Eliminating Race-Based Medicine Wright, Joseph L; Davis, Wendy S; Joseph, Madeline M ...
Pediatrics (Evanston),
07/2022, Volume:
150, Issue:
1
Journal Article
Peer reviewed
Race-based medicine has been pervasively interwoven into the fabric of health care delivery in the United States for more than 400 years. Race is a historically derived social construct that has no ...place as a biologic proxy. In addition to valid measures of social determinants of health, the effects of racism require consideration in clinical decision-making tools in ways that are evidence informed and not inappropriately conflated with the limiting phenotype of race categorization. This policy statement addresses the elimination of race-based medicine as part of a broader commitment to dismantle the structural and systemic inequities that lead to racial health disparities.
The United States has the highest incarceration rate in the world, with spillover impacts on 5 million children with an incarcerated parent. Children exposed to parental incarceration (PI) have ...suboptimal health care access, use, and outcomes in adulthood compared to their peers. However, little is known about their access and utilization during childhood. We evaluated relationships between PI and health care use and access throughout childhood and adolescence.
We analyzed the nationally representative 2019 National Health Interview Survey Child Sample to examine cross-sectional associations between exposure to incarceration of a residential caregiver, access to care, and health care use among children aged 2–17. Respondents were asked about measures of preventive care access, unmet needs due to cost, and acute care use over the last year. We estimated changes associated with PI exposure using multiple logistic regression models adjusted for age, sex, race, ethnicity, parental education, family structure, rurality, income, insurance status, and disability.
Of 7,877 sample individuals representing a weighted population of 63,046,969 children, 484 (weighted 3,761,207; 6.0% 95% CI 5.4-6.6) were exposed to PI. In adjusted analyses to produce national estimates, exposure to PI was associated with an additional 123,703 children lacking a usual source of care, 114,795 with forgone dental care needs, 75,434 with delayed mental health care needs, and 53,678 with forgone mental health care needs.
Exposure to PI was associated with worse access to a usual source of care and unmet dental and mental health care needs. Our findings highlight the need for early intervention by demonstrating that these barriers emerge during childhood and adolescence.
Early life adversities (ELA), include experiences such as child maltreatment, household dysfunction, bullying, exposure to crime, discrimination, bias, and victimization, and are recognized as social ...determinants of cardiovascular disease (CVD). Strong evidence shows exposure to ELA directly impacts cardiometabolic risk in adulthood and emerging evidence suggests there may be continuity in ELA's prediction of cardiometabolic risk over the life course.
Extant research has primarily relied on a cumulative risk framework to evaluate the relationship between ELA and CVD. In this framework, risk is considered a function of the number of risk factors or adversities that an individual was exposed to across developmental periods. The cumulative risk exposure approach treats developmental periods and types of risk as equivalent and interchangeable. Moreover, cumulative risk models do not lend themselves to investigating the chronicity of adverse exposures or consider individual variation in susceptibility, differential contexts, or adaptive resilience processes, which may modify the impact of ELA on CVD risk.
To date, however, alternative models have received comparatively little consideration. Overall, this paper will highlight existing gaps and offer recommendations to address these gaps that would extend our knowledge of the relationship between ELA and CVD development. We focus specifically on the roles of: 1) susceptibility and resilience, 2) timing and developmental context; and 3) variation in risk exposure. We propose to expand current conceptual models to incorporate these factors to better guide research that examines ELA and CVD risk across the life course.
With 2.3 million individuals incarcerated in the United States, incarceration remains a pressing social influence on health. While risk factors for incarceration are known, research has been slow to ...identify protective factors. Characterizing adolescent protective and risk factors for incarceration outcomes can inform interventions to prevent incarceration. Using survey data from the National Longitudinal Study of Adolescent to Adult Health, we tested the influence of adolescent risk and protective factors for incarceration of young people. We used ordinal logistic regressions, investigating the relationship between adolescent characteristics (wave I, grades 7–12) with two outcomes: incarceration onset (no incarceration, onset of incarceration as a juvenile, and onset of incarceration as an adult) and incarceration frequency (never incarcerated, incarcerated once, incarcerated more than once) during adolescence and into adulthood (
N
= 12,136, wave IV, ages 24–32). Adolescent protective factors against incarceration onset and higher incarceration frequency centered on education, including a higher grade point average and a higher likelihood of having future plans to attend college. Risk factors included disruptive behavior, physical or sexual abuse in childhood, parental incarceration, and living with a stepfather figure. Stratified analyses suggested that Latinos may have unique risk profiles compared to African American and White youth. The educational system may be a locus for protective interventions promoting academic achievement and educational aspirations. Understanding both incarceration risk and protective factors may allow interventions to be tailored appropriately.
