Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation.

BACKGROUND: Non-Hispanic Black and Hispanic patients with symptomatic PAD may receive different treatments than White patients with symptomatic PAD. The delivery of guideline-directed medical treatment may be a modifiable upstream driver of race and ethnicity-related disparities in outcomes such as limb amputation. The purpose of our study was to investigate the prescription of preoperative antiplatelets and statins in producing disparities in the risk of amputation following revascularization for symptomatic peripheral artery disease (PAD). METHODS: We used data from the Vascular Quality Initiative, a vascular procedure-based registry in the United States (2011-2018). We estimated the probability of preoperative antiplatelet and statin prescriptions and 1-year incidence of amputation. We then estimated the amputation risk difference between race/ethnicity groups that could be eliminated under a hypothetical intervention. RESULTS: Across 100,579 revascularizations, the 1-year amputation risk was 2.5% (2.4%, 2.6%) in White patients, 5.3% (4.9%, 5.6%) in Black patients, and 5.3% (4.7%, 5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive antiplatelet and statin therapy. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received these medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (-2.9%, 21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (-0.7%, 38.6%). CONCLUSION: Even though guideline-directed care appeared evenly distributed by race/ethnicity, increasing access to such care may decrease health care disparities in major limb amputation.

Examining ACCURE's Nurse Navigation Through an Antiracist Lens: Transparency and Accountability in Cancer Care.

There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black-White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.

Considerations Before Selecting a Stepped-Wedge Cluster Randomized Trial Design for a Practice Improvement Study.

PURPOSE: Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design's advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS: The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS: All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS: The challenges experienced by EvidenceNOW grantees suggest that certain favorable real-world conditions constitute a context that increases the odds of a successful SW-CRT. An existing infrastructure can support the recruitment of many practices. Strong retention plans are needed to continue to engage sites waiting to start the intervention. Finally, study outcomes should be ones already captured in routine practice; otherwise, funders and investigators should assess the feasibility and cost of data collection.VISUAL ABSTRACT.

A Path Toward Health Care Equity: System-Based Interventions for Change.

Despite documentation spanning decades, health care disparities across North Carolina have remained persistent for populations of color, especially for Black patients. This commentary reviews recent studies that used system-based interventions to reduce disparities and improve outcomes for everyone, and outlines how clinicians, partnering with NC AHEC, can apply results to practice.

The role of patient-physician relationship on health-related quality of life and pain in cancer patients.

PURPOSE: Health-related quality of life (HRQOL) and pain are important supportive cancer care outcomes. The patient-provider relationship, a modifiable care experience, has been linked to healthcare outcomes; however, less is known about associations between patient-provider relationship and supportive care outcomes in cancer patients. We examined the role of multiple aspects of the patient-provider relationship in explaining patterns of HRQOL and pain among breast and lung cancer patients. METHODS: Our analysis included 283 breast and lung cancer patients from two cancer centers. Clinical data and survey data on patient sociodemographic factors, physical and mental HRQOL, pain, and patient-physician relationship (i.e., doctor's respectfulness, time spent with doctors, patient involvement in decision-making, satisfaction with care, and following doctor's advice/treatment plan) were collected at baseline and during treatment. We estimated adjusted modified Poisson regression models to assess associations between patient-physician relationship factors and physical and mental HRQOL and pain. RESULTS: Compared with patients reporting suboptimal respect from doctors, patients reporting optimal respect were less likely to report below average physical HRQOL (adjusted risk ratio (ARR), 0.73; 95%CI, 0.62-0.86), below average mental HRQOL (ARR, 0.71; 95%CI, 0.54-0.93), and moderate-to-severe pain (ARR, 0.53; 95%CI, 0.35-0.79). Patients reporting optimal involvement in care decision-making and patients who reported following their doctor's advice/treatment plan were less likely to report below average mental HRQOL than their respective counterparts (ARR, 0.64; 95%CI, 0.50-0.83; ARR, 0.65; 95%CI, 0.48-0.86). CONCLUSION: Multiple patient-physician relationship factors account for variations in HRQOL and pain in cancer patients. These findings provide insight into potential targets for improving the patient-provider relationship and supportive cancer care outcomes.

