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Tung EL, Bruch JD, Chin MH, Menconi M, Peek ME, Huang ES. Associations of U.S. hospital closure (2007-2018) with area socioeconomic disadvantage and racial/ethnic composition. Ann Epidemiol 2024; 92:40-46. [PMID: 38432535 DOI: 10.1016/j.annepidem.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE To examine whether hospital closure is associated with high levels of area socioeconomic disadvantage and racial/ethnic minority composition. METHODS Pooled cross-sectional analysis (2007-2018) of 6467 U.S. hospitals from the American Hospital Association's Annual Survey, comparing hospital population characteristics of closed hospitals to all remaining open hospitals. We used multilevel mixed-effects logistic regression models to assess closure as a function of population characteristics, including area deprivation index ([ADI], a composite measure of socioeconomic disadvantage), racial/ethnic composition, and rural classification, nesting hospitals within hospital service areas (HSAs) and hospital referral regions. Secondary analyses examined public or private hospital type. RESULTS Overall, 326 (5.0%) of 6467 U.S. hospitals closed during the study period. In multivariable models, hospitals in HSAs with a higher burden of socioeconomic disadvantage (per 10% above median ADI ZIP codes, AOR 1.05; 95% CI, 1.01-1.09) and Black Non-Hispanic composition (highest quartile, AOR 4.03; 95% CI, 2.62-6.21) had higher odds of closure. We did not observe disparities in closure by Hispanic/Latino composition or rurality. Disparities persisted for Black Non-Hispanic communities, even among HSAs with the lowest burden of disadvantage. CONCLUSIONS Disproportionate hospital closure in communities with higher socioeconomic disadvantage and Black racial composition raises concerns about unequal loss of healthcare resources in the U.S.
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Affiliation(s)
- Elizabeth L Tung
- Section of General Internal Medicine, University of Chicago, United States; Center for Health and the Social Sciences, University of Chicago, United States.
| | - Joseph D Bruch
- Section of General Internal Medicine, University of Chicago, United States; Department of Public Health Sciences, University of Chicago, United States
| | - Marshall H Chin
- Section of General Internal Medicine, University of Chicago, United States; Center for Chronic Disease Research and Policy, University of Chicago, United States
| | - Maxwell Menconi
- Section of General Internal Medicine, University of Chicago, United States
| | - Monica E Peek
- Section of General Internal Medicine, University of Chicago, United States; Center for Chronic Disease Research and Policy, University of Chicago, United States
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, United States; Center for Chronic Disease Research and Policy, University of Chicago, United States
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Wilson MR, Smith NA, Peek ME, Tung EL. Primary Care Patients' Perspectives on Health Care Screening for Firearms in a Diverse, Urban Area: A Qualitative Study. JAMA Intern Med 2024; 184:194-200. [PMID: 38190173 PMCID: PMC10775074 DOI: 10.1001/jamainternmed.2023.7588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/17/2023] [Indexed: 01/09/2024]
Abstract
Importance Firearm violence is increasingly recognized as a public health issue, but whether physicians should intervene remains politically contested. Objective To explore self-described patient perspectives about the appropriateness and acceptability of health care screening for firearms. Design, Setting, and Participants This qualitative study recruited 50 adult patients from a primary care clinic in Chicago, Illinois, from June 7, 2019, to January 11, 2021, to participate in 1 of 12 one-time qualitative focus groups. Focus group discussions were facilitated using an in-depth, semistructured guide, transcribed verbatim from audio recordings, and analyzed for major themes using a pragmatic approach to basic thematic analysis, which is commonly used in implementation science, between December 12, 2019, and November 29, 2022. Main Outcomes and Measures Patient perspectives of health care screening for firearms were evaluated to examine complexities of a practice change goal. Results Participants were a median age of 60.0 (IQR, 50.5-66.5) years and predominantly female (37 [74%]; male, 11 [22%]; nonbinary, 1 [2%]; transgender, 1 [2%]) and non-Hispanic Black (42 [84%]; non-Hispanic Asian or Pacific Islander, 2 [4%]; non-Hispanic White, 5 [10%]). Two-thirds (32 [64%]) of participants thought that health care screening for firearms was at least sometimes appropriate, recognizing clear benefits, for instance, among patients at risk for suicide. However, few (2 [4%]) had ever discussed firearms with a physician or other health care professional. Even among those who recognized benefits, several barriers to acceptability were described, especially related to bias, stigma, and increased risk for criminal legal involvement. Other major themes included insufficient time to address firearms during health care visits and doubts about a clinician's ability to intervene. Facilitators to acceptability included screening strategies that were patient centered, sensitive to racial bias, clinically efficient, and accompanied by tangible resources. Conclusions and Relevance Incorporating these findings and emergent themes into clinical practice may guide efforts to make firearm screening more acceptable for patients from historically marginalized communities.
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Affiliation(s)
| | - Nichole A. Smith
- Department of Medicine, University of Pennsylvania, Philadelphia
| | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
- Center for Chronic Disease Research and Policy, University of Chicago, Chicago, Illinois
| | - Elizabeth L. Tung
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
- Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
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3
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Wesevich A, Peek ME, Ratain MJ. An Ethical and Financial Obligation for Sickle Cell Disease Gene Therapy in the United States. Ann Intern Med 2024; 177:85-86. [PMID: 38048579 DOI: 10.7326/m23-2428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Affiliation(s)
- Austin Wesevich
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois (A.W., M.J.R.)
| | - Monica E Peek
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (M.E.P.)
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois (A.W., M.J.R.)
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Peek ME, Gottlieb LM, Doubeni CA, Viswanathan M, Cartier Y, Aceves B, Fichtenberg C, Cené CW. Advancing health equity through social care interventions. Health Serv Res 2023; 58 Suppl 3:318-326. [PMID: 38015863 PMCID: PMC10684037 DOI: 10.1111/1475-6773.14244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
OBJECTIVE To use evidence on addressing racism in social care intervention research to create a framework for advancing health equity for all populations with marginalized social identities (e.g., race, gender, and sexual orientation). Such groups have disproportionate social needs (e.g., food insecurity) and negative social determinants of health (SDOH; e.g., poverty). We recommend how the Agency for Healthcare Research and Quality (AHRQ) could advance health equity for marginalized populations through social care research and care delivery. DATA SOURCES AND STUDY SETTING This commentary is informed by a literature review of social care interventions that were affiliated with healthcare systems; input from health equity researchers, policymakers, and community leaders attending the AHRQ Health Equity Summit; and consensus of the authors. PRINCIPAL FINDINGS We recommend that AHRQ: (1) create an ecosystem that values research on SDOH and the effectiveness and implementation of social care interventions in the healthcare sector; (2) work with other federal agencies to (a) develop position statements with actionable recommendations about racism and other systems that perpetuate marginalization based on social identity and (b) develop aligned, complementary approaches to research and care delivery that address social marginalization; (3) advance both inclusive care delivery and inclusive research teams; (4) advance understanding of racism as a social determinant of health and effective strategies to mitigate its adverse impact on health; (5) advance the creation and scaling of effective strategies for addressing SDOH in healthcare systems, particularly in co-creation with community partners; and (6) require social care intervention researchers to use methods that advance our understanding of social health equity. CONCLUSIONS AHRQ, as a federal agency, could help advance health equity using a range of strategies, including using the agency's levers to ensure AHRQ stakeholders examine and address the unique experiences of socially marginalized populations in SDOH and social care intervention research.
