A Secret Shopper Study of Language Accessibility of Community-based Behavioral Health Services for Children in Families Who Speak Spanish and English.

OBJECTIVE: To compare outpatient behavioral health scheduling for children in Spanish-speaking families in Pennsylvania with that for children in families who speak English. STUDY DESIGN: We made paired English and Spanish telephone calls to outpatient behavioral health facilities using a standardized script, describing a simulated, stable, Medicaid-insured child. Facilities were identified using the Pennsylvania Department of Human Services Online Provider Directory for Mental Health and Substance Abuse Services, which had 288 outpatient facilities with non-duplicate telephone numbers. An English-language caller following a script made up to two call attempts per facility from December 2019 through February 2020. The 126 facilities that did not answer the phone, accept Medicaid, or see children were removed. A Spanish-language caller then made up to two scripted call attempts to the 162 remaining facilities. The primary outcome was whether the facility tried to schedule an appointment for the simulated adolescent. RESULTS: 125 facilities answered both English- and Spanish-language calls. For the English-language caller, 71% of facilities attempted to schedule an appointment and 100% communicated in the caller's preferred language. For the Spanish-language caller, 24% attempted to schedule an appointment (P<0.001) and 25% communicated in the caller's preferred language (P<0.001). CONCLUSIONS: Among outpatient behavioral health facilities for Medicaid-insured children in Pennsylvania, there were inequities in access to appointments for families who speak Spanish compared with English. This a modifiable barrier to care. Community-based behavioral health care for children should strengthen language access training, contracting, and oversight.

Social Vulnerability and National Diabetes Prevention Program Recognition Status.

INTRODUCTION: The CDC National Diabetes Prevention Program (National DPP) aims to reduce the incidence of diabetes in the U.S. Organizations delivering the National DPP receive pending, preliminary, full, or full-plus recognition status based on specific program criteria and outcomes. Achieving full/full-plus recognition is critical for organizations to sustain the program and receive reimbursements to cover costs, but organizations in disadvantaged areas may face barriers to obtaining this level of recognition. This study examined the association between county-level social vulnerability and full/full-plus recognition status within the National DPP. METHODS: Using the 2022 National DPP registry and the 2018 CDC Social Vulnerability Index (SVI), a three-level categorical dependent variable was created (n=843): counties without organizations having full/full-plus recognition, counties with at least one organization not having full/full-plus recognition, and counties with all organizations having full/full-plus recognition. A multinomial logit model was analyzed in 2023 to examine the association between SVI and in-person full/full-plus recognition organizations at the county level, adjusting for confounders. RESULTS: Compared to counties with low social vulnerability, counties with higher social vulnerability had significantly higher odds of having no organizations with full/full-plus recognition. For example, counties with high SVI had 2.63 (95% CI: 1.55-4.47) times higher odds of having no organizations with full/full-plus recognition compared to having all organizations with full/full-plus CDC recognition. CONCLUSIONS: The findings suggest disparities in the National DPP recognition status among organizations in vulnerable communities. Developing strategies to ensure organizations in high social vulnerability areas achieve at least full recognition status is critical for program sustainability and reducing diabetes-related health disparities.

Assessment of Distinct Gut Microbiome Signatures in a Diverse Cohort of Patients Undergoing Definitive Treatment for Rectal Cancer.

Introduction: Disparities in incidence and outcome of rectal cancer are multifactorial in etiology but may be due, in part, to differences in gut microbiome composition. We used serial robust statistical approaches to assess baseline gut microbiome composition in a diverse cohort of patients with rectal cancer receiving definitive treatment. Methods: Microbiome composition was compared by age at diagnosis (< 50 vs ≥ 50 years), race and ethnicity (White Hispanic vs non-Hispanic), and response to therapy. Alpha diversity was assessed using the Shannon, Chao1, and Simpson diversity measures. Beta diversity was explored using both Bray-Curtis dissimilarity and Aitchison distance with principal coordinate analysis. To minimize false-positive findings, we used two distinct methods for differential abundance testing: LinDA and MaAsLin2 (all statistics two-sided, Benjamini-Hochberg corrected false discovery rate < 0.05). Results: Among 64 patients (47% White Hispanic) with median age 51 years, beta diversity metrics showed significant clustering by race and ethnicity (p < 0.001 by both metrics) and by onset (Aitchison p = 0.022, Bray-Curtis p = 0.035). White Hispanic patients had enrichment of bacterial family Prevotellaceae (LinDA fold change 5.32, MaAsLin2 fold change 5.11, combined adjusted p = 0.0007). No significant differences in microbiome composition were associated with neoadjuvant therapy response. Conclusion: We identified distinct gut microbiome signatures associated with race and ethnicity and age of onset in a diverse cohort of patients undergoing definitive treatment for rectal cancer.

