Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process.

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic.

Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.

Race, Ethnicity, and Ancestry in Clinical Pathways: A Framework for Evaluation.

Clinical algorithms, or "pathways," promote the delivery of medical care that is consistent and equitable. Race, ethnicity, and/or ancestry terms are sometimes included in these types of guidelines, but it is unclear if this is appropriate for clinical decision-making. At our institution, we developed and applied a structured framework to determine whether race, ethnicity, or ancestry terms identified in our clinical pathways library should be retained, modified, or removed. First, we reviewed all text and associated reference documents for 132 institutionally-developed clinical pathways and identified 8 pathways that included race, ethnicity, or ancestry terms. Five pathways had clear evidence or a change in institutional policy that supported removal of the term. Multispecialty teams conducted additional in-depth evaluation of the 3 remaining pathways (Acute Viral Illness, Hyperbilirubinemia, and Weight Management) by applying the framework. In total, based on these reviews, race, ethnicity, or ancestry terms were removed (n = 6) or modified (n = 2) in all 8 pathways. Application of the framework established several recommended practices, including: (1) define race, ethnicity, and ancestry rigorously; (2) assess the most likely mechanisms underlying epidemiologic associations; (3) consider whether inclusion of the term is likely to mitigate or exacerbate existing inequities; and (4) exercise caution when applying population-level data to individual patient encounters. This process and framework may be useful to other institutional programs and national organizations in evaluating the inclusion of race, ethnicity, and ancestry in clinical guidelines.

Racial and ethnic disparities in pediatric magnetic resonance imaging missed care opportunities.

BACKGROUND: Imaging missed care opportunities (MCOs), previously referred to as "no shows," impact timely patient diagnosis and treatment and can exacerbate health care disparities. Understanding factors associated with imaging MCOs could help advance pediatric health equity. OBJECTIVE: To assess racial/ethnic differences in pediatric MR imaging MCOs and whether health system and socioeconomic factors, represented by a geography-based Social Vulnerability Index (SVI), influence racial/ethnic differences. MATERIALS AND METHODS: We conducted a retrospective analysis of MR imaging MCOs in patients younger than 21 years at a pediatric academic medical center (2015-2019). MR imaging MCOs were defined as: scheduled but appointment not attended, canceled within 24 h, and canceled but not rescheduled. Mixed effects multivariable logistic regression assessed the association between MCOs and race/ethnicity and community-level social factors, represented by the SVI. RESULTS: Of 68,809 scheduled MRIs, 6,159 (9.0%) were MCOs. A higher proportion of MCOs were among Black/African-American and Hispanic/Latino children. Multivariable analysis demonstrated increased odds of MCOs among Black/African-American (adjusted odds ratio [aOR] 1.9, 95% confidence interval [CI] 1.7-2.3) and Hispanic/Latino (aOR 1.5, 95% CI 1.3-1.7) children compared to White children. The addition of SVI >90th percentile to the adjusted model had no effect on adjusted OR for Black/African-American (aOR 1.9, 95% CI 1.7-2.2) or Hispanic/Latino (aOR 1.5, 95% CI 1.3-1.6) children. Living in a community with SVI >90th percentile was independently associated with MCOs. CONCLUSION: Black/African-American and Hispanic/Latino children were almost twice as likely to experience MCOs, even when controlling for factors associated with MCOs. Independent of race/ethnicity, higher SVI was significantly associated with MCOs. Our study supports that pediatric health care providers must continue to identify systemic barriers to health care access for Black/African-American and Hispanic/Latino children and those from socially vulnerable areas.

Housing Quality and Mental Health: the Association between Pest Infestation and Depressive Symptoms among Public Housing Residents.

