Frontline work and racial disparities in social and economic pandemic stressors during the first COVID-19 surge

Objective

To assess the magnitude of racial–ethnic disparities in pandemic-related social stressors and examine frontline work's moderating relationship on these stressors.

Data Sources

Employed Californians' responses to the Institute for Governmental Studies (IGS) poll from April 16–20, 2020, were analyzed. The Pandemic Stressor Scale (PSS) assessed the extent to which respondents experienced or anticipated problems resulting from the inability to pay for basic necessities, job instability, lacking paid sick leave, unavailability of childcare, and reduced wages or work hours due to COVID-19.

Study Design

Mixed-effects generalized linear models estimated (1) racial–ethnic disparities in pandemic stressors among workers during the first COVID-19 surge, adjusting for covariates, and (2) tested the interaction between race–ethnicity and frontline worker status, which includes a subset of essential workers who must perform their job on-site, to assess differential associations of frontline work by race–ethnicity.

Data Collection

The IGS poll data from employed workers (n = 4795) were linked to the 2018 Centers for Disease Control and Prevention Social Vulnerability Index at the zip code level (N = 1068).

Principal Findings

The average PSS score was 37.34 (SD = 30.49). Whites had the lowest PSS score (29.88, SD = 26.52), and Latinxs had the highest (50.74, SD = 32.61). In adjusted analyses, Black frontline workers reported more pandemic-related stressors than White frontline workers (PSS = 47.73 vs. 36.96, p < 0.001). Latinxs reported more pandemic stressors irrespective of frontline worker status. However, the 5.09-point difference between Latinx frontline and non-frontline workers was not statistically different from the 4.6-point disparity between White frontline and non-frontline workers.

Conclusion

Latinx workers and Black frontline workers disproportionately reported pandemic-related stressors. To reduce stress on frontline workers during crises, worker protections like paid sick leave, universal access to childcare, and improved job security are needed, particularly for those disproportionately affected by structural inequities, such as racially minoritized populations.     

Effects of an electronic health record-based mobility assessment and automated referral for inpatient physical therapy on patient outcomes: A quasi-experimental study

Objective

To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission.

Data Sources

EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017–February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019–July 2021).

Study Design

We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted.

Data Extraction

We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay.

Principal Findings

In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI −0.57, −0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission (β = 0.01; 95% CI −0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI −0.88, −0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA.

Conclusions

Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments.     

Primary sources of health care among LGBTQ+ veterans: Findings from the Behavioral Risk Factor Surveillance System

Objective

This study examined the primary source of health care between veterans with lesbian, gay, bisexual, queer and similar identities (LGBTQ+) and non-LGBTQ+ veterans.

Data Sources and Study Setting

Veterans (N = 20,497) from 17 states who completed the CDC's Behavioral Risk Factor Surveillance System from 2016 to 2020, including the Sexual Orientation and Gender Identity and Health Care Access modules.

Study Design

We used survey-weighted multiple logistic regression to estimate average marginal effects of the prevalence of utilization of Veteran's Health Administration (VHA)/military health care reported between LGBTQ+ and non-LGBTQ+ veterans. Prevalence estimates were adjusted for age group, sex, race and ethnicity, marital status, educational attainment, employment status, survey year, and US state.

Data Collection Methods

Study data were gathered via computer-assisted telephone interviews with probability-based samples of adults aged 18 and over. Data are publicly available.

Principal Findings

Overall, there was not a statistically significant difference in estimated adjusted prevalence of primary use of VHA/military health care between LGBTQ+ and non-LGBTQ+ veterans (20% vs. 23%, respectively, p = 0.13). When examined by age group, LGBTQ+ veterans aged 34 and younger were significantly less likely to report primary use of VHA/military health care compared to non-LGBTQ+ veterans (25% vs. 44%, respectively; p = 0.009). Similarly, in sex-stratified analyses, fewer female LGBTQ+ veterans than female non-LGBTQ+ veterans reported VHA/military health care as their primary source of care (13% vs. 29%, respectively, p = 0.003). Implications and limitations to these findings are discussed.