Understanding and Addressing Prostate Cancer Disparities in Diagnosis, Treatment, and Outcomes Among Black Men.

Despite advances in screening, diagnosis, and treatment for prostate cancer (PCa), Black men tend to be diagnosed at younger ages, have higher mortality rates, and are at increased risk of recurrence or metastasis compared to their White counterparts. PCa disparities among Black men are caused by a complex interaction of social, behavioral, and biological factors across the public policy, community, organizational, interpersonal, and individual levels. Key contributing factors include mistrust in the health care system, poor communication between patients and providers, low awareness of screening guidelines, and high medical costs. These disparities are further exacerbated by the low representation of Black men in clinical trials, which limits access to high-quality cancer care and generalizability for PCa treatments. In this narrative review of the existing literature, we examined the epidemiology and identified contributing factors, and propose multi-level strategies to address and mitigate disparities among Black men with PCa.

Remoteness-attributable financial inequality in dental service utilization in Australian older adults: A Blinder-Oaxaca decomposition.

OBJECTIVE: Oral health is often overlooked in ageing health issues, despite its impact on overall health and quality of life. Older Australians, especially those in rural and remote areas, face difficulties accessing oral health services. The aim of the study was to investigate the factors that contribute to financial barriers to accessing dental services among the ageing population in Australia in relation to their residential location. METHOD: The study included a weighted sample of Australian adults aged 65 years and over from a population-based survey called the National Study of Adult Oral Health (NSAOH) conducted in 2017-18. Descriptive analysis was conducted and generated cross-tabulation tables to investigate the distributions of the outcome, exposure and covariates, including Sex, Education level (the highest level of education), Equivalised household income, Dental insurance, Concession card ownership, Difficulty paying a dental bill and last dental visit. Blinder-Oaxaca decomposition counterfactual analysis was used to explore the potential impact of a person's residence on their financial difficulty accessing dental services. RESULTS: The findings showed that 26.2% (95% CI: 24.3-29.3) of major city residents and 30.1% (95% CI: 26.9-33.3) of rural residents avoided or delayed dental visits due to cost. The decomposition analysis indicated that 53.8% of the disparities in the prevalence of avoided or delayed dental visits due to cost were explained by the selected variables, while 46.2% remained unexplained. The explanatory variable with the largest contribution was difficulty paying a $200 dental bill, accounting for 62.4% of the differences, followed by dental insurance, last dental visit and equivalised household income, which explained 42.1%, 20.8% and 14.9% of the differences, respectively. CONCLUSION: Regional/remote populations experience more financial barriers to accessing dental care than major city populations and the identified factors explain a significant proportion of these disparities. Based on the study findings, recommendations include expanding public dental service coverage, evaluating concession card mechanisms and advocating for regular dental visits to mitigate disparities in dental care access.

Socio-economic conditions affect health-related quality of life, during recovery from acute SARS-CoV-2 infection : Results from the VASCO study (VAriabili Socioeconomiche e COVID-19), on the "Surviving-COVID" cohort, from Bergamo (Italy).

