From race-based to race-conscious medicine: how anti-racist uprisings call us to act

Development of the UroARC Surgical Calculator: A Novel Risk Calculator for Older Adults Undergoing Surgery for Bladder Outlet Obstruction

PURPOSE

Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist.

MATERIALS AND METHODS

Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications.

RESULTS

In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit.

CONCLUSIONS

This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

The diagnostic performance of CA-125 for the detection of ovarian cancer in women from different ethnic groups: a cohort study of English primary care data

BACKGROUND

CA-125 testing is a recommended first line investigation for women presenting with possible symptoms of ovarian cancer in English primary care, to help determine whether further investigation for ovarian cancer is needed. It is currently not known how well the CA-125 test performs in ovarian cancer detection for patients from different ethnic groups.

METHODS

A retrospective cohort study utilising English primary care data linked to the national cancer registry was undertaken. Women aged ≥ 40 years with a CA-125 test between 2010 and 2017 were included. Logistic regression predicted one-year ovarian cancer incidence by ethnicity, adjusting for age, deprivation status, and comorbidity score. The estimated incidence of ovarian cancer by CA-125 level was modelled for each ethnic group using restricted cubic splines.

RESULTS

The diagnostic performance of CA-125 differed for women from different ethnicities. In an unadjusted analysis, predicted CA-125 levels for Asian and Black women were higher than White women at corresponding probabilities of ovarian cancer. The higher PPVs for White women compared to Asian or Black women were eliminated by inclusion of covariates.

CONCLUSION

The introduction of ethnicity-specific thresholds may increase the specificity and PPVs of CA-125 in ovarian cancer detection at the expense of sensitivity, particularly for Asian and Black women. As such, we cannot recommend the use of ethnicity-specific thresholds for CA-125.

A health equity ECHO for clinicians of individuals with SCD

SCD is the most common genetic disorder in the United States, affecting nearly 100 000 Americans, with the majority of affected individuals identifying as Black. Studies have shown that both children and adults with SCD face stigmatization resulting in low-quality care stemming from institutional racism and implicit bias by clinicians. Clinician biases often result from a lack of awareness of their own racial identity, failure to develop an anti-racist or social justice lens, and absence of skills to mitigate racist practices and policies. The Sickle Treatment and Outcomes Research in the Midwest (STORM) multi-state regional learning network developed a health equity training curriculum that was delivered as a continuing education learning series using the Project ECHO® virtual telementoring framework supplemented with an online learning management system. The curriculum addressed foundations of race, racism, and whiteness along with social justice strategies for the individual and institutional level and was piloted with 2 clinician cohorts to assess its feasibility, acceptability, and the potential impact on clinician self-efficacy. Feasibility and acceptability data, including qualitative feedback, suggest that this is a promising method for multidisciplinary clinicians and trainees for raising self-awareness about racism and bias, providing a safe community for self-reflection, and building skills to address inequities within healthcare settings.

Implementation of Universal Screening for G6PD Deficiency in Newborns

We describe the implementation of universal glucose-6-phosphate dehydrogenase (G6PD) screening during the first year of New York State mandated testing, as well as operational challenges and clinical knowledge gained. All infants born at or transferred to our center between June 21, 2022 and June 30, 2023, underwent testing for G6PD enzyme deficiency and were included in the study cohort. Infant blood samples were collected and sent to a reference laboratory for quantitative assay. After initiation of universal screening, a quality improvement initiative was launched to: monitor and improve the suitability of blood sample collection to ensure timely return of results;improve the reliability and validity of the reference laboratory enzyme assay; andestablish accurate reference ranges for G6PD deficiency in newborns.A total of 5601 newborns were included. Within the first year of implementation, the percentage of samples yielding any test result increased from 76% to 85%, and most patients had a G6PD result available within 1 day of discharge. We established a more accurate threshold for G6PD deficiency in newborns of <4.9 U/g Hb and G6PD intermediate of <10.0 U/g Hb. Using the updated reference ranges, 224 patients in our cohort were identified as G6PD deficient or intermediate (4.0%). Through a quality-sensitive process, we identified the importance of a standardized approach, improved sample collection processes, decreased sample turnaround time, and established more accurate reference ranges. We hope our experiences will help others seeking to improve processes and implement similar programs at other institutions.

Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM)

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

Trends in Black-White Differences of Antihypertensive Treatment in Individuals With and Without History of Stroke

BACKGROUND

Recent hypertension guidelines for the general population have included race-specific recommendations for antihypertensives, whereas current stroke-specific recommendations for antihypertensives do not vary by race. The impact of these guidelines on antihypertensive regimen changes over time, and if this has varied by prevalent stroke status, is unclear.

METHODS

The use of antihypertensive medications was studied cross-sectionally among self-identified Black and White participants, aged ≥45 years, with and without history of stroke, from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). Participants completed an in-home examination in 2003-2007 (visit 1) with/without an examination in 2013-2016 (visit 2). Stratified by prevalent stroke status, logistic regression mixed models examined associations between antihypertensive class use for visit 2 versus visit 1 and Black versus White individuals with an interaction adjusted for demographics, socioeconomic status, and vascular risk factors/vital signs.

RESULTS

Of 17 244 stroke-free participants at visit 1, Black participants had greater adjusted odds of angiotensin-converting enzyme inhibitor usage than White participants (odds ratio [OR], 1.51 [95% CI, 1.30-1.77]). This difference was smaller in the 7476 stroke-free participants at visit 2 (OR, 1.16 [95% CI, 1.08-1.25]). In stroke-free participants at visit 1, Black participants had lower odds of calcium channel blocker (CCB) usage than White participants (OR, 0.47 [95% CI, 0.41-0.55]), but CCB usage did not differ significantly between Black and White stroke-free participants at visit 2 (OR, 1.02 [95% CI, 0.95-1.09]). Among 1437 stroke survivor participants at visit 1, Black participants had lower odds of CCB use than White participants (OR, 0.34 [95% CI, 0.26-0.45]). In 689 stroke survivor participants at visit 2, CCB use did not differ between Black and White participants (OR, 0.80 [95% CI, 0.61-1.06]).

CONCLUSIONS

Racial differences in the use of guideline-recommended antihypertensives decreased between 2003-2007 and 2013-2016 in stroke-free individuals. In stroke survivors, racial differences in CCB usage narrowed over the time periods. These findings suggest there is still a mismatch between race-specific hypertension guidelines and recent clinical practice.

Feasibility of wearable sensor signals and self-reported symptoms to prompt at-home testing for acute respiratory viruses in the USA (DETECT-AHEAD): a decentralised, randomised controlled trial

BACKGROUND

Early identification of an acute respiratory infection is important for reducing transmission and enabling earlier therapeutic intervention. We aimed to prospectively evaluate the feasibility of home-based diagnostic self-testing of viral pathogens in individuals prompted to do so on the basis of self-reported symptoms or individual changes in physiological parameters detected via a wearable sensor.

