Implementation of US Post-Acute Care Payment Reform and COVID-19 Policies: Examining Experiences of Health System Leaders, Staff, Patients, and Family Caregivers-A Protocol.

In fiscal year 2020, new national Medicare payment models were implemented in the two most common post-acute care settings (i.e., skilled nursing facilities (SNFs) and home health agencies (HHAs)), which were followed by the emergence of COVID-19. Given concerns about the unintended consequence of these events, this study protocol will examine how organizations responded to these policies and whether there were changes in SNF and HHA access, care delivery, and outcomes from the perspectives of leadership, staff, patients, and families. We will conduct a two-phase multiple case study guided by the Institute of Medicine's Model of Healthcare Systems. Phase I will include three cases for each setting and a maximum of fifty administrators per case. Phase II will include a subset of Phase I organizations, which are grouped into three setting-specific cases. Each Phase II case will include a maximum of four organizations. Semi-structured interviews will explore the perspectives of frontline staff, patients, and family caregivers (Phase II). Thematic analysis will be used to examine the impact of payment policy and COVID-19 on organizational operations, care delivery, and patient outcomes. The results of this study intend to develop evidence addressing concerns about the unintended consequences of the PAC payment policy during the COVID-19 pandemic.

Efficacy of Antidopaminergic Pharmacotherapy in Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections (PANDAS): A Case Report.

PANDAS, or pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, is a neuropsychiatric disease seen in children that presents with prevailing symptoms of obsessive-compulsive disorder (OCD), tic disorder, or both. These symptoms appear suddenly following a streptococcal infection, such as strep throat or scarlet fever. The antibodies formed to eradicate the streptococcal infection have been shown to alter central dopamine signaling. In spite of being acknowledged in the medical community for the last two to three decades, PANDAS is a disorder that goes unnoticed by many healthcare professionals. Unfortunately, even with correct diagnosis and utilization of commonly prescribed pharmacotherapy and psychotherapy, medical management can often be ineffective at treating the neuropsychiatric symptoms. Here, we describe a case of a 15-year-old male who presented to the primary care office with complaints of episodic behavioral changes that would occur multiple times daily. The general symptoms were centered around body dysmorphia where the patient became obsessed with fixed portions of food and became highly focused on only specific food types. The symptoms would exacerbate and progress with a dire need to burn calories, leading the patient to damage carpeted areas in the home due to regular and fanatical pacing. The patient underwent trials with serotonergic pharmacotherapy with little to no relief of the psychiatric symptoms. After discussion with his primary care physician, the patient underwent trial management with antidopaminergic therapy that resulted in significant neurological and psychiatric improvement. The use of antidopaminergic pharmacotherapy to target the induction of D1 and D2 dopamine receptors was efficacious in this patient; however, it warrants additional research with a larger sample to determine its effectiveness in the treatment of this psychiatric condition.

Long-Term Hearing Outcomes After Hybrid Cochlear Implantation.

OBJECTIVE: To examine long-term (>5 yr) low-frequency hearing preservation after hybrid cochlear implantation. STUDY DESIGN: Retrospective cross-sectional study. SETTING: Tertiary care center outpatient clinic. PATIENTS: All patients older than 21 years implanted with a Cochlear Hybrid L24 device from 2014 to 2021. MAIN OUTCOME MEASURE: Changes in low-frequency pure-tone average (LFPTA) were calculated at each of several time points relative to the date of implantation. The proportion of patients with preserved LFPTA at last follow-up and Kaplan-Meier estimates for loss of residual hearing were calculated in addition to hazard ratios for hearing loss according to patient- and surgery-specific factors. RESULTS: Thirty ears in 29 patients underwent hybrid cochlear implantation and were eligible for inclusion (mean age, 59 yr; 65% female). Mean preoperative LFPTA was 31.7 dB. Mean LFPTA across all implanted ears at first follow-up was 45.1 dB; no patient had experienced loss of residual hearing at first follow-up. Six patients had loss of residual hearing during the follow-up period, with Kaplan-Meier probability estimates of preserved hearing of 100% at 1 month, 90% at 12 months, 87% at 24 months, and 80% at 48 months. There was no association between loss of residual hearing and patient age, preoperative LFPTA, surgeon, or use of topical steroids intraoperatively (hazard ratios, 1.05 [0.96-1.15], 0.97 [0.88-1.05], 1.39 [0.20-9.46], 0.93 [0.09-9.74], respectively). CONCLUSIONS: Long-term (>5 yr) outcomes after hybrid cochlear implantation demonstrate good preservation of low-frequency hearing, with only modest decline in the long-term postimplantation, and a low proportion of loss of residual low-frequency hearing.

