Distribution of Cancer Care Resources Across US Hospitals by Patient Race and Ethnicity.

This cross-sectional study assesses the availability of cancer-related services in hospitals with predominantly racial and ethnic minority patient populations.

Hospitals That Serve Many Black Patients Have Lower Revenues and Profits: Structural Racism in Hospital Financing.

BACKGROUND: Care for Black patients is concentrated at a relatively small proportion of all US hospitals. Some previous studies have documented quality deficits at Black-serving hospitals, which may be due to inequities in financial resources for care. OBJECTIVE: To assess disparities in funding between hospitals associated with the proportion of Black patients that they serve. PARTICIPANTS: All Medicare-participating hospitals, 2016-2018. MAIN MEASURES: Patient care revenues and profits per patient day at Black-serving hospitals (the top 10% of hospitals ranked by the share of Black patients among all Medicare inpatients) and at other hospitals, unadjusted and adjusted for differences in case mix and hospital characteristics. KEY RESULTS: Among the 574 Black-serving hospitals, an average of 43.7% of Medicare inpatients were Black, vs. 5.2% at the 5,166 other hospitals. Black-serving hospitals were slightly larger, and were more often urban, teaching, and for-profit or government (vs. non-profit) owned. Patient care revenues and profits averaged $1,736 and $-17 per patient day respectively at Black-serving hospitals vs. $2,213 and $126 per patient day at other hospitals (p<.001 for both comparisons). Adjusted for patient case mix and hospital characteristics, mean revenues were $283 lower/patient day (p<.001) and mean profits were $111/patient day lower (p<.001) at Black-serving hospitals. Equalizing reimbursement levels would have required $14 billion in additional payments to Black-serving hospitals in 2018, a mean of approximately $26 million per Black-serving hospital. CONCLUSIONS: US hospital financing effectively assigns a lower dollar value to the care of Black patients. To reduce disparities in care, health financing reforms should eliminate the underpayment of hospitals serving a large share of Black patients.

Examination of Stigmatizing Language in the Electronic Health Record.

Importance: Stigmatizing language in the electronic health record (EHR) may alter treatment plans, transmit biases between clinicians, and alienate patients. However, neither the frequency of stigmatizing language in hospital notes, nor whether clinicians disproportionately use it in describing patients in particular demographic subgroups are known. Objective: To examine the prevalence of stigmatizing language in hospital admission notes and the patient and clinician characteristics associated with the use of such language. Design, Setting, and Participants: This cross-sectional study of admission notes used natural language processing on 48 651 admission notes written about 29 783 unique patients by 1932 clinicians at a large, urban academic medical center between January to December 2018. The admission notes included 8738 notes about 4309 patients with diabetes written by 1204 clinicians; 6197 notes about 3058 patients with substance use disorder by 1132 clinicians; and 5176 notes about 2331 patients with chronic pain by 1056 clinicians. Statistical analyses were performed between May and September 2021. Exposures: Patients' demographic characteristics (age, race and ethnicity, gender, and preferred language); clinicians' characteristics (gender, postgraduate year [PGY], and credential [physician vs advanced practice clinician]). Main Outcome and Measures: Binary indicator for any vs no stigmatizing language; frequencies of specific stigmatizing words. Linear probability models were the main measure, and logistic regression and odds ratios were used for sensitivity analyses and further exploration. Results: The sample included notes on 29 783 patients with a mean (SD) age of 46.9 (27.6) years. Of these patients, 1033 (3.5%) were non-Hispanic Asian, 2498 (8.4%) were non-Hispanic Black, 18 956 (63.6%) were non-Hispanic White, 17 334 (58.2%) were female, and 2939 (9.9%) preferred a language other than English. Of all admission notes, 1197 (2.5%) contained stigmatizing language. The diagnosis-specific stigmatizing language was present in 599 notes (6.9%) for patients with diabetes, 209 (3.4%) for patients with substance use disorders, and 37 (0.7%) for patients with chronic pain. In the whole sample, notes about non-Hispanic Black patients vs non-Hispanic White patients had a 0.67 (95% CI, 0.15 to 1.18) percentage points greater probability of containing stigmatizing language, with similar disparities in all 3 diagnosis-specific subgroups. Greater diabetes severity and the physician-author being less advanced in their training was associated with more stigmatizing language. A 1 point increase in the diabetes severity index was associated with a 1.23 (95% CI, .23 to 2.23) percentage point greater probability of a note containing stigmatizing language. In the sample restricted to physicians, a higher PGY was associated with less use of stigmatizing language overall (-0.05 percentage points/PGY [95% CI, -0.09 to -0.01]). Conclusions and Relevance: In this cross-sectional study, stigmatizing language in hospital notes varied by medical condition and was more often used to describe non-Hispanic Black patients. Training clinicians to minimize stigmatizing language in the EHR might improve patient-clinician relationships and reduce the transmission of bias between clinicians.

Alternatives to intensive treatment in patients with AML.

