Does diversity beget diversity? A scientometric analysis of over 150,000 studies and 49,000 authors published in high-impact medical journals between 2007 and 2022.

Background: Health research that significantly impacts global clinical practice and policy is often published in high-impact factor (IF) medical journals. These outlets play a pivotal role in the worldwide dissemination of novel medical knowledge. However, researchers identifying as women and those affiliated with institutions in low- and middle-income countries (LMIC) have been largely underrepresented in high-IF journals across multiple fields of medicine. To evaluate disparities in gender and geographical representation among authors who have published in any of five top general medical journals, we conducted scientometric analyses using a large-scale dataset extracted from the New England Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), The Lancet, and Nature Medicine. Methods: Author metadata from all articles published in the selected journals between 2007 and 2022 were collected using the DimensionsAI platform. The Genderize.io API was then utilized to infer each author's likely gender based on their extracted first name. The World Bank country classification was used to map countries associated with researcher affiliations to the LMIC or the high-income country (HIC) category. We characterized the overall gender and country income category representation across the medical journals. In addition, we computed article-level diversity metrics and contrasted their distributions across the journals. Findings: We studied 151,536 authors across 49,764 articles published in five top medical journals, over a long period spanning 15 years. On average, approximately one-third (33.1%) of the authors of a given paper were inferred to be women; this result was consistent across the journals we studied. Further, 86.6% of the teams were exclusively composed of HIC authors; in contrast, only 3.9% were exclusively composed of LMIC authors. The probability of serving as the first or last author was significantly higher if the author was inferred to be a man (18.1% vs 16.8%, P < .01) or was affiliated with an institution in a HIC (16.9% vs 15.5%, P < .01). Our primary finding reveals that having a diverse team promotes further diversity, within the same dimension (i.e., gender or geography) and across dimensions. Notably, papers with at least one woman among the authors were more likely to also involve at least two LMIC authors (11.7% versus 10.4% in baseline, P < .001; based on inferred gender); conversely, papers with at least one LMIC author were more likely to also involve at least two women (49.4% versus 37.6%, P < .001; based on inferred gender). Conclusion: We provide a scientometric framework to assess authorship diversity. Our research suggests that the inclusiveness of high-impact medical journals is limited in terms of both gender and geography. We advocate for medical journals to adopt policies and practices that promote greater diversity and collaborative research. In addition, our findings offer a first step towards understanding the composition of teams conducting medical research globally and an opportunity for individual authors to reflect on their own collaborative research practices and possibilities to cultivate more diverse partnerships in their work.

Variation in monitoring: Glucose measurement in the ICU as a case study to preempt spurious correlations.

OBJECTIVE: Health inequities can be influenced by demographic factors such as race and ethnicity, proficiency in English, and biological sex. Disparities may manifest as differential likelihood of testing which correlates directly with the likelihood of an intervention to address an abnormal finding. Our retrospective observational study evaluated the presence of variation in glucose measurements in the Intensive Care Unit (ICU). METHODS: Using the MIMIC-IV database (2008-2019), a single-center, academic referral hospital in Boston (USA), we identified adult patients meeting sepsis-3 criteria. Exclusion criteria were diabetic ketoacidosis, ICU length of stay under 1 day, and unknown race or ethnicity. We performed a logistic regression analysis to assess differential likelihoods of glucose measurements on day 1. A negative binomial regression was fitted to assess the frequency of subsequent glucose readings. Analyses were adjusted for relevant clinical confounders, and performed across three disparity proxy axes: race and ethnicity, sex, and English proficiency. RESULTS: We studied 24,927 patients, of which 19.5% represented racial and ethnic minority groups, 42.4% were female, and 9.8% had limited English proficiency. No significant differences were found for glucose measurement on day 1 in the ICU. This pattern was consistent irrespective of the axis of analysis, i.e. race and ethnicity, sex, or English proficiency. Conversely, subsequent measurement frequency revealed potential disparities. Specifically, males (incidence rate ratio (IRR) 1.06, 95% confidence interval (CI) 1.01 - 1.21), patients who identify themselves as Hispanic (IRR 1.11, 95% CI 1.01 - 1.21), or Black (IRR 1.06, 95% CI 1.01 - 1.12), and patients being English proficient (IRR 1.08, 95% CI 1.01 - 1.15) had higher chances of subsequent glucose readings. CONCLUSION: We found disparities in ICU glucose measurements among patients with sepsis, albeit the magnitude was small. Variation in disease monitoring is a source of data bias that may lead to spurious correlations when modeling health data.

Patient diversity and author representation in clinical studies supporting the Surviving Sepsis Campaign guidelines for management of sepsis and septic shock 2021: a systematic review of citations.

