Meredith Manze

Perceptions of Race/Ethnicity-Based Discrimination: A Review of Measures and Evaluation of Their Usefulness for the Health Care Setting

Background. To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed. Objective. To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers. Methods. Literature review of measures of perceived race/ethnicity-based discrimination (1966–2007), using MEDLINE, PsycINFO, and Social Science Citation Index. Results. We identified 34 measures of racism/discrimination; 16 specifically assessed dynamics in the health care setting. Few measures were theoretically based; most assessed only general dimensions of racism and focused specifically on the experiences of African American patients. Acceptable psychometric properties were documented for about half of the instruments. Conclusions. Additional measures are needed for detailed assessments of perceived discrimination in the health care setting; they should be relevant for a wide variety of racial/ethnic groups, and they must assess how racism/discrimination affects health care decision making and treatments offered.

Intensifying Therapy for Hypertension Despite Suboptimal Adherence

More intensive management can improve control blood pressure (BP) in hypertensive patients. However, many would posit that treatment intensification (TI) is not beneficial in the face of suboptimal adherence. We investigated whether the effect of TI on BP varies by adherence. We enrolled 819 patients with hypertension, managed in primary care at an academically-affiliated inner-city hospital. We used the following formula to characterize TI: (visits with a medication change−visits with elevated BP)/total visits. Adherence was characterized using electronic monitoring devices (“MEMS caps”). Patients who returned their MEMS caps (671) were divided into quartiles of adherence, whereas patients who did not return their MEMS caps (148) had “missing” adherence. We examined the relationship between TI and the final systolic blood pressure (SBP), controlling for patient-level covariates. In the entire sample, each additional therapy increase per 10 visits predicted a 2.0 mm Hg decrease in final SBP (P<0.001). After stratifying by adherence, in the “best” adherence quartile each therapy increase predicted a 2.1-mm Hg decrease in final SBP, followed by 1.8 for the “next-best” adherence quartile, 2.3 in the third quartile, and 2.4 in the “worst” adherence quartile. The effect size for patients with “missing” adherence was 1.6 mm Hg. The differences between the group with “best” adherence and the other 4 groups were not statistically significant. In this observational study, treatment intensification was associated with similar BP improvement regardless of the patient’s level of adherence. A randomized trial could further examine optimal management of patients with suboptimal adherence.

Comparing Methods of Measuring Treatment Intensification in Hypertension Care

Background—Greater treatment intensification (TI) improves hypertension control. However, we do not know the ideal way to measure TI for research and quality improvement efforts. We compared the ability of different TI measures to predict blood pressure (BP) control. Methods and Results—We enrolled 819 hypertensive outpatients from an urban academic hospital. Each patient was assigned 3 scores to characterize TI. The any/none score divides patients into those who had any therapy increases during the study versus none. The norm-based method models the chance of a medication increase at each visit, then scores each patient based on whether they received more or fewer medication increases than predicted. The standard-based method is similar to the norm-based method but expects a medication increase whenever the blood pressure is uncontrolled. We compared the ability of these scores to predict the final systolic blood pressure (SBP). The any/none score showed a paradoxical result: any therapy increase was associated with SBP 4.6 mm Hg higher than no increase (P<0.001). The norm-based method score did not predict SBP in a linear fashion (P=0.18); further investigation revealed a U-shaped relationship between the norm-based method score and SBP. However, the standard-based method score was a strong linear predictor of SBP (2.1 mm Hg lower for each additional therapy increase per 10 visits, P<0.001). Similarly, the standard-based method predicted dichotomized blood pressure control, as measured by SBP <140 mm Hg (odds ratio, 1.30; P<0.001). Conclusions—Our results suggest that standard-based method is the preferred measure of treatment intensity for hypertension care.

Effect of Massachusetts healthcare reform on racial and ethnic disparities in admissions to hospital for ambulatory care sensitive conditions: retrospective analysis of hospital episode statistics.

