Addressing Health Equity Through Action on the Social Determinants of Health: A Global Review of Policy Outcome Evaluation Methods

Global Burden of Kidney Cancer Attributable to High Body Mass Index in Adults Aged 60 and Older from 1990 to 2021 and Projections to 2040: A Systematic Analysis for the Global Burden of Disease Study

Background

With global aging, cancer burden rises. Kidney cancer is significantly influenced by high body mass index (BMI), especially in the elderly. This study analyzes the burden of kidney cancer attributable to high BMI in those aged ≥60, clarifying causes and future trends.

Methods

Using Global Burden of Disease (GBD) 2021 study, we assessed kidney cancer burden due to high BMI in population aged ≥60 from 1990 to 2021, comparing deaths, disability-adjusted life years (DALYs), age-standardized rate (ASR) of DALYs (ASDR), and mortality (ASMR). Stratified by Socio-Demographic Index (SDI), region, sex, and age, we evaluated spatiotemporal trends and inequalities. Finally, the Bayesian Age-Period-Cohort (BAPC) model predicted burden changes through 2040.

Results

From 1990 to 2021, DALYs and deaths from high BMI-induced kidney cancer in those aged ≥60 increased by 165.82% and 186.39%, driven by population growth. In 2021, ASDR was 45.55/100,000 and ASMR 2.39/100,000. Regional differences were significant. DALYs and deaths expanded, especially in those aged ≥95. Males had higher burden than females. SDI correlated positively with ASDR and ASMR (r>0, P<0.05). Health inequalities continue to rise. By 2040, burden is projected to rise, especially in low-middle and low SDI regions, more in males.

Conclusion

This study shows a significant increase in kidney cancer burden due to high BMI in those aged ≥60 over 32 years, driven by population growth. Disparities across regions, genders, and age groups highlight the need for targeted prevention and early intervention, especially for high-risk groups (males, elderly, low-middle SDI regions), to reduce burden and optimize healthcare resource allocation.

Impact of Social Determinants of Health on Outcomes of Nontraumatic Subarachnoid Hemorrhage

BACKGROUND

Nontraumatic subarachnoid hemorrhage (SAH) presents a significant health burden, yet the influence of social determinants of health on outcomes remains unclear. This study examines the impact of social determinants of health on outcomes of patients with SAH.

METHODS AND RESULTS

We conducted a retrospective analysis of prospectively collected data from the GWTG (Get With The Guidelines)-Stroke registry, including patients with SAH across the United States from 2012 to 2021. The role of the Social Deprivation Index (SDI) and adjusted gross income, stratified into tertiles, were assessed. Outcomes included in-hospital death, length of stay, and discharge disposition (good: home/rehabilitation; poor: long-term facility/hospice/death). Covariates included demographics, medical history, vascular risk factors, and SAH severity. Multivariable regressions were used to estimate associations, presenting odds ratios (ORs) and relative risks. Our study comprised 108 090 patients with nontraumatic SAH (mean age, 59.76 years; 61.3% women). The average length of stay was 12.04 days, 55.6% had good discharge disposition, and the overall mortality rate was 15.5%. Analyses showed that a high Social Deprivation Index was associated with reduced odds of a good discharge (unadjusted OR, 0.90 [95% CI, 0.87-0.92]; adjusted OR, 0.87 [95% CI, 0.82-0.92]), while higher adjusted gross income correlated with decreased death (unadjusted OR, 0.94 [95% CI, 0.90-0.97]; adjusted OR, 0.90 [95% CI, 0.83-0.96]). A high Social Deprivation Index was significantly associated with longer length of stay (unadjusted relative risk, 1.06 [95% CI, 1.07-1.26]; adjusted relative risk, 1.03 [95% CI, 1.01-1.13]).

CONCLUSIONS

Social determinants of health shape outcomes for patients with SAH, with a clear gradient of impact across socioeconomic levels.

