BACKGROUND:Health disparities are differences in health or health care between groups based on social, economic, and/or environmental disadvantage. Disparity research often follows 3 stepsdetecting ...(phase 1), understanding (phase 2), and reducing (phase 3), disparities. Although disparities have narrowed over time, many remain.
OBJECTIVES:We argue that implementation science could enhance disparities research by broadening the scope of phase 2 studies and offering rigorous methods to test disparity-reducing implementation strategies in phase 3 studies.
METHODS:We briefly review the focus of phase 2 and phase 3 disparities research. We then provide a decision tree and case examples to illustrate how implementation science frameworks and research designs could further enhance disparity research.
RESULTS:Most health disparities research emphasizes patient and provider factors as predominant mechanisms underlying disparities. Applying implementation science frameworks like the Consolidated Framework for Implementation Research could help disparities research widen its scope in phase 2 studies and, in turn, develop broader disparities-reducing implementation strategies in phase 3 studies. Many phase 3 studies of disparity-reducing implementation strategies are similar to case studies, whose designs are not able to fully test causality. Implementation science research designs offer rigorous methods that could accelerate the pace at which equity is achieved in real-world practice.
CONCLUSIONS:Disparities can be considered a “special case” of implementation challenges—when evidence-based clinical interventions are delivered to, and received by, vulnerable populations at lower rates. Bringing together health disparities research and implementation science could advance equity more than either could achieve on their own.
This study investigates the role of students' sense of belonging to their university in college student retention. Using individual growth curve modeling, we examined (a) whether sense of belonging ...predicts intentions to persist, and (b) the effects of an intervention designed to enhance students' sense of belonging. African American and white first-year students completed surveys three times throughout the academic year. Students were randomly assigned to a group that received an intervention to enhance students' sense of belonging or to one of two control groups. Sense of belonging was found to predict intentions to persist, controlling for background variables and other predictors of persistence. Overall, sense of belonging and intentions to persist declined over the academic year. However, the decline in sense of belonging was smaller for students in the intervention group. Implications for the development of college retention programs and for existing models of student persistence are discussed.
Background Healthcare experiences associated with perceived racial/ethnic discrimination among patients are poorly understood. Objective Identify domains of patient dissatisfaction associated with ...perceived racial/ethnic discrimination among patients with pain. Design Semi-structured telephone surveys completed in 2013–2015. Participants White, African American, and Latino participants who reported receiving pain management from 25 Veterans Affairs (VA) Medical Centers. Main measures Surveys included open-ended questions about healthcare satisfaction/dissatisfaction and a measure of perceived racial/ethnic-based discrimination while seeking VA healthcare. Binary indicators for ten qualitative domains of dissatisfaction were derived from open-ended questions. We used multilevel models to identify dissatisfaction domains associated with perceived discrimination, adjusting for patient characteristics and site. Within domains associated with discrimination, we identified the most frequent codes and examined whether patients primarily referenced clinical or non-clinical staff in their experiences. Key results Overall, 622 participants (30.4% White, 37.8% African American, 31.8% Latino; 57.4% female; mean age = 53.4) reported a median discrimination score of 1.0 (IQR: 1.0–1.3) on a scale of 1 to 5; 233 (37.5%) perceived any racial/ethnic discrimination in healthcare. Individually, 7 of 10 qualitative domains were significantly associated with perceived discrimination: dissatisfaction with care quality, facilities, continuity of care, interactions with staff, staff demeanor, unresolved pain, and pharmacy services (ps<0.005). In combined models stratified by racial/ethnic group, 3 domains remained statistically significant: poor interactions for Latinos (adjOR = 5.24, 95% CI = 2.28–12.06), negative demeanor for African Americans (adjOR = 2.82, 95% CI = 1.45–5.50), and unresolved pain for Whites (adjOR = 6.23, 95% CI = 2.39–16.28). Clinical staff were referenced more often than non-clinical staff for all domains (interactions: 51% vs. 30%; demeanor: 46% vs. 15%; unresolved pain: 18% vs. 1%, respectively). Conclusion Negative interpersonal experiences and unresolved pain are strong correlates of perceived racial/ethnic discrimination among patients with pain. Future studies should test whether interventions targeting these domains reduce patient perceptions of racial/ethnic discrimination in healthcare.
To estimate the prevalence and consequences of receiving prescription opioids from both the Department of Veterans Affairs (VA) and Medicare Part D.
