Perspectives of Black Patients on Racism Within Emergency Care.

Importance: Numerous Black individuals experience racism persistently throughout their lives, with repercussions extending into health care settings. The perspectives of Black individuals regarding emergency department (ED) care, racism, and patient-centered approaches for dismantling structural racism remain less explored. Objective: To qualitatively explore the perspectives and experiences of Black patients related to race, racism, and health care following a recent ED visit. Design, Setting, and Participants: In this qualitative study, the audio from semistructured interviews of Black patients discharged from an academic urban ED between August 2021 to April 2022 were recorded, transcribed, and analyzed using thematic analysis. Main Outcomes and Measures: The main outcomes encompassed the main themes from the analysis of the interviews with Black patients regarding their perspectives on race, racism, and clinical care. Results: A total of 25 Black patients (20 [80%] female; mean [SD] age, 44.6 [12.9] years) discharged from the ED were interviewed. Three broad domains were identified: (1) racism in health care; (2) ED clinical care; and (3) recommendations for improvement. Within these domains, the first 2 were grouped into specific themes. Within the first domain, racism in health care, 7 themes were identified using thematic analysis: (1) a history of medical racism; (2) dismissiveness; (3) patient expectations on encountering racism; (4) medical mistrust; (5) health literacy; (6) postencounter outcomes, and (7) discrimination beyond but associated with race. Within the second theme, ED clinical care, 5 themes were identified using the same thematic analysis method: (1) discharge plan; (2) patient experience; (3) waiting room perceptions; (4) medication treatment; and (5) pain management. The third domain, recommendations for improvement, incorporated patient-generated suggestions for enhancing the Black patient experience. Conclusions and Relevance: In this qualitative study, the fabric of clinical care delivery in the ED was intricately woven with Black patients' experiences of racism. Patients expressed a pervasive sense of mistrust, skepticism, and dismissiveness at the system level. Instances of racism were consistently highlighted by patients from their entry to the ED to discharge. These perspectives illuminate the pervasive nature of racism in clinical care, providing valuable insights for exploring patient-centered approaches to foster antiracist cultures in the ED and throughout the broader medical landscape.

Health Care Access and Use Among U.S. Children Exposed to Neighborhood Violence.

INTRODUCTION: Neighborhood violence is an adverse childhood experience which impacts millions of U.S. children and is associated with poor health outcomes across the life course. These effects may be mitigated by access to care. Yet, the ways in which exposure to neighborhood violence shapes children's health care access have been understudied. METHODS: This is a cross-sectional analysis of 16,083 children (weighted N=67,214,201) ages 1 to <18 years from the 2019 and 2021 National Health Interview Survey. Guardians were asked about preventive care access, unmet health needs, and health care utilization in the last year. Changes associated with exposure to neighborhood violence were estimated using marginal effects from multivariable logistic regression models adjusted for year, age, sex, race/ethnicity, parental education, family structure, rurality, income, insurance type, insurance discontinuity, and overall reported health. RESULTS: Of 16,083 sample children, 863 (weighted 5.3% [95% CI 4.8-5.7]) reported exposure to neighborhood violence, representing a weighted population of ∼3.5 million. In adjusted analyses, exposure to violence was associated with forgone prescriptions (adjusted difference 1.2 percentage-points (pp) [95%CI 0.1-2.3]; weighted national population impact 42,833 children), trouble paying medical bills (7.7pp [4.4-11.0]; 271,735), delayed medical (1.5pp [0.2-2.9]; 54,063) and mental health care (2.8pp [1.1-4.6]; 98,627), and increased urgent care (4.5pp [0.9-8.1]; 158,246) and emergency department utilization (6.4pp [3.1-9.8]; 227,373). CONCLUSIONS: In this nationally representative study, neighborhood violence exposure among children was associated with unmet health needs and increased acute care utilization. Evidence-based interventions to improve access to care and reduce economic precarity in communities impacted by violence are needed to mitigate downstream physical and mental health consequences.

Leveraging Implementation Science to Advance Environmental Justice Research and Achieve Health Equity through Neighborhood and Policy Interventions.

