A Disparity.

As a living being that was passed down the role of storytelling, I describe the conditions under which individuals find themselves. Science, and specifically public health research, affords me the opportunity to deploy my storytelling skills toward advocacy and intervention for communities that disproportionately bear the burden of poor health. Although neither role makes space for the emotional toll of this work. Neither allows me to rest long enough to move through the emotional mist of what it means to be perceived as a queer, Black, cisgender woman, and storytelling scientist in a stratified and hateful world where I am so much more. This poem pools from various worlds within me for each stanza. The poem seeks to reconcile for my whole self, and others who experience marginality, why our colleagues, countrypersons, and community members see it fit to perpetuate notions of human difference along racialized, socioeconomic, sexualized, gendered, able-bodied, and other stratified lines-to the detriment of our lives. How can my colleagues, countrypersons, and community members be willing to receive the privileges of a democratic society but discard the lives from which that society was built? How can my colleagues, countrypersons, and community members be willing to receive our science but discard our health? This poem brings together multidisciplinary discourse from the humanities and the social and biological sciences to state plainly what many others have academically. May this poem be paired with existing literature on the falsity of biologized race, reparations, and methodologies of reflexivity in science.To view the original version of this poem, see the Supplemental Material section of this article online.

Language Matters: Exploring Preferred Terms for Diverse Populations.

This article explores the significance of employing preferred terms and inclusive language in research practices concerning diverse populations. It highlights how inappropriate terminology can lead to labeling, stereotyping, and stigma, particularly for equity-denied groups. The study aimed to identify and analyze terminology preferences for diverse communities by major international organizations. Through a systematic environmental scan methodology, data were collected from 12 prominent organizations. The results indicate a concerted effort toward adopting inclusive language, with organizations favoring respectful and accurate terminology. For instance, terms like "people made vulnerable by systemic inequities" and "migrant workers" were preferred over outdated or stigmatizing alternatives. The discussion emphasizes the importance of identifying conflicting terms and trends in terminology preferences over time. We recommend prioritizing the use of preferred terms to promote respectful and accurate discourse, with a focus on person-centered language. Ultimately, the findings underscore the critical role of language in shaping perceptions and attitudes toward diverse communities, and advocate for continued efforts to promote inclusivity and equity in research, policy, and practice.

Acknowledging and Addressing Microaggressions: A Virtual Experiential Learning Approach for Faculty.

Introduction: Although the ACGME and other accrediting organizations are increasingly emphasizing the importance of clinical learning environments that value diversity, equity, and inclusion, faculty development surrounding behavioral skills that promote inclusivity in the learning environment still needs cultivation. We designed a virtual longitudinal faculty development curriculum focused on direct observation, feedback, and practice of behavioral skills to acknowledge and address microaggressions in the learning environment. Methods: We used Kern's six steps of curriculum development to create four voluntary virtual workshops offered twice throughout the academic year, with topics including: (1) recognizing and naming microaggressions, (2) apologizing when harm has been experienced, (3) setting expectations surrounding microaggressions, and (4) debriefing microaggressions. Participant learners included residency program directors, associate program directors, and other leaders across all medical and surgical departments from one institution. Results: Thirty-one faculty from 10 departments participated in this yearlong curriculum. Pre- and postworkshop surveys analyzed participants' self-assessments of confidence and comfort in applying learned skills. Participants were more confident in openly naming bias, delivering expectations surrounding microaggressions, and debriefing microaggressions with learners. Participants also reported greater comfort in apologizing to learners when harm has occurred in public, in person, and electronically. Discussion: To create an inclusive learning environment, faculty can increase their comfort and confidence with addressing bias and microaggressions through practice and feedback. Our curriculum demonstrates how experiential learning allows for continual practice to solidify a new skill.

Missed opportunities to provide sexually transmitted and blood-borne infections testing in British Columbia: An interpretive description of users' experiences of Get Checked Online's design and implementation.

