Social Determinants of Health Needs and Health-related Quality of Life Among Surgical Patients: A Retrospective Analysis of 8512 Patients.

OBJECTIVE: To assess associations between social determinants of health (SDOH) needs and health-related quality of life (HRQOL) among surgical patients. BACKGROUND: Despite the profound impact of SDOH on health outcomes, studies examining the effect of SDOH needs on HRQOL among surgical patients are limited. METHODS: A retrospective study was conducted using responses from the SDOH needs assessment and the Patient-Reported Outcomes Measurement Information Systems Global Health instrument of adults seen in surgical clinics at a single institution. Patient characteristics including socioeconomic status (insurance type, education level, and employment status) were extracted. Stepwise multivariable logistic regression analyses were performed to identify independent predictors of global health scores. RESULTS: A total of 8512 surgical patients (mean age: 55.6±15.8 years) were included. 25.2% of patients reported one or more SDOH needs. The likelihood of reporting at least one SDOH need varied by patient characteristics and socioeconomic status variables. In fully adjusted regression models, food insecurity [odds ratio (OR), 1.53; 95% CI, 1.38-1.70 and OR, 1.49; 95% CI, 1.22-1.81, respectively], housing instability (OR, 1.27; 95% CI, 1.12-1.43 and OR, 1.39; 95% CI, 1.13-1.70, respectively) lack of transportation (OR, 1.46; 95% CI, 1.27-1.68 and OR, 1.25; 95% CI, 1.00-1.57, respectively), and unmet medication needs (OR, 1.31; 95% CI, 1.13-1.52 and OR, 1.61; 95% CI, 1.28-2.03, respectively) were independent predictors of poor physical and mental health. CONCLUSIONS: SDOH needs are independent predictors of poor patient-reported physical and mental health among surgical patients. Assessing and addressing SDOH needs should be prioritized in health care settings and by policymakers to improve HRQOL.

Patterns of Social Needs Predict Quality-of-Life and Healthcare Utilization Outcomes in Patients from a Large Hospital System.

BACKGROUND: Unmet social needs (SNs) often coexist in distinct patterns within specific population subgroups, yet these patterns are understudied. OBJECTIVE: To identify patterns of social needs (PSNs) and characterize their associations with health-related quality-of-life (HRQoL) and healthcare utilization (HCU). DESIGN: Observational study using data on SNs screening, HRQoL (i.e., low mental and physical health), and 90-day HCU (i.e., emergency visits and hospital admission). Among patients with any SNs, latent class analysis was conducted to identify unique PSNs. For all patients and by race and age subgroups, compared with no SNs, we calculated the risks of poor HRQoL and time to first HCU following SNs screening for each PSN. PATIENTS: Adult patients undergoing SNs screening at the Mass General Brigham healthcare system in Massachusetts, United States, between March 2018 and January 2023. MAIN MEASURES: SNs included: education, employment, family care, food, housing, medication, transportation, and ability to pay for household utilities. HRQoL was assessed using the Patient-Reported Outcomes Measurement Information System Global-10. KEY RESULTS: Six unique PSNs were identified: "high number of social needs," "food and utility access," "employment needs," "interested in education," "housing instability," and "transportation barriers." In 14,230 patients with HRQoL data, PSNs increased the risks of poor mental health, with risk ratios ranging from 1.07(95%CI:1.01-1.13) to 1.80(95%CI:1.74-1.86). Analysis of poor physical health yielded similar findings, except that the "interested in education" showed a mild protective effect (0.97[95%CI:0.94-1.00]). In 105,110 patients, PSNs increased the risk of 90-day HCU, with hazard ratios ranging from 1.09(95%CI:0.99-1.21) to 1.70(95%CI:1.52-1.90). Findings were generally consistent in subgroup analyses by race and age. CONCLUSIONS: Certain SNs coexist in distinct patterns and result in poorer HRQoL and more HCU. Understanding PSNs allows policymakers, public health practitioners, and social workers to identify at-risk patients and implement integrated, system-wide, and community-based interventions.