Environmental justice research is increasingly focused on community-engaged, participatory investigations that test interventions to improve health. Such research is primed for the use of implementation science-informed approaches to optimize the uptake and use of interventions proven to be effective. This review identifies synergies between implementation science and environmental justice with the goal of advancing both disciplines. Specifically, the article synthesizes the literature on neighborhood-, community-, and policy-level interventions in environmental health that address underlying structural determinants (e.g., structural racism) and social determinants of health. Opportunities to facilitate and scale the equitable implementation of evidence-based environmental health interventions are highlighted, using urban greening as an illustrative example. An environmental justice-focused version of the implementation science subway is provided, which highlights these principles: Remember and Reflect, Restore and Reclaim, and Reinvest. The review concludes with existing gaps and future directions to advance the science of implementation to promote environmental justice.

The role of neighborhood deprivation in the cervicovaginal microbiota.

BACKGROUND: Lactobacillus-deficient cervicovaginal microbiota is associated with spontaneous preterm birth and is more common among Black individuals. Persistent racial segregation in the United States has led to differential neighborhood exposures by race that can affect pregnancy outcomes. The extent to which neighborhood exposures may explain racial differences in the cervicovaginal microbiota is unknown. OBJECTIVE: This study aimed to determine whether neighborhood deprivation, defined as material community deprivation, is associated with a Lactobacillus-deficient cervicovaginal microbiota in a prospective cohort of pregnant individuals. Our hypothesis was that racial differences in neighborhood deprivation may explain the higher prevalence of Lactobacillus-deficient cervicovaginal microbiota in Black birthing people. STUDY DESIGN: This study analyzed data from Motherhood and Microbiome, a prospective pregnancy cohort enrolled from prenatal clinics in a single hospital system 2013-2016 in which a Lactobacillus-deficient cervicovaginal microbiota was previously shown to be associated with spontaneous preterm birth. This study geocoded addresses to obtain census tract neighborhood deprivation data from the Brokamp Nationwide Community Deprivation Index that uses weighted proportions of poverty, income, public assistance, lack of health insurance, and vacant housing. Generalized linear mixed models quantified associations of deprivation with the cervicovaginal microbiota accounting for geographic clustering by census tract and potential confounders. Because of different distributions of neighborhood deprivation and the cervicovaginal microbiota, race-stratified models were used. Mediation analyses quantified the extent to which deprivation may contribute to racial differences in the cervicovaginal microbiota. RESULTS: Higher neighborhood deprivation was associated with a Lactobacillus-deficient cervicovaginal microbiota. Per standard deviation increment of deprivation, participants had 28% higher adjusted odds (adjusted odds ratio, 1.28; 95% confidence interval, 1.04-1.58) of a Lactobacillus-deficient microbiota. Black participants had higher odds of a Lactobacillus-deficient microbiota than White participants (adjusted odds ratio, 4.00; 95% confidence interval, 2.05-8.26), and mediation analysis revealed that deprivation accounted for 22% (P=.046) of that disparity. CONCLUSION: Neighborhood deprivation was associated with Lactobacillus-deficient cervicovaginal microbiota and may partially explain Black-White disparities in the cervicovaginal microbiota. Mechanistic studies to explore how environmental exposures modify the cervicovaginal microbiota are warranted to identify novel opportunities for future interventional strategies to prevent preterm birth. As the findings demonstrate a potential biological effect from neighborhood conditions, policies that drive urban planning should be explored to improve pregnancy outcomes.

Neighborhood Deprivation and Racial Disparities in Early Pregnancy Impaired Glucose Tolerance.

OBJECTIVE: There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. STUDY DESIGN: This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks' gestation from 1 January 2017-31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7-6.4%) at <20 weeks' gestation. Addresses were geocoded and census tract neighborhood deprivation index (range 0-1, higher indicating more deprivation) was calculated. Mixed-effects logistic regression and causal mediation models adjusted for covariates were used. RESULTS: Of the 10,642 patients who met the inclusion criteria, 49% self-identified as Black, 49% were Medicaid insured, 32% were obese, and 11% had IGT. There were large racial disparities in IGT (16% vs. 3%) and obesity (45% vs. 16%) among Black vs. White patients, respectively (p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black-White disparity in obesity may be explained by neighborhood deprivation. CONCLUSION: Neighborhood deprivation may contribute to early pregnancy IGT and obesity-surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety.

Importance: Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety. Objective: To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care. Design, Setting, and Participants: In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022. Main Outcomes and Measures: Themes and subthemes of nursing perspectives on EHR behavioral flags were identified. Results: This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19-related strain and burnout). Conclusions and Relevance: In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

Emergency Physician Observations and Attitudes on Law Enforcement Activities in the Emergency Department.

