The representation of minorities among medical students has increased over the past two decades, but diversity among orthopaedic residents lags behind. This phenomenon has occurred despite a recent ...focus by the American Academy of Orthopaedic Surgeons on the recruitment of minorities and women.
To analyze the impact of recent efforts on diversity in orthopaedic residents in comparison with other surgical specialties from 2006 to 2015.
Data from the American Association of Medical Colleges on residents in surgical specialty programs in the years 2006 to 2015 were analyzed. Linear regression models were used to estimate trends in diversity among orthopaedic residents and residents in other surgical specialties. A mixed model analysis of variance was used to compare rates of diversification among different specialties over time.
Female representation in orthopaedic programs increased from 10.9% to 14.4% between 2006 and 2015. However, the rate of increase was significantly lower compared with other specialties (all P < 0.05) studied, except for urology (P = 0.64). Minority representation in orthopaedics averaged 25.6% over the 10-year period. Residents of Hispanic origin in orthopaedic programs increased (P = 0.0003) but decreased for Native Hawaiian/Pacific Islander (P < 0.0001). During the same period, white representation increased (P = 0.004). No significant changes were found in African Americans or Asian American representation. Diversity decreased among orthopaedic residents over the period studied (P = 0.004).
Recruitment efforts have not reversed the sex, racial, and ethnic disparities in orthopaedic residents. Orthopaedics has the lowest representation of women and minorities among residencies studied. The rate of increase in women lags behind all surgical subspecialties, except for urology.
Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood.
To determine whether disparities in first ...central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities.
This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022.
Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes.
Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes.
Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean IQR age, 1.34 0.07-8.83 years; female, 122 43.3%; male, 160 56.7%; English-speaking, 236 83.7%; LOE, 46 16.3%; American Indian or Alaska Native, 3 1.1%; Asian, 14 5.0%; Black, 26 9.2%; Hispanic, 61 21.6%; Native Hawaiian or Other Pacific Islander, 4 1.4%; White, 139 49.3%; ≥2 races, 14 5.0%; unknown race and ethnicity or refused to answer, 15 5.3%). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27).
The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.
To assess the emergence of sentinel lymph node biopsy (SLNB) for disparities in utilization, and impacts on perioperative outcomes.
Retrospective cohort study of the National Cancer Database, ...selecting for patients with T1NxM0 endometrial cancer undergoing minimally invasive surgical staging from 2012 to 2016. Disparities in SLNB utilization were described. Propensity matching was performed. Association of SLNB with perioperative outcomes was assessed with logistic regression.
Among 67,365 patients, 6356 (9.4%) underwent SLNB, increasing from 2.8% to 16.3% from 2012 to 2016. Disparities were identified within race (7.0% Black, 9.4% non-Black), ethnicity (8.3% Hispanic, 9.5% non-Hispanic), insurance (6.0% uninsured, 9.5% insured), county density (3.7% rural, 9.8% metro), and income (7.0% bottom-quartile, 11.8% top-quartile). Risk of conversion to open surgery was lower with SLNB alone (1.03%) or SLNB followed by LND (1.40%), versus upfront LND (2.80%). SLNB was associated with reduced risk of conversion to open surgery in Intention-To-Treat (SLNB+/-LND vs. upfront LND; ORITT = 0.53; 95%CI 0.39–0.72) and Per-Protocol (PP; SLNB alone vs. upfront LND or SLNB+LND; ORPP = 0.49; 95%CI 0.32–0.75) comparisons. SLNB was also associated with lower risk of length of stay >1 day (overall rate 6.3%; ORITT = 0.51; 95%CI 0.40–0.64; ORPP = 0.39; 95%CI 0.28–0.55), and unplanned readmission (overall rate 2.3%; ORPP = 0.52; 95%CI 0.33–0.81). There were no deaths within 90 days among 1370 SLNB alone cases, versus 2/1294 (0.15%) for SLNB+LND, and 123/28,828 (0.41%) for upfront LND.
We identified significant disparities in the utilization of SLNB, as well as evidence that this less-invasive technique is associated with lower rates of certain perioperative complications. Equitable access to this emerging technique could lessen disparate outcomes.
•Sentinel lymph node biopsy in minimally invasive staging of endometrial cancer grew from 3% in 2012, to 16% in 2016.•Sentinel lymph node biopsy was less likely in Black, Hispanic, uninsured, rural, and low-income patients.•Compared with full lymph node dissection, sentinel lymph node biopsy had reduced conversion to open surgery from ~3% to ~1%.•No perioperative deaths occurred with sentinel lymph node biopsy alone (versus 0.4% after upfront lymph node dissection)•Reductions in certain perioperative complications were robust to propensity matching and varying cohort specifications.
Background
Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease ...(ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in‐person on an outpatient basis at a hospital or other healthcare facility (referred to as centre‐based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home‐based models and the use of telehealth.
Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.
Objectives
To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.