How is health equity considered in policy evaluations employing quasi-experimental methods? A scoping review and content analysis

Public health researchers employ quasi-experimental methods (QEM) to evaluate the effects of policies. Whilst some policies are designed to improve (health) equity, others may intentionally or unintentionally have detrimental effects on disadvantaged populations. We thus sought to investigate how health equity is addressed in policy evaluations which employ QEM. We conducted a content analysis on studies sourced from a scoping review. We drew a random sample of 350 records identified in systematic database searches in Medline, EMBASE, and EconLit (December 2022). Studies that employed QEM labels and examined public policies implemented in the WHO European region were included. We extracted data on study design, policies, and populations; assessed whether outcomes were examined in population sub-groups (as defined by PROGRESS-Plus criteria); and analysed discussion sections for equity-related conclusions. We included 59 studies, of which 39 (66.1%) studies considered health equity-albeit to variable depth. Twenty-five studies were focused exclusively on examining policy outcomes in a disadvantaged population (42.4%), of which 19 studies evaluated policies that targeted disadvantaged groups (e.g. minimum wage, social housing policies). Outcomes were stratified for one or more sub-populations in 22 studies (37.3%), most commonly for gender (n = 15, 25.4%) and a measure of socio-economic status (n = 13, 22%), particularly income and employment. Equity-related results and implications were discussed in 24 studies. While policy evaluations employing QEM have considerable value for informing decision-making in public health and other sectors that influence health, their potential to investigate equity impacts is currently not harnessed.

Trends in NHANES Biomonitored Exposures in California and the United States following Enactment of California's Proposition 65

BACKGROUND

The prevalence of toxic chemicals in US commerce has prompted some states to adopt laws to reduce exposure. One with broad reach is California's Proposition 65 (Prop 65), which established a list of chemicals that cause cancer, developmental harm, or reproductive toxicity. The law is intended to discourage businesses from using these chemicals and to minimize consumer exposure. However, a key question remains unanswered: Has Prop 65 reduced population-level exposure to the listed chemicals?

OBJECTIVE

We used national biomonitoring data from the Centers for Disease Control and Prevention (CDC) to evaluate the impact of Prop 65 on population-level exposures.

METHODS

We evaluated changes in blood and urine concentrations of 37 chemicals (including phthalates, phenols, VOCs, metals, PAHs, and PFAS), among US National Health and Nutrition Examination Survey (NHANES) participants in relation to the time of chemicals' Prop 65 listing. Of these, 11 were listed prior to, 11 during, and 4 after the biomonitoring period. The remaining 11 were not listed but were closely related to a Prop 65-listed chemical. Where biomonitoring data were available from before and after the date of Prop 65 listing, we estimated the change in concentrations over time for Californians compared with non-Californians, using a difference-in-differences model. We used quantile regression to estimate changes in exposure over time, as well as differences between Californians and non-Californians at the 25th, 75th, and 95th percentiles.

RESULTS

We found that concentrations of biomonitored chemicals generally declined nationwide over time irrespective of their inclusion on the Prop 65 list. Median bisphenol A (BPA) concentrations decreased 15% after BPA's listing on Prop 65, whereas concentrations of the nonlisted but closely related bisphenol S (BPS) increased 20% over this same period, suggesting chemical substitution. Californians generally had lower levels of biomonitored chemicals than the rest of the US population.

DISCUSSION

Our findings suggest that increased scientific and regulatory attention, as well as public awareness of the harms of Prop 65-listed chemicals, prompted changes in product formulations that reduced exposure to those chemicals nationwide. Trends in bisphenols and several phthalates suggest that manufacturers replaced some listed chemicals with closely related but unlisted chemicals, increasing exposure to the substitutes. Our findings have implications for the design of policies to reduce toxic exposures, biomonitoring programs to inform policy interventions, and future research into the regulatory and market forces that affect chemical exposure. https://doi.org/10.1289/EHP13956.

The effect of urban-rural resident basic medical insurance on physical health of the rural older adult in China

Introduction

Urban-Rural Resident Basic Medical Insurance (URRBMI) is an important system for effectively transferring disease risks to the rural older adult. As China experiences rapid aging, maintaining the physical health of the rural older adult is key to achieving the goal of healthy aging.