INTRODUCTION: Law enforcement officers (LEO) interact with patients and clinicians in the emergency department (ED) for many reasons. There is no current consensus on what should comprise, or how to best enact, guidelines that ideally balance LEO activities in the service of public safety with patient health, autonomy, and privacy. The purpose of this study was to explore how a national sample of emergency physicians (EP) perceives activities of LEOs during the delivery of emergency medical care. METHODS: Members of the Emergency Medicine Practice Research Network (EMPRN) were recruited via an email-delivered, anonymous survey that elicited experiences, perceptions, and knowledge of policies that guide interactions with LEOs in the ED. The survey included multiple-choice items, which we analyzed descriptively, and open-ended questions, which we analyzed using qualitative content analysis. RESULTS: Of 765 EPs in the EMPRN, 141 (18.4%) completed the survey. Respondents represented diverse locations and years in practice. A total of 113 (82%) respondents were White, and 114 (81%) were male. Over a third reported LEO presence in the ED on a daily basis. A majority (62%) perceived LEO presence as helpful for clinicians and clinical practice. When asked about the factors deemed highly important in allowing LEOs to access patients during care, 75% reported patients' potential as a threat to public safety. A small minority of respondents (12%) considered the patients' consent or preference to interact with LEOs. While 86% of EPs felt that information-gathering by LEO was appropriate in the ED setting, only 13% were aware of policy to guide these decisions. Perceived barriers to implementation of policy in this area included: issues of enforcement; leadership; education; operational challenges; and potential negative consequences. CONCLUSION: Future research is warranted to explore how policies and practices that guide intersections between emergency medical care and law enforcement impact patients, clinicians, and the communities that health systems serve.

"The new normal has become a nonstop crisis": a qualitative study of burnout among Philadelphia's harm reduction and substance use disorder treatment workers during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic worsened the ongoing overdose crisis in the United States (US) and caused significant mental health strain and burnout among health care workers (HCW). Harm reduction, overdose prevention, and substance use disorder (SUD) workers may be especially impacted due to underfunding, resources shortages, and chaotic working environments. Existing research on HCW burnout primarily focuses on licensed HCWs in traditional environments and fails to account for the unique experiences of harm reduction workers, community organizers, and SUD treatment clinicians. METHODS: We conducted a qualitative secondary analysis descriptive study of 30 Philadelphia-based harm reduction workers, community organizers, and SUD treatment clinicians about their experiences working in their roles during the COVID-19 pandemic in July-August 2020. Our analysis was guided by Shanafelt and Noseworthy's model of key drivers of burnout and engagement. We aimed to assess the applicability of this model to the experiences of SUD and harm reduction workers in non-traditional settings. RESULTS: We deductively coded our data in alignment with Shanafelt and Noseworthy's key drivers of burnout and engagement: (1) workload and job demands, (2) meaning in work, (3) control and flexibility, (4) work-life integration, (5) organizational culture and values, (6) efficiency and resources and (7) social support and community at work. While Shanafelt and Noseworthy's model broadly encompassed the experiences of our participants, it did not fully account for their concerns about safety at work, lack of control over the work environment, and experiences of task-shifting. CONCLUSIONS: Burnout among healthcare providers is receiving increasing attention nationally. Much of this coverage and the existing research have focused on workers in traditional healthcare spaces and often do not consider the experiences of community-based SUD treatment, overdose prevention, and harm reduction providers. Our findings indicate a gap in existing frameworks for burnout and a need for models that encompass the full range of the harm reduction, overdose prevention, and SUD treatment workforce. As the US overdose crisis continues, it is vital that we address and mitigate experiences of burnout among harm reduction workers, community organizers, and SUD treatment clinicians to protect their wellbeing and to ensure the sustainability of their invaluable work.

Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department.

