Showing papers in "Journal of Health Care for the Poor and Underserved in 2018"

The Racial and Ethnic Composition and Distribution of Primary Care Physicians.

Abstract: Racial and ethnic minority physicians are more likely to practice primary care and serve in underserved communities. However, there are micro-practice patterns within primary care specialties that are not well understood. To examine the differences among primary care physician practice locations by specialty and race/ethnicity, a retrospective study was conducted on U.S. medical graduates who were direct patient care physicians in 2012. The group-specific contributions to primary care accessibility were decomposed by individual group of minorities underrepresented in medicine (URM). Results confirm significant differences not only in their distribution across underserved areas but also in their racial/ethnic composition by primary care specialties, with internist most diverse and family physicians least diverse. However, stratified analysis shows that within each primary care subspecialty, URM physicians were more likely to practice in underserved areas than their White peers regardless of specific specialties.

Strategies for Achieving Diversity through Medical School Admissions

Abstract: The relative lack of diversity in medicine is a rate limiting factor in efforts to eliminate health care disparities. Many medical schools struggle to matriculate student bodies that reflect the diversity of this country. Actively recruiting is one tactic to diversify a medical school's applicant pool, but in isolation is not enough. Our medical school admissions committee made a number of programmatic changes that contributed to our current compositional diversity that may be instructive to others. This report from the field on the experience of one U.S. medical school describes several admissions committee initiatives that can be undertaken to increase the yield of students from groups underrepresented in medicine who matriculate to medical school.

Racial/Ethnic Health Disparities Among Rural Adults—United States, 2012–2015: MMWR Surveillance Summaries / November 17, 2017 / 66(23);1–9

Abstract: Problem/Condition: Rural communities often have worse health outcomes, have less access to care, and are less diverse than urban communities. Much of the research on rural health disparities examines disparities between rural and urban communities, with fewer studies on disparities within rural communities. This report provides an overview of racial/ethnic health disparities for selected indicators in rural areas of the United States. Reporting Period: 2012–2015. Description of System: Self-reported data from the 2012–2015 Behavioral Risk Factor Surveillance System were pooled to evaluate racial/ethnic disparities in health, access to care, and health-related behaviors among rural residents in all 50 states and the District of Columbia. Using the National Center for Health Statistics 2013 Urban-Rural Classification Scheme for Counties to assess rurality, this analysis focused on adults living in noncore (rural) counties. Results: Racial/ethnic minorities who lived in rural areas were younger (more often in the youngest age group) than non-Hispanic whites. Except for Asians and Native Hawaiians and other Pacific Islanders (combined in the analysis), more racial/ethnic minorities (compared with non-Hispanic whites) reported their health as fair or poor, that they had obesity, and that they were unable to see a physician in the past 12 months because of cost. All racial/ethnic minority populations were less likely than non-Hispanic whites to report having a personal health care provider. Non-Hispanic whites had the highest estimated prevalence of binge drinking in the past 30 days. Interpretation: Although persons in rural communities often have worse health outcomes and less access to health care than those in urban communities, rural racial/ethnic minority populations have substantial health, access to care, and lifestyle challenges that can be overlooked when considering aggregated population data. This study revealed difficulties among non-Hispanic whites as well, primarily related to health-related risk behaviors. Across each population, the challenges vary. Public Health Action: Stratifying data by different demographics, using community health needs assessments, and adopting and implementing the National Culturally and Linguistically Appropriate Services Standards can help rural communities identify disparities and develop effective initiatives to eliminate them, which aligns with a Healthy People 2020 overarching goal: achieving health equity.

Successes, Challenges, and Considerations for Integrating Referral into Food Insecurity Screening in Pediatric Settings.