BACKGROUND: Recovery from acute COVID-19 may be slow and incomplete: cases of Post-Acute Sequelae of COVID (PASC) are counted in millions, worldwide. We aimed to explore if and how the pre-existing Socio-economic-status (SES) influences such recovery. METHODS: We analyzed a database of 1536 consecutive patients from the first wave of COVID-19 in Italy (February-September 2020), previously admitted to our referral hospital, and followed-up in a dedicated multidisciplinary intervention. We excluded those seen earlier than 12 weeks (the conventional limit for a possible PASC syndrome), and those reporting a serious complication from the acute phase (possibly accounting for symptoms persistence). We studied whether the exposition to disadvantaged SES (estimated through the Italian Institute of Statistics's model - ISTAT 2017) was affecting recovery outcomes, that is: symptoms (composite endpoint, i.e. at least one among: dyspnea, fatigue, myalgia, chest pain or palpitations); Health-Related-Quality-of-Life (HRQoL, as by SF-36 scale); post-traumatic-stress-disorder (as by IES-R scale); and lung structural damage (as by impaired CO diffusion, DLCO). RESULTS: Eight-hundred and twenty-five patients were included in the analysis (median age 59 years; IQR: 50-69 years, 60.2% men), of which 499 (60.5%) were previously admitted to hospital and 27 (3.3%) to Intensive-Care Unit (ICU). Those still complaining of symptoms at follow-up were 337 (40.9%; 95%CI 37.5-42.2%), and 256 had a possible Post-Traumatic Stress Disorder (PTSD) (31%, 95%CI 28.7-35.1%). DLCO was reduced in 147 (19.6%, 95%CI 17.0-22.7%). In a multivariable model, disadvantaged SES was associated with a lower HRQoL, especially for items exploring physical health (Limitations in physical activities: OR = 0.65; 95%CI = 0.47 to 0.89; p = 0.008; AUC = 0.74) and Bodily pain (OR = 0.57; 95%CI = 0.40 to 0.82; p = 0.002; AUC = 0.74). We did not observe any association between SES and the other outcomes. CONCLUSIONS: Recovery after COVID-19 appears to be independently affected by a pre-existent socio-economic disadvantage, and clinical assessment should incorporate SES and HRQoL measurements, along with symptoms. The socioeconomic determinants of SARS-CoV-2 disease are not exclusive of the acute infection: this finding deserves further research and specific interventions.

Cross-cultural serious neurological illness communication: qualitative analysis of multidisciplinary perspectives.

BACKGROUND: Cultural competence is important in approaching serious illness communication with diverse patients about goals of care. Culture colors patients' perspectives on many healthcare issues, including end-of-life care, and impacts how clinicians make decisions with patients. Communication about serious neurological illnesses can be additionally challenging due to disease impact on patients' cognition and decision-making abilities. We aim to understand provider experiences regarding cross-cultural serious neurological illness communication with diverse patients and families. METHODS: Using non-stratified purposive and snowball sampling, we conducted semi-structured interviews with 17 multidisciplinary participants, including neurosurgeons, neurologists, and social workers, who provide care for patients diagnosed with serious neurological disorders, at three hospital settings between 2021 and 2022. We used standard qualitative content analysis methods with dual review. RESULTS: Five themes reflected provider perspectives about serious neurological illness communication with diverse patients and families. Theme 1: providers recognize that patients' personal biases and lived experiences impact attitudes about healthcare and communication. Theme 2: challenges in communication can arise when providers miss chances to identify important cultural values. Theme 3: understanding how to engage with family members is important for effective communication about serious neurological illness. Theme 4: providers want to accommodate patients. Theme 5: cultivating trust builds a strong patientprovider partnership, even when racial or cultural discordance is present. CONCLUSIONS: Our study highlights elements of cross-cultural communication and opportunities for providers to approach diverse patients and families within a racial or culturally discordant context. Effective communication, fostered through respecting individual experiences and variation, eliciting cultural perspectives, engaging family, and cultivating trust reflects processes and learned skills required of highquality teams caring for patients with serious neurological conditions.

Unmet healthcare needs and the local extinction index: an analysis of regional disparities impacting South Korea's older adults.

Background: This study examines the factors affecting unmet healthcare experiences by integrating individual-and community-level extinction indices. Methods: Using spatial autocorrelation and multilevel modeling, the study utilizes data from the Community Health Survey and Statistics Korea for 218 local government regions from 2018 to 2019. Results: The analysis identifies significant clustering, particularly in non-metropolitan regions with a higher local extinction index. At the individual level, some factors affect unmet medical needs, and unmet healthcare needs increase as the local extinction index at the community level increases. Conclusion: The findings underscore the need for strategic efforts to enhance regional healthcare accessibility, particularly for vulnerable populations and local infrastructure development.

Regional and socioeconomic disparities in calcium scans.