Self-perceived health of older adults in Latin America and the Caribbean: a scoping review.

Objective: To systematically map the existing evidence on self-perceived health among adults aged 60 and older in Latin America and the Caribbean, describe the use of the single-item measure of self-perceived health with this population, and identify gaps in the existing literature. Methods: Following PRISMA Extension for Scoping Reviews guidelines, eight databases were searched for publications that were published between 2009 and 2019 and reported self-perceived health of adults over 60 years old in Latin America and the Caribbean. Data on study characteristics, sample characteristics, and the use and analysis of the self-perceived health measure were charted. Results: The database and secondary searches identified 516 articles. After removing duplicates and assessing titles and abstracts for inclusion, 263 full-text articles were assessed for eligibility using the inclusion criteria and an additional 89 articles were excluded. Ultimately, 174 articles were included in the scoping review. Studies included participants from 17 countries in the region, led in frequency by Brazil with 120 articles. The self-perceived health question most often included a five-category response scale (130), and response options were predominantly divided into two (86) or three (48) categories for analysis. Conclusions: Information on the health and social needs of people aged 60 and older across Latin America and the Caribbean, particularly their perceptions of health, is limited. We highlight the need to expand research throughout the region, include particularly vulnerable populations, utilize data from longitudinal and qualitative studies, and call for transparency in how questions and responses are worded and analyzed. This review serves to inform future studies, programs, and policies directed at this population.

Self-perceived health of older adults in Latin America and the Caribbean: a scoping review

[ABSTRACT]. Objective. To systematically map the existing evidence on self-perceived health among adults aged 60 and older in Latin America and the Caribbean, describe the use of the single-item measure of self-perceived health with this population, and identify gaps in the existing literature. Methods. Following PRISMA Extension for Scoping Reviews guidelines, eight databases were searched for publications that were published between 2009 and 2019 and reported self-perceived health of adults over 60 years old in Latin America and the Caribbean. Data on study characteristics, sample characteristics, and the use and analysis of the self-perceived health measure were charted. Results. The database and secondary searches identified 516 articles. After removing duplicates and assess- ing titles and abstracts for inclusion, 263 full-text articles were assessed for eligibility using the inclusion criteria and an additional 89 articles were excluded. Ultimately, 174 articles were included in the scoping review. Studies included participants from 17 countries in the region, led in frequency by Brazil with 120 articles. The self-perceived health question most often included a five-category response scale (130), and response options were predominantly divided into two (86) or three (48) categories for analysis. Conclusions. Information on the health and social needs of people aged 60 and older across Latin America and the Caribbean, particularly their perceptions of health, is limited. We highlight the need to expand research throughout the region, include particularly vulnerable populations, utilize data from longitudinal and qualitative studies, and call for transparency in how questions and responses are worded and analyzed. This review serves to inform future studies, programs, and policies directed at this population.