Strengthening community-clinical linkages to reduce cardiovascular disease risk in rural NC: feasibility phase of the CHANGE study.

BACKGROUND: Community Health Workers (CHW) are recommended for delivery of interventions to prevent cardiovascular disease, but there is insufficient evidence to guide implementation of CHW interventions in rural, medically underserved areas. METHODS: Using a hybrid implementation-effectiveness design, we evaluated the implementation and effectiveness of an adapted, evidence-based cardiovascular disease risk reduction intervention among rural high-risk adults. CHWs at a community health center and local health department recruited, enrolled and counseled participants during 4 monthly home visits and 3 brief phone contacts. Participant data collection included pre- and post-intervention measurements of blood pressure, weight, and dietary and physical activity behaviors. We evaluated implementation with measures of intervention reach and delivery fidelity. Statistical analyses included descriptive statistics and paired t-tests. RESULTS: Study participants (n = 105) had a mean age of 62 years and included 88% Non-Hispanic Blacks and 82% females. Recruitment strategies resulted in the enrollment of 38% of interested and eligible participants who received 80% of the planned intervention visits and phone contacts. Mean differences in pre-/post-intervention measures showed significant mean reductions in blood pressure (- 5.4 mmHg systolic, p = .006; - 2.3 mmHg diastolic, p = .04) and body weight (- 3.8 lb., p = .02). Self-reported dietary and physical activity behaviors also improved significantly. CONCLUSION: This feasibility study demonstrated preliminary implementation and program effectiveness of a CHW-delivered intervention to reduce cardiovascular disease risk factors. Additionally, it identified areas for future refinements to strategies that strengthen community-clinical linkages with an integrated role of CHWs in rural health care delivery. If results from this feasibility study can be enhanced in a larger sample, there would be significant potential to positively impact the excess burden of chronic diseases that adversely impact rural, low-income, and medically underserved populations. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03582696.

Practice level factors associated with enhanced engagement with practice facilitators; findings from the heart health now study.

BACKGROUND: Practice facilitation is a promising strategy to enhance care processes and outcomes in primary care settings. It requires that practices and their facilitators engage as teams to drive improvement. In this analysis, we explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month practice facilitation intervention focused on implementing cardiovascular prevention activities in practice. Understanding factors associated with greater engagement with facilitators in practice-based quality improvement can assist practice facilitation programs with planning and resource allocation. METHODS: One hundred thirty-six ambulatory care small to medium sized primary care practices that participated in the EvidenceNow initiative's NC Cooperative, named Heart Health Now (HHN), fit the eligibility criteria for this analysis. We explored the practice and facilitator factors associated with greater team engagement at the mid-point of a 12-month intervention using a retrospective cohort design that included baseline survey data, monthly practice activity implementation data and information about facilitator's experience. Generalized linear mixed-effects models (GLMMs) identified variables associated with greater odds of team engagement using an ordinal scale for level of team engagement. RESULTS: Among our practice cohort, over half were clinician-owned and 27% were Federally Qualified Health Centers. The mean number of clinicians was 4.9 (SD 4.2) and approximately 40% of practices were in Medically Underserved Areas (MUA). GLMMs identified a best fit model. The Model presented as odd ratios and 95% confidence intervals suggests greater odds ratios of higher team engagement with greater practice QI leadership 17.31 (5.24-57.19), [0.00], and practice location in a MUA 7.25 (1.8-29.20), [0.005]. No facilitator characteristics were independently associated with greater engagement. CONCLUSIONS: Our analysis provides information for practice facilitation stakeholders to consider when considering which practices may be more amendable to embracing facilitation services.

Reducing cardiovascular disease in a rural community.

In this case report, we describe the one-year formative phase of a five-year study to develop, implement, and test a community health worker (CHW)-delivered cardiovascular disease (CVD) prevention intervention. The purpose of the formative phase was to engage community partners in the adaptation of an existing evidence-based CVD prevention intervention to fit the needs and preferences of a rural, predominantly African-American community. The formative work was guided by a framework for adapting evidence-based interventions and involved engaging stakeholders in assessing the intervention's fit with the local context and then applying assessment findings to iteratively adapt the intervention's contents, materials, and delivery methods. Findings from the formative work were then applied to develop CHW position descriptions, workflow diagrams, and a training plan. Findings also were applied to adapt intervention materials and protocols to fit the needs of the community. This case report illustrates how community-engaged formative work can be applied to adapt an evidence-based intervention to fit community needs and resources.

