Shifting gears: Creating equity informed leaders for effective learning health systems.

Leadership is vital to a well-functioning and effective health system. This importance was underscored during the COVID-19 pandemic. As disparities in infection and mortality rates became pronounced, greater calls for equity-informed healthcare emerged. These calls led some leaders to use the Learning Health System (LHS) approach to quickly transform research into healthcare practice to mitigate inequities causing these rates. The LHS is a relatively new framework informed by many within and outside health systems, supported by decision-makers and financial arrangements and encouraged by a culture that fosters quick learning and improvements. Although studies indicate the LHS can enhance patients' health outcomes, scarce literature exists on health leaders' use and incorporation of equity into the LHS. This article begins addressing this gap by examining how equity can be incorporated into LHS activities and discussing ways leaders can ensure equity is considered and achieved in rapid learning cycles.

Fairness for Whom? Learning Health Systems' Approach to Equity in Healthcare.

Many healthcare systems use "equity" as a catch-all term to underscore their commitment to delivering care matching users' needs. Despite its ubiquity, it is often haphazardly used and applied to care and improvement efforts. As the learning health systems (LHSs) approach gains prominence, LHS researchers have sought to embed equity into their work while navigating systems with differing views of equity. We examine several components of equity, its definitions within LHSs and knowledge from LHSs' equity approach that could be implemented across systems. We conclude by suggesting various ways in which readers can embed equity into their respective LHSs.

Everybody's talking about equity, but is anyone really listening?: The case for better data-driven learning in health systems.

Data collection, analysis, and data driven action cycles have been viewed as vital components of healthcare for decades. Throughout the COVID-19 pandemic, case incidence and mortality data have consistently been used by various levels of governments and health institutions to inform pandemic strategies and service distribution. However, these responses are often inequitable, underscoring pre-existing healthcare disparities faced by marginalized populations. This has prompted governments to finally face these disparities and find ways to quickly deliver more equitable pandemic support. These rapid data informed supports proved that learning health systems (LHS) could be quickly mobilized and effectively used to develop healthcare actions that delivered healthcare interventions that matched diverse populations' needs in equitable and affordable ways. Within LHS, data are viewed as a starting point researchers can use to inform practice and subsequent research. Despite this innovative approach, the quality and depth of data collection and robust analyses varies throughout healthcare, with data lacking across the quadruple aims. Often, large data gaps pertaining to community socio-demographics, patient perceptions of healthcare quality and the social determinants of health exist. This prevents a robust understanding of the healthcare landscape, leaving marginalized populations uncounted and at the sidelines of improvement efforts. These gaps are often viewed by researchers as indication that more data is needed rather than an opportunity to critically analyze and iteratively learn from multiple sources of pre-existing data. This continued cycle of data collection and analysis leaves one to wonder if healthcare has a data problem or a learning problem. In this commentary, we discuss ways healthcare data are often used and how LHS disrupts this cycle, turning data into learning opportunities that inform healthcare practice and future research in real time. We conclude by proposing several ways to make learning from data just as important as the data itself.

Gathering speed and countering tensions in the rapid learning health system.

The vision of the learning health system (LHS), conceptualized 15 years ago, is for the rapid generation, use, and spread of high-quality evidence that yields better health experiences, outcomes, efficiencies, and equity in everyday practice settings across communities. However, despite the emergence of many useful LHS frameworks and examples to guide adoption, large gaps remain in the speed and consistency with which evidence is generated and used across the range of settings from the bedside to the policy table. Gaps in progress are not surprising, however, given the tensions that predictably arise when key stakeholders-researchers, health systems, and funders-comingle in these efforts. This commentary examines eight core tensions that naturally arise and offers practical actions that stakeholders can take to address these tensions and speed LHS adoption. The urgency for attenuating these tensions and accelerating health system improvements has never been higher. Timeliness, rigor, and prioritization can be aligned across stakeholders, but only if all partners are intentional about the operational and cultural challenges that exist.

Psychological sense of community, community civic participation, and ethnic identity on social justice orientation and psychological empowerment between LGBQ and Non-LGBQ youth of color.

For lesbian, gay, bisexual, and questioning (LGBQ) youth of color, the intersection of identifying as both LGBQ and a person of color results in not only managing racial stereotypes, but also heterosexism and genderism. Developing a critical understanding of oppressive social conditions and ways to engage in social action is a form of resistance for these youth. Research is needed among LGBQ youth of color that examines the range of predictors and outcomes related to civic engagement, development, and empowerment. Drawing on data derived from a sample of urban youth of color (N = 383; 53.1% Female; 75% Hispanic; Age range = 14 to 18 years; 15% identify as LGBQ), this study will: (1) examine the relationship between community-based perceptions (e.g., psychological sense of community), ethnic identity, behaviors (e.g., community civic participation) and awareness of social justice concerns with dimensions of psychological empowerment; and (2) assess differences that these relationships have between LGBQ and non-LGBQ youth of color. Findings indicate that main predictors have a positive impact on intrapersonal and cognitive dimensions of psychological empowerment through social justice orientation, with noted variations between LGBQ and non-LGBQ youth of color.

