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1.
Ann Glob Health ; 87(1): 34, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33828952

RESUMO

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.


Assuntos
Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Saúde das Minorias , Qualidade de Vida , Justiça Social/normas , /epidemiologia , /psicologia , Saúde Global , Disparidades em Assistência à Saúde/ética , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Saúde das Minorias/ética , Saúde das Minorias/normas , Saúde das Minorias/estatística & dados numéricos , Melhoria de Qualidade , Determinantes Sociais da Saúde
2.
Heart ; 107(9): 734-740, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33685933

RESUMO

OBJECTIVE: There are concerns that healthcare and outcomes of black, Asian and minority ethnic (BAME) communities are disproportionately impacted by the COVID-19 pandemic. We investigated admission rates, treatment and mortality of BAME with acute myocardial infarction (AMI) during COVID-19. METHODS: Using multisource national healthcare records, patients hospitalised with AMI in England during 1 February-27 May 2020 were included in the COVID-19 group, whereas patients admitted during the same period in the previous three consecutive years were included in a pre-COVID-19 group. Multilevel hierarchical regression analyses were used to quantify the changes in-hospital and 7-day mortality in BAME compared with whites. RESULTS: Of 73 746 patients, higher proportions of BAME patients (16.7% vs 10.1%) were hospitalised with AMI during the COVID-19 period compared with pre-COVID-19. BAME patients admitted during the COVID-19 period were younger, male and likely to present with ST-elevation acute myocardial infarction. COVID-19 BAME group admitted with non-ST-elevation acute myocardial infarction less frequently received coronary angiography (86.1% vs 90.0%, p<0.001) and had a longer median delay to reperfusion (4.1 hours vs 3.7 hours, p<0.001) compared with whites. BAME had higher in-hospital (OR 1.68, 95% CI 1.27 to 2.28) and 7-day mortality (OR 1.81 95% CI 1.31 to 2.19) during COVID-19 compared with pre-COVID-19 period. CONCLUSION: In this multisource linked cohort study, compared with whites, BAME patients had proportionally higher hospitalisation rates with AMI, less frequently received guidelines indicated care and had higher early mortality during COVID-19 period compared with pre-COVID-19 period. There is a need to develop clinical pathways to achieve equity in the management of these vulnerable populations.


Assuntos
Procedimentos Clínicos , Disparidades em Assistência à Saúde , Infarto do Miocárdio sem Supradesnível do Segmento ST , Infarto do Miocárdio com Supradesnível do Segmento ST , /mortalidade , Angiografia Coronária/métodos , Angiografia Coronária/estatística & dados numéricos , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/normas , Inglaterra/epidemiologia , Feminino , Necessidades e Demandas de Serviços de Saúde , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/etnologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde , Fatores Raciais , Infarto do Miocárdio com Supradesnível do Segmento ST/etnologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia
3.
Lancet Glob Health ; 9(3): e331-e339, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33607031

RESUMO

BACKGROUND: Many governments have introduced pay-for-performance programmes to incentivise health providers to improve quality of care. Evidence on whether these programmes reduce or exacerbate disparities in health care is scarce. In this study, we aimed to assess socioeconomic inequalities in the performance of family health teams under Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ). METHODS: For this longitudinal study, we analysed data on the quality of care delivered by family health teams participating in PMAQ over three rounds of implementation: round 1 (November, 2011, to March, 2013), round 2 (April, 2013, to September, 2015), and round 3 (October, 2015, to December, 2019). The primary outcome was the percentage of the maximum performance score obtainable by family health teams (the PMAQ score), based on several hundred (ranging from 598 to 914) indicators of health-care delivery. Using census data on household income of local areas, we examined the PMAQ score by income ventile. We used ordinary least squares regressions to examine the association between PMAQ scores and the income of each local area across implementation rounds, and we did an analysis of variance to assess geographical variation in PMAQ score. FINDINGS: Of the 40 361 family health teams that were registered as ever participating in PMAQ, we included 13 934 teams that participated in the three rounds of PMAQ in our analysis. These teams were located in 11 472 census areas and served approximately 48 million people. The mean PMAQ score was 61·0% (median 61·8, IQR 55·3-67·9) in round 1, 55·3% (median 56·0, IQR 47·6-63·4) in round 2, and 61·6% (median 62·7, IQR 54·4-69·9) in round 3. In round 1, we observed a positive socioeconomic gradient, with the mean PMAQ score ranging from 56·6% in the poorest group to 64·1% in the richest group. Between rounds 1 and 3, mean PMAQ performance increased by 7·1 percentage points for the poorest group and decreased by 0·8 percentage points for the richest group (p<0·0001), with the gap between richest and poorest narrowing from 7·5 percentage points (95% CI 6·5 to 8·5) to -0·4 percentage points over the same period (-1·6 to 0·8). INTERPRETATION: Existing income inequalities in the delivery of primary health care were eliminated during the three rounds of PMAQ, plausibly due to a design feature of PMAQ that adjusted financial payments for socioeconomic inequalities. However, there remains an important policy agenda in Brazil to address the large inequities in health. FUNDING: UK Medical Research Council, Newton Fund, and CONFAP (Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa).