A significant proportion of patients with acute myeloid leukemia (AML) are unable to tolerate standard induction chemotherapy regimens. This is particularly true for patients who are of advanced age, have a poor performance status, and/or have significant medical comorbidities. Recent advances in understanding the genetic and molecular properties of AML have led to a spate of new treatment options for patients considered ineligible for standard chemotherapy. Here, we discuss these new treatment options, provide an overview of the completed and ongoing trials of the new agents, and highlight promising future directions in the treatment of AML in patients ineligible for intensive induction chemotherapy.

Association of Eviction With Adverse Birth Outcomes Among Women in Georgia, 2000 to 2016.

Importance: More than 2 million families face eviction annually, a number likely to increase due to the coronavirus disease 2019 pandemic. The association of eviction with newborns' health remains to be examined. Objective: To determine the association of eviction actions during pregnancy with birth outcomes. Design: This case-control study compared birth outcomes of infants whose mothers were evicted during gestation with those whose mothers were evicted at other times. Participants included infants born to mothers who were evicted in Georgia from January 1, 2000, to December 31, 2016. Data were analyzed from March 1 to October 4, 2020. Exposures: Eviction actions occurring during gestation. Main Outcomes and Measures: Five metrics of neonatal health included birth weight (in grams), gestational age (in weeks), and dichotomized outcomes for low birth weight (LBW) (<2500 g), prematurity (gestational age <37.0 weeks), and infant death. Results: A total of 88 862 births to 45 122 mothers (mean [SD] age, 26.26 [5.76] years) who experienced 99 517 evictions were identified during the study period, including 10 135 births to women who had an eviction action during pregnancy and 78 727 births to mothers who had experienced an eviction action when not pregnant. Compared with mothers who experienced eviction actions at other times, eviction during pregnancy was associated with lower infant birth weight (difference, -26.88 [95% CI, -39.53 to 14.24] g) and gestational age (difference, -0.09 [95% CI, -0.16 to -0.03] weeks), increased rates of LBW (0.88 [95% CI, 0.23-1.54] percentage points) and prematurity (1.14 [95% CI, 0.21-2.06] percentage points), and a nonsignificant increase in mortality (1.85 [95% CI, -0.19 to 3.89] per 1000 births). The association of eviction with birth weight was strongest in the second and third trimesters of pregnancy, with birth weight reductions of 34.74 (95% CI, -57.51 to -11.97) and 35.80 (95% CI, -52.91 to -18.69) g, respectively. Conclusions and Relevance: These findings suggest that eviction actions during pregnancy are associated with adverse birth outcomes, which have been shown to have lifelong and multigenerational consequences. Ensuring housing, social, and medical assistance to pregnant women at risk for eviction may improve infant health.

Inequality Set in Concrete: Physical Resources Available for Care at Hospitals Serving People of Color and Other U.S. Hospitals.

Racial inequities in health outcomes are widely acknowledged. This study seeks to determine whether hospitals serving people of color in the United States have lesser physical assets than other hospitals. With data on 4,476 Medicare-participating hospitals in the United States, we defined those in the top decile of the share of black and Hispanic Medicare inpatients as "black-serving" and "Hispanic-serving," respectively. Using 2017 Medicare cost reports and American Hospital Association data, we compared the capital assets (value of land, buildings, and equipment), as well as the availability of capital-intensive services at these and other hospitals, adjusted for other hospital characteristics. Hospitals serving people of color had lower capital assets: for example, US$5,197/patient-day (all dollar amounts in U.S. dollars) at black-serving hospitals, $5,763 at Hispanic-serving hospitals, and $8,325 at other hospitals (P < .0001 for both comparisons). New asset purchases between 2013 and 2017 averaged $1,242, $1,738, and $3,092/patient-day at black-serving, Hispanic-serving, and other hospitals, respectively (P < .0001). In adjusted models, hospitals serving people of color had lower capital assets (-$215,121/bed, P < .0001) and recent purchases (-$83,608/bed, P < .0001). They were also less likely to offer 19 of 27 specific capital-intensive services. Our results show that hospitals that serve people of color are substantially poorer in assets than other hospitals and suggest that equalizing investments in hospital facilities in the United States might attenuate racial inequities in care.

Effect of the Affordable Care Act's Medicaid Expansions on Food Security, 2010-2016.

Objectives. To examine whether the expansion of Medicaid under the Affordable Care Act (ACA) decreased the prevalence of severe food insecurity.Methods. With data on adult respondents to the Food Security Supplement to the Current Population Survey in US states for the years 2010 to 2013 and 2015 to 2016, I used a difference-in-difference design to compare trends in very low food security (VLFS) among low-income childless adults in states that did and did not expand Medicaid in 2014 under the ACA.Results. Among low-income, nonelderly childless adults, VLFS rose from 17.4% before ACA to 17.5% after ACA in nonexpansion states, and fell from 17.6% to 15.9% in expansion states. In difference-in-difference analysis, Medicaid expansion was associated with a significant adjusted 2.2-percentage-point decline in rates of VLFS, equivalent to a 12.5% relative reduction.Conclusions. The improvement in food security after the ACA's health insurance expansion suggests that health insurance provision has spillover effects that reduce other dimensions of poverty.Public Health Implications. Providing free or low-cost health insurance coverage may free up household funds, reducing food insecurity and improving this important social determinant of health.