[RESUMEN]. Objetivo. Realizar una búsqueda sistemática de la evidencia sobre la autopercepción de la salud en las personas mayores de 60 años en América Latina y el Caribe, describir el uso de la medición basada en un solo ítem para dicha autopercepción en este grupo poblacional y detectar posibles lagunas en la bibliografía existente. Métodos. Se realizaron búsquedas en ocho bases de datos de publicaciones aparecidas entre el 2009 y el 2019 sobre la autopercepción de la salud por las personas mayores de 60 años en América Latina y el Caribe. Las búsquedas se realizaron de conformidad con la guía de la extensión PRISMA para revisiones explorato- rias. Se graficaron los datos sobre las características del estudio, las características de la muestra y el uso y análisis de la medición de autopercepción de la salud. Resultados. Las búsquedas en las bases de datos y las secundarias permitieron localizar 516 artículos. Tras eliminar los duplicados y examinar los títulos y resúmenes para su inclusión, se utilizaron los criterios de inclusión para evaluar la admisibilidad de 263 artículos completos y se excluyeron otros 89 artículos. A fin de cuentas, quedaron seleccionados 174 artículos para la revisión exploratoria. Los estudios incluían participantes de 17 países de la región, con Brasil como el país con el mayor número (120 artículos). Lo más frecuente fue que la pregunta sobre autopercepción en materia de salud incluyera una escala de respuesta de cinco categorías (130), y las opciones de respuesta se dividían predominantemente en dos (86) o tres (48) categorías para su análisis. Conclusiones. La información sobre las necesidades sociales y de salud de las personas mayores de 60 años en América Latina y el Caribe, en particular sus percepciones sobre la propia salud, es limitada. Los autores destacan la necesidad de ampliar la investigación en toda la región, abarcar a los grupos pobla- cionales especialmente vulnerables, utilizar datos de estudios longitudinales y cualitativos y exhortar a la transparencia sobre la manera en que se formulan las preguntas y respuestas. Esta revisión sirve como fun- damento para futuros estudios, programas y políticas orientados a este grupo poblacional.

[RESUMO]. Objetivo. Mapear de forma sistemática as evidências existentes sobre a autopercepção de saúde em pes- soas com 60 anos ou mais na América Latina e no Caribe, descrever o uso de uma medida de item único da autopercepção de saúde nessa população e identificar lacunas na literatura existente. Métodos. Em conformidade com as diretrizes da extensão da ferramenta PRISMA para revisões de escopo, oito bancos de dados foram pesquisados em busca de trabalhos publicados entre 2009 e 2019 que relat- assem a autopercepção de saúde de pessoas com mais de 60 anos de idade na América Latina e no Caribe. Foram tabulados dados sobre as características do estudo, as características da amostra e o uso e a análise da medida de autopercepção de saúde. Resultados. As buscas nos bancos de dados e secundárias identificaram 516 artigos. Depois de descartar artigos repetidos e avaliar títulos e resumos para inclusão, 263 artigos completos foram avaliados quanto à elegibilidade usando os critérios de inclusão, o que levou à exclusão de mais 89 artigos. Por fim, 174 artigos foram incluídos na revisão de escopo. Os estudos incluíam participantes de 17 países da região, e o Brasil foi o país com o maior número de publicações: 120 artigos. A pergunta sobre a autopercepção de saúde incluía, na maioria das vezes, uma escala de resposta com cinco categorias (130), e as opções de resposta foram predominantemente divididas em duas (86) ou três (48) categorias para análise. Conclusões. As informações sobre as necessidades sociais e de saúde das pessoas com 60 anos ou mais na América Latina e no Caribe, especialmente suas percepções de saúde, são limitadas. Destacamos a necessidade de expandir a pesquisa em toda a região, incluir populações particularmente vulneráveis, uti- lizar dados de estudos longitudinais e qualitativos e solicitar transparência na forma como as perguntas e respostas são formuladas e analisadas. Esta análise serve de guia para futuros estudos, programas e políti- cas voltados para essa população.