Assuntos
Saúde da Família/normas , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Reembolso de Incentivo/estatística & dados numéricos , Brasil , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/normas , Humanos , Estudos Longitudinais , Equipe de Assistência ao Paciente/organização & administração , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/normas , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde/economia , Qualidade da Assistência à Saúde/normas , Fatores Socioeconômicos
4.
PLoS Med ; 18(1): e1003490, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33428624

RESUMO

BACKGROUND: The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level. METHODS AND FINDINGS: We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID-19 deaths and correlations among these variables in the general population from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% non-Hispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%-59.6%, p < 0.001), individuals with income below the median (67.5%, 95% CI 63.4%-71.5%, p < 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% -27.9%, p < 0.001), and veterans (19.5%, 95% CI 15.8%-23.4%, p < 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression. Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incarcerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents. CONCLUSIONS: Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.


Assuntos
/mortalidade , Disparidades em Assistência à Saúde/normas , Saúde Pública , Determinantes Sociais da Saúde/estatística & dados numéricos , Fatores Socioeconômicos , Idoso , Comorbidade , Grupos Étnicos/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Mortalidade , Saúde Pública/métodos , Saúde Pública/normas , Melhoria de Qualidade/organização & administração , Estados Unidos , Saúde dos Veteranos/estatística & dados numéricos
8.
Anticancer Res ; 40(10): 5727-5734, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32988898

RESUMO

BACKGROUND/AIM: To examine the impact of ACA and the association of socioeconomic factors on delay in initial treatment for multiple myeloma (MM). PATIENTS AND METHODS: Patients diagnosed with MM between 2004-2016 were identified in the National Cancer Database (NCDB). Time-to-initial treatment (TTI) was defined as the number of days from diagnosis to initial therapy. Patients were classified into quartiles and those belonging to the fourth quartile for TTI constituted the delayed treatment group. Study period was divided into pre-ACA and post-ACA using 2010 as the cut-off. RESULTS: A total of 65,723 patients met the eligibility criteria. Median TTI was 13 (IQR=5-27) days. Racial-ethnic minorities were associated with delayed-TTI. Delayed treatment was more likely for Hispanics pre-ACA but not post-ACA, while non-Hispanic Blacks (NHB) were more likely to have delayed treatment both, pre- and post-ACA. CONCLUSION: While ACA has been shown to help mitigate healthcare disparities in certain cancer diagnoses, the study suggests that the effect is still limited among MM patients.


Assuntos
Disparidades em Assistência à Saúde/normas , Cobertura do Seguro/normas , Mieloma Múltiplo/epidemiologia , Patient Protection and Affordable Care Act , Idoso , Grupos de Populações Continentais , Grupos Étnicos , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Humanos , Masculino , Pessoa de Meia-Idade , Mieloma Múltiplo/patologia , Mieloma Múltiplo/terapia , Fatores Socioeconômicos , Estados Unidos/epidemiologia
9.
Obstet Gynecol ; 136(4): 657-662, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925626

