Centering Racial and Ethnic Equity in Health Care Throughout Spatial Data Analysis

BackgroundThe ongoing COVID-19 pandemic as well as a host of social movements have put a nation-sized spotlight on structural inequality and racial disparities in health throughout America. As health care systems begin to advance health equity by holding plans and payers accounting for racial and socioeconomic disparities in care, quantitative methods are needed that emphasize the distinct linkages between physical locations and racially disparate outcomes.MethodsWe apply a counterfactual model to compare differences in avoidable and potentially avoidable emergency department (ED) admissions among a panel of 8,924 non-Hispanic White, Black, and Hispanic Medicaid participants between 2016 - 2018. The magnitude of disparity estimates is examined in relation to geographic proximity to health care providers, neighborhood socioeconomic contexts, as well as the type of primary care delivery model individuals received. The adjusted rates were assessed by generalized estimating equations (GEE) and average marginal effects models to contrast differences in probability of events in association with race/ethnicity, proximity to care, and treatment through patient-centered medical homes (PCMH). ResultsAttending a patient-centered medical home was associated with a 3.4 percentage point (p <0.001) decrease in Black-White racial disparity and a 1.8 percentage point (p < 0.10) reduction in the overall Black-White disparity for potentially avoidable ED admissions. PCMH attendance was attributed to a 2.6 percentage point (p < 0.10) reduction in Hispanic-White disparities in potentially avoidable admissions, but this difference was not substantial enough to curb the overall Hispanic-White racial disparity in ED admissions. No statistically significant reductions in Black-White or Hispanic-White disparities in avoidable ED admissions were observed. ConclusionMedical homes may be able to curb, but not necessarily eliminate, racial disparities in ED admissions. Counterfactual models of health disparities are in line with recent transitions toward evaluating patient- and value-centered health care reform changes as they are designed to measure health and racial equity. This strategy, or variations of it, are adaptable to other investigations where emphasis on physical locations is considered essential to understanding racial disparities in health outcomes.

Racial Disparities in the Military Health System: A Framework Synthesis

ABSTRACT Introduction Racial disparities in health care are a well-documented phenomenon in the USA. Universal insurance has been suggested as a solution to mitigate these disparities. We examined race-based disparities in the Military Health System (MHS) by constructing and analyzing a framework of existing studies that measured disparities between direct care (care provided by military treatment facilities) and private sector care (care provided by civilian health care facilities). Materials and Methods We conducted a framework synthesis on 77 manuscripts published in partnership with the Comparative Effectiveness and Provider-Induced Demand Collaboration Project that use MHS electronic health record data to present an overview of racial disparities assessed for multiple treatment interventions in a nationally representative, universally insured population. Results We identified 32 studies assessing racial disparities in areas of surgery, trauma, opioid prescription and usage, women’s health, and others. Racial disparities were mitigated in postoperative complications, trauma care, and cancer screenings but persisted in diabetes readmissions, opioid usage, and minimally invasive women’s health procedures. Conclusion Universal coverage mitigates many, but not all, racial disparities in health care. An examination of a broader range of interventions, a closer look at variation in care provided by civilian facilities, and a look at the quality of care by race provide further opportunities for research.

The Interplay of COVID 19, Remote Contact, and Race as Risk Factors for Depression

There have been concerns about how social distance policies and lockdowns due to COVID-19 have affected loneliness and depression among older adults in ways that may magnify racial disparities in health. We conducted panel logistic regression analyses with random effects using national data spanning 2004 to 2016 and the COVID-19 module (Wave 2020, administered in June and September) from the Health & Retirement Study (n=15,504). Individuals living in a nursing home, diagnosed with dementia or Alzheimer’s disease, and 64 years of age or younger were excluded from analyses. Age, gender, Hispanic status, education, marital status, working status, wealth, BMI, physical activity, smoking, drinking, and difficulty in meal preparation, eating without help, and grocery shopping were included as control variables. Findings suggest that older adults did not appear to experience increased loneliness during the pandemic relative to prior waves. However, Wave 2020 was an independent risk factor for depression. Greater in-person contact (OR: 0.97, CI: 0.95-0.99, p-val: 0.001) and remote contact (OR: 0.99, CI: 0.97-0.996, p-val: 0.008) were each independently associated with slightly decreased depression. Older Black Americans tended to be more depressed than their White counterparts (OR: 1.50, CI: 1.20-1.86, p-val: &lt;0.001). However, a null interaction between race and wave suggested that Black Americans did not experience more increased depression in 2020 relative to prior waves. Analyses suggest that the COVID-19 pandemic might change at-risk groups for depression and communication by remote technology – often considered an inferior but necessary stopgap measure. Implications for practice and policy will be discussed.

Teaching Anti-Racism in an Aging Services Course: Lessons Developed and Lessons Learned

Despite high levels of racial disparities in health and well-being among older adults, curricula addressing how aging services systems contribute to or work to ameliorate these disparities are scarce. This paper introduces a module on inequalities and anti-racism in aging developed for an online course on aging services within a Master of Social Work program. First, materials that help students identify and understand racial inequalities in aging and in the programs that serve older adults are presented. Next, students are introduced to the applied context of how COVID-19 has exacerbated these inequalities. Finally, students critically engage in reflections and assessments of the available resources within aging services and advocacy organizations, providing recommendations for how these systems may better incorporate anti-racist practices. Challenges and opportunities will be discussed, including piloting this module in a virtual, asynchronous environment.

“Seropedagogy”

Since the beginnings of the HIV/AIDS pandemic, pedagogy has been a crucial survival strategy, especially when government agencies failed to prevent mass deaths. However, contemporary sex education on HIV/AIDS—if taught to undergraduates before they arrive on campus—often does not account for the disproportionate effects of the pandemic on racial minorities and global South countries. In this teaching essay, the author describes how his course on the history of HIV/AIDS takes a global approach to highlight that the AIDS crisis is not over. Starting with histories of HIV/AIDS in the United States, Haiti, China, and elsewhere that sought to find a scapegoat for the pandemic, the course then turns to the global power of the pharmaceutical industry. It examines the marketing and lobbying strategies of companies such as Gilead, which use the stigma of HIV/AIDS to transform impoverished global South countries into new markets for research and capital extraction. Finally, it also highlights how the AIDS crisis remains an ongoing struggle against racial disparities in health care that prevent access to life-saving treatments and preventative drugs such as Truvada and Descovy for pre-exposure prophylaxis (PrEP). Using a range of materials from podcasts to pills, the author introduces students to the globalizing forces that take the bodies of the poor, women, and Black, Latinx, trans, and global South citizens as expendable in the fight against HIV/AIDS.

Quantifying the contribution of occupational segregation to racial disparities in health: A gap-closing perspective

Racism causes racial disparities in health, and structural racism has many components. Focusing on one of those components, this paper addresses occupational segregation. I document high onset of work-limiting disabilities in occupations where many workers identify as non-Hispanic Black or as Hispanic. I then pivot to a causal question. Suppose we took a sample from the population and reassigned their occupations to be a function of education alone. To what degree would health disparities narrow for that sample? Using observational data, I estimate that the disparity between non-Hispanic Black and white workers would narrow by one-third. This estimate is credible because of adjustment for lagged measures of demographics, human capital, and health carried out under transparent causal assumptions. The result contributes to understanding about inequality and health by quantifying the contribution of occupational segregation to a disparity: if we took a sample and reassigned occupations, the disparity would narrow but would not disappear. The paper contributes to methodology by illustrating an approach to macro-level claims (how segregation affects a population disparity) that draws on explicitly causal micro-level analyses (potential outcomes for individuals) for which data are abundant.