Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach

Objective: Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. Results: The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. Conclusions: At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.     

The role of race/ethnicity in cerclage efficacy

Objective: To measure the impact of race/ethnicity on cerclage efficacy, as measured by the prevalence of spontaneous preterm birth (PTB), in a cohort of patients with history-indicated, ultrasound-indicated and physical-exam indicated cerclages.

Methods: We conducted a retrospective cohort study of patients undergoing history-indicated, ultrasound-indicated and physical-exam indicated cerclage placement from January 2003 to July 2013 at a tertiary care hospital. Patients’ race/ethnicity was self-declared. Our primary outcome was spontaneous preterm birth (SPTB) Results: One hundred and eighty-one subjects met inclusion criteria. Forty-seven percent self-identified as non-Hispanic black (NHB), 12% as Hispanic and 41% as non-Hispanic white (NHW). There was no significant difference in the prevalence of SPTB race/ethnicity groups (33% versus 19% versus 40%, respectively, p?=?0.22), nor for SPTB less than 34 or 28 weeks. Finally, there was no difference in SPTB prevalence by race after controlling for smoking, history of CKC/LEEP, and 17-OHPC with logistic regression.

Conclusion: Race/ethnicity does not appear to be associated with cerclage efficacy, as measured by the risk of SPTB, in a cohort of patients with history-indicated, ultrasound-indicated and physical-exam indicated cerclages.     

African American women's preventative care usage: the role of social support and racial experiences and attitudes

Research suggests that African Americans are less likely to utilise preventative care services than Americans of European descent, and that these patterns may contribute to racial health disparities in the United States. Despite the persistence of inequalities in preventative care utilisation, culturally relevant factors influencing the use of these gateway health services have been understudied among marginalised groups. Using a stratified sample of 205 low‐income African American women, this research examines the predictors of receiving a physical exam, with a particular emphasis on how differing levels of social support from friend and family networks and experiences of racial discrimination and cultural mistrust shape utilisation. The findings underscore the importance of traditional predictors of utilisation, including insurance status and having a usual physician. However, they also indicate that supportive ties to friendship networks are associated with higher predicted rates of having an annual physical exam, while social support from family and sentiments of cultural mistrust are associated with lower rates of utilisation. Broadly, the findings indicate that even as traditional predictors of help‐seeking become less relevant, it will be critical to explore how variations in discrimination experiences and social relationships across marginalised groups drive patterns of preventative care utilisation.     

Differences in Developmental Concerns of Young Children with Autism Spectrum Disorder Across Racial/Ethnic Groups

Purpose: Parents/caregivers of children with autism spectrum disorder (ASD) have varying types of initial concerns regarding their child’s development, which may be culturally bound to parents’ perceptions of their child’s development. This study investigated differences in the types of initial developmental concerns reported by parents or caregivers of different racial/ethnic groups with children in an early intervention program.

Method: This study examined the frequency of endorsement of different types of concerns in African American, Caucasian, and Hispanic families.

Results: No significant differences between racial/ethnic groups were found in the endorsement of concerns related to communication, language/speech, motor, problem behavior, sensory, feeding, prematurity, attention, adaptive functioning, and medical conditions. Racial/ethnic groups differed significantly in their endorsement for social concerns.

Conclusion: Racial/ethnic group differences were confirmed regarding initial developmental concerns related to social behavior, which may be due to cultural beliefs. The implications of these findings on early identification are discussed.     

竞赛驱动下医学专业“课程思政”的实践教学改革探索

当今医患矛盾日益突出、医患关系不断恶化的背景下,医学高等教育坚持用社会主义核心价值观引领意识形态的潮流,遵循社会主义核心价值观做导向,做到勤学、修德、立志、成才达到全方位育人目的。为落实立德树人根本任务,深度挖掘课程德育内涵,推动"课程思政"责任共同体,教师为主体,既可创新教学改革方法,有效充分发挥课程"育人"功能,将"课程思政"贯穿教育教学全过程,目的是医学专业基础课与思想政治理论同向同行,形成协同效应",以赛促教,增进实效"多元化竞赛,深入挖掘蕴含在专业知识里的德育元素,竞赛活动为载体促进"课程思政"与医学知识融合。在调研医学课程中专业课"课程思政"的现状基础上,不断充分挖掘医学专业课程中的思政元素,做到润物细无声,构建"竞赛驱动—课程思政融入-教学改革-学生批判能力培养"的教学改革实践模式,既将以竞赛为驱动力,并以医学专业知识为载体融入思政元素,提高医学生社会价值观的形成。坚持理论学习与实践教学相衔接,体会理论知识外化为实践能力,化知为行、知行合一。以赛促教、以赛促学"从专业角度发挥课堂主渠道,做好立德树人工作。     