Self-perceived health of older adults in Latin America and the Caribbean: a scoping review / Revisión exploratoria sobre la autopercepción de la salud por las personas mayores en América Latina y el Caribe / Autopercepção de saúde de pessoas idosas na América Latina e no Caribe: revisão de escopo

ABSTRACT Objective. To systematically map the existing evidence on self-perceived health among adults aged 60 and older in Latin America and the Caribbean, describe the use of the single-item measure of self-perceived health with this population, and identify gaps in the existing literature. Methods. Following PRISMA Extension for Scoping Reviews guidelines, eight databases were searched for publications that were published between 2009 and 2019 and reported self-perceived health of adults over 60 years old in Latin America and the Caribbean. Data on study characteristics, sample characteristics, and the use and analysis of the self-perceived health measure were charted. Results. The database and secondary searches identified 516 articles. After removing duplicates and assessing titles and abstracts for inclusion, 263 full-text articles were assessed for eligibility using the inclusion criteria and an additional 89 articles were excluded. Ultimately, 174 articles were included in the scoping review. Studies included participants from 17 countries in the region, led in frequency by Brazil with 120 articles. The self-perceived health question most often included a five-category response scale (130), and response options were predominantly divided into two (86) or three (48) categories for analysis. Conclusions. Information on the health and social needs of people aged 60 and older across Latin America and the Caribbean, particularly their perceptions of health, is limited. We highlight the need to expand research throughout the region, include particularly vulnerable populations, utilize data from longitudinal and qualitative studies, and call for transparency in how questions and responses are worded and analyzed. This review serves to inform future studies, programs, and policies directed at this population.

RESUMEN Objetivo. Realizar una búsqueda sistemática de la evidencia sobre la autopercepción de la salud en las personas mayores de 60 años en América Latina y el Caribe, describir el uso de la medición basada en un solo ítem para dicha autopercepción en este grupo poblacional y detectar posibles lagunas en la bibliografía existente. Métodos. Se realizaron búsquedas en ocho bases de datos de publicaciones aparecidas entre el 2009 y el 2019 sobre la autopercepción de la salud por las personas mayores de 60 años en América Latina y el Caribe. Las búsquedas se realizaron de conformidad con la guía de la extensión PRISMA para revisiones exploratorias. Se graficaron los datos sobre las características del estudio, las características de la muestra y el uso y análisis de la medición de autopercepción de la salud. Resultados. Las búsquedas en las bases de datos y las secundarias permitieron localizar 516 artículos. Tras eliminar los duplicados y examinar los títulos y resúmenes para su inclusión, se utilizaron los criterios de inclusión para evaluar la admisibilidad de 263 artículos completos y se excluyeron otros 89 artículos. A fin de cuentas, quedaron seleccionados 174 artículos para la revisión exploratoria. Los estudios incluían participantes de 17 países de la región, con Brasil como el país con el mayor número (120 artículos). Lo más frecuente fue que la pregunta sobre autopercepción en materia de salud incluyera una escala de respuesta de cinco categorías (130), y las opciones de respuesta se dividían predominantemente en dos (86) o tres (48) categorías para su análisis. Conclusiones. La información sobre las necesidades sociales y de salud de las personas mayores de 60 años en América Latina y el Caribe, en particular sus percepciones sobre la propia salud, es limitada. Los autores destacan la necesidad de ampliar la investigación en toda la región, abarcar a los grupos poblacionales especialmente vulnerables, utilizar datos de estudios longitudinales y cualitativos y exhortar a la transparencia sobre la manera en que se formulan las preguntas y respuestas. Esta revisión sirve como fundamento para futuros estudios, programas y políticas orientados a este grupo poblacional.