Abstract: Food insecurity, lack of access to enough food for an active and healthy life, is associated with poor child health. Three pediatric clinics implemented a two-question food insecurity screening of 7,284 families with children younger than five years. Over one thousand (1,133, 15.6%) reported food insecurity and 630 (55.6%) were referred to a benefits access organization for connection to public benefits and community resources. This study evaluated the efficacy of screening and referral through process evaluation, key informant interviews, and focus groups with 19 caregivers and 11 clinic staff. Using grounded theory, transcript themes were coded into facilitators and barriers of screening and referral. Facilitators included trust between caregivers and staff, choice of screening methods, and assistance navigating benefits application. Barriers included complex administration of referral, privacy and stigma concerns, and caregivers' current benefit enrollment or ineligibility. Results demonstrate importance of integrated screening and referral consent processes, strong communication, and convenient outreach for families.

Transgender and Genderqueer Individuals' Experiences with Health Care Providers: What's Working, What's Not, and Where Do We Go from Here?

Abstract: Research demonstrates health disparities between gender-minority individuals and cisgender individuals. These disparities arise from multiple sources, including negative health care experiences. This study examines interactions between transgender and gender non-binary (TGGNB) individuals and their health care providers. We analyzed 119 participants' descriptions of positive and negative health care experiences, and what they wish providers knew about caring for TGGNB patients. Health care experiences went well when providers and staff used inclusive language, demonstrated their experience and education, and treated identity disclosure as routine. Negative interactions were characterized by misgendering, unfamiliarity with TGGNB people and health issues, and transphobic practices. Participants wished providers understood their health concerns, did not expect their patients to educate them, and created a welcoming clinical environment. Medical educators, administrators, and providers share responsibility for improving TGGNB patient experiences. Through a framework of cultural safety, we recommend several changes to ensure more equitable treatment in health care.

Higher Perceived Clinic Capacity to Address Patients' Social Needs Associated with Lower Burnout in Primary Care Providers

Abstract: Purpose Primary care physicians (PCP) experience high rates of professional burnout. These symptoms may be magnified in underserved populations. This study explores relationships between clinic capacity to address patients' social needs (SN) and PCP burnout. Methods We conducted a cross-sectional survey of PCPs from three delivery systems in San Francisco. Surveys included three components of burnout, measured by the Maslach Burnout Inventory (MBI) and a four-item instrument exploring attitudes, confidence, individual skills and organizational capacity to address patients' SN. Results Provider perception of higher clinic capacity to address patients' SN was the strongest independent predictor of lower burnout. Providers who perceived high clinic capacity and resources to address SN reported significantly greater professional efficacy (p l.01), lower emotional exhaustion (p l.05), and lower cynicism (p l.05). Conclusions Provider perceptions of greater clinic capacity to address SN are significantly associated with lower burnout. Devoting organizational resources to address SN may reduce PCP burnout.

Measuring the Effect of Social Determinants on Patient Outcomes: A Systematic Literature Review.

Abstract: Given the movement towards value-based purchasing in the United States, health care leaders need methods to characterize and address the complex effect that social determinants have on health care outcomes. This systematic literature review was specifically designed to understand current research on the effect that patient material and social deprivation has on health care delivery outcomes and the potential benefit of clinical interventions designed to mediate this effect. A total of 310 studies were identified for review with 80 studies included in the final synthesis. Results highlight significant variation in the methods used to measure the effect of social determinants on health care outcomes and the need for common measurement standards. More robust identification of deprivation-sensitive diseases or conditions is needed to channel scarce program resources to effected conditions. Finally, further research is needed to evaluate the benefits of data-driven, tailored clinical interventions designed to serve the needs of materially-deprived patient populations.

Mental Health Interventions with Community Health Workers in the United States: A Systematic Review.

Abstract: Mental health conditions are common in the United States, yet the mental health workforce is limited in its capacity to reach disadvantaged populations. While a number of recent reviews demonstrate that community health worker (CHW)-supported physical health interventions are effective, and increase access to services, there are no recent reviews that systematically assess CHW-supported mental health interventions. To address this gap, the authors conducted a systematic review of mental health interventions with CHWs in the United States, and assessed the methodological rigor of such studies. Nine studies met review criteria. Though most of the studies reviewed showed inadequate methodological rigor, findings suggest CHW-supported mental health interventions show promise, particularly given evidence of feasibility and acceptability with underserved populations. The authors describe the rationale for mental health CHWs in the workforce, offer recommendations to strengthen the evidence base, and discuss implications of mental health interventions with CHWs for underserved populations.