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Affiliation(s)
- Monica E. Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, MacLean Center for Clinical Medical Ethics, Center for the Study of Race, Politics and CultureThe University of ChicagoChicagoIllinoisUSA
| | - Laura M. Gottlieb
- Social Interventions Research and Evaluation Network (SIREN), Center for Health and CommunityUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Chyke A. Doubeni
- The Ohio State University Wexner Medical Center, Family and Community MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | | | - Yuri Cartier
- Social Interventions Research and Evaluation Network (SIREN), Center for Health and CommunityUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Benjamin Aceves
- School of Public HealthSan Diego State UniversitySan DiegoCaliforniaUSA
| | - Caroline Fichtenberg
- Department of Family and Community Medicine, Social Interventions Research and Evaluation Network (SIREN), Center for Health and Community ResearcherUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Crystal W. Cené
- Section of General Internal MedicineUniversity of CaliforniaSan DiegoCaliforniaUSA
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Stulberg DB, Schumm LP, Schueler K, Giurcanu M, Peek ME. Preconception care utilization: Self-report versus claims-based measures among women with Medicaid. PLOS Glob Public Health 2023; 3:e0002592. [PMID: 38032882 PMCID: PMC10688716 DOI: 10.1371/journal.pgph.0002592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
The objective of this study is to compare self-reported preconception care utilization (PCU) among Medicaid-covered births to Medicaid claims. We identified all Medicaid-covered births to women ages 15-45 in 26 states in the year 2012 among the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey and Medicaid Analytic eXtract (MAX) claims data, and identified preconception services in the latter using diagnosis codes published by Health and Human Services' Office of Population Affairs. We fit mixed-effects logistic regression models for the probability of PCU on sociodemographic factors (age, race, and ethnicity) and clinical diagnoses (depression, diabetes, or hypertension), separately for each dataset. Among 652,929 women delivering in MAX, 28.1% received at least one claims-based preconception service while an estimated 23.6% (95% CI 22.1-25.3) of PRAMS respondents reported receiving preconception care. Adjusting for age, chronic diseases, and state, PCU rates in both MAX and PRAMS were higher for non-Hispanic Black versus non-Hispanic White women (OR 1.51, 95% CI 1.49-1.54 and OR 2.05, 95% CI 1.60-2.62, respectively). Adjusting for differences in age, race and ethnicity, and state, PCU rates were higher for patients with diabetes (OR 1.34, 95% CI 1.29-1.40 and OR 1.82, 95% CI 1.16-2.85) or hypertension (OR 1.22, 95% CI 1.18-1.27 and OR 1.85, 95% CI 1.41-2.44). While Hispanic and Asian women were also more likely to report PCU than their non-Hispanic White counterparts (OR 2.07, 95% CI 1.53-2.80 and OR 3.37, 95% CI 2.28-4.98), they were less likely to have received it (OR 0.74, 95% CI 0.73-0.75 and OR 0.65, 95% CI 0.63-0.67). In conclusion, comparing self-report to claims measures of PCU, we found similar trends in the differences between non-Hispanic Black and White women, and between those with vs. without diabetes and hypertension. However, the two data sources differed in trends in other racial/ethnic groups (differences between Hispanic vs. non-Hispanic White women, and between Asian vs. non-Hispanic White women), and in those with vs. without depression. This suggests that while Medicaid claims can be a useful tool for studying preconception care, they may miss certain types of care among some sub-groups of the population or be subject to reporting differences that are hard to surmise. Both data sets have potential benefits and drawbacks as research tools.
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Affiliation(s)
- Debra B. Stulberg
- Department of Family Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - L. Philip Schumm
- Center for Translational Data Science, University of Chicago, Chicago, Illinois, United States of America
| | - Kellie Schueler
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, California, United States of America
| | - Mihai Giurcanu
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, United States of America
| | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, United States of America
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Peek ME, Goheer A, Saha S. The RWJF Health Policy Research Scholars: Interdisciplinary leaders advancing health equity. Health Serv Res 2023; 58 Suppl 2:145-149. [PMID: 37439189 DOI: 10.1111/1475-6773.14186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Attia Goheer
- Health Policy Research Scholars Program National Program Center, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Somnath Saha
- Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
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Huang ES, Sinclair A, Conlin PR, Cukierman-Yaffe T, Hirsch IB, Huisingh-Scheetz M, Kahkoska AR, Laffel L, Lee AK, Lee S, Lipska K, Meneilly G, Pandya N, Peek ME, Peters A, Pratley RE, Sherifali D, Toschi E, Umpierrez G, Weinstock RS, Munshi M. The Growing Role of Technology in the Care of Older Adults With Diabetes. Diabetes Care 2023; 46:1455-1463. [PMID: 37471606 PMCID: PMC10369127 DOI: 10.2337/dci23-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 07/22/2023]
Abstract
The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.
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Affiliation(s)
| | | | - Paul R. Conlin
- Harvard Medical School, Boston, MA
- Veteran Affairs Boston Healthcare System, Boston, MA
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes, and Metabolism, Ramat Gan, Israel
- Sheba Medical Centre, Ramat Gan, Israel
- Epidemiology Department, Sackler Faculty of Medicine, Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | - Sei Lee
- University of California San Francisco, San Francisco, CA
| | | | - Graydon Meneilly
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL
| | | | - Anne Peters
- University of Southern California, Los Angeles, CA
| | - Richard E. Pratley
- AdventHealth Diabetes Institute, AdventHealth Translational Research Institute, AdventHealth, Orlando, FL
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Ehrhardt N, Bouchonville M, Peek ME, Thomas CC, Zou T, Cuttriss N, Desimone M, Weinstock RS, Baer LG, Gabbay RA. Telementoring With Project ECHO: A New Era in Diabetes-Related Continuing Education for Primary Care to Address Health Disparities. J Diabetes Sci Technol 2023; 17:916-924. [PMID: 36879471 PMCID: PMC10348009 DOI: 10.1177/19322968231155150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Project ECHO® is a telementoring workforce development model that targets under-resourced communities lacking access to specialty care. The model builds virtual communities of practice, including specialists and community primary care professionals (PCPs) to combat clinical inertia and health disparities. While the ECHO model has gained global recognition, implementation of the model related to diabetes is lagging compared to other specialty conditions. This review highlights diabetes-endocrine (ENDO)-focused ECHOs using data reported in the ECHO Institute's centralized data repository (iECHO) and the learning collaborative for diabetes ECHOs. It also describes the implementation of diabetes ECHOs and their evaluation. Learner and patient-centered outcomes related to diabetes ECHOs are reviewed. Program implementation and evaluations have demonstrated utility of the ECHO model for diabetes programs to (1) address unmet needs of diabetes care in the primary care setting, (2) improve knowledge and confidence in managing complex diabetes and change provider prescribing habits, (3) improve patient outcomes, and (4) address diabetes quality improvement practices in primary care. More studies with broader collaboration among sites are needed to evaluate the model related to diabetes, especially applied to addressing therapeutic inertia, adoption of diabetes technology, and reducing health disparities.
