How Hospitals Are Addressing The Effects Of Racism: A Mixed-Methods Study Of Hospital Equity Officers.

Hospital equity officers have become critical leaders in the effort to address the determinants of health care disparities, including structural racism. In this mixed-methods study, we surveyed a national sample of equity officers and interviewed a subset of respondents to provide additional perspective. About one-half of survey respondents reported at least some obstacles to achieving their health equity objectives, including racist beliefs among people working in their hospitals and health care systems, policies that perpetuate racism, and a lack of staff diversity. To address these challenges, some hospitals are collecting information about instances of racism, reviewing clinical algorithms for evidence of bias, or forming community partnerships. However, in interviews, equity officers pointed out that racism is a public health issue that cannot be adequately addressed solely within the health care system. Given the relative newness of most hospital equity officer positions, our research may be viewed as an early glimpse into the challenges and opportunities of this evolving work.

What matters to me: an equity lens on patient experience.

This commentary explores what matters to patients and their experience through an equity lens, with action points and recommendations given the current health care environment.

Patient characteristics associated with the successful transition to virtual care: Lessons learned from the first million patients.

INTRODUCTION: The increased use of telehealth to maintain ambulatory care during the COVID-19 pandemic had potential to exacerbate or diminish disparities in access to care. OBJECTIVE: The purpose of this study was to describe patient characteristics associated with successful transition from in-person to virtual care, and video vs audio-only participation. METHODS: This was a retrospective analysis of electronic health record data from all patients with ambulatory visits from 1 October 2019-30 September 2020 in a large integrated health system in the Northeast USA. The outcome of interest was receipt of virtual care, and video vs audio-only participation. We matched home addresses with census-tract level area social vulnerability index (SVI) and Internet access. Among ambulatory care patients, we used logistic regression to identify characteristics associated with virtual participation. Among virtual participants, we identified characteristics associated with video vs audio-only visits. RESULTS: Among 1,241,313 patients, 528,542 (42.6%) were virtual participants. Relative to in-person only, virtual participants were older, more often English-proficient and with activated patient portal. Characteristics associated with virtual participation included patients with: only behavioural health visits, COVID patients, highest quartile of visit frequency, and multiple visit types. Characteristics associated with video participation (relative to audio-only) included being younger and patients with: only behavioural health visits, highest quartile of visit frequency, non-Hispanic black race, limited English proficiency and inactivated portal account. DISCUSSION: In our regional healthcare system, the transition to virtual care during COVID was vital for continued access to care, but substantial inequity remained. Without audio-only visits, access to care would have been even more limited for our most vulnerable patients.

The impact of broadening COVID-19 testing eligibility on communities of color - A lesson for overcoming structural barriers to health care.

CDC guidelines for COVID-19 testing in March 2020 did not prioritize underserved communities. We present the effect that expanding COVID-19 testing had for residents of the predominantly Hispanic city of Chelsea, MA, which had the highest case rate in the state. Results were compared to another city with similar demographics, Lynn, MA, where testing eligibility remained unchanged. Institutional data were used to identify outpatient visits for influenza-like illness or COVID-19 exposure, COVID-19 tests, and hospitalizations for confirmed COVID-19 between 3/30/2020-4/28/2020. Multivariable logistic regressions were used to compare outcomes before and after the change in testing eligibility occurred on 4/13/2020. A total of 3,060 patients were included, 1,374 Chelsea residents and 1,686 Lynn residents. After guidelines changed, Chelsea residents were more likely to present as outpatients (adjusted odds ratio [AOR] 4.2, p < 0.001) and less likely to be hospitalized (AOR 0.2, p < 0.001). They were more likely to be tested (AOR 8.8, p < 0.001), but less likely to test positive (AOR 0.6, p = 0.05). Lynn residents were also more likely to be tested after 4/13/2020 (AOR 1.9, p < 0.001), but no significant differences in visit acuity or test positivity were observed. This study demonstrates how broadening testing eligibility for one highly affected, predominantly Hispanic community was associated with an increase in outpatient presentations and a concomitant decrease in test positivity and hospitalizations. These results highlight the impact of improved access to care on utilization of services among underserved communities, a lesson that is especially crucial as we continue to grapple with the COVID pandemic.

Crossing the Virtual Chasm: Practical Considerations for Rethinking Curriculum, Competency, and Culture in the Virtual Care Era.

Virtual care, introduced previously as a replacement for in-person visits, is now being integrated into clinical care delivery models to complement in-person visits. The COVID-19 pandemic sped up this process. The rapid uptake of virtual care at the start of the pandemic prevented educators from taking deliberate steps to design the foundational elements of the related learning environment, including workflow, competencies, and assessment methods. Educators must now pursue an informed and purposeful approach to design a curriculum and implement virtual care in the learning environment. Engaging learners in virtual care offers opportunities for novel ways to teach and assess their performance and to effectively integrate technology such that it is accessible and equitable. It also offers opportunities for learners to demonstrate professionalism in a virtual environment, to obtain a patient's history incorporating interpersonal and communication skills, to interact with multiple parties during a patient encounter (patient, caregiver, translator, telepresenter, faculty member), to enhance physical examination techniques via videoconferencing, and ideally to optimize demonstrations of empathy through "webside manner." Feedback and assessment, important features of training in any setting, must be timely, specific, and actionable in the new virtual care environment. Recognizing the importance of integrating virtual care into education, leaders from across the United States convened on September 10, 2020, for a symposium titled, "Crossing the Virtual Chasm: Rethinking Curriculum, Competency, and Culture in the Virtual Care Era." In this article, the authors share recommendations that came out of this symposium for the implementation of educational tools in the evolving virtual care environment. They present core competencies, assessment tools, precepting workflows, and technology to optimize the delivery of high-quality virtual care that is safe, timely, effective, efficient, equitable, and patient-centered.

Addressing virtual care disparities for patients with limited English proficiency.

During a surge of COVID-19 cases, the majority of care delivery at a large academic medical center moved to virtual care. Due to COVID-19-associated regulatory changes, virtual care is now delivered through telephone and videoconferencing platforms. Although virtual platforms allow patients to access care while socially distancing, patients with limited English proficiency (LEP) face structural barriers to these platforms, including lack of access to technology, need for medical interpreters, unfriendly patient portals, and increased privacy concerns. Strategies for increasing access to virtual platforms and technology for patients with LEP included offering patient education in multiple languages, reducing barriers to patient portal enrollment, and addressing the technology literacy gap through the use of tablets and bilingual interns. Strategies for addressing privacy concerns for patients with LEP included developing a low-literacy script and other actions that address patient concerns about Immigration and Customs Enforcement and mitigate perceived risk, as well as identifying a virtual platform that meets privacy regulations and does not require a patient to download an application to their phone or computer to join. Strategies for integrating medical interpreters into virtual visits included assessing existing virtual platforms for the ability to host a third party, changing the electronic health record software (Epic) interface, and convening directors of interpreter departments at each site to ensure comprehensive system rollout. Health care organizations that rely heavily on virtual visits to provide patient care will need to take all these challenges into consideration for patients with LEP.

The role of race, ethnicity, and language in care transitions.

OBJECTIVES: To identify areas where transition from hospital to community could be improved, with a special focus on racial, ethnic, and language differences. STUDY DESIGN: A cross-sectional survey administered by postal mail and bilingual telephone interviewers. METHODS: Patients were randomly selected within strata by race, ethnicity, and language proficiency. A total of 224 patients (response rate: 63.5%) who had recently experienced a hospital stay completed the survey. RESULTS: Overall, 1 in 4 patients were alone at discharge. More than half of patients with limited English proficiency reported lack of access to medical interpreters and translated materials. We noted significant differences by race, ethnicity, and language in technology access and in patient-reported worries in the posthospital period. Hispanic or Latino patients and patients with limited English proficiency were less likely to report access to a computer and less likely to access the Patient Gateway portal. Black or African American patients were also less likely to use the Patient Gateway portal. Asian patients were more likely to be worried about getting home health services. CONCLUSIONS: Our findings highlight the enhanced difficulties that diverse patients may experience when transitioning from hospital to community-based settings. When considering how to best address the complex needs of diverse populations, interventions must be sensitive to the presence or absence of others, potential digital divides, and medical interpretation.

Racial and Ethnic Disparities in Radiology: A Call to Action.

The US health care system is in the midst of incredible transformation. High-value, high-quality health care is the ultimate goal. Guided by the Institute of Medicine report "Crossing the Quality Chasm," the focus is to deliver care that is safe, efficient, effective, timely, patient centered, and equitable. Equity is the principle that quality of care should not vary based on patient characteristics, such as race or ethnicity. Even with the same insurance and socioeconomic status and when comorbidities, stage of presentation, and other confounders are controlled for, minorities often receive a lower quality of health care than their white counterparts. These racial and ethnic disparities in quality of care contribute to disparities in health outcomes and higher costs. Radiology is not exempt from this issue, as disparities related to imaging services have been reported in the literature. The root causes of racial and ethnic disparities in health care are complex and include the negative impact of the social determinants of health, limited access to care, as well as health system, provider, and patient factors. The field of radiology has a unique opportunity to engage in efforts to improve quality, address disparities, and achieve equity. A call to action is necessary, with a focus on addressing social determinants of health; creating culturally, linguistically, and health literacy-appropriate outreach and services; investing in cross-cultural education; and diversifying the radiology workforce. Ultimately, radiologists can provide equitable access to radiology care and promote person-centered care solutions that are tailored to the needs of diverse populations.

A patient and family data domain collection framework for identifying disparities in pediatrics: results from the pediatric health equity collaborative.

BACKGROUND: By 2020, the child population is projected to have more racial and ethnic minorities make up the majority of the populations and health care organizations will need to have a system in place that collects accurate and reliable demographic data in order to monitor disparities. The goals of this group were to establish sample practices, approaches and lessons learned with regard to race, ethnicity, language, and other demographic data collection in pediatric care setting. METHODS: A panel of 16 research and clinical professional experts working in 10 pediatric care delivery systems in the US and Canada convened twice in person for 3-day consensus development meetings and met multiple times via conference calls over a two year period. Current evidence on adult demographic data collection was systematically reviewed and unique aspects of data collection in the pediatric setting were outlined. Human centered design methods were utilized to facilitate theme development, facilitate constructive and innovative discussion, and generate consensus. RESULTS: Group consensus determined six final data collection domains: 1) caregivers, 2) race and ethnicity, 3) language, 4) sexual orientation and gender identity, 5) disability, and 6) social determinants of health. For each domain, the group defined the domain, established a rational for collection, identified the unique challenges for data collection in a pediatric setting, and developed sample practices which are based on the experience of the members as a starting point to allow for customization unique to each health care organization. Several unique challenges in the pediatric setting across all domains include: data collection on caregivers, determining an age at which it is appropriate to collect data from the patient, collecting and updating data at multiple points across the lifespan, the limits of the electronic health record, and determining the purpose of the data collection before implementation. CONCLUSIONS: There is no single approach that will work for all organizations when collecting race, ethnicity, language and other social determinants of health data. Each organization will need to tailor their data collection based on the population they serve, the financial resources available, and the capacity of the electronic health record.

Organizational Change Management For Health Equity: Perspectives From The Disparities Leadership Program.

Leaders of health care organizations need to be prepared to improve quality and achieve equity in today's health care environment characterized by a focus on achieving value and addressing disparities in a diverse population. To help address this need, the Disparities Solutions Center at Massachusetts General Hospital launched the Disparities Leadership Program in 2007. The leadership program is an ongoing, year-long, executive education initiative that trains leaders from hospitals, health plans, and health centers to improve quality and eliminate racial and ethnic disparities in health care. Feedback from participating organizations demonstrates that health care leaders seem to possess knowledge about what disparities are and about what should be done to eliminate them. Data collection, performance measurement, and multifaceted interventions remain the tools of the trade. However, the barriers to success are lack of leadership buy-in, organizational prioritization, energy, and execution, which can be addressed through organizational change management strategies.

Designing Patient-Centered Text Messaging Interventions for Increasing Physical Activity Among Participants With Type 2 Diabetes: Qualitative Results From the Text to Move Intervention.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a disease affecting approximately 29.1 million people in the United States, and an additional 86 million adults have prediabetes. Diabetes self-management education, a complex health intervention composed of 7 behaviors, is effective at improving self-care behaviors and glycemic control. Studies have employed text messages for education, reminders, and motivational messaging that can serve as "cues to action," aiming to improve glucose monitoring, self-care behaviors, appointment attendance, and medication adherence. OBJECTIVES: The Text to Move (TTM) study was a 6-month 2-parallel group randomized controlled trial of individuals with T2DM to increase physical activity, measured by a pedometer. The intervention arm received text messages twice daily for 6 months that were tailored to the participant's stage of behavior change as defined by the transtheoretical model of behavior change. METHODS: We assessed participants' attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audiorecorded, transcribed verbatim, coded, and analyzed using a grounded theory approach. RESULTS: The response rate was 67% (31/46 participants). The average age was 51.4 years and 61% (19/31 participants) were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of the participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their health care center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants. CONCLUSIONS: Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes. TRIAL REGISTRATION: Clinicaltrials.gov NCT01569243; http://clinicaltrials.gov/ct2/show/NCT01569243 (Archived by Webcite at http://www.webcitation.org/6pfH6yXag).