The Power and Promise of Postpartum Self Care: Evaluation of a Web-Based Tool for Underserved Women.

OBJECTIVES: Joyuus is a culturally diverse, comprehensive online tool designed to address the self-care needs of underserved postpartum women. The tool provides actionable self-care information, knowledge, and skills to improve postpartum health and identifies red flags for when self-care shifts to seeking care. METHODS: We employed a mixed-methods multiphase design to evaluate the Joyuus prototype, including a pre-post evaluation (N = 87) to assess behavioral health outcomes before and after using the tool for a one-month period. 91% completed the post-test (N = 79). The analysis focused on estimation of treatment effect (via 95% confidence intervals) and fitness of instruments in this population. RESULTS: Participants were between 6 months pregnant and one year postpartum, a mean age of 30 years, 100% female, 99% Black, with nearly equal distribution of married (55%) and not married (44%), and above (47%) and below (46%) annual income of $60 K. Key measures saw significant improvement from pre- (mean = 26.44, SD = 5.39) to post (mean = 28.29, SD = 5.26) on the Connor-Davidson Resilience Scale (p < 0.001) Trends toward improvement (not statistically significant) were noted for Depression (EPDS) (p = 0.624) and Anxiety (STAI) (p = 0.286), and no meaningful change on MOS Social Support or COVID-19 Mental Health Impacts Measures. CONCLUSIONS FOR PRACTICE: This pilot study demonstrates that a self-care mobile tool has the potential to address significant health outcomes related to maternal morbidity and mortality. By providing a continuously available companion addressing physical, mental, and real-life questions, it creates value during postpartum for mothers who can often feel overwhelmed or isolated.

Trends in State-Level Maternal Mortality by Racial and Ethnic Group in the United States.

Importance: Evidence suggests that maternal mortality has been increasing in the US. Comprehensive estimates do not exist. Long-term trends in maternal mortality ratios (MMRs) for all states by racial and ethnic groups were estimated. Objective: To quantify trends in MMRs (maternal deaths per 100 000 live births) by state for 5 mutually exclusive racial and ethnic groups using a bayesian extension of the generalized linear model network. Design, Setting, and Participants: Observational study using vital registration and census data from 1999 to 2019 in the US. Pregnant or recently pregnant individuals aged 10 to 54 years were included. Main Outcomes and Measures: MMRs. Results: In 2019, MMRs in most states were higher among American Indian and Alaska Native and Black populations than among Asian, Native Hawaiian, or Other Pacific Islander; Hispanic; and White populations. Between 1999 and 2019, observed median state MMRs increased from 14.0 (IQR, 5.7-23.9) to 49.2 (IQR, 14.4-88.0) among the American Indian and Alaska Native population, 26.7 (IQR, 18.3-32.9) to 55.4 (IQR, 31.6-74.5) among the Black population, 9.6 (IQR, 5.7-12.6) to 20.9 (IQR, 12.1-32.8) among the Asian, Native Hawaiian, or Other Pacific Islander population, 9.6 (IQR, 6.9-11.6) to 19.1 (IQR, 11.6-24.9) among the Hispanic population, and 9.4 (IQR, 7.4-11.4) to 26.3 (IQR, 20.3-33.3) among the White population. In each year between 1999 and 2019, the Black population had the highest median state MMR. The American Indian and Alaska Native population had the largest increases in median state MMRs between 1999 and 2019. Since 1999, the median of state MMRs has increased for all racial and ethnic groups in the US and the American Indian and Alaska Native; Asian, Native Hawaiian, or Other Pacific Islander; and Black populations each observed their highest median state MMRs in 2019. Conclusion and Relevance: While maternal mortality remains unacceptably high among all racial and ethnic groups in the US, American Indian and Alaska Native and Black individuals are at increased risk, particularly in several states where these inequities had not been previously highlighted. Median state MMRs for the American Indian and Alaska Native and Asian, Native Hawaiian, or Other Pacific Islander populations continue to increase, even after the adoption of a pregnancy checkbox on death certificates. Median state MMR for the Black population remains the highest in the US. Comprehensive mortality surveillance for all states via vital registration identifies states and racial and ethnic groups with the greatest potential to improve maternal mortality. Maternal mortality persists as a source of worsening disparities in many US states and prevention efforts during this study period appear to have had a limited impact in addressing this health crisis.