METHODS

DETECT-AHEAD was a prospective, decentralised, randomised controlled trial carried out in a subpopulation of an existing cohort (DETECT) of individuals enrolled in a digital-only observational study in the USA. Participants aged 18 years or older were randomly assigned (1:1:1) with a block randomisation scheme stratified by under-represented in biomedical research status. All participants were offered a wearable sensor (Fitbit Sense smartwatch). Participants in groups 1 and 2 received an at-home self-test kit (Alveo be.well) for two acute respiratory viral pathogens: SARS-CoV-2 and respiratory syncytial virus. Participants in group 1 could be alerted through the DETECT study app to take the at-home test on the basis of changes in their physiological data (as detected by our algorithm) or due to self-reported symptoms; those in group 2 were prompted via the app to self-test only due to symptoms. Group 3 served as the control group, without alerts or home testing capability. The primary endpoints, assessed on an intention-to-treat basis, were the number of acute respiratory infections presented (self-reported) and diagnosed (electronic health record), and the number of participants using at-home testing in groups 1 and 2. This trial is registered with ClinicalTrials.gov, NCT04336020.

FINDINGS

Between Sept 28 and Dec 30, 2021, 450 participants were recruited and randomly assigned to group 1 (n=149), group 2 (n=151), or group 3 (n=150). 179 (40%) participants were male, 264 (59%) were female, and seven (2%) identified as other. 232 (52%) were from populations historically under-represented in biomedical research. 118 (39%) of the 300 participants in groups 1 and 2 were prompted to self-test, with 61 (52%) successfully completing self-testing. Participants were prompted to home-test more frequently due to symptoms (41 [28%] in group 1 and 51 [34%] in group 2) than due to detected physiological changes (26 [17%] in group 1). Significantly more participants in group 1 received alerts to test than did those in group 2 (67 [45%] vs 51 [34%]; p=0·047). Of the 61 individuals who were prompted to test and successfully did so, 19 (31%) tested positive for a viral pathogen-all for SARS-CoV-2. The individuals diagnosed as positive for SARS-CoV-2 in the electronic health record were eight (5%) in group 1, four (3%) in group 2, and two (1%) in group 3, but it was difficult to confirm if they were tied to symptomatic episodes documented in the trial. There were no adverse events.

INTERPRETATION

In this direct-to-participant trial, we showed early feasibility of a decentralised programme to prompt individuals to use a viral pathogen diagnostic test based on symptoms tracked in the study app or physiological changes detected using a wearable sensor. Barriers to adequate participation and performance were also identified, which would need to be addressed before large-scale implementation.

FUNDING

Janssen Pharmaceuticals.

Sexual Debut in Early Adolescence and Individual, School, and Neighborhood Social Capital

PURPOSE

Sexual debut in early adolescence is associated with poor health outcomes in adulthood. We examined the associations of social capital within families, schools, and neighborhoods with early sexual debut.

METHODS

Using data from the Healthy Passages cohort, a longitudinal multilevel study of adolescents, we performed a series of cross-classified multilevel logistic regression models to examine (1) the relative contribution of schools and neighborhoods to the variance and (2) the association of markers of social cohesion/social capital in families, schools, and neighborhoods with sexual debut by 10th grade.

RESULTS

There were 4,001 youth participants nested in 115 schools and 751 neighborhoods, with a high degree of cross-classification (1,340 unique combinations of school and neighborhoods). In models adjusting for individual demographics, neighborhoods contributed more to the variance (log odds U [95% confidence interval {CI}] [intra class correlation {ICC}%]) in sexual debut than schools: Uneighborhoods = 0.11 (0.02, 0.23) [3.2%] versus Uschools = 0.07 (0.01, 0.16) [2%]. Restriction of dating and family cohesion, markers of family social capital, were associated with reduced odds of sexual debut by 10th grade (odds ratio = 0.45 95% CI: 0.41-0.49 and 0.93, 95% CI: 0.86, 1.00). Neighborhood cohesion and education level were associated with early debut. Although reduced, there remained significant, unexplained variance in both the school and neighborhood level in the fully adjusted model (Uschool = 0.08 [0.01, 0.17] [2.3%], Uneighborhood = 0.08 [0.02, 0.17] [2.2%]).

DISCUSSION

Markers of social capital at the family and neighborhood levels were associated with sexual debut by 10th grade. Developers of public health programs aiming to delay sexual debut should consider family-focused and neighborhood-focused interventions.

An Institutional Approach to Equity and Improvement in Child Health Outcomes

Pediatric health inequities are pervasive. Approaches by health care institutions to address inequities often, and increasingly, focus on social needs screening without linked, robust responses. Even when actions in pursuit of health equity do occur within health care institutions, efforts occur in isolation from each other, standing in the way of cross-learning and innovation. Learning network methods hold promise when institutions are confronted with complex, multidimensional challenges. Equity-oriented learning networks may therefore accelerate action to address complex factors that contribute to inequitable pediatric health outcomes, enabling rapid learning along the way. We established an institutional Health Equity Network (HEN) in pursuit of excellent and equitable health outcomes for children and adolescents in our region. The HEN supports action teams seeking to eliminate pediatric health inequities in their clinical settings. Teams deploy targeted interventions to meet patients' and families' needs, addressing both medical and social factors affecting health and wellbeing. The primary, shared HEN measure is the equity gap in hospitalization rates between Black patients and all other patients. The HEN currently has 10 action teams and promotes rapid learning and scaling of interventions via monthly "action period calls" and "solutions labs" focused on successes, challenges, and potential common solutions (eg, scaling of existing medical-legal partnership to subspecialty clinics). In this Advocacy Case Study, we detail the design, implementation, and early outcomes from the HEN, our equity-oriented learning network.

Skin Color Representation in Teaching Photographs: One Institution's Approach to Addressing Visual Racism in Medical Education

Problem: Visual racism refers to both the underrepresentation and inappropriate representation of darker skin types in medical education. By not teaching medical students and resident physicians to recognize common conditions in darker skin, it perpetuates biases that contribute to healthcare disparities for racial and ethnic minoritized groups. In this paper we describe our efforts to engage in institutional anti-racism work by addressing imbalances in representation of darker skin types in visual teaching images within our institution's curriculum. Intervention: We initially surveyed preclinical medical students regarding their perceptions of skin color representation in two courses. Researchers recorded the skin types of all teaching photographs in these courses in 2020. We then provided feedback and education to faculty, proposing that they increase brown and black skin color representation in educational content. During 2021, we reviewed the same courses and surveyed students again to ascertain the implementation and impact of our proposal. Context: We applied our intervention to two courses, Host & Defense (H&D) and Skin, Muscle, Bone, and Joint (SMBJ) since both courses utilize a large number of teaching images. Impact: From 2020 to 2021, both H&D and SMBJ significantly increased the proportion of visual teaching images that included darker skin types, with an increase from 28% to 42% in H&D and 20% to 30% in SMBJ. Significantly more students in the courses' 2021 iterations (73% in H&D, 93% in SMBJ) felt that lectures had appropriate representations of darker skin types when compared to students who took the course in 2020 (8% in H&D, 51% in SMBJ). Students in 2021 felt more confident in recognizing dermatological signs and symptoms in patients with darker skin than students in 2020. The majority of students in both 2020 and 2021 reported wanting to see a gradient of skin types for every dermatological condition discussed. Lessons learned: Our work suggests that addressing visual racism can be achieved partly by setting expectations for increased visual representation, collaborating across educational departments, and establishing clear metrics for assessing implementation. Future interventions will require a continual feedback loop of monitoring learning material, assessing faculty and student perception, refining resources, and recommending revisions to improve visual representation across the entire curriculum.

