Community-based teaching about health disparities: combining education, scholarship, and community service.

The Institute of Medicine recommends that clinicians receive training to better understand and address disparities. While disparities in health status are primarily due to inequities in social determinants of health, current curricula largely focus on how to teach about disparities within the health care setting. Learners may more fully understand and appreciate how social contextual factors contribute to disparities through instruction about disparities in community settings. Community-based teaching about health disparities may be advantageous for learners, medical institutions, and participating communities. This manuscript aims to guide medical educators in teaching students and residents about health disparities through community-based activities, including service learning and research.

Medical-legal partnership: collaborating with lawyers to identify and address health disparities.

INTRODUCTION: Medical-legal partnerships (MLPs) bring together medical professionals and lawyers to address social causes of health disparities, including access to adequate food, housing and income. SETTING: Eighty-one MLPs offer legal services for patients whose basic needs are not being met. PROGRAM DESCRIPTION: Besides providing legal help to patients and working on policy advocacy, MLPs educate residents (29 residency programs), health care providers (160 clinics and hospitals) and medical students (25 medical schools) about how social conditions affect health and screening for unmet basic needs, and how these needs can often be impacted by enforcing federal and state laws. These curricula include medical school courses, noon conferences, advocacy electives and CME courses. PROGRAM EVALUATION: Four example programs are described in this paper. Established MLPs have changed knowledge (MLP | Boston-97% reported screening for two unmet needs), attitudes (Stanford reported reduced concern about making patients "nervous" with legal questions from 38% to 21%) and behavior (NY LegalHealth reported increasing resident referrals from 15% to 54%) after trainings. One developing MLP found doctors experienced difficulty addressing social issues (NJ LAMP-67% of residents felt uncomfortable). DISCUSSION: MLPs train residents, students and other health care providers to tackle socially caused health disparities.

Disparities in reported reasons for not initiating or stopping antiretroviral treatment among a diverse sample of persons living with HIV.

BACKGROUND: Disparities in the use of antiretroviral therapy (ART) for HIV disease have been documented across race, gender, and substance use groups. OBJECTIVE: The current analysis compares self-reported reasons for never taking or stopping ART among a diverse sample of men and women living with HIV. DESIGN: Cross-sectional interview. PARTICIPANTS: HIV + (N = 3,818) adults, 968 of whom reported discontinuing or never using ART. MEASUREMENTS: Computerized self-administered and interviewer-administered self-reported demographic and treatment variables, including gender, race, ethnicity, CD4 count, detectable viral load, and reported reasons for not taking antiretroviral therapy. RESULTS: Despite equivalent use of ART in the current sample, African-American respondents were 1.7 times more likely to report wanting to hide their HIV status and 1.7 times more likely to report a change in doctors/clinics as reasons for stopping ART (p = .049, and p = .042) and had odds 4.5 times those of non-African Americans of reporting waiting for viral marker counts to worsen (p = < .0001). There was a lower tendency (OR = 0.4) for women to endorse concerns of keeping their HIV status hidden as a reason for stopping ART compared to men (p = .003). Although those with an IDU history were less likely to be on ART, no differences in reasons for stopping or never initiating ART were found between those with and without an IDU history. CONCLUSIONS: A desire to conceal HIV status as well as a change in doctors/clinics as reasons for discontinuing ART were considerably more common among African Americans, suggesting that perceived HIV/AIDS stigma is an obstacle to maintenance of treatment. Findings also indicate differences in reasons for stopping ART by gender and a perceived desire to wait for counts to worsen as a reason for not taking ART by African Americans, regardless of detectable viral load, CD4 count, age, education, employment, sexual orientation, and site.

Closing the osteoporosis care gap: increased osteoporosis awareness among geriatrics and rehabilitation teams.

