Racial Discrimination in Health Care and Utilization of Health Care: a Cross-sectional Study of California Adults

Racial discrimination in healthcare services among Black individuals in Canada as a major threat for public health: its association with COVID-19 vaccine mistrust and uptake, conspiracy beliefs, depression, anxiety, stress, and community resilience

OBJECTIVES

To examine the prevalence of major racial discrimination (MRD) in healthcare services and its association with COVID-19 vaccine mistrust and uptake, conspiracy theories, COVID-19-related stressors, community resilience, anxiety, depression, and stress symptoms.

STUDY DESIGN

The study used a population-based cross-sectional design.

METHODS

Data from the BlackVax dataset on COVID-19 vaccination in Black individuals in Canada was analyzed (n = 2002, 51.66% women). Logistic regression analyses were performed to examine the association between MRD and independent variables.

RESULTS

32.55% of participants declared having experienced MRD in healthcare services. Participants with MRD were less vaccinated against COVID-19, presented higher scores of vaccine mistrust, conspiracy beliefs, COVID-19 related stressors, depression, anxiety, and stress, and had lower scores of community resilience. They were more likely to experience depression (AOR = 2.13, P < 0.001), anxiety (AOR = 2.00, P < 0.001), and stress symptoms (AOR = 2.15, P < 0.001). Participants who experienced MRD were more likely to be unvaccinated (AOR = 1.35, P = 0.009).

CONCLUSIONS

Racial discrimination experienced by Black individuals in health services is a major public health concern and threat to population health in Canada. Federal, provincial, and municipal public health agencies should adapt their programs, strategies, tools, and campaigns to address the mistrust created by racial discrimination.

Anti-Black discrimination in primary health care: a qualitative study exploring internalized racism in a Canadian context

OBJECTIVES

A growing body of evidence points to persistent health inequities within racialized minority communities, and the effects of racial discrimination on health outcomes and health care experiences. While much work has considered how anti-Black racism operates at the interpersonal and institutional levels, limited attention has focused on internalized racism and its consequences for health care. This study explores patients' attitudes towards anti-Black racism in a Canadian health care system, with a particular focus on internalized racism in primary health care.

DESIGN

This qualitative study employed purposive maximal variation and snowball sampling to recruit and interview self-identified Black persons aged 18 years and older who: (1) lived in Montréal during the COVID-19 pandemic, (2) could speak English or French, and (3) were registered with the Québec health insurance program. Adopting a phenomenological approach, in-depth interviews took place from October 2021 to July 2022. Following transcription, data were analyzed thematically.

RESULTS

Thirty-two participants were interviewed spanning an age range from 22 years to 79 years (mean: 42 years). Fifty-nine percent of the sample identified as women, 38% identified as men, and 3% identified as non-binary. Diversity was also reflected in terms of immigration experience, financial situation, and educational attainment. We identified three major themes that describe mechanisms through which internalized racism may manifest in health care to impact experiences: (1) the internalization of anti-Black racism by Black providers and patients, (2) the expression of anti-Black prejudice and discrimination by non-Black racialized minority providers, and (3) an insensitivity towards racial discrimination.

CONCLUSION

Our study suggests that multiple levels of racism, including internalized racism, must be addressed in efforts to promote health and health care equity among racialized minority groups, and particularly within Black communities.

Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic

OBJECTIVE

Evaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms.

METHOD

Veterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care.

RESULTS

A total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated.

CONCLUSIONS

Black race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.

Sociocultural and Economic Disparities in Physical Therapy Utilization Among Insured Older Adults With Rheumatoid Arthritis

OBJECTIVE

To examine influences of sociocultural and economic determinants on physical therapy (PT) utilization for older adults with rheumatoid arthritis (RA).