The Evidence Base for Social Determinants of Health as Risk Factors for Infant Mortality: A Systematic Scoping Review.

Abstract: The objectives of this study were to identify social determinants of health as risk factors for infant mortality, particularly among African Americans, and to determine the extent to which research has demonstrated an association between each social determinant of health and infant mortality. A systematic scoping review was conducted following PRISMA guidelines. Databases searched include: EBSCOhost, CINAHL Plus, PsycINFO, SocINDEX, Social Work Abstracts, and Sociological Collection. Following a three-step selection process conducted by two reviewers, 89 studies were included. The social ecological model was used to categorize both the search terms and the findings. Findings revealed that the majority of studies focused on the individual and public policy levels, and most failed to account for the complexity of the issue. Additional research is needed to explore the social determinants of health that are hypothesized to affect infant mortality across all levels, applying more complex, system-level approaches.

Social and Behavioral Factors in Sickle Cell Disease: Employment Predicts Decreased Health Care Utilization

Abstract: The purpose: to determine frequency of health care encounters among people with sickle cell disease (SCD) seeking treatment for a vaso-occlusive crisis (VOC). Health care encounters are categorized by visit type (day hospital, ED visit, hospitalization), prevalence of self-reported behavioral and social factors, and any associations between behavioral and social factors and health care encounters. Ninety-five people with SCD were enrolled in a prospective descriptive study in North Carolina. Patients were interviewed concerning behavioral-social factors, and a report of health care encounters was produced, generated by ICD codes associated with VOCs between October 2011 and March 2014. Among 95 patients, there were a total of 839 day hospital and 1,990 ED visits, and 1,101 hospital admissions. Prevalent behavioral and social factors were depression (29%), anxiety (34%), illicit drug use (6%); unstable home situation (17%); and unemployment (81%). Employment and stable home were significantly associated with decreased frequency of health care encounters.

Using Health Information Technology to Bring Social Determinants of Health into Primary Care: A Conceptual Framework to Guide Research.

Abstract: Several recent national initiatives have called for increased efforts to integrate social determinants of health (SDH) into health care settings using health information technology (HIT). However, there is limited evidence to guide the implementation of these recommendations in practice. Research is needed to understand what SDH information is most important to collect, how SDH information can be used to inform clinical care and referrals, and ultimately, whether and how integrating SDH screening and action into primary care affects individual and population health. We recently proposed a conceptual framework to illustrate how HIT can be used to bring SDH information into primary care. In this paper, we describe how we are putting this conceptual model into practice within the OCHIN network of community health centers by highlighting examples of ongoing research, identifying knowledge gaps, and outlining a roadmap of future research to move the field forward.

Racism and Health in Rural America.

Abstract: This commentary responds to the recent article by Dr. James et al. on racial and ethnic health disparities in rural America, published in the November 16 issue of Morbidity and Mortality Weekly Report . We applaud Dr. James and colleagues for their important contribution uncovering intra-rural racial and ethnic disparities and build on their paper by discussing potential mechanisms, including structural racism. We also discuss several pragmatic steps that can be taken in research, policy, and practice to address racial and ethnic disparities in rural communities and to work toward health equity for all rural residents.

Perspectives of Community Advisory Board Members in a Community-Academic Partnership.