Examining Injustices: Transfusion Medicine and Race

Race and ethnicity are sociopolitical and not biological constructs, and assertions that these population descriptors have scientific meaning has caused significant harm. A critical assessment of the transfusion medicine literature is an important aspect of promoting race-conscious as opposed to race-based medicine. Utilizing current definitions and health equity frameworks, this review will provide a critical appraisal of transfusion medicine studies at the intersection of race and healthcare disparities, with a focus on larger methodological challenges facing the transfusion medicine community. Moving forward, risk modelling accounting for upstream factors, patient input, as well as an expert consensus on how to critically conduct and evaluate this type of literature are needed. Further, when using race and ethnicity in research contexts, investigators must be aware of existing guidelines for such reporting.

Knowledge translation in Indigenous health research: voices from the field

OBJECTIVES

To better understand what knowledge translation activities are effective and meaningful to Indigenous communities and what is required to advance knowledge translation in health research with, for, and by Indigenous communities.

STUDY DESIGN

Workshop and collaborative yarning.

SETTING

Lowitja Institute International Indigenous Health Conference, Cairns, June 2023.

PARTICIPANTS

About 70 conference delegates, predominantly Indigenous people involved in research and Indigenous health researchers who shared their knowledge, experiences, and recommendations for knowledge translation through yarning and knowledge sharing.

RESULTS

Four key themes were developed using thematic analysis: knowledge translation is fundamental to research and upholding community rights; knowledge translation approaches must be relevant to local community needs and ways of mobilising knowledge; researchers and research institutions must be accountable for ensuring knowledge translation is embedded, respected and implemented in ways that address community priorities; and knowledge translation must be planned and evaluated in ways that reflect Indigenous community measures of success.

CONCLUSION

Knowledge translation is fundamental to making research matter, and critical to ethical research. It must be embedded in all stages of research practice. Effective knowledge translation approaches are Indigenous-led and move beyond Euro-Western academic metrics. Institutions, funding bodies, and academics should embed structures required to uphold Indigenous knowledge translation. We join calls for reimaging health and medical research to embed Indigenous knowledge translation as a prerequisite for generative knowledge production that makes research matter.

Enhancing hypertension pharmacotherapeutics education by integrating social determinants of health

OBJECTIVE

Social determinants of health (SDOHs) play a significant role in hypertension management. Pharmacy program accreditation standards include that students should understand SDOHs. However, there are limited data regarding approaches to incorporating SDOHs within pharmacotherapeutics courses. This study evaluated the changes in student knowledge, understanding, perceptions, beliefs, and confidence by integrating SDOH topics in hypertension pharmacotherapeutics lectures.

METHODS

The study invited students enrolled in cardiovascular pharmacotherapeutics courses at 2 institutions to participate. Participation involved a preintervention questionnaire, a lecture on clinical management of hypertension incorporating SDOH concepts, an assignment involving reading a journal article and answering related questions, and a postintervention questionnaire. Data analysis was conducted using SPSS, with a predetermined α level of 0.05 for statistical significance. Mean composite questionnaire scores were calculated and compared with Wilcoxon signed rank test.

RESULTS

Of 109 students, the response rate was 85.3 % (93 participants). The combined questionnaire results demonstrated a statistically significant improvement in all questionnaire item composites. The open-ended knowledge assessment yielded a mean score of 5.75 (range 3-6).

CONCLUSION

The study intervention enhanced student knowledge, understanding, perceptions, beliefs, and confidence regarding the impact of SDOHs on hypertension. This practical and reproducible approach offers a valuable method for incorporating SDOH concepts into pharmacotherapeutics courses.

Barriers to and opportunities for advancing racial equity in cervical cancer screening in the United States

BACKGROUND

In the United States (U.S.), racially minoritized people have higher rates of cervical cancer morbidity and mortality compared to white individuals as a result of racialized structural, social, economic, and health care inequities. However, cervical cancer screening guidelines are based on studies of predominately white individuals and do not substantially discuss or address racialized cervical cancer inequities and their social determinants, including racism.

METHODS

We conducted in-depth interviews with health care providers (N = 30) and key informants with expertise in health equity (N = 18). We utilized semi-structured interview guides that addressed providers' views and experiences delivering cervical cancer screening to racially minoritized individuals and key informants' recommendations for advancing racial equity in the development and implementation of cervical cancer screening guidelines. Interviews were analyzed using a template style thematic analysis approach involving deductive and inductive coding, memo writing, and matrix analysis for theme development.

RESULTS

Most health care providers adopted a universal, one-size-fits-all approach to cervical cancer screening with the stated goal of ensuring racial equality. Despite frequently acknowledging the existence of racialized cervical cancer inequities, few providers recognized the role of social inequities in influencing them, and none discussed the impact of racism. In contrast, key informants overwhelmingly recommended that providers adopt an approach to cervical cancer screening and follow-up care that recognizes the role of racism in shaping racialized cervical cancer and related social inequities, is developed in partnership with racially minoritized communities, and involves person-centered, structurally-competent, and trauma-informed practices that address racially minoritized peoples' unique lived experiences in historical and social context. This racism-conscious approach is not to be confused with race-based medicine, which is an essentialist and racist approach to health care that treats race as a biological variable rather than as a social and political construct.

CONCLUSIONS

Developers and implementers of cervical cancer screening guidelines should explicitly recognize and address the impact of racism on cervical cancer screening, follow-up care, and outcomes, meaningfully incorporate racially minoritized communities' perspectives and experiences, and facilitate provider- and institutional-level practices that foster racial equity in cervical cancer.

Racial and ethnic differences in uncontrolled diabetes mellitus among adults taking antidiabetic medication

AIM

To examine whether racial and ethnic disparities in uncontrolled type 2 diabetes mellitus (T2DM) persist among those taking medication and after accounting for other demographic, socioeconomic, and health indicators.

METHODS

Adults aged ≥20 years with T2DM using prescription diabetes medication were among participants assessed in a retrospective cohort study of the National Health and Nutrition Examination Survey 2007-2018. We estimated weighted sequential multivariable logistic regression models to predict odds of uncontrolled T2DM (HbA1c ≥ 8%) from racial and ethnic identity, adjusting for demographic, socioeconomic, and health indicators.