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Affiliation(s)
- Nicole Ehrhardt
- Division of Endocrinology, Diabetes and Metabolism, University of Washington Diabetes Institute, Seattle, WA, USA
| | - Matt Bouchonville
- Division of Endocrinology, Diabetes, and Metabolism, School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Monica E. Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, The MacLean Center for Clinical Medical Ethics, and The University of Chicago, Chicago, IL, USA
| | - Celeste C. Thomas
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, The University of Chicago, Chicago, IL, USA
| | - Tracy Zou
- Division of Endocrinology, Diabetes and Metabolism, University of Washington Diabetes Institute, Seattle, WA, USA
| | - Nicolas Cuttriss
- ECHO Diabetes Action Network, ENDO Diabetes & Wellness, Washington, DC, USA
| | - Marisa Desimone
- Endocrinology, Diabetes and Metabolism, Joslin Diabetes Center, and SUNY Upstate Medical University, Syracuse, NY, USA
| | - Ruth S. Weinstock
- Endocrinology, Diabetes and Metabolism, Clinical Research Unit and Joslin Diabetes Center, and SUNY Upstate Medical University, Syracuse, NY, USA
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Peek ME, Wan W, Noriea A. A Physician's Sense of Responsibility to Address Disparities: Does It Relate to Reported Behaviors About Screening for and Addressing Social Needs? Acad Med 2023; 98:S63-S68. [PMID: 36811973 DOI: 10.1097/acm.0000000000005180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE It is widely accepted that negative social determinants of health (e.g., poverty) are underlying drivers of poor health and health disparities. There is overwhelming support among physicians to screen for patient-level social needs, but only a minority of clinicians actually do so. The authors explored potential associations between physician beliefs about health disparities and behaviors to screen and address social needs among patients. METHOD The authors used 2016 data from the American Medical Association Physician Masterfile database to identify a purposeful sample of U.S. physicians (n = 1,002); data obtained in 2017 were analyzed. Chi-squared tests of proportions and binomial regression analyses were employed to investigate associations between the belief that it is a physician's responsibility to address health disparities and perceptions of physician behaviors to screen for and address social needs, accounting for physician, clinical practice, and patient characteristics. RESULTS Of 188 respondents, respondents who felt that physicians have a responsibility to address health disparities were more likely than their peers (who did not feel that physicians have such a responsibility) to report that a physician on their health care team would screen for social needs that were psychosocial (e.g., safety, social support) (45.5% vs 29.6%, P = .03) and material (e.g., food, housing) (33.0% vs 13.6%, P < .0001). They were also more likely to report that a physician on their health care team would address both psychosocial needs (48.1% vs 30.9%, P = .02) and material needs (21.4% vs 9.9%, P = .04). With the exception of screening for psychosocial needs, these associations persisted in adjusted models. CONCLUSIONS Engaging physicians to screen for and address social needs should couple efforts to expand infrastructure with educational efforts about professionalism and health disparities, especially underlying drivers such as structural racism and the social determinants of health.
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Affiliation(s)
- Monica E Peek
- M.E. Peek is Ellen H. Block Professor for Health Justice, senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, and codirector, Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, Chicago, Illinois
| | - Wen Wan
- W. Wan is research associate professor of biostatistics, Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Ashley Noriea
- A. Noriea is senior medical director, Oak Street Health, Houston, Texas
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Peek ME. Increasing Representation of Black Primary Care Physicians-A Critical Strategy to Advance Racial Health Equity. JAMA Netw Open 2023; 6:e236678. [PMID: 37058312 DOI: 10.1001/jamanetworkopen.2023.6678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Affiliation(s)
- Monica E Peek
- The University of Chicago, Section of General Internal Medicine, Center for the Study of Race, Politics and Culture, Chicago, Illinois
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11
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Saulsberry L, Gunter KE, O'Neal Y, Tanumihardjo J, Gauthier R, Chin MH, Peek ME. "Everything in One Place": Stakeholder Perceptions of Integrated Medical and Social Care for Diabetes Patients in Western Maryland. J Gen Intern Med 2023; 38:25-32. [PMID: 36864266 PMCID: PMC10043057 DOI: 10.1007/s11606-022-07919-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 10/31/2022] [Indexed: 03/04/2023]
Abstract
BACKGROUND Patients with type 2 diabetes frequently have both medical- and health-related social needs that must be addressed for optimal disease management. Growing evidence suggests that intersectoral partnerships between health systems and community-based organizations may effectively support improved health outcomes for patients with diabetes. OBJECTIVE The purpose of this study was to describe stakeholders' perceptions of the implementation factors associated with a diabetes management program, an intervention involving coordinated clinical and social services supports to address both medical- and health-related social needs. This intervention delivers proactive care alongside community partnerships, and leverages innovative financing mechanisms. DESIGN Qualitative study with semi-structured interviews. PARTICIPANTS Study participants included adults (18 years or older) who were patients with diabetes and essential staff (e.g., members of a diabetes care team, health care administrators) and leaders of community-based organizations. APPROACH We used the Consolidated Framework for Implementation Research (CFIR) to develop a semi-structured interview guide designed to elicit perspectives from patients and essential staff on their experiences within an outpatient center to support patients with chronic conditions (the CCR) as a part of an intervention to improve care for patients with diabetes. KEY RESULTS Interviews illuminated three key takeaways: (1) team-based care held an important role in promoting accountability across stakeholders motivating patient engagement and positive perceptions, (2) mission-driven alignment across the health care and community sectors was needed to synergize a broad range of efforts, and (3) global payment models allowing for flexible resource allocation can invaluably support the appropriate care being directed where it is needed the most whether medical or social services. CONCLUSIONS The views and experiences of patient and essential staff stakeholder groups reported here thematically according to CFIR domains may inform the development of other chronic disease interventions that address medical- and health-related social needs in additional settings.
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Affiliation(s)
- Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, IL, USA.
| | - Kathryn E Gunter
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Yolanda O'Neal
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Jacob Tanumihardjo
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Richard Gauthier
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Marshall H Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
- Chicago Center for Diabetes Translation Research, Chicago, IL, USA
| | - Monica E Peek
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
- Chicago Center for Diabetes Translation Research, Chicago, IL, USA
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Tanumihardjo JP, Eversole C, Zhu M, Gunter KE, Peek ME. Glycemic Control and Patient-Reported Outcomes Among Patients with Diabetes Engaged with Community Health Workers in Rural Settings. J Gen Intern Med 2023; 38:45-47. [PMID: 36864277 PMCID: PMC10043142 DOI: 10.1007/s11606-022-07929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 10/31/2022] [Indexed: 03/04/2023]
Affiliation(s)
| | | | - Mengqi Zhu
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Kathryn E Gunter
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Monica E Peek
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
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13
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Williams JS, Walker RJ, Peek ME, Chin MH. Integrating Medical and Social Care to Reduce Diabetes Inequities: Lessons from the Bridging the Gap Program. J Gen Intern Med 2023; 38:1-3. [PMID: 36864265 PMCID: PMC10043067 DOI: 10.1007/s11606-022-07977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Affiliation(s)
- Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Monica E Peek
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
- Chicago Center for Diabetes Translation Research, Chicago, IL, USA
| | - Marshall H Chin
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
- Chicago Center for Diabetes Translation Research, Chicago, IL, USA
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Cené CW, Viswanathan M, Fichtenberg CM, Sathe NA, Kennedy SM, Gottlieb LM, Cartier Y, Peek ME. Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review. JAMA Netw Open 2023; 6:e2250654. [PMID: 36656582 PMCID: PMC9857687 DOI: 10.1001/jamanetworkopen.2022.50654] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities. OBJECTIVE To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity. EVIDENCE REVIEW Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity). FINDINGS Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences. CONCLUSIONS AND RELEVANCE In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.
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Affiliation(s)
- Crystal W. Cené
- Department of Medicine, University of California, San Diego Health, San Diego
- School of Medicine, University of California, San Diego
| | - Meera Viswanathan
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, RTI International, Research Triangle Park
| | - Caroline M. Fichtenberg
- University of California, San Francisco Social Intervention Research and Evaluation Network, San Francisco
- School of Medicine, Department of Family and Community Medicine, Center for Health and Community, University of California, San Francisco
| | - Nila A. Sathe
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, RTI International, Research Triangle Park
| | - Sara M. Kennedy
- RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, RTI International, Research Triangle Park
| | - Laura M. Gottlieb
- School of Medicine, Department of Family and Community Medicine, Center for Health and Community, University of California, San Francisco
| | - Yuri Cartier
- University of California, San Francisco Social Intervention Research and Evaluation Network, San Francisco
| | - Monica E. Peek
- Section of General Internal Medicine, MacLean Center for Clinical Medical Ethics, Center for the Study of Race, Politics and Culture, The University of Chicago, Chicago, Illinois
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15
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Abstract
Racial microaggressions, racially based remarks, or actions that negatively impact marginalized physicians of color (Black, Latino/a/x, and American Indian/Alaskan Natives) often go unaddressed. This article provides four strategies for how individuals and institutions can engage in anti-racism allyship: (1) be an upstander during microaggressions, (2) be a sponsor and advocate for physicians of color, (3) acknowledge academic titles and accomplishments, and (4) challenge the idea of a "standard fit" for academic faculty and research. Skills in academic allyship should be taught to all physicians throughout the educational continuum to mitigate feelings of isolation that racialized minority physicians frequently experience.