Abstract: Background Community-academic partnerships are increasingly used to engage community members and researchers in research activities; however, little is known about the motivations and perceptions of community members to participate in such projects. Objectives The overall goal was to elicit Community Advisory Board (CAB) members' motivations and perceptions of involvement in a community-academic partnership about cancer prevention. Methods An external evaluator conducted 15 one-on-one semi-structured interviews with CAB members of the project. Coders conducted a conventional content analysis to derive themes from the interview data. Results Emergent themes were grouped into four categories: CAB members' 1) motivation to participate in the project, 2) perceptions that they had insider information, 3) views of roles and responsibilities in project planning and implementation, and 4) challenges and suggestions to improve the community-academic relationship. Conclusions This study found substantial evidence that CAB members perceived they were working to involve the Hispanic community in health promotion.

Racial Disparities in PAD-Related Amputation Rates among Native Americans and non-Hispanic Whites: An HCUP Analysis.

Abstract: Introduction This study analyzed the impact of sociodemographic characteristics, patient comorbidities, risk factors for critical limb ischemia and hospital characteristics on racial disparities in amputation rates for Native American patients with peripheral artery disease (PAD). Methods The study used the Healthcare Cost and Utilization Program inpatient discharge data from 2006-2013 for patients with a primary diagnosis of PAD. Multivariable models using the Blinder-Oaxaca decomposition method were estimated to isolate the impact of individual covariates to identify determinants of amputation rates for Native Americans compared with non-Hispanic Whites. Results Region of the country made a difference in this analysis with Native Americans residing in the West Census Region being twice as likely to undergo amputation as non-Hispanic Whites. Conclusions After adjusting for sociodemographic characteristics, patient comorbidities, and hospital characteristics, Native Americans with PAD who reside in the West Census Region are substantially more likely to undergo amputation than are non-Hispanic Whites.

Health Literacy Mediates Racial Disparities in Cardiopulmonary Resuscitation Knowledge among Chronic Kidney Disease Patients.

Abstract: Black patients with chronic kidney disease (CKD) receive more cardiopulmonary resuscitation (CPR) than other racial groups, and knowledge of CPR influences preferences for care. As limited health literacy disproportionately affects Blacks and contributes to disparities in end-of-life (EOL) care, we investigated whether health literacy mediates racial disparities in CPR knowledge. Black and White adult patients with advanced CKD completed CPR knowledge surveys. Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Among 149 patients, Black patients were more likely to have limited health literacy and lower mean CPR knowledge scores than White patients. In adjusted analyses, health literacy mediated racial differences in CPR knowledge. Knowledge of CPR is lower among Black compared with White CKD patients and health literacy is a mediator of this difference. Future CPR educational interventions should target health literacy barriers to improve informed decision-making and decrease racial disparities at the end of life.

Diagnosis and Management of Pneumocystis Pneumonia in Resource-poor Settings

Abstract: Globally, Pneumocystis pneumonia (PCP) remains a common and lethal infection in both HIV-positive and HIV-negative patients, particularly in developing countries where rates of PCP increases with rising GDP. Pneumocystis jirovecii cannot be cultured in routine clinical laboratories; thus diagnosis relies on microscopy, histology, serology and/or polymerase chain reaction (PCR) of the Pneumocystis DNA. Most of these methods are expensive and require training. Accessing lower respiratory tract specimens in young children is often challenging and only PCR testing of nasopharyngeal aspirates is useful. Early treatment with high-dose co-trimoxazole is effective therapy; however, adverse reactions are common along with reports of emerging resistance. Improved outcomes are associated with adding corticosteroid to treatment in those with moderate/severe PCP, although this has not been studied in resource-poor settings. This review compares the available diagnostic techniques in relation to their suitability for use in resource-poor settings. We also addressed the non-availability of the alternative medications in these regions.

Cervical Cancer Screening Behaviors and Perceptions of Medical Mistrust among Rural Black and White Women.

