Telehealth use in cystic fibrosis during COVID-19: Association with race, ethnicity, and socioeconomic factors.

BACKGROUND: Due to the COVID-19 pandemic, there was an uptake of telehealth in cystic fibrosis care. Previous studies show disparities in telehealth use based on socioeconomic status (SES). We aimed to: (1) understand telehealth use and perceptions and (2) identify the facilitators and barriers to telehealth use among people with CF and their families (PwCF) from diverse racial/ethnic and socioeconomic backgrounds. METHODS: We conducted an analysis of the 2020 Cystic Fibrosis State of Care surveys completed by PwCF (PFSoC), CF Care Programs (SoC1) and the CF Foundation Patient Registry (CFFPR). RESULTS: A total of 424 PwCF and 286 programs responded to the PFSoC and SoC1. Among PwCF, 90% self-identified as White, 6% as Hispanic/Latino, and 2% as Black. Racial/ethnic minorities were less likely to have had a telehealth visit (p=.015). This difference was pronounced among the Hispanic/Latino population (p<.01). Telehealth use did not differ by health insurance and was similarly offered independent of financial status. Compared to PwCF who denied financial constraints, those who reported financial difficulties found telehealth more difficult to use (p=.018) and were less likely to think that their concerns (p=.010) or issues that mattered most to them (p=.020) were addressed during telehealth. Programs perceived lack of technology, language barriers, and home conditions as barriers to telehealth in vulnerable populations. CONCLUSION: PFSoC and SoC1 identified differences in telehealth use and care perceptions by ethnicity, race, and socioeconomic characteristics. Further studies are needed to understand how telehealth can change access to CF care in diverse subpopulations.

COVID-19 and Health Disparities: Structural Evil Unmasked.

Background: Incidence and mortality from COVID-19 are starkly elevated in poor, minority and marginalized communities. These differences reflect longstanding disparities in income, housing, air quality, preexisting health status, legal protections, and access to health care. The COVID-19 pandemic and its economic consequences have made these ancient disparities plainly visible. Methodology: As scholars in Catholic research universities committed to advancing both scientific knowledge and social justice, we examined these disparities through the lenses of both epidemiology and ethics. Findings: We see these widening disparities as not only as threats to human health, societal stability, and planetary health, but also as moral wrongs - outward manifestations of unrecognized privilege and greed. They are the concrete consequences of policies that promote structural violence and institutionalize racism. Recommendations: We encourage governments to take the following three scientific and ethical justified actions to reduce disparities, prevent future pandemics, and advance the common good: (1) Invest in public health systems; (2) Reduce economic inequities by making health care affordable to all; providing education, including early education, to all children; strengthening environmental and occupational safeguards; and creating more just tax structures; and (3) Preserve our Common Home, the small blue planet on which we all live.

A Social Shift: COVID-19 Disparities Prompt Emphasis on Value-Based Care.

COVID-19 disparities prompt Medicare to call for stronger emphasis on value-based care.

On Answering the Call to Action for COVID-19: Continuing a Bold Legacy of Health Advocacy.

The indelible impacts on our nation from the Coronavirus pandemic along with high fatality rates that disproportionately burden racial and ethnic minorities necessitate long-term coordinated federal, state and local action to improve critical determinants of population health, specifically important health and public health infrastructures as well as emergency and disaster preparedness systems. While our purview as the new pandemic epicenter should be a sufficient driver, coordinated health professionals bringing thoughtful attention to our historical context may be warranted. Prompting our advocacy should be the reality that our collective ability to rebound from such crises may ultimately hinge on protecting and equipping our most vulnerable racial-ethnic minority groups and any susceptible individuals within those populations. Recent historic firsts on behalf of racial and ethnic minorities taken by U.S. Department of Health and Human Services, through the Health Resources and Services Administration, the Office of Minority Health and the Centers for Disease Control and Prevention in response to COVID-19, if proven effective, should be considered for permanency within policy, practice and funding. In addition, given the complex history of Black Americans in this country and persistent and substantial Black-white disparities on health and economic measures across the board, the ultimate solution for improving the health and status Black Americans may look slightly different. Influenced by the 400th year anniversary of the first documented arrival of unfree Africans in North America in 1619, as well as the introduction of bills S.1080 and H.R.40 into Congress (The Commission to Study and Develop Reparation Proposals for African-Americans Act), some kind of reparations for Black Americans might serve as the logical starting point for further advocacy. Nevertheless, we remain supportive allies of all organizations concerned with communities who suffer the weight of this pandemic and any future world health disasters. What is additionally needed is a thoughtful unification of efforts and a commitment to sustained progress with measurable results for as long as the need exists and certainly for the foreseeable future. Let us as humane clinicians and public health professionals capture this moment of challenge and follow through on this urgent call to action.

