An examination of concordance and cultural competency in the diabetes care pathway: South Asians living in the United Kingdom

Promoting Inclusion, Diversity, Access, and Equity Through Enhanced Institutional Culture and Climate

Advancing the health of all members of the global community remains core to the mission of the infectious diseases profession. Training, research, healthcare-delivery, and other infectious diseases-related institutions play a central role in meeting this goal. The promotion of inclusion, diversity, access, and equity (IDA&E) is critical to harnessing the full range of human creativity, innovation, and talent necessary to realizing the education, research, patient care, and service missions that constitute the principal objectives of such institutions. Strong and positive institutional cultures and climates are essential to achieving these IDA&E goals. We discuss opportunity gaps that exist in leveraging institutional culture and climate to optimize IDA&E. We further identify effective strategies to address these gaps and achieve excellence in education, research, patient care, and service in infectious diseases and the broader healthcare and biomedical space. We discuss the importance of both local and global context in conceptualizing IDA&E to best achieve these aims.

Experience of Culturally-Tailored Diabetes Interventions for Ethnic Minorities: A Qualitative Systematic Review

This qualitative systematic review synthesizes recent qualitative studies of culturally tailored interventions to better understand the experiences that individuals who are members of ethnic minorities have when undergoing type 2 diabetes treatment in the United States. Such interventions have been shown to be effective among ethnic minority populations; however, no qualitative synthesis has reported on recent findings from studies of these interventions. This systematic review identified seven relevant qualitative studies from five electronic databases-CINAHL, PsycINFO, PubMed, Ovid, and Web of Science-published from 2009 to 2019, and used a thematic synthesis review methodology. Methodological rigor was assessed for an appraisal of study quality. Five themes were identified as experiences of culturally tailored diabetes interventions: culturally appropriate healthy lifestyle behaviors, knowledge about diabetes care, emotional supports, access to the healthcare system, and family involvement. The findings of this review can be utilized as resources for improving diabetes care for ethnic minorities.

I Am an African American: Distinguishing Between African American and African Applicants in Medical School Admissions Matters

Ignoring the diverse and rich cultures and histories of Africa and the African diaspora by applying the term African American to anyone of sub-Saharan African ancestry in medical school admissions does a disservice to applicants, medical schools, and the communities they serve. To determine how applicants can contribute to a diverse educational environment, admissions decisions must go beyond racial and ethnic self-reporting and recognize the diversity that applicants bring to their medical school. Using a holistic approach, institutions can fairly evaluate applicants and strategically fill their incoming classes. What each medical school is looking for based on its mission and how each student reflects that mission and enhances the educational environment should be revisited as each application is considered. Medical schools must adopt practices that strategically enroll applicants who help achieve their mission and better the communities they serve. The benefits of diversity are not achieved in a linear fashion but require a critical mass for each diverse group. Different strategies are needed to enhance the educational environment, address underrepresentation in medicine, and eliminate health disparities. If racial justice and health equity are to be realized, diversity policies need to recognize the differences between African and Afro Caribbean immigrants and African Americans.In this Perspective, the author argues for distinguishing between these groups in medical school admissions. He explores the differences in their history, culture, and experiences and demonstrates their uniqueness. He concludes by discussing diversity in medicine and offering suggestions for considering diversity in medical school admissions.

Patients with ulcerative colitis from diverse populations: The Leicester experience

BACKGROUND

Ulcerative colitis is common in migrant communities. There is evidence that access to care in general is impaired among such communities. The purpose of this study was to investigate whether South Asians experienced the same quality of care as English patients with ulcerative colitis.

METHOD

The study assessed clinical care in the decade subsequent to diagnosis through a retrospective review of case notes. Newly diagnosed patients who lived in Leicester were identified and the frequency and type of consultation, in-patient admissions, surveillance colonoscopies, discharge rates, surgery and death were recorded.

RESULTS

Of 372 candidate cases identified, 70 met the criteria to be included in the study. Forty-two were of English origin and 28 South Asian. South Asian patients were significantly less likely to see a consultant and more likely to be discharged. South Asian patients were admitted to hospital more often but had significantly fewer tests than European patients. This trend was also seen in surveillance colonoscopy, although it did not reach significance. Despite these differences in the provision of care, surgical and death rates were comparable.

CONCLUSIONS

Patients with ulcerative colitis who are of South Asian origin receive poorer quality clinical care than their European counterparts.