INTRODUCTION: Disparities in cardiovascular care are well recognized, with socioeconomic status being one of the strongest determinants of cardiovascular disease outcomes. This study evaluates whether these disparities translate to coronary artery calcium (CAC) scan utilization. Specifically, we aim to describe regional variation and socioeconomic variables that impact CAC utilization across the United States relative to the prevalence of coronary artery disease (CAD) and related comorbidities. METHODS: This cross-sectional study integrates county-level CAC utilization with CAD prevalence and publicly available socioeconomic variables including self-identified ethnicity, education, and adjusted gross income. CAC utilization rates were sourced from 2022 hospital commercial claims, outpatient Medicare service claims, and independent imaging center claims. Heart disease prevalence and socioeconomic variables were extracted from the Centers for Disease Control and Prevention and the National Center for Chronic Disease Prevention and Health Promotion. Adjusted gross income per capita was gathered from Internal Revenue Service data. RESULTS: CAC utilization was evaluated across 808 counties within the United States, representing 600,379 claims. Median utilization was 1.62 scans per 1,000 persons with a range of 0.03 to 104.39. The West had the highest CAC scan utilization rate (median 3.09 scans per 1,000 persons) with a CAD prevalence of 548 per 100,000 persons. In contrast, the Midwest had the lowest utilization rate (median 1.24 scans per 1,000 persons) with a CAD prevalence of 635 per 100,000 persons. Socioeconomic factors that favor higher CAC utilization include a larger density of White/Caucasian ethnicity (p = 0.007) and a higher adjusted gross income per capita (p = 0.006). Counties with the lowest rates of CAC utilization have a higher population of African Americans (p <0.001) and a higher proportion of females (p <0.001). CONCLUSION: This analysis highlights regional and socioeconomic differences in CAC utilization in the United States. Under-represented ethnicities such as African Americans have among the lowest rates of CAC utilization despite having a higher burden and mortality from heart disease. Discordance between CAC utilization, heart disease prevalence and socioeconomic status reveals a need for targeted interventions and policies aimed at mitigating structural barriers that perpetuate health inequities.

All cause and cause specific mortality in 15-24-year-olds in Denmark 2010 to 2022: nationwide study of socioeconomic predictors.

Objective: To assess inequalities in all cause and cause specific mortality in young people and if there are differences across gender and age groups. Design: Nationwide cohort study of socioeconomic predictors. Setting: Denmark, 1 January 2010 to 31 December 2022. Participants: All Danes of ages 15 to 24 years during the study period summing to a total of 9 314 807 person years and 2297 deaths. Participant and parental information were linked to obtain information on socioeconomic background to investigate differences in parents' educational level, employment status, and family's disposable income, using annually updated nationwide registers. Main outcome measures: All cause and cause specific mortality including natural deaths (ie, medical conditions and diseases) and unnatural deaths (accidents, suicides, and homicides). Poisson regression was used to calculate incidence rate ratios and 95% confidence intervals (CI). Results: Overall mortality rate was 24.7 (95% CI 23.7 to 25.7) and higher for men (33.2 (31.5 to 34.8)) compared with women (15.8 (14.6 to 16.9)). All cause and cause specific mortality were higher in financially disadvantaged groups compared with more affluent groups, and consistently so for all three measures of socioeconomic position. Results generally reflected a dose dependent association showing a higher mortality with lower levels of socioeconomic position. For instance, incidence rate ratios of all cause mortality related to parents' education was 2.3 (95% CI 2.0 to 2.7) for elementary level, 1.5 (1.3 to 1.6) for low, and 1.3 (1.1 to 1.4) for medium level as compared with high level. For deaths, incidence rate ratios of elementary education level compared with the most well educated group were 2.2 (1.5 to 3.2) for natural causes, 3.3 (2.5 to 4.4) for accidents, 1.6 (1.2 to 2.2) for suicides, and 3.1 (0.8 to 12) for homicides. Associations were similar in strata of men and women and by age group (15-17 v 18-24 years). Mortality in young men was considerably higher than in young women for all of the causes. Conclusion: Young people from disadvantaged backgrounds have a markedly higher mortality from all causes than those from more affluent families. The socioeconomic position of their parents was associated with premature mortality in a dose dependent manner meaning that this effect is not only a concern for marginalised groups. Public health attention should be directed to respond to these inequities by strengthening advocacy for adolescent health, ensuring focus on adolescents in health policies and strategies, using the response to adolescent health as an indicator of equity, and prioritising research into the underlying mechanisms linking socioeconomic position in adolescence and mortality.