Housing quality, which includes structural and environmental risks, has been associated with multiple physical health outcomes including injury and asthma. Cockroach and mouse infestations can be prime manifestations of diminished housing quality. While the respiratory health effects of pest infestation are well documented, little is known about the association between infestation and mental health outcomes. To address this gap in knowledge and given the potential to intervene to reduce pest infestation, we assessed the association between household pest infestation and symptoms of depression among public housing residents. We conducted a cross-sectional study in 16 Boston Housing Authority (BHA) developments from 2012 to 2014 in Boston, Massachusetts. Household units were randomly selected and one adult (n = 461) from each unit was surveyed about depressive symptoms using the Center for Epidemiologic Study-Depression (CES-D) Scale, and about pest infestation and management practices. In addition, a home inspection for pests was performed. General linear models were used to model the association between pest infestation and high depressive symptoms. After adjusting for important covariates, individuals who lived in homes with current cockroach infestation had almost three times the odds of experiencing high depressive symptoms (adjusted OR = 2.9, 95% CI 1.9-4.4) than those without infestation. Dual infestation (cockroach and mouse) was associated with over five times the odds (adjusted odds = 5.1, 95% CI 3.0-8.5) of experiencing high depressive symptoms. Using a robust measure of cockroach and mouse infestation, and a validated depression screener, we identified associations between current infestation and depressive symptoms. Although the temporal directionality of this association remains uncertain, these findings suggest that the health impact of poor housing conditions extend beyond physical health to include mental health. The study adds important information to the growing body of evidence that housing contributes to population health and improvements in population health may not be possible without addressing deficiencies in the housing infrastructure.

Subsidized Housing and Adult Asthma in Boston, 2010-2015.

OBJECTIVES: To examine whether subsidized housing, specifically public housing and rental assistance, is associated with asthma in the Boston, Massachusetts, adult population. METHODS: We analyzed a pooled cross-sectional sample of 9554 adults taking part in 3 Boston Behavioral Risk Factor Surveillance System surveys from 2010 to 2015. We estimated odds ratios for current asthma in association with housing status (public housing development [PHD] resident, rental assistance [RA] renter, non-RA renter, nonrenter nonowner, homeowner as reference) in logistic regression analyses adjusting for year, age, sex, race/ethnicity, education, and income. RESULTS: The odds of current asthma were 2.02 (95% confidence interval [CI] = 1.35, 3.03) and 2.34 (95% CI = 1.60, 3.44) times higher among PHD residents and RA renters, respectively, than among homeowners. We observed smoking-related effect modification (interaction P = .04); elevated associations for PHD residents and RA renters remained statistically significant (P < .05) only among ever smokers. Associations for PHD residents and RA renters remained consistent in magnitude in comparison with non-RA renters who were eligible for subsidized housing according to income. CONCLUSIONS: Public housing and rental assistance were strongly associated with asthma in this large cross-sectional sample of adult Boston residents.

No-cost gym visits are associated with lower weight and blood pressure among non-Latino black and Latino participants with a diagnosis of hypertension in a multi-site demonstration project.

Well documented, persistent racial/ethnic health disparities in obesity and hypertension in the US demonstrate the continued need for interventions that focus on people of color who may be at higher risk. We evaluated a demonstration project funded by the CDC's Racial/Ethnic Approaches to Community Health (REACH) program at four federally qualified health centers (FQHC) and YMCA fitness and wellness centers in Boston. No-cost YMCA memberships were offered from June 2014 to June 2015 to non-Latino black and Latino adults with a diagnosis of hypertension. YMCA visit data were merged with health data for 224 participants (n = 1265 health center visits). We assessed associations between gym visit frequency and weight, body mass index (BMI), systolic blood pressure (SBP), and diastolic blood pressure (DBP) using longitudinal time-varying linear fixed-effects models. The total number of gym visits over the entire program duration was 5.5, while the conditional total number of visits (after the first gym visit has been made) was 17.3. Having visited the gym at least 10 times before an FQHC exam was, on average, associated with lower weight (1.19 kg, p = 0.01), lower BMI (0.43 kg/m2, p = 0.01) and reductions in SBP (-3.20 mm Hg, p = 0.01) and DBP (-2.06 mm Hg p = 0.01). Having visited the gym an average of 1.4 times per month (study average) was associated with reductions in weight, BMI, and DBP. No-cost gym visits were associated with improved weight and blood pressure in hypertensive non-Latino black and Latino adults in this program. Additional evaluation is necessary to assess the sustainability of these effects.

Referral Strategies to a Tobacco Quitline and Racial and/or Ethnic Differences in Participation.