Search methods
We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting s.
Selection criteria
All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.
Data collection and analysis
We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS‐I tool to assess bias in non‐randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in‐person (centre‐based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.
Main results
We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in‐person pulmonary rehabilitation for exercise capacity measured as 6‐Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) ‐10.82 m to 10.94 m; 556 participants; four studies; moderate‐certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD ‐1.26, 95% CI ‐3.97 to 1.45; 274 participants; two studies; low‐certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI ‐0.13 to 0.40; 426 participants; three studies; low‐certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in‐person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI ‐38.89 m to 83.23 m; 94 participants; two studies; low‐certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low‐certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in‐person rehabilitation or no rehabilitation.
Authors' conclusions
This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre‐based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.
Despite declines in both the incidence of and mortality following hip fracture, there are racial and socioeconomic disparities in treatment access and outcomes. We evaluated the presence and ...implications of disparities in delivery of care, hypothesizing that race and community socioeconomic characteristics would influence quality of care for patients with a hip fracture.
We collected data from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS), which prospectively captures information on all discharges from nonfederal acute-care hospitals in New York State. Records for 197,290 New York State residents who underwent surgery for a hip fracture between 1998 and 2010 in New York State were identified from SPARCS using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multivariable regression models were used to evaluate the association of patient characteristics, social deprivation, and hospital/surgeon volume with time from admission to surgery, in-hospital complications, readmission, and 1-year mortality.
After adjusting for patient and surgery characteristics, hospital/surgeon volume, social deprivation, and other variables, black patients were at greater risk for delayed surgery (odds ratio OR = 1.49; 95% confidence interval CI = 1.42, 1.57), a reoperation (hazard ratio HR = 1.21; CI = 1.11, 1.32), readmission (OR = 1.17; CI = 1.11, 1.22), and 1-year mortality (HR = 1.13; CI = 1.07, 1.21) than white patients. Subgroup analyses showed a greater risk for delayed surgery for black and Asian patients compared with white patients, regardless of social deprivation. Additionally, there was a greater risk for readmission for black patients compared with white patients, regardless of social deprivation. Compared with Medicare patients, Medicaid patients were at increased risk for delayed surgery (OR = 1.17; CI = 1.10, 1.24) whereas privately insured patients were at decreased risk for delayed surgery (OR = 0.77; CI = 0.74, 0.81), readmission (OR = 0.77; CI = 0.74, 0.81), complications (OR = 0.80; CI = 0.77, 0.84), and 1-year mortality (HR = 0.80; CI = 0.75, 0.85).
There are race and insurance-based disparities in delivery of care for patients with hip fracture, some of which persist after adjusting for social deprivation. In addition to investigation into reasons contributing to disparities, targeted interventions should be developed to mitigate effects of disparities on patients at greatest risk.
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Widespread deficits in the quality of US health care were described over a decade ago. Since then, local, regional, and national efforts have sought to improve quality and patient experience, but ...there is incomplete information about whether such efforts have been successful.
To measure changes in outpatient quality and patient experience in the United States from 2002 to 2013.
We analyzed temporal trends from 2002 to 2013 using quality measures constructed from the Medical Expenditure Panel Survey (MEPS), a nationally representative annual survey of the US population that collects data from individual respondents as well as respondents' clinicians, hospitals, pharmacies, and employers. Participants were noninstitutionalized US adults 18 years or older (range, 20 679-26 509 individuals each year).
Outpatient quality measures were compiled through a structured review of prior studies and measures endorsed by national organizations. Nine clinical quality composites (5 "underuse" composites, eg, recommended medical treatment; 4 "overuse" composites, eg, avoidance of inappropriate imaging) based on 39 quality measures; an overall patient experience rating; and 2 patient experience composites (physician communication and access) based on 6 measures.
From 2002 to 2013 (MEPS sample size, 20 679-26 509), 4 clinical quality composites improved: recommended medical treatment (from 36% to 42%; P < .01), recommended counseling (from 43% to 50%; P < .01), recommended cancer screening (from 73% to 75%; P < .01), and avoidance of inappropriate cancer screening (from 47% to 51%; P = .02). Two clinical quality composites worsened: avoidance of inappropriate medical treatments (from 92% to 89%) and avoidance of inappropriate antibiotic use (from 50% to 44%; P < .01 for both comparisons). Three clinical quality measures were unchanged: recommended diagnostic and preventive testing (76%), recommended diabetes care (68%), and inappropriate imaging avoidance (90%). The proportion of participants highly rating their care experience improved for overall care (from 72% to 77%), physician communication (from 55% to 63%), and access to care (from 48% to 58%; P < .01 for all comparisons).
Despite more than a decade of efforts, the clinical quality of outpatient care delivered to American adults has not consistently improved. Patient experience has improved. Deficits in care continue to pose serious hazards to the health of the American public.