Meeting the Challenge of Diabetes in Ageing and Diverse Populations: A Review of the Literature from the UK

The impact of type 2 diabetes on ageing societies is great and populations across the globe are becoming more diverse. Complications of diabetes unequally affect particular groups in the UK older people, and people with a South Asian background are two population groups with increased risk whose numbers will grow in the future. We explored the evidence about diabetes care for older people with South Asian ethnicity to understand the contexts and mechanisms behind interventions to reduce inequalities. We used a realist approach to review the literature, mapped the main areas where relevant evidence exists, and explored the concepts and mechanisms which underpinned interventions. From this we constructed a theoretical framework for a programme of research and put forward suggestions for what our analysis might mean to providers, researchers, and policy makers. Broad themes of cultural competency; comorbidities and stratification; and access emerged as mid-level mechanisms which have individualised, culturally intelligent, and ethical care at their heart and through which inequalities can be addressed. These provide a theoretical framework for future research to advance knowledge about concordance; culturally meaningful measures of depression and cognitive impairment; and care planning in different contexts which support effective diabetes care for aging and diverse populations.

Hemodialysis in Asia

BACKGROUND

Asia is the largest, most populous and most heterogeneous continent in the world. The number of patients with end-stage renal disease is growing rapidly in Asia.

SUMMARY

A fully informed report on the status of dialysis therapies including hemodialysis (HD) is limited by the lack of systematic registries. Available data suggest remarkable heterogeneities, with some countries like Taiwan, Japan and Korea exhibiting well-established HD systems, high prevalence and universal access to all patients, while low- and low-middle income countries are unable to provide HD to eligible patients because of high cost and poor healthcare systems. Many Asian countries have unregulated dialysis units, with poor standards of delivery, quality control and outcome reporting. This leads to high mortality due to preventable complications like infections. Modeling data suggest that at least 2.9 million people need dialysis in Asia, which represents a gap in availability of dialysis to the tune of -66%. The population is projected to grow rapidly in the coming years. Several countries are expanding access to HD. Innovative modifications in dialysis practice are being made to optimize outcomes. It is important to develop robust systems of documentation and outcome reporting to evaluate the effects of such changes. HD needs to develop in conjunction with effective preventive programs and improvement of health systems.

KEY MESSAGES

The practice of HD in Asia is growing and evolving. Rapid expansion will improve the currently dismal access to care for large sections of the population. Quality issues need to be addressed if the full benefit of this therapy is to reach the population. Developed countries of Asia can provide substantial messages to developing economies. HD programs must develop in conjunction with prevention efforts.

FACTS FROM EAST AND WEST

(1) While developed Western and Asian countries provide end-stage renal disease patients full access to HD, healthcare systems from South and South-East Asia can offer access to HD only to a limited fraction of the patients in need. Even though the annual costs of HD are much lower in less developed countries (for instance 30 times lower in India compared to the US), patients often cannot afford costs not covered by health insurance. (2) The recommended dialysis pattern in the West is at least three sessions weekly with high-flux dialyzers. Studies from Shanghai and Taiwan might however indicate a benefit of twice versus thrice weekly sessions. In less developed Asian countries, a twice weekly pattern is common, sometimes with dialyzer reuse and inadequate water treatment. A majority of patients decrease session frequency or discontinue the program due to financial constraint. (3) As convective therapies are gaining popularity in Europe, penetration in Asia is low and limited by costs. (4) In Asian countries, in particular in the South and South-East, hepatitis and tuberculosis infections in HD patients are higher than in the West and substantially increase mortality. (5) Progress has recently been made in countries like Thailand and Brunei to provide universal HD access to all patients in need. Nevertheless, well-trained personnel, reliable registries and better patient follow-up would improve outcomes in low-income Asian countries.

Completeness and usability of ethnicity data in UK-based primary care and hospital databases

BACKGROUND

Ethnicity recording across the National Health Service (NHS) has improved dramatically over the past decade. This study profiles the completeness, consistency and representativeness of routinely collected ethnicity data in both primary care and hospital settings.

METHODS

Completeness and consistency of ethnicity recording was examined in the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), and the ethnic breakdown of the CPRD was compared with that of the 2011 UK censuses.

RESULTS

27.1% of all patients in the CPRD (1990-2012) have ethnicity recorded. This proportion rises to 78.3% for patients registered since April 2006. The ethnic breakdown of the CPRD is comparable to the UK censuses. 79.4% of HES inpatients, 46.8% of outpatients and 26.8% of A&E patients had their ethnicity recorded. Amongst those with ethnicity recorded on >1 occasion, consistency was over 90% in all data sets except for HES inpatients. Combining CPRD and HES increased completeness to 97%, with 85% of patients having the same ethnicity recorded in both databases.

CONCLUSIONS

Using CPRD ethnicity from 2006 onwards maximizes completeness and comparability with the UK population. High concordance within and across NHS sources suggests these data are of high value when examining the continuum of care. Poor completeness and consistency of A&E and outpatient data render these sources unreliable.