RESUMO

The maternal mortality ratio in the United States is increasing; understanding the significance of this change and developing effective responses requires a granular analysis of the contributing factors that a well-informed maternal mortality review committee can provide. Data collection and analysis, clinical factors, preventability, social determinants of health, and racial inequities combine to affect this outcome, and each factor must be considered individually and in combination to recommend a robust response. Obstetrician-gynecologists formed the State of Michigan's Maternal Mortality Review Committee (the Committee) in 1950 to identify gaps in care that needed to be systematically addressed at the time. In the early years, the Committee witnessed a reduction in the number of maternal deaths; over time, prioritization of maternal mortality decreased, yet the Committee witnessed changing patterns of death, varied data collection and evaluation processes, delayed reviews, and unimplemented recommendations. The calculation of the maternal mortality ratio was not informed by the outcomes of Committee reviews. Today, the Committee, with increased support from the Michigan Department of Health & Human Services, can clearly identify and report preventable pregnancy-related mortality along with its causes and is close to achieving a near real-time surveillance system that allows the development of timely clinical and policy recommendations and interventions. The Committee's adaptations in response to the rise in maternal mortality have resulted in several lessons learned that may be helpful for currently operating committees and in the formation of new ones.


Assuntos
Uso Indevido de Medicamentos , Mortalidade Materna/tendências , Complicações na Gravidez , Serviços Preventivos de Saúde , Melhoria de Qualidade , Suicídio , Adulto , Comitês Consultivos/normas , Comitês Consultivos/estatística & dados numéricos , Uso Indevido de Medicamentos/mortalidade , Uso Indevido de Medicamentos/prevenção & controle , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Disparidades em Assistência à Saúde/normas , Humanos , Michigan/epidemiologia , Mortalidade , Gravidez , Complicações na Gravidez/mortalidade , Complicações na Gravidez/prevenção & controle , Serviços Preventivos de Saúde/métodos , Serviços Preventivos de Saúde/normas , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/tendências , Determinantes Sociais da Saúde/etnologia , Suicídio/prevenção & controle , Suicídio/estatística & dados numéricos
10.
Health Psychol ; 39(9): 745-757, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32833476

RESUMO

OBJECTIVES: Physiological stress responses have been suggested as a mechanism through which social and biological factors contribute to racial disparities in breast cancer outcomes. Many African Americans experience stressful life events and circumstances. These social factors may contribute to an increased risk of advanced stage disease at diagnosis and/or faster progression, but not all African American women exposed to adverse social factors develop advanced stage disease. Similarly, women who have a limited number of stressors can develop advanced stage breast cancer. Highly individualized stress reactivity may account for these inconsistent associations. METHOD: This report describes the rationale, design, and methods for an exploratory study that uses the experimental medicine approach to: (a) characterize the nature and distribution of stress reactivity among African American breast cancer survivors based on socioeconomic, clinical, and social stressors; (b) examine the impact of stress reactivity on temporal discounting; and (c) determine the extent to which stress reactivity and temporal discounting are associated with adherence to recommendations for cancer control behaviors and treatment compliance as part of the Science of Behavior Change Network. RESULTS: This study addresses several empirical gaps about the most effective ways to develop behavior change interventions for a medically underserved population that continues to experience disparities in cancer morbidity and mortality. CONCLUSIONS: Results from this research will provide the empirical and conceptual basis for future intervention protocols that target mechanisms that are critical to disparities in African American breast cancer survivors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).


Assuntos
Sobreviventes de Câncer/psicologia , Disparidades em Assistência à Saúde/normas , Estresse Psicológico/psicologia , Adulto , Feminino , Humanos
11.
J Stroke Cerebrovasc Dis ; 29(9): 105012, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807427

RESUMO

BACKGROUND: Located on the Borneo Island, Sarawak is the largest state of Malaysia and has a population distinctive from Peninsular Malaysia. The ischaemic stroke data in Sarawak had not been reported despite the growing number of patients annually. We aimed to investigate patient characteristics, management, and outcomes of ischaemic stroke in Sarawak and benchmark the results with national and international published data. METHODS: We included ischaemic stroke cases admitted to Sarawak General Hospital between June 2013 and August 2018 from Malaysia National Stroke Registry. We performed descriptive analyses on patient demographics, cardiovascular risk factors, prior medications, smoking status, arrival time, thrombolysis rate, Get With The Guidelines (GWTG)-Stroke measures, and outcomes at discharge. We also numerically compared the results from Sarawak with the published data from selected national and international cohorts. RESULTS: We analysed 1435 ischaemic stroke cases. The mean age was 60.1±13.2 years old; 64.9% were male; median baseline National Institute of Health Stroke Scale was seven points. Hypertension was the most prevalent risk factor of ischaemic stroke; 12.7% had recurrent stroke; 13.7% were active smokers. The intravenous thrombolysis rate was 18.8%. We achieved 80-90% in three GWTG-Stroke performance measures and 90-98% in four additional quality measures in our ischaemic stroke management. At discharge, 57% had modified Rankin Scale of 0-2; 6.7% died during hospitalisation. When compared with selected national and international data, patients in Sarawak were the youngest; Sarawak had more male and more first-ever stroke. Thrombolysis rate in Sarawak was higher compared with most studies in the comparison. Functional outcome at discharge in Sarawak was better than national cohort but still lagging behind when compared with the developed countries. In-hospital mortality rate in Sarawak was slightly lower than the national data but higher when compared with other countries. CONCLUSION: Our study described characteristics, management, and outcomes of ischaemic stroke in Sarawak. We achieved high compliance with most of GTWG-Stroke performance and quality indicators. Sarawak had better outcomes than the national results on ischaemic stroke. However, there is still room for improvement when compared with other countries. Actions are needed to reduce the cardiovascular burdens for stroke prevention, enhance healthcare resources for stroke care, and improve intravenous thrombolysis treatment in Sarawak.