Objectives To examine the impact of Massachusetts healthcare reform on changes in rates of admission to hospital for ambulatory care sensitive conditions (ACSCs), which are potentially preventable with good access to outpatient medical care, and racial and ethnic disparities in such rates, using complete inpatient discharge data (hospital episode statistics) from Massachusetts and three control states. Design Difference in differences analysis to identify the change, overall and according to race/ethnicity, adjusted for secular changes unrelated to reform. Setting Hospitals in Massachusetts, New York, New Jersey, and Pennsylvania, United States. Participants Adults aged 18-64 (those most likely to have been affected by the reform) admitted for any of 12 ACSCs in the 21 months before and after the period during which reform was implemented (July 2006 to December 2007). Main outcome measures Admission rates for a composite of all 12 ACSCs, and subgroup composites of acute and chronic ACSCs. Results After adjustment for potential confounders, including age, race and ethnicity, sex, and county income, unemployment rate and physician supply, we found no evidence of a change in the admission rate for overall composite ACSC (1.2%, 95% confidence interval −1.6% to 4.1%) or for subgroup composites of acute and chronic ACSCs. Nor did we find a change in disparities in admission rates between black and white people (−1.9%, −8.5% to 5.1%) or white and Hispanic people (2.0%, −7.5% to 12.4%) for overall composite ACSC that existed in Massachusetts before reform. In analyses limited to Massachusetts only, we found no evidence of a change in admission rate for overall composite ACSC between counties with higher and lower rates of uninsurance at baseline (1.4%, −2.3% to 5.3%). Conclusions Massachusetts reform was not associated with significantly lower overall or racial and ethnic disparities in rates of admission to hospital for ACSCs. In the US, and Massachusetts in particular, additional efforts might be needed to improve access to outpatient care and reduce preventable admissions.

The effect of Massachusetts health reform on 30 day hospital readmissions: retrospective analysis of hospital episode statistics

Objectives To analyse changes in overall readmission rates and disparities in such rates, among patients aged 18-64 (those most likely to have been affected by reform), using all payer inpatient discharge databases (hospital episode statistics) from Massachusetts and two control states (New York and New Jersey). Design Difference in differences analysis to identify the post-reform change, adjusted for secular changes unrelated to reform. Setting US hospitals in Massachusetts, New York, and New Jersey. Participants Adults aged 18-64 admitted for any cause, excluding obstetrical. Main outcome measure Readmissions at 30 days after an index admission. Results After adjustment for known confounders, including age, sex, comorbidity, hospital ownership, teaching hospital status, and nurse to census ratio, the odds of all cause readmission in Massachusetts was slightly increased compared with control states post-reform (odds ratio 1.02, 95% confidence interval 1.01 to 1.04, P<0.05). Racial and ethnic disparities in all cause readmission rates did not change in Massachusetts compared with control states. In analyses limited to Massachusetts only, there were minimal overall differences in changes in readmission rates between counties with differing baseline uninsurance rates, but black people in counties with the highest uninsurance rates had decreased odds of readmission (0.91, 0.84 to 1.00) compared with black people in counties with lower uninsurance rates. Similarly, white people in counties with the highest uninsurance rates had decreased odds of readmission (0.96, 0.94 to 0.99) compared with white people in counties with lower uninsurance rates. Conclusions In the United States, and in Massachusetts in particular, extending health insurance coverage alone seems insufficient to improve readmission rates. Additional efforts are needed to reduce hospital readmissions and disparities in this outcome.

