Barriers to health care services among US-based undocumented Latinx immigrants within the sociopolitical climate under the Trump administration: A comparative analysis between client experiences and provider perceptions

As President Biden's administration works towards a 'fair and humane' immigration overhaul, it becomes critical to examine the implications of immigration policies/laws under the Trump administration on the well-being of undocumented residents to inform equitable reformations. We investigate challenges faced by undocumented Latinx immigrants in accessing health care services in the sociopolitical climate under the Trump administration. This study, which follows a similar study among frontline service providers, presents key findings from 23 in-depth interviews with Latinx individuals. Understanding their experiences is necessary to advance access to health-promoting services and uphold the human right to health. Our study participants' narratives document multiple barriers to health care services, many notably exacerbated by increasingly restrictive immigration policies/laws and heightened punitive interior enforcement practices under the Trump administration. As the nation awaits equitable immigration reform, health care organizations should immediately incorporate, amplify, or alter programs/practices to facilitate access among their undocumented clients. Focused organizational changes have the potential to reduce unmet health needs, minimize financial burdens for families, and curtail potential public health threats, the latter a particularly imperative goal within the current COVID-19 pandemic. We also distill conclusions drawn from our interviews with clients and their convergence with and divergence from conclusions drawn from our related research with providers. While providers recognize the negative impact of sociopolitical factors on their clients' access to health care services, client experiences illuminate potential gaps in their understanding. Bridging understanding between providers and clients can improve access, utilization, and retention in health care services.Copyright © 2022 The Authors

Providing preventative care during the SARS-CoV-2 pandemic: Street medicine interventions amongst those experiencing unsheltered homelessness in the City of Detroit

Background. In 2021, there were approximately 1300 people on a given day who have experienced homelessness within the city of Detroit, Michigan. Sheltered beds within the 24 homeless shelters in the city were drastically cut in half during the COVID-19 pandemic due to concerns of overcrowding perpetuating SARS-CoV-2 outbreaks. We aimed to describe the outreach efforts made by Street Medicine Organizations (SMO) of Detroit during the SARS-CoV-2 pandemic, highlighting infection prevention and control strategies, and promotion of COVID-19 vaccinations amongst the unsheltered homeless. Methods. Health promotion interventions were directed at individuals who were unsheltered (defined as those living on the streets of Detroit, encampment sites and abandoned buildings). Education, which was provided through in-person sessions, as well as targeted COVID-19 informational pamphlets were distributed with every street-based run. Hygiene kits, which included masks, hand sanitizer and gloves were distributed thrice weekly at shelters and encampment sites. Since access to hand hygiene was drastically limited, the SMO constructed 10 hand washing stations throughout the city. COVID-19 vaccination in people experiencing homelessness started in April 2021. Results. SMO prioritized a 60 square mile range within the city of Detroit, providing care to approximately 500 persons over the months of April 2020 to April 2021. Demographics for this population varied;age ranged from 23 to 76 years old, sex was 70% males, race were 67% Black, 29% White and 4% Hispanic. More than 2000 hygiene kits were distributed throughout this period. Ninety-one individuals experiencing unsheltered homelessness were provided the COVID-19 vaccine in April 2021. Conclusion. Individuals experiencing unsheltered homelessness face unique challenges to accessing timely medical care, which has been further exacerbated during the pandemic. These individuals have limited or no access to necessary measures needed to prevent the spread and severity of diseases of SARS-CoV-2. We describe a focused and effective approach to preventing infection among these individuals as a model for organizations nationally.

The fine line of defensive medicine.

Defensive medicine is a practice that has been utilized by clinicians in efforts of preventing patient dissatisfaction and malpractice claims and may be done through either omission or commission. As much as 57% of physicians have disclosed that they practice defensive medicine. However, this practice does not necessarily prevent malpractice claims and more importantly, neither does it equate to good medical practice, with some leading to poor outcomes. Unfortunately, there is a high percentage of malpractice claims lodged against clinicians in both primary care and hospital settings. Specialists such as surgeons, obstetricians, and gynecologists face the highest claims. In particular, during the SARS CoV-2 pandemic, with new challenges and limited treatment algorithms, there is an even greater concern for possible bourgeoning claims. Counteracting defensive medicine can be accomplished through decriminalizing malpractice claims, leaving physician oversight up to state medical boards and hospital claims management committees. Additional tort reform measures must also be taken such as caps on noneconomic damages to ensure emphasis on beneficence and nonmaleficence. Once these are in place, it may well serve to increase clinician-patient trust and improve patient independence in the shared decision-making process of their treatment, allowing clinicians to practice their full scope of practice without feeling wary of potential malpractice claims.