Assuntos
Benchmarking/normas , Isquemia Encefálica/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/normas , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Feminino , Disparidades em Assistência à Saúde/normas , Mortalidade Hospitalar , Humanos , Malásia/epidemiologia , Masculino , Pessoa de Meia-Idade , Alta do Paciente/normas , Padrões de Prática Médica/normas , Recidiva , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
13.
Eur J Vasc Endovasc Surg ; 60(4): 502-508, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32732140

RESUMO

OBJECTIVE: Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA). METHODS: All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits. RESULTS: In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66). CONCLUSION: In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Doenças dos Nervos Cranianos/epidemiologia , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Disparidades em Assistência à Saúde/normas , Humanos , Ataque Isquêmico Transitório/epidemiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Readmissão do Paciente , Hemorragia Pós-Operatória/epidemiologia , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
14.
Transplantation ; 104(8): 1627-1632, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32732840

RESUMO

BACKGROUND: In December 2018, United Network for Organ Sharing approved an allocation scheme based on recipients' geographic distance from a deceased donor (acuity circles [ACs]). Previous analyses suggested that ACs would reduce waitlist mortality overall, but their impact on pediatric subgroups was not considered. METHODS: We applied Scientific Registry of Transplant Recipients data from 2011 to 2016 toward the Liver Simulated Allocation Model to compare outcomes by age and illness severity for the United Network for Organ Sharing-approved AC and the existing donor service area-/region-based allocation schemes. Means from each allocation scheme were compared using matched-pairs t tests. RESULTS: During a 3-year period, AC allocation is projected to decrease waitlist deaths in infants (39 versus 55; P < 0.001), children (32 versus 50; P < 0.001), and teenagers (15 versus 25; P < 0.001). AC allocation would increase the number of transplants in infants (707 versus 560; P < 0.001), children (677 versus 547; P < 0.001), and teenagers (404 versus 248; P < 0.001). AC allocation led to decreased median pediatric end-stage liver disease/model for end-stage liver disease at transplant for infants (29 versus 30; P = 0.01), children (26 versus 29; P < 0.001), and teenagers (26 versus 31; P < 0.001). Additionally, AC allocation would lead to fewer transplants in status 1B in children (97 versus 103; P = 0.006) but not infants or teenagers. With AC allocation, 77% of pediatric donor organs would be allocated to pediatric candidates, compared to only 46% in donor service area-/region-based allocation (P < 0.001). CONCLUSIONS: AC allocation will likely address disparities for pediatric liver transplant candidates and recipients by increasing transplants and decreasing waitlist mortality. It is more consistent with federally mandated requirements for organ allocation.


Assuntos
Doença Hepática Terminal/cirurgia , Acesso aos Serviços de Saúde/organização & administração , Transplante de Fígado/métodos , Modelos Organizacionais , Alocação de Recursos/organização & administração , Índice de Gravidade de Doença , Adolescente , Adulto , Fatores Etários , Aloenxertos/provisão & distribução , Criança , Simulação por Computador , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/normas , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Lactente , Transplante de Fígado/estatística & dados numéricos , Masculino , Sistema de Registros/estatística & dados numéricos , Alocação de Recursos/normas , Alocação de Recursos/estatística & dados numéricos , Análise de Sobrevida , Transplantados/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos/epidemiologia , Listas de Espera/mortalidade
15.
J Med Internet Res ; 22(5): e12611, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-32356775