Massachusetts health reform and disparities in joint replacement use: difference in differences study

Objective To estimate the impact of the insurance expansion in 2006 on use of knee and hip replacement procedures by race/ethnicity, area income, and the use of hospitals that predominantly serve poor people (“safety net hospitals”). Design Quasi-experimental difference in differences study examining change after reform in the share of procedures performed in safety net hospitals by race/ethnicity and area income, with adjustment for patients’ residence, demographics, and comorbidity. Setting State of Massachusetts, United States. Participants Massachusetts residents aged 40-64 as the target beneficiaries of reform and similarly aged residents of New Jersey, New York, and Pennsylvania as the comparison (control) population. Main outcomes measures Number of knee and hip replacement procedures per 10 000 population and use of safety net hospitals. Procedure counts from state discharge data for 2.5 years before and after reform, and multivariate difference in differences. Poisson regression was used to adjust for demographics, economic conditions, secular time, and geographic factors to estimate the change in procedure rate associated with health reform by race/ethnicity and area income. Results Before reform, the number of procedures (/10 000) in Massachusetts was lower among Hispanic people (12.9, P<0.001) than black people (28.1) and white people (30.1). Overall, procedure use increased 22.4% during the 2.5 years after insurance expansion; reform in Massachusetts was associated with a 4.7% increase. The increase associated with reform was significantly higher among Hispanic people (37.9%, P<0.001) and black people (11.4%, P<0.05) than among white people (2.8%). Lower income was not associated with larger increases in procedure use. The share of knee and hip replacement procedures performed in safety net hospitals in Massachusetts decreased by 1.0% from a level of 12.7% before reform. The reduction was larger among Hispanic people (−6.4%, P<0.001) than white people (−1.0%), and among low income residents (−3.9%, p<0.001) than high income residents (0%). Conclusions Insurance expansion can help reduce disparities by race/ethnicity but not by income in access to elective surgical care and could shift some elective surgical care away from safety net hospitals.

Self-reported willingness to have cancer screening and the effects of sociodemographic factors.

BACKGROUND The relative effects of race/ethnicity and other sociodemographic factors, compared to those of attitudes and beliefs on willingness to have cancer screening, are not well understood. METHODS We conducted telephone interviews with 1148 adults (22% Hispanic, 31% African American, and 46% white) [corrected] from 3 cities in mainland United States and Puerto Rico. Respondents reported their sociodemographic characteristics, attitudes about barriers and facilitators of cancer screening, and willingness to have cancer screening under 4 scenarios: when done in the community vs ones doctors office, and whether or not one had symptoms. RESULTS Racial/ethnic minority status, age, and lower income were frequently associated with increased willingness to have cancer screening, even after including attitudes and beliefs about screening. Having screening nearby was important for community screening, and anticipation of embarrassment from screening for when there were no cancer symptoms. Associations varied across 4 screening scenarios, with the fewest predictors for screening by ones doctor when there were symptoms. CONCLUSIONS Sociodemographic characteristics not only were related to willingness to have cancer screenings in almost all cases, but were generally much stronger factors than attitudinal barriers and facilitators. Cancer screening campaigns should affect attitudinal change where possible, but should also recognize that targeting screening to specific population groups may be necessary.

Brief provider communication skills training fails to impact patient hypertension outcomes.

OBJECTIVES Hypertension remains a prevalent risk factor for cardiovascular disease, and improved medication adherence leads to better blood pressure (BP) control. We sought to improve medication adherence and hypertension outcomes among patients with uncontrolled BP through communication skills training targeting providers. METHODS We conducted a randomized controlled trial to assess the effects of a communication skills intervention for primary care doctors compared to usual care controls, on the outcomes of BP (systolic, diastolic), patient self-reported medication adherence, and provider counseling, assessed at baseline and post-intervention. We enrolled 379 patients with uncontrolled BP; 203 (54%) with follow-up data comprised our final sample. We performed random effects least squares regression analyses to examine whether the provider training improved outcomes, using clinics as the unit of randomization. RESULTS In neither unadjusted nor multivariate analyses were significant differences in change detected from baseline to follow-up in provider counseling, medication adherence or BP, for the intervention versus control groups. CONCLUSION The intervention did not improve the outcomes; it may have been too brief and lacked sufficient practice level changes to impact counseling, adherence or BP. PRACTICE IMPLICATIONS Future intervention efforts may require more extensive provider training, along with broader systematic changes, to improve patient outcomes.