Highlights
Nationally representative study examined risk factors and protective factors in adolescence associated with incarceration.
Protective factors in adolescence centered on educational success and future educational plans.
Latino youth appeared to have differences in incarceration risk factors as compared to youth from other racial groups that warrant further examination.
Educational success may be a locus for the prevention of incarceration in adolescence and adulthood.
Translational research should examine racism and bias and improve health equity. We designed and implemented a course for the Master of Science in Clinical Investigation program of the Northwestern ...University Clinical and Translational Sciences Institute. We describe curriculum development, content, outcomes, and revisions involving 36 students in 2 years of "Anti-Racist Strategies for Clinical and Translational Science." Ninety-six percent of students reported they would recommend the course. Many reported changes in research approaches based on course content. A course designed to teach anti-racist research design is feasible and has a positive short-term impact on learners.
For the 1.4 million emergency department (ED) visits for traumatic brain injury (TBI) annually in the United States, computed tomography (CT) may be over utilized. The Pediatric Emergency Care ...Applied Research Network developed 2 prediction rules to identify children at very low risk of clinically important TBI. We implemented these prediction rules as decision support within our electronic health record (EHR) to reduce CT.
To test EHR decision support implementation in reducing CT rates for head trauma at 2 pediatric EDs.
We compared monthly CT rates 1 year before preimplementation (PRE) and 1 year after postimplementation (POST) decision support implementation. The primary outcome was change in CT use rate over time, measured using statistical process control charts. Secondary analyses included multivariate comparisons of PRE to POST. Balancing measures included ED length of stay and returns within 7 days after ED release.
There were 2,878 patients with head trauma (1,329 PRE and 1,549 POST) included. Statistical process control charts confirmed decreased CT rates over time POST that was not present PRE. Secondary statistical analyses confirmed that CT scan utilization rates decreased from 26.8% to 18.9% (unadjusted Odds Ratio OR, 0.64; 95% Confidence Interval CI, 0.53 -0.76; adjusted OR, 0.71; 95% CI, 0.58 -0.86). Length of stay was unchanged. There was no increase in returns within 7 days and no significant missed diagnoses.
Implementation of EHR-integrated decision support for children with head trauma presenting to the ED is associated with a decrease in CT utilization and no increase in significant safety events.
Background/Aims
The SARS-CoV-2 pandemic disproportionately impacted communities with lower access to health care in the United States, particularly before vaccines were widely available. These same ...communities are often underrepresented in clinical trials. Efforts to ensure equitable enrollment of participants in trials related to treatment and prevention of Covid-19 can raise concerns about exploitation if communities with lower access to health care are targeted for recruitment.
Methods
To enhance equity while avoiding exploitation, our site developed and implemented a three-part recruitment strategy for pediatric Covid-19 vaccine studies. First, we publicized a registry for potentially interested participants. Next, we applied public health community and social vulnerability indices to categorize the residence of families who had signed up for the registry into three levels to reflect the relative impact of the pandemic on their community: high, medium, and low. Finally, we preferentially offered study participation to interested families living in areas categorized by these indices as having high impact of the Covid-19 pandemic on their community.
Results
This approach allowed us to meet goals for study recruitment based on public health metrics related to disease burden, which contributed to a racially diverse study population that mirrored the surrounding community demographics. While this three-part recruitment strategy improved representation of minoritized groups from areas heavily impacted by the Covid-19 pandemic, important limitations were identified that would benefit from further study.
Conclusion
Future use of this approach to enhance equitable access to research while avoiding exploitation should test different methods to build trust and communicate with underserved communities more effectively.
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