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1.
Med Clin North Am ; 106(1): 29-41, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34823733

RESUMO

The Half-Century long problem of addiction treatment disparities. We cannot imagine addressing disparities in addiction treatment without first acknowledging and deconstructing the etiology of this inequity. This article examines the history of addiction treatment disparities beginning with early twentieth-century drug policies. We begin by discussing structural racism, its contribution to treatment disparities, using opioid use disorder as a case study to highlight the importance of a structural competency framework in obtaining care. We conclude by discussing diversity in the workforce as an additional tool to minimizing disparities. Addiction treatment should be aimed at addressing care delivery in the context of the social, economic, and political determinants of health, which require appreciation of their historical origins to move toward equitable treatment.

3.
J Gen Intern Med ; 2021 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-34561823

RESUMO

BACKGROUND: Racial and ethnic diversity of healthcare workers have benefits on team functioning and patient care. However, a significant barrier to retaining diverse providers is discrimination. OBJECTIVE: To assess the predictors, perpetrators, and narratives of racial discrimination among healthcare workers. DESIGN: Survey study. PARTICIPANTS: Healthcare workers employed at academic hospitals. MAIN MEASURES: We assessed prevalence and perpetrators of racial and ethnic discrimination using the General Ethnic Discrimination Scale. We included an open-ended question asking respondents to recount experiences of discrimination and analyzed responses using grounded theory. KEY RESULTS: Of the 997 participants, 12.2% were females from backgrounds underrepresented in medicine (URM), 4.0% URM males, 10.1% Asian females, 4.7% Asian males, 49.1% non-Hispanic White females, and 19.8% non-Hispanic White males. Among healthcare workers of color, 85.2% reported discrimination. Over half of URM females (51.4%), URM males (52.6%), and Asian females (62.5%) reported discrimination by patients. About 20-25% of URM females, URM males, and Asian females reported discrimination by teachers, supervisors, co-workers, and institutions. In adjusted binary logistic models, URM females had 10.14 odds (95% confidence interval [95%CI]: 5.13, 20.02, p<.001), URM males 6.23 odds (95%CI: 2.59, 14.98, p<.001), Asian females 7.90 odds (95%CI: 4.07, 15.33, p<.001), and Asian males 2.96 odds (95% CI: 1.47, 5.97, p=.002) of reporting discrimination compared with non-Hispanic White males. Needing more support was associated with 2.51 odds (95%CI: 1.54, 4.08, p<.001) of reporting discrimination. Our qualitative findings identified that the murder of George Floyd intensified URM healthcare workers' experiences of discrimination through increased fear of violence and requests for unpaid diversity work. Asian healthcare workers reported that pandemic-related anti-Asian violence shaped their experiences of discrimination through increased fear of violence and care refusal from patients. CONCLUSIONS: Our findings provide insights into experienced discrimination among healthcare workers and opportunities for hospitals to create programs that improve inclusivity.

4.
Acad Med ; 2021 Sep 28.
Artigo em Inglês | MEDLINE | ID: mdl-34591035

RESUMO

Medical students demonstrate their passion for participating in and improving health care both within and outside the classroom. As the COVID-19 pandemic swept across the world, medical students in the United States engaged in student-led service-learning initiatives to contribute to medicine and their local communities, including collecting and distributing personal protective equipment, creating and translating pandemic-related educational materials, and providing childcare for frontline workers. Their impact was recognized and appreciated. Service learning is an education method that incorporates community outreach with didactic coursework and student reflection. In this Invited Commentary, the authors argue for including service learning as a required component in the medical school curriculum to provide students with the tools and support to be advocates and leaders within society, as no such curriculum currently exists. The authors also discuss the history of medical student-led service-learning efforts through to the present day, barriers to implementing and sustaining student-led service-learning initiatives, and solutions to prepare students for service-learning initiatives.