Effect of Hydroxychloroquine on Clinical Status at 14 Days in Hospitalized Patients With COVID-19: A Randomized Clinical Trial.

Importance: Data on the efficacy of hydroxychloroquine for the treatment of coronavirus disease 2019 (COVID-19) are needed. Objective: To determine whether hydroxychloroquine is an efficacious treatment for adults hospitalized with COVID-19. Design, Setting, and Participants: This was a multicenter, blinded, placebo-controlled randomized trial conducted at 34 hospitals in the US. Adults hospitalized with respiratory symptoms from severe acute respiratory syndrome coronavirus 2 infection were enrolled between April 2 and June 19, 2020, with the last outcome assessment on July 17, 2020. The planned sample size was 510 patients, with interim analyses planned after every 102 patients were enrolled. The trial was stopped at the fourth interim analysis for futility with a sample size of 479 patients. Interventions: Patients were randomly assigned to hydroxychloroquine (400 mg twice daily for 2 doses, then 200 mg twice daily for 8 doses) (n = 242) or placebo (n = 237). Main Outcomes and Measures: The primary outcome was clinical status 14 days after randomization as assessed with a 7-category ordinal scale ranging from 1 (death) to 7 (discharged from the hospital and able to perform normal activities). The primary outcome was analyzed with a multivariable proportional odds model, with an adjusted odds ratio (aOR) greater than 1.0 indicating more favorable outcomes with hydroxychloroquine than placebo. The trial included 12 secondary outcomes, including 28-day mortality. Results: Among 479 patients who were randomized (median age, 57 years; 44.3% female; 37.2% Hispanic/Latinx; 23.4% Black; 20.1% in the intensive care unit; 46.8% receiving supplemental oxygen without positive pressure; 11.5% receiving noninvasive ventilation or nasal high-flow oxygen; and 6.7% receiving invasive mechanical ventilation or extracorporeal membrane oxygenation), 433 (90.4%) completed the primary outcome assessment at 14 days and the remainder had clinical status imputed. The median duration of symptoms prior to randomization was 5 days (interquartile range [IQR], 3 to 7 days). Clinical status on the ordinal outcome scale at 14 days did not significantly differ between the hydroxychloroquine and placebo groups (median [IQR] score, 6 [4-7] vs 6 [4-7]; aOR, 1.02 [95% CI, 0.73 to 1.42]). None of the 12 secondary outcomes were significantly different between groups. At 28 days after randomization, 25 of 241 patients (10.4%) in the hydroxychloroquine group and 25 of 236 (10.6%) in the placebo group had died (absolute difference, -0.2% [95% CI, -5.7% to 5.3%]; aOR, 1.07 [95% CI, 0.54 to 2.09]). Conclusions and Relevance: Among adults hospitalized with respiratory illness from COVID-19, treatment with hydroxychloroquine, compared with placebo, did not significantly improve clinical status at day 14. These findings do not support the use of hydroxychloroquine for treatment of COVID-19 among hospitalized adults. Trial Registration: ClinicalTrials.gov: NCT04332991.

Rationale and Design of ORCHID: A Randomized Placebo-controlled Clinical Trial of Hydroxychloroquine for Adults Hospitalized with COVID-19.

The ORCHID (Outcomes Related to COVID-19 treated with Hydroxychloroquine among In-patients with symptomatic Disease) trial is a multicenter, blinded, randomized trial of hydroxychloroquine versus placebo for the treatment of adults hospitalized with coronavirus disease (COVID-19). This document provides the rationale and background for the trial and highlights key design features. We discuss five novel challenges to the design and conduct of a large, multicenter, randomized trial during a pandemic, including 1) widespread, off-label use of the study drug before the availability of safety and efficacy data; 2) the need to adapt traditional procedures for documentation of informed consent during an infectious pandemic; 3) developing a flexible and robust Bayesian analysis incorporating significant uncertainty about the disease, outcomes, and treatment; 4) obtaining indistinguishable drug and placebo without delaying enrollment; and 5) rapidly obtaining administrative and regulatory approvals. Our goals in describing how the ORCHID trial progressed from study conception to enrollment of the first patient in 15 days are to inform the development of other high-quality, multicenter trials targeting COVID-19. We describe lessons learned to improve the efficiency of future clinical trials, particularly in the setting of pandemics. The ORCHID trial will provide high-quality, clinically relevant data on the safety and efficacy of hydroxychloroquine for the treatment of COVID-19 among hospitalized adults.Clinical trial registered with www.clinicaltrials.gov (NCT04332991).