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Affiliation(s)
- Cassandra D.L. Fritz
- Division of Gastroenterology, Diversity, Equity, and Inclusion for Internal Medicine Residency Program, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Address correspondence to: Cassandra D.L. Fritz, MD, MPHS, Division of Gastroenterology, Diversity, Equity, and Inclusion for Internal Medicine Residency Program, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA.
| | - Shirlene Obuobi
- Division of Cardiology, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Monica E. Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA
| | - Monica B. Vela
- Department of Medicine, The Hispanic Center of Excellence, University of Illinois College of Medicine, Chicago, Illinois, USA
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16
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Chin MH, Orlov NM, Callender BC, Dolan JA, Miller DC, Peek ME, Rusiecki JM, Vela MB. Improvisational and Standup Comedy, Graphic Medicine, and Theatre of the Oppressed to Teach Advancing Health Equity. Acad Med 2022; 97:1732-1737. [PMID: 35947462 DOI: 10.1097/acm.0000000000004905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ninety-minute virtual workshops that used improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed were implemented in 2020 within a required health equity course at the University of Chicago Pritzker School of Medicine to train 90 first-year medical students in advancing health equity. Learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive students and how students perceive them to gain insight into one's identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White and other social privileges, and systemic factors that lead to health inequities. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of respondents thought workshops were very good or excellent, and 83% agreed or strongly agreed they would recommend workshops to others. Key recommendations are to (1) incorporate experiential storytelling and discussion; (2) define clear learning goals for each workshop, map exercises to these goals, and explain their relevance to students; and (3) create a safe, courageous, brave space for exploration and discussion. For health equity, transformation happens as students share their perspectives of curriculum content from their intersectional identities, experiences, and varied privileges; are challenged by others' perspectives; and attempt to understand how others can experience the same content differently. The arts create a powerful form of sharing beyond routine conversations or discussions, which is critical for honest dialogue on difficult topics, such as racism, homophobia, and White privilege and other social privileges. Educators should enable students to have the space, time, and courage to share their true perspectives and engage in authentic discussions that may be uncomfortable but transformative.
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Affiliation(s)
- Marshall H Chin
- M.H. Chin is the Richard Parrillo Family Distinguished Service Professor of Healthcare Ethics, Department of Medicine, and senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as codirector, Robert Wood Johnson Foundation Advancing Health Equity: Leading Care, Payment, and Systems Transformation National Program Office, and codirector, Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, Chicago, Illinois; ORCID: https://orcid.org/0000-0003-1924-5641
| | - Nicola M Orlov
- N.M. Orlov is assistant professor of pediatrics, Department of Pediatrics, associate program director, Pediatric Residency Training Program, and junior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as clerkship director for pediatrics, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Brian C Callender
- B.C. Callender is associate professor of medicine, Department of Medicine, associate junior faculty scholar, Bucksbaum Institute for Clinical Excellence, and core faculty, Institute on the Formation of Knowledge, University of Chicago, as well as career adviser, University of Chicago Pritzker School of Medicine, and senior medical director, University of Chicago Medicine, Chicago, Illinois
| | - James A Dolan
- J.A. Dolan is a research fellow in science communication, King's College, and assistant teaching professor, Engineering and Physical Sciences Research Council Centre for Doctoral Training in Nanoscience and Nanotechnology, Department of Physics, University of Cambridge, Cambridge, United Kingdom; ORCID: https://orcid.org/0000-0001-5019-1544
| | - Doriane C Miller
- D.C. Miller is professor of medicine, Department of Medicine, and senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as director, Center for Community Health and Vitality, Urban Health Initiative, University of Chicago Medicine, and director, Health Equity Integration, Institute for Translational Medicine, University of Chicago and Rush University, Chicago, Illinois
| | - Monica E Peek
- M.E. Peek is the Ellen H. Block Professor for Health Justice, and senior faculty scholar, Bucksbaum Institute for Clinical Excellence, University of Chicago, as well as codirector, Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care National Program Office, Chicago, Illinois
| | - Jennifer M Rusiecki
- J.M. Rusiecki is assistant professor of medicine, Department of Medicine, and women's health track director, Internal Medicine Residency, University of Chicago, Chicago, Illinois
| | - Monica B Vela
- M.B. Vela is professor of medicine, Department of Medicine, and director, Hispanic Center of Excellence, University of Illinois College of Medicine at Chicago, Chicago, Illinois
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17
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Parker WF, Persad G, Peek ME. Errors in Converting Principles to Protocols: Where the Bioethics of U.S. Covid-19 Vaccine Allocation Went Wrong. Hastings Cent Rep 2022; 52:8-14. [PMID: 36226880 PMCID: PMC9827540 DOI: 10.1002/hast.1416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
For much of 2021, allocating the scarce supply of Covid-19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the ACIP violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy-five years of age as the only criterion to identify individuals at high risk of death from Covid-19 during phase 1b, failing to recommend place-based vaccine distribution, and implicitly endorsing first-come, first-served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade-offs between principles may have prevented these mistakes and saved lives.
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18
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White DB, Lo B, Peek ME. Rebuttal From Dr White et al. Chest 2022; 162:44-45. [PMID: 35809940 PMCID: PMC9257200 DOI: 10.1016/j.chest.2022.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/20/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
- Douglas B White
- Program on Ethics and Decision Making in Critical Illness; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Bernard Lo
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; The Greenwall Foundation, New York, NY
| | - Monica E Peek
- Section of General Internal Medicine, MacLean Center for Clinical Medical Ethics, Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, IL
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19
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White DB, Lo B, Peek ME. POINT: Is Considering Social Determinants of Health Ethically Permissible for Fair Allocation of Critical Care Resources During the COVID-19 Pandemic? Yes. Chest 2022; 162:37-40. [PMID: 35809936 PMCID: PMC9257161 DOI: 10.1016/j.chest.2022.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 03/20/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Pittsburgh, PA; Department of Critical Care Medicine, Pittsburgh, PA.