5.
Artigo em Inglês | MEDLINE | ID: mdl-34501818

RESUMO

Racial and gender discrimination are risk factors for adverse mental health outcomes in the general population; however, the effects of discrimination on the mental health of healthcare workers needs to be further explored, especially in relation to competing stressors. Thus, we administered a survey to healthcare workers to investigate the associations between perceived racial and gender discrimination and symptoms of depression, anxiety, posttraumatic stress, and burnout during a period of substantial stressors related to the COVID-19 pandemic and a national racial reckoning. We used multivariable linear regression models, which controlled for demographics and pandemic-related stressors. Of the 997 participants (Mean Age = 38.22 years, SD = 11.77), 688 (69.01%) were White, 148 (14.84%) Asian, 86 (8.63%) Black, 73 (7.32%) Latinx, and 21 (2.11%) identified as another race. In multivariable models, racial discrimination predicted symptoms of depression (B = 0.04; SE: 0.02; p = .009), anxiety (B = 0.05; SE: 0.02; p = .004), and posttraumatic stress (B = 0.01; SE: 0.01; p = .006) and gender discrimination predicted posttraumatic stress (B = 0.11; SE: 0.05; p = .013) and burnout (B = 0.24; SE: 0.07; p = .001). Discrimination had indirect effects on mental health outcomes via inadequate social support. Hospital-wide diversity and inclusion initiatives are warranted to mitigate the adverse mental health effects of discrimination.


Assuntos
COVID-19 , Pandemias , Adulto , Estudos Transversais , Depressão/epidemiologia , Grupo com Ancestrais do Continente Europeu , Pessoal de Saúde , Humanos , Avaliação de Resultados em Cuidados de Saúde , SARS-CoV-2 , Sexismo
6.
PLoS One ; 16(9): e0256763, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34529684

RESUMO

BACKGROUND: The COVID-19 pandemic has had a devastating impact in the United States, particularly for Black populations, and has heavily burdened the healthcare system. Hospitals have created protocols to allocate limited resources, but there is concern that these protocols will exacerbate disparities. The sequential organ failure assessment (SOFA) score is a tool often used in triage protocols. In these protocols, patients with higher SOFA scores are denied resources based on the assumption that they have worse clinical outcomes. The purpose of this study was to assess whether using SOFA score as a triage tool among COVID-positive patients would exacerbate racial disparities in clinical outcomes. METHODS: We analyzed data from a retrospective cohort of hospitalized COVID-positive patients in the Yale-New Haven Health System. We examined associations between race/ethnicity and peak overall/24-hour SOFA score, in-hospital mortality, and ICU admission. Other predictors of interest were age, sex, primary language, and insurance status. We used one-way ANOVA and chi-square tests to assess differences in SOFA score across racial/ethnic groups and linear and logistic regression to assess differences in clinical outcomes by sociodemographic characteristics. RESULTS: Our final sample included 2,554 patients. Black patients had higher SOFA scores compared to patients of other races. However, Black patients did not have significantly greater in-hospital mortality or ICU admission compared to patients of other races. CONCLUSION: While Black patients in this sample of hospitalized COVID-positive patients had higher SOFA scores compared to patients of other races, this did not translate to higher in-hospital mortality or ICU admission. Results demonstrate that if SOFA score had been used to allocate care, Black COVID patients would have been denied care despite having similar clinical outcomes to white patients. Therefore, using SOFA score to allocate resources has the potential to exacerbate racial inequities by disproportionately denying care to Black patients and should not be used to determine access to care. Healthcare systems must develop and use COVID-19 triage protocols that prioritize equity.


Assuntos
COVID-19/prevenção & controle , Atenção à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitais Universitários , Escores de Disfunção Orgânica , Triagem/estatística & dados numéricos , Adolescente , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , COVID-19/epidemiologia , COVID-19/virologia , Connecticut , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/etnologia , Hispano-Americanos/estatística & dados numéricos , Mortalidade Hospitalar/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , SARS-CoV-2/fisiologia , Triagem/métodos , Adulto Jovem
7.
PLoS One ; 16(9): e0257608, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34535009