Conclusions

Female and younger LGBTQ+ veterans appear far less likely to use VHA/military for health care compared to their cisgender, heterosexual peers; however, because of small sample sizes, estimates may be imprecise. Future research should corroborate these findings and identify potential reasons for these disparities.     

Relationship of neighborhood social determinants of health on racial/ethnic mortality disparities in US veterans—Mediation and moderating effects

Objective

To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.

Data sources

Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.

Study design

Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.

Principal findings

Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.

Conclusions

Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

     

Provision of abortion and other reproductive health services among former Midwest Access Project trainees

Objective

The Midwest Access Project (MAP) offers opt-in training to students, residents and practicing clinicians in reproductive health care including abortion. We surveyed MAP alumni to identify current practice characteristics and assess predictors of reproductive health service provision.

Association between non-profit hospital community benefit spending and health outcomes

Objective

To determine if greater non-profit hospital spending for community benefits is associated with better health outcomes in the county where they are located.

Data Sources and Study Setting

Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non-profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included.

Study Design

We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county.

Data Collection

The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level.

Principal Findings

Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes.

Conclusions

Despite varying levels of non-profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption.     

Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

ObjectiveHealth disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.DesignA systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).Setting and ParticipantsOlder NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.MethodsThree electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.ResultsEighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).Conclusions and ImplicationsThis review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.     

Differences in patient perceptions of integrated care among black,hispanic, and white Medicare beneficiaries

ObjectiveThis study sought to identify potential disparities among racial/ethnic groups in patient perceptions of integrated care (PPIC) and to explore how methodological differences may influence measured disparities.Data SourceData from Medicare beneficiaries who completed the 2015 Medicare Current Beneficiary Survey (MCBS) and were enrolled in Part A benefits for an entire year.Study DesignWe used 4‐point measures of eight dimensions of PPIC and assessed differences in dimensions among racial/ethnic groups. To estimate differences, we applied a “rank and replace” method using multiple regression models in three steps, balancing differences in health status among racial groups and adjusting for differences in socioeconomic status. We reran all analyses with additional SES controls and using standard multiple variable regression.Data Collection/Extraction MethodsNot applicable.Principal FindingsWe found several significant differences in perceived integrated care between Black versus White (three of eight measures) and Hispanic versus White (one of eight) Medicare beneficiaries. On average, Black beneficiaries perceived more integrated support for self‐care than did White beneficiaries (mean difference = 0.14, SE = 0.06, P =.02). Black beneficiaries perceived more integrated specialists’ knowledge of past medical history than did White beneficiaries (mean difference = 0.12, SE = 0.06, P =.01). Black and Hispanic beneficiaries also each reported, on average, 0.18 more integrated medication and home health management than did White beneficiaries (P <.01 and P <.01). These findings were robust to sensitivity analyses and model specifications.ConclusionsThere exist some aspects of care for which Black and Hispanic beneficiaries may perceive greater integrated care than non‐Hispanic White beneficiaries. Further studies should test theories explaining why racial/ethnic groups perceive differences in integrated care.     

Time to delivery: Transfers for threatened preterm labour and prelabour rupture of membranes in Western Australia

Objective

To describe the outcomes of patients transferred to King Edward Memorial Hospital (KEMH) with signs of labour at preterm gestations.

Design

A retrospective observational study of the 69 cases transferred to KEMH during 2015.

Setting

Patient transfers from all locations across Western Australia (WA) to the sole tertiary perinatal centre in Perth.

Participants

Pregnant women within WA with threatened or actual preterm labour (PTL) or preterm prelabour rupture of membranes (PPROM) between 23 and 32 weeks gestation.

Main outcome measures

The occurrence of delivery during the admission and time‐to‐delivery as well as length of admission and association between clinical factors and time‐to‐delivery.

Results

The percentage of the study population delivered during the admission following transfer was 72.5%. Eighty‐six per cent of those who delivered did so within 72 hours of transfer. The median time from transfer to delivery was 1 day. Sixty‐three per cent of those who did not deliver during the admission progressed to 36 weeks gestation. Patients transferred with PPROM were less likely to deliver during the admission compared to those with uterine activity (50% versus 19.6%, P = 0.007) and nulliparas were more likely to deliver (93.5% versus 55.3%, P < 0.001).