BACKGROUND: Tobacco use inflicts a disproportionate burden of disease on people of color. We evaluated the reach among African American and Hispanic smokers in Boston of 2 referral strategies to the Massachusetts quitline: (1) a provider-referred strategy based in pediatric and dental clinics and (2) a targeted media campaign to promote self-referral to the quitline. METHODS: Selected demographic characteristics of Boston quitline participants during the study period (2010-2012) were compared between strategies. Self-referred smoker characteristics were also compared in the years before and after the media campaign. Finally, the characteristics of quitline participants were compared with smokers in the 2010 Boston Behavioral Risk Factor Surveillance Survey. RESULTS: During the study period, 4066 smokers received cessation services from the quitline; 3722 (91.5%) were self-referred, and 344 (8.5%) were referred by pediatric and dental providers. The proportion of black (31.6%) and Hispanic (20.3%) participants referred by providers was higher than among self-referred participants (18.3% and 7.8%, respectively; P <.001). Overall, provider-referred participants were less likely to be white (17.9%) than to be people of color. Self-referred smokers were more likely to be white (68.0%) than the estimated population of Boston smokers overall (62.9%; P <.001). CONCLUSIONS: The large-scale media campaign, which promoted self-referral, was associated with higher quitline participation overall, but the provider-referred strategy based in community health centers yielded participation from a greater proportion of smokers of color. The 2 strategies reached different subpopulations of smokers, and their combined reach enhanced access to cessation services among smokers from different racial and ethnic backgrounds.

Comparison of Methods for Estimating Prevalence of Chronic Diseases and Health Behaviors for Small Geographic Areas: Boston Validation Study, 2013.

INTRODUCTION: Local health authorities need small-area estimates for prevalence of chronic diseases and health behaviors for multiple purposes. We generated city-level and census-tract-level prevalence estimates of 27 measures for the 500 largest US cities. METHODS: To validate the methodology, we constructed multilevel logistic regressions to predict 10 selected health indicators among adults aged 18 years or older by using 2013 Behavioral Risk Factor Surveillance System (BRFSS) data; we applied their predicted probabilities to census population data to generate city-level, neighborhood-level, and zip-code-level estimates for the city of Boston, Massachusetts. RESULTS: By comparing the predicted estimates with their corresponding direct estimates from a locally administered survey (Boston BRFSS 2010 and 2013), we found that our model-based estimates for most of the selected health indicators at the city level were close to the direct estimates from the local survey. We also found strong correlation between the model-based estimates and direct survey estimates at neighborhood and zip code levels for most indicators. CONCLUSION: Findings suggest that our model-based estimates are reliable and valid at the city level for certain health outcomes. Local health authorities can use the neighborhood-level estimates if high quality local health survey data are not otherwise available.

Measures of Local Segregation for Monitoring Health Inequities by Local Health Departments.

OBJECTIVES: To assess the use of local measures of segregation for monitoring health inequities by local health departments. METHODS: We analyzed preterm birth and premature mortality (death before the age of 65 years) rates for Boston, Massachusetts, for 2010 to 2012, using the Index of Concentration at the Extremes (ICE) and the poverty rate at both the census tract and neighborhood level. RESULTS: For premature mortality at the census tract level, the rate ratios comparing the worst-off and best-off terciles were 1.58 (95% confidence interval [CI] = 1.36, 1.83) for the ICE for income, 1.66 (95% CI = 1.43, 1.93) for the ICE for race/ethnicity, and 1.63 (95% CI = 1.40, 1.90) for the ICE combining income and race/ethnicity, as compared with 1.47 (95% CI = 1.27, 1.71) for the poverty measure. Results for the ICE and poverty measures were more similar for preterm births than for premature mortality. CONCLUSIONS: The ICE, a measure of social spatial polarization, may be useful for analyzing health inequities at the local level. Public Health Implications. Local health departments in US cities can meaningfully use the ICE to monitor health inequities associated with racialized economic segregation.

Comparison of indoor air quality in smoke-permitted and smoke-free multiunit housing: findings from the Boston Housing Authority.

INTRODUCTION: Secondhand smoke remains a health concern for individuals living in multiunit housing, where smoke has been shown to easily transfer between units. Building-wide smoke-free policies are a logical step for minimizing smoke exposure in these settings. This evaluation sought to determine whether buildings with smoke-free policies have less secondhand smoke than similar buildings without such policies. Furthermore, this study assessed potential secondhand smoke transfer between apartments with and without resident smokers. METHODS: Fine particulate matter (PM2.5), airborne nicotine, and self-reported smoking activity were recorded in 15 households with resident smokers and 17 households where no one smoked in 5 Boston Housing Authority developments. Of these, 4 apartment pairs were adjacent apartments with and without resident smokers. Halls between apartments and outdoor air were also monitored to capture potential smoke transfer and to provide background PM2.5 concentrations. RESULTS: Households within buildings with smoke-free policies showed lower PM2.5 concentrations compared to buildings without these policies (median: 4.8 vs 8.1 µg/m(3)). Although the greatest difference in PM2.5 between smoking-permitted and smoke-free buildings was observed in households with resident smokers (14.3 vs 7.0 µg/m(3)), households without resident smokers also showed a significant difference (5.1 vs 4.0 µg/m(3)). Secondhand smoke transfer to smoke-free apartments was demonstrable with directly adjacent households. CONCLUSION: This evaluation documented instances of secondhand smoke transfer between households as well as lower PM2.5 measurements in buildings with smoke-free policies. Building-wide smoke-free policies can limit secondhand smoke exposure for everyone living in multiunit housing.

