Health system resource use among populations with complex social and behavioral needs in an urban, safety-net health system

How legal problems are conceptualized and measured in healthcare settings: a systematic review

Legal problems encompass issues requiring resolution through the justice system. This social risk factor creates barriers in accessing services and increases risk of poor health outcomes. A systematic review of the peer-reviewed English-language health literature following the PRISMA guidelines sought to answer the question, how has the concept of patients' "legal problems" been operationalized in healthcare settings? Eligible articles reported the measurement or screening of individuals for legal problems in a United States healthcare or clinical setting. We abstracted the prevalence of legal problems, characteristics of the sampled population, and which concepts were included. 58 studies reported a total of 82 different measurements of legal problems. 56.8% of measures reflected a single concept (e.g., incarcerated only). The rest of the measures reflected two or more concepts within a single reported measure (e.g., incarcerations and arrests). Among all measures, the concept of incarceration or being imprisoned appeared the most frequently (57%). The mean of the reported legal problems was 26%. The literature indicates that legal concepts, however operationalized, are very common among patients. The variation in measurement definitions and approaches indicates the potential difficulties for organizations seeking to address these challenges.

An Evidence-Based Roadmap for the Provision of More Equitable Telemedicine

OBJECTIVE

During the coronavirus disease 2019 pandemic, as a safety-net organization with a substantial percentage of patients of color and with limited English proficiency (LEP), we were wary of furthering health disparities in our community. We analyzed gaps in telemedicine (telephone and video) delivery in our communities, quantified the effects of our tests of change, and began the process of accumulating evidence to create a road map for other organizations.

METHODS

We leveraged Lean problem-solving strategies to identify modifiable gaps across multiple domains that could inhibit equity in telemedicine. We implemented tests of change across domains of community engagement, technology, education, and access. We observed the proportion of telemedicine encounters across races and languages between April and November, 2020. Regression analyses tested the impact of race and language on telemedicine controlling for age, gender, insurance, and time.

RESULTS

Several rounds of changes and enhancements were associated with changes in telemedicine use of +5.5% (p < 0.0001) for Hispanic, +4.0% (p < 0.0001) for Spanish-speaking, -2.1% for Black (p < 0.05), and -4.4% for White patients (p < 0.001). African-American, Hispanic, and non-English-speaking patients had between 2.3 and 4.6 times the odds of preferring telephone to video encounters (p < 0.0001), with increases in preferences for video use over time (p < 0.05).

CONCLUSION

Our roadmap to improve equitable delivery of telemedicine was associated with a significant improvement in telemedicine use among certain minority populations. Most populations of color used telephone more often than video. This preference changed over time and with equity-focused changes in telemedicine delivery.