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Increased social services spending ups cancer survival of Blacks
Five-year overall survival increased among non-Hispanic Black patients by 2.02% in conjunction with a 10% increase in spending. In addition, there was a decrease in racial disparities in survival between non-Hispanic Black patients and White patients for many types of cancers.
However, public welfare spending had no real impact on the overall 5-year survival for the entire cohort (0.25 % per 10% increase in spending; P = .78) or for non-Hispanic White patients (0.52% per 10% increase in spending, P = .58).
“We know from prior research that outcomes are worse for minorities,” said lead author Justin Michael Barnes, MD, from the department of radiation oncology at Washington University in St. Louis, Mo. “It’s thought that some of the differences are related to impaired access to health care for minorities, which is related to social determinants of health. This includes socioeconomic factors, educational attainment, place of residence, as well as environmental stressors.
“Our data show that greater state welfare expenditures were associated with greater 5-year survival among Black patients and decreased Black–White disparities,” said Dr. Barnes. “I think these data are thought provoking, but they certainly aren’t the end. I see these data as a proof-of-concept project.”
Dr. Barnes reported the findings at a press conference held in advance of the annual meeting of the American Society of Clinical Oncology, during which the study will be presented (Abstract 6509).
Improved 5-year survival in Black patients
For the study, Dr. Barnes and colleagues evaluated the association of 5-year overall survival and public welfare spending in 2,925,550 individuals aged 18 years and older who were diagnosed with cancer during the period 2007-2016. The cohort was drawn from the Surveillance, Epidemiology, and End Results Program. In addition, annual state spending data were obtained from the U.S. Census Bureau. The team examined survival outcomes by race and ethnicity as well as by cancer site. The investigators accounted for factors such as age, sex, metropolitan residence, state, county-level income and education, insurance status, cancer site, stage at diagnosis, and year of diagnosis.
Much of public welfare spending was related to Medicaid but also included programs that provide subsidy assistance for individuals, such as Supplemental Security Income.
As compared with White patients, the 5-year overall survival rate was 10.8% lower among non-Hispanic Black patients. But there was a 4.46% (P for interaction <.001) narrowing of the 5-year overall survival disparity in non-Hispanic Black patients in comparison with White patients per 10% increase in spending, or a 42% closure of the 10.8% disparity.
Regarding specific cancer types, increased public welfare spending was associated with a narrowing of the 5-year overall survival disparity between Black patients and non-Hispanic White patients for the following cancers: breast (a 6.15% survival increase for Black patients led to a 39% closing of the disparity), cervix (a 11.9% survival increase led to a 46% closing of the disparity), colorectum (a 4.42% survival increase led to a 48% closing of the disparity), head and neck (a 9.41% survival increase led to a 38% closing of the disparity), liver (a 7.02% survival increase led to a 49% closing of the disparity), ovary (an 8.95% survival increase led to a 41% closing of the disparity), bladder (an 8.18% survival increase led to a 44% closing of the disparity), and uterus (a 14.1% survival increase led to a 40% closing of the disparity).
“Some type of public welfare seems to be helping improve oncologic outcomes for some of our most socioeconomically at-risk patients, but we don’t know the specifics,” Dr. Barnes concluded. “Additional work is needed to identify the most influential public health expenditures. If we can do this, we can more rigorously evaluate state-level policies and their association with cancer outcomes.”
Public welfare improves outcomes
Weighing in on the data, Sarah P. Cate, MD, director, Special Surveillance and Breast Program, Mount Sinai Health System, New York, noted that racial disparities have been identified in many areas of health care and with respect to many diseases. “In the world of oncology, time to diagnosis and treatment significantly impacts overall survival,” she told this news organization. “Many studies are currently underway to investigate why certain ethnic groups have worse cancer outcomes.”
This study is important, she noted, in that it “highlights a discrete source of correcting these disparities in a large group of patients. Obviously there are multiple barriers to care, but increased public welfare spending in oncology should decrease some of these disparities.”
Julie R. Gralow, MD, ASCO’s chief medical officer and executive vice president, commented that it is known that state public welfare spending can mitigate structural racism and at least partially address social determinants of health, such as financial stability, education, place of residence, and insurance status. “This research found that states that increased their public health spending improved overall survival in Black patients with a variety of solid tumors and also resulted in a decrease in racial disparities in survival,” she said. “This important data provides clear support for the benefits of investment in public welfare spending at the state level, including Medicaid expansion.”
The study did not receive funding. Dr. Barnes and Dr. Cate have disclosed no relevant financial relationships. Dr. Gralow has relationships with Genentech, AstraZeneca Hexal, Puma BioTechnology, Roche, Novartis, Seagen, and Genomic Health.
A version of this article first appeared on Medscape.com.
Five-year overall survival increased among non-Hispanic Black patients by 2.02% in conjunction with a 10% increase in spending. In addition, there was a decrease in racial disparities in survival between non-Hispanic Black patients and White patients for many types of cancers.
However, public welfare spending had no real impact on the overall 5-year survival for the entire cohort (0.25 % per 10% increase in spending; P = .78) or for non-Hispanic White patients (0.52% per 10% increase in spending, P = .58).
“We know from prior research that outcomes are worse for minorities,” said lead author Justin Michael Barnes, MD, from the department of radiation oncology at Washington University in St. Louis, Mo. “It’s thought that some of the differences are related to impaired access to health care for minorities, which is related to social determinants of health. This includes socioeconomic factors, educational attainment, place of residence, as well as environmental stressors.
“Our data show that greater state welfare expenditures were associated with greater 5-year survival among Black patients and decreased Black–White disparities,” said Dr. Barnes. “I think these data are thought provoking, but they certainly aren’t the end. I see these data as a proof-of-concept project.”
Dr. Barnes reported the findings at a press conference held in advance of the annual meeting of the American Society of Clinical Oncology, during which the study will be presented (Abstract 6509).
Improved 5-year survival in Black patients
For the study, Dr. Barnes and colleagues evaluated the association of 5-year overall survival and public welfare spending in 2,925,550 individuals aged 18 years and older who were diagnosed with cancer during the period 2007-2016. The cohort was drawn from the Surveillance, Epidemiology, and End Results Program. In addition, annual state spending data were obtained from the U.S. Census Bureau. The team examined survival outcomes by race and ethnicity as well as by cancer site. The investigators accounted for factors such as age, sex, metropolitan residence, state, county-level income and education, insurance status, cancer site, stage at diagnosis, and year of diagnosis.
Much of public welfare spending was related to Medicaid but also included programs that provide subsidy assistance for individuals, such as Supplemental Security Income.
As compared with White patients, the 5-year overall survival rate was 10.8% lower among non-Hispanic Black patients. But there was a 4.46% (P for interaction <.001) narrowing of the 5-year overall survival disparity in non-Hispanic Black patients in comparison with White patients per 10% increase in spending, or a 42% closure of the 10.8% disparity.
Regarding specific cancer types, increased public welfare spending was associated with a narrowing of the 5-year overall survival disparity between Black patients and non-Hispanic White patients for the following cancers: breast (a 6.15% survival increase for Black patients led to a 39% closing of the disparity), cervix (a 11.9% survival increase led to a 46% closing of the disparity), colorectum (a 4.42% survival increase led to a 48% closing of the disparity), head and neck (a 9.41% survival increase led to a 38% closing of the disparity), liver (a 7.02% survival increase led to a 49% closing of the disparity), ovary (an 8.95% survival increase led to a 41% closing of the disparity), bladder (an 8.18% survival increase led to a 44% closing of the disparity), and uterus (a 14.1% survival increase led to a 40% closing of the disparity).
“Some type of public welfare seems to be helping improve oncologic outcomes for some of our most socioeconomically at-risk patients, but we don’t know the specifics,” Dr. Barnes concluded. “Additional work is needed to identify the most influential public health expenditures. If we can do this, we can more rigorously evaluate state-level policies and their association with cancer outcomes.”
Public welfare improves outcomes
Weighing in on the data, Sarah P. Cate, MD, director, Special Surveillance and Breast Program, Mount Sinai Health System, New York, noted that racial disparities have been identified in many areas of health care and with respect to many diseases. “In the world of oncology, time to diagnosis and treatment significantly impacts overall survival,” she told this news organization. “Many studies are currently underway to investigate why certain ethnic groups have worse cancer outcomes.”
This study is important, she noted, in that it “highlights a discrete source of correcting these disparities in a large group of patients. Obviously there are multiple barriers to care, but increased public welfare spending in oncology should decrease some of these disparities.”
Julie R. Gralow, MD, ASCO’s chief medical officer and executive vice president, commented that it is known that state public welfare spending can mitigate structural racism and at least partially address social determinants of health, such as financial stability, education, place of residence, and insurance status. “This research found that states that increased their public health spending improved overall survival in Black patients with a variety of solid tumors and also resulted in a decrease in racial disparities in survival,” she said. “This important data provides clear support for the benefits of investment in public welfare spending at the state level, including Medicaid expansion.”
The study did not receive funding. Dr. Barnes and Dr. Cate have disclosed no relevant financial relationships. Dr. Gralow has relationships with Genentech, AstraZeneca Hexal, Puma BioTechnology, Roche, Novartis, Seagen, and Genomic Health.
A version of this article first appeared on Medscape.com.
Five-year overall survival increased among non-Hispanic Black patients by 2.02% in conjunction with a 10% increase in spending. In addition, there was a decrease in racial disparities in survival between non-Hispanic Black patients and White patients for many types of cancers.
However, public welfare spending had no real impact on the overall 5-year survival for the entire cohort (0.25 % per 10% increase in spending; P = .78) or for non-Hispanic White patients (0.52% per 10% increase in spending, P = .58).
“We know from prior research that outcomes are worse for minorities,” said lead author Justin Michael Barnes, MD, from the department of radiation oncology at Washington University in St. Louis, Mo. “It’s thought that some of the differences are related to impaired access to health care for minorities, which is related to social determinants of health. This includes socioeconomic factors, educational attainment, place of residence, as well as environmental stressors.
“Our data show that greater state welfare expenditures were associated with greater 5-year survival among Black patients and decreased Black–White disparities,” said Dr. Barnes. “I think these data are thought provoking, but they certainly aren’t the end. I see these data as a proof-of-concept project.”
Dr. Barnes reported the findings at a press conference held in advance of the annual meeting of the American Society of Clinical Oncology, during which the study will be presented (Abstract 6509).
Improved 5-year survival in Black patients
For the study, Dr. Barnes and colleagues evaluated the association of 5-year overall survival and public welfare spending in 2,925,550 individuals aged 18 years and older who were diagnosed with cancer during the period 2007-2016. The cohort was drawn from the Surveillance, Epidemiology, and End Results Program. In addition, annual state spending data were obtained from the U.S. Census Bureau. The team examined survival outcomes by race and ethnicity as well as by cancer site. The investigators accounted for factors such as age, sex, metropolitan residence, state, county-level income and education, insurance status, cancer site, stage at diagnosis, and year of diagnosis.
Much of public welfare spending was related to Medicaid but also included programs that provide subsidy assistance for individuals, such as Supplemental Security Income.
As compared with White patients, the 5-year overall survival rate was 10.8% lower among non-Hispanic Black patients. But there was a 4.46% (P for interaction <.001) narrowing of the 5-year overall survival disparity in non-Hispanic Black patients in comparison with White patients per 10% increase in spending, or a 42% closure of the 10.8% disparity.
Regarding specific cancer types, increased public welfare spending was associated with a narrowing of the 5-year overall survival disparity between Black patients and non-Hispanic White patients for the following cancers: breast (a 6.15% survival increase for Black patients led to a 39% closing of the disparity), cervix (a 11.9% survival increase led to a 46% closing of the disparity), colorectum (a 4.42% survival increase led to a 48% closing of the disparity), head and neck (a 9.41% survival increase led to a 38% closing of the disparity), liver (a 7.02% survival increase led to a 49% closing of the disparity), ovary (an 8.95% survival increase led to a 41% closing of the disparity), bladder (an 8.18% survival increase led to a 44% closing of the disparity), and uterus (a 14.1% survival increase led to a 40% closing of the disparity).
“Some type of public welfare seems to be helping improve oncologic outcomes for some of our most socioeconomically at-risk patients, but we don’t know the specifics,” Dr. Barnes concluded. “Additional work is needed to identify the most influential public health expenditures. If we can do this, we can more rigorously evaluate state-level policies and their association with cancer outcomes.”
Public welfare improves outcomes
Weighing in on the data, Sarah P. Cate, MD, director, Special Surveillance and Breast Program, Mount Sinai Health System, New York, noted that racial disparities have been identified in many areas of health care and with respect to many diseases. “In the world of oncology, time to diagnosis and treatment significantly impacts overall survival,” she told this news organization. “Many studies are currently underway to investigate why certain ethnic groups have worse cancer outcomes.”
This study is important, she noted, in that it “highlights a discrete source of correcting these disparities in a large group of patients. Obviously there are multiple barriers to care, but increased public welfare spending in oncology should decrease some of these disparities.”
Julie R. Gralow, MD, ASCO’s chief medical officer and executive vice president, commented that it is known that state public welfare spending can mitigate structural racism and at least partially address social determinants of health, such as financial stability, education, place of residence, and insurance status. “This research found that states that increased their public health spending improved overall survival in Black patients with a variety of solid tumors and also resulted in a decrease in racial disparities in survival,” she said. “This important data provides clear support for the benefits of investment in public welfare spending at the state level, including Medicaid expansion.”
The study did not receive funding. Dr. Barnes and Dr. Cate have disclosed no relevant financial relationships. Dr. Gralow has relationships with Genentech, AstraZeneca Hexal, Puma BioTechnology, Roche, Novartis, Seagen, and Genomic Health.
A version of this article first appeared on Medscape.com.
FROM ASCO 2022
White children more likely to get imaging in EDs: Study
Non-Hispanic White children were more likely to receive diagnostic imaging at children’s hospitals’ emergency departments across the United States than were Hispanic children and non-Hispanic Black children, according to a large study published in JAMA Network Open.
Researchers found that, the more the percentage of children from minority groups cared for by a hospital increased, the wider the imaging gap between those children and non-Hispanic White children.
The cross-sectional study, led by Margaret E. Samuels-Kalow, MD, MPhil, MSHP, with the department of emergency medicine, Massachusetts General Hospital and Harvard Medical School in Boston, included 38 children’s hospitals and more than 12 million ED visits.
“These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine,” the authors write.
Patients included in the study were younger than 18 and visited an ED from January 2016 through December 2019. Data were pulled from the Pediatric Health Information System.
Of the more than 12 million visits in this study, 3.5 million (28.7%) involved at least one diagnostic imaging test.
Diagnostic imaging was performed in 1.5 million visits (34.2%) for non-Hispanic White children; 790,961 (24.6%) for non-Hispanic Black children; and 907,222 (26.1%) for Hispanic children (P < .001).
Non-Hispanic Black children were consistently less likely to get diagnostic imaging than non-Hispanic White counterparts at every hospital in the study, no matter the imaging modality: radiography, ultrasonography, computed tomography, or magnetic resonance imaging.
Hispanic patients were generally less likely to get imaging than non-Hispanic White patients, though results were less consistent for ultrasound and MRI.
In a sensitivity analysis, when looking at imaging from patients’ first visit across the study cohort, non-Hispanic Black children were significantly less likely to get imaging than non-Hispanic White children (adjusted odds ratio, 0.77; 95% confidence interval, 0.74-0.79).
“This remained significant even after adjustment for a priori specified confounders including hospital propensity to image,” the authors write.
Authors acknowledge that it is possible that some of the differences may be attributable to the patient mix regarding severity of cases or indications for imaging by hospital, but they note that all models were adjusted for diagnosis-related group and other potential confounders.
This study did not assess whether one group is being overtested. Researchers also note that higher rates of imaging do not necessarily indicate higher quality of care.
However, the authors note, previous research has suggested overtesting of non-Hispanic White patients for head CT and chest pain, as well as patterns of overtreatment of non-Hispanic White patients who have bronchiolitis or viral upper respiratory tract infections.
Medell Briggs-Malonson, MD, MPH, chief of health equity, diversity and inclusion for the University of California, Los Angeles, Hospital and Clinic System, who was not part of the study, said in an interview “this all rings true.”
“This is not the first study we have had in either the pediatric or adult populations that shows disparate levels of care as well as health outcomes. Now we are starting to be able to measure it,” she said.
This study is further evidence of medical racism, she says, and highlights that it’s not the hospital choice or the insurance type affecting the numbers, she said.
“When you control for those factors, it looks to be it’s only due to race and that’s because of the very deep levels of implicit bias as well as explicit bias that we still have in our health systems and even in our providers,” said Dr. Briggs-Malonson, who is also an associate professor of emergency medicine at UCLA. “It’s incredibly important to identify and immediately address.”
What can be done?
Changing these patterns starts with knowing the numbers, the authors write.
“Hospitals should measure their own differences in imaging rates and increase awareness of existing areas of differential treatment as a starting point for improvement,” Dr. Samuels-Kalow and coauthors say.
Dr. Briggs-Malonson added that guidelines are very clear about when children should get imaging. Adhering to evidence-based guidelines can help avoid variations in care from external factors.
“If children are not receiving the absolute best comprehensive evaluation in the emergency department that they deserve, we can miss many different illnesses, which can lead to worse outcomes,” she noted.
As for what might motivate lack of imaging, Dr. Briggs-Malonson pointed to longstanding trends of providers thinking complaints raised by minority patients may not be as severe as they report. Conversely, in caring for White patients there may be a feeling that more tests and imaging may be better out of more fear of missing something, she said.
At UCLA, she says, dashboards have been developed to track statistics on care by age, race, ethnicity, language, insurance type, etc., though not specifically in pediatric imaging, to assess and address any care inequities.
Summer L. Kaplan, MD, MS, director of emergency radiology at Children’s Hospital of Philadelphia, who also was not part of the study, said the finding of racial disparities in pediatric ED imaging provides evidence that gaps still exist in providing the best care to all children and families seeking emergency care.
“However, it is important to recognize that more imaging does not equal better care,” she said. “More imaging may be associated with unnecessary, low-value tests that may add radiation and other risks but do not improve care.”
She said higher rates of imaging may occur when patients present early in the course of a disease, when the differential diagnosis remains broad.
If families have delayed seeking care because of time constraints, transportation problems, cost of care, or mistrust of the health system, children may present later in the course of a disease and require less imaging for a diagnosis, she explained.