RESUMO

BACKGROUND: Emails securely exchanged between patients and clinicians offer the promise of improved access to care and indirectly improved health outcomes. Yet research to date is mixed on who-among both patients and clinicians-is using secure messaging. OBJECTIVE: Using data from two large nationally representative cross-sectional surveys, this study aimed to compare the prevalence of secure messaging use among patients and their access to the functionality through their physicians, and to explore the clinical practice and physician characteristics and patient sociodemographic characteristics associated with the use of secure messaging. METHODS: We conducted regression analyses to identity statistical associations between self-reported secure messaging use and access, and the patient, practice, and physician characteristics from the National Health Interview Survey (NHIS) and the National Ambulatory Medical Care Survey (NAMCS). The NHIS data collected between 2013 and 2018, with approximately 150,000 adult individuals, were used to evaluate patient characteristics associated with email communication with clinicians. The NAMCS data included 7340 physicians who reported on secure messaging use between 2013 and 2016 and provided context on physician specialty, use of certified health information technology (IT), and practice size and ownership associated with secure messaging access and use. RESULTS: By 2016, two-thirds of ambulatory care visits were conducted by a physician who reported using secure messaging, up from 40.70% in 2013. The percentage of US residents who reported sending an email to their clinician, however, only increased from 7.22% to 16.67% between 2013 and 2018. We observed a strong positive association between certified health IT use and secure messaging use (odds ratio [OR] 11.46, 95% CI 7.55-17.39). Individuals who were black, had lower levels of education, had Medicaid or other public payer insurance, or those who were uninsured had reduced odds for using email to communicate with clinicians. No differences were observed in secure messaging use based on physician specialty, but significant differences were observed by practice size (OR 0.46, 95% CI 0.35-0.60 in solo practices vs nonsolo practices) and practice ownership (P<.001 for the different categories). CONCLUSIONS: This study is the first to use two large nationally representative surveys to produce longitudinal estimates on the access and use of patient-clinician email communication in the United States. The survey findings complement each other: one provides the patient perspective of their use and the other indicates potential patient access to secure messaging based on the use of the functionality by the physicians providing treatment. This study provides nationally representative data on the characteristics of patients and physicians who have access to and are using secure messaging. This information can be used to target interventions to promote adoption and use of secure messaging.


Assuntos
Correio Eletrônico/normas , Pesquisas sobre Serviços de Saúde/métodos , Disparidades em Assistência à Saúde/normas , Adolescente , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Estados Unidos , Adulto Jovem
17.
Circ Cardiovasc Qual Outcomes ; 13(4): e005977, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32228065

RESUMO

BACKGROUND: Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have voiced concern that value-based payment programs may penalize practices that serve vulnerable populations. This study evaluated whether outpatient practices that serve socioeconomically disadvantaged populations have worse CAD outcomes, and if this reflects the delivery of lower-quality care or rather, patient and community factors beyond the care provided by physician practices. METHODS AND RESULTS: Retrospective cohort study of Medicare fee-for-service patients ≥65 years with CAD at outpatient practices participating in the the Practice Innovation and Clinical Excellence registry from January 1, 2010 to January 1, 2015. Outpatient practices were stratified into quintiles by the proportion of most disadvantaged patients-defined by an area deprivation score in the highest 20% nationally-served at each practice site. Prescription of guideline recommended therapies for CAD as well as clinical outcomes (emergency department presentation for chest pain, hospital admission for unstable angina or acute myocardial infarction [AMI], 30-day readmission after AMI, and 30-day mortality after AMI) were evaluated by practice-level socioeconomic disadvantage with hierarchical logistic regression models, using practices serving the fewest socioeconomically disadvantaged patients as a reference. The study included 453 783 Medicare fee-for-service patients ≥65 years of age with CAD (mean [SD] age, 75.3 [7.7] years; 39.7% female) cared for at 271 outpatient practices. At practices serving the highest proportion of socioeconomically disadvantaged patients (group 5), compared with practices serving the lowest proportion (group 1), there was no significant difference in the likelihood of prescription of antiplatelet therapy (odds ratio [OR], 0.94 [95% CI, 0.69-1.27]), ß-blocker therapy if prior myocardial infarction or left ventricular ejection fraction <40% (OR, 0.97 [95% CI, 0.69-1.35]), ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker if left ventricular ejection fraction <40% and/or diabetes mellitus (OR, 0.93 [95% CI, 0.74-1.19]), statin therapy (OR, 0.88 [95% CI, 0.68-1.14]), or cardiac rehabilitation (OR, 0.45 [95% CI, 0.20-1.00]). Patients cared for at the most disadvantaged-serving practices (group 5) were more likely to be admitted for unstable angina (adjusted OR, 1.46 [95% CI, 1.04-2.05]). There was no significant difference in the likelihood of emergency department presentation for chest pain or hospital admission for AMI between practices. Thirty day mortality rates after AMI were higher among patients at the most disadvantaged-serving practices (aOR, 1.31 [95% CI, 1.02-1.68]), but 30-day readmission rates did not differ. All associations were attenuated after additional adjustment for patient-level area deprivation index. CONCLUSIONS: Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs. Social factors beyond care provided by outpatient practices may partly explain worse outcomes. Policymakers should consider accounting for socioeconomic disadvantage in value-based payment programs initiatives that target outpatient practices.