The brief sense of community scale: Testing dimensionality and measurement invariance by gender among Hispanic/Latinx youth.

Psychological sense of community is defined as feelings of belongingness and a shared belief that community members will meet one another's needs. Psychological sense of community has four dimensions: membership, influence, needs fulfillment, and emotional connection. In this study, multigroup confirmatory factor analysis was used to examine the first and second-order factor structure of the brief sense of community scale (BSCS) between male and female Hispanic/Latinx adolescents from an urban community (N = 947). To help validate the BSCS model, the second-order factor model was tested with regression to predict the measures of intrapersonal psychological empowerment and ethnic identity, as constructs conceptually related to psychological sense of community. Findings support that: (1) psychological sense of community can be measured through the BSCS and as a four-factor model among Hispanic/Latinx youth, supporting McMillan and Chavis's (1986) original theoretical discussions; (2) while no differences between genders were present at the model-level, there was path-specific variation; and (3) intrapersonal psychological empowerment and ethnic identity were associated with psychological sense of community.

The Mediating Role of Ethnic Identity and Social Justice Orientation Between Community Civic Participation, Psychological Sense of Community, and Dimensions of Psychological Empowerment Among Adolescents of Color.

There is an emerging interest in studying social action and civic engagement as a part of the developmental process. Studies among youth of color indicate that empowerment has been associated with well-being, a critical perspective, and in combating social oppression. These studies also show that civic involvement and awareness of social justice issues are associated with positive developmental outcomes including empowerment. The range of predictors and outcomes related to empowerment have been insufficiently explored. This study used structural equation modeling path analysis techniques to examine the association community civic participation and psychological sense of community have with intrapersonal and cognitive psychological empowerment, through both ethnic identity and social justice orientation among urban youth of color (N =383; 53.1% Female; 75% Hispanic; 50.6% were 13 and 15 years of age). Findings illustrate that greater community civic participation and psychological sense of community are associated with both intrapersonal and cognitive psychological empowerment, through both ethnic identity and a social justice orientation; however, with some noted variations. Ethnic identity and social justice orientation mediated community civic participation and psychological sense of community and both intrapersonal and cognitive psychological empowerment. Implications put forward for community youth-workers and community programming.

Improving Value Means Increasing Population Health and Equity.

The purpose of this commentary is to outline a vision for the future of value-based healthcare in provinces across Canada and offer a few suggestions for the requirements to make substantial gains in value, based on learnings from past initiatives. We declare as our premise that improving value in healthcare means to improve population health. The goal of improving population health means to improve both average quality of life and life expectancy and to reduce inequalities in these health outcomes. That is, to "shift and squeeze" the population health distribution, as Dr. Patricia Martens phrased it in the Emmett Hall lecture at the Canadian Health Services and Policy Research conference in 2014.

Contextualizing negative sense of community and disconnection among urban youth of color: "Community We ain't got that".

We explore the experiences of urban youth of color, as well as perceptions, of feeling disconnected and having an overall negative sense of community (SOC). Drawing on data from 11 focus groups, youth (N = 59) describe their communities and lived experiences. We document several themes put forward through the lens of SOC and community connection that highlight perceived lack of membership, needs fulfillment, influence, and overall emotional connection to their community. Unpacking youth's perceptions of their community, we suggest that-in the face of such realities-community-based organizations, such as those the youth find themselves in, aid in creating connectedness and help heal youth from the effects of social conditions experienced daily.

Increasing Viral Hepatitis Knowledge Among Urban Ethnic Minority Youth: Findings from a Community Based Prevention Intervention.

Viral hepatitis (VH) knowledge among youth is understudied in the United States. There has been a rise in VH cases in the U.S. in the wake of the opioid epidemic. Innovative approaches to preventing the infection are needed especially in urban communities. This study presents preliminary findings from a community-based HIV/AIDS, substance abuse, and VH prevention education intervention for ethnic minority youth in a northeastern urban community. We aimed to evaluate VH knowledge and factors associated with knowledge. Participants in the study completed a baseline survey followed by an exit survey measuring VH knowledge after the intervention. The survey was completed by 691 individuals. Logistic regression analyses were conducted and indicated that there was a significant increase (82.3%) in VH knowledge among youth who participated in the intervention. The development and implementation of VH knowledge interventions can be crucial in alleviating the rise of VH infections in the U.S.

Development and Reliability of an Appropriateness and Prioritization Instrument for Eye Care Practice: A Modified Delphi Process.

