Development of a cultural competency curriculum.

There has been increased focus on health disparities and how to address them (Baciu et al., 2017; National Institutes of Health, 2021; Williams et al., 2021). Greater integration of social determinants of health (SDoH) education into undergraduate medical education has been identified as one possible intervention (Mangold et al., 2019; Doobay-Persaud et al., 2019; Lewis et al., 2020). The Liaison Committee on Medical Education places this education among its accreditation requirements (Mangold et al., 2019); however, no consensus exists on the most effective programming for training culturally competent physicians. This paper describes the development, implementation, and reception of one such program; a combined two-week Diversity Retreat and Washington University Medical Plunge at Washington University School of Medicine in St. Louis. This program exposed students to the historical, social, and cultural context of health disparities in the city and challenged them to recognize their own biases. Survey data showed that the program was well received and increased learners' subjective understandings of SDoH, the background of St. Louis, and patient-centered care. Learners also identified separation of SDoH material from other aspects of the curriculum and limited reinforcement of SDoH as areas for improvement. In 2020, the program was expanded and integrated into the broader curriculum. Here, we present WUMP, an example of one approach to SDoH training for medical students that was grounded in the local political and social context of St. Louis and prepared students to learn, train, and practice within that context.

Understanding contributors to racial and ethnic inequities in COVID-19 incidence and mortality rates.

BACKGROUND: Racial inequities in Coronavirus 2019 (COVID-19) have been reported over the course of the pandemic, with Black, Hispanic/Latinx, and Native American individuals suffering higher case rates and more fatalities than their White counterparts. METHODS: We used a unique statewide dataset of confirmed COVID-19 cases across Missouri, linked with historical statewide hospital data. We examined differences by race and ethnicity in raw population-based case and mortality rates. We used patient-level regression analyses to calculate the odds of mortality based on race and ethnicity, controlling for comorbidities and other risk factors. RESULTS: As of September 10, 2020 there were 73,635 confirmed COVID-19 cases in the State of Missouri. Among the 64,526 case records (87.7% of all cases) that merged with prior demographic and health care utilization data, 12,946 (20.1%) were Non-Hispanic (NH) Black, 44,550 (69.0%) were NH White, 3,822 (5.9%) were NH Other/Unknown race, and 3,208 (5.0%) were Hispanic. Raw cumulative case rates for NH Black individuals were 1,713 per 100,000 population, compared with 2,095 for NH Other/Unknown, 903 for NH White, and 1,218 for Hispanic. Cumulative COVID-19-related death rates for NH Black individuals were 58.3 per 100,000 population, compared with 38.9 for NH Other/Unknown, 19.4 for NH White, and 14.8 for Hispanic. In a model that included insurance source, history of a social determinant billing code in the patient's claims, census block travel change, population density, Area Deprivation Index, and clinical comorbidities, NH Black race (OR 1.75, 1.51-2.04, p<0.001) and NH Other/Unknown race (OR 1.83, 1.36-2.46, p<0.001) remained strongly associated with mortality. CONCLUSIONS: In Missouri, COVID-19 case rates and mortality rates were markedly higher among NH Black and NH Other/Unknown race than among NH White residents, even after accounting for social and clinical risk, population density, and travel patterns during COVID-19.

Patient Engagement and Cost Savings Achieved by Automated Telemonitoring Systems Designed to Prevent and Identify Surgical Site Infections After Joint Replacement.

BACKGROUND: We designed two telemonitoring text and voice messaging interventions, EpxDecolonization (EpxDecol) and EpxWound, to improve management of orthopedic joint replacement patients at Washington University. We reviewed the use of these tools for a period of 88 weeks. METHODS: Cohorts of 1,392 and 1,753 participants completed EpxDecol and EpxWound, respectively. All patients who completed EpxDecol also completed EpxWound. We assessed patient use of and satisfaction with these interventions. A return on investment (ROI) analysis was conducted to determine the cost savings generated by EpxWound and EpxDecol. RESULTS: The proportions of patients who responded daily to EpxDecol and EpxWound were 91.9% and 77.7%, respectively, over the lengths of each intervention. The percent of daily responders declined <5% during each intervention. Ultimately, 88.4% of EpxDecol patients and 67.8% of EpxWound patients responded to ≥80% of all messages. Median patient survey responses (n = 1,246) were 9/9 (best possible) for care, 8/9 for improved communication, and 5/9 (perfect number) for number of messages received. ROI analysis for this 88-week period showed that using EpxDecol and EpxWound to engage patients (instead of nurses calling patients) saved the equivalent of 2.275 full-time nursing equivalents per week. We calculated net savings of $260,348 with an ROI of 14.85x for 1,753 patients over 88 weeks. One-year cost savings from these interventions were $153,800 with an ROI of 14.79x. CONCLUSIONS: EpxDecol and EpxWound may serve important roles in the perioperative process for orthopedic joint reconstruction surgery given high patient usage of and satisfaction with these interventions. Implementing EpxDecol and EpxWound for a large patient population could yield substantial cost savings and ROI.

Maternal Diet and Morbidity Factors Associated with Low Birth Weight in Haiti: A Case-Control Study.

Objective: A matched, case-control study was conducted to examine the association between development of low birth weight (LBW) and maternal factors, including dietary intake, comorbidities, and socioeconomic factors, among women in Cap Haitien, Haiti. Design: Mothers who delivered LBW babies; defined as ≤2.5 kg, were identified by review of the medical record and matched to mothers of similar age, parity, with normal birth weight (NBW) babies. A survey was administered consisting of Women's Dietary Diversity Score (WDDS), maternal reporting of comorbidities, income, and educational level. Subjects: Women were eligible if they delivered and had newborns weighed within the last 2 years. Total study participants consisted of 32 cases and 34 controls matched for age, parity, and month of delivery. Results: Mothers who consume eggs were 78% less likely to have given birth to a LBW infant (OR 0.22 (95% CI: 0.05-0.87). Mothers with NBW babies had a nonsignificant trend towards higher WDDS. The prevalence of hypertension in mothers who were seen in the clinic at least once over the past 2 years was found to be 27%, and 78% of mothers were not aware of their diagnosis. Conclusion: Enhancing maternal nutrition during pregnancy has broad implications for reducing LBW, improving fetal health and reducing fetal predilection for chronic diseases in adulthood. Longitudinal prospective studies are needed to evaluate the selective benefit of eggs and other high-quality foods in protecting fetal growth. Efforts to improve knowledge and awareness of hypertension in Haiti should be undertaken.