Perspectives of Black Patients on Racism Within Emergency Care.

Importance: Numerous Black individuals experience racism persistently throughout their lives, with repercussions extending into health care settings. The perspectives of Black individuals regarding emergency department (ED) care, racism, and patient-centered approaches for dismantling structural racism remain less explored. Objective: To qualitatively explore the perspectives and experiences of Black patients related to race, racism, and health care following a recent ED visit. Design, Setting, and Participants: In this qualitative study, the audio from semistructured interviews of Black patients discharged from an academic urban ED between August 2021 to April 2022 were recorded, transcribed, and analyzed using thematic analysis. Main Outcomes and Measures: The main outcomes encompassed the main themes from the analysis of the interviews with Black patients regarding their perspectives on race, racism, and clinical care. Results: A total of 25 Black patients (20 [80%] female; mean [SD] age, 44.6 [12.9] years) discharged from the ED were interviewed. Three broad domains were identified: (1) racism in health care; (2) ED clinical care; and (3) recommendations for improvement. Within these domains, the first 2 were grouped into specific themes. Within the first domain, racism in health care, 7 themes were identified using thematic analysis: (1) a history of medical racism; (2) dismissiveness; (3) patient expectations on encountering racism; (4) medical mistrust; (5) health literacy; (6) postencounter outcomes, and (7) discrimination beyond but associated with race. Within the second theme, ED clinical care, 5 themes were identified using the same thematic analysis method: (1) discharge plan; (2) patient experience; (3) waiting room perceptions; (4) medication treatment; and (5) pain management. The third domain, recommendations for improvement, incorporated patient-generated suggestions for enhancing the Black patient experience. Conclusions and Relevance: In this qualitative study, the fabric of clinical care delivery in the ED was intricately woven with Black patients' experiences of racism. Patients expressed a pervasive sense of mistrust, skepticism, and dismissiveness at the system level. Instances of racism were consistently highlighted by patients from their entry to the ED to discharge. These perspectives illuminate the pervasive nature of racism in clinical care, providing valuable insights for exploring patient-centered approaches to foster antiracist cultures in the ED and throughout the broader medical landscape.

Leveraging Implementation Science to Advance Environmental Justice Research and Achieve Health Equity through Neighborhood and Policy Interventions.

Environmental justice research is increasingly focused on community-engaged, participatory investigations that test interventions to improve health. Such research is primed for the use of implementation science-informed approaches to optimize the uptake and use of interventions proven to be effective. This review identifies synergies between implementation science and environmental justice with the goal of advancing both disciplines. Specifically, the article synthesizes the literature on neighborhood-, community-, and policy-level interventions in environmental health that address underlying structural determinants (e.g., structural racism) and social determinants of health. Opportunities to facilitate and scale the equitable implementation of evidence-based environmental health interventions are highlighted, using urban greening as an illustrative example. An environmental justice-focused version of the implementation science subway is provided, which highlights these principles: Remember and Reflect, Restore and Reclaim, and Reinvest. The review concludes with existing gaps and future directions to advance the science of implementation to promote environmental justice. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance.

OBJECTIVE: There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN: This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS: Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION: Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department.

Importance: Behavioral flags in the electronic health record (EHR) are designed to alert clinicians of potentially unsafe or aggressive patients. These flags may introduce bias, and understanding how they are used is important to ensure equitable care. Objective: To investigate the incidence of behavioral flags and assess whether there were differences between Black and White patients and whether the flags were associated with differences in emergency department (ED) clinical care. Design, Setting, and Participants: This was a retrospective cohort study of EHR data of adult patients (aged ≥18 years) from 3 Philadelphia, Pennsylvania, EDs within a single health system between January 1, 2017, and December 31, 2019. Secondary analyses excluded patients with sickle cell disease and high ED care utilization. Data were analyzed from February 1 to April 4, 2022. Main Outcomes and Measures: The primary outcome of interest was the presence of an EHR behavioral flag. Secondary measures included variation of flags across sex, race, age, insurance status, triage status, ED clinical care metrics (eg, laboratory, medication, and radiology orders), ED disposition (discharge, admission, or observation), and length of key intervals during ED care. Results: Participating EDs had 195 601 eligible patients (110 890 [56.7%] female patients; 113 638 Black patients [58.1%]; 81 963 White patients [41.9%]; median [IQR] age, 42 [28-60] years), with 426 858 ED visits. Among these, 683 patients (0.3%) had a behavioral flag notification in the EHR (3.5 flags per 1000 patients), and it was present for 6851 ED visits (16 flagged visits per 1000 visits). Patient differences between those with a flag and those without included male sex (56.1% vs 43.3%), Black race (71.2% vs 56.7%), and insurance status, particularly Medicaid insurance (74.5% vs 36.3%). Flag use varied across sites. Black patients received flags at a rate of 4.0 per 1000 patients, and White patients received flags at a rate of 2.4 per 1000 patients (P < .001). Among patients with a flag, Black patients, compared with White patients, had longer waiting times to be placed in a room (median [IQR] time, 28.0 [10.5-89.4] minutes vs 18.2 [7.2-75.1] minutes; P < .001), longer waiting times to see a clinician (median [IQR] time, 42.1 [18.8-105.5] minutes vs 33.3 [15.3-84.5] minutes; P < .001), and shorter lengths of stay (median [IQR] time, 274 [135-471] minutes vs 305 [154-491] minutes; P = .01). Black patients with a flag underwent fewer laboratory (eg, 2449 Black patients with 0 orders [43.4%] vs 441 White patients with 0 orders [36.7%]; P < .001) and imaging (eg, 3541 Black patients with no imaging [62.7%] vs 675 White patients with no imaging [56.2%]; P < .001) tests compared with White patients with a flag. Conclusions and Relevance: This cohort study found significant differences in ED clinical care metrics, including that flagged patients had longer wait times and were less likely to undergo laboratory testing and imaging, which was amplified in Black patients.