Critical Race Theory as a Lens for Examining Primary Care Provider Responses to Persistently-Elevated HbA1c

IntroductionClinical inertia remains a persistent problem in the treatment of diabetes in clinical care. Primary care provider behavior is thought to be a significant contributor to diabetes clinical inertia. This study used the lens of Critical Race Theory to examine whether provider's diabetes management activities differ by patient race and frame implications for future research.MethodsChart abstractors retrospectively reviewed a random sample of charts from primary care patients with persistently-elevated HbA1c to assess providers' diabetes management activities in the subsequent year. Provider activities aligned with the American Diabetes Association's standards of medical care and included HbA1c test ordering, documentation of patient medication adherence, counseling on lifestyle modification, lifestyle modification referral, endocrinologist participation in care, and medication titration. Differences in provider actions by patient race (Black, white, or other) were examined using chi-square tests.ResultsA total of 188 patient charts were reviewed. For all provider actions, there were statistically-significant differences by patient race. Black patients were least likely to be counseled on dietary changes (72.0%) or physical activity (57.7%) by their primary care provider, but most likely to be referred to an outside specialist for this counseling (46.2%). Black patients were also least likely to have medication adjustments made (72%).DiscussionStudy findings showed an association between provider diabetes management behaviors and patient race, Future studies showed explore providers' racial beliefs, attitudes and clinical decision-making, and patients’ experiences with historical exclusion from medical care and racism in healthcare encounters In addition, more research is needed to explore the role of structural racism in clinical inertia.     

Racial Differences in the Associations of Posttraumatic Stress and Insomnia With Body Mass Index Among Trauma-Exposed Veterans

Posttraumatic stress is associated with increased body mass index (BMI) and rates of obesity. Black adults are at greater risk for obesity, trauma exposure, development of posttraumatic stress disorder, and comorbid sleep problems compared to White adults. Accordingly, Black adults with a history of trauma exposure may be at greater risk for elevated BMI associated with posttraumatic stress and insomnia. Multiple linear regression was used to examine race as a moderator of the relationship between posttraumatic symptoms and insomnia with BMI in a sample of Black and White trauma-exposed Veterans (N = 171), controlling for age and sex. There was a significant interaction of race with PTSD (p = 0.042) and insomnia symptoms (p = 0.045) on BMI. Simple slopes showed a significant positive association of posttraumatic stress and BMI among Black (p = 0.003), but not White Veterans (p = 0.590). Similarly, insomnia was significantly associated with greater BMI for Black (p = 0.023), but not White Veterans (p = 0.496). Posttraumatic stress and insomnia may play a particularly important role in the development of weight related health problems among Black Veterans. Early identification and treatment of these symptoms may reduce the risk of obesity among this vulnerable population.     

Doll tales: foregrounding children's voices in research

This paper discusses how the use of Persona dolls in research is an effective means of enabling children (ages 4–6) to share life experiences openly. It investigated the place of race in the peer choice of preschool children. Two key research questions drove the inquiry: (1) Do four‐ to six‐year‐old children know their own racial identity? (2) Do four‐ to six‐year‐old children choose friends based on racial characteristics? Semi‐structured interviews using Persona dolls were conducted, with the dolls acting as conduits through which the children engaged in conversations with the researcher. Findings revealed that children were aware of stereotypes and discrimination. One minority child showed deep empathy with the posed dilemma of a dark skinned Persona doll and her inability to establish friendships. Implications are shared with regard to the significance of Persona dolls, play and life stories in presenting the views of young children.