Abstract: Background This study examined the relationship of medical mistrust using the Group-based Medical Mistrust Scale (GBMMS), and Papanicolaou testing behaviors among rural Black and White women. Methods Utilizing a convenience sample, a cross-sectional study was performed. Inclusion criteria included self-identification as a non-Hispanic Black or White woman, at least 21 years of age, and a resident of one of the selected counties in the region. Analyses conducted were two-sample t-tests, Fisher's exact tests, Spearman's rho, and logistical regression. Results Among 338 women, four GBMMS items had statistically significant outcomes using multiple significance tests; significance remained when adjusting for demographic variables. Analyses indicated that Whites were dissatisfied with the health care system to a greater extent than Blacks. Conclusions The impact of medical mistrust should be explored beyond individuals of a racial/ethnic minority group. Future directions include the development of a community-informed screening intervention to foster adherence among diverse rural populations.

"We feel like it was better back home:" Stress, Coping, and Health in a U.S. Dwelling African Immigrant Community.

Abstract: Background This study examines stress and stress management from the perspective of African immigrants in southwestern Pennsylvania. Our research questions explore how participants define stress, the most common causes of stress, manifestations of stress, and common strategies for stress management. Methods We conducted a descriptive, cross-sectional, qualitative study with 34 African immigrants. Data were collected via three focus groups. Qualitative data were audio-recorded, transcribed verbatim, and analyzed to identify common themes. Results Five major types of stressors included: remittances, financial and job-related challenges, children, disconnected families, and unrealized expectations. Participants reported both physical and mental manifestations of stress and used both group-based and individual-focused coping strategies. Discussion African immigrants suffer from sources of stress that are uniquely attributed to their cultural background, immigration modalities, acculturation processes, and unrealized expectations. Health care providers must be aware of these sources of stress and potential management strategies.

Water, Sanitation and Hygiene Situation in Kenya's Urban Slums

Abstract: Kenya has undergone rapid urbanization as people migrate to the cities in search of economic opportunities. This has given rise to informal settlements characterized by overcrowding, poor infrastructure, and inadequate social amenities. A cross-sectional study on water, sanitation, and hygiene (WASH) status was carried out in Mathare, an informal settlement in Nairobi. A random sample of 380 households was used. The average household size was five people, and 26% of the household heads had completed secondary or higher level of education. The main source of income (70%) was self-employment with 41% of the households living on less than 1.5 USD per day. The WASH situation in the urban slums is below the minimum standard recommended by the World Health Organization (WHO). There is need to improve the situation by improving and installing basic infrastructure including water, sanitation, and solid waste collection.

Philadelphia Telemedicine Glaucoma Detection and Follow-up Study: Ocular Findings at Two Health Centers

Abstract: Blindness from glaucoma can be prevented by early detection and treatment. Telemedicine improves access to treatment in high-risk populations that face barriers to receiving adequate ophthalmic care. We used a practice-based telemedicine screening model at two health centers. Telemedicine imaging of the fundus and optic nerve, followed by a complete eye exam at the same location for participants with abnormal findings, unreadable images, or ocular hypertension (OHTN), was performed. A total of 182 participants were screened, of whom 108 qualified for a complete eye exam. Of these, 62 (34.1%) had abnormal images, 12 (6.6%) had OHTN, and 34 (18.7%) had unreadable images. Eighty-nine of the 108 (82%) returned for the complete eye exam. Predominantly, participants were African American with glaucoma suspect and cataract. Screening location was an important factor for follow-up. Assessment of the fundus and optic disc using telemedicine resulted in early detection of glaucoma and other ocular pathology.

Exploring the Relationship between Maternal Health Literacy, Parenting Self-Efficacy, and Early Parenting Practices among Low-Income Mothers with Infants.

Abstract: OBJECTIVE To explore the association of maternal health literacy (MHL), parenting self-efficacy and early parenting practices among low-income mothers with infants. DESIGN A cross-sectional, descriptive correlational design. PARTICIPANTS Low-income mothers (N=186) with infants. METHODS Face-to-face interviews were conducted using English and Spanish versions of questionnaires by trained bilingual research assistants. The Newest Vital Sign (NVS) screening tool was used to measure MHL. RESULTS Nearly three-quarters (72%) of mothers were rated as having low MHL. In the bivariate analysis, MHL was positively correlated with education, household income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children. The study findings demonstrate that parenting self-efficacy had a mediating effect on MHL and early parenting practices among mothers with infants. CONCLUSION Results suggest that future research is needed to advance MHL in low-income mothers and to inform potential HL interventions for this target population.