METHODS

In these annual cross-sectional analyses between 2012 and 2016, we accessed Medicare enrollment data and fee-for-service claims. The cohort included Medicare beneficiaries with RA based on 3 diagnosis codes or 2 codes plus a disease-modifying antirheumatic drug medication claim. We defined race and ethnicity and dual Medicare/Medicaid coverage (proxy for income) using enrollment data. Adults with a Current Procedural Terminology code for PT evaluation were classified as utilizing PT services. Associations between race and ethnicity and dual coverage and PT utilization were estimated with logistic regression analyses. Potential interactions between race and ethnicity status and dual coverage were tested using interaction terms.

RESULTS

Of 106,470 adults with RA (75.1% female; aged 75.8 [SD 7.3] years; 83.9% identified as non-Hispanic White, 8.8% as non-Hispanic Black, 7.2% as Hispanic), 9.6-12.5% used PT in a given year. Non-Hispanic Black (adjusted odds ratio [aOR] 0.77, 95% CI 0.73-0.82) and Hispanic (aOR 0.92, 95% CI 0.87-0.98) individuals had lower odds of PT utilization than non-Hispanic White individuals. Adults with dual coverage (lower income) had lower odds of utilization than adults with Medicare only (aOR 0.44, 95% CI 0.43-0.46). There were no significant interactions between race and ethnicity status and dual coverage on utilization.

CONCLUSION

We found sociocultural and economic disparities in PT utilization in older adults with RA. We must identify and address the underlying factors that influence these disparities in order to mitigate them.

Prospective Survey of Discrimination in Pregnant Persons and Correlation with Unplanned Healthcare Utilization

OBJECTIVE

To determine the association between lifetime exposure to discrimination and unplanned healthcare utilization in pregnant persons.

METHODS

This was a prospective cohort study of pregnant persons receiving care from 2021 to 2022. Primary data was collected from participants on sociodemographic factors and on Perceived Ethnic Discrimination Questionnaire (PED-Q), a validated 17-item scale measuring perceived lifetime interpersonal racial and ethnic discrimination in four domains: work/school, social exclusion, stigmatization, and threat. The primary outcome was unplanned healthcare utilization, defined as unplanned labor and delivery admissions, triage, Emergency Department, or urgent care visits. Bivariate and multivariate analyses were done to examine the association between lifetime exposure to discrimination and unplanned healthcare utilization.

RESULTS

A total of 289 completed the PED-Q and were included in the analysis. Of these, 123 (42.6%) had unplanned healthcare utilization. Mean (SD) of lifetime racial and ethnic discrimination was significantly higher in people with unplanned healthcare utilization compared to those with planned healthcare utilization [1.67 (0.63) vs 1.48 (0.45), p = 0.003]. Univariate analysis showed that lifetime racial and ethnic discrimination was significantly associated with unplanned healthcare utilization (OR 1.96, 95% CI 0.23-3.11). Significant associations were found between unplanned healthcare utilization and maternal age (p = 0.04), insurance type (p = 0.01), married status (p < 0.001), education (p = 0.013), household income (p = 0.001), and chronic hypertension (p = 0.004). After controlling for potential confounding factors, self-reported lifetime racial and ethnic discrimination remained significantly associated with higher odds of unplanned healthcare utilization (aOR 1.78, CI 95% 1.01-3.11).

CONCLUSION

We found that a higher level of self-reported lifetime racial and ethnic discrimination was associated with increased unplanned healthcare utilization during pregnancy.

Culture of discrimination in healthcare: A grounded theory

BACKGROUND

Discrimination in health care is an international challenge and a serious obstacle to justice and equality in health.

RESEARCH OBJECTIVE

The purpose of this study was to design a grounded theory of discrimination in health care based on the experiences and perceptions of Iranian healthcare providers and patients.

RESEARCH DESIGN

This qualitative study was conducted using by the grounded theory method.

PARTICIPANTS AND RESEARCH CONTEXT

Data were collected through semi-structured interviews with 18 healthcare providers including 11 nurses, two physicians, two nurse's assistants, and three patients in two general hospitals in Tehran, Iran. Participants were selected through purposeful sampling and analyzed simultaneously using the Corbin and Strauss (2015) approach.

