COVID-19 Conversations Within Black/Brown Minority Communities: A Stakeholder and Psychoeducation Approach Using Zoom/Facebook Live.

As communities of color are disproportionately affected by COVID-19, there is an urgent need for dissemination of timely and accurate information to community members. In this article, we describe a stakeholder approach for the implementation, evaluation, and lessons learned from COVID-19 Conversations, a program developed and delivered virtually by researchers and academics at Northwell Health. The goal of the program was to address the mental, physical, and psychosocial needs of community members. The program used Zoom/Facebook Live to deliver interactive discussions on topics ranging from health education on COVID-19 and mental health to resources for unmet social needs. This interprofessional, cross-sector collaboration highlights the importance of public health interventions aimed at reducing the spread of COVID-19 through easy online access and culturally relevant community education and outreach.

Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care.

BACKGROUND: There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. OBJECTIVE: We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. METHODS: We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care. RESULTS: The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care. CONCLUSION: Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area.

Importance: There is limited information describing the presenting characteristics and outcomes of US patients requiring hospitalization for coronavirus disease 2019 (COVID-19). Objective: To describe the clinical characteristics and outcomes of patients with COVID-19 hospitalized in a US health care system. Design, Setting, and Participants: Case series of patients with COVID-19 admitted to 12 hospitals in New York City, Long Island, and Westchester County, New York, within the Northwell Health system. The study included all sequentially hospitalized patients between March 1, 2020, and April 4, 2020, inclusive of these dates. Exposures: Confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by positive result on polymerase chain reaction testing of a nasopharyngeal sample among patients requiring admission. Main Outcomes and Measures: Clinical outcomes during hospitalization, such as invasive mechanical ventilation, kidney replacement therapy, and death. Demographics, baseline comorbidities, presenting vital signs, and test results were also collected. Results: A total of 5700 patients were included (median age, 63 years [interquartile range {IQR}, 52-75; range, 0-107 years]; 39.7% female). The most common comorbidities were hypertension (3026; 56.6%), obesity (1737; 41.7%), and diabetes (1808; 33.8%). At triage, 30.7% of patients were febrile, 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The rate of respiratory virus co-infection was 2.1%. Outcomes were assessed for 2634 patients who were discharged or had died at the study end point. During hospitalization, 373 patients (14.2%) (median age, 68 years [IQR, 56-78]; 33.5% female) were treated in the intensive care unit care, 320 (12.2%) received invasive mechanical ventilation, 81 (3.2%) were treated with kidney replacement therapy, and 553 (21%) died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. The median postdischarge follow-up time was 4.4 days (IQR, 2.2-9.3). A total of 45 patients (2.2%) were readmitted during the study period. The median time to readmission was 3 days (IQR, 1.0-4.5) for readmitted patients. Among the 3066 patients who remained hospitalized at the final study follow-up date (median age, 65 years [IQR, 54-75]), the median follow-up at time of censoring was 4.5 days (IQR, 2.4-8.1). Conclusions and Relevance: This case series provides characteristics and early outcomes of sequentially hospitalized patients with confirmed COVID-19 in the New York City area.

Financial resources, access to care, and quality of care mediate racial disparities in statin usage for secondary prevention.

BACKGROUND: There are disparities in statin therapy for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). The role of structural racism in this disparity has not been examined. METHODS: This is a cross-sectional study of participants with ASCVD in the Medical Expenditure Panel Survey from 2014-2017. Mediation analysis is utilized to estimate the direct effect of race and indirect effect of financial resources, access to care, and quality of care on statin usage. RESULTS: The proportion of participants using statins by race/ethnicity were 58.5% for non-Hispanic Whites, 45% for Hispanics, 48.6% for Blacks, 61.6% for Asians, and 46.8% for Others. Statin usage was lower for Hispanics (OR = 0.79, 95% confidence interval [0.65-0.96]) and Blacks (OR = 0.80 [0.66-0.95]) compared to Whites. Hispanic, Black, and Other participants with the same financial resources, access to care, and quality of care as White participants did not have significantly different statin usage compared to White participants (Hispanic: OR = 0.98 [0.79-1.13]; Black (OR = 0.88 [0.76-1.06], Other: OR 0.76, 95% CI [0.56-1.15]). Hispanic, Black, and Other participants had significantly lower statin usage than subjects of the same race but with financial resources, access to care, and quality of care observed in White subjects (Hispanic: OR = 0.83 [0.83-0.92]; Black: OR = 0.91[0.88-0.94]; Other: OR = 0.92 [0.87-0.98]). DISCUSSION: The indirect effect of race and ethnicity on statin therapy are significant but the direct effect of race and ethnicity on statin therapy are insignificant among Blacks and Hispanics compared to non-Hispanic Whites. This suggests that racial disparities in statin therapy are mediated through inequitably distributed resources, suggestive of the impact of structural racism.

