile of costs (P < .001). CONCLUSIONS: Among Medicare beneficiaries with stage IV colon cancer, treatment by a provider affiliated with an academic medical center was associated with a 2 month improvement in overall survival. Except for patients in the 99.9th percentile of the cost distribution, costs at academic medical centers were not found to be significantly different from those at nonacademic medical centers.

Variation in chemotherapy utilization in ovarian cancer: the relative contribution of geography.

OBJECTIVE: This study investigates geographic variation in chemotherapy utilization for ovarian cancer in both absolute and relative terms and examines area characteristics associated with this variation. DATA SOURCES: Surveillance, Epidemiology, and End Results (SEER) Medicare data from 1990 to 2001 for Medicare patients over 65 with a diagnosis of ovarian cancer between 1990 and 1999. Chemotherapy within a year of diagnosis was identified by Medicare billing codes. The hospital referral region (HRR) represents the geographic unit of analysis. STUDY DESIGN: A logit model predicting the probability of receiving chemotherapy by each of the 39 HRRs. Control variables included medical characteristics (patient age, stage, year of diagnosis, and comorbidities) and socioeconomic characteristics (race, income, and education). The variation among HRRs was tested by the chi2 statistic, and the relative contribution was measured by the omega statistic. HHR market characteristic are then used to explain HRR-level variation. PRINCIPAL FINDINGS: The average chemotherapy rate was 56.6 percent, with a range by HRR from 33 percent to 67 percent. There were large and significant differences in chemotherapy use between HRRs, reflected by a chi2 for HRR of 146 (df = 38, p < .001). HRR-level variation in chemotherapy use can be partially explained by higher chemotherapy rates in HRRs with a higher percentage of hospitals with oncology services. However, an omega analysis indicates that, by about 15 to one, the variation between patients in use of chemotherapy reflects variations in patient characteristics rather than unexplained variation among HRRs. CONCLUSIONS: While absolute levels of chemotherapy variation between geographic areas are large and statistically significant, this analysis suggests that the role of geography in determining who gets chemotherapy is small relative to individual medical characteristics. Nevertheless, while variation by medical characteristics can be medically justified, the same cannot be said for geographic variation. Our finding that density of oncology hospitals predicts chemotherapy use suggests that provider supply is positively correlated with geographic variation.