| | - Bernard Lo
- University of Pittsburgh School of Medicine, San Francisco, CA; Department of Medicine, University of California San Francisco School of Medicine, San Francisco, CA; The Greenwall Foundation, New York, NY
| | - Monica E Peek
- Section of General Internal Medicine, MacLean Center for Clinical Medical Ethics, Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, IL
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20
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Opel DJ, Reich JA, Peek ME. Amplifying Appeals to the Common Good in COVID-19 Vaccine Messaging. JAMA Health Forum 2022; 3:e220991. [DOI: 10.1001/jamahealthforum.2022.0991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Douglas J. Opel
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington
| | | | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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21
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Zeng S, Pelzer KM, Gibbons RD, Peek ME, Parker WF. Association of Zip Code Vaccination Rate With COVID-19 Mortality in Chicago, Illinois. JAMA Netw Open 2022; 5:e2214753. [PMID: 35622360 PMCID: PMC9142872 DOI: 10.1001/jamanetworkopen.2022.14753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/13/2022] [Indexed: 11/14/2022] Open
Abstract
Importance There has been large geographic inequity in vaccination coverage across Chicago, Illinois, with higher vaccination rates in zip codes with residents who predominantly have high incomes and are White. Objective To determine the association between inequitable zip code-level vaccination coverage and COVID-19 mortality in Chicago. Design, Setting, and Participants This retrospective cohort study used Chicago Department of Public Health vaccination and mortality data and Cook County Medical Examiner mortality data from March 1, 2020, through November 6, 2021, to assess the association of COVID-19 mortality with zip code-level vaccination rates. Data were analyzed from June 1, 2021, to April 13, 2022. Exposures Zip code-level first-dose vaccination rates before the Alpha and Delta waves of COVID-19. Main Outcomes and Measures The primary outcome was deaths from COVID-19 during the Alpha and Delta waves. The association of a marginal increase in zip code-level vaccination rate with weekly mortality rates was estimated with a mixed-effects Poisson regression model, and the total number of preventable deaths in the least vaccinated quartile of zip codes was estimated with a linear difference-in-difference design. Results The study population was 2 686 355 Chicago residents in 52 zip codes (median [IQR] age 34 [32-38] years; 1 378 658 [51%] women; 773 938 Hispanic residents [29%]; 783 916 non-Hispanic Black residents [29%]; 894 555 non-Hispanic White residents [33%]). Among residents in the least vaccinated quartile, 80% were non-Hispanic Black, compared with 8% of residents identifying as non-Hispanic Black in the most vaccinated quartile (P < .001). After controlling for age distribution and recovery from COVID-19, a 10-percentage point increase in zip code-level vaccination 6 weeks before the peak of the Alpha wave was associated with a 39% lower relative risk of death from COVID-19 (incidence rate ratio [IRR], 0.61 [95% CI, 0.52-0.72]). A 10-percentage point increase in zip code vaccination rate 6 weeks before the peak of the Delta wave was associated with a 24% lower relative risk of death (IRR, 0.76 [95% CI, 0.66-0.87]). The difference-in-difference estimate was that 119 Alpha wave deaths (72% [95% CI, 63%-81%]) and 108 Delta wave deaths (75% [95% CI, 66%-84%]) might have been prevented in the least vaccinated quartile of zip codes if it had had the vaccination coverage of the most vaccinated quartile. Conclusions and Relevance These findings suggest that low zip code-level vaccination rates in Chicago were associated with more deaths during the Alpha and Delta waves of COVID-19 and that inequitable vaccination coverage exacerbated existing racial and ethnic disparities in COVID-19 deaths.
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Affiliation(s)
- Sharon Zeng
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Kenley M. Pelzer
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Robert D. Gibbons
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Monica E. Peek
- Department of Medicine, University of Chicago, Chicago, Illinois
- Division of the Biological Sciences, University of Chicago, Chicago, Illinois
| | - William F. Parker
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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22
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Abstract
Abundant evidence demonstrates that enduring, endemic racism plays an important role in determining patient health. This commentary reviews a patient case about disease self-management and subsequent health outcomes that are shaped by social and economic circumstances. We analyze the case using a framework for social care developed in 2019 by the National Academies of Sciences, Engineering, and Medicine (NASEM). We then propose that the NASEM framework be adapted by adding the category abolition, which could make the other social care practices transformative for historically marginalized populations.
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Affiliation(s)
- Laura M Gottlieb
- Professor in the Department of Family and Community Medicine at the University of California, San Francisco
| | - Stacy Tessler Lindau
- Professor of obstetrics and gynecology and medicine-geriatrics as well as a practicing gynecologist at the University of Chicago in Illinois
| | - Monica E Peek
- Professor of medicine and the director of research (and associate director) at the MacLean Center for Clinical Medical Ethics at the University of Chicago in Illinois
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23
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Affiliation(s)
- Austin B. Frakt
- Partnered Evidence‐Based Policy Resource Center, VA Boston Healthcare SystemBostonMA
- Department of Health Law, Policy & ManagementBoston University School of Public HealthBostonMA
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMA
| | - Monica E. Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, Center for the Study of Race, Politics and CultureThe University of ChicagoChicagoIllinois
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24
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Abstract
Little is known about how racism and bias may be communicated in the medical record. This study used machine learning to analyze electronic health records (EHRs) from an urban academic medical center and to investigate whether providers' use of negative patient descriptors varied by patient race or ethnicity. We analyzed a sample of 40,113 history and physical notes (January 2019-October 2020) from 18,459 patients for sentences containing a negative descriptor (for example, resistant or noncompliant) of the patient or the patient's behavior. We used mixed effects logistic regression to determine the odds of finding at least one negative descriptor as a function of the patient's race or ethnicity, controlling for sociodemographic and health characteristics. Compared with White patients, Black patients had 2.54 times the odds of having at least one negative descriptor in the history and physical notes. Our findings raise concerns about stigmatizing language in the EHR and its potential to exacerbate racial and ethnic health care disparities.
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25
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Abstract
Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.
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Affiliation(s)
- Monica B Vela
- Department of Medicine, Section of Academic Internal Medicine, University of Illinois College of Medicine in Chicago, Chicago, Illinois, USA;
| | - Amarachi I Erondu
- Department of Internal Medicine and Pediatrics, University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Nichole A Smith
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Monica E Peek
- Department of Medicine, Section of General Internal Medicine and Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA
| | - James N Woodruff
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Marshall H Chin
- Department of Medicine and Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA
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26
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Akingbade O, Peek ME, Tung EL. Network Size or Proximity? Association of Network Characteristics with Violence-Related Stress and PTSD Among Racial/Ethnic Minorities in Chicago. J Gen Intern Med 2022; 37:255-257. [PMID: 33506401 PMCID: PMC7840066 DOI: 10.1007/s11606-021-06607-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Ololade Akingbade
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.
| | - Monica E Peek
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA.,Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, IL, USA
| | - Elizabeth L Tung
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA.,Center for Health and The Social Sciences, University of Chicago, Chicago, IL, USA
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27
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Abstract
The US Food and Drug Administration (FDA) has issued emergency use authorizations (EUAs) for monoclonal antibodies (mAbs) for nonhospitalized patients with mild or moderate coronavirus disease 2019 (COVID-19) disease and for individuals exposed to COVID-19 as postexposure prophylaxis. EUAs for oral antiviral drugs have also been issued. Due to increased demand because of the Delta variant, the federal government resumed control over the supply and asked states to ration doses. As future variants (eg, the Omicron variant) emerge, further rationing may be required. We identify relevant ethical principles (ie, benefiting people and preventing harm, equal concern, and mitigating health inequities) and priority groups for access to therapies based on an integrated approach to population health and medical factors (eg, urgently scarce healthcare workers, persons in disadvantaged communities hard hit by COVID-19). Using priority categories to allocate scarce therapies effectively operationalizes important ethical values. This strategy is preferable to the current approach of categorical exclusion or inclusion rules based on vaccination, immunocompromise status, or older age, or the ad hoc consideration of clinical risk factors.
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Affiliation(s)
- Govind Persad
- Sturm College of Law, University of Denver, Denver, CO
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28
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Bhavani SV, Luo Y, Miller WD, Sanchez-Pinto LN, Han X, Mao C, Sandıkçı B, Peek ME, Coopersmith CM, Michelson KN, Parker WF. Simulation of Ventilator Allocation in Critically Ill Patients with COVID-19. Am J Respir Crit Care Med 2021; 204:1224-1227. [PMID: 34499587 PMCID: PMC8759315 DOI: 10.1164/rccm.202106-1453le] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | - Yuan Luo
- Northwestern University Fienberg School of MedicineChicago, Illinois
| | | | | | - Xuan Han
- University of Chicago Pritzker School of MedicineChicago, Illinois
| | - Chengsheng Mao
- Northwestern University Fienberg School of MedicineChicago, Illinois
| | | | - Monica E. Peek
- University of Chicago Pritzker School of MedicineChicago, Illinois
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29
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Peek ME. By any means necessary: why lowering insulin prices is relevant to racial health equity. Lancet 2021; 398:1783-1784. [PMID: 34774134 PMCID: PMC9172261 DOI: 10.1016/s0140-6736(21)02315-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, Center for the Study of Race, Culture and Politics, and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL 60637, USA.