“This paper offers a valuable look at the inequities that exist in pediatric emergency imaging use, and further research will be essential to understand and address the causes of these differences,” Dr. Kaplan said.
A coauthor reported compensation as a member of a Medical Review Committee for Highmark. Other coauthors reported grants from the U.S. Agency for Healthcare Research and Quality outside the submitted work. Dr. Briggs-Malonson and Dr. Kaplan reported no relevant financial relationships.
Non-Hispanic White children were more likely to receive diagnostic imaging at children’s hospitals’ emergency departments across the United States than were Hispanic children and non-Hispanic Black children, according to a large study published in JAMA Network Open.
Researchers found that, the more the percentage of children from minority groups cared for by a hospital increased, the wider the imaging gap between those children and non-Hispanic White children.
The cross-sectional study, led by Margaret E. Samuels-Kalow, MD, MPhil, MSHP, with the department of emergency medicine, Massachusetts General Hospital and Harvard Medical School in Boston, included 38 children’s hospitals and more than 12 million ED visits.
“These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine,” the authors write.
Patients included in the study were younger than 18 and visited an ED from January 2016 through December 2019. Data were pulled from the Pediatric Health Information System.
Of the more than 12 million visits in this study, 3.5 million (28.7%) involved at least one diagnostic imaging test.
Diagnostic imaging was performed in 1.5 million visits (34.2%) for non-Hispanic White children; 790,961 (24.6%) for non-Hispanic Black children; and 907,222 (26.1%) for Hispanic children (P < .001).
Non-Hispanic Black children were consistently less likely to get diagnostic imaging than non-Hispanic White counterparts at every hospital in the study, no matter the imaging modality: radiography, ultrasonography, computed tomography, or magnetic resonance imaging.
Hispanic patients were generally less likely to get imaging than non-Hispanic White patients, though results were less consistent for ultrasound and MRI.
In a sensitivity analysis, when looking at imaging from patients’ first visit across the study cohort, non-Hispanic Black children were significantly less likely to get imaging than non-Hispanic White children (adjusted odds ratio, 0.77; 95% confidence interval, 0.74-0.79).
“This remained significant even after adjustment for a priori specified confounders including hospital propensity to image,” the authors write.
Authors acknowledge that it is possible that some of the differences may be attributable to the patient mix regarding severity of cases or indications for imaging by hospital, but they note that all models were adjusted for diagnosis-related group and other potential confounders.
This study did not assess whether one group is being overtested. Researchers also note that higher rates of imaging do not necessarily indicate higher quality of care.
However, the authors note, previous research has suggested overtesting of non-Hispanic White patients for head CT and chest pain, as well as patterns of overtreatment of non-Hispanic White patients who have bronchiolitis or viral upper respiratory tract infections.
Medell Briggs-Malonson, MD, MPH, chief of health equity, diversity and inclusion for the University of California, Los Angeles, Hospital and Clinic System, who was not part of the study, said in an interview “this all rings true.”
“This is not the first study we have had in either the pediatric or adult populations that shows disparate levels of care as well as health outcomes. Now we are starting to be able to measure it,” she said.
This study is further evidence of medical racism, she says, and highlights that it’s not the hospital choice or the insurance type affecting the numbers, she said.
“When you control for those factors, it looks to be it’s only due to race and that’s because of the very deep levels of implicit bias as well as explicit bias that we still have in our health systems and even in our providers,” said Dr. Briggs-Malonson, who is also an associate professor of emergency medicine at UCLA. “It’s incredibly important to identify and immediately address.”
What can be done?
Changing these patterns starts with knowing the numbers, the authors write.
“Hospitals should measure their own differences in imaging rates and increase awareness of existing areas of differential treatment as a starting point for improvement,” Dr. Samuels-Kalow and coauthors say.
Dr. Briggs-Malonson added that guidelines are very clear about when children should get imaging. Adhering to evidence-based guidelines can help avoid variations in care from external factors.
“If children are not receiving the absolute best comprehensive evaluation in the emergency department that they deserve, we can miss many different illnesses, which can lead to worse outcomes,” she noted.
As for what might motivate lack of imaging, Dr. Briggs-Malonson pointed to longstanding trends of providers thinking complaints raised by minority patients may not be as severe as they report. Conversely, in caring for White patients there may be a feeling that more tests and imaging may be better out of more fear of missing something, she said.
At UCLA, she says, dashboards have been developed to track statistics on care by age, race, ethnicity, language, insurance type, etc., though not specifically in pediatric imaging, to assess and address any care inequities.
Summer L. Kaplan, MD, MS, director of emergency radiology at Children’s Hospital of Philadelphia, who also was not part of the study, said the finding of racial disparities in pediatric ED imaging provides evidence that gaps still exist in providing the best care to all children and families seeking emergency care.
“However, it is important to recognize that more imaging does not equal better care,” she said. “More imaging may be associated with unnecessary, low-value tests that may add radiation and other risks but do not improve care.”
She said higher rates of imaging may occur when patients present early in the course of a disease, when the differential diagnosis remains broad.
If families have delayed seeking care because of time constraints, transportation problems, cost of care, or mistrust of the health system, children may present later in the course of a disease and require less imaging for a diagnosis, she explained.
“This paper offers a valuable look at the inequities that exist in pediatric emergency imaging use, and further research will be essential to understand and address the causes of these differences,” Dr. Kaplan said.
A coauthor reported compensation as a member of a Medical Review Committee for Highmark. Other coauthors reported grants from the U.S. Agency for Healthcare Research and Quality outside the submitted work. Dr. Briggs-Malonson and Dr. Kaplan reported no relevant financial relationships.
Non-Hispanic White children were more likely to receive diagnostic imaging at children’s hospitals’ emergency departments across the United States than were Hispanic children and non-Hispanic Black children, according to a large study published in JAMA Network Open.
Researchers found that, the more the percentage of children from minority groups cared for by a hospital increased, the wider the imaging gap between those children and non-Hispanic White children.
The cross-sectional study, led by Margaret E. Samuels-Kalow, MD, MPhil, MSHP, with the department of emergency medicine, Massachusetts General Hospital and Harvard Medical School in Boston, included 38 children’s hospitals and more than 12 million ED visits.
“These findings emphasize the urgent need for interventions at the hospital level to improve equity in imaging in pediatric emergency medicine,” the authors write.
Patients included in the study were younger than 18 and visited an ED from January 2016 through December 2019. Data were pulled from the Pediatric Health Information System.
Of the more than 12 million visits in this study, 3.5 million (28.7%) involved at least one diagnostic imaging test.
Diagnostic imaging was performed in 1.5 million visits (34.2%) for non-Hispanic White children; 790,961 (24.6%) for non-Hispanic Black children; and 907,222 (26.1%) for Hispanic children (P < .001).
Non-Hispanic Black children were consistently less likely to get diagnostic imaging than non-Hispanic White counterparts at every hospital in the study, no matter the imaging modality: radiography, ultrasonography, computed tomography, or magnetic resonance imaging.
Hispanic patients were generally less likely to get imaging than non-Hispanic White patients, though results were less consistent for ultrasound and MRI.
In a sensitivity analysis, when looking at imaging from patients’ first visit across the study cohort, non-Hispanic Black children were significantly less likely to get imaging than non-Hispanic White children (adjusted odds ratio, 0.77; 95% confidence interval, 0.74-0.79).
“This remained significant even after adjustment for a priori specified confounders including hospital propensity to image,” the authors write.
Authors acknowledge that it is possible that some of the differences may be attributable to the patient mix regarding severity of cases or indications for imaging by hospital, but they note that all models were adjusted for diagnosis-related group and other potential confounders.
This study did not assess whether one group is being overtested. Researchers also note that higher rates of imaging do not necessarily indicate higher quality of care.
However, the authors note, previous research has suggested overtesting of non-Hispanic White patients for head CT and chest pain, as well as patterns of overtreatment of non-Hispanic White patients who have bronchiolitis or viral upper respiratory tract infections.
Medell Briggs-Malonson, MD, MPH, chief of health equity, diversity and inclusion for the University of California, Los Angeles, Hospital and Clinic System, who was not part of the study, said in an interview “this all rings true.”
“This is not the first study we have had in either the pediatric or adult populations that shows disparate levels of care as well as health outcomes. Now we are starting to be able to measure it,” she said.
This study is further evidence of medical racism, she says, and highlights that it’s not the hospital choice or the insurance type affecting the numbers, she said.
“When you control for those factors, it looks to be it’s only due to race and that’s because of the very deep levels of implicit bias as well as explicit bias that we still have in our health systems and even in our providers,” said Dr. Briggs-Malonson, who is also an associate professor of emergency medicine at UCLA. “It’s incredibly important to identify and immediately address.”
What can be done?
Changing these patterns starts with knowing the numbers, the authors write.
“Hospitals should measure their own differences in imaging rates and increase awareness of existing areas of differential treatment as a starting point for improvement,” Dr. Samuels-Kalow and coauthors say.
Dr. Briggs-Malonson added that guidelines are very clear about when children should get imaging. Adhering to evidence-based guidelines can help avoid variations in care from external factors.
“If children are not receiving the absolute best comprehensive evaluation in the emergency department that they deserve, we can miss many different illnesses, which can lead to worse outcomes,” she noted.
As for what might motivate lack of imaging, Dr. Briggs-Malonson pointed to longstanding trends of providers thinking complaints raised by minority patients may not be as severe as they report. Conversely, in caring for White patients there may be a feeling that more tests and imaging may be better out of more fear of missing something, she said.
At UCLA, she says, dashboards have been developed to track statistics on care by age, race, ethnicity, language, insurance type, etc., though not specifically in pediatric imaging, to assess and address any care inequities.
Summer L. Kaplan, MD, MS, director of emergency radiology at Children’s Hospital of Philadelphia, who also was not part of the study, said the finding of racial disparities in pediatric ED imaging provides evidence that gaps still exist in providing the best care to all children and families seeking emergency care.
“However, it is important to recognize that more imaging does not equal better care,” she said. “More imaging may be associated with unnecessary, low-value tests that may add radiation and other risks but do not improve care.”
She said higher rates of imaging may occur when patients present early in the course of a disease, when the differential diagnosis remains broad.
If families have delayed seeking care because of time constraints, transportation problems, cost of care, or mistrust of the health system, children may present later in the course of a disease and require less imaging for a diagnosis, she explained.
“This paper offers a valuable look at the inequities that exist in pediatric emergency imaging use, and further research will be essential to understand and address the causes of these differences,” Dr. Kaplan said.
A coauthor reported compensation as a member of a Medical Review Committee for Highmark. Other coauthors reported grants from the U.S. Agency for Healthcare Research and Quality outside the submitted work. Dr. Briggs-Malonson and Dr. Kaplan reported no relevant financial relationships.
FROM JAMA NETWORK OPEN
Caring for Muslim patients who fast during Ramadan
Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.1 With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.
For some patients, fasting may pose risks
Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.2 During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.
Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.3 It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.4 These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.5 Circadian rhythm disturbances also may worsen depression.6 Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.7
Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.5 Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.8
The practice also may have benefits for mental health
For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.9 A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.10 Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.11
Clinical considerations
To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.12 For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.
One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.
1. Pew Research Center. Demographic portrait of Muslim Americans. Published July 26, 2017. Accessed January 15, 2019. https://www.pewforum.org/2017/07/26/demographic-portrait-of-muslim-americans
2. Basit A, Hamid M. Mental health issues of Muslim Americans. J IMA. 2010;42(3):106-110.
3. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49-53.
4. Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm. Sleep Breath. 2017;21(3):577-586.
5. Eddahby S, Kadri N, Moussaoui D. Fasting during Ramadan is associated with a higher recurrence rate in patients with bipolar disorder. World Psychiatry. 2014;13(1):97.
6. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol. 2008;23(7):571-585.
7. Akgül S, Derman O, Kanbur NÖ. Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents. Int J Eat Disord. 2014;47(8):905-910.
8. Kadri N, Mouchtaq N, Hakkou F, et al. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol. 2000;3(1):45-49.
9. Taktak S, Kumral B, Unsal A, et al. Evidence for an association between suicide and religion: a 33-year retrospective autopsy analysis of suicide by hanging during the month of Ramadan in Istanbul. Aust J Forensic Sci. 2016;48(2):121-131.
10. Hussin NM, Shahar S, Teng NI, et al. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013;17(8):674-680.
11. Amin A, Sai Sailesh K, Mishra S, et al. Effects of fasting during Ramadan month on depression, anxiety and stress and cognition. Int J Med Res Rev. 2016;4(5):771-774.
12. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan. Lancet Psychiatry. 2019;6(7):556-557.
Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.1 With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.
For some patients, fasting may pose risks
Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.2 During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.
Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.3 It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.4 These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.5 Circadian rhythm disturbances also may worsen depression.6 Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.7
Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.5 Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.8
The practice also may have benefits for mental health
For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.9 A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.10 Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.11
Clinical considerations
To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.12 For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.
One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.
Ramadan is one of the obligatory pillars in Islam during which healthy Muslims are required to fast from dawn until sunset every day for 1 month. There are an estimated 3.45 million Muslims in the United States, and this population will continue to grow by 100,000 per year.1 With the increased growth of the Muslim population, it is important for clinicians to be aware of how patients of Muslim faith are affected during Ramadan. In this article, we explore the potential risks, as well as the benefits, the month of Ramadan brings to patients. We will also explain how being religiously aware is necessary to provide optimal care for these individuals.
For some patients, fasting may pose risks
Similar to other communities in the United States, individuals who are Muslim experience mood disorders, anxiety disorders, posttraumatic stress disorder, obsessive-compulsive disorder, schizophrenia, substance use disorders, and other psychiatric illnesses.2 During the month of Ramadan, Muslims are to abstain completely from eating and drinking from dawn until sunset. This includes medications as well as food and drink.
Due to these circumstances, patients will often change the timing, frequency, and dosing of their medications to allow them to fast. One study found 60% of Muslims made medication adjustments during Ramadan without seeking medical advice.3 It is possible that such alterations may be detrimental. During Ramadan, some Muslims wake up early in the morning to eat a pre-dawn meal, and often go back to sleep. This has been reported to cause a delay in sleep-wake times and to reduce rapid eye movement sleep.4 These circadian rhythm changes can be detrimental to patients with bipolar disorder. One study found higher rates of relapse to depression and mania in patients with bipolar disorder who were fasting during Ramadan.5 Circadian rhythm disturbances also may worsen depression.6 Another point of concern is patients with eating disorders. One small case series (N = 6) found that fasting during Ramadan exacerbated symptoms in patients with eating disorders.7
Another concern is that dehydration while fasting can lead to lithium toxicity. However, one study found lithium levels remained stable while fasting for 10 to 12 hours.5 Another showed that changing lithium dosing from twice a day to once a day allowed for easier administration without causing a subtherapeutic change in blood lithium levels.8
The practice also may have benefits for mental health
For many Muslims, Ramadan is the best time of the year, where they reconnect with their religion and experience the utmost spiritual growth. Studies have shown that the incidence of suicide is lowest during Ramadan compared to other months.9 A study of older men found that intermittent fasting and calorie restriction (not during Ramadan) resulted in decreases in tension, confusion, anger, and mood disturbance.10 Another study found that fasting during Ramadan had a positive impact on depression, anxiety, stress, and cognitive function.11
Clinical considerations
To provide the best care for Muslim patients during Ramadan, clinicians should take a holistic approach and take all factors into consideration. It is common for circadian rhythm disruptions to exacerbate mood disorders, so encourage patients to maintain healthy sleep hygiene to their best ability during this month. Another important consideration is medication timing and dosing.12 For patients prescribed a medication that typically is taken twice a day, determine if this dosing can be changed to once a day, or if both doses can be taken when it is permissible to eat (sunset to dawn). For medications that are absorbed with food, consider how these medications might be adjusted and maintained while a patient is fasting. Some medications may be sedating or activating, so the timing of administration may need to be adjusted to meet the patient’s needs. Lastly, keep in mind that certain medications can have withdrawal effects, and the likelihood of this occurring while a patient is fasting.
One vital point is that if a patient is at high risk of clinically decompensating due to fasting or medication adjustments or discontinuation, advise them to not fast. Muslims with physical or mental illnesses are excused from fasting. Bear in mind that because Ramadan is meant to be a month of heightened spirituality, many Muslims will prefer to fast.
1. Pew Research Center. Demographic portrait of Muslim Americans. Published July 26, 2017. Accessed January 15, 2019. https://www.pewforum.org/2017/07/26/demographic-portrait-of-muslim-americans
2. Basit A, Hamid M. Mental health issues of Muslim Americans. J IMA. 2010;42(3):106-110.
3. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49-53.
4. Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm. Sleep Breath. 2017;21(3):577-586.
5. Eddahby S, Kadri N, Moussaoui D. Fasting during Ramadan is associated with a higher recurrence rate in patients with bipolar disorder. World Psychiatry. 2014;13(1):97.
6. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol. 2008;23(7):571-585.
7. Akgül S, Derman O, Kanbur NÖ. Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents. Int J Eat Disord. 2014;47(8):905-910.
8. Kadri N, Mouchtaq N, Hakkou F, et al. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol. 2000;3(1):45-49.
9. Taktak S, Kumral B, Unsal A, et al. Evidence for an association between suicide and religion: a 33-year retrospective autopsy analysis of suicide by hanging during the month of Ramadan in Istanbul. Aust J Forensic Sci. 2016;48(2):121-131.
10. Hussin NM, Shahar S, Teng NI, et al. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013;17(8):674-680.
11. Amin A, Sai Sailesh K, Mishra S, et al. Effects of fasting during Ramadan month on depression, anxiety and stress and cognition. Int J Med Res Rev. 2016;4(5):771-774.
12. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan. Lancet Psychiatry. 2019;6(7):556-557.
1. Pew Research Center. Demographic portrait of Muslim Americans. Published July 26, 2017. Accessed January 15, 2019. https://www.pewforum.org/2017/07/26/demographic-portrait-of-muslim-americans
2. Basit A, Hamid M. Mental health issues of Muslim Americans. J IMA. 2010;42(3):106-110.
3. Aslam M, Assad A. Drug regimens and fasting during Ramadan: a survey in Kuwait. Public Health. 1986;100(1):49-53.
4. Qasrawi SO, Pandi-Perumal SR, BaHammam AS. The effect of intermittent fasting during Ramadan on sleep, sleepiness, cognitive function, and circadian rhythm. Sleep Breath. 2017;21(3):577-586.
5. Eddahby S, Kadri N, Moussaoui D. Fasting during Ramadan is associated with a higher recurrence rate in patients with bipolar disorder. World Psychiatry. 2014;13(1):97.
