Investigating demographic differences in patients' decisions to consent to COVID-19 research.

OBJECTIVE: COVID-19 disease severely impacted pregnant persons, resulting in a significant increase in poor maternal health outcomes, with a disproportionate impact on minority populations and individuals with low socioeconomic status. We sought to determine demographic differences between birthing parents with SARS-CoV-2 infections who consented to research study participation versus those who declined. By analyzing demographic differences, we are able to ensure the generalizability of study outcomes and to aid in future prospective research design, with the ultimate goal of recognizing and ameliorating research disparities. METHODS: We conducted a secondary analysis to investigate demographic differences in patients who consented to versus declined study participation, in an effort to confirm the external validity of the study results and ensure minority populations most affected by SARS-CoV-2 infection were accurately represented. An IRB waiver was obtained to conduct retrospective chart review for demographic data collection of all patients approached for the COVID-19 Analysis on Perinatal Specimens Related to ExpoSure (CARES) research study. Pregnant patients with SARS-CoV-2 infection were identified at a single hospital center and approached either in person or via phone, with a translator if primary language listed as non-English. Demographic variables including race, ethnicity, primary language, and insurance type were obtained from the electronic medical record and analyzed via Chi-square to determine significant differences between individuals who consented to participation and those who declined participation. RESULTS: One hundred and fifty-eight pregnant patients with SARS-CoV-2 infection were approached for CARES study participation. Eighty-nine patients consented to study participation, while 69 declined study participation. A retrospective chart review was conducted on all 158 patients. Patients who identified as Black race or non-White race were more likely to decline participation (23.2%, p = .031, 68.1%, p = .026), compared to patients who identified as White (31.9%) (Table 1). Patients with public insurance were also more likely to decline study participation (72.5%, p = .049) compared to those with private insurance (27.5%). There was no significant difference between primary language spoken or ethnicity in patients who participated or declined. There was no difference in study participation between patients who identified as Asian race or Other race, compared to patients who identified as White race. CONCLUSIONS: We found significant differences in race and insurance type between pregnant patients with SARS-CoV-2 infection who consented versus declined research study participation. Our study showed that patients who identify as Black race or have public insurance are less likely to consent to research study participation. However, when demographics of consented patients are compared to county, state, and national demographics of female patients age 18-49 with confirmed SARS-CoV-2 infection obtained from a dataset collected by the Center for Disease Control and Prevention (CDC), there was no significant difference between race representation of patients who consented to study participation. This suggests that though the external validity of the CARES study is confirmed, more efforts need to be made to address racial and socioeconomic disparities in research participation.

'I Am Not The Doctor For You': Physicians' Attitudes About Caring For People With Disabilities.

People with disabilities face barriers when attempting to gain access to health care settings. Using qualitative analysis of three physician focus groups, we identified physical, communication, knowledge, structural, and attitudinal barriers to care for people with disabilities. Physicians reported feeling overwhelmed by the demands of practicing medicine in general and the requirements of the Americans with Disabilities Act of 1990 specifically; in particular, they felt that they were inadequately reimbursed for accommodations. Some physicians reported that because of these concerns, they attempted to discharge people with disabilities from their practices. Increasing health care access for people with disabilities will require increasing the accessibility of space and the availability of proper equipment, improving the education of clinicians about the care of people with disabilities, and removing structural barriers in the health care delivery system. Our findings also suggest that physicians' bias and general reluctance to care for people with disabilities play a role in perpetuating the health care disparities they experience.

The Relationship Between Governing Board Composition and Medicare Shared Savings Program Accountable Care Organizations Outcomes: an Observational Study.

BACKGROUND: Early studies of Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs) suggested that physician leadership was an important driver of ACO success, but it is unknown whether the demographic and professional composition of current MSSP ACO governing boards is associated with ACOs' publicly reported outcomes. OBJECTIVE: To investigate whether governing boards with higher physician participation and greater female involvement have better outcomes. DESIGN: Cross-sectional observational study. PARTICIPANTS: All 2017 MSSP ACOs identified by the Center for Medicare and Medicaid Services ACO Public Use Files (PUF). MAIN MEASURES: We collected governing board composition from ACO websites in 2019. Outcome metrics included risk-standardized readmission and unplanned admissions rates. We used descriptive statistics and linear regression models to examine the association between board composition and outcomes. KEY RESULTS: Of the 339 ACOs that still existed in 2019 and had available data, 77% had physician-majority boards and 11.5% had no women on their boards. Eighty-nine percent reported a Medicare beneficiary on their board, of which about one-third had a woman representative. The average number of members on MSSP ACO boards was 12, with a mean of 67% physicians and 24% women. Board composition varied minimally by ACO characteristics, such as geographic region, number of beneficiaries, or type of participants. Higher levels of physician participation in ACO governing boards were associated with lower all-cause unplanned admission rates for patients with heart failure (p = - 0.26, p < 0.001) and for patients with multiple chronic conditions (p = - 0.28, p = 0.001). The number of women on the board was not associated with any outcome differences. CONCLUSIONS: MSSP ACO governing boards were predominately male and physician-led. Physician involvement may be important for achieving quality goals, while lack of female involvement showcases an opportunity to diversify boards.