The Use of Traditional and Complementary Medicine for Diabetes in Rural Guatemala.

Abstract: Objectives The global burden of type 2 diabetes mellitus is increasing, especially in Central America. In resource-limited settings, such as Guatemala, there are significant barriers to diabetes care and many Guatemalans use medicinal plants as treatment. The purpose of this study is to understand the use of medicinal plants in an indigenous population with diabetes in rural Guatemala. Methods Semi-structured interviews were conducted in communities around San Lucas Toliman, Guatemala with people with diabetes, health promoters, and traditional healers. Results Out of the 55 people with diabetes interviewed, 35 (63.6%) had used medicinal plants, most frequently using Artemisia absinthium, Moringa oleifera, Carica papaya, and Neurolaena lobata. The majority of participants cited lack of access to medications as the reason for their use of medicinal plants. Conclusion There is widespread use of medicinal plants in San Lucas Toliman. More research is needed to understand the degree of glycemic control in these communities.

Undocumented Latino Immigrants and Research: New Challenges in Changing Times

Abstract: Latinos are the largest immigrant group in the United States, representing 17.6% of the total U.S. population, and are therefore critical to include in research. However, Latino immigrants-and particularly those who are undocumented residents-may be increasingly wary of participating in research amidst hostile anti-immigrant rhetoric and high profile cases of deportation. In this commentary we discuss challenges of conducting research with undocumented Latino immigrants in the current sociopolitical climate. We provide suggestions for data collection, data protection, and research recruitment techniques that may mitigate some of these challenges.

A Community Health Worker-Led Rotation to Train Medical Students in the Social Determinants of Health.

Abstract: Medical students often lack training in understanding and addressing the social determinants that shape the health of high-risk populations. We describe a novel clinical elective rotation in which fourth-year medical students served as apprentices to community health workers in order to develop community engagement skills and cultural humility.

Perceived Neighborhood Quality and HIV-related Stigma among African Diasporic Youth; Results from the African, Caribbean, and Black Youth (ACBY) Study.

Abstract: Socio-environmental factors such as neighborhood quality are increasingly recognized drivers of HIV disparities. Additionally, HIV- related stigma heightens HIV vulnerability among youth in the African Diaspora. However, little research examines the intersection of neighborhood quality and HIV- related stigma. This study uses survey data (N=495) from African, Caribbean, and Black youth in a midsized city in Ontario, Canada to address this research deficit. Analysis of variance and multivariate ordinary least squares regressions were conducted to determine differences in HIV- related stigma by neighborhood quality, experiences of discrimination, HIV- knowledge, and demographic factors. Residents in more socially disordered neighborhoods (p<.05), males (p<.0001), African- Muslim youth (p<.01), and individuals with lower HIV- knowledge (p<.0001) endorsed stigmatizing beliefs more often. Addressing neighborhood disadvantage may have implications for HIV- related stigma. More research should be conducted to understand the impact of socio- environmental disadvantage and HIV- related stigma.

"Birth Control can Easily Take a Back Seat": Challenges Providing IUDs in Community Health Care Settings.

Abstract: Objective. To assess community health centers' (CHCs) capacity to offer streamlined intrauterine devices (IUDs) services. Methods. Prior to implementing a contraceptive training project, we surveyed health care staff (N=97) from 11 CHC sites that offer IUDs onsite. Twenty interviews with clinicians explored more deeply their challenges offering IUDs in the CHC setting. Results. Most practices required multiple visits for IUD placement, most (66%) clinician survey respondents had placed an IUD and 19% had placed an IUD as emergency contraception. Need for screening tests, scheduling challenges, pressures to meet patient quotas, and lack of priority given to women's health hindered streamlined IUD provision. Conclusions. Although access to IUDs has increased, significant barriers to provision in CHC settings persist. Clinic policies may need to address a variety of system and provider-level barriers to meet the needs of patients.