Assuntos
Assistência Ambulatorial/normas , Doença da Artéria Coronariana/terapia , Medicare/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Classe Social , Determinantes Sociais da Saúde/normas , Seguro de Saúde Baseado em Valor , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/mortalidade , Planos de Pagamento por Serviço Prestado/normas , Feminino , Disparidades em Assistência à Saúde/normas , Humanos , Masculino , Medicare/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Padrões de Prática Médica/normas , Indicadores de Qualidade em Assistência à Saúde/economia , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Determinantes Sociais da Saúde/economia , Resultado do Tratamento , Estados Unidos , Seguro de Saúde Baseado em Valor/economia
18.
J Med Internet Res ; 22(4): e16680, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32234699

RESUMO

BACKGROUND: Engaging socioeconomically disadvantaged populations in health research is vital to understanding and, ultimately, eliminating health-related disparities. Digital communication channels are increasingly used to recruit study participants, and recent trends indicate a growing need to partner with the social service sector to improve population health. However, few studies have recruited participants from social service settings using multiple digital channels. OBJECTIVE: This study aimed to recruit and survey 3791 adult clients of a social service organization via telephone and digital channels. This paper aimed to describe recruitment outcomes across five channels and compare participant characteristics by recruitment channel type. METHODS: The Cancer Communication Channels in Context Study recruited and surveyed adult clients of 2-1-1, a social service-focused information and referral system, using five channels: telephone, website, text message, web-based live chat, and email. Participants completed surveys administered either by phone (if recruited by phone) or on the web (if recruited from digital channels, ie, website, text message, Web-based live chat, or email). Measures for the current analysis included demographic and health characteristics. RESULTS: A total of 3293 participants were recruited, with 1907 recruited by phone and 1386 recruited from digital channels. Those recruited by phone had a moderate study eligibility rate (42.23%) and the highest survey completion rate (91.24%) of all channels. Individuals recruited by text message had a high study eligibility rate (94.14%) yet the lowest survey completion rate (74.0%) of all channels. Sample accrual goals were achieved for phone, text message, and website recruitment. Multivariable analyses found differences in participant characteristics by recruitment channel type. Compared with participants recruited by phone, those recruited from digital channels were younger (adjusted odds ratio [aOR] 0.96, 95% CI 0.96-0.97) and more likely to be female (aOR 1.52, 95% CI 1.23-1.88), married (aOR 1.52, 95% CI 1.22-1.89), and other than non-Hispanic black (aOR 1.48, 95% CI 1.22-1.79). Those recruited via phone also were more likely to have more than a high school education (aOR 2.17, 95% CI 1.67-2.82), have a household income ≥US $25,000 a year (aOR 2.02, 95% CI 1.56-2.61), and have children living in the home (aOR 1.26, 95% CI 1.06-1.51). Additionally, participants recruited from digital channels were less likely than those recruited by phone to have public health insurance (aOR 0.75, 95% CI 0.62-0.90) and more likely to report better overall health (aOR 1.52, 95% CI 1.27-1.83 for good-to-excellent health). CONCLUSIONS: Findings indicate the feasibility and utility of recruiting socioeconomically disadvantaged adults from the social service sector using multiple communication channels, including digital channels. As social service-based health research evolves, strategic recruitment using a combination of traditional and digital channels may be warranted to avoid underrepresentation of highly medically vulnerable individuals, which could exacerbate disparities in health.