A national population-based cohort study to investigate inequalities in maternal mortality in the United Kingdom, 2009-17.

BACKGROUND: Disparities have been documented in maternal mortality rates between women from different ethnic, age and socio-economic groups in the UK. It is unclear whether there are differential changes in these rates amongst women from different groups over time. The objectives of this analysis were to describe UK maternal mortality rates in different age, ethnic and socio-economic groups between 2009 and 2017, and to identify whether there were changes in the observed inequalities, or different trends amongst population subgroups. METHODS: Maternal mortality rates with 95% confidence intervals (CI) in specific age, deprivation and ethnic groups were calculated using numbers of maternal deaths as numerator and total maternities as denominator. Relative risks (RR) with 95% CI were calculated and compared using ratios of relative risk. Change over time was investigated using non-parametric tests for trend across ordered groups. RESULTS: Women from black and Asian groups had a higher mortality rate than white women in most time periods, as did women aged 35 and over and women from the most deprived quintile areas of residence. There was evidence of an increasing trend in maternal mortality amongst black women and a decrease in mortality amongst women from the least deprived areas, but no trends over time in any of the other ethnic, age or IMD groups were seen. There was a widening of the disparity between black and white women (RR 2.59 in 2009-11 compared with 5.27 in 2015-17, ratio of the relative risks 2.03, 95% CI 1.11, 3.72). CONCLUSIONS: The clear differences in the patterns of maternal mortality amongst different ethnic, age and socio-economic groups emphasise the importance of research and policies focussed specifically on women from black and minority ethnic groups, together with other disadvantaged groups, to begin to reduce maternal mortality in the UK.

Specialization and minority health care: hormone therapy for trans people in England.

Specialization serves an important purpose in health services, ensuring resources are used efficiently and patients can access specialized skills and interventions. However, specialization also results in services being concentrated in fewer locations, with less patient choice. Focussing upon the example of gender-identity services for trans people in England, this paper outlines contemporary debates regarding hormone prescription pathways and argues that concepts of 'specialization' in health care may at times disadvantage minority populations who have needs that are uncommon but not clinically complex. Supplying gender-identity services in specialized clinics has sometimes been presented as avoiding discrimination that may occur in wider health services, but may reinforce perceptions that other health providers do not need to engage with trans populations. Primary care-led models for providing trans health care operate internationally and are being explored in the UK. However, reform processes may be helped by further critical attention to the purposes and implications of specialization.

"Progress in Medicine Is Slower to Happen": Qualitative Insights Into How Trans and Gender Nonconforming Medical Students Navigate Cisnormative Medical Cultures at Canadian Training Programs.

PURPOSE: Trans and gender nonconforming (TGNC) people face significant health disparities compared with their cisgender (nontrans) counterparts. Physician-level factors play a role in these disparities, and increasing the participation of individuals from sexuality and gender minority (SGM) communities in medical training has been proposed as one way of addressing this issue; however, very little is known about the experiences of TGNC medical students. This study aimed to understand the experiences of TGNC medical students in Canada. METHOD: Between April 2017 and April 2018, 7 TGNC participants either currently enrolled in or recently graduated from a Canadian medical school completed audiorecorded semistructured interviews. Interviewers asked about experiences with admissions; academic, clinical, and social environments; and interactions with administration. The authors analyzed interviews using a constructivist grounded theory approach. RESULTS: The authors developed 5 overarching themes: navigating cisnormative medical culture; balancing authenticity, professionalism, and safety; negotiating privilege and power differentials; advocating for patients and curricular change; and seeking mentorship in improving access and quality of care to TGNC patients. This article focuses on the first theme, with associated subthemes of culture and context; interactions with classmates, curriculum, policy, and administration; and gendered spaces. CONCLUSIONS: The results of this study delineate heterogeneous experiences of medical cultures with a shared underlying pattern of erasure of TGNC people as both patients and clinicians. Findings were largely consistent with previously published recommendations for improving academic medical institutional climates for SGM people, though the need for access to appropriate gendered spaces beyond washrooms was highlighted.

Changes in Perceptions of Discrimination in Health Care in California, 2003 to 2017.