Conclusion

The majority of women transferred with signs of PTL progress to delivery during the same admission with the highest risk of delivery being the first 72 hours following transfer. If the pregnancy is ongoing at 72 hours, there is a reasonable chance of progression to late preterm gestation supporting the return of woman to their place of origin for antenatal care following discharge.     

Participation in a Medicare advanced primary care model and the delivery of high-value services

Objective

To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services.

Data Sources

Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare.

Study Design

We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year.

Data Collection/Extraction Methods

Secondary data are linked at the provider level.

Principal Findings

We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening.

Conclusions

CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.     

Early Elective Delivery Disparities between Non-Hispanic Black and White Women after Statewide Policy Implementation

Background

In 2011, Oregon implemented a policy that reduced the state's rate of early (before 39 weeks' gestation) elective (without medical need) births.

Collaborating toward equity in Pennsylvania: The Age-Friendly Care,PA project

Objective

To collaboratively implement the age-friendly health systems framework, known as the 4Ms: What Matters, Medication, Mentation, and Mobility, at The Primary Health Network (PHN), a federally qualified health center.

Data Sources

Data were collected from PHN electronic medical records (EMRs) for individuals over age 65 from December 30, 2019 to December 24, 2021 and from Project ECHO© attendance and evaluation surveys.

Study Design

The telementoring educational program, Project ECHO©, was used to engage PHN health care professionals working in rural areas of Pennsylvania to incorporate the 4Ms into their practice starting with the annual wellness visit (AWV). Project ECHO© was launched at three primary care sites. After 18 months, it was then disseminated to an additional 18 sites creating pilot and comparison groups. Outcomes included codesigned patient process metrics using EMR data and project ECHO© participant data.

Data Collection Methods

EMR data were generated by system reports created by PHN's quality assurance program manager. Project ECHO© data were collected and managed using REDCap electronic data capture tools. Outcomes were aggregated, analyzed for trends over time, and compared between groups.

Principal Findings

All nine process outcomes increased from baseline to follow-up at the three initial sites, ranging from 4% to 43% g. At year two, the three initial sites had higher rates on AWVs (pilot 24%, comparison 12%; p < 0.0001), Advance Care Planning (New on file, pilot 8%, comparison 2%; Discussed with patient, pilot 18%, comparison 13%; Patient declined, pilot 0%, comparison 0%; p = 0.0001), Dementia Screening (pilot 24%, comparison 12%; p < 0.0001), Fall Risk Management (pilot 43%, comparison 10%; p < 0.0001), and Mobility Goal (pilot 19%, comparison 9%; p < 0.0001); and lower rates on High-Risk Medication Elimination (pilot 54%, comparison, 63%, p < 0.02).

Conclusions

Access to high-quality geriatric care for rural older adults can be improved by increasing health care professionals' knowledge of the 4Ms, beginning with its incorporation into the AWV.     

Racial disparities in U.S. maternal influenza vaccine uptake: Results from analysis of Pregnancy Risk Assessment Monitoring System (PRAMS) data, 2012–2015

Background

Pregnant women are at increased risk of hospitalization, serious complications, poor pregnancy outcomes, and mortality from influenza. Prior research suggests that there are racial/ethnic disparities in vaccination coverage and that a healthcare provider vaccination recommendation is associated with significantly higher vaccine uptake than without such a recommendation. The purpose of this study is to examine racial/ethnic disparities in healthcare providers’ recommendations for pregnant women to receive the influenza vaccine and in vaccine uptake.

Testing for intersectional measurement invariance with the alignment method: Evaluation of the 8-item patient health questionnaire

Objective

To demonstrate the use of the alignment method to evaluate whether surveys function similarly (i.e., have evidence of measurement invariance) across culturally diverse intersectional groups. Intersectionality theory recognizes the interconnected nature of social categories such as race, gender, ethnicity, and socioeconomic status.

Data Sources

A total of 30,215 American adult's responses to the eight-item Patient Health Questionnaire depression assessment scale (PHQ-8) from the 2019 National Health Interview Survey (NHIS).