RESULTS

Of 3649 individuals with T2DM who reported taking medication, 27.4% had uncontrolled T2DM (mean HgA1c 9.6%). Those with uncontrolled diabetes had a mean BMI of 33.8, age of 57.3, and most were non-Hispanic white (54%), followed by 17% non-Hispanic Black, and 20% Hispanic identity. In multivariable analyses, odds of uncontrolled T2DM among those with Black or Hispanic identities lessened, but persisted, after accounting for other indicators (Black OR 1.38, 97.5% CI: 1.04, 1.83; Hispanic OR 1.79, 97.5% CI 1.25, 2.57).

CONCLUSIONS

Racial and ethnic disparities in T2DM control persisted among individuals taking medication. Future research might focus on developmental and epigenetic pathways of disparate T2DM control across racially and ethnically minoritized populations.

Clinicians' perspectives on race-specific guidelines for hypertensive treatment

Despite the general consensus that there is no biological basis to race, racial categorization is still used by clinicians to guide diagnosis and treatment plans for certain diseases. In medicine, race is commonly used as a rough proxy for unmeasured social, environmental, and genetic factors. The American College of Cardiology's Eighth Joint National Committee's (JNC 8) guidelines for the treatment of hypertension provide race-specific medication recommendations for Black versus non-Black patients, without strong evidence for race-specific physiological differences in drug response. Clinicians practicing family or geriatric medicine (n = 21) were shown a video of a mock hypertensive patient with genetic ancestry test results that could be viewed as discordant with their phenotype and self-identified race. After viewing the videos, we conducted in-depth interviews to examine how clinicians value and prioritize different cues about race -- namely genetic ancestry data, phenotypic appearance, and self-identified racial classifications - when making treatment decisions in the context of race-specific guidelines, particularly in situations when patients claim mixed-race or complex racial identities. Results indicate that clinicians inconsistently follow the race-specific guidelines for patients whose genetic ancestry test results do not match neatly with their self-identified race or phenotypic features. However, many clinicians also emphasized the importance of clinical experience, side effects, and other factors in their decision making. Clinicians' definitions of race, categorization of the patient's race, and prioritization of racial cues greatly varied. The existence of the race-specific guidelines clearly influences treatment decisions, even as clinicians' express uncertainty about how to incorporate consideration of a patient's genetic ancestry. In light of widespread debate about removal of race from medical diagnostics, researchers should revisit the clinical justification for maintaining these race-specific guidelines. Based on our findings and prior studies indicating a lack of convincing evidence for biological differences by race in medication response, we suggest removing race from the JNC 8 guidelines to avoid risk of perpetuating or exacerbating health disparities in hypertension.

Embracing unity at OMERACT: Valuing equity, promoting diversity, fostering inclusivity

OBJECTIVE

To increase awareness and understanding of the principles of Equity, Diversity, and Inclusivity (EDI) within Outcome Measures in Rheumatology's (OMERACT) members. For this, we aimed to obtain ideas on how to promote and foster these principles within the organization and determine the diversity of the current membership in order to focus future efforts.

METHODS

We held a plenary workshop session at OMERACT 2023 with roundtable discussions on barriers and solutions to increased diversity within OMERACT. We conducted an anonymous, web-based survey of members to record characteristics including population group, gender identity, education level, age, and ability.

RESULTS

The workshop generated ideas to increase diversity of participants across the themes of building relationships [12 topics], materials and methods [5 topics], and conference-specific [6 topics]. Four hundred and seven people responded to the survey (25 % response rate). The majority of respondents were White (75 %), female (61 %), university-educated (94 %), Christian (42 %), spoke English at home (60 %), aged 35 to 55 years (50 %), and did not report a disability (64 %).

CONCLUSION

OMERACT is committed to improving its diversity. Next steps include strategic recruitment of members to the EDI working group, drafting an EDI mission statement centering equity and inclusivity in the organization, and developing guidance for the OMERACT Handbook to help all working groups create actionable plans for promoting EDI principles.

Priorities for health outcomes in glaucoma in an ethnically diverse UK cohort: an observational study

OBJECTIVES

To assess whether patients from minority ethnic groups have different perceptions about the quality-of-life outcomes that matter most to them.

DESIGN

Cross-sectional observational study.

SETTING

High volume eye centres serving the most ethnically diverse region in the UK, recruiting from July 2021 to February 2022.

PARTICIPANTS

511 patients with primary open-angle glaucoma and the predisease state of ocular hypertension.

MAIN OUTCOME MEASURES

The main outcome was participants' self-reported priorities for health outcomes.

RESULTS

Participants fell into one of four clusters with differing priorities for health outcomes, namely: (1) vision, (2) drop freedom, (3) intraocular pressure and (4) one-time treatment. Ethnicity was the strongest determinant of cluster membership after adjusting for potential confounders. Compared with white patients prioritising vision alone, the OR for black/black British patients was 7.31 (95% CI 3.43 to 15.57, p<0.001) for prioritising drop freedom; 5.95 (2.91 to 12.16, p<0.001) for intraocular pressure; and 2.99 (1.44 to 6.18, p=0.003) for one-time treatment. For Asian/Asian British patients, the OR was 3.17 (1.12 to 8.96, p=0.030) for prioritising intraocular pressure as highly as vision. Other ethnic minority groups also had higher ORs for prioritising health outcomes other than vision alone: 4.50 (1.03 to 19.63, p=0.045) for drop freedom and 5.37 (1.47 to 19.60, p=0.011) for intraocular pressure.

CONCLUSIONS

Ethnicity is strongly associated with differing perceptions about the health outcomes that matter. An individualised and ethnically inclusive approach is needed when selecting and evaluating treatments in clinical and research settings.

Discussing and Teaching About Race and Health Inequities

Health inequities are prevalent in our medical institutions and result in unfair access to and delivery of health care. Some of the most profound health disparities are related to race, which has erroneously been used to make biological inferences to explain disease states in medicine. Our profession continues to shift away from such race-based medical narratives, which do not examine how social determinants of health, social injustice, systemic racism, and existing power structures shape health outcomes toward a health equity mindset and race-conscious medicine. Clinician educators are responsible for teaching and engaging with learners around issues of inequity in medicine, although many may feel they lack the knowledge or skills to do so. Opportunities for conversations on health equity abound, either as a response to statements made by clinical peers or patients, or through direct clinical care of affected populations. In this paper, we focus our discussion of health equity around the topic of race corrections in spirometry, which is one of several salient areas of conversation in the field of pulmonary medicine undergoing reconciliation. We review basic definitions and concepts in health equity and apply three strategies to engage in conversations around equity with colleagues and learners: actively learning and reflecting on health inequities, recognizing and naming inequities, and consciously role-modeling equity-conscious language and care. We also will summarize strategies for implementing health equity concepts into the continuum of medical education and our clinical learning environments.