BACKGROUND: A care gap exists between recommendations and practice regarding the diagnosis and treatment of osteoporosis in fracture patients. The current study was designed to determine rates and predictors of in-hospital diagnosis and treatment of osteoporosis in patients admitted with fragility hip fractures, and to assess differences in these rates since the outset of the multipronged "Fracture? Think Osteoporosis" (FTOP) Program, which includes education of geriatrics and rehabilitation teams. METHODS: This is a retrospective cohort study conducted with data from two Hamilton, Ontario, university-based tertiary-care hospitals, and represents a follow-up to a previous study conducted 8 years earlier. Data pertaining to all 354 patients, age > or = 50, admitted between March 2003 and April 2004, inclusive, with a diagnosis of fragility hip fracture were evaluated. Twelve patients were excluded leaving 342 patients for analysis, with 75% female, mean age 81.Outcomes included: Primary -- In-hospital diagnosis of osteoporosis and/or initiation of anti-resorptive treatment ("new osteoporosis diagnosis/treatment"). Secondary -- In-hospital mortality, BMD referrals, pre-admission osteoporosis diagnosis and treatment. RESULTS: At admission, 27.8% of patients had a pre-existing diagnosis of osteoporosis and/or were taking anti-resorptive treatment. Among patients with no previous osteoporosis diagnosis/treatment: 35.7% received a new diagnosis of osteoporosis, 21% were initiated on anti-resorptive treatment, and 14.3% received a BMD referral. The greatest predictor of new osteoporosis diagnosis/treatment was transfer to a rehabilitation or geriatrics unit: 79.5% of rehabilitation/geriatrics versus 18.5% of patients receiving only orthopedics care met this outcome (p < 0.001). CONCLUSION: New diagnosis of osteoporosis among patients admitted with hip fracture has improved from 1.8% in the mid 1990's to 35.7%. Initiation of bisphosphonate therapy has likewise improved from 0% to 21%. Although multiple factors have likely contributed, the differential response between rehabilitation/geriatrics versus orthopedics patients suggests that education of the geriatric and rehabilitation teams, including one-on-one and group-based sessions, implemented as part of the FTOP Program, has played a role in this improvement. A significant care gap still exists for patients discharged directly from orthopedic units. The application of targeted inpatient and post-discharge initiatives, such as those that comprise the entire FTOP Program, may be of particular value in this setting.

Increasing culturally competent neuropsychological services for ethnic minority populations: a call to action.

US demographic and sociopolitical shifts have resulted in a rapidly growing need for culturally competent neuropsychological services. However, clinical neuropsychology as a field has not kept pace with the needs of ethnic minority clients. In this discussion we review: historical precedents and the limits of universalism in neuropsychology; ethical/professional guidelines pertinent to neuropsychological practice with ethnic minority clients; critical cultural considerations in neuropsychology; current disparities germane to practice; and challenges to the provision of services to racial/ethnic minority clients. We provide a call to action for neuropsychologists and related organizations to advance multiculturalism and diversity within the field by increasing multicultural awareness and knowledge, multicultural education and training, multicultural neuropsychological research, and the provision of culturally competent neuropsychological services to racial/ethnic minority clients. Lastly, we discuss strategies for increasing the provision of culturally competent neuropsychological services, and offer several resources to meet these goals.

Comparing methods of racial and ethnic disparities measurement across different settings of mental health care.

INTRODUCTION: The ability to track improvement against racial/ethnic disparities in mental health care is hindered by the varying methods and disparity definitions used in previous research. DATA: Nationally representative sample of whites, blacks, and Latinos from the 2002 to 2006 Medical Expenditure Panel Survey. Dependent variables are total, outpatient, and prescription drug mental health care expenditure. METHODS: Rank- and propensity score-based methods concordant with the Institute of Medicine (IOM) definition of health care disparities were compared with commonly used disparities methods. To implement the IOM definition, we modeled expenditures using a two-part GLM, adjusted distributions of need variables, and predicted expenditures for each racial/ethnic group. FINDINGS: Racial/ethnic disparities were significant for all expenditure measures. Disparity estimates from the IOM-concordant methods were similar to one another but greater than a method using the residual effect of race/ethnicity. Black-white and Latino-white disparities were found for any expenditure in each category and Latino-white disparities were significant in expenditure conditional on use. CONCLUSIONS: Findings of disparities in access among blacks and disparities in access and expenditures after initiation among Latinos suggest the need for continued policy efforts targeting disparities reduction. In these data, the propensity score-based method and the rank-and-replace method were precise and adequate methods of implementing the IOM definition of disparity.

How federal implementation choices can maximize the impact of CHIPRA on health care of children with developmental and behavioral needs.

Regardless of the ultimate outcome of health reform, the Children's Health Insurance Program Reauthorization Act of 2009 set the stage for the potential to transform children's health care in the United States. The legislation included landmark provisions to find and enroll eligible low income children, as well as an unprecedented investment in quality measurement and demonstrations focused on improving health care delivery for children. However, many choices remain for the Federal government and states in implementing these provisions that could significantly affect their ultimate success. This commentary summarizes a larger report developed from legislative analysis and expert input and provides a set of recommendations for the federal government officials charged with implementing Children's Health Insurance Program Reauthorization Act. It focuses on two key provisions of the legislation which will be important regardless of the outcome of current health reform debates, enrollment and outreach and the broad set of quality related provisions, and explores the importance and specific potential impact of this legislation on children with developmental and behavioral needs.

Routine vaccination coverage of 11 year olds, by ethnicity, through school-based vaccination in South Auckland.

AIMS: To determine vaccination coverage, by ethnicity, for the routine publicly funded vaccinations for 11 year olds, from school-based vaccination data in South Auckland, New Zealand. METHODS: De-identified aggregate data were obtained with permission from the Counties Manukau District Health Board (CMDHB) Public Health Nurses Database on the 11-year-old tetanus and polio vaccinations from 2005, and analysed to determine percentages of form return, consent and vaccination receipt by ethnicity, including relative risks for Maori compared to non-Maori students. Reasons for vaccination refusal were also analysed. RESULTS: Overall, 48% of Maori and 56% of non-Maori in Year 7 in CMDHB in 2005 (n=8642) were immunised through the school-based programme. Assuming that parents who stated their child had already received these vaccinations were all correct, the estimated overall coverage in this population for the recommended Year 7 tetanus vaccination was 67% (53% for Maori, and 71% for non-Maori). CONCLUSIONS: Vaccination coverage amongst 11 year olds in this population was lower than coverage for other childhood vaccinations in New Zealand, and there was a large Maori:non-Maori disparity.

Racial and ethnic disparities in pain: causes and consequences of unequal care.

UNLABELLED: The purpose of our review is to evaluate critically the recent literature on racial and ethnic disparities in pain and to determine how far we have come toward reducing and eliminating disparities in pain. We examined peer-reviewed research articles published between 1990 and early 2009 that focused on racial and ethnic disparities in pain in the United States. The databases used were PubMed, Medline, Scopus, CINAHL, and PsycInfo. The probable causes of minority group disparities in pain are discussed, along with suggested strategies for eliminating pain-related disparities. This review reveals the persistence of racial and ethnic disparities in acute, chronic, cancer, and palliative pain care across the lifespan and treatment settings, with minorities receiving lesser quality pain care than non-Hispanic whites. Although health and health care disparities attract local, state, and federal attention, disparities in pain care continue to be missing from publicized public health agendas and health care reform plans. Ensuring optimal pain care for all is critically important from a public health and policy perspective. A robust research program on disparities in pain is needed, and the results must be successfully translated into practices and policies specifically designed to reduce and eliminate disparities in care. PERSPECTIVE: This review evaluates the recent literature on racial and ethnic disparities in pain and pain treatment. Racial and ethnic disparities in acute pain, chronic cancer pain, and palliative pain care continue to persist. Rigorous research is needed to develop interventions, practices, and policies for eliminating disparities in pain.

Rural-urban differences in acute stroke management practices: a modifiable disparity.

Acute stroke management practices in rural areas of the United States are suboptimal, which creates an unacceptable health disparity between urban patients with stroke and their rural counterparts. The existing gap between urban and rural stroke care may widen in the future as more urban-tested interventions are incorporated into the treatment of acute stroke. We conducted a PubMed search to identify all the articles published from 1997 to 2007 that addressed acute stroke, paramedics, ambulances, emergency services, and interhospital transportation pertaining to the US rural, urban, or nonurban environment. We review herein the problems and potential solutions that exist in 3 aspects of the current rural stroke care system: prehospital care, rural local hospital emergency department care, and interhospital transfer of patients and subsequent reception at a larger tertiary care institution, which often involve long distances and considerable time. We conclude that the current gap in rural-urban stroke management practices could be overcome with a comprehensive strategy that addresses the existing issues, including further education of rural caregivers, remote support from tertiary care institutions, and implementation of future acute clinical trials that test the rural strategies to stroke care.