ETHICAL CONSIDERATIONS

The study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Ethics code: IR.USWR.REC.1398.023). Also, after explaining the objectives of the study, all the participants completed and signed the written consent form.

FINDINGS

The "culture of discrimination" was the study's core category, reflecting the nature of discrimination in health care. The theory of "culture of discrimination in health care" is the result of five main categories: "individual social stimuli," "culture of discrimination," "unintentional discrimination," "conflict with discrimination," and "dissatisfaction with discriminatory behavior." These categories cover the underlying factors, strategies, and outcomes of the discrimination process in health care.

DISCUSSION

The results of the study showed that nurses and other health care providers experience unintentional discrimination. Unintentional discrimination refers to discriminatory behaviors and practices of health care providers.

CONCLUSION

The theory of culture of discrimination in health care can be used as a practical guide to describe and understand the role of health care providers, especially nurses. Further studies with a quantitative approach to applying this theory in medical settings are recommended.

Impact of Racial/Ethnic Discrimination on Quality of Life Among Breast Cancer Survivors

Although racial/ethnic disparities in health-care access, treatment, and cancer outcomes are well documented, the impact of racial/ethnic discrimination on cancer survivorship is unclear. We examined associations between quality of life (QoL) and self-reported discrimination among 3,991 women with breast cancer recruited during 2006-2013 from the Pathways Study in the Kaiser Permanente Northern California integrated health-care system, using linear regression models. Overall, 31% of women reported experiencing racial/ethnic discrimination, with differences by race/ethnicity (82% among non-Hispanic Black women vs. 19% among non-Hispanic White women) and nativity (40% among foreign-born Hispanic women vs. 76% among US-born Asian-American women). Experiencing racial/ethnic discrimination was associated with lower QoL in fully adjusted models. The mean QoL score was 119.6 (95% confidence interval (CI): 102.0, 137.1) for women who did not report discrimination, 115.5 (95% CI: 98.0, 133.0) for those who reported some discrimination/less than the median level, and 110.2 (95% CI: 92.7, 127.7) for those who reported more discrimination/greater than or equal to the median level. Discrimination was associated with lower QoL among women who used passive coping strategies or lived in neighborhoods with high neighborhood socioeconomic status, neighborhoods with high levels of segregation, or non-ethnic enclaves. Among breast cancer survivors, clinically meaningful differences in QoL scores were associated with racial/ethnic discrimination. Additional studies are needed to understand potential pathways through which these social factors affect survivorship outcomes.

Asian American Self-Reported Discrimination in Healthcare and Having a Usual Source of Care

BACKGROUND

Self-reported racial or ethnic discrimination in a healthcare setting has been linked to worse health outcomes and not having a usual source of care, but has been rarely examined among Asian ethnic subgroups.

OBJECTIVE

We examined the association between Asian ethnic subgroup and self-reported discrimination in a healthcare setting, and whether both factors were associated with not having a usual source of care.

DESIGN

Using the California Health Interview Survey (CHIS) 2015-2017, we used logistic regression models to assess associations among Asian ethnic subgroup, self-reported discrimination, and not having a usual source of care. Interactions between race and self-reported discrimination, foreign-born status, poverty level, and limited English proficiency were also analyzed.

PARTICIPANTS

Respondents represented adults age 18 + residing in California who identified as White, Black, Hispanic, American Indian/Alaska Native, Asian (including Chinese, Filipino, Japanese, Korean, Vietnamese, and Other Asian), and Other.

MAIN MEASURES

We examined two main outcomes: self-reported discrimination in a healthcare setting and having a usual source of care.