Accommodating patients with obesity and mobility difficulties: Observations from physicians.

BACKGROUND: Given the growing population of U.S. adults with obesity and mobility disability, physicians will need to accommodate these patients. OBJECTIVE: To explore attitudes and practices of US physicians related to caring for patients with obesity and mobility disability. METHODS: Three open-ended, semi-structured, web-based focus group interviews with practicing physicians in selected specialties, which reached data saturation. Interviews were video recorded and transcribed for qualitative, conventional content analysis. Measurements included commonly expressed themes around caring for patients with obesity. RESULTS: Physicians recognized obesity as a disability that poses challenges to high quality, safe, and efficient patient care. Observations coalesced around four themes: (1) difficulty routinely tracking weight; (2) reluctance to transfer obese patients to exam tables; (3) barriers to diagnostic testing; and (4) weight stigma. Physicians described difficulties accurately assessing weight, performing complete physical examinations, arranging diagnostic imaging, and providing prenatal care for obese patients. Lack of accessible medical diagnostic equipment impeded care for patients with obesity. Other participants did not contest comments of individual participants' that suggested weight stigma. CONCLUSIONS: Our findings suggest that important gaps may remain in providing equitable access to care for patients with obesity, requiring additional training and accessible medical diagnostic equipment to safely accommodate these patients.

Association between patient outcomes and accreditation in US hospitals: observational study.

OBJECTIVES: To determine whether patients admitted to US hospitals that are accredited have better outcomes than those admitted to hospitals reviewed through state surveys, and whether accreditation by The Joint Commission (the largest and most well known accrediting body with an international presence) confers any additional benefits for patients compared with other independent accrediting organizations. DESIGN: Observational study. SETTING: 4400 hospitals in the United States, of which 3337 were accredited (2847 by The Joint Commission) and 1063 underwent state based review between 2014 and 2017. PARTICIPANTS: 4 242 684 patients aged 65 years and older admitted for 15 common medical and six common surgical conditions and survey respondents of the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS). MAIN OUTCOME MEASURES: Risk adjusted mortality and readmission rates at 30 days and HCAHPS patient experience scores. Hospital admissions were identified from Medicare inpatient files for 2014, and accreditation information was obtained from the Centers for Medicare and Medicaid Services and The Joint Commission. RESULTS: Patients treated at accredited hospitals had lower 30 day mortality rates (although not statistically significant lower rates, based on the prespecified P value threshold) than those at hospitals that were reviewed by a state survey agency (10.2% v 10.6%, difference 0.4% (95% confidence interval 0.1% to 0.8%), P=0.03), but nearly identical rates of mortality for the six surgical conditions (2.4% v 2.4%, 0.0% (-0.3% to 0.3%), P=0.99). Readmissions for the 15 medical conditions at 30 days were significantly lower at accredited hospitals than at state survey hospitals (22.4% v 23.2%, 0.8% (0.4% to 1.3%), P<0.001) but did not differ for the surgical conditions (15.9% v 15.6%, 0.3% (-1.2% to 1.6%), P=0.75). No statistically significant differences were seen in 30 day mortality or readmission rates (for both the medical or surgical conditions) between hospitals accredited by The Joint Commission and those accredited by other independent organizations. Patient experience scores were modestly better at state survey hospitals than at accredited hospitals (summary star rating 3.4 v 3.2, 0.2 (0.1 to 0.3), P<0.001). Among accredited hospitals, The Joint Commission did not have significantly different patient experience scores compared to other independent organizations (3.1 v 3.2, 0.1 (-0.003 to 0.2), P=0.06). CONCLUSIONS: US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.

Differences in Patient Experience Between Hispanic and Non-Hispanic White Patients Across U.S. Hospitals.

INTRODUCTION: Despite the increased emphasis on patient experience, little is known about whether there are meaningful differences in hospital satisfaction between Hispanic and non-Hispanic whites. METHODS: To determine if satisfaction differs, we used Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey data (2009-2010) reported by hospitals to compare responses between Hispanic and non-Hispanic white patients. Clustered logistic regression models identified within-hospital and between-hospital differences in satisfaction. RESULTS: Of the 3,864,938 respondents, 6.2% were Hispanics, who were more often younger and females and less likely to have graduated from high school. Hispanics were overall more likely to recommend their hospital (74.1% vs. 70.9%, p < .001) and to rate it 9 or 10 (72.5% vs. 65.9%, p < .001) than whites. Increased satisfaction among Hispanics was more pronounced when compared with whites within the same hospitals, with significantly higher ratings on all HCAHPS measures. However, hospitals serving a higher percentage of Hispanics had lower satisfaction scores for both Hispanic and white patients than other hospitals. CONCLUSION: There were significant but only modest-sized differences in patient experience between Hispanic and white patients across U.S. hospitals. Hispanics tended to be more satisfied with their care but received care at lower-performing hospitals.