Assessing experiences of racism among Black and White patients in the emergency department.

Objective: The objective of this study was to investigate the differences in patient-reported experiences related to emergency department (ED) care using a post-discharge text messaging survey. Methods: This was a prospective cohort study of patients discharged from the ED using an automated text messaging platform to assess patient experience and impact of race on ED care. The study was conducted for 7 weeks between August 6 and September 24, 2021. Participants included adults (aged ≥18 years) discharged from 2 urban, academic EDs with an active mobile phone number in the electronic health record. The primary outcome of interest was patient-reported impact of race on overall rating of ED care. Secondary outcomes included overall satisfaction with care and perceived impact of race on components of care, including respect, communication, and quality of care. A 6-point Likert scale was used, and chi-square and Wilcoxon rank sum tests were used to analyze responses. Results: A total of 590 (14%) discharged patients consented, and 462 patients completed the entire survey; the mean age was 43 years (SD 17.3); 67% were women, and 60.0% were Black. Black patients reported a higher overall rating of ED care (median 5 [3, 5]; P = 0.013). Proportionately, when compared with White patients, more Black patients reported that race negatively impacted the rating of care (10.8% vs 1.4%; P = 0.002). More than a quarter of Black patients (27.4%) reported race highly impacting being treated with respect (P = 0.024), and 22.4% reported a high impact on quality of service (P = 0.003) when compared with White patients. Conclusion: Health systems lack methods that specifically identify patient experiences of racism. We demonstrate the feasibility of using text messaging to collect patient-reported experiences of racism. For a significant number of Black patients, race negatively impacted their care, including communication, quality, and respect.

Advancing health equity through integrated biology and population health research: A community-based sample cortisol feasibility and exploratory study.

Background: Community-based research inclusive of self-assessment and objective environmental metrics can be enhanced by the collection of biomarker data in unity toward assessing the health impacts of the totality of environmental stress driven by structural racism. Cortisol dynamic range (CDR), a measure of chronic stress burden, may underpin place-based connections to health, but a gap remains in elucidating community-based CDR methodology. Purpose: To 1) assess the feasibility of cortisol collection and CDR measurement in a community-based study with home-based, participant-directed specimen collection, and 2) explore the association between CDR and other individual and environmental measures in a sample of predominantly Black participants. Methods: In this cross-sectional, observational study in predominantly Black urban neighborhoods, participants (n = 73) completed health assessments and in-home, self-collected salivary cortisol. For feasibility, CDR (peak-nadir) was compared to cortisol awakening response (CAR) slope over time. Comparisons of CDR quartile by person and place variables were explored (ANOVA). Results: The cohort (77% Black, 39.7% <$15 k/year income, high perceived stress) completed 98.6% of cortisol collection timepoints. CDR was calculated in all participants without interruptions to sleep-wake cycle as seen with CAR collection. Participants in the lowest quartile of CDR were the oldest (p = 0.03) with lowest reported mental health (p = 0.048) with no associations seen for CAR. Conclusion: Participant-collected CDR is more feasible than cortisol measures dependent on slopes over time in a community-based, predominately Black cohort with exploratory findings supporting relevance to outcomes of interest to future work. Future community-based studies should integrate CDR with environment and psychosocial measures.

Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education-a Narrative Review.

In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.

Association Between Structural Housing Repairs for Low-Income Homeowners and Neighborhood Crime.