Mode of Delivery and Unplanned Cesarean: Differences in Rates and Indication by Race, Ethnicity, and Sociodemographic Characteristics

OBJECTIVE

We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery.

STUDY DESIGN

We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t-tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test.

RESULTS

Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001).

CONCLUSION

Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings.

KEY POINTS

· Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.. · Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.. · There may be unmeasured provider level factors which contribute to disparities in cesarean rates..

Establishing a Pediatric Health Equity, Diversity, and Inclusion Research Review Process

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice.

FEV1Q: a race-neutral approach to assessing lung function

BACKGROUND

Forced expiratory volume in 1 s quotient (FEV1Q) is a simple approach to spirometry interpretation that compares measured lung function to a lower boundary. This study evaluated how well FEV1Q predicts survival compared with current interpretation methods and whether race impacts FEV1Q.

METHODS

White and Black adults with complete spirometry and mortality data from the National Health and Nutrition Examination Survey (NHANES) III and the United Network for Organ Sharing (UNOS) database for lung transplant referrals were included. FEV1Q was calculated as FEV1 divided by 0.4 L for females or 0.5 L for males. Cumulative distributions of FEV1 were compared across races. Cox proportional hazards models tested mortality risk from FEV1Q adjusting for age, sex, height, smoking, income and among UNOS individuals, referral diagnosis. Harrell's C-statistics were compared between absolute FEV1, FEV1Q, FEV1/height2, FEV1 z-scores and FEV1 % predicted. Analyses were stratified by race.

RESULTS

Among 7182 individuals from NHANES III and 7149 from UNOS, 1907 (27%) and 991 (14%), respectively, were Black. The lower boundary FEV1 values did not differ between Black and White individuals in either population (FEV1 first percentile difference ≤0.01 L; p>0.05). Decreasing FEV1Q was associated with increasing hazard ratio (HR) for mortality (NHANES III HR 1.33 (95% CI 1.28-1.39) and UNOS HR 1.18 (95% CI 1.12-1.23)). The associations were not confounded nor modified by race. Discriminative power was highest for FEV1Q compared with alternative FEV1 approaches in both Black and White individuals.

CONCLUSIONS

FEV1Q is an intuitive and simple race-neutral approach to interpreting FEV1 that predicts survival better than current alternative methods.

A systematic review of barriers to pursuing careers in medicine among Black premedical students

Among the various etiologies of the exclusion of Black male physicians from the healthcare workforce, it is critical to identify and examine the barriers in their trajectory. Given that most medical school matriculants graduate and pursue residency training, medical school admission has been identified as the primary impediment to a career in medicine. Thus, this work aims to identify barriers in the journey of primarily Black, and secondarily underrepresented minority, premedical students. A systematic review of the medical literature was conducted for articles pertaining to the undergraduate/premedical period, Black experiences, and the medical school application process. The search yielded 5336 results, and 13 articles were included. Most papers corroborated common barriers, such as financial/socioeconomic burdens, lack of access to preparatory materials and academic enrichment programs, lack of exposure to the medical field, poor mentorship/advising experiences, systemic and interpersonal racism, and limited support systems. Common facilitators of interest and interventions included increasing academic enrichment programs, improving mentorship and career guidance quality and availability, and improving access to and availability of resources as well as exposure opportunities. No article explicitly discussed addressing racism. There is a dearth of studies exploring the premedical stage-the penultimate point of entry into medicine. Though interest in becoming a physician may be present, multiple and disparate impediments restrict Black men's participation in medicine. Addressing the barriers Black and underrepresented minority premedical students face requires an awareness of how multiple systems work together to discriminate and restrict access to careers in medicine beyond the traditional pipeline understanding.

The Impact of Health Care Algorithms on Racial and Ethnic Disparities : A Systematic Review

BACKGROUND

There is increasing concern for the potential impact of health care algorithms on racial and ethnic disparities.

PURPOSE

To examine the evidence on how health care algorithms and associated mitigation strategies affect racial and ethnic disparities.

DATA SOURCES

Several databases were searched for relevant studies published from 1 January 2011 to 30 September 2023.

STUDY SELECTION

Using predefined criteria and dual review, studies were screened and selected to determine: 1) the effect of algorithms on racial and ethnic disparities in health and health care outcomes and 2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms.

DATA EXTRACTION

Outcomes of interest (that is, access to health care, quality of care, and health outcomes) were extracted with risk-of-bias assessment using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and adapted CARE-CPM (Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models) equity extension.

DATA SYNTHESIS

Sixty-three studies (51 modeling, 4 retrospective, 2 prospective, 5 prepost studies, and 1 randomized controlled trial) were included. Heterogenous evidence on algorithms was found to: a) reduce disparities (for example, the revised kidney allocation system), b) perpetuate or exacerbate disparities (for example, severity-of-illness scores applied to critical care resource allocation), and/or c) have no statistically significant effect on select outcomes (for example, the HEART Pathway [history, electrocardiogram, age, risk factors, and troponin]). To mitigate disparities, 7 strategies were identified: removing an input variable, replacing a variable, adding race, adding a non-race-based variable, changing the racial and ethnic composition of the population used in model development, creating separate thresholds for subpopulations, and modifying algorithmic analytic techniques.

LIMITATION

Results are mostly based on modeling studies and may be highly context-specific.

CONCLUSION

Algorithms can mitigate, perpetuate, and exacerbate racial and ethnic disparities, regardless of the explicit use of race and ethnicity, but evidence is heterogeneous. Intentionality and implementation of the algorithm can impact the effect on disparities, and there may be tradeoffs in outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Quality and Research.

Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital

OBJECTIVE

To examine characteristics associated with formal ethics consultation (EC) referral in pediatric extracorporeal membrane oxygenation (ECMO) cases, and document ethical issues presented.

DESIGN

Retrospective cohort study using mixed methods.

SETTING

Single-center quaternary pediatric hospital.

PATIENTS

Patients supported on ECMO (January 2012 to December 2021).

INTERVENTIONS

We compared clinical variables among ECMO patients according to the presence of EC. We defined optimal cutoffs for EC based on run duration, ICU length of stay (LOS), and sum of procedures or complications. To identify independent explanatory variables for EC, we used a forward stepwise selection multivariable logistic regression model. EC records were thematically characterized into ethical issues.

MEASUREMENTS AND MAIN RESULTS

Of 601 ECMO patients and 225 patients with EC in 10 years, 27 ECMO patients received EC (4.5% of ECMO patients, 12% of all ECs). On univariate analysis, use of EC vs. not was associated with multiple ECMO runs, more complications/procedures, longer ICU LOS and ECMO duration, cardiac admissions, decannulation outcome, and higher mortality. Cutoffs for EC were ICU LOS >52 days, run duration >160 hours, and >6 complications/procedures. Independent associations with EC included these three cutoffs and older age. The model showed good discrimination (area under the curve 0.88 [0.83, 0.93]) and fit. The most common primary ethical issues were related to end-of-life, ECMO discontinuation, and treatment decision-making. Moral distress was cited in 22 of 27 cases (82%).