Purpose: To modify the Western Canada Waiting List Project (WCWLP) cataract prioritization criteria into measurement instruments for assessing appropriateness and prioritization emphasizing health-related quality of life (HRQoL) and examining reliability.Methods: A modified Delphi process was conducted using two rounds of online surveys and a face-to-face meeting. A panel of eye care experts rated the relevancy of criteria on a 5-point scale. Patient narratives highlighted the patient experience. A G-theory framework was used to assess inter- and intra-rater agreement using the criteria.Results: Nine Ophthalmologists, three Optometrists, and one General Practitioner participated in the modified Delphi process. Consensus to include/exclude was reached on all criteria. Seventeen criteria were included and 16 were excluded. The most significant changes were related to the categorization of comorbidities and expansion of HRQoL questions. The overall reliability was good (ϕ = 0.852).Conclusion: The WCWLP was modified to include appropriateness and to better reflect HRQoL. Having achieved consensus and demonstrated reliability of the criteria, the next step is to estimate weights for criteria and to validate against patient health outcomes data.

A latent class analysis of cognitive empowerment and ethnic identity: An examination of heterogeneity between profile groups on dimensions of emotional psychological empowerment and social justice orientation among urban youth of color.

Psychological empowerment (PE) encompasses key aspects of youth development and civic engagement. Empowerment scholarship has largely focused on the intrapersonal or emotional component of PE, which considers perceptions of control and self-efficacy, specifically in the sociopolitical sphere. Fewer studies have assessed the interactional or cognitive component of PE. Even less have examined the empirical association aspects of PE, including cognitive empowerment, with conceptually related variables, such as ethnic identity. Those studies that are present have shown that the association between aspects of PE and ethnic identity are complex. The current study of urban high school students of color (N = 383; 53.1% female; 75% Hispanic/Latinx) investigates the heterogeneity present between cognitive empowerment and ethnic identity. Latent class cluster analyses were conducted and five distinct profile groups emerged. Differences were observed on the basis of profile groups of cognitive empowerment and ethnic identity on self-reported dimensions of emotional PE (e.g., leadership and policy control) and social justice orientation. The majority of study participants were clustered in groups that identified moderate to high levels of both cognitive empowerment and ethnic identity. Results provide useful insights for theory and programming.

Youth Cognitive Empowerment: Development and Evaluation of an Instrument.

Psychological empowerment (PE) is a multicomponent construct that involves the mechanisms through which people and groups gain control over their lives and environments. Psychological empowerment has previously been operationalized using measures of sociopolitical control among young people, with findings indicating links between PE and other positive developmental outcomes. Sociopolitical control, however, is only an indicator for the emotional component of PE. Research has largely neglected the cognitive component of PE, particularly in studies of younger people. In fact, few studies to date have presented and empirically tested measurement instruments for the cognitive component of PE among youth. In this study, we adapted a measure, which previously had been validated and used among adults, for use among young people and tested it in a sample of high school students (53% female, 75% Hispanic) in an urban school in the northeastern U.S. Confirmatory factor analyses were used to assess the hypothesized three-factor structure of cognitive empowerment, and the measure was examined for association with the construct of social justice orientation. Results indicate an adequate fit for the second-order factor, and an expected relationship with the related construct.

Community coalitions as spaces for collective voice, action, and the sharing of resources.

This study examined how a community coalition, focused on prevention efforts, can aid in bridging resources between community organizations in a resource-deprived area. We also explored how it may serve as a venue to support significant changes to the community, adults, and youth who live there. Drawing on 18 individual interviews with adult coalition members from various community organizations, in a large, underserved city in the northeastern United States, we examined these data for narrations of the coalition's place within the broader prevention community and how the coalition may be an organizational venue for collective voice. We were specifically interested in hearing if these adult community members saw the coalition as filling a gap within their community. Our data revealed that while organizations within the community have been decimated due to reduced funding, the present coalition aided in meeting a variety of needs. These needs included the facilitation of community voice while helping to bridge resources between organizations, which would otherwise work alone.

Smoking Cessation and Cardiac Rehabilitation: A Priority!

Cardiac rehabilitation programmes afford the opportunity to enhance cardiovascular health and reduce the risk of subsequent cardiac events. They permit the management of cardiac risk factors while addressing significant psychosocial and vocational issues. Tobacco addiction is the most important of the modifiable cardiac risk factors, and smoking cessation is the most important secondary prevention strategy. Cessation is more likely when cessation pharmacotherapy is accompanied by supportive advice and strategic assistance. A systematic approach to the delivery of cessation services, such as the Ottawa Model of Smoking Cessation, greatly enhances the likelihood of success. Cardiac rehabilitation programmes are ideal venues for the delivery of such programmes.