Delayed diagnosis and racial bias in children with genetic conditions.

As more therapeutics for genetic conditions become available, the need for timely and equitable genetic diagnosis has become urgent. Using clinical cases, we consider the health system-, provider-, and patient-level factors that contribute to the delayed diagnosis of genetic conditions in pediatric patients from minority populations, leading to health disparities between racial groups. We then provide suggestions to address these factors, with the aim of improving minority health and access to genetic care for all children.

Society for Maternal-Fetal Medicine Special Statement: Race in maternal-fetal medicine research- Dispelling myths and taking an accurate, antiracist approach.

Profound inequities in maternal and infant outcomes based on race exist, and the maternal-fetal medicine community has an important role in eliminating these disparities. Accurately employing race and ethnicity as social constructs within research that guides clinical practice is essential to achieving health equity. We must abandon commonly propagated myths that race is a surrogate for genetics or economic status and that data are exempt from potential bias. These myths can lead to harmful misconceptions that exacerbate racial disparities in maternal and infant health outcomes. Furthermore, these myths obscure racism as the true underlying etiology of racial disparities. Understanding that race is a social construct and using an antiracist approach to research are essential in combating racism and eliminating unacceptable disparities in maternal and infant health. This document provides specific suggestions to approach the research process with an antiracist framework.

Toward the elimination of race-based medicine: replace race with racism as preeclampsia risk factor.

Pregnancy-related morbidity and mortality continue to disproportionately affect birthing people who identify as Black. The use of race-based risk factors in medicine exacerbates racial health inequities by insinuating a false conflation that fails to consider the underlying impact of racism. As we work toward health equity, we must remove race as a risk factor in our guidelines to address disparities due to racism. This includes the most recent US Preventive Services Taskforce, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine guidelines for aspirin prophylaxis in preeclampsia, where the risk factor for "Black race" should be replaced with "anti-Black racism." In this commentary, we reviewed the evidence that supports race as a sociopolitical construct and the health impacts of racism. We presented a call to action to remove racial determination in the guidelines for aspirin prophylaxis in preeclampsia and more broadly in our practice of medicine.

Mode of Delivery and Unplanned Cesarean: Differences in Rates and Indication by Race, Ethnicity, and Sociodemographic Characteristics.

OBJECTIVE: We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery. STUDY DESIGN: We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t-tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test. RESULTS: Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001). CONCLUSION: Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings. KEY POINTS: · Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.. · Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.. · There may be unmeasured provider level factors which contribute to disparities in cesarean rates..

Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas.

OBJECTIVE: This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI. STUDY DESIGN: This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations. RESULTS: Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81). CONCLUSION: Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI. KEY POINTS: · Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..

The safety of asthma medications during pregnancy and lactation: Clinical management and research priorities.

Asthma is one of the most common underlying diseases in women of reproductive age that can lead to potentially serious medical problems during pregnancy and lactation. A group of key stakeholders across multiple relevant disciplines was invited to take part in an effort to prioritize, strategize, and mobilize action steps to fill important gaps in knowledge regarding asthma medication safety in pregnancy and lactation. The stakeholders identified substantial gaps in the literature on the safety of asthma medications used during pregnancy and lactation and prioritized strategies to fill those gaps. Short-term action steps included linking data from existing complementary study designs (US and international claims data, single drug pregnancy registries, case-control studies, and coordinated systematic data systems). Long-term action steps included creating an asthma disease registry, incorporating the disease registry into electronic health record systems, and coordinating care across disciplines. The stakeholders also prioritized establishing new infrastructures/collaborations to perform research in pregnant and lactating women and to include patient perspectives throughout the process. To address the evidence gaps, and aid in populating product labels with data that inform clinical decision making, the consortium developed a plan to systematically obtain necessary data in the most efficient and timely manner.