RESUMO Objetivo. Mapear de forma sistemática as evidências existentes sobre a autopercepção de saúde em pessoas com 60 anos ou mais na América Latina e no Caribe, descrever o uso de uma medida de item único da autopercepção de saúde nessa população e identificar lacunas na literatura existente. Métodos. Em conformidade com as diretrizes da extensão da ferramenta PRISMA para revisões de escopo, oito bancos de dados foram pesquisados em busca de trabalhos publicados entre 2009 e 2019 que relatassem a autopercepção de saúde de pessoas com mais de 60 anos de idade na América Latina e no Caribe. Foram tabulados dados sobre as características do estudo, as características da amostra e o uso e a análise da medida de autopercepção de saúde. Resultados. As buscas nos bancos de dados e secundárias identificaram 516 artigos. Depois de descartar artigos repetidos e avaliar títulos e resumos para inclusão, 263 artigos completos foram avaliados quanto à elegibilidade usando os critérios de inclusão, o que levou à exclusão de mais 89 artigos. Por fim, 174 artigos foram incluídos na revisão de escopo. Os estudos incluíam participantes de 17 países da região, e o Brasil foi o país com o maior número de publicações: 120 artigos. A pergunta sobre a autopercepção de saúde incluía, na maioria das vezes, uma escala de resposta com cinco categorias (130), e as opções de resposta foram predominantemente divididas em duas (86) ou três (48) categorias para análise. Conclusões. As informações sobre as necessidades sociais e de saúde das pessoas com 60 anos ou mais na América Latina e no Caribe, especialmente suas percepções de saúde, são limitadas. Destacamos a necessidade de expandir a pesquisa em toda a região, incluir populações particularmente vulneráveis, utilizar dados de estudos longitudinais e qualitativos e solicitar transparência na forma como as perguntas e respostas são formuladas e analisadas. Esta análise serve de guia para futuros estudos, programas e políticas voltados para essa população.

Audiometric and Surgical Outcomes of a Novel Bone-Conduction Hearing Aid.

OBJECTIVE: To report the audiometric and surgical outcomes of a series of patients having undergone implantation of a novel transcutaneous bone conduction implant (t-BCI). STUDY DESIGN: Retrospective case series. SETTING: Single academic tertiary referral center. PATIENTS: Adults (≥18 yr) implanted between December 1, 2019, and August 1, 2021, with audiometric data available before and after device implantation and a minimum of 4 weeks follow-up. INTERVENTIONS: Surgical t-BCI. MAIN OUTCOME MEASURES: Change in aided pure tone average (PTA) after implantation. Secondary outcomes include average operative time, and adverse events. RESULTS: Twenty-three patients underwent implantation of the t-BCI via either a conventional or minimally invasive surgical approach. The most common indication for implantation was unilateral conductive hearing loss with a history of chronic otitis media. The mean operative time was 59 minutes. The mean preimplantation unaided air conduction PTA was 65 dB, and mean postimplantation was 27.2 dB. The mean change in PTA was 37.8 dB, which was significant ( p < 0.0001). There were 30.4% of the patients that suffered from adverse events, the most common of which were pain (8.7%) and device-related complications (13%). One major adverse event occurred, involving magnet displacement that impaired device activation and required reoperation for replacement. CONCLUSION: Forming the largest series of patients implanted with this t-BCI in the published literature, our data demonstrate that implantation of the device is feasible via either a traditional or minimally invasive surgical approach, with good audiometric benefit and a favorable safety profile.

Lateral Wall Electrodes Increase the Rate of Postactivation Nonauditory Percepts.

OBJECTIVE: To evaluate factors influencing the development of nonauditory percepts and facial nerve stimulation after cochlear implant (CI) activation. STUDY: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Over the course of 5 years, 433 consecutive patients were evaluated for CI and 518 ears were implanted. Of those, 497 ears had information regarding CI activation. INTERVENTIONS: Lateral wall electrodes (LWE) or perimodiolar/mid-scalar electrodes (PME) were used during implantation. PRIMARY OUTCOME MEASURE: Nonauditory percepts and facial nerve stimulation after activation of CI. RESULTS: Among the 497 devices, which were activated at our institution, 357 (72%) had LWE while 140 (28%) patients had a PME. Of the patients with LWE, 49 (13.7%) patients experienced some form of nonauditory percept. In comparison, 11 (9.2%) patients with a PME had some form of nonauditory percept (p < 0.05). Among the patients who had an LWE, 33 (9.2%) patients had facial nerve stimulation compared with 6 (4.3%) patients with PME (p < 0.05). Additionally, there were 11 (2.2%) patients with incomplete insertion of the electrode who had a significant increase (p < 0.05) in facial nerve stimulation. The mean number of electrodes requiring programming modification to control symptoms was 2.9. CONCLUSIONS: The use of LWE and incomplete insertions significantly increase the rate of nonauditory percepts and FNS after activation of CIs. Otic capsule anomalies are an independent risk factor for both.