Organizational Leadership and Adaptive Reserve in Blood Pressure Control: The Heart Health NOW Study.

PURPOSE: Our purpose was to assess whether a practice's adaptive reserve and high leadership capability in quality improvement are associated with population blood pressure control. METHODS: We divided practices into quartiles of blood pressure control performance and considered the top quartile as the benchmark for comparison. Using abstracted clinical data from electronic health records, we performed a cross-sectional study to assess the association of top quartile hypertension control and (1) the baseline practice adaptive reserve (PAR) scores and (2) baseline practice leadership scores, using modified Poisson regression models adjusting for practice-level characteristics. RESULTS: Among 181 practices, 46 were in the top quartile, which averaged 68% or better blood pressure control. Practices with higher PAR scores compared with lower PAR scores were not more likely to reside in the top quartile of performance (prevalence ratio [PR] = 1.92 for highest quartile; 95% CI, 0.9-4.1). Similarly, high quality improvement leadership capability compared with lower capability did not predict better blood pressure control performance (PR = 0.94; 95% CI, 0.57-1.56). Practices with higher proportions of commercially insured patients were more likely than practices with lower proportions of commercially insured patients to have top quartile performance (37% vs 26%, P =.002), whereas lower proportions of the uninsured (8% vs 14%, P =.055) were associated with better performance. CONCLUSIONS: Our findings show that adaptive reserve and leadership capability in quality improvement implementation are not statistically associated with achieving top quartile practice-level hypertension control at baseline in the Heart Health NOW project. Our findings, however, may be limited by a lack of patient-related factors and small sample size to preclude strong conclusions.

Racial differences in symptom management experiences during breast cancer treatment.

PURPOSE: Racial disparities in cancer treatment-related symptom burden are well documented and linked to worse treatment outcomes. Yet, little is known about racial differences in patients' treatment-related symptom management experiences. Such understanding can help identify modifiable drivers of symptom burden inequities. As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, we examined racial differences in symptom management experiences among Black and White breast cancer survivors (BCS). METHODS: We conducted six focus groups (n = 3 Black BCS groups; n = 3 White BCS groups) with 22 stages I-IV BCS at two cancer centers. Focus groups were audio-recorded and transcribed verbatim. Based on key community-based participatory research principles, our community/academic/medical partner team facilitated focus groups and conducted qualitative analyses. RESULTS: All BCS described positive symptom management experiences, including clinician attentiveness to symptom concerns and clinician recommendations for pre-emptively managing symptoms. Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians' failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS often described dissatisfaction regarding inadequate information on symptom origins and clinicians' failure to offer reassurance. CONCLUSIONS: This study elucidates opportunities for future research aimed at improving equity for cancer treatment-related symptom management. For Black women, warnings about anticipated symptoms and treatment for ongoing symptoms were particular areas of concern. Routine symptom assessment for all women, as well as clinicians' management of symptoms for racially diverse cancer patients, need to be more thoroughly studied and addressed.

Meaningful Use in Chronic Care: Improved Diabetes Outcomes Using a Primary Care Extension Center Model.

BACKGROUND: The effect of practice facilitation that provides onsite quality improvement (QI) and electronic health record (EHR) coaching on chronic care outcomes is unclear. This study evaluates the effectiveness of such a program-similar to an agricultural extension center model-that provides these services. METHODS: Through the Health Information Technology for Economic and Clinical Health (HITECH) portion of the American Recovery and Reinvestment Act, the North Carolina Area Health Education Centers program became the Regional Extension Center for Health Information Technology (REC) for North Carolina. The REC program provides onsite technical assistance to help small primary care practices achieve meaningful use of certified EHRs. While pursuing meaningful use functionality, practices were also offered complementary onsite advice regarding QI issues. We followed the first 50 primary care practices that utilized both EHR and QI advice targeting diabetes care. RESULTS: The achievement of meaningful use of certified EHRs and performance of QI with onsite practice facilitation showed an absolute improvement of 19% in the proportion of patients who achieved excellent diabetes control (hemoglobin A1c < 7%) compared to baseline. In addition, the percentages of patients with poorly controlled diabetes (hemoglobin A1c > 9%) fell steeply in these practices. LIMITATIONS: No control group was available for comparison. CONCLUSION: Practice facilitation that provided EHR and QI coaching support showed important improvements in diabetes outcomes in practices that achieved meaningful use of their EHR systems. This approach holds promise as a way to help small primary care practices achieve excellent patient outcomes.