Oxytocin Compared to Buccal Misoprostol for Induction of Labor after Term Prelabor Rupture of Membranes.

OBJECTIVE: This study was aimed to determine if admission-to-delivery times vary between term nulliparous women with prelabor rupture of membranes (PROM) who initially receive oxytocin compared with buccal misoprostol for labor induction. STUDY DESIGN: This is a retrospective cohort of 130 term, nulliparous women with PROM and cervical dilation of ≤2 cm who underwent induction of labor with intravenous oxytocin or buccal misoprostol. The primary outcome was time from admission to delivery. Linear regressions with log transformation were used to estimate the effect of induction agent on time to delivery. RESULTS: Women receiving oxytocin had faster admission-to-delivery times than women receiving misoprostol (16.9 vs. 19.9 hours, p = 0.013). There were no significant differences in secondary outcomes between the groups. In the adjusted model, women who received misoprostol had a 22% longer time from admission to delivery (95% CI 5.0-42.0%) compared with women receiving oxytocin. CONCLUSION: In term nulliparous patients with PROM, intravenous oxytocin is associated with faster admission-to-delivery times than buccal misoprostol.

Racial and Ethnic Disparities in Maternal and Infant Outcomes Among Opioid-Exposed Mother-Infant Dyads in Massachusetts (2017-2019).

Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity.Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge.Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes.Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all mother-infant dyads.

Effect of a Patient-Centered Decision Support Tool on Rates of Trial of Labor After Previous Cesarean Delivery: The PROCEED Randomized Clinical Trial.

Importance: Reducing cesarean delivery rates in the US is an important public health goal; despite evidence of the safety of vaginal birth after cesarean delivery, most women have scheduled repeat cesarean deliveries. A decision support tool could help increase trial-of-labor rates. Objective: To analyze the effect of a patient-centered decision support tool on rates of trial of labor and vaginal birth after cesarean delivery and decision quality. Design, Setting, and Participants: Multicenter, randomized, parallel-group clinical trial conducted in Boston, Chicago, and the San Francisco Bay area. A total of 1485 English- or Spanish-speaking women with 1 prior cesarean delivery and no contraindication to trial of labor were enrolled between January 2016 and January 2019; follow-up was completed in June 2019. Interventions: Participants were randomized to use a tablet-based decision support tool prior to 25 weeks' gestation (n=742) or to receive usual care (without the tool) (n=743). Main Outcomes and Measures: The primary outcome was trial of labor; vaginal birth was the main secondary outcome. Other secondary outcomes focused on maternal and neonatal outcomes and decision quality. Results: Among 1485 patients (mean age, 34.0 [SD, 4.5] years), 1470 (99.0%) completed the trial (n = 735 in both randomization groups) and were included in the analysis. Trial-of-labor rates did not differ significantly between intervention and control groups (43.3% vs 46.2%, respectively; adjusted absolute risk difference, -2.78% [95% CI, -7.80% to 2.25%]; adjusted relative risk, 0.94 [95% CI, 0.84-1.05]). There were no statistically significant differences in vaginal birth rates (31.8% in both groups; adjusted absolute risk difference, -0.04% [95% CI, -4.80% to 4.71%]; adjusted relative risk, 1.00 [95% CI, 0.86-1.16]) or in any of the other 6 clinical maternal and neonatal secondary outcomes. There also were no significant differences between the intervention and control groups in the 5 decision quality measures (eg, mean decisional conflict scores were 17.2 and 17.5, respectively; adjusted mean difference, -0.38 [95% CI, -1.81 to 1.05]; scores >25 are considered clinically important). Conclusions and Relevance: Among women with 1 previous cesarean delivery, use of a decision support tool compared with usual care did not significantly change the rate of trial of labor. Further research may be needed to assess the efficacy of this tool in other clinical settings or when implemented at other times in pregnancy.