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30
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Tung EL, Peek ME, Rivas MA, Yang JP, Volerman A. Association Of Neighborhood Disadvantage With Racial Disparities In COVID-19 Positivity In Chicago. Health Aff (Millwood) 2021; 40:1784-1791. [PMID: 34724418 DOI: 10.1377/hlthaff.2021.00695] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Racial health inequities exemplified during the COVID-19 crisis have awakened a sense of urgency among public health and policy experts to examine contributing factors. One potential factor includes the socioeconomic disadvantage of racially segregated neighborhoods. This study quantified associations of neighborhood socioeconomic disadvantage in Chicago, Illinois, as measured by the Area Deprivation Index (ADI), with racial disparities in COVID-19 positivity. A retrospective cohort included 16,684 patients tested for COVID-19 at an academic medical center and five community-based testing sites during Chicago's "first wave" (March 12, 2020-June 25, 2020). Patients living in Black majority neighborhoods had two times higher odds of COVID-19 positivity relative to those in White majority neighborhoods. The ADI accounted for 20 percent of the racial disparity; however, COVID-19 positivity remained substantially higher at every decile of the ADI in Black relative to White neighborhoods. The remaining disparities (80 percent) suggest a large, cumulative effect of other structural disadvantages in urban communities of color.
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Affiliation(s)
- Elizabeth L Tung
- Elizabeth L. Tung is an associate professor in the Sections of General Internal Medicine and Academic Pediatrics, University of Chicago, in Chicago, Illinois
| | - Monica E Peek
- Monica E. Peek is a professor in the Section of General Internal Medicine, University of Chicago
| | - Marco A Rivas
- Marco A. Rivas is a medical student in the Pritzker School of Medicine, University of Chicago
| | - Joyce P Yang
- Joyce P. Yang is an assistant professor in the Department of Psychology, University of San Francisco, in San Francisco, California
| | - Anna Volerman
- Anna Volerman is an associate professor in the Sections of General Internal Medicine and Academic Pediatrics, University of Chicago
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31
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Glasser NJ, Tung EL, Peek ME. Policing, health care, and institutional racism: Connecting history and heuristics. Health Serv Res 2021; 56:1100-1103. [PMID: 34618369 DOI: 10.1111/1475-6773.13888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Nathaniel J Glasser
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Elizabeth L Tung
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA.,Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA.,Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA
| | - Monica E Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois, USA.,Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois, USA.,MacLean Center for Medical Ethics, University of Chicago, Chicago, Illinois, USA.,Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, Illinois, USA
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Gunter KE, Peek ME, Tanumihardjo JP, Carbrey E, Crespo RD, Johnson TW, Rueda-Yamashita B, Schwartz EI, Sol C, Wilkinson CM, Wilson JO, Loehmer E, Chin MH. Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes. Milbank Q 2021; 99:928-973. [PMID: 34468996 DOI: 10.1111/1468-0009.12522] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk. CONTEXT Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models. METHODS Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources. FINDINGS Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions. CONCLUSIONS Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.
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Affiliation(s)
| | | | | | - Evalyn Carbrey
- Minneapolis Healthy Living Initiative, Minneapolis Health Department
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Affiliation(s)
- Monica B Vela
- From the Section of General Internal Medicine, Department of Medicine (M.B.V., M.H.C., M.E.P.), the Pritzker School of Medicine (M.B.V.), the Chicago Center for Diabetes Translation Research (M.H.C., M.E.P.), the Center for the Study of Race, Politics, and Culture (M.B.V, M.E.P.), and the MacLean Center for Clinical Medical Ethics (M.H.C., M.E.P.), University of Chicago, Chicago
| | - Marshall H Chin
- From the Section of General Internal Medicine, Department of Medicine (M.B.V., M.H.C., M.E.P.), the Pritzker School of Medicine (M.B.V.), the Chicago Center for Diabetes Translation Research (M.H.C., M.E.P.), the Center for the Study of Race, Politics, and Culture (M.B.V, M.E.P.), and the MacLean Center for Clinical Medical Ethics (M.H.C., M.E.P.), University of Chicago, Chicago
| | - Monica E Peek
- From the Section of General Internal Medicine, Department of Medicine (M.B.V., M.H.C., M.E.P.), the Pritzker School of Medicine (M.B.V.), the Chicago Center for Diabetes Translation Research (M.H.C., M.E.P.), the Center for the Study of Race, Politics, and Culture (M.B.V, M.E.P.), and the MacLean Center for Clinical Medical Ethics (M.H.C., M.E.P.), University of Chicago, Chicago
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Peek ME. Racism and health: A call to action for health services research. Health Serv Res 2021; 56:569-572. [PMID: 34155638 DOI: 10.1111/1475-6773.13693] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, Center for the Study of Race, Politics and Culture, The University of Chicago, Chicago, Illinois, USA
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Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, Center for the Study of Race, Politics, and Culture, University of Chicago, Chicago, Illinois
| | - Celeste C Thomas
- Section of Endocrinology, Chicago Center for Diabetes Translation Research, University of Chicago, Chicago, Illinois
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Miller WD, Han X, Peek ME, Charan Ashana D, Parker WF. Accuracy of the Sequential Organ Failure Assessment Score for In-Hospital Mortality by Race and Relevance to Crisis Standards of Care. JAMA Netw Open 2021; 4:e2113891. [PMID: 34143190 PMCID: PMC8214156 DOI: 10.1001/jamanetworkopen.2021.13891] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Crisis Standards of Care (CSC) are guidelines for rationing health care resources during public health emergencies. The CSC adopted by US states ration intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) score, which is used to compare expected in-hospital mortality among eligible patients. However, it is unknown if Black and White patients with equivalent SOFA scores have equivalent in-hospital mortality. OBJECTIVE To investigate whether reliance on SOFA is associated with bias against Black patients in CSC. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using data from the eICU Collaborative Research Database of patients admitted to 233 US ICUs in 2014 to 2015. Included individuals were Black and White adult patients in the ICU, who were followed up to hospital discharge. Data were analyzed from May 2020 through April 2021. EXPOSURE SOFA scores at ICU admission. MAIN OUTCOMES AND MEASURES Hierarchical logistic regression with hospital fixed effects was used to measure the interaction between race and SOFA as a factor associated with in-hospital mortality, as well as the odds of death among Black and White patients with equivalent priority for resource allocation according to the SOFA-based ranking rules of 3 statewide CSC (denoted A, B, and C) under shortage conditions that were severe (ie, only patients with the highest priority would be eligible for allocation), intermediate (ie, patients in the highest 2 tiers would be eligible for allocation), or low (ie, only patients with the lowest priority would be at risk of exclusion). RESULTS Among 111 885 ICU encounters representing 95 549 patients, there were 16 688 encounters with Black patients (14.9%) and 51 464 (46.0%) encounters with women and the mean (SD) age was 63.3 (16.9) years. The median (interquartile range) SOFA score was not statistically significantly different between Black and White patients (4 [2-6] for both groups; P = .19), but mortality was lower among Black individuals compared with White individuals with equivalent SOFA scores (odds ratio [OR], 0.98; 95% CI, 0.97-0.99; P < .001). This was associated with lower mortality among Black patients compared with White patients prioritized for resource allocation in 3 CSC under shortage conditions that were severe (system A: OR, 0.65; 95% CI, 0.58-0.74; P < .001; system B: OR, 0.70; 95% CI, 0.64-0.78; P < .001; system C: OR, 0.73; 95% CI, 0.67-0.80; P < .001), intermediate (system A: OR, 0.73; 95% CI, 0.67-0.80; P < .001; system B: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.82; 95% CI, 0.77-0.89; P < .001), and low (system A: OR, 0.83; 95% CI, 0.77-0.89; P < .001; system C: OR, 0.86; 95% CI, 0.81-0.92; P < .001; not applicable for system B, which had fewer tiers). When SOFA-based ranking rules were adjusted for Black patients to simulate equitable allocation based on observed mortality, the proportion upgraded to higher priority ranged from 379 Black patient encounters (2.3%) in low shortage conditions to 2601 Black patient encounters (15.6%) in severe shortage conditions. CONCLUSIONS AND RELEVANCE This study found that SOFA scores were associated with overestimated mortality among Black patients compared with White patients, and this was associated with a structural disadvantage for Black patients in CSC allocation systems. These findings suggest that guidelines should be revised to correct this inequity and alternative methods should be developed for more equitable triage.