Among US veterans enrolled in both VA and Part D ...filling 1 or more opioid prescriptions in 2012 (n = 539 473), we calculated 3 opioid safety measures using morphine milligram equivalents (MME): (1) proportion receiving greater than 100 MME for 1 or more days, (2) mean days receiving greater than 100 MME, and (3) proportion receiving greater than 120 MME for 90 consecutive days. We compared these measures by opioid source.
Overall, 135 643 (25.1%) veterans received opioids from VA only, 332 630 (61.7%) from Part D only, and 71 200 (13.2%) from both. The dual-use group was more likely than the VA-only group to receive greater than 100 MME for 1 or more days (34.3% vs 10.9%; adjusted risk ratio ARR = 3.0; 95% confidence interval CI = 2.9, 3.1), have more days with greater than 100 MME (42.5 vs 16.9 days; adjusted difference = 16.4 days; 95% CI = 15.7, 17.2), and to receive greater than 120 MME for 90 consecutive days (7.8% vs 3.1%; ARR = 2.2; 95% CI = 2.1, 2.3).
Among veterans dually enrolled in VA and Medicare Part D, dual use of opioids was associated with more than 2 to 3 times the risk of high-dose opioid exposure.
Despite well-documented racial disparities in prescribing opioid medications for pain, little is known about whether there are disparities in the monitoring and follow-up treatment of patients who ...are prescribed opioid medications. We conducted a retrospective cohort study to examine whether there are racial differences in the use of recommended opioid monitoring and follow-up treatment practices. Our sample included 1646 white and 253 black patients who filled opioid prescriptions for noncancer pain for ≥ 90 consecutive days at the Veterans Affairs Pittsburgh Healthcare System pharmacy in fiscal years 2007 and 2008. Several opioid monitoring and follow-up treatment practices were extracted from electronic health records for a 12-month follow-up period. Findings indicated that 26.3% of patients had opioid agreements on file, pain was documented in 71.7% of primary care follow-up visits, urine drug tests were administered to 49.3% of patients, and 21.2% and 4.2% of patients were referred to pain and substance abuse specialists, respectively. Racial differences were observed in several of these practices. In adjusted comparisons, pain was documented less frequently for black patients than for white patients. Among those who had at least 1 urine drug test, black patients were subjected to more tests, especially if they were on higher doses of opioids. Compared with white patients, black patients were less likely to be referred to a pain specialist and more likely to be referred for substance abuse assessment. Addressing disparities in opioid monitoring and follow-up treatment practices may be a previously neglected route to reducing racial disparities in pain management.
Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences.
Describe ...the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans.
A cross-sectional, telephone-based survey of a random national sample of young female Veterans.
Female VA primary care patients aged 18-45 years.
The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrimination and cumulative perceived discrimination with patient and health service characteristics.
Among 2294 women Veterans, 33.7% perceived gender-based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08, mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI=2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women's health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrimination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care.
One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women's health clinic at one's VA were associated with less perceived discrimination.
More than half of enrollees in the U.S. Department of Veterans Affairs (VA) are also covered by Medicare and can choose to receive their prescriptions from VA or from Medicare-participating ...providers. Such dual-system care may lead to unsafe opioid use if providers in these 2 systems do not coordinate care or if prescription use is not tracked between systems.
To evaluate the association between dual-system opioid prescribing and death from prescription opioid overdose.
Nested case-control study.
VA and Medicare Part D.
Case and control patients were identified from all veterans enrolled in both VA and Part D who filled at least 1 opioid prescription from either system. The 215 case patients who died of a prescription opioid overdose in 2012 or 2013 were matched (up to 1:4) with 833 living control patients on the basis of date of death (that is, index date), using age, sex, race/ethnicity, disability, enrollment in Medicaid or low-income subsidies, managed care enrollment, region and rurality of residence, and a medication-based measure of comorbid conditions.
The exposure was the source of opioid prescriptions within 6 months of the index date, categorized as VA only, Part D only, or VA and Part D (that is, dual use). The outcome was unintentional or undetermined-intent death from prescription opioid overdose, identified from the National Death Index. The association between this outcome and source of opioid prescriptions was estimated using conditional logistic regression with adjustment for age, marital status, prescription drug monitoring programs, and use of other medications.
Among case patients, the mean age was 57.3 years (SD, 9.1), 194 (90%) were male, and 181 (84%) were non-Hispanic white. Overall, 60 case patients (28%) and 117 control patients (14%) received dual opioid prescriptions. Dual users had significantly higher odds of death from prescription opioid overdose than those who received opioids from VA only (odds ratio OR, 3.53 95% CI, 2.17 to 5.75; P < 0.001) or Part D only (OR, 1.83 CI, 1.20 to 2.77; P = 0.005).