Importance: Behavioral flags in the electronic health record (EHR) are designed to alert clinicians of potentially unsafe or aggressive patients. These flags may introduce bias, and understanding how they are used is important to ensure equitable care. Objective: To investigate the incidence of behavioral flags and assess whether there were differences between Black and White patients and whether the flags were associated with differences in emergency department (ED) clinical care. Design, Setting, and Participants: This was a retrospective cohort study of EHR data of adult patients (aged ≥18 years) from 3 Philadelphia, Pennsylvania, EDs within a single health system between January 1, 2017, and December 31, 2019. Secondary analyses excluded patients with sickle cell disease and high ED care utilization. Data were analyzed from February 1 to April 4, 2022. Main Outcomes and Measures: The primary outcome of interest was the presence of an EHR behavioral flag. Secondary measures included variation of flags across sex, race, age, insurance status, triage status, ED clinical care metrics (eg, laboratory, medication, and radiology orders), ED disposition (discharge, admission, or observation), and length of key intervals during ED care. Results: Participating EDs had 195 601 eligible patients (110 890 [56.7%] female patients; 113 638 Black patients [58.1%]; 81 963 White patients [41.9%]; median [IQR] age, 42 [28-60] years), with 426 858 ED visits. Among these, 683 patients (0.3%) had a behavioral flag notification in the EHR (3.5 flags per 1000 patients), and it was present for 6851 ED visits (16 flagged visits per 1000 visits). Patient differences between those with a flag and those without included male sex (56.1% vs 43.3%), Black race (71.2% vs 56.7%), and insurance status, particularly Medicaid insurance (74.5% vs 36.3%). Flag use varied across sites. Black patients received flags at a rate of 4.0 per 1000 patients, and White patients received flags at a rate of 2.4 per 1000 patients (P < .001). Among patients with a flag, Black patients, compared with White patients, had longer waiting times to be placed in a room (median [IQR] time, 28.0 [10.5-89.4] minutes vs 18.2 [7.2-75.1] minutes; P < .001), longer waiting times to see a clinician (median [IQR] time, 42.1 [18.8-105.5] minutes vs 33.3 [15.3-84.5] minutes; P < .001), and shorter lengths of stay (median [IQR] time, 274 [135-471] minutes vs 305 [154-491] minutes; P = .01). Black patients with a flag underwent fewer laboratory (eg, 2449 Black patients with 0 orders [43.4%] vs 441 White patients with 0 orders [36.7%]; P < .001) and imaging (eg, 3541 Black patients with no imaging [62.7%] vs 675 White patients with no imaging [56.2%]; P < .001) tests compared with White patients with a flag. Conclusions and Relevance: This cohort study found significant differences in ED clinical care metrics, including that flagged patients had longer wait times and were less likely to undergo laboratory testing and imaging, which was amplified in Black patients.

Effect of Abandoned Housing Interventions on Gun Violence, Perceptions of Safety, and Substance Use in Black Neighborhoods: A Citywide Cluster Randomized Trial.

Importance: Structural racism has resulted in long-standing disinvestment and dilapidated environmental conditions in Black neighborhoods. Abandoned houses signal neglect and foster stress and fear for residents, weakening social ties and potentially contributing to poor health and safety. Objective: To determine whether abandoned house remediation reduces gun violence and substance-related outcomes and increases perceptions of safety and use of outdoor space. Design, Setting, and Participants: This cluster randomized trial was conducted from January 2017 to August 2020, with interventions occurring between August 2018 and March 2019. The study included abandoned houses across Philadelphia, Pennsylvania, and surveys completed by participants living nearby preintervention and postintervention. Data analysis was performed from March 2021 to September 2022. Interventions: The study consisted of 3 arms: (1) full remediation (installing working windows and doors, cleaning trash, weeding); (2) trash cleanup and weeding only; and (3) a no-intervention control. Main Outcomes and Measures: Difference-in-differences mixed-effects regression models were used to estimate the effect of the interventions on multiple primary outcomes: gun violence (weapons violations, gun assaults, and shootings), illegal substance trafficking and use, public drunkenness, and perceptions of safety and time outside for nearby residents. Results: A master list of 3265 abandoned houses was randomly sorted. From the top of this randomly sorted list, a total of 63 clusters containing 258 abandoned houses were formed and then randomly allocated to 3 study arms. Of the 301 participants interviewed during the preintervention period, 172 (57.1%) were interviewed during the postintervention period and were included in this analysis; participants were predominantly Black, and most were employed. Study neighborhoods were predominantly Black with high percentages of low-income households. Gun violence outcomes increased in all study arms, but increased the least in the full remediation arm. The full housing remediation arm, compared with the control condition, showed reduced weapons violations by -8.43% (95% CI, -14.68% to -1.19%), reduced gun assaults by -13.12% (95% CI, -21.32% to -3.01%), and reduced shootings by a nonsignificant -6.96% (95% CI, -15.32% to 3.03%). The trash cleanup arm was not associated with a significant differential change in any gun violence outcome. Instances of illegal substance trafficking and use and public drunkenness outcomes were not significantly affected by the housing remediation or trash cleanup treatment. Perceptions of neighborhood safety and time spent outside were unaffected by the intervention. The study arms did differ in a baseline characteristic and some preintervention trends, which raises questions regarding other potential nonmeasured differences between study arms that could have influenced estimates. No evidence of displacement of gun violence outcomes was found. Conclusions and Relevance: In this cluster randomized controlled trial among low-income, predominantly Black neighborhoods, inexpensive, straightforward abandoned housing remediation was directly linked to significant relative reductions in weapons violations and gun assaults, and suggestive reductions in shootings. Trial Registration: isrctn.org Identifier: ISRCTN14973997.