The New Mexico Peer Education Project: Filling a Critical Gap in HCV Prison Education

Abstract: Introduction Hepatitis C (HCV) is an epidemic in the incarcerated population in the United States. In New Mexico, more than 40% of people entering the prison systems test positive for HCV antibodies. Project ECHO's New Mexico Peer Education Project (NMPEP) was developed to educate prisoners about HCV and impact the cycle of HCV transmission in the prison system. Methods Evaluation of NMPEP included multiple methods. Surveys focused on the short-term impact of training. Focus groups and post-release interviews were conducted to assess the intermediate impact of training on peer educators. Results Significant changes were observed in knowledge, attitudes, behavioral intention and self-efficacy. The program had a powerful positive impact on peer educators giving them a unique skill set, a sense of agency and a passion to help others. Conclusions Prison peer educators can learn to effectively teach HCV prevention and harm reduction strategies and disease specific information to their peers.

Integrated Care with Indigenous Populations: Considering the Role of Health Care Systems in Health Disparities.

Abstract: Introduction There is increased evidence for the effectiveness of integrated behavioral health care, however, it is unknown if integrated care is effective or culturally appropriate for Indigenous populations-the population with the largest health disparities in the nation. Methods We conducted a literature review to analyze the state of Indigenous health care focusing specifically on the appropriateness of integrated care in this population. Results Integrated care could improve access to comprehensive care, quality of care, and may be a promising model to reduce health disparities for Indigenous people. Discussion Indigenous people experience significant barriers to effective health care services that require strategic, systemic, and collaborative interventions to close these gaps. Integrated care appears to be an appropriate solution but additional research is needed to determine this. Further, any health intervention must be carried out in collaboration with tribal communities and nations to ensure success.

Disparities in Access to Sorafenib in Communities with Low Socioeconomic Status.

Abstract: Objective In the United States, hepatocellular carcinoma (HCC) is more common among communities with low socioeconomic status (SES), and these groups tend to be diagnosed with later-stage cancers. Sorafenib is the primary treatment for advanced HCC, however its substantial cost raises concern for access to treatment. Methods The newly developed Case-Background method was used to estimate odds ratios for the impacts of various sociodemographic factors on sorafenib access in clinically eligible patients. Socioeconomic status was defined as a factor of median income and education level based on ZIP code of residence. Results There was a strong association between sorafenib prescription and residence in an area of higher SES. While controlling for age, race/ethnicity, and insurance status, high SES residence doubled the odds of sorafenib prescription (OR=2.05, pl.01). Conclusions Low socioeconomic status communities appear to have a reduced chance of receiving the only effective treatment for advanced HCC.

Provider perceptions of the organization’s cultural competence climate and their skills and behaviors targeting patient-centered care for socially at-risk populations

Abstract: As part of a cultural competence needs assessment study at a large academic health care system, we conducted a survey among 1,220 practicing physicians to assess their perceptions of the organization's cultural competence climate and their skills and behaviors targeting patient-centered care for culturally and socially diverse patients. Less than half of providers reported engaging in behaviors to address cultural and social barriers more than 75% of the time. In multivariable logistic regression models, providers who reported moderate or major structural problems were more likely to report low skillfulness in identifying patient mistrust (aOR: 2.01; 95% CI: 1.23-3.28, p<0.01), how well patients read and write English (aOR: 1.63; 95% CI: 1.03-2.57, p=0.03), and socioeconomic barriers (aOR: 2.14; 95% CI: 1.14-4.01, p=0.01), than providers who reported only small or no structural problems. Improved structural support for socially and culturally complex medical encounters is needed to enhance care for socially at-risk patients.