The Benefits and Concerns Surrounding the Automation of Clinical Guidelines.

Automated guidelines often improve outcomes when applied to simple clinical states. They are more effective when human-computer interaction and workflow changes are considered in implementation. "Alert fatigue" might lead to uneven implementation of guidelines. For complex patients with multiple illnesses, more research should be geared toward the structure and effect of guidelines. Evidentiary uncertainty and complicating comorbid conditions continue to require meticulous incorporation of patient values and physician judgment.

Patient characteristics associated with favorable perceptions of patient-provider communication in early-stage lung cancer treatment.

Perceived quality of lung cancer communication is strongly associated with receiving potentially curative surgery for early-stage disease. The patient characteristics associated with poor quality communication in the setting of new lung cancer diagnosis are not known, although race may be a contributing factor. Using data from a prospective study of decision making in early-stage non-small cell lung cancer patients in five academic and community medical centers (N = 386), the authors used logistic regression techniques to identify patient-level characteristics correlated with scoring in the lowest quartile of a communication scale and a single-item communication variable describing shared communication. Income, lung cancer diagnostic status, and trust score were significantly associated with the overall communication scale. Lung cancer diagnostic status and trust score were also associated with patient perceptions of the single shared communication item, in addition to participation in a religious organization. Improving patient perceptions of communication with their provider is an important next step in ensuring that eligible patients receive optimal care for this deadly disease. This analysis identifies several modifiable factors that could improve patient perceptions of patient-provider communication. The fact that patient perception of communication is a predictor of the decision to undergo surgery independent of race highlights the need for broad communication interventions to ensure that as many eligible patients as possible are receiving surgery.

Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons.

Background: Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD). Methods: The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias. Results: There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making. Conclusions: Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.

Use of Sociodemographic Information in Clinical Vignettes of Multiple-Choice Questions for Preclinical Medical Students.

Purpose: This paper aims to characterize the use of demographic data in multiple-choice questions from a commercial preclinical question bank and determine if there is appropriate use of different distractors. Background: Multiple-choice questions for medical students often include vignettes describing a patient's presentation to help guide students to a diagnosis, but overall patterns of usage between different types of nonmedical patient information in question stems have yet to be determined. Methods: Three hundred eighty of 453 randomly selected questions were included for analysis after determining they contained a clinical vignette and required a diagnosis. The vignettes and following explanations were then examined for the presence/absence of 11 types of demographic information, including age, sex/gender, and socioeconomic status. We compared both the usage frequency and relevance between the 11 information types. Results: Most information types were present in less than 10% of clinical vignettes, but age and sex/gender were present in over 95% of question stems. Over 50% of questions included irrelevant information about age and sex/gender, but 75% of questions did not include any irrelevant information of other types. Patient weight and environmental exposures were significantly more likely to be relevant than age or sex/gender. Discussion: Students using the questions in this study will frequently gain practice incorporating age and sex/gender into their clinical reasoning while receiving little exposure to other demographic information. Based on our findings, we posit that questions could include more irrelevant information, outside age and sex/gender, to better approximate real clinical scenarios and ensure students do not overvalue certain demographic data. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01778-z.

Improving care transitions means more than reducing hospital readmissions.