RESUMO

BACKGROUND: Sequential Organ Failure Assessment (SOFA) score predicts probability of in-hospital mortality. Many crisis standards of care suggest the use of SOFA scores to allocate medical resources during the COVID-19 pandemic. RESEARCH QUESTION: Are SOFA scores elevated among Non-Hispanic Black and Hispanic patients hospitalized with COVID-19, compared to Non-Hispanic White patients? STUDY DESIGN AND METHODS: Retrospective cohort study conducted in Yale New Haven Health System, including 5 hospitals with total of 2681 beds. Study population drawn from consecutive patients aged ≥18 admitted with COVID-19 from March 29th to August 1st, 2020. Patients excluded from the analysis if not their first admission with COVID-19, if they did not have SOFA score recorded within 24 hours of admission, if race and ethnicity data were not Non-Hispanic Black, Non-Hispanic White, or Hispanic, or if they had other missing data. The primary outcome was SOFA score, with peak score within 24 hours of admission dichotomized as <6 or ≥6. RESULTS: Of 2982 patients admitted with COVID-19, 2320 met inclusion criteria and were analyzed, of whom 1058 (45.6%) were Non-Hispanic White, 645 (27.8%) were Hispanic, and 617 (26.6%) were Non-Hispanic Black. Median age was 65.0 and 1226 (52.8%) were female. In univariate logistic screen and in full multivariate model, Non-Hispanic Black patients but not Hispanic patients had greater odds of an elevated SOFA score ≥6 when compared to Non-Hispanic White patients (OR 1.49, 95%CI 1.11-1.99). INTERPRETATION: Given current unequal patterns in social determinants of health, US crisis standards of care utilizing the SOFA score to allocate medical resources would be more likely to deny these resources to Non-Hispanic Black patients.


Assuntos
COVID-19 , Escores de Disfunção Orgânica , Pandemias , Adolescente , Adulto , COVID-19/etnologia , COVID-19/mortalidade , Connecticut/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
8.
Environ Res ; 201: 111620, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34216611

RESUMO

OBJECTIVE: To examine the association of urban residential tree canopy cover with perceived stress in a cohort of pregnant women in Philadelphia, PA, and explore whether this association differed among participants with a history of anxiety and depression. STUDY DESIGN: We performed a secondary analysis of 1294 participants of the Motherhood & Microbiome (M&M) pregnancy cohort who lived in Philadelphia, with first visit perceived stress (Cohen's Perceived Stress Scale, PSS-14), and key covariate data. Tree canopy cover was calculated as percent cover within 100 and 500 m radii buffers around participants' homes. We performed multilevel mixed effects linear regression models, with perceived stress as the dependent variable. The main independent variable was tree canopy coverage. Individual-level covariates included season of last menstrual period, history of depression or anxiety, race/ethnicity, insurance, parity, and age. Census tract neighborhood deprivation index was used to account for area-level socioeconomic confounding variables. We also examined whether a history of anxiety or depression, modified the association between tree canopy coverage and perceived stress. RESULTS: Most participants were non-Hispanic Black (70.6%, n = 913), on Medicaid or uninsured (60.4%, n = 781), and 15.8% (n = 204) of participants had a prior history of depression or anxiety. We did not detect associations between tree canopy coverage and perceived stress overall. However, we detected effect modification; among participants with a history of depression or anxiety, each standard deviation increase in tree canopy cover was associated with lower PSS-14 in 100 m buffers (ß -1.0, 95% CI -1.8, -0.2), but not among participants with no histories of depression or anxiety (ß 0.2, 95% CI -0.3, 0.7) (interaction P = 0.007). Results were similar in directionality but not statistically significant within 500 m buffers. CONCLUSION: Residential tree canopy coverage was associated with reduced perceived stress among urban-dwelling pregnant women with history of anxiety or depression. Future studies of the effects of greenness and other stress-reducing efforts should consider underlying mental health conditions as effect modifiers.


Assuntos
Gestantes , Árvores , Humanos , Gravidez , Estresse Psicológico/epidemiologia
9.
JAMA Netw Open ; 4(7): e2118801, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34323984

RESUMO

Importance: Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. Objective: To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. Design, Setting, and Participants: This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. Interventions: The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. Main Outcomes and Measures: Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. Results: Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. Conclusions and Relevance: In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. Trial Registration: ClinicalTrials.gov Identifier: NCT03134092.