6. Germain A, Kupfer DJ. Circadian rhythm disturbances in depression. Hum Psychopharmacol. 2008;23(7):571-585.
7. Akgül S, Derman O, Kanbur NÖ. Fasting during Ramadan: a religious factor as a possible trigger or exacerbator for eating disorders in adolescents. Int J Eat Disord. 2014;47(8):905-910.
8. Kadri N, Mouchtaq N, Hakkou F, et al. Relapses in bipolar patients: changes in social rhythm? Int J Neuropsychopharmacol. 2000;3(1):45-49.
9. Taktak S, Kumral B, Unsal A, et al. Evidence for an association between suicide and religion: a 33-year retrospective autopsy analysis of suicide by hanging during the month of Ramadan in Istanbul. Aust J Forensic Sci. 2016;48(2):121-131.
10. Hussin NM, Shahar S, Teng NI, et al. Efficacy of fasting and calorie restriction (FCR) on mood and depression among ageing men. J Nutr Health Aging. 2013;17(8):674-680.
11. Amin A, Sai Sailesh K, Mishra S, et al. Effects of fasting during Ramadan month on depression, anxiety and stress and cognition. Int J Med Res Rev. 2016;4(5):771-774.
12. Furqan Z, Awaad R, Kurdyak P, et al. Considerations for clinicians treating Muslim patients with psychiatric disorders during Ramadan. Lancet Psychiatry. 2019;6(7):556-557.
Uterine cancer mortality is highest in Black women
A cohort study has found increases in mortality rates among women with non-endometrioid uterine carcinoma, despite incident rates that have stabilized. After correction with hysterectomy, mortality risk was about doubled for Black women, compared with White women, and these results could not be explained by differences in cancer subtype or cancer stage at diagnosis. Non-endometroid uterine carcinoma represents 15%-20% of uterine cancers diagnosed and carries a worse prognosis.
“We do not know why non-endometrioid subtypes are disproportionately increasing among all women, nor do we understand why they are so much more common among non-Hispanic Black women. We need more research to identify risk factors and exposures more specifically associated with non-endometrioid cancers to better understand the strong increases in this subtype among all women and the particularly high rates and recent increases in non-Hispanic black women,” said lead author Megan Clarke, PhD, MHS, the study’s lead author and a cancer epidemiologist with the National Cancer Institute.
The study was published online in JAMA Oncology.
“Physicians should be aware that both incidence and mortality rates of non-endometrioid cancers are on the rise. Because these subtypes are rarer than endometrioid uterine cancers, physicians may be less familiar with diagnosing and treating these aggressive types of cancers. Increasing awareness among clinicians and patients regarding the signs and symptoms of uterine cancer (such as postmenopausal bleeding) and the differences in histologic subtypes among racial and ethnic groups may promote earlier diagnosis and timely referral to appropriate treatment,” Dr. Clarke said.
Previous studies based on death certificates found increased mortality, especially in Black women, but they were limited by an inability to link mortality to tumor characteristics. To address this, the researchers linked mortality data to records of 208,587 women diagnosed with uterine cancer between 2000 and 2017, drawn from the U.S. Surveillance, Epidemiology, and End Results (SEER) Program.
Black women represented 9.7% of cases, but they suffered 17.7% of uterine cancer deaths. Overall, mortality from uterine corpus cancer increased by 1.8% per year (95% confidence interval, 1.5%-2.9%). Non-endometroid cancers increased at 2.7% per year (95% CI, 1.8%-3.6%), and this was higher in Asian (3.4%; 95% CI, 0.3%-6.6%), Black (3.5%; 95% CI, 2.2%-4.9%), Hispanic (6.7%; 95% CI, 1.9%-11.8%), and White women (1.5%; 95% CI, 0.6%-2.4%).
Mortality increased 1.8% per year overall for uterine cancer and 2.7% per year for non-endometrioid uterine cancer. There was no increase in mortality seen in endometrioid cancers.
“The concerning rise in deaths from non-endometrioid cancers warrants clinical attention. Our findings suggest that there may be several factors contributing to racial disparities in uterine cancer mortality. Higher mortality rates among non-Hispanic Black women are partly attributable to higher incidence of tumors with aggressive subtypes and advanced stages. However, non-Hispanic Black women in our study who were diagnosed with less aggressive subtypes and early-stage disease also had the highest mortality rates,” said Dr. Clarke.
That suggests that inequities of treatment and high-quality care may be at least partly to blame, since those factors are known to contribute to differences in uterine cancer outcomes. “Other factors including comorbidities, health care facility characteristics, treatment preferences and adherence, patient and provider communication, provider bias, discrimination and structural racism, and potential biologic differences in response to treatment need to be better understood in terms of how they influence racial disparities,” Dr. Clarke said.
Dr. Clarke reported no relevant disclosures.
A cohort study has found increases in mortality rates among women with non-endometrioid uterine carcinoma, despite incident rates that have stabilized. After correction with hysterectomy, mortality risk was about doubled for Black women, compared with White women, and these results could not be explained by differences in cancer subtype or cancer stage at diagnosis. Non-endometroid uterine carcinoma represents 15%-20% of uterine cancers diagnosed and carries a worse prognosis.
“We do not know why non-endometrioid subtypes are disproportionately increasing among all women, nor do we understand why they are so much more common among non-Hispanic Black women. We need more research to identify risk factors and exposures more specifically associated with non-endometrioid cancers to better understand the strong increases in this subtype among all women and the particularly high rates and recent increases in non-Hispanic black women,” said lead author Megan Clarke, PhD, MHS, the study’s lead author and a cancer epidemiologist with the National Cancer Institute.
The study was published online in JAMA Oncology.
“Physicians should be aware that both incidence and mortality rates of non-endometrioid cancers are on the rise. Because these subtypes are rarer than endometrioid uterine cancers, physicians may be less familiar with diagnosing and treating these aggressive types of cancers. Increasing awareness among clinicians and patients regarding the signs and symptoms of uterine cancer (such as postmenopausal bleeding) and the differences in histologic subtypes among racial and ethnic groups may promote earlier diagnosis and timely referral to appropriate treatment,” Dr. Clarke said.
Previous studies based on death certificates found increased mortality, especially in Black women, but they were limited by an inability to link mortality to tumor characteristics. To address this, the researchers linked mortality data to records of 208,587 women diagnosed with uterine cancer between 2000 and 2017, drawn from the U.S. Surveillance, Epidemiology, and End Results (SEER) Program.
Black women represented 9.7% of cases, but they suffered 17.7% of uterine cancer deaths. Overall, mortality from uterine corpus cancer increased by 1.8% per year (95% confidence interval, 1.5%-2.9%). Non-endometroid cancers increased at 2.7% per year (95% CI, 1.8%-3.6%), and this was higher in Asian (3.4%; 95% CI, 0.3%-6.6%), Black (3.5%; 95% CI, 2.2%-4.9%), Hispanic (6.7%; 95% CI, 1.9%-11.8%), and White women (1.5%; 95% CI, 0.6%-2.4%).
Mortality increased 1.8% per year overall for uterine cancer and 2.7% per year for non-endometrioid uterine cancer. There was no increase in mortality seen in endometrioid cancers.
“The concerning rise in deaths from non-endometrioid cancers warrants clinical attention. Our findings suggest that there may be several factors contributing to racial disparities in uterine cancer mortality. Higher mortality rates among non-Hispanic Black women are partly attributable to higher incidence of tumors with aggressive subtypes and advanced stages. However, non-Hispanic Black women in our study who were diagnosed with less aggressive subtypes and early-stage disease also had the highest mortality rates,” said Dr. Clarke.
That suggests that inequities of treatment and high-quality care may be at least partly to blame, since those factors are known to contribute to differences in uterine cancer outcomes. “Other factors including comorbidities, health care facility characteristics, treatment preferences and adherence, patient and provider communication, provider bias, discrimination and structural racism, and potential biologic differences in response to treatment need to be better understood in terms of how they influence racial disparities,” Dr. Clarke said.
Dr. Clarke reported no relevant disclosures.
A cohort study has found increases in mortality rates among women with non-endometrioid uterine carcinoma, despite incident rates that have stabilized. After correction with hysterectomy, mortality risk was about doubled for Black women, compared with White women, and these results could not be explained by differences in cancer subtype or cancer stage at diagnosis. Non-endometroid uterine carcinoma represents 15%-20% of uterine cancers diagnosed and carries a worse prognosis.
“We do not know why non-endometrioid subtypes are disproportionately increasing among all women, nor do we understand why they are so much more common among non-Hispanic Black women. We need more research to identify risk factors and exposures more specifically associated with non-endometrioid cancers to better understand the strong increases in this subtype among all women and the particularly high rates and recent increases in non-Hispanic black women,” said lead author Megan Clarke, PhD, MHS, the study’s lead author and a cancer epidemiologist with the National Cancer Institute.
The study was published online in JAMA Oncology.
“Physicians should be aware that both incidence and mortality rates of non-endometrioid cancers are on the rise. Because these subtypes are rarer than endometrioid uterine cancers, physicians may be less familiar with diagnosing and treating these aggressive types of cancers. Increasing awareness among clinicians and patients regarding the signs and symptoms of uterine cancer (such as postmenopausal bleeding) and the differences in histologic subtypes among racial and ethnic groups may promote earlier diagnosis and timely referral to appropriate treatment,” Dr. Clarke said.
Previous studies based on death certificates found increased mortality, especially in Black women, but they were limited by an inability to link mortality to tumor characteristics. To address this, the researchers linked mortality data to records of 208,587 women diagnosed with uterine cancer between 2000 and 2017, drawn from the U.S. Surveillance, Epidemiology, and End Results (SEER) Program.
Black women represented 9.7% of cases, but they suffered 17.7% of uterine cancer deaths. Overall, mortality from uterine corpus cancer increased by 1.8% per year (95% confidence interval, 1.5%-2.9%). Non-endometroid cancers increased at 2.7% per year (95% CI, 1.8%-3.6%), and this was higher in Asian (3.4%; 95% CI, 0.3%-6.6%), Black (3.5%; 95% CI, 2.2%-4.9%), Hispanic (6.7%; 95% CI, 1.9%-11.8%), and White women (1.5%; 95% CI, 0.6%-2.4%).
Mortality increased 1.8% per year overall for uterine cancer and 2.7% per year for non-endometrioid uterine cancer. There was no increase in mortality seen in endometrioid cancers.
“The concerning rise in deaths from non-endometrioid cancers warrants clinical attention. Our findings suggest that there may be several factors contributing to racial disparities in uterine cancer mortality. Higher mortality rates among non-Hispanic Black women are partly attributable to higher incidence of tumors with aggressive subtypes and advanced stages. However, non-Hispanic Black women in our study who were diagnosed with less aggressive subtypes and early-stage disease also had the highest mortality rates,” said Dr. Clarke.
That suggests that inequities of treatment and high-quality care may be at least partly to blame, since those factors are known to contribute to differences in uterine cancer outcomes. “Other factors including comorbidities, health care facility characteristics, treatment preferences and adherence, patient and provider communication, provider bias, discrimination and structural racism, and potential biologic differences in response to treatment need to be better understood in terms of how they influence racial disparities,” Dr. Clarke said.
Dr. Clarke reported no relevant disclosures.
FROM JAMA ONCOLOGY
The whitest specialty: Bias
As Usha Lee McFarling has pointed out, the orthopedic surgeon specialty suffers from a gross underrepresentation of minorities and women, more severe than in other medical specialties. There are various reasons for this and a variety of possible paths toward improvement, but the “critical first step,” as American Academy of Orthopedic Surgeons former president Kristy Weber, MD, told Ms. McFarling, “is changing the culture.”
“Changing the culture” is a large, diffuse aspiration. The AAOS has taken a number of steps toward that end, but they have not had much success. The two of us have identified others, which may help to move the needle.
Viewed from this perspective, the cultural barriers to inclusivity are similar to those that perpetuate inequitable health care. Both are driven by ingroup/outgroup prejudices that operate below the level of consciousness and are largely unseen.In our book Seeing Patients, we examined health disparities in six “non-mainstream” groups: African Americans, Hispanic Americans, women, gays and lesbians, and the elderly. We based our work initially on the Institute of Medicine’s breakthrough 2003 compendium, Unequal Treatment, which brought together a large number of studies on health care inequities that had appeared in a variety of journals over many years, but had never generated the critical mass necessary to create a call for action or even attract serious attention.
Unequal Treatment allowed us to understand that each medical specialty, right down the line – orthopedics, cardiology, gynecology, oncology, psychiatry, to name just a few – has its own grim history of discrimination. Our sense of the medical community in the 21st century led us away from the idea that overt bias is a significant cause of these still ongoing inequities. Most physicians, we believed, consider themselves to be, and strive to be, humane, compassionate, and egalitarian caregivers. The answer then seemed to be in subconscious rather than conscious bias.
As we reviewed the literature and strove to understand the primary drivers of the discrimination that systematically affects medical care, our attention was drawn to two critical and complementary mechanisms hard-wired into our systems for parsing and responding to our environment. The first was “stereotyping,” so often used as a pejorative, but which is, in fact, a primary and essential mental function.
“We all make stereotypic judgments,” says Rice University emeritus professor of psychology David Schneider in The Psychology of Stereotyping (page 419). “It happens with race. It happens with disability. It happens ... with gender, age, and physical appearance. ... That’s just the way it is: Our mental apparatus was designed to facilitate quick decisions based on category membership.”
Differentiation – social stereotyping in our case – is a given, then; it’s innate. The content of stereotyping – of Blacks, gays, women, and others – is not innate, but it is deeply ingrained by living in a given milieu and just as impossible to ignore.
The second mechanism we focused on was the neurobiology that underlies the impact of hidden emotion on rational thought. In his seminal book Descartes’ Error, neuroscientist Antonio Damasio spells out how the mind with its cognitive functions has evolved from the body and its emotional systems, and how they function together through neuro-networks that connect the mechanisms of feeling with the brain’s decision-making centers.
“Feelings,” Dr. Damasio tells us, “come first in [brain] development and retain a primacy that pervades our mental life.” The limbic system, the part of the brain that controls our emotional responses, constitutes a “frame of reference and has “a say on how the rest of the brain and cognition go about their business. [Its] influence is immense.” (Page 185)
Dr. Damasio was not focusing on medical decisions, but his insights, we felt, had great relevance for the question of unconscious bias in health care. Various studies by physicians and medical scientists do speak directly to the issue of how affective bias influences diagnosis and treatment. Pat Croskerry, director of Dalhousie University’s Clinical Research Center, argues that “cognitive and affective biases are known to compromise the decision-making” and that commonly “these are largely unconscious mistakes.”
Harvard’s Jerome Groopman, in his book How Doctors Think (page 40), writes that most incorrect diagnoses and treatments are “mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we ... often don’t even recognize.” Cognition and emotion, Dr. Groopman insists, are inseparable. The emotional landscape sets the ground for decision-making.
The underlying mechanisms that enable health care prejudice are the same that enable interpersonal prejudice generally. Unseen and largely unrecognized, they affect ingroup/outgroup relations in every field of interaction, from bias in policing, to bias in housing, to bias in employment – “powerful and universal,” in Dr. Croskerry’s words, “affecting all walks of life.”
Decision-making about acceptance into orthopedic residencies is no exception. As Prof. Schneider says, “That’s just the way it is.”
What conclusions can be drawn from understanding the deep origins of subconscious bias that might improve the inclusion of minorities and women in orthopedics? A growing interest in “debiasing” in both the medical and cognitive psychology literature has identified or suggested methods of counteracting the prejudices we all harbor. (See Bhatti’s “Cognitive Bias in Clinical Practice,” Wilson and Brekke’s “Mental Contamination and Mental Correction: Unwanted Influences on Judgments and Evaluations,” and De Neys and colleagues’ “Feeling We’re Biased: Autonomic Arousal and Reasoning Conflict.”)
Many of these debiasing techniques have to do with education regarding cognitive functions, from training in decision-making processes to “time outs,” to checklists à la Atul Gawande, to other methods of metacognition.
But the two key prerequisites to all of these approaches are more or less self-evident. “For biases to be successfully addressed,” says Dr. Croskerry, “there needs to be ... awareness as well as the motivation for change.”
In a previous article we discussed the need to heighten awareness over and above current levels, and we have suggested steps toward that end. But awareness is only the first prerequisite; the second is motivation, and the depth of motivation necessary to create change in the business of orthopedic inclusion is, for all the AAOS’s efforts, simply inadequate – the result being that the culture does not change, or it changes so glacially as to be hardly noticeable.
Ms. McFarling noted in her interviews with orthopedic leaders, clinicians, residents, and medical students simmering feelings of frustration and perplexity. We would suggest that the frustration is because of the fact that, while there is a general awareness of the problem, there has simply not been the sufficiently determined motivation to fix it. “It is not neglected truths,” as religious scholar Gregory Dix put it, “but those that are at once fully acknowledged and frustrated of their proper expression, which take the most drastic psychological revenge.”
All of this leads back to the original problem posed by Prof. Weber, the former AAOS president: changing the orthopedic culture. The question of how cultures undergo transformation has been addressed by scholars across widely diverse fields (see, for example, Thomas Kuhn’s The Structure of Scientific Revolutions, Francis Fukuyama›s The End of History and the Last Man, and many others). But we are addressing here a narrow, well-defined slice of that problem. And our own explorations have led to the conclusion that the answer here lies in the issue of motivation – namely, how can a community that is aware of a problem be sufficiently motivated to fix it?
In Seeing Patients we argued that doctoring is the paradigmatic humanitarian profession, that physicians’ whole business is to care for and alleviate the suffering of other human beings. In this sense, doctors are the carriers of the humane ideal, which is congruent also with the noblest egalitarian principles of our life as a nation. We argued also that humanitarian medicine with its egalitarian mandate is a win-win-win proposition. The patient wins, the doctor wins, the society wins.
We think arguments like these should provide plenty of motivation for change. But in reality they are not sufficient. Our arguments and those of others along the same lines (see Louis Sullivan’s Breaking Ground and David McBride’s Caring for Equality) are directed for the most part at the better angels of our nature. They appeal to personal and political values: compassion, fairness, equality – powerful yet set against custom, habituation, and the daily pressures of practice, such arguments can and do easily come up short.