CONCLUSION

EC was used in 4.5% of our pediatric ECMO cases, with most ethical issues related to end-of-life care or ECMO discontinuation. Older age, longer ICU LOS, prolonged runs, and multiple procedures/complications were associated with greater odds for EC requests. These data highlight our single-center experience of ECMO-associated ethical dilemmas. Historical referral patterns may guide a supported decision-making framework. Future work will need to include quality improvement projects for timely EC, with evaluation of impacts on relevant endpoints.

Follow the citations: Tracing pathways of "race as biology" assumptions in medical algorithms in eGFR and spirometry

Despite overwhelming evidence to the contrary, the concept of 'race' as a biological unit continues to persist in various scientific disciplines, notably in the field of medicine. This paper explores the persistence of 'race as biology' in medical research via examining select citational practices that have perpetuated this problematic concept. Citations serve as a cornerstone in scientific literature, signifying reliability and expert affirmation. By analyzing citation threads and historical patterns, we aim to shed light on the creation and perpetuation of false scientific truths and their impact on medical research, training, and practice. We focus on two prominent examples, eGFR and Spirometry, and trace key articles' citational histories, highlighting the flawed evidence in support of racial corrections in medical assessments. The eGFR equation incorporates 'race' as a factor based on the erroneous belief that Black individuals have higher muscle mass than white individuals. Our analysis reveals that key cited sources for this belief lack robust and well-developed datasets. Similarly, Spirometry measurements incorporate racial correction factors, relying on questionable evidence dating back to the Civil War era. Citations serve as a cornerstone in scientific literature, signifying reliability and expert affirmation. They play a crucial role in shaping theoretical positions and validating data and assumed knowledge. Evaluating citation threads and key articles consistently referenced over time can reveal how falsehoods and erroneous assertions are constructed and maintained in scientific fields. This study underscores the need for critical examination of citational practices in medical research and urges a shift toward a more cautious approach when citing sources that support 'race as biology.' The paper calls for a reevaluation of pedagogical approaches and assigned readings in medical education to prioritize an anti-racist perspective in future research endeavors.

Efforts in Organized Medicine to Eliminate Harmful Race-Based Clinical Algorithms

This survey study describes efforts to eliminate harmful race-based clinical algorithms among state or territorial medical associations and specialty societies in the US.

Obstetric Racism, Education, and Racial Concordance

ABSTRACT

The United States holds the distinction of being the developed country with the worst perinatal outcomes despite spending the most per capita on health care. Black women are three to four times more likely than White women to experience adverse birth outcomes. These outcomes persist despite access to prenatal care, insurance, and college education. A long overdue racial reckoning has arrived, beginning with acknowledging the fallacy of race-based medicine and the role of enduring systemic racism as foundational to obstetric racism in the reproductive lives of Black women. Centering voices of Black women and honoring their lived experiences are essential to providing respectful maternity care. Naming micro- and macroaggressions experienced by Black women allows for dismantling of systemic barriers which perpetuate inequitable outcomes and enable substandard care. Racial concordance (shared racial identity) is one tool to consider in creating safe health care spaces for Black women. Improving diversity of the nursing workforce specifically, and the health care workforce in general, is necessary to affect racial concordance. Application of skills in cultural humility can mitigate challenges associated with adverse patient encounters for Black women as diversity pipeline strategies are explored. Histories of foundational fallacy, their impact on care and outcomes, and patient-driven indicators for improving pregnancy care experiences for women of color are explored through the lens of a Black physician and the collective reproductive health workforce.

Creating comics, songs and poems to make sense of decolonising the curriculum: a collaborative autoethnography patchwork

Decolonising the curriculum is a complex endeavour, with the potential to cause harm as well as benefit. People doing the work might find themselves questioning their personal and political identities and motives, it is common for people to get disillusioned. While surveys and toolkits are important to help us start the work, we are interested in finding out how decolonising practices can be sustained. We believe to practise meaningfully in this area we need to understand ourselves as practitioners, make sense of the work and have deep connections with colleagues and possibly our institutions.This research uses collaborative autoethnography; our personal experiences, reflected through the lenses of each other's point of view; to help us know ourselves and make sense of our practice. We also show how art, in the form of comics, poems and a song, can be used to deepen our research by adding meaning, connection and joy. We present this research as a patchwork text of writing, art and conversations. Our work is underpinned by theory, particularly drawing on Sara Ahmed and bell hooks. It is produced by the three of us to illuminate the process of decolonising a curriculum. We see this paper as part of our collective resistance: resistance to colonialism, to scientism and to inhumanity. We hope you will find resonances with your practice, and perhaps discover new ways to find meaning and connections.

Psychological Burden of Systemic Racism-Related Distress in New York City Healthcare Workers During the COVID-19 Pandemic

BACKGROUND

Little is known about the relationship among systemic racism, psychological symptoms (depression, anxiety, and/or post-traumatic stress disorders), and burnout in healthcare workers (HCWs).

OBJECTIVE

To determine whether distress related to awareness of systemic racism contributes to psychological symptoms and/or burnout in HCWs. We explored whether this form of racism-related distress may moderate the relationship between race, ethnicity, psychological symptoms, and burnout.

DESIGN

A cross-sectional survey was conducted from November 19, 2020, through January 11, 2021. Statistical analysis was conducted from May 3, 2022, to June 15, 2022.

PARTICIPANTS

Frontline HCWs at an urban tertiary care hospital in New York City.

MAIN MEASURES

Distress related to awareness of systemic racism (SR) and racial disparities in COVID-19 outcomes (RD), psychological symptoms, and burnout.

KEY RESULTS

Two thousand one of 4654 HCWs completed the survey (response rate 43.0%). Most HCWs reported experiencing distress related to awareness of systemic racism (1329 [66.4%]) and to racial disparities in COVID-19 outcomes (1137 [56.8%]). Non-Hispanic Black participants (SR odds ratio (OR) 2.84, p < .001; RD OR 2.34, p < .001), women (SR OR 1.35, p = .01; RD OR 1.67, p < .001), and those with history of mental illness (SR OR 2.13, p < .001; RD OR 1.66, p < .001) were more likely to report SR- and RD-related distress, respectively. HCWs who experienced "quite-a-bit to extreme" SR-related distress were more likely to screen positive for psychological symptoms (OR 5.90, p < .001) and burnout (OR 2.26, p < .001).

CONCLUSIONS

Our findings suggest that distress related to awareness of systemic racism, not race/ethnicity, was associated with experiencing psychological symptoms and burnout in HCWs. As the medical community continues to critically examine the role of systemic racism in healthcare, our work is a first step in characterizing its toll on the psychological well-being of HCWs.