Assuntos
Disparidades em Assistência à Saúde/normas , Serviço Social/normas , Telefone/normas , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Populações Vulneráveis
19.
Arch Sex Behav ; 49(6): 1939-1964, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32157486

RESUMO

Heterosexual African American youth face substantial disparities in sexual health consequences such as HIV and STI. Based on the social ecological framework, the current paper provides a comprehensive, narrative review of the past 14 years of literature examining HIV/STI risk, including risky sexual behavior, among heterosexual African American youth and a conceptual model of risk among this population. The review found that individual psychological and biological factors are insufficient to explain the sexual health disparities faced by this group; instead, structural disadvantage, interpersonal risk, and community dysfunction contribute to the disparity in HIV/STI outcomes directly and indirectly through individual psychological factors. The conceptual model presented suggests that for African American youth, (1) HIV/STI risk commonly begins at the structural level and trickles down to the community, social, and individual levels, (2) risk works in a positive feedback system such that downstream effects compound the influence of structural risks, and (3) contextual and individual risk factors must be considered within the advanced stage of the epidemic facing this population. Despite advanced HIV and STI epidemics among heterosexual African American youth, multisystemic interventions that target structural risk factors and their downstream effects are posited to reduce the disparity among this high-risk population.


Assuntos
Infecções por HIV/epidemiologia , Disparidades em Assistência à Saúde/normas , Doenças Sexualmente Transmissíveis/epidemiologia , Meio Social , Adolescente , Adulto , Afro-Americanos , Feminino , Heterossexualidade , Humanos , Masculino , Estados Unidos , Adulto Jovem
20.
Ann Vasc Surg ; 67: 395-402, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32179142

RESUMO

BACKGROUND: Multiple societal guidelines recommend medical optimization and exercise therapy for patients with claudication prior to lower extremity revascularization (LER). However, the application of those guidelines in practice remains unknown. Our hypothesis is that vascular surgeons (VS) are more adherent to guidelines compared to non-VS treating claudication. METHODS: The records of patients undergoing LER for claudication in a single center were reviewed, and adherence to guidelines prior to LER was assessed. Patients received conservative therapy if the impact of claudication on quality of life was documented, ankle-brachial index (ABI) was obtained, and patients were treated with at least 3 months of walking exercise and smoking cessation when indicated. RESULTS: There were 187 patients treated for claudication (VS = 65, non-VS = 122). There were 161 patients who underwent endovascular intervention, 19 patients had an open revascularization, and 7 patients had a hybrid procedure. Patients treated by VS were younger and more likely to be African American. Patients treated by non-VS were more likely to have hyperlipidemia, coronary artery disease, smoke, and be on antiplatelet and statin medications. VS was more likely to assess pattern of symptoms with claudication and obtain ABIs compared to non-VS, although the mean ABIs were no different. VS was more likely to use walking exercises and smoking cessation when indicated before LER. Even though 70.8% and 31.1% of patients treated by VS and non-VS respectively were recommended walking exercises, only 33.8% and 18.0% were given a period of 3 months to benefit from it prior to LER. Conservative therapy was significantly higher among VS compared to non-VS but was overall low (VS = 12.3%, non-VS = 3.3%, P = 0.016). After a mean follow-up of 3.1 ± 1.3 years, there was no difference in mortality or major amputation. CONCLUSIONS: Although adherence to guidelines in the medical management of vascular claudication prior to LER was higher among VS compared with non-VS, overall rates of adherence were low. Stricter institutional protocols and oversight across specialties are needed to reinforce the application of the established standards of care.


Assuntos
Tratamento Conservador/normas , Procedimentos Endovasculares/normas , Claudicação Intermitente/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Padrões de Prática Médica/normas , Comportamento de Redução do Risco , Centros de Atenção Terciária/normas , Procedimentos Cirúrgicos Vasculares/normas , Idoso , Tratamento Conservador/efeitos adversos , Tratamento Conservador/mortalidade , Registros Eletrônicos de Saúde , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Fidelidade a Diretrizes/normas , Disparidades em Assistência à Saúde/normas , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/mortalidade , Claudicação Intermitente/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Guias de Prática Clínica como Assunto/normas , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade
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