Background: Digital testing services for sexually transmitted and blood-borne infections (STBBIs), such as GetCheckedOnline, experience significant user drop-offs. For example, 32% of GetCheckedOnline users needing testing at account creation do not test, constituting missed opportunities. We explored the influence of users' expectations and experiences of GetCheckedOnline's web design and implementation on missed opportunities. Methods: This interpretive description purposively sampled 14 GetCheckedOnline users who created accounts between April 2022 and February 2023, indicated needed testing at account creation but did not test. We conducted semi-structured interviews and cognitive walkthroughs of GetCheckedOnline on Zoom, exploring participants' expectations and experiences, including problems using the service. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analyses. Results: Three themes were identified: (a) transitioning between GetCheckedOnline and laboratory services is a major testing barrier; (b) users' appraisal of their health and social contexts is a determinant of testing through GetCheckedOnline; and (c) tailoring GetCheckedOnline's design and implementation to accommodate varying user needs can promote equitable testing. Health equity issues occurred along sociodemographic gradients as the GetCheckedOnline-laboratory transition was more onerous for older users. Users' appraisal of their testing needs which varied by age and gender, and their assessment of time, and travel requirements for testing in remote communities influenced testing. Learning about GetCheckedOnline from healthcare providers improved testing compared with learning about the service through Google search which raised trust concerns regarding GetCheckedOnline's authenticity. Suggested improvements to promote health equity include personalized education, mail-in testing options, and simpler seamless web experiences. Conclusions: To promote equitable access to digital STBBI testing services such as GetCheckedOnline, we can adapt web-design and implementation to suit user needs and contexts, ensuring simplicity and options for testing that reduce user burdens.

From trauma to resilience: advancing cultural responsiveness and equity in the Muskowekwan First Nation's healing journey.

Introduction: The Muskowekwan First Nation (MFN) in Saskatchewan, Canada, epitomizes the enduring strength and cultural preservation of the Saulteaux people. This community faces the lasting effects of colonial trauma, especially the violence, abuse, and adversity experienced by students at the Muskowequan Indian Residential School (MIRS). Decades of abuse by institutional leaders caused generational trauma, contributing to current mental health and well-being challenges. This study highlights the community's role in sharing experiences and shaping healing processes to develop the MFN Family Healing and Wellness Centre in response to urgent community concerns. It examines the integration of Justice, Diversity, Equity, and Inclusion (J-DEI) principles and cultural responsiveness in fostering community resilience and mental well-being. Methods: Adopting a community-based participatory research framework, this study employs a mixed-methods approach, including community engagement sessions and surveys. Collaborating closely with the MFN leadership, it draws upon the specialized expertise of Author2 and Author1, leaders in Indigenous health and research. The research uses qualitative and quantitative data collection, emphasizing the importance of community input and leadership in shaping the research process and outcomes. Results: Findings emphasize the community's commitment to spiritual and cultural practices as vital healing components. Amidst the heightened awareness of the lingering effects of the MIRS within the MFN community, these insights informed the development of the Centre, ensuring it incorporates the community's desires for culturally relevant healing practices. The grand opening of Phase I of the Centre in February 2023 emerged as a significant step forward, symbolizing a move towards holistic community health that honors resilience, holistic wellness, and cultural continuity. Discussion: This case study contributes to the literature on integrated, culturally responsive healthcare models that address the needs of Indigenous peoples and communities. The study provides insights to guide the Centre's future programs and services, ensuring they are culturally tailored and responsive to the community's needs. By illustrating the potential for traditional wisdom and contemporary health practices to foster well-being, the case study advocates for holistic approaches to healing in Indigenous settings, offering a replicable framework for similar initiatives globally.

"Sorry, no results found": evaluating LGBTQIA + inclusivity of U.S. cancer centers' websites.