Reporting of social determinants of health in randomized controlled trials conducted in the pediatric intensive care unit

Introduction

The influence of social determinants of health (SDOH) on access to care and outcomes for critically ill children remains an understudied area with a paucity of high-quality data. Recent publications have highlighted the importance of incorporating SDOH considerations into research but the frequency with which this occurs in pediatric intensive care unit (PICU) research is unclear. Our objective was to determine the frequency and categories of SDOH variables reported and how these variables were defined in published PICU randomized controlled trials (RCTs).

Methods

We searched Medline, Embase, Lilacs, and Central from inception to Dec 2022. Inclusion criteria were randomized controlled trials of any intervention on children or their families in a PICU. Data related to study demographics and nine WHO SDOH categories were extracted, and descriptive statistics and qualitative data generated.

Results

586 unique RCTs were included. Studies had a median sample size of 60 patients (IQR 40-106) with 73.0% of studies including ≤100 patients and 41.1% including ≤50 patients. A total of 181 (181/586, 30.9%) studies reported ≥1 SDOH variable of which 163 (163/586, 27.8%) reported them by randomization group. The most frequently reported categories were food insecurity (100/586, 17.1%) and social inclusion and non-discrimination (73/586, 12.5%). Twenty-five of 57 studies (43.9%) investigating feeding or nutrition and 11 of 82 (13.4%) assessing mechanical ventilation reported baseline nutritional assessments. Forty-one studies investigated interventions in children with asthma or bronchiolitis of which six reported on smoking in the home (6/41, 14.6%).

Discussion

Reporting of relevant SDOH variables occurs infrequently in PICU RCTs. In addition, when available, categorizations and definitions of SDOH vary considerably between studies. Standardization of SDOH variable collection along with consistent minimal reporting requirements for PICU RCT publications is needed.

Prevalence of Sexual Violence and Intimate Partner Violence Among US Military Veterans: Findings from Surveys with Two National Samples

BACKGROUND

Sexual violence (SV) and intimate partner violence (IPV) experiences are major social determinants of adverse health. There is limited prevalence data on these experiences for veterans, particularly across sociodemographic groups.

OBJECTIVE

To estimate the prevalence of SV before, during, and after military service and lifetime and past-year IPV for women and men, and explore differences across sociodemographic groups.

DESIGN

Data are from two national cross-sectional surveys conducted in 2020. Weighted prevalence estimates of SV and IPV experiences were computed, and weighted logistic regression models were used for comparisons across gender, race, ethnicity, sexual orientation, and age.

PARTICIPANTS

Study 1 included veterans of all service eras (N = 1187; 50.0% women; 29% response rate). Study 2 included recently separated post-9/11 veterans (N = 1494; 55.2% women; 19.4% response rate).

MAIN MEASURES

SV was assessed with the Deployment Risk and Resilience Inventory-2 (DRRI-2). IPV was assessed with the extended Hurt-Insult-Threaten-Scream Tool.

KEY RESULTS

Women were more likely than men to experience pre-military SV (study 1: 39.9% vs. 8.7%, OR = 6.96, CIs: 4.71-10.28; study 2: 36.2% vs. 8.6%, OR = 6.04, CIs: 4.18-8.71), sexual harassment and/or assault during military service (study 1: 55.0% vs. 16.8%, OR = 6.30, CIs: 4.57-8.58; study 2: 52.9% vs. 26.9%, OR = 3.08, CIs: 2.38-3.98), and post-military SV (study 1: 12.4% vs. 0.9%, OR = 15.49, CIs: 6.42-36.97; study 2: 7.5% vs. 1.5%, OR = 5.20, CIs: 2.26-11.99). Women were more likely than men to experience lifetime IPV (study 1: 45.7% vs. 37.1%, OR = 1.38, CIs: 1.04-1.82; study 2: 45.4% and 34.8%, OR = 1.60, CIs: 1.25-2.04) but not past-year IPV (study 1: 27.9% vs. 28.3%, OR = 0.95, CIs: 0.70-1.28; study 2: 33.1% vs. 28.5%, OR = 1.24, CIs: 0.95-1.61). When controlling for gender, there were few differences across other sociodemographic groups, with the exception of sexual orientation.

CONCLUSIONS

Understanding veterans' experiences of SV and IPV can inform identification and intervention efforts, especially for women and sexual minorities.

The use of race terms in epigenetics research: considerations moving forward

The field of environmental epigenetics is uniquely suited to investigate biologic mechanisms that have the potential to link stressors to health disparities. However, it is common practice in basic epigenetic research to treat race as a covariable in large data analyses in a way that can perpetuate harmful biases without providing any biologic insight. In this article, we i) propose that epigenetic researchers open a dialogue about how and why race is employed in study designs and think critically about how this might perpetuate harmful biases; ii) call for interdisciplinary conversation and collaboration between epigeneticists and social scientists to promote the collection of more detailed social metrics, particularly institutional and structural metrics such as levels of discrimination that could improve our understanding of individual health outcomes; iii) encourage the development of standards and practices that promote full transparency about data collection methods, particularly with regard to race; and iv) encourage the field of epigenetics to continue to investigate how social structures contribute to biological health disparities, with a particular focus on the influence that structural racism may have in driving these health disparities.

Prostate cancer screening in African American men: a review of the evidence

BACKGROUND

Prostate cancer is the most diagnosed cancer in African American men, yet prostate cancer screening regimens in this group are poorly guided by existing evidence, given underrepresentation of African American men in prostate cancer screening trials. It is critical to optimize prostate cancer screening and early detection in this high-risk group because underdiagnosis may lead to later-stage cancers at diagnosis and higher mortality while overdiagnosis may lead to unnecessary treatment.

METHODS

We performed a review of the literature related to prostate cancer screening and early detection specific to African American men to summarize the existing evidence available to guide health-care practice.

RESULTS

Limited evidence from observational and modeling studies suggests that African American men should be screened for prostate cancer. Consideration should be given to initiating screening of African American men at younger ages (eg, 45-50 years) and at more frequent intervals relative to other racial groups in the United States. Screening intervals can be optimized by using a baseline prostate-specific antigen measurement in midlife. Finally, no evidence has indicated that African American men would benefit from screening beyond 75 years of age; in fact, this group may experience higher rates of overdiagnosis at older ages.

CONCLUSIONS

The evidence base for prostate cancer screening in African American men is limited by the lack of large, randomized studies. Our literature search supported the need for African American men to be screened for prostate cancer, for initiating screening at younger ages (45-50 years), and perhaps screening at more frequent intervals relative to men of other racial groups in the United States.