Measuring and monitoring progress toward health equity: local challenges for public health.

To address health disparities, local health departments need high-resolution data on subpopulations and geographic regions, but the quality and availability of these data are often suboptimal. The Boston Public Health Commission and the Los Angeles County Department of Public Health faced challenges in acquiring and using community-level data essential for the design and implementation of programs that can improve the health of those who have social or economic disadvantages. To overcome these challenges, both agencies used practical and innovative strategies for data management and analysis, including augmentation of existing population surveys, the use of combined data sets, and the generation of small-area estimates. These and other strategies show how community-level health data can be analyzed, expanded, and integrated into existing public health surveillance and program infrastructure to inform jurisdictional planning and tailoring of interventions aimed at achieving optimal health for all members of a community.

Impact of maternal HIV coinfection on the vertical transmission of hepatitis C virus: a meta-analysis.

BACKGROUND: Observational studies suggest that maternal human immunodeficiency virus (HIV)-hepatitis C virus (HCV) coinfection is associated with increased odds of vertical HCV transmission. We performed a meta-analysis to summarize current evidence. METHODS: We systematically searched for relevant articles published during the period from January 1992 through July 2006 and independently abstracted articles that met our inclusion criteria. Under a random effects model, we calculated the pooled odds ratio for vertical HCV transmission according to maternal HIV-HCV coinfection status and performed sensitivity analyses. RESULTS: Ten articles met our inclusion criteria. Study quality varied widely, and study estimates displayed high statistical heterogeneity. Restriction of the analysis to studies that included >50 HIV-HCV-coinfected women provided our most reliable estimate: maternal HIV-HCV coinfection increases the odds of vertical HCV transmission by approximately 90% (odds ratio, 1.9; 95% confidence interval, 1.36-2.67), compared with maternal HCV infection alone. When we restricted analyses to HIV-infected mothers with HCV viremia, the odds of vertical HCV transmission were 2.82-fold (95% confidence interval, 1.17-fold to 6.81-fold) greater than the odds for HIV-infected mothers without HCV viremia. CONCLUSIONS: HIV-HCV-coinfected women have significantly higher odds of transmitting HCV to their infants than do women who are infected with HCV alone.

HIV immunosuppression and antimalarial efficacy: sulfadoxine-pyrimethamine for the treatment of uncomplicated malaria in HIV-infected adults in Siaya, Kenya.

BACKGROUND: The altered immune response of persons with human immunodeficiency virus (HIV) infection could result in increased rates of antimalarial treatment failure. We investigated the influence of HIV infection on the response to sulfadoxine-pyrimethamine treatment. METHODS: Febrile adults with Plasmodium falciparum parasitemia were treated with sulfadoxine-pyrimethamine and were monitored for 28 days. HIV status and CD4 cell count were determined at study enrollment. RESULTS: Of the adults enrolled in the study, 508 attended all follow-up visits, including 130 HIV-uninfected adults, 256 HIV-infected adults with a high CD4 cell count (> or =200 cells/ micro L), and 122 HIV-infected adults with a low CD4 cell count (<200 cells/ micro L). The hazard of treatment failure at day 28 of follow-up was significantly higher for HIV-infected adults with a low CD4 cell count (20.5%) than for HIV-uninfected adults (7.7%). Anemia (hemoglobin level, <110 g/L) modified the effect of HIV status on treatment failure. When we controlled for fever and parasite density, the hazard of treatment failure for HIV-infected adults with a low CD4 cell count and anemia was 3.4 times higher than that for HIV-uninfected adults (adjusted hazard ratio, 3.38; 95% confidence interval, 1.56-7.34). CONCLUSIONS: HIV-infected persons with a low CD4 cell count and anemia have an increased risk of antimalarial treatment failure. The response to malaria treatment in HIV-infected persons must be carefully monitored. Proven measures for the control and prevention of malaria must be incorporated into the basic package of services provided by HIV/acquired immunodeficiency syndrome care and treatment programs in malarious areas.