Study Design

Using the alignment method, we examined the measurement invariance (equivalence) of the PHQ-8 depression assessment scale across 16 intersectional subgroups defined at the intersection of age (under 52, 52 and older), gender (male, female), race (Black, non-Black), and education (no bachelor's degree, bachelor's degree).

Principal Findings

Overall, 24% of the factor loadings and 5% of the item intercepts showed evidence of differential functioning across one or more of the intersectional groups. These levels fall beneath the benchmark of 25% suggested for determining measurement invariance with the alignment method.

Conclusions

The results of the alignment study suggest that the PHQ-8 functions similarly across the intersectional groups examined, despite some evidence of different factor loadings and item intercepts in some groups (i.e., noninvariance). By examining measurement invariance through an intersectional lens, researchers can investigate how a person's multiple identities and social positions possibly contribute to their response behavior on an assessment scale.     

Knowledge,Practice Behaviors,and Perceived Barriers to Fertility Care Among Providers of Transgender Healthcare

Purpose

Transgender individuals may experience impaired fertility due to gender-affirming hormonal interventions (e.g., pubertal suppression treatment and/or exogenous hormones). Clinical practice guidelines recommend providers discuss fertility implications and options for fertility preservation. The goal of this study was to examine fertility knowledge, practice behaviors, and perceived barriers to fertility care among multidisciplinary providers who care for transgender pediatric and/or adult patients.

“I'm Not Telling”: The Effects of Racial Disparities Communications on Task Persistence Among Blacks

Research suggests that communications about racial health disparities may adversely affect Blacks. In this study, we varied the message content (Black–White cardiovascular-related disparities + neutral health topics vs. neutral health topics only) embedded in public service announcements given to Black and White participants (N = 86) and had them complete a purported health self-assessment. We used the number of items completed as a measure of task persistence. Our results showed that participants in the disparities condition completed fewer items on average than participants in the neutral condition (p < .01). Planned contrasts revealed that this effect was driven by the responses of Blacks who completed fewer items in the disparities condition (p < .01), though Whites evinced a comparable condition-based trend (p = .12). We found no Black–White differences in the number of items completed in either of our experimental conditions (ps ≥ .53). Although preliminary, our findings suggest that Blacks and Whites exposed to comparative racial disparities messaging about cardiovascular diseases could experience reduced task persistence. Research implications and study limitations are also discussed.     

A Survey of Health Behaviors in Minority Women in Pregnancy: The Influence of Body Mass Index

BackgroundAn effective behavioral intervention for gestational weight gain in minority obese women needs to incorporate their baseline health behaviors and nutrition patterns. The objective of this study was to compare racial/ethnic differences in health behaviors and nutrition in pregnant obese and non-obese minorities.MethodsA face-to-face, 75-item survey was administered to 94 women (46% non-obese, 54% obese; 71% Black, 29% Hispanic) at a prenatal visit to an inner-city clinic. Television watching, exercise, and nutrition were compared between obese and non-obese women and racial/ethnic differences were compared within each body mass index (BMI) category using chi-square and Fisher's exact tests. Interactions between BMI category and race/ethnicity for each health behavior were examined.FindingsMore obese women described their nutrition as “fair” or “poor” (36% vs. 15%; p = .02) and missed more meals per day (21% vs. 6%; p = .03) compared with non-obese women. Obese Blacks were less likely to improve their nutrition during pregnancy compared with obese Hispanics (28% vs. 58%; p = .08). Non-obese Blacks watched more television (p = .03) and exercised less during pregnancy (p = .04) than non-obese Hispanics. Except for dairy products, there were no differences in daily nutrition (fruit, soda, vegetables, chips) among the BMI categories and racial/ethnic groups; however, fewer than 50% of all participants consumed fruits and vegetables every day. There was an interaction between BMI category and race/ethnicity: Obese Hispanics exercised less before pregnancy (p = .02), but exercised more during pregnancy (p = .01) compared with non-obese Hispanics.ConclusionsInterventions for gestational weight gain in obese women may have greater success if they considered racial/ethnic differences in health behaviors, especially related to exercise.