But when looked at straight on, with unblinking eyes, health care disparities should provoke other more forceful emotions: anger, to begin with; chagrin, consternation. Women receive fewer heart catheterizations and reperfusions than men. (See R. Di Cecco and colleagues’ “Is There a Clinically Significant Gender Bias in Post-Myocardial Infarction Pharmacological Management in the Older Population of a Primary Care Practice?” and Jneid and coworkers’ “Sex Difference in Medical Care and Early Death after Acute Myocardial Infarction.”) Because of this, more women die.
Blacks and Hispanics receive fewer analgesics for the excruciating pain of broken bones, and they are amputated more frequently than whites for identical peripheral arterial disease. (See Knox and colleagues’ “Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia,” Bonham’s “Race, Ethnicity and Pain Treatments: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatments,” and Feinglass and coworkers’ “Racial Differences in Primary and Repeat Lower Extremity Amputation: Results From a Multihospital Study.”) They suffer accordingly.
The statistical accounting of these disparities masks the faces of pain and desperation – of disabilities, often of mortality. These are hard visceral truths that derive in part from the underrepresentation of minorities in various specialties, most pronounced in orthopedics. These are the truths that, when actually absorbed rather than just registered, have the capacity to transform awareness into motivation and in so doing can begin reshaping a culture that restricts minorities and women and makes orthopedics, as Ms. McFarling calls it, “the whitest specialty.”
A version of this article first appeared on Medscape.com.
As Usha Lee McFarling has pointed out, the orthopedic surgeon specialty suffers from a gross underrepresentation of minorities and women, more severe than in other medical specialties. There are various reasons for this and a variety of possible paths toward improvement, but the “critical first step,” as American Academy of Orthopedic Surgeons former president Kristy Weber, MD, told Ms. McFarling, “is changing the culture.”
“Changing the culture” is a large, diffuse aspiration. The AAOS has taken a number of steps toward that end, but they have not had much success. The two of us have identified others, which may help to move the needle.
Viewed from this perspective, the cultural barriers to inclusivity are similar to those that perpetuate inequitable health care. Both are driven by ingroup/outgroup prejudices that operate below the level of consciousness and are largely unseen.In our book Seeing Patients, we examined health disparities in six “non-mainstream” groups: African Americans, Hispanic Americans, women, gays and lesbians, and the elderly. We based our work initially on the Institute of Medicine’s breakthrough 2003 compendium, Unequal Treatment, which brought together a large number of studies on health care inequities that had appeared in a variety of journals over many years, but had never generated the critical mass necessary to create a call for action or even attract serious attention.
Unequal Treatment allowed us to understand that each medical specialty, right down the line – orthopedics, cardiology, gynecology, oncology, psychiatry, to name just a few – has its own grim history of discrimination. Our sense of the medical community in the 21st century led us away from the idea that overt bias is a significant cause of these still ongoing inequities. Most physicians, we believed, consider themselves to be, and strive to be, humane, compassionate, and egalitarian caregivers. The answer then seemed to be in subconscious rather than conscious bias.
As we reviewed the literature and strove to understand the primary drivers of the discrimination that systematically affects medical care, our attention was drawn to two critical and complementary mechanisms hard-wired into our systems for parsing and responding to our environment. The first was “stereotyping,” so often used as a pejorative, but which is, in fact, a primary and essential mental function.
“We all make stereotypic judgments,” says Rice University emeritus professor of psychology David Schneider in The Psychology of Stereotyping (page 419). “It happens with race. It happens with disability. It happens ... with gender, age, and physical appearance. ... That’s just the way it is: Our mental apparatus was designed to facilitate quick decisions based on category membership.”
Differentiation – social stereotyping in our case – is a given, then; it’s innate. The content of stereotyping – of Blacks, gays, women, and others – is not innate, but it is deeply ingrained by living in a given milieu and just as impossible to ignore.
The second mechanism we focused on was the neurobiology that underlies the impact of hidden emotion on rational thought. In his seminal book Descartes’ Error, neuroscientist Antonio Damasio spells out how the mind with its cognitive functions has evolved from the body and its emotional systems, and how they function together through neuro-networks that connect the mechanisms of feeling with the brain’s decision-making centers.
“Feelings,” Dr. Damasio tells us, “come first in [brain] development and retain a primacy that pervades our mental life.” The limbic system, the part of the brain that controls our emotional responses, constitutes a “frame of reference and has “a say on how the rest of the brain and cognition go about their business. [Its] influence is immense.” (Page 185)
Dr. Damasio was not focusing on medical decisions, but his insights, we felt, had great relevance for the question of unconscious bias in health care. Various studies by physicians and medical scientists do speak directly to the issue of how affective bias influences diagnosis and treatment. Pat Croskerry, director of Dalhousie University’s Clinical Research Center, argues that “cognitive and affective biases are known to compromise the decision-making” and that commonly “these are largely unconscious mistakes.”
Harvard’s Jerome Groopman, in his book How Doctors Think (page 40), writes that most incorrect diagnoses and treatments are “mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we ... often don’t even recognize.” Cognition and emotion, Dr. Groopman insists, are inseparable. The emotional landscape sets the ground for decision-making.
The underlying mechanisms that enable health care prejudice are the same that enable interpersonal prejudice generally. Unseen and largely unrecognized, they affect ingroup/outgroup relations in every field of interaction, from bias in policing, to bias in housing, to bias in employment – “powerful and universal,” in Dr. Croskerry’s words, “affecting all walks of life.”
Decision-making about acceptance into orthopedic residencies is no exception. As Prof. Schneider says, “That’s just the way it is.”
What conclusions can be drawn from understanding the deep origins of subconscious bias that might improve the inclusion of minorities and women in orthopedics? A growing interest in “debiasing” in both the medical and cognitive psychology literature has identified or suggested methods of counteracting the prejudices we all harbor. (See Bhatti’s “Cognitive Bias in Clinical Practice,” Wilson and Brekke’s “Mental Contamination and Mental Correction: Unwanted Influences on Judgments and Evaluations,” and De Neys and colleagues’ “Feeling We’re Biased: Autonomic Arousal and Reasoning Conflict.”)
Many of these debiasing techniques have to do with education regarding cognitive functions, from training in decision-making processes to “time outs,” to checklists à la Atul Gawande, to other methods of metacognition.
But the two key prerequisites to all of these approaches are more or less self-evident. “For biases to be successfully addressed,” says Dr. Croskerry, “there needs to be ... awareness as well as the motivation for change.”
In a previous article we discussed the need to heighten awareness over and above current levels, and we have suggested steps toward that end. But awareness is only the first prerequisite; the second is motivation, and the depth of motivation necessary to create change in the business of orthopedic inclusion is, for all the AAOS’s efforts, simply inadequate – the result being that the culture does not change, or it changes so glacially as to be hardly noticeable.
Ms. McFarling noted in her interviews with orthopedic leaders, clinicians, residents, and medical students simmering feelings of frustration and perplexity. We would suggest that the frustration is because of the fact that, while there is a general awareness of the problem, there has simply not been the sufficiently determined motivation to fix it. “It is not neglected truths,” as religious scholar Gregory Dix put it, “but those that are at once fully acknowledged and frustrated of their proper expression, which take the most drastic psychological revenge.”
All of this leads back to the original problem posed by Prof. Weber, the former AAOS president: changing the orthopedic culture. The question of how cultures undergo transformation has been addressed by scholars across widely diverse fields (see, for example, Thomas Kuhn’s The Structure of Scientific Revolutions, Francis Fukuyama›s The End of History and the Last Man, and many others). But we are addressing here a narrow, well-defined slice of that problem. And our own explorations have led to the conclusion that the answer here lies in the issue of motivation – namely, how can a community that is aware of a problem be sufficiently motivated to fix it?
In Seeing Patients we argued that doctoring is the paradigmatic humanitarian profession, that physicians’ whole business is to care for and alleviate the suffering of other human beings. In this sense, doctors are the carriers of the humane ideal, which is congruent also with the noblest egalitarian principles of our life as a nation. We argued also that humanitarian medicine with its egalitarian mandate is a win-win-win proposition. The patient wins, the doctor wins, the society wins.
We think arguments like these should provide plenty of motivation for change. But in reality they are not sufficient. Our arguments and those of others along the same lines (see Louis Sullivan’s Breaking Ground and David McBride’s Caring for Equality) are directed for the most part at the better angels of our nature. They appeal to personal and political values: compassion, fairness, equality – powerful yet set against custom, habituation, and the daily pressures of practice, such arguments can and do easily come up short.
But when looked at straight on, with unblinking eyes, health care disparities should provoke other more forceful emotions: anger, to begin with; chagrin, consternation. Women receive fewer heart catheterizations and reperfusions than men. (See R. Di Cecco and colleagues’ “Is There a Clinically Significant Gender Bias in Post-Myocardial Infarction Pharmacological Management in the Older Population of a Primary Care Practice?” and Jneid and coworkers’ “Sex Difference in Medical Care and Early Death after Acute Myocardial Infarction.”) Because of this, more women die.
Blacks and Hispanics receive fewer analgesics for the excruciating pain of broken bones, and they are amputated more frequently than whites for identical peripheral arterial disease. (See Knox and colleagues’ “Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia,” Bonham’s “Race, Ethnicity and Pain Treatments: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatments,” and Feinglass and coworkers’ “Racial Differences in Primary and Repeat Lower Extremity Amputation: Results From a Multihospital Study.”) They suffer accordingly.
The statistical accounting of these disparities masks the faces of pain and desperation – of disabilities, often of mortality. These are hard visceral truths that derive in part from the underrepresentation of minorities in various specialties, most pronounced in orthopedics. These are the truths that, when actually absorbed rather than just registered, have the capacity to transform awareness into motivation and in so doing can begin reshaping a culture that restricts minorities and women and makes orthopedics, as Ms. McFarling calls it, “the whitest specialty.”
A version of this article first appeared on Medscape.com.
As Usha Lee McFarling has pointed out, the orthopedic surgeon specialty suffers from a gross underrepresentation of minorities and women, more severe than in other medical specialties. There are various reasons for this and a variety of possible paths toward improvement, but the “critical first step,” as American Academy of Orthopedic Surgeons former president Kristy Weber, MD, told Ms. McFarling, “is changing the culture.”
“Changing the culture” is a large, diffuse aspiration. The AAOS has taken a number of steps toward that end, but they have not had much success. The two of us have identified others, which may help to move the needle.
Viewed from this perspective, the cultural barriers to inclusivity are similar to those that perpetuate inequitable health care. Both are driven by ingroup/outgroup prejudices that operate below the level of consciousness and are largely unseen.In our book Seeing Patients, we examined health disparities in six “non-mainstream” groups: African Americans, Hispanic Americans, women, gays and lesbians, and the elderly. We based our work initially on the Institute of Medicine’s breakthrough 2003 compendium, Unequal Treatment, which brought together a large number of studies on health care inequities that had appeared in a variety of journals over many years, but had never generated the critical mass necessary to create a call for action or even attract serious attention.
Unequal Treatment allowed us to understand that each medical specialty, right down the line – orthopedics, cardiology, gynecology, oncology, psychiatry, to name just a few – has its own grim history of discrimination. Our sense of the medical community in the 21st century led us away from the idea that overt bias is a significant cause of these still ongoing inequities. Most physicians, we believed, consider themselves to be, and strive to be, humane, compassionate, and egalitarian caregivers. The answer then seemed to be in subconscious rather than conscious bias.
As we reviewed the literature and strove to understand the primary drivers of the discrimination that systematically affects medical care, our attention was drawn to two critical and complementary mechanisms hard-wired into our systems for parsing and responding to our environment. The first was “stereotyping,” so often used as a pejorative, but which is, in fact, a primary and essential mental function.
“We all make stereotypic judgments,” says Rice University emeritus professor of psychology David Schneider in The Psychology of Stereotyping (page 419). “It happens with race. It happens with disability. It happens ... with gender, age, and physical appearance. ... That’s just the way it is: Our mental apparatus was designed to facilitate quick decisions based on category membership.”
Differentiation – social stereotyping in our case – is a given, then; it’s innate. The content of stereotyping – of Blacks, gays, women, and others – is not innate, but it is deeply ingrained by living in a given milieu and just as impossible to ignore.
The second mechanism we focused on was the neurobiology that underlies the impact of hidden emotion on rational thought. In his seminal book Descartes’ Error, neuroscientist Antonio Damasio spells out how the mind with its cognitive functions has evolved from the body and its emotional systems, and how they function together through neuro-networks that connect the mechanisms of feeling with the brain’s decision-making centers.
“Feelings,” Dr. Damasio tells us, “come first in [brain] development and retain a primacy that pervades our mental life.” The limbic system, the part of the brain that controls our emotional responses, constitutes a “frame of reference and has “a say on how the rest of the brain and cognition go about their business. [Its] influence is immense.” (Page 185)
Dr. Damasio was not focusing on medical decisions, but his insights, we felt, had great relevance for the question of unconscious bias in health care. Various studies by physicians and medical scientists do speak directly to the issue of how affective bias influences diagnosis and treatment. Pat Croskerry, director of Dalhousie University’s Clinical Research Center, argues that “cognitive and affective biases are known to compromise the decision-making” and that commonly “these are largely unconscious mistakes.”
Harvard’s Jerome Groopman, in his book How Doctors Think (page 40), writes that most incorrect diagnoses and treatments are “mistakes in thinking. And part of what causes these cognitive errors is our inner feelings, feelings we ... often don’t even recognize.” Cognition and emotion, Dr. Groopman insists, are inseparable. The emotional landscape sets the ground for decision-making.
The underlying mechanisms that enable health care prejudice are the same that enable interpersonal prejudice generally. Unseen and largely unrecognized, they affect ingroup/outgroup relations in every field of interaction, from bias in policing, to bias in housing, to bias in employment – “powerful and universal,” in Dr. Croskerry’s words, “affecting all walks of life.”
Decision-making about acceptance into orthopedic residencies is no exception. As Prof. Schneider says, “That’s just the way it is.”
What conclusions can be drawn from understanding the deep origins of subconscious bias that might improve the inclusion of minorities and women in orthopedics? A growing interest in “debiasing” in both the medical and cognitive psychology literature has identified or suggested methods of counteracting the prejudices we all harbor. (See Bhatti’s “Cognitive Bias in Clinical Practice,” Wilson and Brekke’s “Mental Contamination and Mental Correction: Unwanted Influences on Judgments and Evaluations,” and De Neys and colleagues’ “Feeling We’re Biased: Autonomic Arousal and Reasoning Conflict.”)
Many of these debiasing techniques have to do with education regarding cognitive functions, from training in decision-making processes to “time outs,” to checklists à la Atul Gawande, to other methods of metacognition.
But the two key prerequisites to all of these approaches are more or less self-evident. “For biases to be successfully addressed,” says Dr. Croskerry, “there needs to be ... awareness as well as the motivation for change.”
In a previous article we discussed the need to heighten awareness over and above current levels, and we have suggested steps toward that end. But awareness is only the first prerequisite; the second is motivation, and the depth of motivation necessary to create change in the business of orthopedic inclusion is, for all the AAOS’s efforts, simply inadequate – the result being that the culture does not change, or it changes so glacially as to be hardly noticeable.
Ms. McFarling noted in her interviews with orthopedic leaders, clinicians, residents, and medical students simmering feelings of frustration and perplexity. We would suggest that the frustration is because of the fact that, while there is a general awareness of the problem, there has simply not been the sufficiently determined motivation to fix it. “It is not neglected truths,” as religious scholar Gregory Dix put it, “but those that are at once fully acknowledged and frustrated of their proper expression, which take the most drastic psychological revenge.”
All of this leads back to the original problem posed by Prof. Weber, the former AAOS president: changing the orthopedic culture. The question of how cultures undergo transformation has been addressed by scholars across widely diverse fields (see, for example, Thomas Kuhn’s The Structure of Scientific Revolutions, Francis Fukuyama›s The End of History and the Last Man, and many others). But we are addressing here a narrow, well-defined slice of that problem. And our own explorations have led to the conclusion that the answer here lies in the issue of motivation – namely, how can a community that is aware of a problem be sufficiently motivated to fix it?
In Seeing Patients we argued that doctoring is the paradigmatic humanitarian profession, that physicians’ whole business is to care for and alleviate the suffering of other human beings. In this sense, doctors are the carriers of the humane ideal, which is congruent also with the noblest egalitarian principles of our life as a nation. We argued also that humanitarian medicine with its egalitarian mandate is a win-win-win proposition. The patient wins, the doctor wins, the society wins.
We think arguments like these should provide plenty of motivation for change. But in reality they are not sufficient. Our arguments and those of others along the same lines (see Louis Sullivan’s Breaking Ground and David McBride’s Caring for Equality) are directed for the most part at the better angels of our nature. They appeal to personal and political values: compassion, fairness, equality – powerful yet set against custom, habituation, and the daily pressures of practice, such arguments can and do easily come up short.
But when looked at straight on, with unblinking eyes, health care disparities should provoke other more forceful emotions: anger, to begin with; chagrin, consternation. Women receive fewer heart catheterizations and reperfusions than men. (See R. Di Cecco and colleagues’ “Is There a Clinically Significant Gender Bias in Post-Myocardial Infarction Pharmacological Management in the Older Population of a Primary Care Practice?” and Jneid and coworkers’ “Sex Difference in Medical Care and Early Death after Acute Myocardial Infarction.”) Because of this, more women die.
Blacks and Hispanics receive fewer analgesics for the excruciating pain of broken bones, and they are amputated more frequently than whites for identical peripheral arterial disease. (See Knox and colleagues’ “Ethnicity as a Risk Factor for Inadequate Emergency Department Analgesia,” Bonham’s “Race, Ethnicity and Pain Treatments: Striving to Understand the Causes and Solutions to the Disparities in Pain Treatments,” and Feinglass and coworkers’ “Racial Differences in Primary and Repeat Lower Extremity Amputation: Results From a Multihospital Study.”) They suffer accordingly.
The statistical accounting of these disparities masks the faces of pain and desperation – of disabilities, often of mortality. These are hard visceral truths that derive in part from the underrepresentation of minorities in various specialties, most pronounced in orthopedics. These are the truths that, when actually absorbed rather than just registered, have the capacity to transform awareness into motivation and in so doing can begin reshaping a culture that restricts minorities and women and makes orthopedics, as Ms. McFarling calls it, “the whitest specialty.”
A version of this article first appeared on Medscape.com.
Race-, ethnicity-based clinical guidelines miss the mark: Study
SAN DIEGO – Race-based recommendations and clinical algorithms may be doing more harm than good, according to a systematic review of databases and guidelines.