PURPOSE: Cancer care for lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexuality and gender diverse (LGBTQIA +) individuals is marked by disparities stemming from a history of discrimination, stigma, and systemic inequities. For LGBTQIA + individuals seeking cancer care, cancer center websites may be a first point of contact with healthcare. Two complementary studies sought to evaluate the LGBTQIA + inclusivity of cancer centers' websites. METHODS: The authors conducted two studies in 2022-2023, reviewing the websites of National Cancer Institute (NCI)-designated cancer centers and Children's Oncology Group (COG)-designated health systems and cancer centers. Reviewers manually searched websites and coded several Yes/No criteria for LGBTQIA + inclusivity. RESULTS: Among the 65 NCI cancer centers' websites in 2023, 66% included a nondiscrimination statement, 71% mentioned LGBTQIA + health disparities, 65% included LGBTQIA + tailored resources, and 66% had articles about LGBTQIA + health. There was a trend of increased inclusivity across categories from 2022 to 2023. Among the 204 COG-designated health system websites in 2023, there were 60 pediatric care websites and 144 lifespan care websites. A total of 79.9% of COG health system websites referenced LGBTQIA + patients (80.0% of pediatric and 79.9% of lifespan sites), 16.7% of COG cancer center websites referenced LGBTQIA + patients in the context of cancer care (6.7% of pediatric and 20.8% of lifespan sites), and 82.4% yielded results when search terms were input (83.3% of pediatric and 81.9% of lifespan sites). CONCLUSIONS: Adult and pediatric cancer centers' websites have varying levels of LGBTQIA + inclusivity based on nondiscrimination statements, articles, and the availability of LGBTQIA + resources. While there have been some improvements in inclusivity on the NCI-designated cancer centers' websites between 2022 and 2023, there is a need for further improvement.

The Spanish pathway program: Introducing, recruiting, and retaining Spanish-speaking students to the pharmacy profession.

BACKGROUND AND PURPOSE: Although 19% of the US population is Hispanic or Latino, less than 5 % of pharmacists identify as Hispanic. To increase patients' access to Spanish-speaking pharmacists, we created a Spanish Pathway Program. This program is adaptable to other colleges or schools of pharmacy with high Hispanic or Latino populations or for addressing disparities in other underrepresented groups. EDUCATIONAL ACTIVITY AND SETTING: The program was designed with three objectives: 1) attracting Hispanic, Latino, and/or Spanish-speaking students to pharmacy careers, 2) recruiting and retaining Spanish-speaking pharmacy students to the program with leadership development, mentoring, education, and networking opportunities, and 3) preparing students to serve Hispanic and Latino communities through experiential rotations and health outreaches. Outcomes included student application and retention rates, graduate job placement, and clinical interventions made by program students on experiential rotations in Hispanic/Latino communities. FINDINGS: Over six years, the program has grown from two students on one campus to 20 students from two campuses. Program retention is 97% with three-fourths of graduates securing community pharmacy careers. Students report positive patient interactions because of their ability to communicate in Spanish. DISCUSSION: This program successfully increased the number of Spanish-speaking pharmacists by increasing the number of Spanish-speaking students in our pharmacy program and subsequent employment in practice. We refined the program by adding a medical Spanish certification course and student projects which aid the Hispanic and Latino community. SUMMARY: The Spanish Pathway Program established at Roseman University has had six years of success increasing the Spanish-speaking pharmacist workforce.

Effect of access to antenatal care on risk of preterm birth among migrant women in Italy: A population-based cohort study.

Objective: To evaluate the association between maternal migration status and preterm birth, and whether a better adherence to antenatal care during pregnancy mitigates the risk of preterm birth. Design: Population-based cohort. Setting: Administrative databases of the Lombardy region, Italy. Population: First singleton births of women aged 15-55 years at 22-42 gestational weeks, between 2016 and 2021. Methods: Assessed the risk of preterm birth (<37 weeks). Main outcome measures: A multivariable logistic regression mediation model calculated the mediation effect of adherence to antenatal care in the association between maternal migrant status and preterm birth and the residual effect not mediated by it. Analyses were adjusted for the socio-demographic and pregnant characteristics of the women. Results: Of 349,753 births in the cohort, Italian nationality accounted for 71 %; 28.4 % were documented migrants and 0.4 % undocumented migrants. Among them, 5.3 %, 6.4 %, and 9.3 % had a preterm birth, respectively. Using deliveries of Italian citizens as referent, migrants had a significantly increased risk of preterm birth (adjusted relative risk: 1.22, 95 % confidence interval: 1.18-1.27). Adherence to antenatal care mediated the 62 % of such risk. We have calculated that adherence to antenatal pathways set to the highest level for the whole population could lead to a 37 % reduction in preterm birth risk. Conclusion: Part of the excess of preterm birth among documented and undocumented migrants in Italy can be explained by a lack of adherence to the antenatal care path despite equal access to National Health care. The adherence of all pregnant women to antenatal care would reduce the risk of preterm birth by about one-third.