10.
J Gen Intern Med ; 2021 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-33939079

RESUMO

BACKGROUND: Despite substantial research on medical student mistreatment, there is scant quantitative data on microaggressions in US medical education. OBJECTIVE: To assess US medical students' experiences of microaggressions and how these experiences influenced students' mental health and medical school satisfaction. DESIGN AND PARTICIPANTS: We conducted a cross-sectional, online survey of US medical students' experiences of microaggressions. MAIN MEASURES: The primary outcome was a positive depression screen on the 2-item Patient Health Questionnaire (PHQ-2). Medical school satisfaction was a secondary outcome. We used logistic regression to model the association between respondents' reported microaggression frequency and the likelihood of a positive PHQ-2 screen. For secondary outcomes, we used the chi-squared statistic to test associations between microaggression exposure and medical school satisfaction. KEY RESULTS: Out of 759 respondents, 61% experienced at least one microaggression weekly. Gender (64.4%), race/ethnicity (60.5%), and age (40.9%) were the most commonly cited reasons for experiencing microaggressions. Increased microaggression frequency was associated with a positive depression screen in a dose-response relationship, with second, third, and fourth (highest) quartiles of microaggression frequency having odds ratios of 2.71 (95% CI: 1-7.9), 3.87 (95% CI: 1.48-11.05), and 9.38 (95% CI: 3.71-26.69), relative to the first quartile. Medical students who experienced at least one microaggression weekly were more likely to consider medical school transfer (14.5% vs 4.7%, p<0.001) and withdrawal (18.2% vs 5.7%, p<0.001) and more likely to believe microaggressions were a normal part of medical school culture (62.3% vs 32.1%) compared to students who experienced microaggressions less frequently. CONCLUSIONS: To our knowledge, this is the largest study on the experiences and influences of microaggressions among a national sample of US medical students. Our major findings were that microaggressions are frequent occurrences and that the experience of microaggressions was associated with a positive depression screening and decreased medical school satisfaction.

11.
Subst Abus ; : 1-6, 2021 May 26.
Artigo em Inglês | MEDLINE | ID: mdl-34038333

RESUMO

INTRODUCTION: Rates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons' practices and attitudes toward patients with IDU-IE due to their integral role treating them. METHODS: This is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons' practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD). RESULTS: A minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8-9.27, p = 0.001). CONCLUSION: Access to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.

12.
Ann Intern Med ; 174(8): 1143-1144, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34058105

RESUMO

The year 2020 saw the largest social movement in response to the police killings of Black people and anti-Black racism in U.S. history. As a result, medical schools and professional societies such as the American Medical Association and the Association of American Medical Colleges are reckoning with their role in perpetuating racial inequality and the impact of structural racism on medical training. Whether these efforts will translate into meaningful change has yet to be determined. Success depends on a deep understanding of the fundamental role racism plays in how medical schools function and an acknowledgment that current organizational structures and processes often serve to entrench, not dismantle, racial inequities. Drawing on racialized organizations theory from the field of sociology, this article gives an overview of scholarship on race and racism in medical training to demonstrate how seemingly race-neutral processes and structures within medical education, in conjunction with individuals' biases and interpersonal discrimination, serve to reproduce and sustain racial inequality. From 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 ultimately stunt the careers of trainees of color, particularly those from backgrounds underrepresented in medicine (URM). These compounding disadvantages contribute to URM trainees' lower matching odds, steering into less competitive and lucrative specialties, and burnout and attrition from academic careers. In their commitment against structural racism in medical training and academic medicine, medical schools and larger organizations like the Association of American Medical Colleges should prioritize interventions targeted at these structural barriers to achieve equity.


Assuntos
Grupos de Populações Continentais/educação , Grupos Minoritários/educação , Racismo/prevenção & controle , Faculdades de Medicina/organização & administração , Sociedades Médicas/organização & administração , Diversidade Cultural , Humanos , Objetivos Organizacionais , Critérios de Admissão Escolar , Estados Unidos
13.
Yale J Biol Med ; 94(1): 159-164, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33795993

RESUMO

Black, Latinx, and Indigenous people have contracted the SARS-CoV-2 virus and died of COVID-19 at higher rates than White people. Individuals rated public transit, taxis, and ride-hailing as the modes of transportation putting them at greatest risk of COVID-19 infection. Cycling may thus be an attractive alternative for commuting. Amid the increase in bikeshare usage during the early months of the pandemic, bikeshare companies made changes to membership requirements to increase accessibility, targeting especially essential workers. Essential workers in the United States are disproportionately Black and Latinx, underpaid, and reliant on public transit to commute to work. We document changes made by bikeshare companies, including benefits to various groups of essential workers, and we discuss such changes in the context of longstanding racial disparities in bikeshare access. While well intended, the arbitrary delineation in eligibility for such benefits by class of essential workers unwittingly curtailed access for many who may have benefited most. Given that equity in bikeshare is an important tool to improve access to safe transportation, critical changes in the distribution, accessibility, and usability of bikeshare networks is essential. Bikeshare companies, city planners, and policy makers should collaborate with community-based bike advocates to implement changes, as vocalized by those most in need of alternative forms of transportation.