KEY RESULTS

There were 62,965 respondents. After survey weighting, Asians (OR 1.78, 95% CI 1.19-2.66) as an aggregate group were more likely to report discrimination than non-Hispanic Whites. When Asians were disaggregated, Japanese (3.12, 1.36-7.13) and Koreans (2.42, 1.11-5.29) were more likely to report discrimination than non-Hispanic Whites. Self-reported discrimination was marginally associated with not having a usual source of care (1.25, 0.99-1.57). Koreans were the only group associated with not having a usual source of care (2.10, 1.23-3.60). Foreign-born Chinese (ROR 7.42, 95% CI 1.7-32.32) and foreign-born Japanese (ROR 4.15, 95% CI 0.82-20.95) were more associated with self-reported discrimination than being independently foreign-born and Chinese or Japanese.

CONCLUSIONS

Differences in self-reported discrimination in a healthcare setting and not having a usual source of care were observed among Asian ethnic subgroups. Better understanding of these differences in their sociocultural contexts will guide interventions to ensure equitable access to healthcare.

A framework for health equity in people living with epilepsy

Epilepsy is a disease where disparities and inequities in risk and outcomes are complex and multifactorial. While most epilepsy research to date has identified several key areas of disparities, we set out to provide a multilevel life course model of epilepsy development, diagnosis, treatment, and outcomes to highlight how these disparities represent true inequities. Our piece also presents three hypothetical cases that highlight how the solutions to address inequities may vary across the lifespan. We then identify four key domains (structural, socio-cultural, health care, and physiological) that contribute to the persistence of inequities in epilepsy risk and outcomes in the United States. Each of these domains, and their core components in the context of epilepsy, are reviewed and discussed. Further, we highlight the connection between domains and key areas of intervention to strive towards health equity. The goal of this work is to highlight these domains while also providing epilepsy researchers and clinicians with broader context of how their work fits into health equity.

US medical student perspectives on asian american patient inclusion in medical education: a qualitative Study

BACKGROUND

Asian American (AsAm) representation is lacking in conversations surrounding cultural humility in healthcare. We aimed to investigate US medical student perspectives on AsAm patient inclusion in cultural humility training in medical education.

METHODS

This qualitative study analyzed free-text responses to an optional, open-ended question presented at the conclusion of an online survey assessing medical student experiences with and perceptions regarding AsAm patients in their medical education. This survey was distributed to a convenience sample of nine US medical schools. Medical students who completed at least one clinical rotation were eligible to participate in the survey. Qualitative analysis of free-text responses was conducted in an iterative process to generate emergent themes.

RESULTS

There was a total of 195 optional free-text responses from 688 participants (28%). Motivation to learn about AsAm population included shared identity and desire to better serve the AsAm population in their local community and future careers. Topics of interest included healthcare-related cultural preferences, healthcare delivery strategies, and health disparities for the AsAm population and other minority patients. Students reported that they drew on personal experiences and some pre-clinical or clinical exposures to learn about AsAm patients. Respondents cited the lack of exposure in the medical school curriculum and clinical experiences as the main challenge to learning about AsAm health and provided suggestions for the delivery of this education in their pre-clinical and clinical education. Respondents emphasized that AsAms are treated as a monolith in medical education and healthcare, despite their heterogeneity.

CONCLUSIONS

Medical students identified a need and interest for greater inclusion of AsAm topics in medical education on cultural humility and minority health.

Biopsychosocial Health Outcomes and Experienced Intersectional Stigma in a Mixed HIV Serostatus Longitudinal Cohort of Aging Sexual Minority Men, United States, 2008‒2019

Objectives. To determine whether intersectional stigma is longitudinally associated with biopsychosocial outcomes. Methods. We measured experienced intersectional stigma (EIS; ≥ 2 identity-related attributions) among sexual minority men (SMM) in the United States participating in the Multicenter AIDS Cohort Study. We assessed longitudinal associations between EIS (2008‒2009) and concurrent and future hypertension, diabetes, dyslipidemia, antiretroviral therapy adherence, HIV viremia, health care underutilization, and depression symptoms (2008‒2019). We conducted causal mediation to assess the contribution of intersectional stigma to the relationship between self-identified Black race and persistently uncontrolled outcomes. Results. The mean age (n = 1806) was 51.8 years (range = 22-84 years). Of participants, 23.1% self-identified as Black; 48.3% were living with HIV. Participants reporting EIS (30.8%) had higher odds of hypertension, dyslipidemia, diabetes, depression symptoms, health care underutilization, and suboptimal antiretroviral therapy adherence compared with participants who did not report EIS. EIS mediated the relationship between self-identified Black race and uncontrolled outcomes. Conclusions. Our findings demonstrate that EIS is a durable driver of biopsychosocial health outcomes over the life course. Public Health Implications. There is a critical need for interventions to reduce intersectional stigma, help SMM cope with intersectional stigma, and enact policies protecting minoritized people from discriminatory acts. (Am J Public Health. 2022;112(S4):S452-S462. https://doi.org/10.2105/AJPH.2022.306735).

Perceived healthcare discrimination and well-being among older adults in the United States and Brazil

Despite well-documented evidence illustrating the relationship between discrimination and health, less is known about the influence of unfair treatment when receiving medical care. Moreover, our current knowledge of cross-national and racial variations in healthcare discrimination is limited in aging populations. This article addresses these gaps using two harmonized data sets of aging populations to clarify the relationship between healthcare discrimination and health in the United States and Brazil. We use nationally representative, harmonized data from the Health and Retirement Study in the United States and the Brazilian Longitudinal Study of Aging to examine and compare perceived discrimination in the healthcare setting and its relationship to self-rated health, depression diagnosis, and depressive symptoms across national contexts. Using Poisson regression models and population attributable risk percent estimates, we found that aging adults reporting healthcare discrimination were at higher risk of poor self-rated health, diagnosed depression, and depressive symptoms. Our results also suggest that reducing perceived healthcare discrimination may contribute to improved self-rated health and mental well-being in later life across racialized societies. In two comparative settings, we highlight the differential impact of healthcare discrimination on self-rated health and depression. We describe the implications of our study's findings for national public health strategies focused on eliminating discrimination in the healthcare setting, particularly among aging countries.

Health insurance, healthcare utilization and language use among populations who experience risk for tuberculosis, California 2014–2017

Background

California tuberculosis (TB) prevention goals include testing more than ten million at-risk Californians and treating two million infected with tuberculosis. Adequate health insurance and robust healthcare utilization are crucial to meeting these goals, but information on these factors for populations that experience risk for TB is limited.

Methods

We used data from the 2014–2017 California Health Interview Survey (n = 82,758), a population-based dual-frame telephone survey to calculate survey proportions and 95% confidence intervals (CI) stratified by country of birth, focusing on persons from countries of birth with the highest number of TB cases in California. Survey proportions for recent doctor’s visit, overall health, smoking, and diabetes were age-adjusted.

Results

Among 18–64 year-olds, 27% (CI: 25–30) of persons born in Mexico reported being uninsured in contrast with 3% (CI: 1–5) of persons born in India. Report of recent doctor’s visit was highest among persons born in the Philippines, 84% (CI: 80–89) and lowest among Chinese-born persons, 70% (CI: 63–76). Persons born in Mexico were more likely to report community clinics as their usual source of care than persons born in China, Vietnam, or the Philippines. Poverty was highest among Mexican-born persons, 56% (CI: 54–58) and lowest among Indian-born persons, 9% (CI: 5–13). Of adults with a medical visit in a non-English language, 96% (CI: 96–97) were non-U.S.-born, but only 42% (CI: 40–44) of non-U.S.-born persons had a visit in a non-English language.

Discussion

Many, though not all, of the populations that experience risk for TB had health insurance and used healthcare. We found key differences in usual source of care and language use by country of birth which should be considered when planning outreach to specific providers, clinic systems, insurers and communities for TB prevention and case-finding.

Racial disparities in health care utilization, the affordable care act and racial concordance preference

The Affordable Care Act was implemented with the aim of increasing coverage and affordable access with hopes of improving health outcomes and reducing costs. Yet, disparities persist. Coverage and affordable access alone cannot explain the health care gap between racial/ethnic minorities and white patients. Instead, the focus has turned to other factors affecting utilization rates such as the patient-provider relationship. Data from nationally represented U.S. households in 2009-2017 were used to study the association between patient-provider social distance as measured by "racial/ethnic concordance" and health care utilization rates for periods covering pre- and post-ACA. Despite the reduction in financial barriers to health access with the implementation of the ACA, the correlation between racial/ethnic concordance and utilization remains positive and significant. The results suggest that while the ACA may have improved coverage and affordability, other dimensions of access, particularly acceptability, as measured by patient-provider clinical interaction experience, remains a factor in the decision to utilize care.

Factors Associated with Human Papillomavirus Vaccine Initiation and Compliance Among U.S. Military Service Members

INTRODUCTION

The primary objective of the current study was to assess factors associated with Human Papillomavirus (HPV) vaccine initiation and compliance in a cohort of active duty US military service members (SM).

MATERIALS AND METHODS

We included active-duty participants aged 18-26 years from the Millennium Cohort Study, a longitudinal cohort study of over 200,000 military SMs. The eligible study population included 22,387 female SMs and 31,705 male SMs. Vaccination was assessed over the period 2006-2017. Logistic regression was used to estimate the odds of vaccine initiation and compliance (3 doses within a 1-year period) in relation to demographic, military, health, and behavioral characteristics.

RESULTS

Among female SMs, 37.8% initiated the vaccine and 40.2% of initiators completed the series within a year. Among male SMs, 3.9% initiated the vaccine and 22.1% of initiators completed the series within a year. Differences by sociodemographic factors, deployment status, branch of service, occupation, and smoking status-but not by selected mental health conditions-were observed.

CONCLUSION

HPV vaccination uptake is subpar across all military service branches. Certain subgroups of SMs could be targeted to increase overall HPV vaccine coverage in the US military population.

Examining the Relationship between Discrimination and Prescription Drug Misuse: Findings from a National Survey of Black Americans

Background: Research shows that substance use may be a way individuals cope with psychosocial stressors. Less is known about whether discrimination contributes to prescription drug misuse. Methods: Using a national sample of Black Americans, we examined whether two psychosocial stressors (i.e., everyday and lifetime major discrimination) were associated with lifetime prescription drug misuse (i.e., opioids, tranquilizers, sedatives, or stimulants). Results: Our logistic regression models separately examining the influence of everyday and major discrimination controlling for relevant demographic, health, and other drug use variables showed that only everyday discrimination was associated with higher odds of prescription drug misuse. In the model simultaneously considering both types of discrimination, only unit increases in everyday discrimination were associated with higher odds of prescription drug misuse. Conclusions: Encounters with everyday discrimination may be an important psychosocial stressor linked to prescription drug misuse in Black adults and possibly other racial-ethnic minorities. Intervention strategies aiming to reduce prescription drug misuse should consider developing ways to curb the negative health-related consequences of discriminatory experiences. Strategies to combat discrimination-related prescription drug misuse and limitations of this study are discussed.

More than Hurt Feelings: The Wear and Tear of Day-to-Day Discrimination in Adults with Chronic Pain

OBJECTIVE

To examine the extent to which self-reported experiences of discrimination are associated with pain interference among men and women with chronic non-cancer pain.

METHODS

Data are from the Study of Midlife in the United States (MIDUS) Refresher Cohort. The analytic sample consisted of 207 adults with chronic pain (54.2 ± 12.8 years; 53.6% female) who completed the Major Experiences of Discrimination and Everyday Discrimination scales. Regression analyses examined cross-sectional relations between discrimination and pain interference.

RESULTS

On average, the level of pain interference was moderate in the sample (mean = 3.46, standard deviation = 2.66; observed range 0-10). Approximately a third of respondents reported at least one major discriminatory event in their lifetime, while 22% reported three or more discriminatory lifetime events. Everyday discrimination scores averaged 14.19 ± 5.46 (observed range 0-33). With adjustment for sociodemographics, physical health, cognitive and psychological factors, social isolation, and loneliness, everyday discrimination was associated with increased pain interference (B = 0.099; 95% confidence interval [CI]: 0.02 to 0.17).

CONCLUSION

These findings add weight to the importance of day-to-day experiences of interpersonal discrimination by documenting independent associations with functional interference in adults with chronic pain.

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location

BACKGROUND

As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access.

QUESTIONS/PURPOSES

(1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs?

METHODS

An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC.

RESULTS

Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements.

CONCLUSION

It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective.

LEVEL OF EVIDENCE

Level II, prognostic study.

Acute Care Reimagined: Home Hospital Care Can Support the Triple Aim and Reduce Health Disparities

EXECUTIVE SUMMARY

Home hospital care (HHC) is a new and exciting concept that holds the promise of achieving all three components of the Triple Aim and reducing health disparities. As an innovative care delivery model, HHC substitutes traditional inpatient hospital care with hospital care at home for older patients with certain conditions. Studies have shown evidence of reduced cost of care, improved patient satisfaction, and enhanced quality and safety of care for patients treated through this model. The steady growth in Medicare Advantage enrollment and the expansion in 2020 of the Centers for Medicare & Medicaid Services (CMS) Hospitals Without Walls program to include acute hospital care at home creates an opportunity for hospitals to implement such programs and be financially rewarded for reducing costs. Capacity constraints exacerbated by the COVID-19 pandemic suggest that now is the ideal time for healthcare leaders to test and advance the concept of HHC in their communities.

[Age at diagnosis of Autism Spectrum Disorder depending on ethno-cultural background or migratory status: A systematic literature review]

INTRODUCTION

The early identification and access to health care of toddlers with autism spectrum disorder (ASD) - or at risk of developing it - is a crucial public health issue, as care and intervention may be more effective in younger children in order to improve their development and prognosis. However, there are still disparities in identification and health care access for children with ASD despite better screening methods. Given that misdiagnosis and delayed diagnosis are often due to the cultural gap between clinician and patient in some psychiatric disorders such as depression or schizophrenia, we examined this question concerning ASD and wondered to what extent ethno-cultural or migratory status might have an impact on the age at which a child is diagnosed. The only published review looking for independent factors influencing age of diagnosis concludes that the factors that have been proved to play a role are: socioeconomic status; symptom severity; level of parental concern, and family interactions with the health and education systems prior to diagnosis. The impact of ethno-cultural or migratory status is less clear. And yet, all these factors may be interconnected: migrants have on average a lower socioeconomic status, minorities don't have the same access to health care, and cultural background can have an influence on what is expected of a child's development and health. In order to try and clarify this issue and to analyze the way in which the international literature approaches the subject, we carried out a systematic review.

METHOD

Six databases were interrogated: Pubmed, Embase, Psychinfo, WebOfScience, Cochrane and Cinahl using the key words "ASD", "pervasive developmental disorder", "diagnosis", "age", "migrant", "ethnicity", "cross cultural". We narrowed neither the period of time not selected the articles by their method, as our objective was to collect the entirety of the articles written on the subject. We completed this review by including the pertinent references made in the articles.

RESULTS

Twenty articles were included, all epidemiological and observational, about children diagnosed in specialized centers. Published between 2002 and 2019, they cover a 20-year research period, between 1992 and 2016. The methods are disparate: the diagnosis criteria used are from DSM IV, IV TR and ICD; data originate from medical records, phone or internet surveys, and Medicaid healthcare claims. Comparison of the age at diagnosis is the principal objective for only thirteen studies; statistical data analyses vary, especially concerning adjustments. Seventy-five percent of the articles originate from North America where the compared populations are defined by ethnic and racial categories that are not used in some other countries, notably in Europe. Only five explore the link between migratory status and age at diagnosis. The research results concerning the impact of ethnicity are contradictory, while those concerning migratory status seem to indicate that migrant children are likely to be diagnosed later. But the articles and their methods being too heterogeneous, it was difficult to make a meta-analysis and impossible to reach a scientific conclusion.

CONCLUSION

Nevertheless, this review highlights the existence of a lot of confounding factors and raises many issues. It shows that the United States produces most of the studies whose conclusions cannot be generalized because of the particular history and organization of this country. In Europe, where belonging to minority groups is thought to be through migratory status, studies are rare. There is an urgent need for new research in order to clarify the connection between migratory status and socioeconomic factors, to precisely define the independent variables influencing diagnosis -such as access to healthcare- and finally to explore the possibility of different symptomatic expressions depending on cultural backgrounds. This review falls within studies currently carried out by the psychiatric service at Avicenne hospital in Bobigny, France about ASD in a transcultural context.

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.

The Paradigm Shift-The Impact of HIV/AIDS on Black Women and Families: Speaking Truth to Power

Ethn Dis. 2020;30(2):241-246; doi:10.18865/ed.30.2.241

Changes in Perceptions of Discrimination in Health Care in California, 2003 to 2017

IMPORTANCE

Research in the early 2000s in California demonstrated that racial and ethnic minorities, immigrants, and those with limited English proficiency (LEP) experienced high rates of discrimination in health care. Less is known about how patients' perceptions of discrimination in health care have changed since then.

OBJECTIVE

To determine whether perceptions of discrimination in health care have changed overall and for specific vulnerable populations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the California Health Interview Survey for state residents aged 18 years and older for 2 periods, 2003 to 2005 and 2015 to 2017. χ2 analyses and multivariate logistic regression were performed to compare recent discrimination in health care in late vs early periods controlling for race/ethnicity, poverty level, education, insurance status, usual source of care, self-reported health, and LEP. Additional subanalyses were performed by race/ethnicity, immigrant status, and LEP status. Jackknife replicate weights were provided by the California Health Interview Survey.

EXPOSURE

Survey year was dichotomized as combined 2003 to 2005 and combined 2015 to 2017.

MAIN OUTCOMES AND MEASURES

Survey respondents were identified as having experienced recent discrimination in health care if they responded "yes" to the question, "Was there ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?" and reported that this occurred within the last 5 years.

RESULTS

There were 84 088 participants in 2003 to 2005 (51.0% female; 14.7% aged ≥65 years) and 63 242 participants in 2015 to 2017 (51.1% female; 18.0% aged ≥65 years). Rates of recent discrimination in health care decreased from 6.0% to 4.0% (difference, 2.0%; 95% CI, 1.5%-2.5%; P < .001). In adjusted analyses, perceptions of discrimination in health care decreased in 2015 to 2017 compared with 2003 to 2005 (odds ratio [OR], 0.60; 95% CI, 0.53-0.68; P < .001). There was a significant race × period interaction for Latino individuals (OR, 0.58; 95% CI, 0.40-0.83; P = .003) but not for Asian individuals (OR, 0.76; 95% CI, 0.50-1.16; P = .20) or African American individuals (OR, 1.24; 95% CI, 0.76-2.02; P = .40). There was a significant immigrant status × period interaction (OR, 0.55; 95% CI, 0.44-0.69; P < .001) and LEP status × period interaction (OR, 0.67; 95% CI, 0.51-0.89; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that perceptions of discrimination in health care in California decreased between 2003 to 2005 and 2015 to 2017 among Latino individuals, immigrants, and those with LEP. African American participants reported consistently high rates of discrimination, indicating that interventions targeting health care discrimination are still necessary.