Methods

The study explores the impact of URRBMI on physical health of the rural older adult in China using the Chinese Longitudinal Healthy Longevity Survey (CLHLS) data in 2018. Ordinary least square models were used to analyze the relationship between URRBMI and physical health of the rural older adult, and we used instrumental variable method to address the potential endogenous problem.

Results

We find that URRBMI greatly improves physical health of the rural older adult. The heterogeneity analysis indicates that URRBMI contributes more significantly to the rural older adult in eastern areas and the advanced rural older adult. The results also suggested that URRBMI improves physical health of the rural older adult through increasing life satisfaction and enhancing the timeliness of medical services.

Recommendations

This study implies that we need to further improve the participation rate, increase the actual reimbursement ratio and increase financial subsidies for URRBMI in central and western areas, and further integrate the distribution of medical resources to promote physical health of the rural older adult.

Operationalizing the GRADE-equity criterion to inform guideline recommendations: application to a medical cannabis guideline

OBJECTIVES

Incorporating health equity considerations into guideline development often requires information beyond that gathered through traditional evidence synthesis methodology. This article outlines an operationalization plan for the Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-equity criterion to gather and assess evidence from primary studies within systematic reviews, enhancing guideline recommendations to promote equity. We demonstrate its use in a clinical guideline on medical cannabis for chronic pain.

STUDY DESIGN AND SETTING

We reviewed GRADE guidance and resources recommended by team members regarding the use of evidence for equity considerations, drafted an operationalization plan, and iteratively refined it through team discussion and feedback and piloted it on a medicinal cannabis guideline.

RESULTS

We propose a seven-step approach: 1) identify disadvantaged populations, 2) examine available data for specific populations, 3) evaluate population baseline risk for primary outcomes, 4) assess representation of these populations in primary studies, 5) appraise analyses, 6) note barriers to implementation of effective interventions for these populations, and 7) suggest supportive strategies to facilitate implementation of effective interventions.

CONCLUSION

Our approach assists guideline developers in recognizing equity considerations, particularly in resource-constrained settings. Its application across various guideline topics can verify its feasibility and necessary adjustments.

Decomposing income-related inequality in health-related quality of life in mainland China: a national cross-sectional study

INTRODUCTION

Health equity is an important indicator measuring social development and solidarity. However, there is a paucity in nationwide studies into the inequity in health-related quality of life (HRQoL) in mainland China, in particular using the most recent data measuring HRQoL using the EuroQol 5-Dimension-5 Level (EQ-5D-5L). This study aimed to address the gap in the literature by estimating and decomposing income-related inequality of the utility index (UI) of EQ-5D-5L in mainland China.

METHODS

Data were extracted from the Psychology and Behaviour Investigation of Chinese Residents (2022), including 19 738 respondents over the age of 18 years. HRQoL was assessed by the UI of the EQ-5D-5L. Concentration index (CI) was calculated to measure the degree of income-related inequality in the UI. The contributions of individual, behavioural and context characteristics to the CI were estimated using the Wagstaff decomposition method.

RESULTS

The CI of the EQ-5D-5L UI reached 0.0103, indicating pro-rich inequality in HRQoL. Individual characteristics made the greatest contribution to the CI (57.68%), followed by context characteristics (0.60%) and health behaviours (-3.28%). The contribution of individual characteristics was mainly attributable to disparities in the enabling (26.86%) and need factors (23.86%), with the chronic conditions (15.76%), health literacy (15.56%) and average household income (15.24%) as the top three contributors. Educational level (-5.24%) was the top negative contributor, followed by commercial (-1.43%) and basic medical insurance (-0.56%). Higher inequality was found in the least developed rural (CI=0.0140) and western regions (CI=0.0134).

CONCLUSION

Pro-rich inequality in HRQoL is evident in mainland China. Targeted interventions need to prioritise measures that aim at reducing disparities in chronic conditions, health literacy and income.