Assuntos
Ciclismo/tendências , COVID-19/prevenção & controle , Comércio/tendências , Grupos Étnicos , Disparidades nos Níveis de Saúde , Justiça Social , Transportes/métodos , Ciclismo/economia , COVID-19/etnologia , Comércio/organização & administração , Política de Saúde , Humanos , Pandemias , Segurança , Fatores Socioeconômicos , Transportes/economia , Transportes/estatística & dados numéricos , Estados Unidos/epidemiologia , Saúde da População Urbana
14.
Obstet Gynecol ; 137(4): 687-694, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33706349

RESUMO

OBJECTIVE: To describe trends and factors associated with medication administration for opioid use disorder (OUD) and retention in treatment among pregnant women with OUD. METHODS: This is a retrospective, nationwide, cross-sectional analysis of treatment episodes for primary OUD among pregnant women from 2013 to 2017. The primary outcome was initiation of methadone, buprenorphine, or naltrexone. Secondary outcomes were retention in treatment defined as length of treatment episode lasting six months or greater, and completion of treatment. Descriptive statistics and logistic regression were applied to describe trends in, and identify factors associated with the outcomes. RESULTS: There were 42,239 treatment episodes for primary OUD among pregnant women who reported using heroin (65.0%, 27,459), synthetic opioid (33.2%, 14,034), or nonprescribed methadone (1.8%, 746) between 2013 and 2017. Medications for OUD were administered in 47.4% (20,013) of episodes. Retention in treatment occurred in 16.6% of episodes without medications for OUD, and 37.8% of episodes with medications for OUD (P=.01). The rate of medication administration for OUD increased from 41.0% in 2013 to 52.0% in 2017; however, retention rates declined from 39.0% to 33.0% among treatment episodes with medication for OUD. History of at least one prior treatment episode was associated with both administration of medications for OUD and retention in treatment. CONCLUSION: In spite of current guidelines, most treatment episodes for OUD during pregnancy did not involve administration of medications for OUD. Although administration of medications for OUD has improved over time, retention in treatment is lagging. These findings highlight gaps in the U.S. addiction care system.


Assuntos
Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Complicações na Gravidez/epidemiologia , Cuidado Pré-Natal , Adolescente , Adulto , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/terapia , Cooperação do Paciente , Gravidez , Complicações na Gravidez/terapia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
15.
Artigo em Inglês | MEDLINE | ID: mdl-33392931

RESUMO

In 25 U.S. states, healthcare professionals are mandated to report pregnant people for substance use to child protection service (CPS) agencies. This practice is not evidence-based, and we believe it harms the patient-provider relationship, opposes reproductive autonomy, and contributes to racial disparities in CPS referrals and their outcomes. Black patients are more often screened and reported than white patients for prenatal substance use; besides the impact on their obstetric care, this may be a barrier to seeking treatment for substance use disorders. Furthermore, strict, punitive state-level policies are associated with greater odds of neonatal abstinence syndrome. The treatment of substance use disorders in pregnancy under the Child Abuse Prevention and Treatment Act opposes robust evidence understanding substance use disorders as chronic illnesses. Among non-pregnant people seeking healthcare, substance use is not a "reportable offense." This double marginalization of pregnant patients limits their autonomy and unduly exposes them to the criminal-legal system. Given disparities in prenatal drug screening, Black pregnant patients are at greater risk of such double-jeopardy. Public health and medical organizations have released policy statements against states' punitive laws, but little has changed. Healthcare providers and institutions should prioritize evidence-based care to benefit the health and wellbeing of birthing person and their infant and combat "legal" interference at the clinic and public-health scale.