BACKGROUND: The generalizability of the Surviving Sepsis Campaign (SSC) guidelines to various patient populations and hospital settings has been debated. A quantitative assessment of the diversity and representation in the clinical evidence supporting the guidelines would help evaluate the generalizability of the recommendations and identify strategic research goals and priorities. In this study, we evaluated the diversity of patients in the original studies, in terms of sex, race/ethnicity, and geographical location. We also assessed diversity in sex and geographical representation among study first and last authors. METHODS: All clinical studies cited in support of the 2021 SSC adult guideline recommendations were identified. Original clinical studies were included, while editorials, reviews, non-clinical studies, and meta-analyses were excluded. For eligible studies, we recorded the proportion of male patients, percentage of each represented racial/ethnic subgroup (when available), and countries in which they were conducted. We also recorded the sex and location of the first and last authors. The World Bank classification was used to categorize countries. RESULTS: The SSC guidelines included six sections, with 85 recommendations based on 351 clinical studies. The proportion of male patients ranged from 47 to 62%. Most studies did not report the racial/ ethnic distribution of the included patients; when they did so, most were White patients (68-77%). Most studies were conducted in high-income countries (77-99%), which included Europe/Central Asia (33-66%) and North America (36-55%). Moreover, most first/last authors were males (55-93%) and from high-income countries (77-99%). CONCLUSIONS: To enhance the generalizability of the SCC guidelines, stakeholders should define strategies to enhance the diversity and representation in clinical studies. Though there was reasonable representation in sex among patients included in clinical studies, the evidence did not reflect diversity in the race/ethnicity and geographical locations. There was also lack of diversity among the first and last authors contributing to the evidence.

The Digital Divide in Brazil and Barriers to Telehealth and Equal Digital Health Care: Analysis of Internet Access Using Publicly Available Data.

BACKGROUND: The COVID-19 pandemic has increased the use of digital solutions in medical care, especially for patients in remote areas and those requiring regular medical care. However, internet access is essential for the implementation of digital health care. The digital divide is the unequal distribution of access to digital technology, and the first level digital divide encompasses structural barriers. Brazil, a country with economic inequality and uneven population distribution, faces challenges in achieving internet access for all. OBJECTIVE: This study aims to provide a comprehensive overview of the first-level digital divide in Brazil, estimate the relationship between variables, and identify the challenges and opportunities for digital health care implementation. METHODS: Data were retrieved from the Brazilian Institute of Geography and Statistics National Continuous House survey database, including demographic, health, and internet-related variables. Statistical analysis included 2-tailed t tests, chi-square, and multivariate logistic regression to assess associations between variables. RESULTS: Our analysis included 279,382 interviews throughout Brazil. The sample included more houses from the northeast (n=99,553) and fewer houses from the central west (n=30,804). A total of 223,386 (80.13%) of the interviewed population used the internet, with urban areas having higher internet access (187,671/212,109, 88.48%) than rural areas (35,715/67,077, 53.24%). Among the internet users, those interviewed who lived in urban houses, were women, were younger, and had higher income had a statistically higher prevalence (P<.001). Cell phones were the most common device used to access the internet (141,874/143,836, 98.63%). Reasons for not using the internet included lack of interest, knowledge, availability, and cost, with regional variations. The prevalence of internet access also varied among races, with 84,747 of 98,968 (85.63%) White respondents having access, compared to 22,234 of 28,272 (78.64%) Black respondents, 113,518 of 148,191 (76.6%) multiracial respondents, and 2887 of 3755 (76.88%) other respondents. In the southeast, central west, and south regions, the numbers of people with internet access were 49,790 of 56,298 (88.44%), 27,209 of 30,782 (88.39%), and 27,035 of 31,226 (86.58%), respectively, and in the north and northeast, 45,038 of 61,404 (73.35%) and 74,314 of 99,476 (74.7%). The income of internet users was twice the income of internet nonusers. Among those with diabetes-related limitations in daily activities, 945 of 2377 (39.75%) did not have internet access, and among those with daily activity restrictions, 1381 of 3644 (37.89%) did not have access. In a multivariate logistic regression analysis, women (odds ratio [OR] 1.147, 95% CI 0.118-0.156; P<.001), urban households (OR 6.743, 95% CI 1.888-1.929; P<.001), and those earning more than the minimum wage (OR 2.087, 95% CI 0.716-0.756; P<.01) had a positive association with internet access. CONCLUSIONS: Brazil's diverse regions have different demographic distributions, house characteristics, and internet access levels, requiring targeted measures to address the first-level digital divide in rural areas and reduce inequalities in digital health solutions. Older people, poor, and rural populations face the greatest challenges in the first level digital divide in Brazil, highlighting the need to tackle the digital divide in order to promote equitable access to digital health care.