Black Physicians' Experiences with Anti-Black Racism in Healthcare Systems Explored Through An Attraction-Selection-Attrition Lens.

Anti-Black racism is a specific form of racism directed at Black people. In healthcare, there are poignant examples of anti-Black racism in the recruitment, selection, and retention stages of the job cycle. Research shows that anti-Black racism is associated with inequitable work outcomes and the under-representation of Black physicians. However, empirical findings are scattered with no organizing framework to consolidate these findings. To add to the literature, in this paper we present the attraction-selection-attrition (ASA) model (Schneider, 1987) as an organizing framework to discuss Black physicians' experiences with anti-Black racism and discrimination throughout their careers. We draw from previous literature to highlight specific experiences of Black physicians at each stage of the job cycle (i.e., attraction, selection, retention), and we offer considerations on how practitioners can mitigate anti-Black racism throughout the job cycle. In the wake of COVID-19 and highly publicized social justice movements, healthcare systems are seeking ways to increase the recruitment, selection, and retention of Black physicians to ensure health equity. We believe this guide will be valuable to practitioners, leaders, researchers, and program directions seeking to advance diversity, equity, and inclusion of Black physicians in their healthcare systems. We conclude by providing practical implications and directions for future research.

Expanding Knowledge and Changing Attitudes About Poverty: An Interactive, Interprofessional Approach.

BACKGROUND: Poverty negatively affects the lives and health of the poor. However, health professionals often have limited personal experience and receive little formal education on surviving under conditions of poverty in the United States, which may contribute to suboptimal patient care and outcomes. PURPOSE: We conducted a 3-h, interactive, experiential poverty simulation workshop with an interprofessional group of pre-professional health students to increase their comprehension about the realities of poverty. METHOD: As part of the evaluation, participants completed a self-assessment of their attitudes and skills using a Likert scale and open-ended questions; a reflection prompt about how the workshop might affect their professional practice; and a pre- and post-assessment questionnaire. DISCUSSION: Participants' attitudes about low-income patients became more favorable; they gained awareness and expressed empathy through the role-play experience. Our analysis revealed increased understanding of social determinants of health, of life challenges that patients face outside of healthcare, and that solutions must be collaborative as the challenges facing poor patients are multifactorial. CONCLUSION: The workshop allowed interprofessional students to learn from and with each other about the experiences of poor patients. Future sessions should emphasize interprofessional skill-building and action, potentially in virtual formats.

Using highly variable warfarin dosing to identify patients at risk for adverse events.

BACKGROUND: Patients who receive highly variable doses of warfarin may be at risk for poor anticoagulation control and adverse events. However, we lack a system to identify patients with the highest dose variability. Our objectives were to develop a scoring system to identify patients with high dose variability, and to validate this new measure by demonstrating that patients so identified have poor anticoagulation control and higher rates of adverse events (criterion validity). METHODS: We used a database of over 4, 000 patients who received oral anticoagulation in community practice between 2000-2002. We reviewed the charts of 168 patients with large warfarin dose variation and agreed on 18 risk factor definitions for high dose variability. We identified 109 patients with the highest dose variability (cases), as measured by coefficient of variation (CoV, SD/mean). We matched each case to two controls with low dose variability. Then, we examined all 327 charts, blinded to case/control status, to identify the presence or absence of the 18 risk factors for dose variability. We performed a multivariable analysis to identify independent predictors of high CoV. We also compared anticoagulation control, as measured by percent time in therapeutic range (TTR), and rates of adverse events between groups. RESULTS: CoV corresponded with other measures of anticoagulation control. TTR was 53% among cases and 79% among controls (p < 0.001). CoV also predicted adverse events. Six cases experienced a major hemorrhage versus 1 control (p < 0.001) and 3 cases had a thromboembolic event versus 0 control patients (p = 0.04). Independent predictors of high dose variability included hospitalization (OR = 21.3), decreased oral intake (OR = 12.2), use of systemic steroids (OR = 6.1), acetaminophen (OR = 4.0) and antibiotics (OR = 2.7; p < 0.05 for all). CONCLUSION: CoV can be used to identify patients at risk for poor anticoagulation control and adverse events. This new measure has the potential to identify patients at high risk before they suffer adverse events.

Racial and ethnic minority patient participation in N-of-1 trials: perspectives of healthcare providers and patients.

Aim: Patients from racial and ethnic minority backgrounds in the USA have historically been under-represented in research trials. Understanding their viewpoints regarding participation in N-of-1 trials is imperative as we design and implement these studies. Materials & methods: We conducted six focus groups of racial and ethnic minority patients (n = 25) and providers (n = 9). We used content analysis to identify themes. Results: Our results noted the importance of considering family members in N-of-1 trial recruitment and participation, patients' desire for education as a design feature, for 'lifestyle' changes as a treatment option and for use of nonevidence-based treatments in the design of future N-of-1 trials. Conclusion: Personalized trials have the potential to change the way we deliver primary care and improve disparities for minorities.

Lay abstract Commonly, research studies seek to enroll large groups of individuals to test a new product or medication. However, the personalized trial/N-of-1 trial has a different goal. This is to focus on a single person and study their response to different treatments. Our focus group-based study of medical providers and racial and ethnic minority patients, sought to learn how personalized trials can be designed to include the life experiences and cultural considerations of members of minority populations. Participants noted factors such as the role of family, including educational programming or lifestyle changes in the trial, and the use of natural remedies (not prescribed by a physician) as specific cultural considerations. N-of-1 trials have the potential to change the way we deliver primary care and improve disparities, but we must design them to address the concerns of importance to minority populations.

The impact of United States Medical Licensing Exam (USMLE) step 1 cutoff scores on recruitment of underrepresented minorities in medicine: A retrospective cross-sectional study.

BACKGROUND AND AIMS: United States Medical Licensing Exam (USMLE) scores are the single, most objective criteria for admission into residency programs in the country. Underrepresented minorities in medicine (URiM) are found to have lower USMLE scores compared to their White counterparts. The objective of this study is to examine how USMLE step 1 cutoff scores may exclude self-reported URiM from the residency interview process across various specialties. METHODS: This was a retrospective cross-sectional study of 10 541 applicants to different residency programs at Zucker School of Medicine at Hofstra/Northwell Health between May 2014 and May 2015. We identified Blacks and Hispanics as URiM. The primary outcome is the percentage of applicants with USMLE step 1 score above different ranges of cutoff score, from 205 to 235 in five-point increments, by race/ethnicity and by URiM status. Secondary outcome is percentages of URiM vs non-URiM above and below mean USMLE step 1 scores by different specialties (internal medicine, obstetrics/gynecology, pediatrics, and psychiatry). RESULTS: The study sample included 2707 White, 722 Black, 805 Hispanic, 5006 Asian, and 562 Other Race/Ethnicity applicants. Overall, 50.2% were male, 21.3% URiM, 7.4% had limited English proficiency, 67.6% attended international medical schools, and 2.4% are Alpha Omega Alpha Honor Medical Society (AOA) members. The mean (±SD) USMLE step 1 score was significantly greater among non-URiM applicants as compared to URiM applicants (223.7 ± 19.4 vs 216.1 ± 18.4, P < .01, two-sample t-test). Non-URiM applicants were younger, and the percentage of male and AOA applicants was greater among non-URiM applicants as compared to URiM applicants (50.5% vs 47.7%, P = .02, Chi-Square test; 2.9% vs 1.2%, P < .01, Chi-Square test, respectively). CONCLUSION: Using a USMLE step 1 cutoff score as an initial filter for applicant recruitment and selection could jeopardize the benefits of a diverse residency program. Practical implications are discussed.

Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study.

Psychiatric and behavior problems are common among children and young adults, and many go without care or only receive treatment in carceral settings. We examined racial and ethnic disparities in children's and young adults' receipt of mental health and substance abuse care using nationally representative data from the 2006-2012 Medical Expenditure Panel Surveys. Blacks' and Hispanics' visit rates (and per capita expenditures) were about half those of non-Hispanic whites for all types and definitions of outpatient mental health services. Disparities were generally larger for young adults than for children. Black and white children had similar psychiatric inpatient and emergency department utilization rates, while Hispanic children had lower hospitalization rates. Multivariate control for mental health impairment, demographics, and insurance status did not attenuate racial/ethnic disparities in outpatient care. We conclude that psychiatric and behavioral problems among minority youth often result in school punishment or incarceration, but rarely mental health care.