Discrepancies in pediatric OSA surgery hospital stay length across regions.

OBJECTIVE: To investigate regional disparities in the length of hospital stay (LOS) for pediatric patients undergoing tonsillectomy for obstructive sleep apnea (OSA) in the United States. METHODS: We utilized the Healthcare Cost and Utilization Project (HCUP) Kid Inpatient Database (KID) for 2016, analyzing data on pediatric OSA patients aged 0-20. We compared LOS in different U.S. regions and employed statistical tests to assess significance. RESULTS: Regional variation in LOS was observed among pediatric OSA patients. The Midwest and South regions showed longer LOS compared to the West and Northeast. Notably, standard deviations for LOS in the Midwest and South were substantial, signifying significant variability. CONCLUSION: Our findings emphasize the importance of addressing regional differences in pediatric OSA care. Prolonged hospital stays can impose significant burdens on children and families. Identifying and mitigating factors driving these disparities is crucial for enhancing the quality and efficiency of care, ultimately striving for more equitable healthcare for pediatric OSA patients nationwide.

Position paper on advancing sickle cell disease management in France by bridging the clinical practices and guidelines through expert insights.

In France, sickle cell disease (SCD) is the most common rare disease and represents the most prevalent genetic disorder, with 19,800 to 32,400 patients diagnosed in 2016 and 1:714 newborns affected in 2019. SCD is caused by a single mutation in the ß-globin gene, resulting in the production of abnormal hemoglobin (called HbS), chronic hemolytic anemia, and impaired red blood cell rheology. SCD patients face several severe acute and chronic complications, including stroke, acute chest syndrome (ACS), painful vaso-occlusive crisis (VOC), organ failure, and a high risk of infections. As patients' care pathway remains unclear in France, a roundtable advisory board meeting was organized in the country to provide insights into the management of SCD in alignment with clinical guidelines. The meeting brought together a panel of esteemed key opinion leaders (KOLs) in SCD management, encompassing both clinical practice and research. During the meeting, the KOLs discussed clinical practices and their alignment with French guidelines, identifying areas of concordance and discrepancy. They also addressed disparities in SCD clinical practices across regions and medical centers. The KOLs discussed the prophylactic and therapeutic options currently available for SCD patients in France, with a focus on transfusion therapies, especially automated red blood cell exchange (aRBCX). The results of this advisory board meeting provide a valuable platform for gathering expert perspectives on SCD management, clinical practices, guideline alignment, and the potential for contributions to guideline updates.

Significance of Variants of Uncertain Significance: The Human Cost of Genetic Uncertainty.

This piece narrates the journey of Maria (name of the mother has been altered to protect the family's privacy), a new mother confronting her newborn's unexpected diagnosis of very long chain acyl-CoA dehydrogenase (VLCAD) deficiency, despite undergoing proactive genetic carrier screening within a consanguineous marriage. It highlights the emotional and systemic challenges arising from the lack of diversity in genetic databases, which, in this case, failed to detect pathogenic variants in Maria and her husband. Maria's story sheds light on situations where a masked variant of uncertain significance (VUS) necessitates consultation with a trained genetics specialist and underscores the urgent need for a more equitable healthcare system.

Mortality and Disparities of Acute Myocardial Infarction and Stroke in Korea, 2008-2019.