Single versus multi-item self-assessment of sedentary behaviour: A comparison with objectively measured sedentary time in nurses.

OBJECTIVES: To compare sedentary time (ST) measured by self-report using a single question from the short-form International Physical Activity Questionnaire (SF-IPAQ), 18-items from the Sedentary Behaviour Questionnaire (SBQ) and objectively using an accelerometer among a large sample of nurses. DESIGN: Cross-sectional. METHODS: Participants wore an ActiGraph GT3X accelerometer (≥4 days, ≥10h/day) and self-reported usual day sitting using the IPAQ and sitting in different modes using the SBQ. Measures were compared using correlations, a Friedman test with Wilcoxon signed-ranks tests for pairwise comparisons, linear regression and Bland-Altman plots. RESULTS: A total of 313 nurses (95% female; mean±SD: age=43±12 years) from 14 hospitals participated. Participants self-reported sitting for a median of 240min/day using the SF-IPAQ and 328min/day using the SBQ. Median ST measured by the ActiGraph was 434min/day. All measures were weakly correlated with each other (ρ=0.31-40, ps<0.001). Limits of agreement were wide between all measures. Significant proportional bias between the ActiGraph and the SF-IPAQ and SBQ existed, suggesting that with greater amounts of ST, there is greater disagreement between the self-report and objective measures. CONCLUSIONS: In a sample of nurses, self-reported ST using the SF-IPAQ and SBQ was significantly lower than that measured by accelerometer. A single-item tool performed more poorly than a multi-item questionnaire. Future studies should consider including both objective and self-report measures of ST, and where possible use a tool that quantifies ST across multiple domains, define a 'usual day' and are meaningful for those with daily schedule variations such as among shift-worker populations.

Development and Validation of the Modified Patient-Centered Medical Home Assessment for the Comprehensive Primary Care Initiative.

OBJECTIVE: To describe the modified Patient-Centered Medical Home Assessment (M-PCMH-A) survey module developed to track primary care practices' care delivery approaches over time, assess whether its underlying factor structure is reliable, and produce factor scores that provide a more reliable summary measure of the practice's care delivery than would a simple average of question responses. DATA SOURCES/STUDY SETTING: Survey data collected from diverse practices participating in the Comprehensive Primary Care (CPC) initiative in 2012 (n = 497) and 2014 (n = 493) and matched comparison practices in 2014 (n = 423). STUDY DESIGN: Confirmatory factor analysis. DATA COLLECTION: Thirty-eight questions organized in six domains: Access and Continuity of Care, Planned Care for Chronic Conditions and Preventive Care, Risk-Stratified Care Management, Patient and Caregiver Engagement, Coordination of Care across the Medical Neighborhood, and Continuous Data-Driven Improvement. PRINCIPAL FINDINGS: Confirmatory factor analysis suggested using seven factors (splitting one domain into two), reassigning two questions to different domain factors, and removing one question, resulting in high reliability, construct validity, and stability in all but one factor. The seven factors together formed a single higher-order factor summary measure. Factor scores guard against potential biases from equal weighting. CONCLUSIONS: The M-PCMH-A can validly and reliably track primary care delivery across practices and over time using factors representing seven key components of care as well as an overall score. Researchers should calculate factor loadings for their specific data if possible, but average scores may be suitable if they cannot use factor analysis due to resource or sample constraints.

Design and Implementation of a Physician Coaching Pilot to Promote Value-Based Referrals to Specialty Care.

INTRODUCTION: Referral rates to specialty care from primary care physicians vary widely. To address this variability, we developed and pilot tested a peer-to-peer coaching program for primary care physicians. OBJECTIVES: To assess the feasibility and acceptability of the coaching program, which gave physicians access to their individual-level referral data, strategies, and a forum to discuss referral decisions. METHODS: The team designed the program using physician input and a synthesis of the literature on the determinants of referral. We conducted a single-arm observational pilot with eight physicians which made up four dyads, and conducted a qualitative evaluation. RESULTS: Primary reasons for making referrals were clinical uncertainty and patient request. Physicians perceived doctor-to-doctor dialogue enabled mutual learning and a pathway to return joy to the practice of primary care medicine. The program helped physicians become aware of their own referral data, reasons for making referrals, and new strategies to use in their practice. Time constraints caused by large workloads were cited as a barrier both to participating in the pilot and to practicing in ways that optimize referrals. Physicians reported that the program could be sustained and spread if time for mentoring conversations was provided and/or nonfinancial incentives or compensation was offered. CONCLUSION: This physician mentoring program aimed at reducing specialty referral rates is feasible and acceptable in primary care settings. Increasing the appropriateness of referrals has the potential to provide patient-centered care, reduce costs for the system, and improve physician satisfaction.

Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief.

The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.