Climate change dynamics for global energy security and equity: Evidence from policy stringency drivers.

This study investigates the dynamic interplay between financial integration, political stability, infrastructure, and global integration in enhancing Energy Security (ES) and Energy Equity (EE) across 50 economies from 2006 to 2018. It addresses gaps in understanding how socio-economic, political, and technological factors collectively influence ES and EE during the global transition from fossil fuels to renewable energy sources. The research aims to reveal the complex relationships and potential trade-offs between energy sustainability, economic growth, and equitable energy distribution. Utilizing robust panel data methods including System GMM, Fixed Effects, and Random Effects, the study examines the impacts of various determinants on ES and EE. The dataset includes annual observations on global integration, financial integration, infrastructure quality, political stability, and other relevant metrics from diverse global sources. The findings reveal that increased financial integration significantly enhances ES by easing capital flow into energy infrastructure, which is crucial for stable energy supply chains. Political stability also positively affects ES, underscoring the importance of stable governance in sustaining energy policies. Conversely, rapid urban growth and inadequate social integration pose challenges to achieving EE, highlighting disparities in energy access worsened by urbanization. Technological advancements and digital connectivity appear as positive drivers for EE, enhancing the efficiency and distribution of energy resources. This study contributes to the literature by providing a detailed examination of how integration into global financial and political systems affects energy strategies at a national level. It offers valuable insights for policymakers on fostering environments conducive to sustainable energy development and fair energy access. The research underscores the importance of incorporating socio-economic and technological advancements in energy policy frameworks to achieve balanced growth and sustainability. Future research directions include exploring the causal relationships and long-term impacts of these factors on ES and EE, particularly in the context of evolving global energy policies and technological advancements.

The perception of gender and the approach taken towards female physicians.

AIM: The aim of this study is to evaluate gender perception among patients in the emergency department (ED) and to examine the effect of gender perception on patients' preference of physician's gender. METHODS: This was a cross-sectional survey study. The survey comprised three sections. The first section collected general information, while the second section inquired about patients' preferences for physicians' gender in the ED, in general examinations, and regarding "sensitive" medical issues. The third section of the survey, entitled the "Perception of Gender Scale," comprised a series of questions designed to assess the participants' perceptions of gender. The scale employed a Likert-type response format, with scores ranging from 25 to 125. Higher scores indicated a more egalitarian gender perception. RESULTS: The number of participants in the study was 431, with 194 males and 237 females. The median age of the participants was 38.5 years (interquartile range [IQR] 28-48). Over half of the participants had completed university education. The study population exhibited a Perception of the Gender Scale (PGS) score of 96 (IQR 78.5-109). With regard to the patient's preference for physicians' gender, in emergency settings (ES) and in general examinations (GE), over three-quarters of the participants indicated that they do not have a preference. However, for sensitive medical issues (SMI), the proportion of participants indicating no preference decreased to 45 %. Among those with the lowest quartile of PGS scores, the percentage of individuals who expressed no gender preference in ES, GE and SMI was 65 %, 60 %, 26 % and who expressed a preference for male physicians was 13 %, 19 %, 43 % respectively. In contrast, of those with the highest quartile of PGS scores, the percentages of those who had no gender preference were 86 %, 90 %, 68 %, while the percentages of those who preferred male physicians were 1.9 %, 1 %, and 4.8 %, respectively. CONCLUSION: In the context of emergency settings and general examinations, approximately three-quarters of the participants indicated no preference regarding the gender of the physician. However, in the case of sensitive medical issues, the proportion of participants with no gender preference was less than half. For patients with a gender preference for their physician, perception of gender is a significant predictor.

Clinician Perspectives on Palliative Care for Older Adults With Serious Mental Illnesses: A Multisite Qualitative Study.

OBJECTIVES: Approximately 5.5% of the population live with serious mental illnesses (SMI). Older adults with SMI experience a high burden of serious medical illnesses and disparities in advance care planning, symptom management, and caregiver support. The objectives of this study are to explore interdisciplinary clinician perspectives on the palliative care needs of older adults with SMI and serious medical illnesses. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study utilized thematic analysis of semi-structured interviews of interdisciplinary clinicians practicing palliative care, geriatrics, or geriatric/consultation-liaison psychiatry at four hospitals within an urban health system. MEASUREMENTS: Themes related to care of older adults with serious mental illness and serious medical illness with respect to clinician experiences, challenges in care, and opportunities to improve care. RESULTS: The authors interviewed 45 clinicians. Major themes identified were: (1) Current paradigms of palliative care do not meet the needs of patients with SMI; (2) Clinicians are motivated to care for this population but require more training and interdisciplinary practice; (3) There is a need for structural integration of psychiatric and palliative care services. CONCLUSIONS: The study underscores the inadequacy of current palliative care models in meeting the unique needs of older adults with SMI. Models of integrated psychiatric and serious illness care and enhanced training are needed to improve the delivery of palliative care. Integrated care models and workforce development at the interface of serious illness care and psychiatric have the potential to improve outcomes for this vulnerable population.

Virtual care pathways for people living with HIV: A mixed-methods systematic review.

BACKGROUND: The COVID-19 pandemic prompted an unprecedented surge in virtual services, necessitating a rapid shift to digital healthcare approaches. This review focuses on evaluating the evidence of virtual care (VC) in delivering HIV care, considering the complex nature of HIV and the need for tailored-approaches, especially for marginalized populations. METHODS: A mixed-methods systematic review was performed with searches on five databases, covering studies from January 1946 to May 2022. Inclusion criteria involved two-way virtual consultations between healthcare workers and people living with HIV (PLHIV), with detailed descriptions and outcomes. Qualitative and quantitative studies were included, and the risk of bias was assessed using the Newcastle-Ottawa score and Stenfors' framework. RESULTS: Among 4143 identified records, 26 studies met the criteria, with various models of care described. The majority of studies were observational, and videoconferencing was the primary mode of virtual consultation employed. Quantitative analysis revealed PLHIV generally accept VC, with high attendance rates (87%). Mean acceptability and satisfaction rates were 80% and 85%, respectively, while 87% achieved HIV viral suppression. The setting and models of VC implementation varied, with some introduced in response to COVID-19 while others were as part of trials. CONCLUSIONS: VC for PLHIV is deemed an acceptable and effective approach and is associated with good virological outcomes. Data on other health outcomes is lacking. The review underscores the importance of diverse models of care, patient choice and comprehensive training initiatives for both staff and patients. Establishing a 'gold standard' for VC models is crucial for ensuring appropriate and effective reviews of PLHIV in virtual settings.

Narrowing the Digital Divide: Framework for Creating Telehealth Equity Dashboards.

Telehealth presents both the potential to improve access to care and to widen the digital divide contributing to health care disparities and obliging health care systems to standardize approaches to measure and display telehealth disparities. Based on a literature review and the operational experience of clinicians, informaticists, and researchers in the Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT)-Clinical and Translational Science Awards (CTSA) Network, we outline a strategic framework for health systems to develop and optimally use a telehealth equity dashboard through a 3-phased approach of (1) defining data sources and key equity-related metrics of interest; (2) designing a dynamic and user-friendly dashboard; and (3) deploying the dashboard to maximize engagement among clinical staff, investigators, and administrators.

Health of refugees settled in Australia over time and generations: a transformative mixed methods study protocol.