Building Community Partnerships: The Role of Schools of Public Health

There is an increased recognition of the role that schools of public health can play as a resource to the communities in which they reside. One example of this comes from the Council on Education for Public Health (CEPH), the accrediting body for schools of public health, and its new guidelines for schools to increase collaboration with community stakeholders [1]. It is incumbent upon schools of public health to function as a resource to their neighboring community. This relationship can be beneficial for faculty, students, community organizations, and residents alike. Schools of public health are often situated in or near lowresourced communities. With some exceptions, the typical ‘relationship’ between schools of public health and communities tends to be unilateral, in which schools tap these communities for research, but often without returning with solutions or funds to sustain short or long-term health initiatives. This contributes to the phenomenon of over-researched populations and resulting ‘research fatigue,’ which are common among such communities [2]. This lack of reciprocity has likely contributed to communities’ reservations to work with schools [3]. In 2015, the City University of New York (CUNY) Graduate School of Public Health and Health Policy (SPH) was founded and established residence in Central Harlem, New York City. The mission of the school is “to provide a collaborative and accessible environment for excellence in education, research, and service in public health, to promote and sustain healthier populations in New York City and around the world, and to shape policy and practice in public health for all [4].” To that end, and guided by the principles of public health practice, [5] faculty in the Department of Community Health and Social Sciences (MGM, MAM) invited neighboring organizations to visit the school in an effort to establish collaborative relationships and improve engagement with our community and its residents. Our main aim was to initiate a dialogue with community-based organizations (CBOs) in Central Harlem to explore opportunities for collaboration. CBOs provide invaluable resources to community residents through health and social services. By supporting CBOs, schools of public health are thus promoting community health and contributing toward the reduction of health inequities. We identified four CBOs in our community whose mission aligns with the school’s research and service priority areas (sexual and reproductive health, maternal and child health, food policy, and HIV/AIDS), to participate in a panel discussion open to the public. The convening, dubbed “Academia in Action: Serving the Harlem Community,” took place in April 2017. CBO representatives shared their vision for the role of our school and how this reciprocal relationship could thrive. The collective process envisioned CUNY SPH as:

A systematic review of the effect of reproductive intention screening in primary care settings on reproductive health outcomes

Abstract Purpose No recommendations exist for routine reproductive intention screening in primary care. The objective of this systematic review is to assess the effect of reproductive intention screening in primary care on reproductive health outcomes (PROSPERO CRD42015019726). Methods We performed a systematic search in Ovid Medline, PubMed, CINAHL, Embase, CDR/DARE databases, Web of Science, ISRCTN registry, Clinicaltrials.gov and Cochrane Library. Studies published in English between 2000 and 2017 and whose population was patients of reproductive age (15–49) were included. Studies without a comparison group were excluded. Two independent reviewers assessed eligibility, study quality and abstracted data. Results Of 24 780 titles and/or abstracts reviewed, nine studies met inclusion criteria: four randomized controlled trials (RCTs) and five observational studies. Two RCTs and one quasi-experimental cohort study showed a statistically significant increase in knowledge related to healthier pregnancy, such as the benefits of folic acid supplementation, and increased risk profiles for those with chronic conditions. Among studies measuring contraceptive use, only one cohort study showed any increase while the RCT and retrospective cohort did not show a statistically significant effect. Neither of the two RCTs that assessed the provision of contraception by primary care providers for those not desiring pregnancy found increased access to contraception, although one found increased documentation of contraception in electronic medical records. Acceptability of reproductive intention screening was measured in seven studies, and participant satisfaction was high in all seven studies. Conclusions More research is needed to determine whether routine inclusion of reproductive intention screening in primary care is warranted.