AzBio Speech Understanding Performance in Quiet and Noise in High Performing Cochlear Implant Users.

OBJECTIVE: To evaluate high-performing cochlear implant patients' performance on AzBio sentence testing. METHODS: Retrospective review of prospectively collected database at a tertiary care hospital. Unilateral cochlear implant patients with AzBio testing were included. The primary outcome of interest was AzBio performance scores in quiet and at +10 and +5 decibels signal to noise (dB S/N). RESULTS: One hundred eighty five subjects met inclusion criteria with scores for AzBio in quiet, 114 at +10 dB S/N, and 66 at +5 dB S/N. Linear mixed effects models showed performance significantly correlated with time since activation in all conditions (8.4%/yr; p < 0.0001). Strong correlations between mean performance in quiet and at +10 dB S/N (r = 0.77, p < 0.0001), and between +10 and +5 dB S/N (r = 0.73, p < 0.0001) were found. The correlation between quiet and +5 dB S/N (r = 0.45, p = 0.01) was less robust. Shapiro-Wilks test of normality found only +10 dB S/N to correspond to a normal distribution. Skew analysis demonstrated values of -0.64, -0.11, and 0.8 for quiet, +10 dB S/N, and +5 dB S/N, respectively. CONCLUSIONS: AzBio scores at +10 dB S/N show a strong correlation with, but avoid the ceiling effects that limit the usefulness of testing in quiet for high performing cochlear implant users, making it the preferred test in this population. Significant complexities exist in the study of outcomes in cochlear implant recipients, and there is no single test that is ideal for the entirety of this population.

Difficult healthcare transitions: Ethical analysis and policy recommendations for unrepresented patients.

BACKGROUND: In Ontario, Canada, patients who lack decision-making capacity and have no family or friends to act as substitute decision-makers currently rely on the Office of the Public Guardian and Trustee to consent to long-term care (nursing home) placement, but they have no legal representative for other placement decisions. OBJECTIVES: We highlight the current gap in legislation for difficult transition cases involving unrepresented patients and provide a novel framework for who ought to assist with making these decisions and how these decisions ought to be made. RESEARCH DESIGN: This paper considers models advanced by Volpe and Steinman with regard to who ought to make placement decisions for unrepresented patients, as well as current ethical models for analyzing how these decisions should be made. PARTICIPANTS AND RESEARCH CONTEXT: We describe an anonymized healthcare transition case to illustrate the fact that there is no legally recognized decision-maker for placement destinations other than long-term care facilities and to show how this impacts all stakeholders. ETHICAL CONSIDERATIONS: The case provided is an anonymized vignette representing a typical transition case involving an unrepresented patient. FINDINGS: As a result of a gap in provincial legislation, healthcare providers usually determine the appropriate placement destination without a clear framework to guide the process and this can cause significant moral distress. DISCUSSION: We argue for a team decision-making approach in the short term, and a legislative change in the long-term, to respect the patient voice, evaluate benefit and risk, enhance collaboration between healthcare providers and patients, and promote social justice. We believe that our approach, which draws upon the strengths of interprofessional teams, will be of interest to all who are concerned with the welfare and ethical treatment of the patients for whom they care. CONCLUSIONS: One of the main strengths of our recommendation is that it provides all members of the healthcare team (including nurses, social workers, therapists, and others) an increased opportunity to advocate on behalf of unrepresented patients.

Assessing equitable care for Indigenous and Afrodescendant women in Latin America.

