Social justice in medical education: a student-led approach to addressing COVID-19 vaccine equity in the Hispanic/Latinx community.

The current healthcare system disproportionately affects vulnerable populations, leading to disparities in health outcomes. As a result, medical schools need to equip future physicians with the tools to identify and address healthcare disparities. The University of Nevada, Reno School of Medicine implemented a Scholarly Concentration in Medical Social Justice (SCiMSJ) program to address this issue. Three medical students joined the program and pioneered a project to address the equitable vaccine distribution within the local Hispanic/Latinx community. After identifying the disparity in vaccine uptake and high levels of vaccine hesitancy, they collaborated with local organizations to address vaccine misinformation and accessibility. They organized outreach events, provided vaccine education, and hosted a vaccine clinic at a Catholic church with a high Hispanic/Latinx congregation. Through their efforts, they administered 1,456 vaccines. The estimated economic and societal impacts of their work was 879 COVID-19 cases avoided, 5 deaths avoided, 45 life years saved, and $29,286 in economic value. The project's success highlights the effectiveness of a student-led approach to promote skill development in social justice training. Leadership skills and coalition building were crucial in overcoming resource limitations and connecting organizations with the necessary volunteer force. Building trust with the Hispanic/Latinx community through outreach efforts and addressing vaccine hesitancy contributed to the well-attended vaccine clinic. The project's framework and approach can be adopted by other medical students and organizations to address health disparities and improve health outcomes in their communities.

Accessibility of Telehealth Services During the COVID-19 Pandemic: A Cross-Sectional Survey of Medicare Beneficiaries.

INTRODUCTION: Telehealth plays a role in the continuum of care, especially for older adults during the COVID-19 pandemic. Our objective was to examine factors associated with the accessibility of telehealth services during the COVID-19 pandemic among older adults. METHODS: We analyzed the nationally representative Medicare Current Beneficiary Survey COVID-19 Rapid Response Supplement Questionnaire of beneficiaries aged 65 years or older. Two weighted multivariable logistic regression models were used to examine associations between usual providers who offered telehealth 1) during the COVID-19 pandemic and 2) to replace a regularly scheduled appointment. We examined factors including sociodemographic characteristics, comorbidities, and digital access and literacy. RESULTS: Of the beneficiaries (n = 6,172, weighted n = 32.4 million), 81.2% reported that their usual providers offered telehealth during the COVID-19 pandemic. Among those offered telehealth services, 56.8% reported that their usual providers offered telehealth to replace a regularly scheduled appointment. Disparities in accessibility of telehealth services by sex, residing area (metropolitan vs nonmetropolitan), income level, and US Census region were observed. Beneficiaries who reported having internet access (vs no access) (OR, 1.75, P < .001) and who reported ever having participated in video, voice, or conference calls over the internet before (vs not) (OR, 2.18, P < .001) were more likely to report having access to telehealth. Non-Hispanic Black beneficiaries (versus White) (OR, 1.57, P = .007) and beneficiaries with comorbidities (vs none) (eg, 2 or 3 comorbidities, OR, 1.25, 95% P = .044) were more likely to have their usual provider offer telehealth to replace a regularly scheduled appointment. CONCLUSION: Although accessibility of telehealth has increased, inequities raise concern. Educational outreach and training, such as installing and launching an online web conferencing platform, should be considered for improving accessibility of telehealth to vulnerable populations beyond the COVID-19 pandemic.

Determinants of the access to remote specialised services provided by national sarcoma reference centres.

BACKGROUND: Spatial inequalities in cancer management have been evidenced by studies reporting lower quality of care or/and lower survival for patients living in remote or socially deprived areas. NETSARC+ is a national reference network implemented to improve the outcome of sarcoma patients in France since 2010, providing remote access to specialized diagnosis and Multidisciplinary Tumour Board (MTB). The IGéAS research program aims to assess the potential of this innovative organization, with remote management of cancers including rare tumours, to go through geographical barriers usually impeding the optimal management of cancer patients. METHODS: Using the nationwide NETSARC+ databases, the individual, clinical and geographical determinants of the access to sarcoma-specialized diagnosis and MTB were analysed. The IGéAS cohort (n = 20,590) includes all patients living in France with first sarcoma diagnosis between 2011 and 2014. Early access was defined as specialised review performed before 30 days of sampling and as first sarcoma MTB discussion performed before the first surgery. RESULTS: Some clinical populations are at highest risk of initial management without access to sarcoma specialized services, such as patients with non-GIST visceral sarcoma for diagnosis [OR 1.96, 95% CI 1.78 to 2.15] and MTB discussion [OR 3.56, 95% CI 3.16 to 4.01]. Social deprivation of the municipality is not associated with early access on NETSARC+ remote services. The quintile of patients furthest away from reference centres have lower chances of early access to specialized diagnosis [OR 1.18, 95% CI 1.06 to 1.31] and MTB discussion [OR 1.24, 95% CI 1.10 to 1.40] but this influence of the distance is slight in comparison with clinical factors and previous studies on the access to cancer-specialized facilities. CONCLUSIONS: In the context of national organization driven by reference network, distance to reference centres slightly alters the early access to sarcoma specialized services and social deprivation has no impact on it. The reference networks' organization, designed to improve the access to specialized services and the quality of cancer management, can be considered as an interesting device to reduce social and spatial inequalities in cancer management. The potential of this organization must be confirmed by further studies, including survival analysis.