The study found examples of screening recommendations based on race or ethnicity that were likely misleading since these are social constructs that don’t reflect a patient’s individual risk, said Shazia Siddique, MD, who presented the study at the annual Digestive Disease Week® (DDW). “Historically, we’ve made so many clinical decisions based on somebody’s race and ethnicity. We walk into a room, we don’t even ask people which racial or ethnic category they identify with. We just look at them and we say, ‘Their skin color looks black, and therefore we’re going to apply a different equation to them.’ ”
However, a patient’s risks and unique health circumstances are much more complicated than that. They may be related to genetics, or environmental exposures, or level of access to quality health care. Race can often be inappropriately used as a stand-in for these and other factors, she explained.
“These [racial] categories are truly a social construct. It’s becoming very problematic that people are literally making decisions based on somebody’s skin color. That’s just not what the science supports. If there are specific genes or environmental factors, or differences in access to health care that then impact outcomes for certain racial or ethnic groups, we need to figure out what those are,” said Dr. Siddique, who is an assistant professor of medicine at the University of Pennsylvania, Philadelphia.
Those messages are still entrenched in medical education. “I graduated medical school in 2012, and it was taught to me to use race and ethnicity in clinical decision-making. We need to start in medical education to shift the way that we’re thinking. On the research side, we really need to think about how we can replace or remove race and ethnicity and understand the consequences of that, so that over time we can make a shift,” said Dr. Siddique.
For example, Dr. Siddique discussed recommendations that suggest Asian heritage as a risk factor for hepatitis B screening, but that’s not a good factor to consider: “People were saying that Asians should be screened at an earlier age, but it’s really people that were born and raised in Asian countries where it’s endemic or they may have gotten it from their mothers at birth. It’s a marker for how long you have had the disease and how much virus is in your bloodstream. It’s not because you’re Asian. If you’re born and raised in the United States, and you don’t have any of those risk factors, you shouldn’t be treated differently based on your identified racial and ethnic group,” said Dr. Siddique.
These questions have become even more important in recent years because of patients with multiracial identifies and other considerations. “Now the proxy for which race was being used is even messier,” said Dr. Siddique.
So, how should physicians think about assessing a patient’s personalized risks? The key, said Dr. Siddique, is to look at each patient’s individual factors, such as health care access, environmental exposures from jobs or living conditions, or the country they emigrated from if they weren’t born in the United States. “Disease prevalences are different in different areas, and that changes your index of suspicion,” she said.
And when considering current guidelines that incorporate race or ethnicity, she recommends viewing them skeptically: “If there is a current algorithm in your health system or in a guideline that you’re reading that says you should be making a change based on race and ethnicity, you should look at that with a close eye and say, “What do I think it’s being used as a proxy for, and how can I elicit that from my patient?’ ”
The issues raised by Dr. Siddique’s study are important, but there also could be concerns in taking them too far, according to Gary Falk, MD, a professor of medicine at the University of Pennsylvania who comoderated the session where Dr. Siddique presented. He was not involved in the study, but was listed on Dr. Siddique’s acknowledgement slide.
Dr. Falk coauthored Barrett’s esophagus guidelines in 2016 that incorporated White race as a risk factor.
“There are certain clear ethnic factors or country of origin factors that impact one’s risk for cancer, and there are certain diseases that are more common in certain ethnic groups. I think that if we homogenize everybody, we may potentially hurt some people in the effort to be inclusive. That’s my only concern. I think it’s totally correct that we have to get out of our comfort zone, but I hate to see us reach too far on the other end, and homogenize things to the point that people who have increased risk are not being recognized for that reason,” said Dr. Falk.
He acknowledged that White race as a risk for Barrett’s is not easy to define given the uncertainty of the genetic risk, for example, in patients with mixed heritage. “This is all very provocative. We have to think about it carefully,” said Dr. Falk.
Dr. Siddique and Dr. Falk have no relevant financial disclosures.
SAN DIEGO – Race-based recommendations and clinical algorithms may be doing more harm than good, according to a systematic review of databases and guidelines.
The study found examples of screening recommendations based on race or ethnicity that were likely misleading since these are social constructs that don’t reflect a patient’s individual risk, said Shazia Siddique, MD, who presented the study at the annual Digestive Disease Week® (DDW). “Historically, we’ve made so many clinical decisions based on somebody’s race and ethnicity. We walk into a room, we don’t even ask people which racial or ethnic category they identify with. We just look at them and we say, ‘Their skin color looks black, and therefore we’re going to apply a different equation to them.’ ”
However, a patient’s risks and unique health circumstances are much more complicated than that. They may be related to genetics, or environmental exposures, or level of access to quality health care. Race can often be inappropriately used as a stand-in for these and other factors, she explained.
“These [racial] categories are truly a social construct. It’s becoming very problematic that people are literally making decisions based on somebody’s skin color. That’s just not what the science supports. If there are specific genes or environmental factors, or differences in access to health care that then impact outcomes for certain racial or ethnic groups, we need to figure out what those are,” said Dr. Siddique, who is an assistant professor of medicine at the University of Pennsylvania, Philadelphia.
Those messages are still entrenched in medical education. “I graduated medical school in 2012, and it was taught to me to use race and ethnicity in clinical decision-making. We need to start in medical education to shift the way that we’re thinking. On the research side, we really need to think about how we can replace or remove race and ethnicity and understand the consequences of that, so that over time we can make a shift,” said Dr. Siddique.
For example, Dr. Siddique discussed recommendations that suggest Asian heritage as a risk factor for hepatitis B screening, but that’s not a good factor to consider: “People were saying that Asians should be screened at an earlier age, but it’s really people that were born and raised in Asian countries where it’s endemic or they may have gotten it from their mothers at birth. It’s a marker for how long you have had the disease and how much virus is in your bloodstream. It’s not because you’re Asian. If you’re born and raised in the United States, and you don’t have any of those risk factors, you shouldn’t be treated differently based on your identified racial and ethnic group,” said Dr. Siddique.
These questions have become even more important in recent years because of patients with multiracial identifies and other considerations. “Now the proxy for which race was being used is even messier,” said Dr. Siddique.
So, how should physicians think about assessing a patient’s personalized risks? The key, said Dr. Siddique, is to look at each patient’s individual factors, such as health care access, environmental exposures from jobs or living conditions, or the country they emigrated from if they weren’t born in the United States. “Disease prevalences are different in different areas, and that changes your index of suspicion,” she said.
And when considering current guidelines that incorporate race or ethnicity, she recommends viewing them skeptically: “If there is a current algorithm in your health system or in a guideline that you’re reading that says you should be making a change based on race and ethnicity, you should look at that with a close eye and say, “What do I think it’s being used as a proxy for, and how can I elicit that from my patient?’ ”
The issues raised by Dr. Siddique’s study are important, but there also could be concerns in taking them too far, according to Gary Falk, MD, a professor of medicine at the University of Pennsylvania who comoderated the session where Dr. Siddique presented. He was not involved in the study, but was listed on Dr. Siddique’s acknowledgement slide.
Dr. Falk coauthored Barrett’s esophagus guidelines in 2016 that incorporated White race as a risk factor.
“There are certain clear ethnic factors or country of origin factors that impact one’s risk for cancer, and there are certain diseases that are more common in certain ethnic groups. I think that if we homogenize everybody, we may potentially hurt some people in the effort to be inclusive. That’s my only concern. I think it’s totally correct that we have to get out of our comfort zone, but I hate to see us reach too far on the other end, and homogenize things to the point that people who have increased risk are not being recognized for that reason,” said Dr. Falk.
He acknowledged that White race as a risk for Barrett’s is not easy to define given the uncertainty of the genetic risk, for example, in patients with mixed heritage. “This is all very provocative. We have to think about it carefully,” said Dr. Falk.
Dr. Siddique and Dr. Falk have no relevant financial disclosures.
SAN DIEGO – Race-based recommendations and clinical algorithms may be doing more harm than good, according to a systematic review of databases and guidelines.
The study found examples of screening recommendations based on race or ethnicity that were likely misleading since these are social constructs that don’t reflect a patient’s individual risk, said Shazia Siddique, MD, who presented the study at the annual Digestive Disease Week® (DDW). “Historically, we’ve made so many clinical decisions based on somebody’s race and ethnicity. We walk into a room, we don’t even ask people which racial or ethnic category they identify with. We just look at them and we say, ‘Their skin color looks black, and therefore we’re going to apply a different equation to them.’ ”
However, a patient’s risks and unique health circumstances are much more complicated than that. They may be related to genetics, or environmental exposures, or level of access to quality health care. Race can often be inappropriately used as a stand-in for these and other factors, she explained.
“These [racial] categories are truly a social construct. It’s becoming very problematic that people are literally making decisions based on somebody’s skin color. That’s just not what the science supports. If there are specific genes or environmental factors, or differences in access to health care that then impact outcomes for certain racial or ethnic groups, we need to figure out what those are,” said Dr. Siddique, who is an assistant professor of medicine at the University of Pennsylvania, Philadelphia.
Those messages are still entrenched in medical education. “I graduated medical school in 2012, and it was taught to me to use race and ethnicity in clinical decision-making. We need to start in medical education to shift the way that we’re thinking. On the research side, we really need to think about how we can replace or remove race and ethnicity and understand the consequences of that, so that over time we can make a shift,” said Dr. Siddique.
For example, Dr. Siddique discussed recommendations that suggest Asian heritage as a risk factor for hepatitis B screening, but that’s not a good factor to consider: “People were saying that Asians should be screened at an earlier age, but it’s really people that were born and raised in Asian countries where it’s endemic or they may have gotten it from their mothers at birth. It’s a marker for how long you have had the disease and how much virus is in your bloodstream. It’s not because you’re Asian. If you’re born and raised in the United States, and you don’t have any of those risk factors, you shouldn’t be treated differently based on your identified racial and ethnic group,” said Dr. Siddique.
These questions have become even more important in recent years because of patients with multiracial identifies and other considerations. “Now the proxy for which race was being used is even messier,” said Dr. Siddique.
So, how should physicians think about assessing a patient’s personalized risks? The key, said Dr. Siddique, is to look at each patient’s individual factors, such as health care access, environmental exposures from jobs or living conditions, or the country they emigrated from if they weren’t born in the United States. “Disease prevalences are different in different areas, and that changes your index of suspicion,” she said.
And when considering current guidelines that incorporate race or ethnicity, she recommends viewing them skeptically: “If there is a current algorithm in your health system or in a guideline that you’re reading that says you should be making a change based on race and ethnicity, you should look at that with a close eye and say, “What do I think it’s being used as a proxy for, and how can I elicit that from my patient?’ ”
The issues raised by Dr. Siddique’s study are important, but there also could be concerns in taking them too far, according to Gary Falk, MD, a professor of medicine at the University of Pennsylvania who comoderated the session where Dr. Siddique presented. He was not involved in the study, but was listed on Dr. Siddique’s acknowledgement slide.
Dr. Falk coauthored Barrett’s esophagus guidelines in 2016 that incorporated White race as a risk factor.
“There are certain clear ethnic factors or country of origin factors that impact one’s risk for cancer, and there are certain diseases that are more common in certain ethnic groups. I think that if we homogenize everybody, we may potentially hurt some people in the effort to be inclusive. That’s my only concern. I think it’s totally correct that we have to get out of our comfort zone, but I hate to see us reach too far on the other end, and homogenize things to the point that people who have increased risk are not being recognized for that reason,” said Dr. Falk.
He acknowledged that White race as a risk for Barrett’s is not easy to define given the uncertainty of the genetic risk, for example, in patients with mixed heritage. “This is all very provocative. We have to think about it carefully,” said Dr. Falk.
Dr. Siddique and Dr. Falk have no relevant financial disclosures.
AT DDW 2022
APA targets structural racism, offers solutions
, released to coincide with the annual meeting of the American Psychiatric Association.
The hope is this special issue will “motivate clinicians, educators, and researchers to take actions that will make a difference,” Ned H. Kalin, MD, AJP editor-in-chief, wrotes in an editor’s note.
“We cannot overestimate the impact of structural racism from the standpoint of its consequences related to mental health issues and mental health care,” Dr. Kalin said during an APA press briefing.
“This is one of our highest priorities, if not our highest priority,” he noted. The journal is the “voice of American and international psychiatry” and is a “great vehicle” for moving the field forward, he added.
Articles in the issue highlight “new directions to understand and eliminate mental health disparities [through a] multidimensional lens,” wrote Crystal L. Barksdale, PhD, health scientist administrator and program director with the National Institute on Minority Health and Health Disparities. Dr. Barksdale was guest editor for the issue.
A new agenda for change
In one article, Margarita Alegría, PhD, chief of the disparities research unit at Massachusetts General Hospital, Boston, and colleagues, wrote that the Biden Administration’s new budget offers the opportunity to redesign mental health research and service delivery in marginalized communities.
Given the rising mental health crisis in the U.S., the FY22 budget includes $1.6 billion for the community mental health services block grant program, which is more than double the money allocated in FY21.
Dr. Alegría and colleagues describe several interventions that have “sound evidence” of improving mental health or related outcomes among people of color in the U.S. within 5 years – by addressing social determinants of health.
They include universal school meal programs, community-based interventions delivered by paraprofessionals in after-school recreational programs, individual placement and support for employment, mental health literacy programs, senior centers offering health promotion activities, and a chronic disease self-management program.
Dr. Alegría noted that reducing structural racism and mental health disparities requires multilevel structural solutions and action by multiple stakeholders. In essence, “it takes a village,” she said.
A national conversation
Another article highlighted at the press briefing focuses on structural racism as it relates to youth suicide prevention.
Studies have shown the risk for suicide is higher earlier in life for youth of color. Suicide rates peak in adolescence and young adulthood for youth of color; for White populations, the peak happens in middle age and later life, noted lead author Kiara Alvarez, PhD, research scientist with Mass General’s disparities research unit.
However, there are well documented mental health service disparities where youth of color experiencing suicidal thoughts and behaviors have lower rates of access to needed services. They also have delays in access compared with their White peers, Dr. Alvarez said.
The authors propose a framework to address structural racism and mental health disparities as it relates to youth suicide prevention, with a focus on systems that are “preventive, rather than reactive; restorative, rather than punitive; and community-driven, rather than externally imposed.
“Ultimately, only structural solutions can dismantle structural racism,” they wrote.
The special issue of AJP aligns with the theme of this year’s APA meeting, which is the social determinants of mental health.
“Mental health has clearly become part of the national conversation. This has given us the opportunity to discuss how factors outside of the office and hospitals can impact the lives of many with mental illness and substance use disorder,” APA President Vivian B. Pender, MD, said during a preconference press briefing.
“These factors may include where you live, the air you breathe, how you’re educated, exposure to violence, and the impact of racism. These social determinants have become especially relevant to good mental health,” Dr. Pender said.
The research was supported by grants from the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, the National Institute of Drug Abuse, the National Institute of Alcohol Abuse and Alcoholism, and the National Institute of Child Health and Human Development. Dr. Kalin, Dr. Barksdale, Dr. Alegría, Dr. Alvarez, and Dr. Pender have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, released to coincide with the annual meeting of the American Psychiatric Association.
The hope is this special issue will “motivate clinicians, educators, and researchers to take actions that will make a difference,” Ned H. Kalin, MD, AJP editor-in-chief, wrotes in an editor’s note.
“We cannot overestimate the impact of structural racism from the standpoint of its consequences related to mental health issues and mental health care,” Dr. Kalin said during an APA press briefing.
“This is one of our highest priorities, if not our highest priority,” he noted. The journal is the “voice of American and international psychiatry” and is a “great vehicle” for moving the field forward, he added.
Articles in the issue highlight “new directions to understand and eliminate mental health disparities [through a] multidimensional lens,” wrote Crystal L. Barksdale, PhD, health scientist administrator and program director with the National Institute on Minority Health and Health Disparities. Dr. Barksdale was guest editor for the issue.
A new agenda for change
In one article, Margarita Alegría, PhD, chief of the disparities research unit at Massachusetts General Hospital, Boston, and colleagues, wrote that the Biden Administration’s new budget offers the opportunity to redesign mental health research and service delivery in marginalized communities.
Given the rising mental health crisis in the U.S., the FY22 budget includes $1.6 billion for the community mental health services block grant program, which is more than double the money allocated in FY21.
Dr. Alegría and colleagues describe several interventions that have “sound evidence” of improving mental health or related outcomes among people of color in the U.S. within 5 years – by addressing social determinants of health.
They include universal school meal programs, community-based interventions delivered by paraprofessionals in after-school recreational programs, individual placement and support for employment, mental health literacy programs, senior centers offering health promotion activities, and a chronic disease self-management program.
Dr. Alegría noted that reducing structural racism and mental health disparities requires multilevel structural solutions and action by multiple stakeholders. In essence, “it takes a village,” she said.
A national conversation
Another article highlighted at the press briefing focuses on structural racism as it relates to youth suicide prevention.
Studies have shown the risk for suicide is higher earlier in life for youth of color. Suicide rates peak in adolescence and young adulthood for youth of color; for White populations, the peak happens in middle age and later life, noted lead author Kiara Alvarez, PhD, research scientist with Mass General’s disparities research unit.
However, there are well documented mental health service disparities where youth of color experiencing suicidal thoughts and behaviors have lower rates of access to needed services. They also have delays in access compared with their White peers, Dr. Alvarez said.
The authors propose a framework to address structural racism and mental health disparities as it relates to youth suicide prevention, with a focus on systems that are “preventive, rather than reactive; restorative, rather than punitive; and community-driven, rather than externally imposed.
“Ultimately, only structural solutions can dismantle structural racism,” they wrote.
The special issue of AJP aligns with the theme of this year’s APA meeting, which is the social determinants of mental health.
“Mental health has clearly become part of the national conversation. This has given us the opportunity to discuss how factors outside of the office and hospitals can impact the lives of many with mental illness and substance use disorder,” APA President Vivian B. Pender, MD, said during a preconference press briefing.
“These factors may include where you live, the air you breathe, how you’re educated, exposure to violence, and the impact of racism. These social determinants have become especially relevant to good mental health,” Dr. Pender said.
The research was supported by grants from the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, the National Institute of Drug Abuse, the National Institute of Alcohol Abuse and Alcoholism, and the National Institute of Child Health and Human Development. Dr. Kalin, Dr. Barksdale, Dr. Alegría, Dr. Alvarez, and Dr. Pender have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, released to coincide with the annual meeting of the American Psychiatric Association.
The hope is this special issue will “motivate clinicians, educators, and researchers to take actions that will make a difference,” Ned H. Kalin, MD, AJP editor-in-chief, wrotes in an editor’s note.