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Affiliation(s)
- William Dwight Miller
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Xuan Han
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
- Center for the Study of Race, Politics, and Culture, University of Chicago, Chicago, Illinois
| | - Deepshikha Charan Ashana
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, North Carolina
| | - William F. Parker
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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Abstract
This commentary suggests specific strategies and language that clinicians can use to address mistrust of COVID-19 vaccines among racial and ethnic minorities.
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Affiliation(s)
- Douglas J Opel
- University of Washington School of Medicine, Seattle, Washington (D.J.O.)
| | - Bernard Lo
- University of California, San Francisco, San Francisco, California (B.L.)
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Affiliation(s)
- William F. Parker
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | - Govind Persad
- Sturm College of Law, University of Denver, Denver, Colorado
| | - Monica E. Peek
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
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Peek ME. Black history is America's history. EClinicalMedicine 2021; 32:100755. [PMID: 33659888 PMCID: PMC7890355 DOI: 10.1016/j.eclinm.2021.100755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, The University of Chicago, USA
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Tanumihardjo JP, Gunter KE, Chin MH, Kraus RN, Smith RA, de Oliveira L, Peek ME. Integrating Technology and Human Capital to Address Social Needs: Lessons to Promote Health Equity in Diabetes Care. J Health Care Poor Underserved 2021. [DOI: 10.1353/hpu.2021.0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Peek ME, Simons RA, Parker WF, Ansell DA, Rogers SO, Edmonds BT. COVID-19 Among African Americans: An Action Plan for Mitigating Disparities. Am J Public Health 2020; 111:286-292. [PMID: 33351662 DOI: 10.2105/ajph.2020.305990] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have emerged between different racial groups, particularly African Americans and Whites. Media reports, a growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its myriad effects on the African American community provide important lenses for understanding and addressing these disparities.However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence, we present risk- and place-based recommendations for how to effectively address these disparities in the areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital repurposing, and scarce resource allocation.Our recommendations are supported by an analysis of relevant bioethical principles and public health practices. Additionally, we provide information on the efforts of Chicago, Illinois' mayoral Racial Equity Rapid Response Team to reduce these disparities in a major urban US setting.
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Affiliation(s)
- Monica E Peek
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - Russell A Simons
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - William F Parker
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - David A Ansell
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - Selwyn O Rogers
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
| | - Brownsyne Tucker Edmonds
- Monica E. Peek, Russell A. Simons, William F. Parker, and Selwyn O. Rogers are with the University of Chicago, Chicago, IL. David A. Ansell is with the Department of Medicine, Rush University Medical Center, Chicago. Brownsyne Tucker Edmonds is with the Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis
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Peek ME, Vela MB, Chin MH. Practical Lessons for Teaching About Race and Racism: Successfully Leading Free, Frank, and Fearless Discussions. Acad Med 2020; 95:S139-S144. [PMID: 32889939 DOI: 10.1097/acm.0000000000003710] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Successfully teaching about race and racism requires a careful balance of emotional safety and honest truth-telling. Creating such environments where all learners can thrive and grow together is a challenge, but a consistently doable one. This article describes 12 lessons learned within 4 main themes: ground rules; language and communication; concepts of social constructs, intersectionality, and bidirectional biases; and structural racism, solutions, and advocacy. The authors' recommendations for how to successfully teach health professions students about race and racism come from their collective experience of over 60 years of instruction, research, and practice. Proficiency in discussing race and addressing racism will become increasingly relevant as health care institutions strive to address the social needs of patients (e.g., food insecurity, housing instability) that contribute to poor health and are largely driven by structural inequities. Having interprofessional team-based care, with teams better able to understand and counteract their own biases, will be critical to addressing the social and structural determinants of health for marginalized patients. Recognizing that implicit biases about race impact both patients and health professions students from underrepresented racial/ethnic backgrounds is a critical step toward building robust curricula about race and health equity that will improve the learning environment for trainees and reduce health disparities.
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Affiliation(s)
- Monica E Peek
- M.E. Peek is associate professor of medicine, Section of General Internal Medicine, member, Center for the Study of Race, Politics and Culture, and associate director, Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, Illinois
| | - Monica B Vela
- M.B. Vela is professor of medicine, Section of General Internal Medicine, member, Center for the Study of Race, Politics and Culture, and associate dean, Multicultural Affairs, The University of Chicago, Chicago, Illinois
| | - Marshall H Chin
- M.H. Chin is Richard Parrillo Family Professor of Healthcare Ethics, Department of Medicine, and director, Chicago Center for Diabetes Translation Research, The University of Chicago, Chicago, Illinois
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Affiliation(s)
- Govind Persad
- Sturm College of Law, University of Denver, Denver, Colorado
| | | | - Ezekiel J Emanuel
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
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Blumenthal-Barby J, Opel DJ, Dickert NW, Kramer DB, Tucker Edmonds B, Ladin K, Peek ME, Peppercorn J, Tilburt J. Potential Unintended Consequences Of Recent Shared Decision Making Policy Initiatives. Health Aff (Millwood) 2020; 38:1876-1881. [PMID: 31682503 DOI: 10.1377/hlthaff.2019.00243] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed.