The current study investigates the role of race and county characteristics in substantiation and out-of-home placement decisions in the United States. Using multilevel models, we analyzed data from ...counties in the United States available through the National Child Abuse and Neglect Data Systems and Adoption and Foster Care Analysis and Reporting System to investigate the interactions between children's race and the context in which they live. Our sample consisted exclusively of children whose cases had been investigated; therefore, we were able to focus on the role played by race and county characteristics in substantiation and out-of-home placement decisions made by Child Protective Services, net of the heightened risk factors (or potential biases) that lead to disparate rates of reporting. Adjusting for state and county of investigation, Black, American Indian/Alaskan Native, and multiracial children were more likely than White (non-Hispanic) children to be substantiated or placed out of home, whereas Asian children were less likely to be substantiated or placed out of home. Notably, differences across groups are far smaller in magnitude when demographic and geographic differences are taken into account. Higher county-level poverty, percentages of Black residents, and juvenile arrest rates were associated with lower odds of substantiation and out-of-home placement among investigated children, whereas an elevated percentage of single-headed households was associated with higher odds of both outcomes. We also found that living in a rural county was associated with greater odds of substantiation but lower odds of out-of-home placement. Important differences by race were found for these associations.
Public Policy Relevance Statement
Despite recent efforts to consider the influence of county-level characteristics on racial disparities in child welfare involvement, no known research to this point has included data from smaller counties in the United States because of data system restrictions. As a high degree of geographic variability in decision-making has been documented in the child welfare system, the need for research that considers how the impact of county factors varies by race of individuals has become evident.
To examine changes in outpatient visits for mental health and/or substance use disorders (MH/SUD) in an integrated healthcare organization during the initial Massachusetts COVID-19 surge and partial ...state reopening.
Observational study of outpatient MH/SUD visits January 1st-June 30th, 2018–2020 by: 1) visit diagnosis group, 2) provider type, 3) patient race/ethnicity, 4) insurance, and 5) visit method (telemedicine vs. in-person).
Each year, January–June 52,907–73,184 patients were seen for a MH/SUD visit. While non-MH/SUD visits declined during the surge relative to 2020 pre-pandemic (−38.2%), MH/SUD visits increased (9.1%)—concentrated in primary care (35.3%) and non-Hispanic Whites (10.5%). During the surge, MH visit volume increased 11.7% while SUD decreased 12.7%. During partial reopening, while MH visits returned to 2020 pre-pandemic levels, SUD visits declined 31.1%; MH/SUD visits decreased by Hispanics (−33.0%) and non-Hispanic Blacks (−24.6%), and among Medicaid (−19.4%) and Medicare enrollees (−20.9%). Telemedicine accounted for ~5% of MH/SUD visits pre-pandemic and 83.3%–83.5% since the surge.
MH/SUD visit volume increased during the COVID surge and was supported by rapidly-scaled telemedicine. Despite this, widening diagnostic and racial/ethnic disparities in MH/SUD visit volume during the surge and reopening suggest additional barriers for these vulnerable populations, and warrant continued monitoring and research.
Up to one-third of women with ovarian cancer in the United States do not receive surgical care from a gynecologic oncologist specialist despite guideline recommendations. We aim to investigate the ...impact of rurality on receiving surgical care from a specialist, referral to a specialist, and specialist surgery after referral, and the consequences of specialist care.
We utilized a retrospective cohort created through an extension of standard cancer surveillance in three Midwestern states. Multivariable adjusted logistic regression was utilized to assess gynecologic oncologist treatment of women 18–89 years old, who were diagnosed with primary, histologically confirmed, malignant ovarian cancer in 2010–2012 in Kansas, Missouri and Iowa by rurality.
Rural women were significantly less likely to receive surgical care from a gynecologic oncologist specialist (adjusted odds ratio (OR) 0.37, 95% confidence interval (CI) 0.24–0.58) and referral to a specialist (OR 0.37, 95% CI 0.23–0.59) compared to urban women. There was no significant difference in specialist surgery after a referral (OR 0.56, 95% CI 0.26–1.20). Rural women treated surgically by a gynecologic oncologist versus non-specialist were more likely to receive cytoreduction and more complete tumor removal to ≤1 cm.
There is a large rural-urban difference in receipt of ovarian cancer surgery from a gynecologic oncologist specialist (versus a non-specialist). Disparities in referral rates contribute to the rural-urban difference. Further research will help define the causes of referral disparities, as well as promising strategies to address them.
•Rural ovarian cancer patients are 63% less likely to receive a referral to a gynecologic oncologist for surgery•Rural ovarian cancer patients are significantly less likely to receive surgery from a gynecologic oncologist•After a surgical referral, rural ovarian cancer patients are just as likely to receive surgery from a specialist•Specialist-provided surgery increases receipt of cytoreduction and complete tumor removal for rural ovarian cancer patients•Rural women (versus urban) who receive surgery from a gynecologic oncologist travel farther to surgical care
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