OBJECTIVE: To identify and understand the barriers to equitable care within health care settings that women of ethnic minorities encounter in Latin America and to examine possible strategies for mitigating the issues. METHODS: This was a comprehensive review of the literature from 2000-2015 available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Region and country names. RESULTS: Health provider discrimination against Indigenous and Afrodescendant women is a primary barrier to quality health care access in Latin America. Discrimination is driven by biases against ethnic minority populations, women, and the poor in general. Discriminatory practices can manifest as patient-blaming, purposeful neglect, verbal or physical abuse, disregard for traditional beliefs, and the non-use of Indigenous languages for patient communication. These obstacles prevent delivery of appropriate and timely clinical care, and also produce fear of shame, abuse, or ineffective treatment, which, in addition to financial barriers, deter women from seeking care. CONCLUSIONS: To ensure optimal health outcomes among Indigenous and Afrodescendant women in Latin America, the issue of discrimination in health care settings needs to be understood and addressed as a key driver of inequitable health outcomes. Strategies that target provider behavior alone have limited impact because they do not address women's needs and the context of socioeconomic inequality in which intra-hospital relations are built.

Assessing equitable care for indigenous and afrodescendant women in Latin America / Equitatividad de la atención a las mujeres indígenas y afrodescendientes de América Latina

OBJECTIVE: To identify and understand the barriers to equitable care within health care settings that women of ethnic minorities encounter in Latin America and to examine possible strategies for mitigating the issues. METHODS: This was a comprehensive review of the literature from 2000-2015 available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Region and country names. RESULTS: Health provider discrimination against Indigenous and Afrodescendant women is a primary barrier to quality health care access in Latin America. Discrimination is driven by biases against ethnic minority populations, women, and the poor in general. Discriminatory practices can manifest as patient-blaming, purposeful neglect, verbal or physical abuse, disregard for traditional beliefs, and the non-use of Indigenous languages for patient communication. These obstacles prevent delivery of appropriate and timely clinical care, and also produce fear of shame, abuse, or ineffective treatment, which, in addition to financial barriers, deter women from seeking care. CONCLUSIONS: To ensure optimal health outcomes among Indigenous and Afrodescendant women in Latin America, the issue of discrimination in health care settings needs to be understood and addressed as a key driver of inequitable health outcomes. Strategies that target provider behavior alone have limited impact because they do not address women's needs and the context of socioeconomic inequality in which intra-hospital relations are built.

OBJETIVOS: Determinar y comprender las barreras que impiden en los entornos de atención de salud de América Latina la asistencia equitativa a las mujeres pertenecientes a minorías étnicas, y analizar las posibles estrategias dirigidas a mitigar los problemas. MÉTODOS: Se llevó a cabo una evaluación exhaustiva de la bibliografía publicada del 2000 al 2015 en las bases de datos en línea PubMed, Google Académico, EBSCOhost y SciELO en español, inglés y portugués, mediante una búsqueda de palabras clave que incluyó los nombres de la Región y los países. RESULTADOS: La discriminación por parte de los proveedores de servicios de salud contra las mujeres indígenas y afrodescendientes constituye una barrera primaria que impide a estas el acceso a una atención de salud de calidad en América Latina. La discriminación surge de los prejuicios contra las poblaciones de minorías étnicas, las mujeres y los pobres en general. Las prácticas discriminatorias se pueden manifestar en forma de culpabilización de las pacientes, negligencia intencionada, maltrato verbal o físico, falta de respeto a las creencias tradicionales y no utilización de los idiomas indígenas para comunicarse con las pacientes. Estos obstáculos impiden la prestación de una atención médica apropiada y oportuna, y también provocan temor a pasar vergüenza, al maltrato o a un tratamiento ineficaz que, junto a las barreras económicas, disuaden a las mujeres de acudir en busca de asistencia. CONCLUSIONES: Para garantizar resultados óptimos en materia de salud entre las mujeres indígenas y afrodescendientes de América Latina, es preciso comprender y abordar el problema de la discriminación en los entornos de atención de salud como factor clave de los resultados no equitativos en materia de salud. Las estrategias dirigidas exclusivamente al comportamiento de los proveedores tienen una repercusión limitada, porque no abordan las necesidades de las mujeres y el contexto de desigualdad socioeconómica en el que se forjan las relaciones intrahospitalarias.