Data are from 2012 to 2013 and cannot capture prescriptions obtained outside the VA or Medicare Part D systems.
Among veterans enrolled in VA and Part D, dual use of opioid prescriptions was independently associated with death from prescription opioid overdose. This risk factor for fatal overdose among veterans underscores the importance of care coordination across health care systems to improve opioid prescribing safety.
U.S. Department of Veterans Affairs.
Quality and equity of care in U.S. hospitals Trivedi, Amal N; Nsa, Wato; Hausmann, Leslie R M ...
The New England journal of medicine,
12/2014, Letnik:
371, Številka:
24
Journal Article
Recenzirano
Odprti dostop
Nearly every U.S. hospital publicly reports its performance on quality measures for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia. Because performance ...rates are not reported according to race or ethnic group, it is unclear whether improvements in equity of care have accompanied aggregate improvements in health care quality over time.
We assessed performance rates for quality measures covering three conditions (six measures for acute myocardial infarction, four for heart failure, and seven for pneumonia). These rates, adjusted for patient- and hospital-level covariates, were compared among non-Hispanic white, non-Hispanic black, and Hispanic patients who received care between 2005 and 2010 in acute care hospitals throughout the United States.
Adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points between 2005 and 2010 for white, black, and Hispanic adults (P<0.001 for all comparisons). In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on 3 measures (range of differences, 12.3 to 14.2) and for Hispanic patients on 6 measures (5.6 to 14.5). Gaps decreased significantly on all 9 of these measures between 2005 and 2010, with adjusted changes for differences between white patients and black patients ranging from -8.5 to -11.8 percentage points and from -6.2 to -15.1 percentage points for differences between white patients and Hispanic patients. Decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients.
Improved performance on quality measures for white, black, and Hispanic adults hospitalized for acute myocardial infarction, heart failure, or pneumonia was accompanied by increased racial and ethnic equity in performance rates both within and among U.S. hospitals. (Funded by the Centers for Medicare and Medicaid Services and the Veterans Affairs Health Services Research and Development Career Development Program.).
Background
Oral anticoagulation reduces stroke risk for patients with atrial fibrillation (AF). Prior research demonstrates lower anticoagulant prescribing in Black than in White individuals but few ...studies have examined racial differences in facility-level anticoagulant prescribing for AF.
Objective
To assess variation in anticoagulant initiation by race within Veterans Health Administration (VA) facilities.
Design
Retrospective cohort study.
Participants
Black and White patients enrolled in the VA with incident AF from 2020 through 2021.
Main Measures
The primary outcome was rate of any anticoagulant initiation (i.e., warfarin or direct oral anticoagulant DOAC) or any DOAC therapy within 90 days of an AF diagnosis, overall and for Black and White patients at each facility. We also estimated the adjusted Black-White risk difference.
Key Results
In 82 VA facilities serving 26,832 Black and White patients, overall unadjusted rates of any anticoagulant therapy ranged from 56.8 to 87.1% across facilities; the corresponding ranges for Black and White patients were 47.6 to 91.3% and 58.2 to 87.1%, respectively. Overall unadjusted rates of DOAC therapy ranged from 55.1 to 85.5% by facility; ranges for Black and White patients were 42.8 to 86.9% and 56.4 to 85.5%, respectively. The adjusted risk difference between Black and White patients ranged from − 29.9 (95% CI, − 54.9 to − 4.8) to 14.2 (95% CI, − 9.1 to 25.0) across facilities for any anticoagulant therapy and from − 28.8 (95% CI, − 58.3 to 0.8) to 15.0 (95% CI, − 8.0 to 38.1) for DOAC therapy. For any anticoagulant therapy there were 3 facilities where prescribing was statistically higher in White than Black patients; for DOAC therapy there were 5 such facilities.
Conclusions
In a national cohort of patients with AF, we observed large facility-level variation and adjusted risk differences in any anticoagulant and DOAC initiation, overall and by race. These findings represent a target for local quality improvement in AF care.
The authors argue for the inclusion of students' subjective sense of belonging in an integrated model of student persistence (Cabrera et al., J Higher Educ 64:123-139, 1993). The effects of sense of ...belonging and a simple intervention designed to increase sense of belonging are tested in the context of this model. The intervention increased sense of belonging for white students, but not for African American students. However, sense of belonging had direct effects on institutional commitment and indirect effects on intentions to persist and actual persistence behavior for both white and African American students.
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