Assessing experiences of racism among Black and White patients in the emergency department.

Objective: The objective of this study was to investigate the differences in patient-reported experiences related to emergency department (ED) care using a post-discharge text messaging survey. Methods: This was a prospective cohort study of patients discharged from the ED using an automated text messaging platform to assess patient experience and impact of race on ED care. The study was conducted for 7 weeks between August 6 and September 24, 2021. Participants included adults (aged ≥18 years) discharged from 2 urban, academic EDs with an active mobile phone number in the electronic health record. The primary outcome of interest was patient-reported impact of race on overall rating of ED care. Secondary outcomes included overall satisfaction with care and perceived impact of race on components of care, including respect, communication, and quality of care. A 6-point Likert scale was used, and chi-square and Wilcoxon rank sum tests were used to analyze responses. Results: A total of 590 (14%) discharged patients consented, and 462 patients completed the entire survey; the mean age was 43 years (SD 17.3); 67% were women, and 60.0% were Black. Black patients reported a higher overall rating of ED care (median 5 [3, 5]; P = 0.013). Proportionately, when compared with White patients, more Black patients reported that race negatively impacted the rating of care (10.8% vs 1.4%; P = 0.002). More than a quarter of Black patients (27.4%) reported race highly impacting being treated with respect (P = 0.024), and 22.4% reported a high impact on quality of service (P = 0.003) when compared with White patients. Conclusion: Health systems lack methods that specifically identify patient experiences of racism. We demonstrate the feasibility of using text messaging to collect patient-reported experiences of racism. For a significant number of Black patients, race negatively impacted their care, including communication, quality, and respect.

Neighborhood segregation, tree cover and firearm violence in 6 U.S. cities, 2015-2020.

Neighborhood segregation by race and income is a structural determinant of firearm violence. Addressing green space deficits in segregated neighborhoods is a promising prevention strategy. This study assessed the potential for reducing firearm violence disparities by increasing access to tree cover. Units of analysis were census tracts in six U.S. cities (Baltimore, MD; Philadelphia, PA; Richmond, VA; Syracuse, NY; Washington, DC; Wilmington, DE). We measured segregation using the index of concentration at the extremes (ICE) for race-income. We calculated proportion tree cover based on 2013-2014 imagery. Outcomes were 2015-2020 fatal and non-fatal shootings from the Gun Violence Archive. We modeled firearm violence as a function of ICE, tree cover, and covariates representing the social and built environment. Next, we simulated possible effects of "tree equity" programs, i.e., raising tract-level tree cover to a specified baseline level. In our fully-adjusted model, higher privilege on the ICE measure (1 standard deviation, SD) was associated with a 42% reduction in shootings (incidence rate ratio (IRR) = 0.58, 95% CI [0.54 0.62], p < 0.001). A 1-SD increase in tree cover was associated with a 9% reduction (IRR = 0.91, 95% CI [0.86, 0.97], p < 0.01). Simulated achievement of 40% baseline tree cover was associated with reductions in firearm violence, with the largest reductions in highly-deprived neighborhoods. Advancing tree equity would not disrupt the fundamental causes of racial disparities in firearm violence exposure, but may have the potential to help mitigate those disparities.

Association Between Community-Level Violent Crime and Cardiovascular Mortality in Chicago: A Longitudinal Analysis.