Stakeholder Perspectives on Data-Driven Solutions to Address Cardiovascular Disease and Health Equity in New York City

Introduction

There is growing recognition of the importance of addressing the social determinants of health in efforts to improve health equity. In dense urban environments such as New York City, disparities in chronic health conditions (e.g., cardiovascular disease) closely mimic inequities in social factors such as income, education, and housing. Although there is a wealth of data on these social factors in New York City, little is known about how to rapidly use available data sources to address health disparities.

Methods

Semistructured interviews were conducted with key stakeholders (N=11) from across the public health landscape in New York City (health departments, healthcare delivery systems, and community-based organizations) to assess perspectives on how social determinants of health data can be used to address cardiovascular disease and health equity, what data-driven tools would be useful, and challenges to using these data sources and developing tools. A matrix analysis approach was used to analyze the interview data.

Results

Stakeholders were optimistic about using social determinants of health data to address health equity by delivering holistic care, connecting people with additional resources, and increasing investments in under-resourced communities. However, interviewees noted challenges related to the quality and timeliness of social determinants of health data, interoperability between data systems, and lack of consistent metrics related to cardiovascular disease and health equity.

Conclusions

Future research on this topic should focus on mitigating the barriers to using social determinants of health data, which includes incorporating social determinants of health data from other sectors. There is also a need to assess how data-driven solutions can be implemented within and across communities and organizations.

Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

Reaching consensus on definitions for food and physical activity policies: experience from the Policy Evaluation Network

BACKGROUND

An upsurge in policy evaluation research within public health sciences has led to multi-disciplinary research networks like the 'Policy Evaluation Network' (PEN). This multi-disciplinary collaboration highlighted the need for consensus on clear, common terminology and definitions to facilitate the multi-disciplinary research. This article outlines the development process of the PEN definitions glossary tool, with a focus on the key domains of policy design, implementation and outcomes as they apply to physical activity, sedentary behaviour and dietary behaviours.

METHODS

A project specific participatory process was undertaken, involving PEN researchers (n = 48) from seven European countries across various disciplinary backgrounds. All involved researchers were invited to identify and collate definitions that were commonly used in their research field. Terms and definitions were discussed and debated during three online workshops. Subsequently, the definitions were discussed and refined until consensus was reached.

RESULTS

Consensus definitions for 93 terms related to the evaluation of policy design, implementation and outcomes are provided. Consensus was reached on a range of terms where the terms were understood and used differently across represented disciplines (e.g. 'Outcome' and 'Impact'). A conceptual 'Inter-relations in policy-related concepts' diagram was developed to enable navigation through an online database with key terms.

CONCLUSIONS

The definitions resulting from this participatory process has supported PEN researchers and practitioners across disciplines to reach a shared understanding of different terms related to policy evaluation. Thus, providing a platform for avoiding conflicting use of the same terms in differing contexts over the course of the PEN work programme, facilitating clear and consistent communication, and allowing for clarity within collaborative multi-disciplinary projects and in public-facing messages.

Feasibility of an educational program for public health nurses to promote local healthcare planning: protocol for a pilot randomized controlled trial

BACKGROUND

Promoting of local healthcare planning is crucial for assisting public health nurses in improving community health inequities. However, there is no effective educational program for developing relevant skills and knowledge among these nurses. Therefore, this study aims to assess the feasibility of a newly developed web-based self-learning program to promote the involvement of public health nurses in the local healthcare planning process.

METHODS

A pilot randomized control trial randomly allocated eligible public health nurses to intervention and control wait-list groups [1:1]. The former will be exposed to six web-based learning modules from July to October 2021. After collecting post-test data, the wait-list group will be exposed to the same modules to ensure learning equity. The primary outcome will be evaluated by implementing a validated and standardized scale designed to measure public health policy competencies at the baseline and post-intervention, while secondary outcome will be measured on an action scale to demonstrate the necessity of healthcare activities. The third outcome will be the knowledge and skills related to local healthcare planning by public health nurses. The participants will provide feedback through free descriptions on the trial feasibility and a web-based self-learning program to identify improvement points for continual refinement.