Eliminating disparities among Latinos with type 2 diabetes: Effective eHealth strategies.

Latinos are at increased risk for obesity and type 2 diabetes (T2D). Well-designed information technology (IT) interventions have been shown to be generally efficacious in improving diabetes self-management. However, there are very few published IT intervention studies focused on Latinos. With the documented close of the digital divide, Latinos stand to benefit from such advances. There are limited studies on how best to address the unique socio-cultural-linguistic characteristics that would optimize adoption, use and benefit among Latinos. Successful e-health programs involve frequent communication, bidirectionality including feedback, and multimodal delivery of the intervention. The use of community health workers (CHWs) has been shown consistently to improve T2D outcomes in Latinos. Incorporating CHWs into eHealth interventions is likely to address barriers with technology literacy and improve patient activation, satisfaction and adherence. Additionally, tailored interventions are more successful in improving patient activation. It is important to note that tailoring is more than linguistic translation; tailoring interventions to the Latino population will need to address educational, language, literacy and acculturation levels, along with unique illness beliefs and attitudes about T2D found among Latinos. Interventions will need to go beyond the lone participant and include shared decision making models that incorporate family members and friends.

Improving transgender health by building safe clinical environments that promote existing resilience: Results from a qualitative analysis of providers.

BACKGROUND: Transgender (TG) individuals experience discordance between their sex at birth and their gender identity. To better understand the health care needs and characteristics of TG youth that contribute to resilience, we conducted a qualitative study with clinical and non-clinical providers. METHODS: In-depth interviews were conducted of providers (n = 11) of TG youth (ages 13-21). Convenience and purposive sampling were used to recruit participants in the Boston area. All interviews were audio-recorded and transcribed verbatim. An interview guide of 14 open-ended questions was used to guide the discussion. A grounded theory approach was utilized to code and analyze the data, including double-coding to address issues of inter-rater reliability. RESULTS: Five primary themes emerged: 1) resilience of TG youth 2) lack of access to services that influence health, 3) the critical role of social support, 4) challenges in navigating the health care system, and 5) the need for trans-affirming competency training for providers and frontline staff. CONCLUSION: The findings of this study show that providers recognize multiple barriers and challenges in the care of TG youth. However, they also identify the resilience exhibited by many youth. We propose that providers can further enhance the resilience of TG youth and help them flourish by offering them necessary resources via the creation of safe and welcoming clinical environments.

Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field.

Since the 1999 Institute of Medicine (IOM) report To Err is Human, progress has been made in patient safety, but few efforts have focused on safety in patients with limited English proficiency (LEP). This article describes the development, content, and testing of two new evidence-based Agency for Healthcare Research and Quality (AHRQ) tools for LEP patient safety. In the content development phase, a comprehensive mixed-methods approach was used to identify common causes of errors for LEP patients, high-risk scenarios, and evidence-based strategies to address them. Based on our findings, Improving Patient Safety Systems for Limited English Proficient Patients: A Guide for Hospitals contains recommendations to improve detection and prevention of medical errors across diverse populations, and TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency Module trains staff to improve safety through team communication and incorporating interpreters in the care process. The Hospital Guide was validated with leaders in quality and safety at diverse hospitals, and the TeamSTEPPS LEP module was field-tested in varied settings within three hospitals. Both tools were found to be implementable, acceptable to their audiences, and conducive to learning. Further research on the impact of the combined use of the guide and module would shed light on their value as a multifaceted intervention.

Creating a safe, high-quality healthcare system for all: meeting the needs of limited English proficient populations; Comment on "Patient safety and healthcare quality: the case for language access".

The article by Cheri Wilson, "Patient Safety and Healthcare Quality: The Case for Language Access", highlights the challenges of providing Culturally and Linguistically Appropriate Services (CLAS) to patients with Limited English Proficiency (LEP). As the US pursues high-value, high-performance healthcare, our ability to meet the needs of our most vulnerable will determine whether we succeed or fail in the long run. With the implementation of the Affordable Care Act (ACA), this is more important than ever before, as it is estimated that the newly insured are more likely to be minority and less likely to speak English than their currently insured counterparts. As such, we must create a safe, high-quality healthcare system for all, especially in this time of incredible healthcare transformation and unprecedented diversity. Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals provides a blueprint for achieving this goal, and Massachusetts General Hospital (MGH) is taking action.

Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities.

BACKGROUND: Racial and ethnic disparities in health care have been consistently documented in the diagnosis, treatment, and outcomes of many common clinical conditions. There has been an acceleration of health information technology (HIT) implementation in the United States, with health care reform legislation including multiple provisions for collecting and using health information to improve and monitor quality and efficiency in health care. Despite an uneven and generally low level of implementation, research has demonstrated that HIT has the potential to improve quality of care and patient safety. If carefully designed and implemented, HIT also has the potential to eliminate disparities. HIT AND DISPARITIES: Several root causes for disparities are amenable to interventions using HIT, particularly innovations in electronic health records, as well as strategies for chronic disease management. Recommendations regardinghealth care system, provider, and patient factors can help health care organizations address disparities as they adopt, expand, and tailor their HIT systems. In terms of health care system factors, organizations should (1) automate and standardize the collection of race/ethnicity and language data, (2) prioritize the use of the data for identifying disparities and tailoring improvement efforts, (3) focus HIT efforts to address fragmented care delivery for racial/ethnic minorities and limited-English-proficiency patients, (4) develop focused computerized clinical decision support systems for clinical areas with significant disparities, and (5) include input from racial/ethnic minorities and those with limited English proficiency in developing patient HIT tools to address the digital divide. CONCLUSIONS: As investments are made in HIT, consideration must be given to the impact that these innovations have on the quality and cost of health care for all patients, including those who experience disparities.

Leveraging quality improvement to achieve equity in health care.

INEQUALITY IN QUALITY: Disparities in health care and quality for racial, ethnic, linguistic, and other disadvantaged groups are widespread and persistent. Health care organizations are engaged in efforts to improve quality in general but often make little attempt to address disparities. STANDARD VERSUS CULTURALLY COMPETENT QUALITY IMPROVEMENT (QI): Most QI interventions are broadly targeted to the general population-a "one-size-fits-all" approach. These standard QI efforts may preferentially improve quality for more advantaged patients and maintain or even worsen existing disparities. Culturally competent QI interventions place specific emphasis on addressing the unique needs of minority groups and the root causes of disparities. HOW QI CAN REDUCE DISPARITIES: QI interventions can reduce disparities in at least three ways: (1) In some cases, standard QI interventions can improve quality more for those with the lowest quality, but this is unreliable; (2) group-targeted QI interventions can reduce disparities by preferentially targeting disparity groups; and (3) culturally competent QI interventions, by tailoring care to cultural and linguistic barriers that cause disparities, can improve care for everyone but especially for disparity groups. GUIDELINES FOR CULTURALLY COMPETENT QI: A culturally competent approach to QI should (1) identify disparities and use disparities data to guide and monitor interventions, (2) address barriers unique to specific disparity groups, and (3) address barriers common to many disparity group. CONCLUSIONS: To achieve equity in health care, hospitals and other health care organizations should move toward culturally competent QI and disparities-targeted QI interventions to achieve equity in health care, a key pillar of quality.

A plan for action: key perspectives from the racial/ethnic disparities strategy forum.

CONTEXT: Racial and ethnic disparities in health care in the United States have been well documented, with research largely focusing on describing the problem rather than identifying the best practices or proven strategies to address it. METHODS: In 2006, the Disparities Solutions Center convened a one-and-a-half-day Strategy Forum composed of twenty experts from the fields of racial/ethnic disparities in health care, quality improvement, implementation research, and organizational excellence, with the goal of deciding on innovative action items and adoption strategies to address disparities. The forum used the Results Based Facilitation model, and several key recommendations emerged. FINDINGS: The forum's participants concluded that to identify and effectively address racial/ethnic disparities in health care, health care organizations should: (1) collect race and ethnicity data on patients or enrollees in a routine and standardized fashion; (2) implement tools to measure and monitor for disparities in care; (3) develop quality improvement strategies to address disparities; (4) secure the support of leadership; (5) use incentives to address disparities; and (6) create a message and communication strategy for these efforts. This article also discusses these recommendations in the context of both current efforts to address racial and ethnic disparities in health care and barriers to progress. CONCLUSIONS: The Strategy Forum's participants concluded that health care organizations needed a multifaceted plan of action to address racial and ethnic disparities in health care. Although the ideas offered are not necessarily new, the discussion of their practical development and implementation should make them more useful.