The association of healthcare disparities and patient-specific factors on clinical outcomes in peripheral artery disease.

BACKGROUND: PAD increases the risk of cardiovascular mortality and limb loss, and disparities in treatment and outcomes have been described. However, the association of patient-specific characteristics with variation in outcomes is less well known. METHODS: Patients with PAD from Duke University Health System (DUHS) between January 1, 2015 and March 31, 2016 were identified. PAD status was confirmed through ground truth adjudication and predictive modeling using diagnosis codes, procedure codes, and other administrative data. Symptom severity, lower extremity imaging, and ankle-brachial index (ABI) were manually abstracted from the electronic health record (EHR). Data was linked to Centers for Medicare and Medicaid Services data to provide longitudinal follow up. Primary outcome was major adverse vascular events (MAVE), a composite of all-cause mortality, myocardial infarction (MI), stroke, lower extremity revascularization and amputation. RESULTS: Of 1,768 patients with PAD, 31.6% were asymptomatic, 41.2% had intermittent claudication (IC), and 27.3% had chronic limb-threatening ischemia (CLTI). At 1 year, patients with CLTI had higher rates of MAVE compared with asymptomatic or IC patients. CLTI and Medicaid dual eligibility were independent predictors of mortality. CLTI and Black race were associated with amputation. CONCLUSIONS: Rates of MAVE were highest in patients with CLTI, but patients with IC or asymptomatic disease also had high rates of adverse events. Black and Medicaid dual-eligible patients were disproportionately present in the CLTI subgroup and were at higher risk of amputation and mortality, respectively. Future studies must focus on early identification of high-risk patient groups to improve outcomes in patients with PAD.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care.

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Digital disparities: designing telemedicine systems with a health equity aim.

The use of telemedicine has grown immensely during the COVID-19 pandemic. Telemedicine provides a means to deliver clinical care while limiting patient and provider exposure to the COVID-19. As such, telemedicine is finding applications in a variety of clinical environments including primary care and the acute care setting and the array of patient populations who use telemedicine continues to grow. Yet as telehealth becomes ubiquitous, it is critical to consider its potential to exacerbate disparities in care. Challenges accessing technology and digital literacy, for example, disproportionately impact older patients and those living in poverty. When implemented with the consideration of health disparities, telemedicine provides an opportunity to address these inequities. This manuscript explores potential mechanisms by which telemedicine may play a role in exacerbating or ameliorating disparities in care. We further describe a framework and suggested strategies with which to implement telemedicine systems to improve health equity.

A Study Looking at a Lower Cost Option for Cultural Competence Education.

To meet the growing demands in the US healthcare system caused by multiculturalism and the expansion of health inequities, due diligence must be given to testing the efficacy of tools used in teaching nurses to provide culturally competent care. This project assessed the utility of a free US government-developed training module. The team found an improved trend in nurse-patient communication scores and improved willingness to ask for help with cultural issues for the intervention unit. The use of no-cost, publicly available resources may be a cost-effective option for training materials.

When Scarcity Meets Disparity: "Resources Allocation and COVID-19 Patients with Diabetes".

The COVID-19 pandemic raised distinct challenges in the field of scarce resource allocation, a long-standing area of inquiry in the field of bioethics. Policymakers and states developed crisis guidelines for ventilator triage that incorporated such factors as immediate prognosis, long-term life expectancy, and current stage of life. Often these depend upon existing risk factors for severe illness, including diabetes. However, these algorithms generally failed to account for the underlying structural biases, including systematic racism and economic disparity, that rendered some patients more vulnerable to these conditions. This paper discusses this unique ethical challenge in resource allocation through the lens of care for patients with severe COVID-19 and diabetes.

Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.

The burdens of the coronavirus disease (COVID-19) pandemic have fallen disproportionately on disadvantaged groups, including the poor and Black, Latinx, and Indigenous communities. There is substantial concern that the use of existing ICU triage protocols to allocate scarce ventilators and critical care resources-most of which are designed to save as many lives as possible-may compound these inequities. As governments and health systems revisit their triage guidelines in the context of impending resource shortages, scholars have advocated a range of alternative allocation strategies, including the use of a random lottery to give all patients in need an equal chance of ICU treatment. However, both the save-the-most-lives approach and random allocation are seriously flawed. In this Perspective, we argue that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society. We recommend three strategies to mitigate health inequities during ICU triage: introducing a correction factor into patients' triage scores to reduce the impact of baseline structural inequities; giving heightened priority to individuals in essential, high-risk occupations; and rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. We present a practical triage framework that incorporates these strategies and attends to the twin public health goals of promoting population health and social justice.

World Health Assembly 73: A Step Forward for Global Surgery.

Member States at this year's World Health Assembly 73 (WHA73), held virtually for the first time due to the COVID-19 pandemic, passed multiple resolutions that must be considered when framing efforts to strengthen surgical systems. Surgery has been a relatively neglected field in the global health landscape due to its nature as a cross-cutting treatment rather than focusing on a specific disease or demographic. However, in recent years, access to essential and emergency surgical, obstetric, and anesthesia care has gained increasing recognition as a vital aspect of global health. The WHA73 Resolutions concern specific conditions, as has been characteristic of global health practice, yet proper care for each highlighted disease is inextricably linked to surgical care. Global surgery advocates must recognize how surgical system strengthening aligns with these strategic priorities in order to ensure that surgical care continues to be integrated into efforts to decrease global health disparities.