DISCUSSION

The results will provide suggestions in preparation for a future definitive randomized controlled trial. This will provide preliminary data for an intervention aimed at improving relevant competencies among public health nurses who are tasked with resolving health inequities in their respective communities through local health planning.

TRIAL REGISTRATION

The protocol for this study was registered with the University Hospital Medical Information Network Clinical Trials Registry and approved by the International Committee of Medical Journal Editors (No. UMIN000043628 , March 23, 2021).

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

Outcomes of Total Joint Arthroplasty in Black, Asian, Minority Ethnic Groups Versus Local Population: A Retrospective Review

BACKGROUND

 Total hip and knee replacement decrease the disability caused by osteoarthritis of the lower extremities. Although it has been established that racial and ethnic minorities underutilize these procedures, little data on postoperative outcomes exists. The impact of race on postoperative Oxford scores and complications following total joint arthroplasty (TJA) will be investigated in this retrospective review.

METHODS

 A retrospective review of 120 elective primary TJA procedures was undertaken between January 2016 and December 2019 in a single institution. To measure variations between the various groups, t-tests were used on their Oxford scores, and chi-squared bivariate regression was used to classify all categorical variables and the association of ethnicity and surgery type with gender.

RESULTS

 There were 62 (51.6%) White patients and 59 (49.1.0%) Black, Asian, Minority Ethnic (BAME) patients in total. The majority of the patients were females (60.9% vs 39.2%, p = 0.032). Low vitamin D levels were seen in a small percentage of patients in the sample (15.8% vs 84.2%, p = 0.460). There is a statistically important connection (p = 0.001) between the surgery type (total knee replacement [TKR]/total hip replacement [THR]) and gender; 41 females had TKR surgery, and 32 had THR surgery.

CONCLUSION

The study found that the relationships between ethnicity (White/BAME) and gender as well as surgery type (TKR/THR) and gender are statistically important. In all cases with low vitamin D and normal vitamin D levels, White patients had higher overall Oxford hip scores than the BAME patients. To comprehend the differences discovered, further research is needed. To try to eliminate the difference, targeted approaches should be created.

The benefits of an integrated social medical insurance for health services utilization in rural China: evidence from the China health and retirement longitudinal study

Background

Improving health equity is a fundamental goal for establishing social health insurance. This article evaluated the benefits of the Integration of Social Medical Insurance (ISMI) policy for health services utilization in rural China.

Methods

Using the China Health and Retirement Longitudinal study (2011‒2018), we estimated the changes in rates and equity in health services utilization by a generalized linear mixed model, concentration curves, concentration indices, and a horizontal inequity index before and after the introduction of the ISMI policy.

Results

For the changes in rates, the generalized linear mixed model showed that the rate of inpatient health services utilization (IHSU) nearly doubled after the introduction of the ISMI policy (8.78 % vs. 16.58 %), while the rate of outpatient health services utilization (OHSU) decreased (20.25 % vs. 16.35 %) after the implementation of the policy. For the changes in inequity, the concentration index of OHSU decreased significantly from − 0.0636 (95 % CL: −0.0846, − 0.0430) before the policy to − 0.0457 (95 % CL: −0.0684, − 0.0229) after it. In addition, the horizontal inequity index decreased from − 0.0284 before the implementation of the policy to − 0.0171 after it, indicating that the inequity of OHSU was further reduced. The concentration index of IHSU increased significantly from − 0.0532 (95 % CL: −0.0868, − 0.0196) before the policy was implemented to − 0.1105 (95 % CL: −0.1333, − 0.0876) afterwards; the horizontal inequity index of IHSU increased from − 0.0066 before policy implementation to − 0.0595 afterwards, indicating that more low-income participants utilized inpatient services after the policy came into effect.