Background Violent crime has recently increased in many major metropolitan cities in the United States. Prior studies suggest an association between neighborhood crime levels and cardiovascular disease, but many have been limited by cross-sectional designs. We investigated whether longitudinal changes in violent crime rates are associated with changes in cardiovascular mortality rates at the community level in one large US city-Chicago, IL. Methods and Results Chicago is composed of 77 community areas. Age-adjusted mortality rates by community area for cardiovascular disease, stroke, and coronary artery disease from 2000 to 2014, aggregated at 5-year intervals, were obtained from the Illinois Department of Public Health Division of Vital Records. Mean total and violent crime rates by community area were obtained from the City of Chicago Police Data Portal. Using a 2-way fixed effects estimator, we assessed the association between longitudinal changes in violent crime and cardiovascular mortality rates after accounting for changes in demographic and economic variables and secular time trends at the community area level from 2000 to 2014. Between 2000 and 2014, the median violent crime rate in Chicago decreased from 3620 per 100 000 (interquartile range [IQR], 2256, 7777) in the 2000 to 2004 period to 2390 (IQR 1507, 5745) in the 2010 to 2014 period (P=0.005 for trend). In the fixed effects model a 1% decrease in community area violent crime rate was associated with a 0.21% (95% CI, 0.09-0.33) decrease in cardiovascular mortality rates (P=<0.001) and a 0.19% (95% CI, 0.04-0.33) decrease in coronary artery disease mortality rates (P=0.01). There was no statistically significant association between change in violent crime and stroke mortality rates (-0.17% [95% CI, -0.42 to 0.08; P=0.18]). Conclusions From 2000 to 2014, a greater decrease in violent crime at the community area level was associated with a greater decrease in cardiovascular and coronary artery disease mortality rates in Chicago. These findings add to the growing evidence of the impact of the built environment on health and implicate violent crime exposure as a potential social determinant of cardiovascular health. Targeted investment in communities to decrease violent crime may improve community cardiovascular health.

Advancing health equity through integrated biology and population health research: A community-based sample cortisol feasibility and exploratory study.

Background: Community-based research inclusive of self-assessment and objective environmental metrics can be enhanced by the collection of biomarker data in unity toward assessing the health impacts of the totality of environmental stress driven by structural racism. Cortisol dynamic range (CDR), a measure of chronic stress burden, may underpin place-based connections to health, but a gap remains in elucidating community-based CDR methodology. Purpose: To 1) assess the feasibility of cortisol collection and CDR measurement in a community-based study with home-based, participant-directed specimen collection, and 2) explore the association between CDR and other individual and environmental measures in a sample of predominantly Black participants. Methods: In this cross-sectional, observational study in predominantly Black urban neighborhoods, participants (n = 73) completed health assessments and in-home, self-collected salivary cortisol. For feasibility, CDR (peak-nadir) was compared to cortisol awakening response (CAR) slope over time. Comparisons of CDR quartile by person and place variables were explored (ANOVA). Results: The cohort (77% Black, 39.7% <$15 k/year income, high perceived stress) completed 98.6% of cortisol collection timepoints. CDR was calculated in all participants without interruptions to sleep-wake cycle as seen with CAR collection. Participants in the lowest quartile of CDR were the oldest (p = 0.03) with lowest reported mental health (p = 0.048) with no associations seen for CAR. Conclusion: Participant-collected CDR is more feasible than cortisol measures dependent on slopes over time in a community-based, predominately Black cohort with exploratory findings supporting relevance to outcomes of interest to future work. Future community-based studies should integrate CDR with environment and psychosocial measures.

Medical Schools as Racialized Organizations: How Race-Neutral Structures Sustain Racial Inequality in Medical Education-a Narrative Review.

In 2021, The American Association of Medical Colleges released a framework addressing structural racism in academic medicine, following the significant, nationwide Movement for Black Lives. The first step of this framework is to "begin self-reflection and educating ourselves." Indeed, ample evidence shows that medical schools have a long history of racially exclusionary practices. Drawing on racialized organizations theory from the field of sociology, we compile and examine scholarship on the role of race and racism in medical training, focusing on disparities in educational and career outcomes, experiences along racial lines in medical training, and long-term implications. From the entrance into medical school through the residency application process, organizational factors such as reliance on standardized tests to predict future success, a hostile learning climate, and racially biased performance metrics negatively impact the careers of trainees of color, particularly those underrepresented in medicine (URiM). Indeed, in addition to structural biases associated with otherwise "objective" metrics, there are racial disparities across subjective outcomes such as the language used in medical trainees' performance evaluations, even when adjusting for grades and board exam scores. These disadvantages contribute to URIM trainees' lower odds of matching, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. Additionally, hostile racial climates and less diverse medical schools negatively influence White trainees' interest in practicing in underserved communities, disproportionally racial and ethnic minorities. Trainees' mental health suffers along the way, as do medical schools' recruitment, retention, diversity, and inclusion efforts. Evidence shows that seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, may reproduce and sustain racial inequality among medical trainees. Medical schools whose goals include training a more diverse physician workforce towards addressing racial health disparities require a new playbook.