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Affiliation(s)
- Jennifer Blumenthal-Barby
- Jennifer Blumenthal-Barby ( jsswinde@bcm. edu ) is the Cullen Associate Professor and associate director of the Center for Medical Ethics and Health Policy, Baylor College of Medicine, in Houston, Texas
| | - Douglas J Opel
- Douglas J. Opel is an associate professor of pediatrics at the University of Washington School of Medicine and director of clinical ethics at the Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, in Washington
| | - Neal W Dickert
- Neal W. Dickert is an associate professor of cardiology and epidemiology at Emory University, in Atlanta, Georgia
| | - Daniel B Kramer
- Daniel B. Kramer is an assistant professor at Harvard Medical School and faculty at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, both in Boston, Massachusetts
| | - Brownsyne Tucker Edmonds
- Brownsyne Tucker Edmonds is an associate professor of obstetrics and gynecology and assistant dean for diversity affairs at the Indiana University School of Medicine, in Indianapolis
| | - Keren Ladin
- Keren Ladin is an assistant professor of occupational therapy and community health at Tufts University, in Medford, Massachusetts
| | - Monica E Peek
- Monica E. Peek is an associate professor of medicine at the University of Chicago Medical Center, in Illinois
| | - Jeff Peppercorn
- Jeff Peppercorn is an associate professor in and director of the Cancer Survivorship Program, Cancer Center, Massachusetts General Hospital, in Boston
| | - Jon Tilburt
- Jon Tilburt is a professor of internal medicine and biomedical ethics at Mayo Clinic in Rochester, Minnesota
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Sobotka SA, Lynch E, Peek ME, Graham RJ. Readmission drivers for children with medical complexity: Home nursing shortages cause health crises. Pediatr Pulmonol 2020; 55:1474-1480. [PMID: 32212321 PMCID: PMC7290239 DOI: 10.1002/ppul.24744] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/15/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Children with medical technology dependence (MTD) are frequently readmitted to the hospital. However, due to their medical fragility, it is often difficult to untangle the root causes for readmissions to identify the most effective preventive approaches. We sought to explore environmental and family factors driving hospital readmissions for children with MTD. DESIGN Semi-structured, in-person interviews were conducted with state-wide care coordinators for children with MTD in Illinois with at least 1 year of experience. Interview topics related to children with MTD transitioning from hospital-to-home, essential supports for living in the community, and factors which influenced and prevented hospital readmission. The interview guide served as an initial codebook which was iteratively modified as themes emerged. RESULTS Fifteen care coordinators with on average 6.6 years of experience were interviewed. They described that lack of home nursing was one of the primary drivers of readmissions due to parental exhaustion and lack of medical expertize in the home. Unavoidable medical admissions, a lack of a plan for emergencies, and home environmental factors also contributed to readmissions. CONCLUSION Hospital readmission is an expected occurrence for children with MTD, yet still may be substantially reduced through consistent, quality home health nursing to bolster family capacity and allow for respite from constant caregiving. Improved incentives for the home health workforce to increase manpower would be ultimately offset by reduced hospitalizations for children with MTD. Additionally, more research is needed to understand which home nursing structures and skills optimally support families in the reality of manpower scarcity.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Emma Lynch
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Monica E Peek
- Section of General Internal Medicine, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Robert J Graham
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
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Miller WD, Peek ME, Parker WF. Scarce Resource Allocation Scores Threaten to Exacerbate Racial Disparities in Health Care. Chest 2020; 158:1332-1334. [PMID: 32450243 PMCID: PMC7243750 DOI: 10.1016/j.chest.2020.05.526] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- William D Miller
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL.
| | - Monica E Peek
- Section of General Internal Medicine, University of Chicago, Chicago, IL; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL; Center for the Study of Race, Politics and Culture, University of Chicago, Chicago, IL
| | - William F Parker
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
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Thornton PL, Kumanyika SK, Gregg EW, Araneta MR, Baskin ML, Chin MH, Crespo CJ, de Groot M, Garcia DO, Haire-Joshu D, Heisler M, Hill-Briggs F, Ladapo JA, Lindberg NM, Manson SM, Marrero DG, Peek ME, Shields AE, Tate DF, Mangione CM. New research directions on disparities in obesity and type 2 diabetes. Ann N Y Acad Sci 2019; 1461:5-24. [PMID: 31793006 DOI: 10.1111/nyas.14270] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/18/2019] [Indexed: 12/12/2022]
Abstract
Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.
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Affiliation(s)
- Pamela L Thornton
- Division of Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, Maryland
| | - Shiriki K Kumanyika
- Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Edward W Gregg
- Epidemiology and Statistics Branch, Division of Diabetes Translation, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Maria R Araneta
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla, California
| | - Monica L Baskin
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Carlos J Crespo
- Oregon Health and Science University and Portland State University Joint School of Public Health, Portland, Oregon
| | - Mary de Groot
- Indiana University School of Medicine, Indianapolis, Indiana
| | - David O Garcia
- Department of Health Promotion Sciences, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona
| | - Debra Haire-Joshu
- Washington University in St. Louis, School of Medicine and the Brown School, St. Louis, Missouri
| | | | - Felicia Hill-Briggs
- Johns Hopkins School of Medicine and Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, Maryland
| | - Joseph A Ladapo
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | | | | | | | | | - Alexandra E Shields
- Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute, Massachusetts General Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Deborah F Tate
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Carol M Mangione
- David Geffen School of Medicine at the University of California, and UCLA Fielding School of Public Health, Los Angeles, Los Angeles, California
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Abstract
BACKGROUND Mobile- and Internet-delivered (collectively, digital) interventions are widely used by persons with diabetes (PWD) to assist with self-management and improve/maintain glycemic control (hemoglobin A1c [A1c]). However, evidence concerning the acceptance and benefits of such interventions among disadvantaged/vulnerable PWD is still quite limited. PURPOSE OF REVIEW We reviewed studies published from 2011-April 2019 evaluating the impact of diabetes self-management interventions delivered via mobile device and/or Internet on glycemic control of disadvantaged/vulnerable adults with type 2 diabetes (T2D). Included studies reported ≥ 50% of the sample having a low socioeconomic status and/or being a racial/ethnic minority, or living in a rural setting or low-/middle-income country (LMIC). We identified 21 studies evaluating a digital intervention among disadvantaged/vulnerable PWD. RECENT FINDINGS Although many digital interventions found within-group A1c improvements (16 of 21 studies), only seven of the seventeen studies with a control group found between-group differences in A1c. Three studies found reductions in emergency room (ER) visits and hospitalizations. We synthesize this information, and provide recommendations for increasing access, and improving the design and usability of such interventions. We also discuss the role of human support in digital delivery, issues related to study design, reporting, economic value, and available research in LMICs. There is evidence suggesting that digital interventions can improve diabetes control, healthcare utilization, and healthcare costs. More research is needed to substantiate these early findings, and many issues remain in order to optimize the impact of digital interventions on the health outcomes of disadvantaged/vulnerable persons with diabetes.
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Affiliation(s)
| | | | | | | | - Makenzie Parks
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Monica E Peek
- Section of General Internal Medicine, Chicago Center for Diabetes Translation Research, The University of Chicago, 5841 S. Maryland Avenue, MC 2007, Chicago, IL, 60637, USA.
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49
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Abstract
Social isolation is a key predictor of mortality in the US and may be heightened in communities affected by violence. Qualitative studies have documented that people living in high-crime neighborhoods often report being confined to their homes because of safety concerns. However, few quantitative studies have empirically assessed relationships between violence exposure and social isolation. In 2018 we conducted hour-long, in-person surveys with 504 adults in Chicago, Illinois. Prior exposure to community violence was associated with a 3.3-point reduction (on a 100-point scale) in the frequency of interaction with network confidantes, a 7.3-point reduction in perceived social support from friends, and a 7.8-point increase in loneliness. At a time when public health and policy leaders are calling for solutions to the "epidemic of loneliness," identifying populations at higher risk because of violence could help target interventions and ensure equitable access to social and medical support.
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Affiliation(s)
- Elizabeth L Tung
- Elizabeth L. Tung ( eliztung@uchicago. edu ) is an instructor of medicine in the Section of General Internal Medicine and at the Center for Health and the Social Sciences, University of Chicago, in Illinois
| | - Louise C Hawkley
- Louise C. Hawkley is a senior research scientist at NORC at the University of Chicago
| | - Kathleen A Cagney
- Kathleen A. Cagney is a professor of sociology in the Department of Sociology and director of the Population Research Center, University of Chicago
| | - Monica E Peek
- Monica E. Peek is an associate professor of medicine in the Section of General Internal Medicine, University of Chicago
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50
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Abstract
Children with medical technology dependency (MTD) require a medical device to compensate for a vital body function and substantial nursing care. As such, they require constant high-level supervision. Respite care provides caregivers with a temporary break, and is associated with reduced stress; however, there are often barriers. The study utilizes mixed methodology with the National Survey of Children with Special Health Care Needs (NS-CSHCN) and semistructured interviews with state-wide care coordinators to understand the gap for respite care services. Fifty-nine percent of parents who needed respite care received none. Parents of older children with MTD were more likely to report respite needs. Care coordinators described that home health shortages created barriers to respite care utilization, and the lack of respite care can lead to hospital readmission. Although respite care is a vital resource to support families of children with MTD, it is infrequently available, which can have severe consequences.
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Affiliation(s)
| | - Emma Lynch
- The University of Chicago, Chicago, IL, USA
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