Conclusions

The ISMI policy had a positive effect on improving the rate of IHSU but not on the rate of OHSU. This is in line with this policy’s original intention of focusing on inpatient service rather than outpatients to achieve its principal goal of preventing catastrophic health expenditure. The ISMI policy had a positive effect on reducing the inequity in OHSU but a negative effect on the decrease in inequity in IHSU. Further research is needed to verify this change. This research on the effects of integration policy implementation may be useful to policy makers and has important policy implications for other developing countries facing similar challenges on the road to universal health coverage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01457-8.

Social Determinants of Health Amplify the Association Between Ethnicity and COVID19: A Retrospective-Cohort study

BACKGROUND

People in racial and ethnic minority groups have been shown to be at increased risk for a variety of diseases, including COVID-19. However, the role that social needs play in this increased risk has not yet been quantified. Investigating these roles can elicit a greater understanding of how social needs influence the manner in which this disease is contracted and spread.

METHODS

A retrospective analysis was conducted of 1,969 Lynn Community Health Center patients. Patients that visited the center between February 1st and July 1st, 2020, tested for COVID-19, and screened for social determinants of health (SDOH) risk factors. Demographics were compared between COVID-19 positive and negative patients. Confounding by age on the association between ethnicity and COVID-19 status was evaluated. A stratified analysis was performed to evaluate the effect modification of SDOH on the relationship between race, ethnicity, and COVID-19 status.

RESULTS

Hispanic patients had 2.93 times the odds of a positive COVID-19 test compared to non-Hispanics (95% CI: 2.37 - 3.64, p<0.0001). With at least one SDOH risk factor, Hispanics had 4.71 times the odds of a positive COVID-19 test relative to non-Hispanics (95% CI: 3.10 - 7.14). With no SDOH risk factors, Hispanics had 2.45 times the odds of a positive COVID-19 test relative to non-Hispanics (95% CI: 1.91 - 3.16). No significant associations were found for race.

CONCLUSION

Ethnicity had a significant impact on COVID-19 status in our population, where the effect of ethnicity on COVID-19 status was amplified for those with SDOH risk factors.

Addressing Health Equity in Public Health Practice: Frameworks, Promising Strategies, and Measurement Considerations

This review describes the context of health equity and options for integrating equity into public health practice. We first discuss how the conceptualization of health equity and how equity considerations in US public health practice have been shaped by multidisciplinary engagements. We then discuss specific ways to address equity in core public health functions, provide examples of relevant frameworks and promising strategies, and discuss conceptual and measurement issues relevant to assessing progress in moving toward health equity. Challenges and opportunities and their implications for future directions are identified.

Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces

OBJECTIVE

To explore regional primary care improvement strategies that are potentially determinants of primary care performance.

DESIGN

Multiple comparative embedded case study.

SETTING

Three regions in Canada: Fraser East, British Columbia; Eastern Ontario Health Unit, Ontario; Central Zone, Nova Scotia.

DATA SOURCES

(1) In-depth interviews with purposively selected key informants (eg, primary care decision-makers, physician leads, regulatory agencies) and focus groups with patients and clinicians (n=68 participants) and (2) published and grey literature (n=205 documents).

OUTCOME MEASURES

Variations in spread and uptake of primary care improvement strategies across the three study regions. NVivo (V.11) was used to manage data and perform content analysis to identify categories within and across cases. The coding structure was developed by researchers through iterative collaboration, using inductive and deductive processes.

RESULTS

Six overarching primary care improvement strategies, differing in focus and spread, were implemented across the three study regions: interprofessional team-based approaches, provider skill mix expansion, physician groups and networks, information systems, remuneration and performance measurement and reporting infrastructure.

CONCLUSION

The addition of information on regional improvement strategies to primary care performance reports could add important contextual insights into primary care performance results. This could help identify possible drivers of reported performance outcomes and levers for change in practice, regional and system-level settings.

Differences in Perioperative Outcomes and Complications Between African American and White Patients After Total Joint Arthroplasty

BACKGROUND

Racial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA).

METHODS

Single institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor.

RESULTS

In total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002).

CONCLUSION

AA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity.