County characteristics associated with refusing breast cancer surgery: Evidence from the Surveillance, Epidemiology, and End Results program.

BACKGROUND: Individuals' communities impact cancer disparities and are intimately related to social determinants of health. Studies show that personal factors affect treatment refusals for a potentially curable cancer, but few studies have investigated whether community-based characteristics affect the receipt of surgery. METHODS: We used Surveillance Epidemiology and End Results Program registries from 2010 to 2015 to examine differences in rates of surgery refusal among non-Hispanic White, non-Hispanic Black, and Hispanic women diagnosed with nonmetastatic breast cancer. The community factor measures were based on county-level factors. Sociodemographic and community differences were analyzed using Pearson's χ2 tests and analysis of variance. Multivariate logistic regression of predictors of surgery refusal and the Cox proportional hazard model of disease-specific mortality were performed. RESULTS: Surgery refusers among non-Hispanic Black and Hispanic all races lived in counties with lower rates of educational attainment, median family and household income, and higher rates of poverty, unemployment, foreign-born, language isolation, urban population, and women more than 40 years old having mammography in last 2 years. Multivariate analysis shows surgery refusal rates increased in counties having a high percentage of urban population and declined in counties with an increased percentage of less than high school level education, unemployment, and median household income. Breast cancer-specific mortality increased significantly with surgery refusal. CONCLUSION: Residence in counties with the lowest socioeconomic status and disproportionately populated by racial and ethnic minorities is associated with surgery refusal. Given the high mortality associated with refusing surgery, culturally sensitive education on the benefits of care may be appropriate.

Evaluating Decision-Making Capacity: When a False Belief about Ventilators Is the Reason for Refusal of Life-Sustaining Treatment.

In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum's criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients' preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs.In this article, we discuss the case of Michael Johnson, an African-American man who sought treatment for respiratory distress due to COVID-19, but who was adamant that he did not want to be intubated due to his belief that ventilators directly cause death. This case prompted reflection about the ways in which a false belief can create uncertainty and complexity for clinicians who are responsible for evaluating decision-making capacity (DMC). In our analysis, we consider the extent to which Mr. Johnson demonstrated capacity according to each of Appelbaum's criteria.1 Although it was fairly clear that Mr. Johnson lacked DMC on the basis of both understanding and appreciation, we found ourselves reflecting upon the false belief that seemed to motivate his refusal. This led us to further consider the ways in which our current social and political environment can complicate evaluations of patients' preferences and reasons for declining life-sustaining interventions. In particular, we consider the impact of the role of misinformation and systemic racism in preparing the grounds for false beliefs.

A Retrospective Investigation of Neuraxial Anesthesia Rates for Elective Cesarean Delivery Before and During the SARS-CoV-2 Pandemic.

BACKGROUND: Our hospital used to perform cesarean delivery under general anesthesia rather than neuraxial anesthesia, mostly because of patient refusal of members of the conservative Bedouin society. According to recommendations implemented by the Israeli Obstetric Anesthesia Society, which were implemented due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic, we increased the rate of neuraxial anesthesia among deliveries. OBJECTIVES: To compare the rates of neuraxial anesthesia in our cesarean population before and during SARS-CoV-2 pandemic. METHODS: We included consecutive women undergoing an elective cesarean delivery from two time periods: pre-SARS-CoV-2 pandemic (15 February 2019 to 14 April 2019) and during the SARS-CoV-2 pandemic (15 February 2020 to 15 April 2020). We collected demographic data, details about cesarean delivery, and anesthesia complications. RESULTS: We included 413 parturients undergoing consecutive elective cesarean delivery identified during the study periods: 205 before the SARS-CoV-2 pandemic and 208 during SARS-CoV-2 pandemic. We found a statistically significant difference in neuraxial anesthesia rates between the groups: before the pandemic (92/205, 44.8%) and during (165/208, 79.3%; P < 0.0001). CONCLUSIONS: We demonstrated that patient and provider education about neuraxial anesthesia can increase its utilization. The addition of a trained obstetric anesthesiologist to the team may have facilitated this transition.

Against settler colonial iatrogenesis: Inuit resistance to treatment in Indian Hospitals in Canada.

Canada's program to examine, transfer and treat Indigenous and Inuit peoples with tuberculosis in Indian Hospitals (ca. 1936 and 1969) has generally been framed by official narratives of population health, benevolence, and care. However, letters written by Inuit patients in Indian hospitals and their kin, and which were addressed to government officials and translated by government employees, challenge this assumption. By focusing on the harmful effects of the segregation and long-term detainment of Inuit peoples away from their communities, the letters theorize TB treatment as multiply harmful and iatrogenic. The letters also showcase how Inuit peoples resisted Indian Hospital treatment and articulated the need for care and treatment to occur within a network of intimate relations, rather than in distant sanatoriums.

A review of the use of biological mesh products in modern UK surgical practice: a religious and cultural perspective.

INTRODUCTION: The UK is an increasingly multicultural society. This change coincides with an increasing use of animal products in medicine and surgery and a change in the UK law of consent. The refusal of Jehovah's Witnesses to accept blood products is well known, but the use of animal products in surgery is a neglected topic. As society becomes more diverse and medicine becomes ever more advanced, there is increasing potential for a mismatch between what is medically possible and what is acceptable from a religious perspective. METHODS: Surgical products were identified by searching the literature and contacting manufacturing companies. Literature was identified by using PubMed and OVID (MEDLINE). Religious views were established by contacting national bodies for each group. FINDINGS: The views of common UK religious groups and the constituent parts of biological meshes are summarised in tables intended to be used as a reference during clinical practice. On an elective basis, the Islamic, Hindu. Sikh and Jain leaders contacted had strong views on avoiding animal derived products. The Christian and Jewish leaders contacted did not. All religious leaders contacted accepted the use of mesh derived from human tissue. All products, including those of porcine and bovine origin, were acceptable to all leaders contacted if the procedure was performed to save life. The highlighting of this issue should prompt earlier consideration and discussion in the surgical planning and the consenting process with all final decisions taken by both the surgeon and the individual patient.

Videos to reduce racial disparities in ICD therapy Via Innovative Designs (VIVID) trial: Rational, design and methodology.

BACKGROUND: Despite a higher prevalence of sudden cardiac death (SCD), black individuals are less likely than whites to have an implantable cardioverter defibrillator (ICD) implanted. Racial differences in ICD utilization is in part explained by higher refusal rates in black individuals. Decision support can assist with treatment-related uncertainty and prepare patients to make well-informed decisions. METHODS: The Videos to reduce racial disparities in ICD therapy Via Innovative Designs (VIVID) study will randomize 350 black individuals with a primary prevention indication for an ICD to a racially concordant/discordant video-based decision support tool or usual care. The composite primary outcome is (1) the decision for ICD placement in the combined video groups compared with usual care and (2) the decision for ICD placement in the racially concordant relative to discordant video group. Additional outcomes include knowledge of ICD therapy and SCD risk; decisional conflict; ICD receipt at 90 days; and a qualitative assessment of ICD decision making in acceptors, decliners, and those undecided. CONCLUSIONS: In addition to assessing the efficacy of decision support on ICD acceptance among black individuals, VIVID will provide insight into the role of racial concordance in medical decision making. Given the similarities in the root causes of racial/ethnic disparities in care across health disciplines, our approach and findings may be generalizable to decision making in other health care settings.

Discharge against medical advice in culturally and linguistically diverse Australian children.

OBJECTIVES: This study quantifies the prevalence and rates of discharge against medical advice (DAMA) in culturally and linguistically diverse (CALD) children and assesses the independent association between CALD status and DAMA accounting for key demographic confounders in a large tertiary Australian hospital network. METHODS: Prospectively collected data between 2010 and 2018 were extracted from the hospital network electronic medical records system for admitted patients (n=192 037), outpatients (n=268 904) and between 2015 and 2018 for emergency department (ED) patients (n=158 903). CALD status was defined as 'preferred language being not English' and DAMA was measured as 'discharge at own risk' in admissions, 'no show' in outpatients, 'left without being seen' and 'did not wait' in ED. Data were analysed using χ² test, bivariate analysis and multivariate logistic regression. RESULTS: The prevalence of DAMA was 1.34% in admitted patients, 19.31% in outpatients and 12.64% in ED patients. Rates of DAMA were higher among CALD children compared to non-CALD children (1.75% vs 1.29% in admitted patients, 26.53% vs 17.92% in outpatients and 18.74% vs 11.61% in ED patients). CALD status was independently associated with DAMA in admitted children (OR=1.30, 95% CI 1.15 to 1.44), outpatients (OR=1.55; 95% CI 1.51 to 1.58) and ED patients (OR=1.60; 95% CI 1.53 to 1.66). CONCLUSION: Being from a CALD background places children at increased risks to DAMA. Implementing appropriate health service responses may ensure equitable access and quality care for children from CALD backgrounds to reduce the rates of DAMA and its associated ramifications.

The perceived barriers to insulin therapy among type 2 diabetic patients.

BACKGROUND: Problems may arise with insulin treatment, due to patients' perspective towards it leading to refusal. OBJECTIVES: To evaluate diabetic patients' refusal towards insulin therapy, and to assess patients' perception and perceived barriers towards insulin. METHODS: A cross-sectionalstudy, where type 2 diabetics participated in the study during a period, February through March 2017. They were interviewed in person by a questionnaire including three sections; socio-demography, medical history and a health belief model, comprising barriers to use insulin. Five points Likert scale was used to measure patients' perception and barriers towards insulin therapy. RESULTS: One fourth (24.4%) of the diabetic patients refused insulin. Among the controlled group, 34.4% refused insulin, while 21% refused insulin among the uncontrolled group. The study showed different barriers towards insulin therapy, including fear of injection, pain, insulin injection needs help from others, fear of hypoglycaemia and embarrassment. CONCLUSION: Diabetics showed a negative attitude towards insulin therapy due to social and psychological factors. The results necessitate the development of a strategy to address problems related with a reluctance to initiate insulin and put a strategy to implement education and better interaction with diabetic team to the stigma from phobia from insulin use.

Race and Health Disparities in Patient Refusal of Surgery for Early-Stage Pancreatic Cancer: An NCDB Cohort Study.

AIM: To identify factors associated with refusal of surgery in patients with early-stage pancreatic cancer and estimate the impact of this decision on survival. METHODS: Using the National Cancer Data Base, 26,358 patients were identified with potentially resectable tumors (pretreatment clinical stage I: T1 or T2 N0M0). Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact on survival. RESULTS: Of early-stage patients who were recommended surgery, 7.8% (N = 992) refused surgery for resectable early-stage pancreatic cancer. On multivariable analysis, patients were more likely to refuse surgery if they were older [odds ratio (OR) = 1.18; 95% confidence interval (CI) 1.16-1.19], female (OR = 1.52; 95% CI 1.33-1.73), African American (vs White, OR = 1.79; 95% CI 1.37-2.34), on Medicare/Medicaid (vs private, OR = 2.75; 95% CI 1.54-4.92) or had higher Charlson-Deyo score (2 vs 0, OR = 1.33; 95% CI 1.03-1.72). Patients were also significantly more likely to refuse surgery if they were seen at a center that is not an academic/research program (OR 1.9; 95% CI 1.6-2.27). Patients who were recommended surgery but refused had significantly worse survival than those with stage I who received surgery [median survival 6.8 vs 24 months, Cox hazard ratio (HR) 3.41; 95% CI 3.12-3.60]. CONCLUSIONS: The percentage of patients refusing surgery for operable early-stage pancreatic cancer has been decreasing in the last decade but remains a significant issue that affects survival. Disparities in refusal of surgery are independently associated with several variables including gender, race, and insurance. To mitigate national disparities in surgical care, future studies should focus on exploring potential reasons for refusal and developing communication interventions.

The Secret Drama at the Patient's Bedside-Refusal of Treatment Because of the Practitioner's Ethnic Identity: The Medical Staff 's Point of View.

Patients' refusal of treatment based on the practitioner's ethnic identity reveals a clash of values: neutrality in medicine versus patient-centered care. Taking the Israeli-Palestinian conflict into account, this article aims at examining Israeli health care professionals' points of view concerning patients' refusal of treatment because of a practitioner's ethnic identity. Fifty in-depth interviews were conducted with 10 managers and 40 health care professionals, Jewish and Arab, employed at 11 public hospitals. Most refusal incidents recorded are unidirectional: Jewish patients refusing to be treated by Arab practitioners. Refusals are usually directed toward nurses and junior medical staff members, especially if recognizable as religious Muslims. Refusals are often initiated by the patients' relatives and occur more frequently during periods of escalation in the conflict. The structural competency approach can be applied to increase awareness of the role of social determinants in shaping patients' ethnic-based treatment refusals and to improve the handling of such incidents.

Race-based experiences of ethnic minority health professionals: Arab physicians and nurses in Israeli public healthcare organizations.

Increasing workforce diversity was found to contribute to the narrowing of disparities in health. However, racism toward ethnic minority health professionals has not been adequately researched. In Israel, public healthcare organizations that serve a mixed Jewish-Arab population employ Arab minority healthcare professionals. Instances of prejudice and manifestations of racism toward them, which frequently surface in public discussion and the media, have unfortunately gained little scholarly attention. We used the intergroup contact approach and the theory of the social process of everyday racism as a theoretical framework. The objective of the research was to study race-based experiences of Israeli Arab healthcare professionals. METHODOLOGY: We used a qualitative research method that allows respondents to describe their views, experiences, beliefs and behavior in the way they think about them. During 2013 and 2014 we conducted in-depth interviews with a snowball sample of 10 Arab physicians and 13 Arab nurses who work in Israeli public hospitals. The study protocol was ethically approved. FINDINGS: Interviewees noted institutional efforts to maintain egalitarianism and equality. However, at the micro-level, interviewees, mostly nurses, reported instances that ranged from refusal to accept treatment from an Arab nurse, through verbal abuse, to the use of physical violence against them. At the meso-level, interviewees, mostly physicians, reported experiences of institutional discrimination. At the macro-level, one physician reported policy-related discrimination in the context of the immigration of Russian Jewish physicians to Israel. CONCLUSIONS: We recommend combining the intergroup contact approach with the social process theory of racism to examine minorities' subjective perceptions, especially in conflictual and violent contexts; conducting broad-based quantitative research in Israeli healthcare organizations, which may have important implications for the specific strategies to be used; and emphasizing the importance of institutional support. By reconstructing race-based experiences of ethnic minority health professionals, health organizations can better manage racial situations and reduce their frequency.

Addressing patient biases toward physicians.

[Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

Does Doctor Know Best? Cultural competence is patient-centered care.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].

Central Nervous System Disease, Education, and Race Impact Radiation Refusal in Pediatric Cancer Patients.

To investigate the determinants of radiation therapy refusal in pediatric cancer, we used the Surveillance, Epidemiology, and End Results registry to identify 24,421 patients who met the eligibility criteria, diagnosed between 1974 and 2012. Patients had any stage of cancer, were aged 0 to 19, and received radiation therapy or refused radiation therapy when it was recommended. One hundred twenty-eight patients (0.52%) refused radiation therapy when it was recommended. Thirty-two percent of patients who refused radiation therapy ultimately died from their cancer, at a median of 7 months after diagnosis (95% confidence interval, 3-11 mo), as compared with 29.0% of patients who did not refuse radiation therapy died from their cancer, at a median of 17 months after diagnosis (95% confidence interval, 17-18 mo). On multivariable analysis, central nervous system (CNS) site, education, and race were associated with radiation refusal. The odds ratio for radiation refusal for patients with CNS disease was 1.62 (P=0.009) as compared with patients without CNS disease. For patients living in a county with ≥10% residents having less than ninth grade education, the odds ratio for radiation refusal was 1.71 (P=0.008) as compared with patients living in a county with <10% residents having less than ninth grade education. Asian, Pacific Islander, Alaska Native, and American Indian races had an odds ratio of 2.12 (P=0.002) for radiation refusal as compared with black or white race. Although the radiation refusal rate in the pediatric cancer population is low, we show that CNS site, education level, and race are associated with a significant difference in radiation refusal.

Understanding Black Patients' Refusal of Pneumococcal Vaccination.

OBJECTIVE: Racial disparities in rates of pneumococcal vaccine (PPSV23) exist. In one practice, 3.1 % of white patients refused PPSV23 following doctor recommendation, whereas 11.2 % of black patients refused vaccination. Our objective was to understand reasons black patients refused PPSV23. METHODS: Mixed-method telephone survey in 2012 of black patients aged ≥65 with a documented refusal of PPSV23. The survey assessed beliefs about PPSV23; reasons for non-receipt of PPSV23; receipt of other vaccinations; and comparative perceptions of adult vs. childhood vaccines. Participants responded to items on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). RESULTS: Participants' (N = 40) mean age was 73 years; 95 % were female. Participants recognized pneumonia could be deadly (M = 4.3, SD = 1.0), but reported low levels of personal susceptibility (M = 2.8, SD = 1.4). Participants perceived childhood vaccines to be safer (M = 4.2, SD = 1.2) than adult vaccines (M = 3.4, SD = 1.4; p < 0.01). Qualitative analyses to understand reasons for refusal of vaccine both reinforced identified low perceptions of personal susceptibility as well as identified numerous additional barriers to receipt of PPSV23 (e.g., fear, side effects, and mistrust). CONCLUSIONS: Black patients in our sample who refused PPSV23 may not perceive themselves susceptible to the disease, suggesting that strategies to improve PPSV23 rates among these patients may need to emphasize susceptibility to pneumonia. Further, given the discrepancies in perceptions toward childhood versus adult vaccinations, focusing on vaccination across the lifespan may be a promising vaccine promotion strategy.

Cultural considerations in forensic psychiatry: The issue of forced medication.

There has been an ongoing debate regarding the forced use of antipsychotic medications and both the psychiatric and legal professions have reacted strongly to the growing debate. Within the penological context, cases such as Washington v. Harper, Riggins v. Nevada, and Sell v. United States established the framework for determining when antipsychotic medication may be forcibly administered. Medication decisions under the Sell and Riggins cases are to be approved at judicial hearings; whereas, administrative hearings are sufficient for Harper cases. Forensic psychiatrists are also given responsibility in making the legal decision of whether or not to forcibly treat a patient with psychotropic medication against his will. In making this critical decision, a significant factor that is often minimized is the cultural background of the patient. The purpose of this paper is to present cultural factors to be considered in forced medication. Focusing on the culture defense argument, a review of how the legal system has dealt with cultural implications of a case will be presented. This paper will then discuss cultural issues embedded in the assessment, diagnosis, and treatment of psychiatric patients by forensic psychiatrists who are called upon to make the decision of whether or not to force medicate a patient against his will. Lastly, recommendations and a framework for providing a culturally sensitive assessment during the decision to forcibly medicate a patient with psychotropic medication will be offered.

Health Care Disparities Among English-Speaking and Spanish-Speaking Women With Pelvic Organ Prolapse at Public and Private Hospitals: What Are the Barriers?

OBJECTIVES: The objective of this study was to compare perceptions and barriers between Spanish-speaking and English-speaking women in public and private hospitals being treated for pelvic organ prolapse (POP). METHODS: Eight focus groups, 4 in English and 4 in Spanish, were conducted at 3 institutions with care in female pelvic medicine and reconstructive surgery. Standardized questions were asked regarding patients' emotions to when they initially noticed the POP, if they sought family support, and their response to the diagnosis and treatment. Transcripts were analyzed using grounded theory qualitative methods. RESULTS: Thirty-three women were Spanish-speaking and 25 were English-speaking. Spanish speakers were younger (P = 0.0469) and less likely to have a high school diploma (P < 0.0001) than English speakers. Spanish-speaking women had more concerns that the bulge or treatments could lead to cancer, were more resistant to treatment options, and were less likely to be offered surgery. Women in the private hospital desired more information, were less embarrassed, and were more likely to be offered surgery as first-line treatment. The concept emerged that patient care for POP varied based on socioeconomic status and language and suggested the presence of disparities in care for underserved women with POP. CONCLUSIONS: The discrepancies in care for Spanish-speaking women and women being treated at public hospitals suggest that there are disparities in care for POP treatment for underserved women. These differences may be secondary to profit-driven pressures from private hospitals or language barriers, low socioeconomic status, low health literacy, and barriers to health care.