“We cannot overestimate the impact of structural racism from the standpoint of its consequences related to mental health issues and mental health care,” Dr. Kalin said during an APA press briefing.
“This is one of our highest priorities, if not our highest priority,” he noted. The journal is the “voice of American and international psychiatry” and is a “great vehicle” for moving the field forward, he added.
Articles in the issue highlight “new directions to understand and eliminate mental health disparities [through a] multidimensional lens,” wrote Crystal L. Barksdale, PhD, health scientist administrator and program director with the National Institute on Minority Health and Health Disparities. Dr. Barksdale was guest editor for the issue.
A new agenda for change
In one article, Margarita Alegría, PhD, chief of the disparities research unit at Massachusetts General Hospital, Boston, and colleagues, wrote that the Biden Administration’s new budget offers the opportunity to redesign mental health research and service delivery in marginalized communities.
Given the rising mental health crisis in the U.S., the FY22 budget includes $1.6 billion for the community mental health services block grant program, which is more than double the money allocated in FY21.
Dr. Alegría and colleagues describe several interventions that have “sound evidence” of improving mental health or related outcomes among people of color in the U.S. within 5 years – by addressing social determinants of health.
They include universal school meal programs, community-based interventions delivered by paraprofessionals in after-school recreational programs, individual placement and support for employment, mental health literacy programs, senior centers offering health promotion activities, and a chronic disease self-management program.
Dr. Alegría noted that reducing structural racism and mental health disparities requires multilevel structural solutions and action by multiple stakeholders. In essence, “it takes a village,” she said.
A national conversation
Another article highlighted at the press briefing focuses on structural racism as it relates to youth suicide prevention.
Studies have shown the risk for suicide is higher earlier in life for youth of color. Suicide rates peak in adolescence and young adulthood for youth of color; for White populations, the peak happens in middle age and later life, noted lead author Kiara Alvarez, PhD, research scientist with Mass General’s disparities research unit.
However, there are well documented mental health service disparities where youth of color experiencing suicidal thoughts and behaviors have lower rates of access to needed services. They also have delays in access compared with their White peers, Dr. Alvarez said.
The authors propose a framework to address structural racism and mental health disparities as it relates to youth suicide prevention, with a focus on systems that are “preventive, rather than reactive; restorative, rather than punitive; and community-driven, rather than externally imposed.
“Ultimately, only structural solutions can dismantle structural racism,” they wrote.
The special issue of AJP aligns with the theme of this year’s APA meeting, which is the social determinants of mental health.
“Mental health has clearly become part of the national conversation. This has given us the opportunity to discuss how factors outside of the office and hospitals can impact the lives of many with mental illness and substance use disorder,” APA President Vivian B. Pender, MD, said during a preconference press briefing.
“These factors may include where you live, the air you breathe, how you’re educated, exposure to violence, and the impact of racism. These social determinants have become especially relevant to good mental health,” Dr. Pender said.
The research was supported by grants from the National Institute of Mental Health, the National Institute on Minority Health and Health Disparities, the National Institute of Drug Abuse, the National Institute of Alcohol Abuse and Alcoholism, and the National Institute of Child Health and Human Development. Dr. Kalin, Dr. Barksdale, Dr. Alegría, Dr. Alvarez, and Dr. Pender have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Fewer teens giving birth, but cases are more complex
Debra Katz, CNM, has noticed a shift in the number of teenagers coming to the teen obstetrics program at St. Joseph’s Medical Center in Paterson, N.J. A decade ago, about 30 adolescents gave birth in a given month; now, that figure is closer to 20, said Ms. Katz, chief of the nurse midwifery service at the center.
Ms. Katz’s observations mirror a national trend: The rate of teen births is falling in the United States, according to a study published in Obstetrics and Gynecology.
But, there’s a catch. The adolescents who are giving birth are more likely to have obesity, mental health problems, asthma, and other conditions that can complicate their pregnancies, the research shows. Rates of delivery complications have also increased in this age group.
Ms. Katz said that, compared with adult patients, teens tend to require longer medical visits. Most patients have limited knowledge of what prenatal care entails.
“Most of these patients have never even had a female [gynecologic] exam before,” Ms. Katz said. “They come in and they’re not used to the equipment. They’re not used to the terminology.”
Also consistent with the national trends, St. Joseph’s younger patients often have mental health problems or obesity. Many also lack stable housing and adequate food.
“Unfortunately, we are seeing a greater number of patients with morbid obesity; there’s a lot of bipolar disease; here’s a lot of depression; there’s a lot of anxiety,” Ms. Katz said. “And we also have a bit of PTSD [post traumatic stress disorder] as well.”
These factors make clinical practice more complex, according to the authors of the new study. “To optimize adolescent pregnancy outcomes, prenatal care will likely need to provide increasingly complex clinical management in addition to addressing outreach challenges of this population,” the authors of the new study write.
At St. Joseph’s, teens receive prenatal care in a group setting with other patients who are due to deliver in the same month. This model, called CenteringPregnancy, can increase self-esteem, build community, and may improve patient outcomes, Ms. Katz said. The program uses a team approach that includes a dietitian and social worker to address social support needs.
Shifting health status
To characterize delivery hospitalization trends for patients aged 11-19 years, Anna P. Staniczenko, MD, with Columbia University Irving Medical Center, New York, and her colleagues conducted a cross-sectional analysis of data from the 2000-2018 National Inpatient Sample.
Of more than 73 million estimated delivery hospitalizations during that period, 88,363 occurred in patients aged 11-14 years, and 6,359,331 were among patients aged 15-19 years.
Deliveries among patients aged 11-14 years decreased from 2.1 per 1,000 to 0.4 per 1,000 during the time frame. Deliveries among patients aged 15-19 years decreased from 11.5% of all deliveries to 4.8% over the study period.
Among patients aged 11-19 years, rates of comorbidities significantly increased from 2000 to 2018, the researchers found. The prevalence of obesity increased from 0.2% to 7.2%, asthma increased from 1.6% to 7%, while mental health conditions increased from 0.5% to 7.1%.
Severe maternal morbidity, defined as a patient having at least one of 20 conditions, including stroke, heart failure, and sepsis, increased from 0.5% to 0.7%. The rate of postpartum hemorrhage increased from 2.9% to 4.7%, the rate of cesarean delivery increased from 15.2% to 19.5%, and that of hypertensive disorders of pregnancy increased from 7.5% to 13.7%.
An often overlooked group
Adolescent pregnancies are more common in the United States than in other wealthy nations, and about 80% are unintended. In addition to the growth in comorbid conditions, adolescent mothers are at an increased risk of living under the poverty line, and children born to teen moms may be at increased risk for adverse pediatric outcomes.
Still, these pregnancies “may be planned and desired. ... It is unclear that there is an ‘ideal’ rate of pregnancy for this age group,” the study authors write.
Prior research has shown an increase in rates of chronic conditions among adults giving birth, but, “from what I could tell, this is really the first data” on chronic conditions in the pediatric obstetric population, said Lindsay K. Admon, MD, an ob.gyn. at the University of Michigan, Ann Arbor, who wrote an editorial accompanying the journal article.
Behind the decline
That there are fewer teen deliveries may be because the adolescent population is savvier about contraceptive methods. In addition, the Affordable Care Act expanded insurance coverage of contraception, said Stephanie Teal, MD, MPH, chair of obstetrics and gynecology and reproductive biology at University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland.
Dr. Teal was involved in the Colorado Family Planning Initiative, a state effort that showed that long-acting reversible contraception was effective and acceptable to young people.
“We are definitely seeing more adolescents who use birth control the first time they have sex,” Dr. Teal told this news organization. “When I started in practice, it was fairly uncommon that I would see a teenager who was sexually active who was consistently using a birth control method. And now they just look at me, roll their eyes, and are, like, ‘Duh, of course. He uses condoms, and I have an IUD.’ ”
To the extent that these deliveries include unintended pregnancies, the data may point to a need for clinicians to provide contraceptive education to adolescents with chronic conditions, according to Dr. Admon.
Abortion shifts
If U.S. Supreme Court rulings and state laws further limit access to contraception or abortion, the result could lead to more teen deliveries, Dr. Admon said.
While the adolescent birth rate has plummeted, the teen abortion rate has not increased, Dr. Teal said.
“Pregnancy is a time of health risk for women, and it’s getting riskier,” she said. “Our concern is that if people are having to go through a pregnancy that they don’t feel physically or financially or emotionally prepared to go through, that we will see an increase in these kinds of adverse health outcomes with birth.”
One study author has a leadership role on an American College of Obstetricians and Gynecologists safe motherhood initiative that has received unrestricted funding from Merck for Mothers. Another author has ties to Delfina Care, and one is on the board of directors of Planned Parenthood of Greater New York. Dr. Admon receives funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. Dr. Teal has received grants from Merck, Bayer Healthcare, Sebela, and Medicines360 and personal fees from Merck and from Bayer Healthcare. Ms. Katz has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Debra Katz, CNM, has noticed a shift in the number of teenagers coming to the teen obstetrics program at St. Joseph’s Medical Center in Paterson, N.J. A decade ago, about 30 adolescents gave birth in a given month; now, that figure is closer to 20, said Ms. Katz, chief of the nurse midwifery service at the center.
Ms. Katz’s observations mirror a national trend: The rate of teen births is falling in the United States, according to a study published in Obstetrics and Gynecology.
But, there’s a catch. The adolescents who are giving birth are more likely to have obesity, mental health problems, asthma, and other conditions that can complicate their pregnancies, the research shows. Rates of delivery complications have also increased in this age group.
Ms. Katz said that, compared with adult patients, teens tend to require longer medical visits. Most patients have limited knowledge of what prenatal care entails.
“Most of these patients have never even had a female [gynecologic] exam before,” Ms. Katz said. “They come in and they’re not used to the equipment. They’re not used to the terminology.”
Also consistent with the national trends, St. Joseph’s younger patients often have mental health problems or obesity. Many also lack stable housing and adequate food.
“Unfortunately, we are seeing a greater number of patients with morbid obesity; there’s a lot of bipolar disease; here’s a lot of depression; there’s a lot of anxiety,” Ms. Katz said. “And we also have a bit of PTSD [post traumatic stress disorder] as well.”
These factors make clinical practice more complex, according to the authors of the new study. “To optimize adolescent pregnancy outcomes, prenatal care will likely need to provide increasingly complex clinical management in addition to addressing outreach challenges of this population,” the authors of the new study write.
At St. Joseph’s, teens receive prenatal care in a group setting with other patients who are due to deliver in the same month. This model, called CenteringPregnancy, can increase self-esteem, build community, and may improve patient outcomes, Ms. Katz said. The program uses a team approach that includes a dietitian and social worker to address social support needs.
Shifting health status
To characterize delivery hospitalization trends for patients aged 11-19 years, Anna P. Staniczenko, MD, with Columbia University Irving Medical Center, New York, and her colleagues conducted a cross-sectional analysis of data from the 2000-2018 National Inpatient Sample.
Of more than 73 million estimated delivery hospitalizations during that period, 88,363 occurred in patients aged 11-14 years, and 6,359,331 were among patients aged 15-19 years.
Deliveries among patients aged 11-14 years decreased from 2.1 per 1,000 to 0.4 per 1,000 during the time frame. Deliveries among patients aged 15-19 years decreased from 11.5% of all deliveries to 4.8% over the study period.
Among patients aged 11-19 years, rates of comorbidities significantly increased from 2000 to 2018, the researchers found. The prevalence of obesity increased from 0.2% to 7.2%, asthma increased from 1.6% to 7%, while mental health conditions increased from 0.5% to 7.1%.
Severe maternal morbidity, defined as a patient having at least one of 20 conditions, including stroke, heart failure, and sepsis, increased from 0.5% to 0.7%. The rate of postpartum hemorrhage increased from 2.9% to 4.7%, the rate of cesarean delivery increased from 15.2% to 19.5%, and that of hypertensive disorders of pregnancy increased from 7.5% to 13.7%.
An often overlooked group
Adolescent pregnancies are more common in the United States than in other wealthy nations, and about 80% are unintended. In addition to the growth in comorbid conditions, adolescent mothers are at an increased risk of living under the poverty line, and children born to teen moms may be at increased risk for adverse pediatric outcomes.
Still, these pregnancies “may be planned and desired. ... It is unclear that there is an ‘ideal’ rate of pregnancy for this age group,” the study authors write.
Prior research has shown an increase in rates of chronic conditions among adults giving birth, but, “from what I could tell, this is really the first data” on chronic conditions in the pediatric obstetric population, said Lindsay K. Admon, MD, an ob.gyn. at the University of Michigan, Ann Arbor, who wrote an editorial accompanying the journal article.
Behind the decline
That there are fewer teen deliveries may be because the adolescent population is savvier about contraceptive methods. In addition, the Affordable Care Act expanded insurance coverage of contraception, said Stephanie Teal, MD, MPH, chair of obstetrics and gynecology and reproductive biology at University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland.
Dr. Teal was involved in the Colorado Family Planning Initiative, a state effort that showed that long-acting reversible contraception was effective and acceptable to young people.
“We are definitely seeing more adolescents who use birth control the first time they have sex,” Dr. Teal told this news organization. “When I started in practice, it was fairly uncommon that I would see a teenager who was sexually active who was consistently using a birth control method. And now they just look at me, roll their eyes, and are, like, ‘Duh, of course. He uses condoms, and I have an IUD.’ ”
To the extent that these deliveries include unintended pregnancies, the data may point to a need for clinicians to provide contraceptive education to adolescents with chronic conditions, according to Dr. Admon.
Abortion shifts
If U.S. Supreme Court rulings and state laws further limit access to contraception or abortion, the result could lead to more teen deliveries, Dr. Admon said.
While the adolescent birth rate has plummeted, the teen abortion rate has not increased, Dr. Teal said.
“Pregnancy is a time of health risk for women, and it’s getting riskier,” she said. “Our concern is that if people are having to go through a pregnancy that they don’t feel physically or financially or emotionally prepared to go through, that we will see an increase in these kinds of adverse health outcomes with birth.”
One study author has a leadership role on an American College of Obstetricians and Gynecologists safe motherhood initiative that has received unrestricted funding from Merck for Mothers. Another author has ties to Delfina Care, and one is on the board of directors of Planned Parenthood of Greater New York. Dr. Admon receives funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. Dr. Teal has received grants from Merck, Bayer Healthcare, Sebela, and Medicines360 and personal fees from Merck and from Bayer Healthcare. Ms. Katz has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Debra Katz, CNM, has noticed a shift in the number of teenagers coming to the teen obstetrics program at St. Joseph’s Medical Center in Paterson, N.J. A decade ago, about 30 adolescents gave birth in a given month; now, that figure is closer to 20, said Ms. Katz, chief of the nurse midwifery service at the center.
Ms. Katz’s observations mirror a national trend: The rate of teen births is falling in the United States, according to a study published in Obstetrics and Gynecology.
But, there’s a catch. The adolescents who are giving birth are more likely to have obesity, mental health problems, asthma, and other conditions that can complicate their pregnancies, the research shows. Rates of delivery complications have also increased in this age group.
Ms. Katz said that, compared with adult patients, teens tend to require longer medical visits. Most patients have limited knowledge of what prenatal care entails.
“Most of these patients have never even had a female [gynecologic] exam before,” Ms. Katz said. “They come in and they’re not used to the equipment. They’re not used to the terminology.”
Also consistent with the national trends, St. Joseph’s younger patients often have mental health problems or obesity. Many also lack stable housing and adequate food.
“Unfortunately, we are seeing a greater number of patients with morbid obesity; there’s a lot of bipolar disease; here’s a lot of depression; there’s a lot of anxiety,” Ms. Katz said. “And we also have a bit of PTSD [post traumatic stress disorder] as well.”
These factors make clinical practice more complex, according to the authors of the new study. “To optimize adolescent pregnancy outcomes, prenatal care will likely need to provide increasingly complex clinical management in addition to addressing outreach challenges of this population,” the authors of the new study write.
At St. Joseph’s, teens receive prenatal care in a group setting with other patients who are due to deliver in the same month. This model, called CenteringPregnancy, can increase self-esteem, build community, and may improve patient outcomes, Ms. Katz said. The program uses a team approach that includes a dietitian and social worker to address social support needs.
Shifting health status
To characterize delivery hospitalization trends for patients aged 11-19 years, Anna P. Staniczenko, MD, with Columbia University Irving Medical Center, New York, and her colleagues conducted a cross-sectional analysis of data from the 2000-2018 National Inpatient Sample.
Of more than 73 million estimated delivery hospitalizations during that period, 88,363 occurred in patients aged 11-14 years, and 6,359,331 were among patients aged 15-19 years.
Deliveries among patients aged 11-14 years decreased from 2.1 per 1,000 to 0.4 per 1,000 during the time frame. Deliveries among patients aged 15-19 years decreased from 11.5% of all deliveries to 4.8% over the study period.
Among patients aged 11-19 years, rates of comorbidities significantly increased from 2000 to 2018, the researchers found. The prevalence of obesity increased from 0.2% to 7.2%, asthma increased from 1.6% to 7%, while mental health conditions increased from 0.5% to 7.1%.
Severe maternal morbidity, defined as a patient having at least one of 20 conditions, including stroke, heart failure, and sepsis, increased from 0.5% to 0.7%. The rate of postpartum hemorrhage increased from 2.9% to 4.7%, the rate of cesarean delivery increased from 15.2% to 19.5%, and that of hypertensive disorders of pregnancy increased from 7.5% to 13.7%.
An often overlooked group
Adolescent pregnancies are more common in the United States than in other wealthy nations, and about 80% are unintended. In addition to the growth in comorbid conditions, adolescent mothers are at an increased risk of living under the poverty line, and children born to teen moms may be at increased risk for adverse pediatric outcomes.
Still, these pregnancies “may be planned and desired. ... It is unclear that there is an ‘ideal’ rate of pregnancy for this age group,” the study authors write.
Prior research has shown an increase in rates of chronic conditions among adults giving birth, but, “from what I could tell, this is really the first data” on chronic conditions in the pediatric obstetric population, said Lindsay K. Admon, MD, an ob.gyn. at the University of Michigan, Ann Arbor, who wrote an editorial accompanying the journal article.
Behind the decline
That there are fewer teen deliveries may be because the adolescent population is savvier about contraceptive methods. In addition, the Affordable Care Act expanded insurance coverage of contraception, said Stephanie Teal, MD, MPH, chair of obstetrics and gynecology and reproductive biology at University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland.