Risk of Cesarean Delivery among Nulliparous Asian-Indian Women with Term Singleton Pregnancies.

OBJECTIVE: Asian-Indian women are a growing population in the United States, but little data exist about their risk of cesarean delivery (CD). We characterize the odds of CD among Asian-Indian women and determine whether neonatal birth weight modifies this relationship. STUDY DESIGN: This is a retrospective cohort study using an administrative perinatal database from California. We identified 1,029,940 nulliparous women with live, singleton, nonanomalous deliveries between 37 and 42 completed weeks of gestation. We performed multivariable logistic regression analyses to determine if Asian-Indian women were more likely to deliver by CD, compared with white non-Hispanic women, adjusting for sociodemographic and clinical variables. We explored if birth weight was an effect modifier, testing the interaction term's significance using Wald's test, and performed multivariable logistic regressions stratified by birth weight category. RESULTS: Asian-Indian women comprised 2.0% of the cohort. Compared with white non-Hispanic women, Asian-Indian women had an adjusted odds of 1.41 (95% confidence interval: 1.36-1.46) for CD. However, we noted effect modification of birth weight on the odds of CD by race/ethnicity (p < 0.001). Among all birth weight categories exceeding 3,000 g, Asian-Indian women had higher odds of CD than white non-Hispanic women. CONCLUSION: Asian-Indian women are at greater risk of CD than white non-Hispanic women when birthweight exceeds 3,000 g.

Disparities in 17-Hydroxyprogesterone Caproate Offer and Uptake in Pregnancies at a Risk of Preterm Birth.

OBJECTIVE: To evaluate the offer, acceptance, uptake, and patient experience with 17-hydroxyprogesterone caproate (17OHP-C) over the course of 10 years. STUDY DESIGN: This is a retrospective cohort study with a qualitative component. We identified all women with spontaneous preterm deliveries with subsequent births in our hospital between 2005 and 2015. We used linear regression to calculate unadjusted odds ratios for 17OHP-C offer, acceptance, and doses received associated with predictors of interest, and multivariable modeling further adjusted for potential confounders. A grounded theory approach was used to glean recurrent themes surrounding the patient experience. RESULTS: A total of 265 women fit the eligibility criteria; 39.6% were offered 17OHP-C and 83.8% accepted 17OHP-C. The mean number of documented 17OHP-C doses was 15.7 ± 5.4. Women were less likely to be offered 17OHP-C if they had public insurance or if their earliest preterm birth was of greater gestational age. Non-Hispanic black women were documented to have received four fewer doses than white women. We also identified recurrent themes that hindered acceptance and adherence to 17OHP-C: insurance difficulties, unstable housing, lack of childcare, and job inflexibility. CONCLUSION: Women at a risk of preterm birth are more likely to be offered and receive 17OHP-C if they have private insurance and have had an earlier preterm birth. Non-Hispanic black women were documented to have received fewer doses of 17OHP-C than white women. Further inquiry into the structural causes that lead to disparities in care for women at a risk for preterm birth is important.

SMFM Special Report: Putting the "M" back in MFM: Addressing education about disparities in maternal outcomes and care.

At the 36th Annual meeting of the Society for Maternal-Fetal Medicine (SMFM), leaders in the field of maternal-fetal medicine (MFM) convened to address maternal outcome and care inequities from 3 perspectives: (1) education, (2) clinical care, and (3) research. Meeting attendees identified knowledge gaps regarding disparities within the provider community; reviewed possible frameworks to address these knowledge gaps; and identified models with which to address key clinical issues. Collaboration and communication between all stakeholders will be needed to gain a better understanding of these prevailing disparities and formulate strategies to eliminate them.