Hospital readmissions are not only expensive, avoidable, and dangerous, but are also indicative of the most dysfunctional elements of US health care. The Patient Protection and Affordable Care Act places great emphasis on reducing preventable readmissions by building care systems that are patient-centered and that remove arbitrary silos of care. Hospitals that perform poorly on this measure will experience significant financial penalties beginning this fiscal year. In the short term, decreasing readmission rates will eliminate waste and enhance patient recovery from major illness. However the real vision is to ensure that vulnerable patients, particularly the chronically ill, benefit from coordinated, patient-centered systems that maintain functional independence, improve quality of life, and provide comfort without the trauma, expense, and displacement that unnecessary hospitalization often entails. The commentaries published in this issue of the NCMJ portray some of the most significant barriers to smooth transitions and reducing readmission rates and describe some of the nascent North Carolina and national solutions that demonstrate promise in real world situations.

It takes a community: The North Carolina Division of Public Health and the North Carolina area health education center program partner to reduce strokes and heart attacks.

The North Carolina Division of Public Health is leading a statewide project using a combination of approaches to address cardiovascular risk factors including obesity, hypertension, diabetes, and cigarette smoking. The objectives are to decrease tobacco use, increase physical activity, improve nutrition, and increase access to evidence-based clinical preventive services targeting hypertension, hypercholestrolemia, tobacco use, and weight management.

A Heart Healthy Intervention Improved Tobacco Screening Rates and Cessation Support in Primary Care Practices.

We examined whether an evidence-based cardiovascular disease risk reduction intervention (Heart Health Now) would improve rates for tobacco cessation screening and counseling in small primary care practices in North Carolina. Heart Health Now was a stepped wedge, stratified, cluster randomized trial for primary care practices that were staffed by 10 or fewer clinicians and had an electronic health record. The Heart Health Now intervention consisted of education tools, onsite practice facilitation for one year, and a practice-specific cardiovascular population management dashboard that included monthly, measure-specific run charts to help guide quality improvement. Our primary outcomes were practice-level rates of tobacco screening and tobacco cessation support-extracted from practices' electronic health records-and measured at pre-intervention and 6 months post-intervention. The 28 practices included in our analyses represented 78,120 patients and 17,687 smokers. Significant change occurred in practices' tobacco screening rates and cessation support rates over time. From pre- to post-intervention, screening rates significantly increased from 82.7 to 96.2% (p < 0.001). Similarly, cessation support rates significantly increased from 44.3 to 50.1% (p = 0.03). Several practice-level factors were associated with improvement including being in an academic health center or faculty practice, having more clinicians, and having a lower percentage of White patients. In conclusion, a multi-component intervention focused on multiple cardiovascular disease risk reduction in multiple small primary care practices successfully improved rates of tobacco screening and cessation support.

Development and Validation of the Trust in My Doctor, Trust in Doctors in General, and Trust in the Health Care Team Scales.

RATIONALE: Historic and present-day racism and inequity in the United States (U.S.) have resulted in diminished trust in health care among many populations. A key barrier to improving trust in health care is a dearth of well-validated measures appropriate for diverse populations. Indeed, systematic reviews indicate a need to develop and test updated trust measures that are multidimensional and inclusive of relevant domains (e.g., fairness). OBJECTIVE: We developed three trust measures: the Trust in My Doctor (T-MD), Trust in Doctors in General (T-DiG), and Trust in the Health Care Team (T-HCT) scales. METHODS: After developing an initial item pool, expert reviewers (n = 6) provided feedback on the face validity of each scale. We conducted cognitive interviews (n = 21) with a convenience sample of adults to ensure items were interpreted as intended. In 2020, we administered an online survey to a convenience sample of U.S. adults recruited through the Qualtrics Panel (n = 801) to assess scale reliability and validity. RESULTS: Exploratory and confirmatory factor analyses indicated acceptable model fit for second order latent factor models for each scale (root mean square error of approximation: <0.07, comparative fit index: ≥0.98, and standardized root mean square residual: ≤0.03). The T-MD contained 25 items and six subscales: communication competency, fidelity, systems trust, confidentiality, fairness, and global trust. The T-DiG and T-HCT each contained 29 items and seven subscales (the same subscales in the T-MD plus an additional subscale related to stigma-based discrimination). Each scale was strongly correlated with existing trust measures and perceived racism in health care and was significantly associated with delayed health care seeking and receipt of a routine health exam. CONCLUSIONS: The multidimensional T-MD, T-DiG, and T-HCT scales have sound psychometric properties and may be useful for researchers evaluating trust-related interventions or conducting studies where trust is an important construct or main outcome.