Dr. Teal was involved in the Colorado Family Planning Initiative, a state effort that showed that long-acting reversible contraception was effective and acceptable to young people.
“We are definitely seeing more adolescents who use birth control the first time they have sex,” Dr. Teal told this news organization. “When I started in practice, it was fairly uncommon that I would see a teenager who was sexually active who was consistently using a birth control method. And now they just look at me, roll their eyes, and are, like, ‘Duh, of course. He uses condoms, and I have an IUD.’ ”
To the extent that these deliveries include unintended pregnancies, the data may point to a need for clinicians to provide contraceptive education to adolescents with chronic conditions, according to Dr. Admon.
Abortion shifts
If U.S. Supreme Court rulings and state laws further limit access to contraception or abortion, the result could lead to more teen deliveries, Dr. Admon said.
While the adolescent birth rate has plummeted, the teen abortion rate has not increased, Dr. Teal said.
“Pregnancy is a time of health risk for women, and it’s getting riskier,” she said. “Our concern is that if people are having to go through a pregnancy that they don’t feel physically or financially or emotionally prepared to go through, that we will see an increase in these kinds of adverse health outcomes with birth.”
One study author has a leadership role on an American College of Obstetricians and Gynecologists safe motherhood initiative that has received unrestricted funding from Merck for Mothers. Another author has ties to Delfina Care, and one is on the board of directors of Planned Parenthood of Greater New York. Dr. Admon receives funding from the Agency for Healthcare Research and Quality and the National Institutes of Health. Dr. Teal has received grants from Merck, Bayer Healthcare, Sebela, and Medicines360 and personal fees from Merck and from Bayer Healthcare. Ms. Katz has disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Third-generation Black woman physician makes cancer research history
When Jane Cooke Wright, MD, entered the medical profession in 1945, the notion that toxic drugs could target tumors struck many physicians and patients as outlandish. How could one poison be weaponized against another poison – a cancerous tumor – without creating more havoc? Let alone a combination of two or more chemicals?
Dr. Wright’s story would be extraordinary enough if she’d looked like most of her colleagues, but this surgeon and researcher stood apart. An African American woman at a time when medicine and science – like politics and law – were almost entirely the domain of White men, Dr. Wright had determination in her blood. Her father, once honored by a crowd of dignitaries that included a First Lady, persevered despite his horrific encounters with racism. She shared her father’s commitment to progress and added her own personal twists. She balanced elegance and beauty with scientific savvy, fierce ambition, and a refusal to be defined by anything other than her accomplishments.
“She didn’t focus on race, not at all,” her daughter Alison Jones, PhD, a psychologist in East Lansing, Mich., said in an interview. “Wherever she was, she wanted to be the best, not the best Black person. It was not about how she performed in a category, and she would get upset if someone said she was good as a Black physician.”
On the road to being the best, Dr. Jones said, her mother set a goal of curing cancer. National Cancer Research Month is a fitting opportunity to look back on a scientist dedicated to bringing humanity closer to that elusive achievement.
Medical legacy blazed in toil and trauma
A strong case could be made that Dr. Jane C. Wright and her father Louis Tompkins Wright, MD, are the most accomplished father-and-daughter team in all of medicine.
The elder Dr. Wright, son of a formerly enslaved man turned physician and a stepson of the first African American to graduate from Yale University, New Haven, Conn., himself graduated from Harvard Medical School in 1915. He earned a Purple Heart while serving in World War I, then went on to become the first Black surgeon to join the staff at Harlem Hospital.
Dr. Wright, who had witnessed mob violence and the aftermath of a lynching as a young man, became a supporter of the Harlem Renaissance and a prominent advocate for civil rights and integration. He served as chairman of the National Association for the Advancement of Colored People and was only the second Black member of the American College of Surgeons.
According to the 2009 book “Black Genius: Inspirational Portraits of African American Leaders,” he successfully treated the rare but devastating venereal disease lymphogranuloma venereum with a new antibiotic developed by his former colleague Yellapragada SubbaRow, MD. Dr. Wright even tried the drug himself, “as a lot of doctors in the olden days did,” according to another of his daughters, the late Barbara Wright Pierce, MD, who was quoted in “Black Genius.” She, too, was a physician.
In 1948, Dr. Jane C. Wright joined her father at Harlem Hospital’s Cancer Research Foundation. There the duo explored the cancer-fighting possibilities of a nitrogen mustard–like chemical agent that had been known since World War I to kill white blood cells. Ironically, Dr. Louis Wright himself suffered lifelong health problems because of an attack from the poisonous gas phosgene during his wartime service.
“Remissions were observed in patients with sarcoma, Hodgkin disease, and chronic myelogenous leukemia, mycosis fungoides, and lymphoma,” reported a 2013 obituary in the journal Oncology of the younger Dr. Wright. “They also performed early research into the clinical efficacy and toxicity of folic acid antagonists, documenting responses in 93 patients with various forms of incurable blood cancers and solid tumors.”
This research appears in a study that was authored by three Dr. Wrights – Dr. Louis T. Wright and his daughters Jane and Barbara.
“The elder Dr. Wright died in 1952, just months after 1,000 people – including Eleanor Roosevelt – honored him at a dinner to dedicate a Harlem Hospital library named after him. He was 61.
Scientific savvy mixed with modesty and elegance
After her father’s death, Dr. Janet C. Wright became director of the hospital’s cancer foundation. From the 1950s to the 1970s, she “worked out ways to use pieces of a patient’s own tumor, removed by surgery and grown in a nutrient culture medium in the laboratory, as a ‘guinea pig for testing drugs,’ ” according to the 1991 book “Black Scientists.” Previously, researchers had focused on mice as test subjects.
This approach also allowed Dr. Wright to determine if specific drugs such as methotrexate, a folic acid antagonist, would help specific patients. “She was looking for predictive activity for chemotherapeutic efficacy in vitro at a time when no one had good predictive tests,” wrote James F. Holland, MD, the late Mount Sinai School of Medicine oncologist, who was quoted in Dr. Wright’s 2013 Oncology obituary.
“Her strict attention to detail and concern for her patients helped determine effective dosing levels and establish treatment guidelines,” the Oncology obituary reported. “She treated patients that other physicians had given up on, and she was among the first small cadre of researchers to carefully test the effects of drugs against cancer in a clinical trial setting.”
Dr. Wright also focused on developing ways to administer chemotherapy, such using a catheter to reach difficult-to-access organs like the spleen without surgery, according to “Black Scientists.”
Along with her work, Dr. Wright’s appearance set her apart. According to “Black Genius,” a newspaper columnist dubbed her one of the 10 most beautiful Back woman in America, and Ebony Magazine in 1966 honored her as one of the best-dressed women in America. It featured a photograph of her in a stunning ivory and yellow brocade gown, noting that she was “in private life Mrs. David J. Jones.” (She’d married the Harvard University Law School graduate in 1946.)
Dr. Wright had a sense of modesty despite her accomplishments, according to her daughter Alison Jones. She even downplayed her own mental powers in a newspaper interview. “I know I’m a member of two minority groups,” she told The New York Post in 1967, “but I don’t think of myself that way. Sure, a woman has to try twice as hard. But – racial prejudice? I’ve met very little of it. It could be I met it – and wasn’t intelligent enough to recognize it.”
Sharp-eyed readers might have glimpsed her modesty nearly 2 decades later. In a 1984 article for the Journal of the National Medical Association, a society of African American physicians, she wrote about the past, present, and future of chemotherapy without noting her own prominent role in its development.
‘Global medical pioneer’ cofounds ASCO – and more
In the 1960s, Dr. Wright joined the influential President’s Commission on Heart Disease, Cancer, and Stroke and was named associate dean at New York Medical College, her alma mater, a first for a black woman at a prominent U.S. medical school. Even more importantly, Dr. Wright was the sole woman among seven physicians who founded the American Society of Clinical Oncology in Chicago in 1964. She served as ASCO’s first Secretary-Treasurer and was honored as its longest surviving founder when she passed away 9 years ago.
“Jane Wright had the vision to see that oncology was an important separate discipline within medicine with far-reaching implications for research and discovery,” Georgetown University Medical Center, Washington, oncologist Sandra M. Swain, MD, a former president of the ASCO and author of the 2013 Oncology obituary of Dr. Wright, said in an interview. “It is truly remarkable that, as a woman and an African American woman, she had a seat at the very small table for the formation of such an important group.”
As her friend and fellow oncologist Edith Mitchell, MD, said in a eulogy, “Dr. Wright led delegations of oncologists to China and the Soviet Union, and countries in Africa and Eastern Europe. She led medical teams providing medical and cancer care and education to other nurses and physicians in Ghana in 1957 and Kenya in 1961. From 1973 to 1984, she served as vice-president of the African Research and Medical foundation.”
Dr. Wright also raised two daughters. A 1968 Ebony article devoted to her career and family declared that neither of her teenagers was interested in medical careers. Their perspectives shifted, however – as had Dr. Wright’s. An undergraduate at Smith College, Dr. Wright majored in art, swam on the varsity team, and had a special affinity for German language studies before she switched to premed.
Like their mother, Dr. Wright’s daughters also changed paths, and they ultimately became the fourth generation of their family to enter the medical field. Dr. Alison Jones, the psychologist, currently works in a prison, while Jane Jones, MD, became a clinical psychiatrist. She’s now retired and lives in Guttenberg, N.J.
Both fondly remember their mother as a supportive force who insisted on excellence. “There couldn’t be any excuses for you not getting where you wanted to go,” Dr. Jane Jones recalled in an interview.
Nevertheless, Dr. Wright was still keenly aware of society’s limits. “She told me I had to be a doctor or lawyer,” Dr. Alison Jones said, “because that’s how you need to survive when you’re Black in America.”
Dr. Wright passed away in 2013 at age 93. “Dr. Jane C. Wright truly has made contributions that have changed the practice of medicine,” noted her friend Dr. Mitchell, an oncologist and a retired brigadier general with the U.S. Air Force who now teaches at Thomas Jefferson University, Philadelphia. “A true pioneer. A concerned mentor. A renowned researcher. A global teacher. A global medical pioneer. A talented researcher, beloved sister, wife, and mother, and a beautiful, kind, and loving human being.”
When Jane Cooke Wright, MD, entered the medical profession in 1945, the notion that toxic drugs could target tumors struck many physicians and patients as outlandish. How could one poison be weaponized against another poison – a cancerous tumor – without creating more havoc? Let alone a combination of two or more chemicals?
Dr. Wright’s story would be extraordinary enough if she’d looked like most of her colleagues, but this surgeon and researcher stood apart. An African American woman at a time when medicine and science – like politics and law – were almost entirely the domain of White men, Dr. Wright had determination in her blood. Her father, once honored by a crowd of dignitaries that included a First Lady, persevered despite his horrific encounters with racism. She shared her father’s commitment to progress and added her own personal twists. She balanced elegance and beauty with scientific savvy, fierce ambition, and a refusal to be defined by anything other than her accomplishments.
“She didn’t focus on race, not at all,” her daughter Alison Jones, PhD, a psychologist in East Lansing, Mich., said in an interview. “Wherever she was, she wanted to be the best, not the best Black person. It was not about how she performed in a category, and she would get upset if someone said she was good as a Black physician.”
On the road to being the best, Dr. Jones said, her mother set a goal of curing cancer. National Cancer Research Month is a fitting opportunity to look back on a scientist dedicated to bringing humanity closer to that elusive achievement.
Medical legacy blazed in toil and trauma
A strong case could be made that Dr. Jane C. Wright and her father Louis Tompkins Wright, MD, are the most accomplished father-and-daughter team in all of medicine.
The elder Dr. Wright, son of a formerly enslaved man turned physician and a stepson of the first African American to graduate from Yale University, New Haven, Conn., himself graduated from Harvard Medical School in 1915. He earned a Purple Heart while serving in World War I, then went on to become the first Black surgeon to join the staff at Harlem Hospital.
Dr. Wright, who had witnessed mob violence and the aftermath of a lynching as a young man, became a supporter of the Harlem Renaissance and a prominent advocate for civil rights and integration. He served as chairman of the National Association for the Advancement of Colored People and was only the second Black member of the American College of Surgeons.
According to the 2009 book “Black Genius: Inspirational Portraits of African American Leaders,” he successfully treated the rare but devastating venereal disease lymphogranuloma venereum with a new antibiotic developed by his former colleague Yellapragada SubbaRow, MD. Dr. Wright even tried the drug himself, “as a lot of doctors in the olden days did,” according to another of his daughters, the late Barbara Wright Pierce, MD, who was quoted in “Black Genius.” She, too, was a physician.
In 1948, Dr. Jane C. Wright joined her father at Harlem Hospital’s Cancer Research Foundation. There the duo explored the cancer-fighting possibilities of a nitrogen mustard–like chemical agent that had been known since World War I to kill white blood cells. Ironically, Dr. Louis Wright himself suffered lifelong health problems because of an attack from the poisonous gas phosgene during his wartime service.
“Remissions were observed in patients with sarcoma, Hodgkin disease, and chronic myelogenous leukemia, mycosis fungoides, and lymphoma,” reported a 2013 obituary in the journal Oncology of the younger Dr. Wright. “They also performed early research into the clinical efficacy and toxicity of folic acid antagonists, documenting responses in 93 patients with various forms of incurable blood cancers and solid tumors.”
This research appears in a study that was authored by three Dr. Wrights – Dr. Louis T. Wright and his daughters Jane and Barbara.
“The elder Dr. Wright died in 1952, just months after 1,000 people – including Eleanor Roosevelt – honored him at a dinner to dedicate a Harlem Hospital library named after him. He was 61.
Scientific savvy mixed with modesty and elegance
After her father’s death, Dr. Janet C. Wright became director of the hospital’s cancer foundation. From the 1950s to the 1970s, she “worked out ways to use pieces of a patient’s own tumor, removed by surgery and grown in a nutrient culture medium in the laboratory, as a ‘guinea pig for testing drugs,’ ” according to the 1991 book “Black Scientists.” Previously, researchers had focused on mice as test subjects.
This approach also allowed Dr. Wright to determine if specific drugs such as methotrexate, a folic acid antagonist, would help specific patients. “She was looking for predictive activity for chemotherapeutic efficacy in vitro at a time when no one had good predictive tests,” wrote James F. Holland, MD, the late Mount Sinai School of Medicine oncologist, who was quoted in Dr. Wright’s 2013 Oncology obituary.
“Her strict attention to detail and concern for her patients helped determine effective dosing levels and establish treatment guidelines,” the Oncology obituary reported. “She treated patients that other physicians had given up on, and she was among the first small cadre of researchers to carefully test the effects of drugs against cancer in a clinical trial setting.”
Dr. Wright also focused on developing ways to administer chemotherapy, such using a catheter to reach difficult-to-access organs like the spleen without surgery, according to “Black Scientists.”
Along with her work, Dr. Wright’s appearance set her apart. According to “Black Genius,” a newspaper columnist dubbed her one of the 10 most beautiful Back woman in America, and Ebony Magazine in 1966 honored her as one of the best-dressed women in America. It featured a photograph of her in a stunning ivory and yellow brocade gown, noting that she was “in private life Mrs. David J. Jones.” (She’d married the Harvard University Law School graduate in 1946.)
Dr. Wright had a sense of modesty despite her accomplishments, according to her daughter Alison Jones. She even downplayed her own mental powers in a newspaper interview. “I know I’m a member of two minority groups,” she told The New York Post in 1967, “but I don’t think of myself that way. Sure, a woman has to try twice as hard. But – racial prejudice? I’ve met very little of it. It could be I met it – and wasn’t intelligent enough to recognize it.”
Sharp-eyed readers might have glimpsed her modesty nearly 2 decades later. In a 1984 article for the Journal of the National Medical Association, a society of African American physicians, she wrote about the past, present, and future of chemotherapy without noting her own prominent role in its development.
‘Global medical pioneer’ cofounds ASCO – and more
In the 1960s, Dr. Wright joined the influential President’s Commission on Heart Disease, Cancer, and Stroke and was named associate dean at New York Medical College, her alma mater, a first for a black woman at a prominent U.S. medical school. Even more importantly, Dr. Wright was the sole woman among seven physicians who founded the American Society of Clinical Oncology in Chicago in 1964. She served as ASCO’s first Secretary-Treasurer and was honored as its longest surviving founder when she passed away 9 years ago.
“Jane Wright had the vision to see that oncology was an important separate discipline within medicine with far-reaching implications for research and discovery,” Georgetown University Medical Center, Washington, oncologist Sandra M. Swain, MD, a former president of the ASCO and author of the 2013 Oncology obituary of Dr. Wright, said in an interview. “It is truly remarkable that, as a woman and an African American woman, she had a seat at the very small table for the formation of such an important group.”
As her friend and fellow oncologist Edith Mitchell, MD, said in a eulogy, “Dr. Wright led delegations of oncologists to China and the Soviet Union, and countries in Africa and Eastern Europe. She led medical teams providing medical and cancer care and education to other nurses and physicians in Ghana in 1957 and Kenya in 1961. From 1973 to 1984, she served as vice-president of the African Research and Medical foundation.”
Dr. Wright also raised two daughters. A 1968 Ebony article devoted to her career and family declared that neither of her teenagers was interested in medical careers. Their perspectives shifted, however – as had Dr. Wright’s. An undergraduate at Smith College, Dr. Wright majored in art, swam on the varsity team, and had a special affinity for German language studies before she switched to premed.
Like their mother, Dr. Wright’s daughters also changed paths, and they ultimately became the fourth generation of their family to enter the medical field. Dr. Alison Jones, the psychologist, currently works in a prison, while Jane Jones, MD, became a clinical psychiatrist. She’s now retired and lives in Guttenberg, N.J.
Both fondly remember their mother as a supportive force who insisted on excellence. “There couldn’t be any excuses for you not getting where you wanted to go,” Dr. Jane Jones recalled in an interview.
Nevertheless, Dr. Wright was still keenly aware of society’s limits. “She told me I had to be a doctor or lawyer,” Dr. Alison Jones said, “because that’s how you need to survive when you’re Black in America.”
Dr. Wright passed away in 2013 at age 93. “Dr. Jane C. Wright truly has made contributions that have changed the practice of medicine,” noted her friend Dr. Mitchell, an oncologist and a retired brigadier general with the U.S. Air Force who now teaches at Thomas Jefferson University, Philadelphia. “A true pioneer. A concerned mentor. A renowned researcher. A global teacher. A global medical pioneer. A talented researcher, beloved sister, wife, and mother, and a beautiful, kind, and loving human being.”