Assessing equitable care for Indigenous and Afrodescendant women in Latin America / Evaluación de la equitatividad de la atención a las mujeres indígenas y afrodescendientes de América Latina

Objective. To identify and understand the barriers to equitable care within health care settings that women of ethnic minorities encounter in Latin America and to examine possible strategies for mitigating the issues. Methods. This was a comprehensive review of the literature from 2000–2015 available from the online databases PubMed, Google Scholar, EBSCOhost, and SciELO in Spanish, English, and Portuguese, using a keyword search that included the Region and country names. Results. Health provider discrimination against Indigenous and Afrodescendant women is a primary barrier to quality health care access in Latin America. Discrimination is driven by biases against ethnic minority populations, women, and the poor in general. Discriminatory practices can manifest as patient-blaming, purposeful neglect, verbal or physical abuse, disregard for traditional beliefs, and the non-use of Indigenous languages for patient communication. These obstacles prevent delivery of appropriate and timely clinical care, and also produce fear of shame, abuse, or ineffective treatment, which, in addition to financial barriers, deter women from seeking care. Conclusions. To ensure optimal health outcomes among Indigenous and Afrodescendant women in Latin America, the issue of discrimination in health care settings needs to be understood and addressed as a key driver of inequitable health outcomes. Strategies that target provider behavior alone have limited impact because they do not address women’s needs and the context of socioeconomic inequality in which intra-hospital relations are built.

Objetivos. Determinar y comprender las barreras que impiden en los entornos de atención de salud de América Latina la asistencia equitativa a las mujeres pertenecientes a minorías étnicas, y analizar las posibles estrategias dirigidas a mitigar los problemas. Métodos. Se llevó a cabo una evaluación exhaustiva de la bibliografía publicada del 2000 al 2015 en las bases de datos en línea PubMed, Google Académico, EBSCOhost y SciELO en español, inglés y portugués, mediante una búsqueda de palabras clave que incluyó los nombres de la Región y los países. Resultados. La discriminación por parte de los proveedores de servicios de salud contra las mujeres indígenas y afrodescendientes constituye una barrera primaria que impide a estas el acceso a una atención de salud de calidad en América Latina. La discriminación surge de los prejuicios contra las poblaciones de minorías étnicas, las mujeres y los pobres en general. Las prácticas discriminatorias se pueden manifestar en forma de culpabilización de las pacientes, negligencia intencionada, maltrato verbal o físico, falta de respeto a las creencias tradicionales y no utilización de los idiomas indígenas para comunicarse con las pacientes. Estos obstáculos impiden la prestación de una atención médica apropiada y oportuna, y también provocan temor a pasar vergüenza, al maltrato o a un tratamiento ineficaz que, junto a las barreras económicas, disuaden a las mujeres de acudir en busca de asistencia. Conclusiones. Para garantizar resultados óptimos en materia de salud entre las mujeres indígenas y afrodescendientes de América Latina, es preciso comprender y abordar el problema de la discriminación en los entornos de atención de salud como factor clave de los resultados no equitativos en materia de salud. Las estrategias dirigidas exclusivamente al comportamiento de los proveedores tienen una repercussion limitada, porque no abordan las necesidades de las mujeres y el contexto de desigualdad socioeconómica en el que se forjan las relaciones intrahospitalarias.

Ethical considerations in transition.

The objective of this paper is to explore ethical issues in the provision of transitional care. Using five case studies a number of ethical issues in transition and transition care are discussed. These issues include: 1) preserving, promoting and ensuring dignity and respect for patients; 2) fostering and supporting the trusting relationships that young people and their parents have for pediatric providers to their new adult providers by using a graduated system of transfer; 3) recognizing graduated capacity; 4) promoting autonomy and self-management; 5) duties of beneficence and non-maleficence; 6) truthtelling; 7) duty to provide developmentally appropriate care; and 8) duty of pediatric providers to advocate for transitioning patients in the adult system. Attention to the ethical issues surrounding these complex cases has the potential to positively influence a successful transition to adult-oriented health care.