BACKGROUND: Refugees resettled in Australia may experience significant physical, mental and emotional health issues on arrival and difficulty accessing mainstream healthcare that often demands specialised services. It is not known if and how refugee health needs and service use change over time and generations, how this compares with the broader Australian population and what level of resourcing is required to maintain specialised services. There is also a significant knowledge gap concerning the resources and skills of refugees that can be harnessed to sustain the health and well-being of individuals and communities. Such knowledge gaps impede the ability of the health system to deliver responsive, efficient, acceptable and cost-effective care and services and limit the engagement of refugees in the coproduction of these services. METHODS: This study will be the first to provide comprehensive, longitudinal, population-based evidence of refugee health, service use and the accumulated resources or assets related to positive health and well-being (compared with data on deficits, illness and death) across the lifespan and generations. This will enable a comprehensive understanding of the relationships among assets, health status, service gaps and behaviours. We will identify the assets contributing to increased capacities to protect and promote health. This evidence is essential for planning health prevention programmes.This project has three phases: (1) employ national linked datasets to examine the health and social outcomes of refugees in Australia; (2) engage with refugees in a participatory manner to map the social, economic, organisational, physical and cultural assets in their communities and deliver an integrated model of health; and (3) codesign a roadmap of agreed actions required to attain health and well-being in communities and indicators to assess outcomes. ETHICS AND DISSEMINATION: Ethics and procedures-phase I:Ethical approval for phase I was gained from the Australian Bureau of Statistics (ABS) for Person Level Integrated Data Asset microdata (unit record data) via the ABS DataLab and the NSW Population and Health Services Research Ethics Committee (2023ETH01728), which can provide a single review of multijurisdictional data linkage research projects under the National Mutual Acceptance Scheme. This will facilitate approval for the Victorian and ACT datasets. The ABS will be the integrating/linkage authority. The Centre for Health Record Linkage (CHeReL) and the Victorian Data Linkage Unit will prepare a data extract representing all data records from the dataset to provide to the ABS for linkage.Ethics and procedures-phases 2 and 3:Written consent will be obtained from all participants, as well as consent to publish. We have obtained ethical approval from the University of Technology Sydney Medical Research Ethics Committee; however, as we deepen our consultation with community members and receive input from expert stakeholders, we will likely seek amendments to hone the survey and World Café questions. We will also need to provide flexible offerings that may extend to individual interviews and online interactions. DISCUSSION: This innovative approach will empower refugees and put them at the centre of their health and decision-making.

Rethinking Our Approach to Accessibility in the Era of Rapidly Emerging Technologies.

Accessibility has always played catch-up to the detriment of people with disabilities - and this appears to be exacerbated by the rapid advancements in technology. A key question becomes, can we better predict where technology will be in 10 or 20 years and develop a plan to be better positioned to make these new technologies accessible when they make it to market? To attempt to address this question, a "Future of Interface Workshop" was convened in February 2023, chaired by Vinton Cerf and Gregg Vanderheiden that brought together leading researchers in artificial intelligence, brain-computer interfaces, computer vision, and VR/AR/XR, and disability to both a) identify barriers these new technologies might present and how to address them, and b) how these new technologies might be tapped to address current un- or under-addressed problems and populations. This paper provides an overview of the results of the workshop as well as the current version of the R&D Agenda work that was initiated at the conference. It will also present an alternate approach to accessibility that is being proposed based on the new emerging technologies.

Hostel support workers' experiences navigating healthcare alongside people experiencing homelessness: a qualitative study in the UK.

OBJECTIVES: This study aimed to explore how hostel support workers (HSWs) experience navigating healthcare alongside people experiencing homelessness (PEH). PEH experience poor health outcomes, increased mortality and face many barriers when accessing healthcare. HSWs have a dynamic and holistic role, working with PEH to navigate access to health and social care, whilst facilitating independence. HSWs have been described as important in addressing barriers to access and linking healthcare and PEH. However, HSWs' experiences navigating this role across sectors remains underexplored. DESIGN: In this qualitative study, semistructured interviews were conducted, and phenomenological thematic analysis was performed. SETTING: Interviews were conducted with participants from 13 hostels across four UK counties. PARTICIPANTS: 17 HSWs were interviewed, with experience in their role ranging from 3 months to over 10 years. RESULTS: Three themes were identified.HSWs feeling stigmatised by healthcare staff (HCS), including power inequalities between HSWs and HCS, and the impact of stigma against PEH in healthcare on HSWs.Working across sectors, including both collaborative and disconnected experiences.In-reach and its role in linking PEH and healthcare. This included the contrasting subthemes of in-reach as an effective link versus in-reach being an impractical and unsustainable solution. CONCLUSIONS: Cross-sector collaboration has been recognised as an effective way to increase healthcare access and improve outcomes for Inclusion Health Groups, including PEH. This has been further highlighted by the formation of Integrated Care Systems, which strive to bring sectors together to tackle inequalities in outcomes, experience and access. Collaborative relationships between sectors, that is, hostels and healthcare, are vital for increasing healthcare access for PEH. We explored the experiences of HSWs navigating healthcare access for this marginalised population. Recognising and understanding these experiences are the first steps in building collaborative cross-sector relationships to improve healthcare accessibility, experiences and outcomes for PEH.