Disparities from bedside to "webside": barriers to achieving equity in telemedicine in obstetrics.

Given the urgency of the COVID-19 pandemic, telehealth was swiftly implemented in the United States and shifted from an optional to an essential modality of care. This was important in both maintaining continuity of care, especially for those with chronic illnesses, and in evaluating individuals presenting with illness or acute needs. One of the primary benefits of telemedicine is convenience; however, this is juxtaposed with the various downsides that result from a lack of physical appointments and accessible technology. Notably, there are large barriers to achieving equity for certain communities, of which the most apparent is the "digital divide" that results from a lack of adequate broadband infrastructure and lower technology literacy among members of certain communities and those in rural areas. Without attention to factors that can improve availability, uptake, and experience, disparities will increase with telemedicine. As this technology becomes common practice, it will be important to provide equal reimbursement for in-person and telehealth visits, center patient design and cultural competency in telemedicine programs, and improve broadband and technology access, ensuring that the highest-quality care is delivered to all patients.

A Health System Framework for Addressing Structural Racism: Mass General Brigham's United Against Racism Initiative.

The legacy of racism and structural inequality has taken a heavy toll on the health care system and the health outcomes of patients and members of community catchment areas. To achieve optimal health outcomes for all, health systems will need to enact structural change that is meaningful, measurable, and rooted in evidence. We describe an antiracism campaign organized into three pillars of focus (Leadership/Employees/Culture, Patient Care Equity, and Community Health and Policy Advocacy) and implemented across Mass General Brigham, a large integrated health system in the northeast of the United States. Our study ranges from the foundational to the aspirational and examples of data-driven areas of focus, programs (e.g., staff education, social risk mitigation, and new models of clinical service), and metrics developed for the health care workforce, patients, and surrounding communities are presented.

Availability Versus Accessibility: Identifying COVID-19 Testing Deserts Across Massachusetts.

Throughout the COVID-19 pandemic, communities of color have faced significantly higher rates of COVID-19 infection, as well as poor clinical outcomes. These differences are driven by long-standing structural inequities that prevent effective social distancing efforts and are further exacerbated by disparities in COVID-19 testing. Our study applied the concept of "COVID-19 testing deserts" to systematically identify gaps in testing resource allocation across Massachusetts in May 2020 and March 2021. Testing deserts were identified at the census tract level, using criteria developed by the Department of Agriculture for food deserts. Testing deserts occurred more frequently in segregated Hispanic, segregated Black, mixed minority, and integrated communities, as well as in neighborhoods with low vehicle access and in federally designated Medically Underserved Areas. Segregated communities were those in which more than 50 percent of the population self-identified as non-Hispanic White, Hispanic, non-Hispanic Black, or non-Hispanic Asian, respectively. Testing deserts were overrepresented in counties with high COVID-19 incidence rates, suggesting that testing accessibility is essential for prompt COVID-19 diagnosis and self-isolation.

Transcending Language Barriers in Obstetrics and Gynecology: A Critical Dimension for Health Equity.

There is growing evidence that language discordance between patients and their health care teams negatively affects quality of care, experience of care, and health outcomes, yet there is limited guidance on best practices for advancing equitable care for patients who have language barriers within obstetrics and gynecology. In this commentary, we present two cases of language-discordant care and a framework for addressing language as a critical lens for health inequities in obstetrics and gynecology, which includes a variety of clinical settings such as labor and delivery, perioperative care, outpatient clinics, and inpatient services, as well as sensitivity around reproductive health topics. The proposed framework explores drivers of language-related inequities at the clinician, health system, and societal level. We end with actionable recommendations for enhancing equitable care for patients experiencing language barriers. Because language and communication barriers undergird other structural drivers of inequities in reproductive health outcomes, we urge obstetrician-gynecologists to prioritize improving care for patients experiencing language barriers.