Importance: The root causes of violent crime in Black urban neighborhoods are structural, including residential racial segregation and concentrated poverty. Previous work suggests that simple and scalable place-based environmental interventions can overcome the legacies of neighborhood disinvestment and have implications for health broadly and crime specifically. Objective: To assess whether structural repairs to the homes of low-income owners are associated with a reduction in nearby crime. Design, Setting, and Participants: This cross-sectional study using difference-in-differences analysis included data from the City of Philadelphia Basic Systems Repair Program (BSRP) from January 1, 2006, through April 30, 2013. The unit of analysis was block faces (single street segments between 2 consecutive intersecting streets) with or without homes that received the BSRP intervention. The blocks of homes that received BSRP services were compared with the blocks of eligible homes that were still on the waiting list. Data were analyzed from December 1, 2019, to February 28, 2021. Exposures: The BSRP intervention includes a grant of up to $20 000 provided to low-income owners for structural repairs to electrical, plumbing, heating, and roofing damage. Eligible homeowners must meet income guidelines, which are set by the US Department of Housing and Urban Development and vary yearly. Main Outcomes and Measures: The main outcome was police-reported crime across 7 major categories of violent and nonviolent crimes (homicide, assault, burglary, theft, robbery, disorderly conduct, and public drunkenness). Results: A total of 13 632 houses on 6732 block faces received the BSRP intervention. Owners of these homes had a mean (range) age of 56.5 (18-98) years, were predominantly Black (10 952 [78.6%]) or Latino (1658 [11.9%]) individuals, and had a mean monthly income of $993. These census tracts compared with those without BSRP intervention had a substantially larger Black population (49.5% vs 12.2%; |D| = 0.406) and higher unemployment rate (17.3% vs 9.3%; |D| = 0.357). The main regression analysis demonstrated that the addition to a block face of a property that received a BSRP intervention was associated with a 21.9% decrease in the expected count of total crime (incidence rate ratio [IRR], 0.78; 95% CI, 0.76-0.80; P < .001), 19.0% decrease in assault (IRR, 0.81; 95% CI, 0.79-0.84; P < .001), 22.6% decrease in robbery (IRR, 0.77; 95% CI, 0.75-0.80; P < .001), and 21.9% decrease in homicide (IRR, 0.78; 95% CI, 0.71-0.86; P < .001). When restricting the analysis to blocks with properties that had ever received a BSRP intervention, a total crime reduction of 25.4% was observed for each additional property (IRR, 0.75; 95% CI, 0.73-0.77; P < .001). A significant dose-dependent decrease in total crime was found such that the magnitude of association increased with higher numbers of homes participating in the BSRP on a block. Conclusions and Relevance: This study found that the BSRP intervention was associated with a modest but significant reduction in crime. These findings suggest that intentional and targeted financial investment in structural, scalable, and sustainable place-based interventions in neighborhoods that are still experiencing the lasting consequences of structural racism and segregation is a vital step toward achieving health equity.

Urban Blight Remediation as a Cost-Beneficial Solution to Firearm Violence.

OBJECTIVES: To determine if blight remediation of abandoned buildings and vacant lots can be a cost-beneficial solution to firearm violence in US cities. METHODS: We performed quasi-experimental analyses of the impacts and economic returns on investment of urban blight remediation programs involving 5112 abandoned buildings and vacant lots on the occurrence of firearm and nonfirearm violence in Philadelphia, Pennsylvania, from 1999 to 2013. We adjusted before-after percent changes and returns on investment in treated versus control groups for sociodemographic factors. RESULTS: Abandoned building remediation significantly reduced firearm violence -39% (95% confidence interval [CI] = -28%, -50%; P < .05) as did vacant lot remediation (-4.6%; 95% CI = -4.2%, -5.0%; P < .001). Neither program significantly affected nonfirearm violence. Respectively, taxpayer and societal returns on investment for the prevention of firearm violence were $5 and $79 for every dollar spent on abandoned building remediation and $26 and $333 for every dollar spent on vacant lot remediation. CONCLUSIONS: Abandoned buildings and vacant lots are blighted structures seen daily by urban residents that may create physical opportunities for violence by sheltering illegal activity and illegal firearms. Urban blight remediation programs can be cost-beneficial strategies that significantly and sustainably reduce firearm violence.

Neighborhood blight, stress, and health: a walking trial of urban greening and ambulatory heart rate.

We measured dynamic stress responses using ambulatory heart rate monitoring as participants in Philadelphia, Pennsylvania walked past vacant lots before and after a greening remediation treatment of randomly selected lots. Being in view of a greened vacant lot decreased heart rate significantly more than did being in view of a nongreened vacant lot or not in view of any vacant lot. Remediating neighborhood blight may reduce stress and improve health.