Evaluating and Improving the Performance and Racial Fairness of Algorithms for GFR Estimation

Data-driven clinical prediction algorithms are used widely by clinicians. Understanding what factors can impact the performance and fairness of data-driven algorithms is an important step towards achieving equitable healthcare. To investigate the impact of modeling choices on the algorithmic performance and fairness, we make use of a case study to build a prediction algorithm for estimating glomerular filtration rate (GFR) based on the patient's electronic health record (EHR). We compare three distinct approaches for estimating GFR: CKD-EPI equations, epidemiological models, and EHR-based models. For epidemiological models and EHR-based models, four machine learning models of varying computational complexity (i.e., linear regression, support vector machine, random forest regression, and neural network) were compared. Performance metrics included root mean squared error (RMSE), median difference, and the proportion of GFR estimates within 30% of the measured GFR value (P30). Differential performance between non-African American and African American group was used to assess algorithmic fairness with respect to race. Our study showed that the variable race had a negligible effect on error, accuracy, and differential performance. Furthermore, including more relevant clinical features (e.g., common comorbidities of chronic kidney disease) and using more complex machine learning models, namely random forest regression, significantly lowered the estimation error of GFR. However, the difference in performance between African American and non-African American patients did not decrease, where the estimation error for African American patients remained consistently higher than non-African American patients, indicating that more objective patient characteristics should be discovered and included to improve algorithm performance.

Increasing dental and medical students' understanding of race as a social construct

PURPOSE

To improve health equity, dental and medical students must have a firm grasp of the proper use of race as a social construct. The purpose of this study was to determine the degree to which an innovative learning event affected students' understanding of race as a social construct. It also sought to examine the effects that personally experienced and/or witnessed racism and previous education had on students' responses to the learning event.

METHODS

In 2022, all incoming first-year dental (N = 48) and medical (N = 114) students completed an online pre-matriculation assignment about the use of race in healthcare. Students initially completed an anonymous 14-item pre-survey and then read assigned publications, followed by answering questions about a real-life vignette concerning the topic of race as a social construct. Students finished the assignment by completing an anonymous seven-item post-survey. Data from the pre- and post-surveys were collected and analyzed to assess if differences existed among students and between the two surveys.

RESULTS

Dental and medical students were significantly more likely to endorse race as a social construct after the learning experience (p < 0.001). Students who had experienced discrimination or obtained training were more likely to define race as a social construct before and after the learning event.

CONCLUSION

Dental and medical schools can increase students' understanding of race as a social construct, rather than a biological construct, with educational interventions.

Clinical Perspectives, Eligibility, and Success Criteria for Bariatric/Metabolic Surgery

Obesity is a worldwide chronic, complex, and progressive disease that poses a challenge for physicians to pursue optimal therapeutic decision making. This chapter focuses on the definition of obesity, based on excessive fat accumulation, and thus underscores the importance of body composition, and the clinical tools used to diagnose it in the context of excess weight, metabolic alteration, and obesity-associated comorbidity development. Additionally, it addresses the indications for surgery that are currently applicable and the description of the different types of patients who could benefit the most from the surgical management of excessive body fat and its associated metabolic derangements and quality of life improvement. Furthermore, it also highlights plausible underlying mechanisms of action for the beneficial effects following bariatric/metabolic surgery.

A Canadian Commentary on the NKF-ASN Task Force Recommendations on Reassessing the Inclusion of Race in Diagnosing Kidney Disease

In 2021, a committee was commissioned by the Canadian Society of Nephrology to comment on the 2021 National Kidney Foundation-American Society of Nephrology Task Force recommendations on the use of race in glomerular filtration rate estimating equations. The committee met on numerous occasions and agreed on several recommendations. However, the committee did not achieve unanimity, with a minority group disagreeing with the scope of the commentary. As a result, this report presents the viewpoint of the majority members. We endorsed many of the recommendations from the National Kidney Foundation-American Society of Nephrology Task Force, most importantly that race should be removed from the estimated glomerular filtration rate creatinine-based equation. We recommend an immediate implementation of the new Chronic Kidney Disease Epidemiology Collaboration equation (2021), which does not discriminate among any group while maintaining precision. Additionally, we recommend that Canadian laboratories and provincial kidney organizations advocate for increased testing and access to cystatin C because the combination of cystatin C and creatinine in revised equations leads to more precise estimates. Finally, we recommend that future research studies evaluating the implementation of the new equations and changes to screening, diagnosis, and management across provincial health programs be prioritized in Canada.

Longitudinal Antiracism Training for Family Medicine Residency Faculty

Introduction

Medical educators have often perpetuated misunderstandings about race-based medicine and at times failed to create safe educational environments for diverse learners who frequently experience mistreatment. It is imperative that family medicine faculty be equipped to recognize and mitigate bias and inequities in our teaching, research, and clinical care.

Methods

Our residency formed a diversity, equity, inclusion, and antiracism (DEIA) faculty work group to address the need for faculty training. We developed and administered a 32-item needs assessment survey in 2020 to determine gaps in antiracist knowledge and skills among our faculty members. Over the following year, faculty members designed and implemented a series of faculty training sessions including a half-day faculty retreat to address the highest need areas. We reassessed faculty confidence and skills using a follow-up survey in 2021.

Results

Faculty respondents demonstrated increased confidence in their knowledge of various DEIA topics and ability to intervene when observing biased or culturally insensitive behaviors from colleagues. Participants also reported increased confidence in their ability to mitigate bias in their teaching and clinical work.

Conclusions

Our longitudinal DEIA faculty training series, embedded into the existing structure of the residency, resulted in improvements in DEIA-related confidence and skills among faculty members. This training model could be adapted to a variety of residency settings as one step toward dismantling racism in medical education and clinical practice.

Review of health research and data on/with racially minoritised groups: Implications for addressing racism and racial disparities in public health practice and policies in Europe: a study protocol

Historically, across Europe, data and research on/with racially minoritised groups have not been collected or carried out in a sufficient, adequate, or appropriate manner. Yet, to understand emerging and existing health disparities among such groups, researchers and policymakers must obtain and use data to build evidence that informs decision-making and action on key structural and social determinants of health. This systematic search and review aims to contribute to closing this gap and promote a race-conscious approach to health research, strengthening the utilisation and deployment of data and research on/with racially minoritised groups in Europe. Its ultimate goal is to improve equality and equity in health*. Concretely, the study will do so by reviewing and critically analysing the usage of the concepts of race, ethnicity, and their related euphemisms and proxies in health-related research. It will examine the collection, use, and deployment of data and research on/with racially minoritised groups in this area. The study will focus on Belgium, France, and the Netherlands, three countries with graphical proximity and several similarities, one of which is the limited attention that is given to racism and racial inequalities in health in research and policy. This choice is also justified by practical knowledge of the context and languages. The results of the review will be used to develop guidance on how to use and deploy data and research on/with racially minoritised groups. The review is part of a larger project which aims to promote race-conscious research and data. The project does this by a three-pronged approach which: 1) highlights the need for a race-conscious approach when collecting and using data, carrying out research on/with racially minoritised groups; 2) builds expertise for their effective use and deployment, and; 3) creates a knowledge network and community of practice for public health researchers working in Europe.