Assessing Equitable Adherence to the Age-Friendly Health System's 4Ms Framework in an Academic Inpatient Setting.

While thousands of health systems have begun to implement the Age-Friendly Health System's 4Ms Framework to improve care for older patients, an important phase of work is achieving consistent adherence to 4Ms care processes. Identifying mechanisms that may lead to higher versus lower adherence serves to guide efforts to achieve consistent, equitable adherence. Drawing from prior literature, we identified three mechanisms that may influence 4Ms adherence. We then conducted a 3-year retrospective, observational study of inpatient encounters (n = 28 833) at UCSF Health System with patients aged 65+. We used least squares regression models to assess associations between hospital encounter-level measures of 4Ms adherence and proxy measures of patient and encounter characteristics for each hypothesized mechanism along with control variables. Encounter-level adherence to the 4Ms was 65.5% (SD = 14.3%). We found support for all three mechanisms. Negative implicit biases were associated with lower adherence for patients who were obese [0.79 percentage points (PP) lower; P < .001] or on Medicaid (0.64 PP lower; P = .002). Positive implicit biases were associated with higher adherence for the oldest old (aged 85+; 2.85 PP higher; P < .001) or with reduced mobility (2.01 PP higher; P < .001). Patients with comprehensive geriatrics care contact (ACE unit and a geriatrics consult) had 5.33 PP higher adherence (P < .001). While most effects were modest in magnitude, our results suggest that both positive and negative implicit biases, as perceived by the provider, may influence the level of 4Ms adherence. Contact with comprehensive geriatrics care appeared most influential. These insights can be leveraged to develop strategies to achieve equitable delivery of 4Ms care.

Unintended consequences - Risk for bias in competency-based assessment.

As nursing education transitions to competency-based education, careful attention to the assessment methodology must be considered. As nursing education contends with structural implicit bias and supports social justice, any transition to the education delivery model must consider the underserved and marginalized. Multilingual and marginalized students have long had inequitable experiences when taking standardized assessments influenced by the perspectives and values of the dominant culture. Resourced and under-resourced nurse educators must be empowered to access information to inform the competency-based assessment design. This perspective article aims to uncover the risk of bias in competency-based assessment when not properly implemented and to present strategies to reduce bias in competency-based assessment. Considerations for schools/colleges of nursing as they implement competency-based assessment are explored.

Inequities in Unexpected Cost-Sharing for Preventive Care in the United States.

INTRODUCTION: Unexpected out-of-pocket (OOP) costs for preventive care reduce future uptake. Because adherence to service guidelines differs by patient populations, understanding the role of patient demographics and social determinants of health (SDOH) in the incidence and size of unexpected cost-sharing is necessary to address these disparities. This study examined the associations between patient demographics and cost-sharing for common preventive services. METHODS: This cross-sectional study used a national sample of insurance claims for recommended preventive services provided to privately insured adult patients between 2017 and 2020. The relationships between patient demographics and OOP costs were adjusted for service type, insurance type, geographic location, and time trends using regression analysis. Analyses were conducted in 2024. RESULTS: The sample included 1,736,063 unique preventive care encounters of 1,078,010 individuals. 40.3% of preventive encounters resulted in OOP costs. Lower-educated patients had 9.4% (odds ratio [OR]: 1.094; 95% CI: 1.082 to 1.106) higher odds of incurring OOP costs than patients with college degrees. Low-income patients (annual household income of $49,999 or less) had 10.7% (OR: 0.893; 95% CI: 0.880 to 0.906) lower odds of incurring OOP costs than high-income patients. Conditional on incurring costs, lower educated patients paid $15.07 (95% CI: -$15.24 to -$14.91) less than higher educated patients, and low-income patients paid $11.76 (CI, $11.58 to $11.95) more than high-income patients. Significant differences across racial and ethnic groups were observed. CONCLUSIONS: The likelihood and size of OOP costs for preventive care varied considerably by patient demographics; this may contribute to inequitable access to high-value care.