When Jane Cooke Wright, MD, entered the medical profession in 1945, the notion that toxic drugs could target tumors struck many physicians and patients as outlandish. How could one poison be weaponized against another poison – a cancerous tumor – without creating more havoc? Let alone a combination of two or more chemicals?
Dr. Wright’s story would be extraordinary enough if she’d looked like most of her colleagues, but this surgeon and researcher stood apart. An African American woman at a time when medicine and science – like politics and law – were almost entirely the domain of White men, Dr. Wright had determination in her blood. Her father, once honored by a crowd of dignitaries that included a First Lady, persevered despite his horrific encounters with racism. She shared her father’s commitment to progress and added her own personal twists. She balanced elegance and beauty with scientific savvy, fierce ambition, and a refusal to be defined by anything other than her accomplishments.
“She didn’t focus on race, not at all,” her daughter Alison Jones, PhD, a psychologist in East Lansing, Mich., said in an interview. “Wherever she was, she wanted to be the best, not the best Black person. It was not about how she performed in a category, and she would get upset if someone said she was good as a Black physician.”
On the road to being the best, Dr. Jones said, her mother set a goal of curing cancer. National Cancer Research Month is a fitting opportunity to look back on a scientist dedicated to bringing humanity closer to that elusive achievement.
Medical legacy blazed in toil and trauma
A strong case could be made that Dr. Jane C. Wright and her father Louis Tompkins Wright, MD, are the most accomplished father-and-daughter team in all of medicine.
The elder Dr. Wright, son of a formerly enslaved man turned physician and a stepson of the first African American to graduate from Yale University, New Haven, Conn., himself graduated from Harvard Medical School in 1915. He earned a Purple Heart while serving in World War I, then went on to become the first Black surgeon to join the staff at Harlem Hospital.
Dr. Wright, who had witnessed mob violence and the aftermath of a lynching as a young man, became a supporter of the Harlem Renaissance and a prominent advocate for civil rights and integration. He served as chairman of the National Association for the Advancement of Colored People and was only the second Black member of the American College of Surgeons.
According to the 2009 book “Black Genius: Inspirational Portraits of African American Leaders,” he successfully treated the rare but devastating venereal disease lymphogranuloma venereum with a new antibiotic developed by his former colleague Yellapragada SubbaRow, MD. Dr. Wright even tried the drug himself, “as a lot of doctors in the olden days did,” according to another of his daughters, the late Barbara Wright Pierce, MD, who was quoted in “Black Genius.” She, too, was a physician.
In 1948, Dr. Jane C. Wright joined her father at Harlem Hospital’s Cancer Research Foundation. There the duo explored the cancer-fighting possibilities of a nitrogen mustard–like chemical agent that had been known since World War I to kill white blood cells. Ironically, Dr. Louis Wright himself suffered lifelong health problems because of an attack from the poisonous gas phosgene during his wartime service.
“Remissions were observed in patients with sarcoma, Hodgkin disease, and chronic myelogenous leukemia, mycosis fungoides, and lymphoma,” reported a 2013 obituary in the journal Oncology of the younger Dr. Wright. “They also performed early research into the clinical efficacy and toxicity of folic acid antagonists, documenting responses in 93 patients with various forms of incurable blood cancers and solid tumors.”
This research appears in a study that was authored by three Dr. Wrights – Dr. Louis T. Wright and his daughters Jane and Barbara.
“The elder Dr. Wright died in 1952, just months after 1,000 people – including Eleanor Roosevelt – honored him at a dinner to dedicate a Harlem Hospital library named after him. He was 61.
Scientific savvy mixed with modesty and elegance
After her father’s death, Dr. Janet C. Wright became director of the hospital’s cancer foundation. From the 1950s to the 1970s, she “worked out ways to use pieces of a patient’s own tumor, removed by surgery and grown in a nutrient culture medium in the laboratory, as a ‘guinea pig for testing drugs,’ ” according to the 1991 book “Black Scientists.” Previously, researchers had focused on mice as test subjects.
This approach also allowed Dr. Wright to determine if specific drugs such as methotrexate, a folic acid antagonist, would help specific patients. “She was looking for predictive activity for chemotherapeutic efficacy in vitro at a time when no one had good predictive tests,” wrote James F. Holland, MD, the late Mount Sinai School of Medicine oncologist, who was quoted in Dr. Wright’s 2013 Oncology obituary.
“Her strict attention to detail and concern for her patients helped determine effective dosing levels and establish treatment guidelines,” the Oncology obituary reported. “She treated patients that other physicians had given up on, and she was among the first small cadre of researchers to carefully test the effects of drugs against cancer in a clinical trial setting.”
Dr. Wright also focused on developing ways to administer chemotherapy, such using a catheter to reach difficult-to-access organs like the spleen without surgery, according to “Black Scientists.”
Along with her work, Dr. Wright’s appearance set her apart. According to “Black Genius,” a newspaper columnist dubbed her one of the 10 most beautiful Back woman in America, and Ebony Magazine in 1966 honored her as one of the best-dressed women in America. It featured a photograph of her in a stunning ivory and yellow brocade gown, noting that she was “in private life Mrs. David J. Jones.” (She’d married the Harvard University Law School graduate in 1946.)
Dr. Wright had a sense of modesty despite her accomplishments, according to her daughter Alison Jones. She even downplayed her own mental powers in a newspaper interview. “I know I’m a member of two minority groups,” she told The New York Post in 1967, “but I don’t think of myself that way. Sure, a woman has to try twice as hard. But – racial prejudice? I’ve met very little of it. It could be I met it – and wasn’t intelligent enough to recognize it.”
Sharp-eyed readers might have glimpsed her modesty nearly 2 decades later. In a 1984 article for the Journal of the National Medical Association, a society of African American physicians, she wrote about the past, present, and future of chemotherapy without noting her own prominent role in its development.
‘Global medical pioneer’ cofounds ASCO – and more
In the 1960s, Dr. Wright joined the influential President’s Commission on Heart Disease, Cancer, and Stroke and was named associate dean at New York Medical College, her alma mater, a first for a black woman at a prominent U.S. medical school. Even more importantly, Dr. Wright was the sole woman among seven physicians who founded the American Society of Clinical Oncology in Chicago in 1964. She served as ASCO’s first Secretary-Treasurer and was honored as its longest surviving founder when she passed away 9 years ago.
“Jane Wright had the vision to see that oncology was an important separate discipline within medicine with far-reaching implications for research and discovery,” Georgetown University Medical Center, Washington, oncologist Sandra M. Swain, MD, a former president of the ASCO and author of the 2013 Oncology obituary of Dr. Wright, said in an interview. “It is truly remarkable that, as a woman and an African American woman, she had a seat at the very small table for the formation of such an important group.”
As her friend and fellow oncologist Edith Mitchell, MD, said in a eulogy, “Dr. Wright led delegations of oncologists to China and the Soviet Union, and countries in Africa and Eastern Europe. She led medical teams providing medical and cancer care and education to other nurses and physicians in Ghana in 1957 and Kenya in 1961. From 1973 to 1984, she served as vice-president of the African Research and Medical foundation.”
Dr. Wright also raised two daughters. A 1968 Ebony article devoted to her career and family declared that neither of her teenagers was interested in medical careers. Their perspectives shifted, however – as had Dr. Wright’s. An undergraduate at Smith College, Dr. Wright majored in art, swam on the varsity team, and had a special affinity for German language studies before she switched to premed.
Like their mother, Dr. Wright’s daughters also changed paths, and they ultimately became the fourth generation of their family to enter the medical field. Dr. Alison Jones, the psychologist, currently works in a prison, while Jane Jones, MD, became a clinical psychiatrist. She’s now retired and lives in Guttenberg, N.J.
Both fondly remember their mother as a supportive force who insisted on excellence. “There couldn’t be any excuses for you not getting where you wanted to go,” Dr. Jane Jones recalled in an interview.
Nevertheless, Dr. Wright was still keenly aware of society’s limits. “She told me I had to be a doctor or lawyer,” Dr. Alison Jones said, “because that’s how you need to survive when you’re Black in America.”
Dr. Wright passed away in 2013 at age 93. “Dr. Jane C. Wright truly has made contributions that have changed the practice of medicine,” noted her friend Dr. Mitchell, an oncologist and a retired brigadier general with the U.S. Air Force who now teaches at Thomas Jefferson University, Philadelphia. “A true pioneer. A concerned mentor. A renowned researcher. A global teacher. A global medical pioneer. A talented researcher, beloved sister, wife, and mother, and a beautiful, kind, and loving human being.”
Poorest children at higher risk for PICU admissions, death
SAN FRANCISCO – Children who live in neighborhoods that are at the bottom of the socioeconomic ladder are at significantly greater risk for being admitted to a pediatric intensive care unit (PICU) and of dying there, a study of Medicaid data showed.
Among more than 4 million children and adolescents in 12 U.S. states, those in the most socioeconomically deprived quartile had a significantly higher risk for PICU admission and in-hospital death, compared with patients from the least-deprived areas.
Black children were also at significantly higher risk for death than children of other races, reported Hannah K. Mitchell, BMBS, MSc, from Evelina Children’s Hospital, London.“I think we need to do better work for trying to understand the mechanisms behind these disparities, ... whether they can be intervened over in a hospital setting, and to try to identify targeted interventions,” she said during a presentation at the American Thoracic Society International Conference 2022.
Medicaid data
During her residency in pediatrics at Children’s Hospital of Philadelphia, Ms. Mitchell and colleagues conducted a study to determine whether there were disparities in PICU admissions and mortality according to socioeconomic deprivation in specific neighborhoods.
They created a retrospective cohort study of Medicaid patients from birth to age 20 who were covered from 2007 through 2014 in 12 U.S. states, using ZIP codes to identify areas of social deprivation.
They restricted the analysis to children from households with annual incomes below 150% of the federal poverty line and divided the cohort into socioeconomic quartiles.
A total of nearly 4.1 million children and adolescents were included in the sample. Of this group, 274,782 were admitted to a PICU during the study period.
The median age of children admitted to a PICU was 4 years (interquartile range 0-15), and slightly more than two-thirds (68.5%) had a chronic complex condition.
In all, 43.5% were identified as White, and 32.1% were identified as Black. Ms. Mitchell noted that one of the limitations of the study was missing data on patients of Hispanic/Latinx origin.
The mortality rate among all patients admitted to a PICU was 2.5%.
In univariate logistic regression analysis, the odds ratio for PICU admission among children living in the most impoverished circumstances was 1.21 (P < .0001).
Among all patients admitted to a PICU, the OR for death for children in the most deprived quartile, compared with the least deprived was 1.12 (P = .0047).
In addition, Black children were significantly more likely than White children to be admitted to a PICU (OR, 1.14; P < .0001) and to die in hospital (OR, 1.18, P < .0001).
Ms. Mitchell said that clinicians need to move beyond describing disparities and should instead begin to focus on interventions to eliminate or reduce them.
She noted that children in poor neighborhoods may be more likely to receive care in lower-quality hospitals or may be treated differently from other children when hospitalized because of their socioeconomic status.
Poor housing, environmental injustice
A pediatric pulmonary specialist who works in a safety net hospital told this news organization that there are multiple factors that contribute to increased risk for PICU admissions and mortality in disadvantaged neighborhoods.
“The overwhelming majority of our patients are not only of low socioeconomic status on an individual level but also live in areas of great socioeconomic deprivation, and all of those social determinants of health are resulting in increased admissions to the PICU,” said Robyn T. Cohen, MD, associate professor of pediatrics at Boston University Medical Center.
“They’re living in poor housing conditions with environmental pollution and experiencing competing priorities that prevent early access to care or the ability to obtain medications. We should be doing better to prevent that from happening” said Dr. Cohen, who co-moderated the session but was not involved with the study.
The study was supported by a grant from the National Institutes of Health. Ms. Mitchell and Dr. Cohen have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
SAN FRANCISCO – Children who live in neighborhoods that are at the bottom of the socioeconomic ladder are at significantly greater risk for being admitted to a pediatric intensive care unit (PICU) and of dying there, a study of Medicaid data showed.
Among more than 4 million children and adolescents in 12 U.S. states, those in the most socioeconomically deprived quartile had a significantly higher risk for PICU admission and in-hospital death, compared with patients from the least-deprived areas.
Black children were also at significantly higher risk for death than children of other races, reported Hannah K. Mitchell, BMBS, MSc, from Evelina Children’s Hospital, London.“I think we need to do better work for trying to understand the mechanisms behind these disparities, ... whether they can be intervened over in a hospital setting, and to try to identify targeted interventions,” she said during a presentation at the American Thoracic Society International Conference 2022.
Medicaid data
During her residency in pediatrics at Children’s Hospital of Philadelphia, Ms. Mitchell and colleagues conducted a study to determine whether there were disparities in PICU admissions and mortality according to socioeconomic deprivation in specific neighborhoods.
They created a retrospective cohort study of Medicaid patients from birth to age 20 who were covered from 2007 through 2014 in 12 U.S. states, using ZIP codes to identify areas of social deprivation.
They restricted the analysis to children from households with annual incomes below 150% of the federal poverty line and divided the cohort into socioeconomic quartiles.
A total of nearly 4.1 million children and adolescents were included in the sample. Of this group, 274,782 were admitted to a PICU during the study period.
The median age of children admitted to a PICU was 4 years (interquartile range 0-15), and slightly more than two-thirds (68.5%) had a chronic complex condition.
In all, 43.5% were identified as White, and 32.1% were identified as Black. Ms. Mitchell noted that one of the limitations of the study was missing data on patients of Hispanic/Latinx origin.
The mortality rate among all patients admitted to a PICU was 2.5%.
In univariate logistic regression analysis, the odds ratio for PICU admission among children living in the most impoverished circumstances was 1.21 (P < .0001).
Among all patients admitted to a PICU, the OR for death for children in the most deprived quartile, compared with the least deprived was 1.12 (P = .0047).
In addition, Black children were significantly more likely than White children to be admitted to a PICU (OR, 1.14; P < .0001) and to die in hospital (OR, 1.18, P < .0001).
Ms. Mitchell said that clinicians need to move beyond describing disparities and should instead begin to focus on interventions to eliminate or reduce them.
She noted that children in poor neighborhoods may be more likely to receive care in lower-quality hospitals or may be treated differently from other children when hospitalized because of their socioeconomic status.
Poor housing, environmental injustice
A pediatric pulmonary specialist who works in a safety net hospital told this news organization that there are multiple factors that contribute to increased risk for PICU admissions and mortality in disadvantaged neighborhoods.
“The overwhelming majority of our patients are not only of low socioeconomic status on an individual level but also live in areas of great socioeconomic deprivation, and all of those social determinants of health are resulting in increased admissions to the PICU,” said Robyn T. Cohen, MD, associate professor of pediatrics at Boston University Medical Center.
“They’re living in poor housing conditions with environmental pollution and experiencing competing priorities that prevent early access to care or the ability to obtain medications. We should be doing better to prevent that from happening” said Dr. Cohen, who co-moderated the session but was not involved with the study.
The study was supported by a grant from the National Institutes of Health. Ms. Mitchell and Dr. Cohen have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
SAN FRANCISCO – Children who live in neighborhoods that are at the bottom of the socioeconomic ladder are at significantly greater risk for being admitted to a pediatric intensive care unit (PICU) and of dying there, a study of Medicaid data showed.
Among more than 4 million children and adolescents in 12 U.S. states, those in the most socioeconomically deprived quartile had a significantly higher risk for PICU admission and in-hospital death, compared with patients from the least-deprived areas.
Black children were also at significantly higher risk for death than children of other races, reported Hannah K. Mitchell, BMBS, MSc, from Evelina Children’s Hospital, London.“I think we need to do better work for trying to understand the mechanisms behind these disparities, ... whether they can be intervened over in a hospital setting, and to try to identify targeted interventions,” she said during a presentation at the American Thoracic Society International Conference 2022.
Medicaid data
During her residency in pediatrics at Children’s Hospital of Philadelphia, Ms. Mitchell and colleagues conducted a study to determine whether there were disparities in PICU admissions and mortality according to socioeconomic deprivation in specific neighborhoods.
They created a retrospective cohort study of Medicaid patients from birth to age 20 who were covered from 2007 through 2014 in 12 U.S. states, using ZIP codes to identify areas of social deprivation.
They restricted the analysis to children from households with annual incomes below 150% of the federal poverty line and divided the cohort into socioeconomic quartiles.
A total of nearly 4.1 million children and adolescents were included in the sample. Of this group, 274,782 were admitted to a PICU during the study period.
The median age of children admitted to a PICU was 4 years (interquartile range 0-15), and slightly more than two-thirds (68.5%) had a chronic complex condition.
In all, 43.5% were identified as White, and 32.1% were identified as Black. Ms. Mitchell noted that one of the limitations of the study was missing data on patients of Hispanic/Latinx origin.
The mortality rate among all patients admitted to a PICU was 2.5%.
In univariate logistic regression analysis, the odds ratio for PICU admission among children living in the most impoverished circumstances was 1.21 (P < .0001).
Among all patients admitted to a PICU, the OR for death for children in the most deprived quartile, compared with the least deprived was 1.12 (P = .0047).
In addition, Black children were significantly more likely than White children to be admitted to a PICU (OR, 1.14; P < .0001) and to die in hospital (OR, 1.18, P < .0001).
Ms. Mitchell said that clinicians need to move beyond describing disparities and should instead begin to focus on interventions to eliminate or reduce them.
She noted that children in poor neighborhoods may be more likely to receive care in lower-quality hospitals or may be treated differently from other children when hospitalized because of their socioeconomic status.
Poor housing, environmental injustice
A pediatric pulmonary specialist who works in a safety net hospital told this news organization that there are multiple factors that contribute to increased risk for PICU admissions and mortality in disadvantaged neighborhoods.
“The overwhelming majority of our patients are not only of low socioeconomic status on an individual level but also live in areas of great socioeconomic deprivation, and all of those social determinants of health are resulting in increased admissions to the PICU,” said Robyn T. Cohen, MD, associate professor of pediatrics at Boston University Medical Center.
“They’re living in poor housing conditions with environmental pollution and experiencing competing priorities that prevent early access to care or the ability to obtain medications. We should be doing better to prevent that from happening” said Dr. Cohen, who co-moderated the session but was not involved with the study.
The study was supported by a grant from the National Institutes of Health. Ms. Mitchell and Dr. Cohen have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.