Importance: Research in the early 2000s in California demonstrated that racial and ethnic minorities, immigrants, and those with limited English proficiency (LEP) experienced high rates of discrimination in health care. Less is known about how patients' perceptions of discrimination in health care have changed since then. Objective: To determine whether perceptions of discrimination in health care have changed overall and for specific vulnerable populations. Design, Setting, and Participants: This cross-sectional study used data from the California Health Interview Survey for state residents aged 18 years and older for 2 periods, 2003 to 2005 and 2015 to 2017. χ2 analyses and multivariate logistic regression were performed to compare recent discrimination in health care in late vs early periods controlling for race/ethnicity, poverty level, education, insurance status, usual source of care, self-reported health, and LEP. Additional subanalyses were performed by race/ethnicity, immigrant status, and LEP status. Jackknife replicate weights were provided by the California Health Interview Survey. Exposure: Survey year was dichotomized as combined 2003 to 2005 and combined 2015 to 2017. Main Outcomes and Measures: Survey respondents were identified as having experienced recent discrimination in health care if they responded "yes" to the question, "Was there ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?" and reported that this occurred within the last 5 years. Results: There were 84 088 participants in 2003 to 2005 (51.0% female; 14.7% aged ≥65 years) and 63 242 participants in 2015 to 2017 (51.1% female; 18.0% aged ≥65 years). Rates of recent discrimination in health care decreased from 6.0% to 4.0% (difference, 2.0%; 95% CI, 1.5%-2.5%; P < .001). In adjusted analyses, perceptions of discrimination in health care decreased in 2015 to 2017 compared with 2003 to 2005 (odds ratio [OR], 0.60; 95% CI, 0.53-0.68; P < .001). There was a significant race × period interaction for Latino individuals (OR, 0.58; 95% CI, 0.40-0.83; P = .003) but not for Asian individuals (OR, 0.76; 95% CI, 0.50-1.16; P = .20) or African American individuals (OR, 1.24; 95% CI, 0.76-2.02; P = .40). There was a significant immigrant status × period interaction (OR, 0.55; 95% CI, 0.44-0.69; P < .001) and LEP status × period interaction (OR, 0.67; 95% CI, 0.51-0.89; P < .001). Conclusions and Relevance: This study suggests that perceptions of discrimination in health care in California decreased between 2003 to 2005 and 2015 to 2017 among Latino individuals, immigrants, and those with LEP. African American participants reported consistently high rates of discrimination, indicating that interventions targeting health care discrimination are still necessary.

A value-critical policy analysis of the nursing home reform act: a focus on care of African American and Latino residents.

Improving nursing home care has been a central legislative focus since the 1980s; The major response effort to address these reports of poor-quality care was first met with a federal rule in 1987, the Nursing Home Reform Act (NHRA). Since enactment of the NHRA in 1987, and despite an increasing utilization of nursing home care by aging minorities, the standardization of care practice, or quality indicators (e.g., structural, process, and outcome measures), within long-term nursing home care have remained relatively unchanged. This paper reports a value-critical policy analysis of the most recent final action rule, effective on November 28 of 2016 by the Centers for Medicare and Medicaid Services (CMS) with a particular focus on its impact on African-American and Latino older adults. This paper presents results of two policy analyses. Taken together, this merged analysis focuses on an overview of the problem, the groups most affected by the problem, current program goals and objectives, forms of benefits and services, and a current state of the social problem. Following the analysis, we present changes and improvements to be made, as well as proposals for reform and recommendations for policy changes.

Uniting the Vision for Health Equity through Partnerships: The 2nd Annual Dr. Elijah Saunders & Dr. Levi Watkins Memorial Lecture.

Minority health research focuses on outcomes by race and ethnicity categories used in the United States census. Overall mortality has decreased significantly for African Americans, Latinos, and Asians over the past 20 years even though it has stopped improving for poor Whites and continues to increase for American Indians/Alaska Natives. Prevention and treatment of cardiovascular disease partly account for this trend, but there is room for improvement. Health disparities research also includes persons of less privileged socioeconomic status, underserved rural residents, and sexual and gender minorities of any race and ethnicity when the outcomes are worse than a reference population. Understanding mechanisms that lead to health disparities from behavioral, biological, environmental and health care perspectives will lead to interventions that reduce these disparities and promote health equity. Experiences with racism and discrimination generate a chronic stress response with measurable effects on biological processes and study is needed to evaluate long-term effects on health outcomes. A clinical example of effective approaches to reducing disparities is management of hypertension to promote stroke reduction that requires health system changes, patient-clinician partnerships and engagement of community organizations. Clinicians in health care settings have the potential to promote health equity by implementing standardized measures of social determinants, leveraging the power of health information technology, maximizing cultural competence and socially precise care and engaging communities to reduce health disparities. Strategic partnerships between health care institutions and community-based organizations need to parallel patient-clinician partnerships and are essential to promote health equity and reduce disparities.