18.
Semin Thorac Cardiovasc Surg ; 33(3): 703-709, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33279690

RESUMO

U.S. cardiac surgeons encounter complex decision-making when treating patients with injection drug use-associated infective endocarditis (IDU-IE). We evaluated surgeons' treatment approaches for IDU-IE compared to non-IDU-IE. This is an anonymous survey of U.S. cardiac surgeons who answered hypothetical infective endocarditis (IE) clinical scenarios that varied based on patient substance use history, addiction treatment, and history of IE. Treatment approaches were classified as operative vs nonoperative. Responses were descriptively analyzed. The survey response rate was 8.7% (n = 208). Survey respondents were mostly male (85.6%) and non-Hispanic white (67.8%), but were from all regions of the United States. Surgeons reported they would operate at similar proportions for patients with native valve non-IDU-IE (63%) and IDU-IE engaged in methadone treatment (64.5%). Most surgeons reported they would operate on patients with recurrent non-IDU-IE (93.1%) compared to only 26.4% for patients with recurrent IDU-IE (P < 0.001). Most surgeons reported they would place no limits on the number of operations for patients with recurrent non-IDU-IE (73.1%), whereas 83.5% of surgeons would limit the number of surgeries for patients with recurrent IDU-IE (P < 0.001). Most respondents reported having declined to operate on patients with IDU-IE (63.5%). Cardiac surgeons are less likely to report favoring operative management for primary and recurrent infection in patients with IDU-IE, though patient engagement in methadone treatment increased the likelihood of them taking an operative approach. There is opportunity to standardize the care, including addiction treatment, of patients with IDU-IE to optimize positive short and long-term outcomes.

19.
JAMA Netw Open ; 3(12): e2029043, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33306115

RESUMO

Importance: The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone. Objective: To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019. Design, Setting, and Participants: A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list. Exposures: State-level NAS incidence and county-level uninsured rates and rurality. Main Outcomes and Measures: Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine. Results: Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007). Conclusions and Relevance: Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.


Assuntos
Buprenorfina , Metadona , Síndrome de Abstinência Neonatal , Obstetrícia , Transtornos Relacionados ao Uso de Opioides , Médicos/estatística & dados numéricos , Complicações na Gravidez , Adulto , Buprenorfina/administração & dosagem , Buprenorfina/efeitos adversos , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Masculino , Medicaid , Metadona/administração & dosagem , Metadona/efeitos adversos , Antagonistas de Entorpecentes/administração & dosagem , Antagonistas de Entorpecentes/efeitos adversos , Síndrome de Abstinência Neonatal/epidemiologia , Síndrome de Abstinência Neonatal/etiologia , Síndrome de Abstinência Neonatal/prevenção & controle , Obstetrícia/educação , Obstetrícia/métodos , Obstetrícia/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/tratamento farmacológico , Complicações na Gravidez/epidemiologia , Prevalência , Saúde da População Rural/estatística & dados numéricos , Desenvolvimento de Pessoal/métodos , Estados Unidos/epidemiologia
20.
Artigo em Inglês | MEDLINE | ID: mdl-32756321

RESUMO

Stress has been shown to adversely affect pregnancy outcomes. Neighborhood crime rates may serve as one publicly available social determinant of health for pregnancy studies that use registry or electronic health record datasets in which individual-level stress data are not available. We sought to determine whether neighborhood violent crime incidents were associated with measured perceived stress in a largely minority, urban pregnancy cohort. We performed a secondary analysis of the 1309 Philadelphia residents participating in the Motherhood and Microbiome cohort (n = 2000) with both neighborhood violent crime and Cohen's Perceived Stress Scale (PSS-14) data. Generalized linear mixed models accounting for confounding variables and geographic clustering demonstrated that, regardless of race, women with the highest quartile of neighborhood violent crime had significantly elevated odds of high stress compared to women with lower crime. We also found that Black women were more likely to have both the highest quartile of neighborhood violent crime and high stress than non-Black women. Overall, this study demonstrates that neighborhood violent crime is associated with perceived stress in pregnancy. Given disparate exposure to crime and prenatal stress by race, future work is warranted to determine whether urban neighborhood violence and/or stress reduction strategies would improve birth outcome racial disparities.


Assuntos
Crime , Características de Residência , Estresse Psicológico , Violência , Adulto , Afro-Americanos , Feminino , Humanos , Philadelphia/epidemiologia , Gravidez/psicologia , Adulto Jovem
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