PURPOSE: Acute myocardial infarction (AMI) and stroke are leading global causes of death and can be used to assess acute care quality. We examined the 30-day mortality trends after emergency department admission for AMI and stroke in Korea from 2008 to 2019, focusing on regional and income disparities. MATERIALS AND METHODS: The AMI and stroke patients admitted to hospitals in Korea were collected from the claims data. We analyzed age and sex-standardized 30-day mortality for AMI, as well as hemorrhagic and ischemic strokes. Disparities in mortality were analyzed using absolute differences and relative ratios between the Organization for Economic Cooperation Development (OECD) and Korea, and among income levels and regions in Korea. A 12-year joinpoint regression was used to determine the annual percent change and the average annual percent change. RESULTS: The trends in the 30-day AMI mortality of Korea were not significantly changed from 2008 to 2019; the gap remained at 1.2 between the OECD and Korea. Korea maintained lower mortality rates for hemorrhagic and ischemic stroke than the mean of OECD. In Korea, the 30-day hemorrhagic stroke mortality showed a constant decreasing trend for the higher-income group living in urban areas; it led to a widened gap based on income levels in urban areas. The 30-day mortality for ischemic stroke tended to decrease in the higher-income group and urban areas. CONCLUSION: National-level intervention is needed to manage regional and income-based disparities in AMI and stroke 30-day mortality. It is important to understand the variance in mortality rate by different geographical regions and income levels to establish an appropriate public health strategy.

Insurance Types and All-Cause Mortality in Korean Cancer Patients: A Nationwide Population-Based Cohort Study.

BACKGROUND: Economic deprivation is expected to influence cancer mortality due to its impact on screening and treatment options, as well as healthy lifestyle. However, the relationship between insurance type, premiums, and mortality rates remains unclear. This study investigated the relationship between insurance type and mortality in patients with newly diagnosed cancer using data from the Korean National Health Insurance Database. METHODS: this retrospective cohort study included 111,941 cancer patients diagnosed between 1 January 2007 and 31 December 2008, with a median follow-up period of 13.41 years. The insurance types were categorized as regional and workplace subscribers and income-based insurance premiums were divided into tertiles (T1, T2, and T3). RESULTS: Cox proportional hazards regression analysis adjusted for age, lifestyle factors, health metrics, and comorbidities showed workplace subscribers (n = 76,944) had a lower all-cause mortality hazard ratio (HR) (95% confidence interval [CI]: 0.940 [0.919-0.961]) compared to regional subscribers (n = 34,997). Higher income tertiles (T2, T3) were associated with lower mortality compared to the T1 group, notably in male regional and workplace subscribers, and female regional subscribers. CONCLUSION: The study identified that insurance types and premiums significantly influence mortality in cancer patients, highlighting the necessity for individualized insurance policies for cancer patients.

Sex bias in pain management decisions.

In the pursuit of mental and physical health, effective pain management stands as a cornerstone. Here, we examine a potential sex bias in pain management. Leveraging insights from psychological research showing that females' pain is stereotypically judged as less intense than males' pain, we hypothesize that there may be tangible differences in pain management decisions based on patients' sex. Our investigation spans emergency department (ED) datasets from two countries, including discharge notes of patients arriving with pain complaints (N = 21,851). Across these datasets, a consistent sex disparity emerges. Female patients are less likely to be prescribed pain-relief medications compared to males, and this disparity persists even after adjusting for patients' reported pain scores and numerous patient, physician, and ED variables. This disparity extends across medical practitioners, with both male and female physicians prescribing less pain-relief medications to females than to males. Additional analyses reveal that female patients' pain scores are 10% less likely to be recorded by nurses, and female patients spend an additional 30 min in the ED compared to male patients. A controlled experiment employing clinical vignettes reinforces our hypothesis, showing that nurses (N = 109) judge pain of female patients to be less intense than that of males. We argue that the findings reflect an undertreatment of female patients' pain. We discuss the troubling societal and medical implications of females' pain being overlooked and call for policy interventions to ensure equal pain treatment.

Addressing dermatologic concerns and teledermatology in undomiciled and sheltered populations.

Homelessness in the United States is a significant public health issue, with dermatologic disease being the most prevalent health concern among the undomiciled and sheltered populations. Despite a growing need for dermatologic care, the supply of dermatologists remains insufficient, contributing to disparities in healthcare access for this vulnerable group. This review aims to detail the spectrum of dermatologic conditions experienced by homeless individuals, identify barriers to adequate care, and explore teledermatology as a potential solution to bridge these gaps. A comprehensive literature review was conducted, analyzing studies and reports on dermatologic issues prevalent among the homeless population and the efficacy of teledermatology in addressing these concerns. Homeless individuals face a wide range of dermatologic problems, from common conditions like acne and eczema to severe issues such as cellulitis, leg ulcers, and skin cancer. Drug abuse, domestic and sexual abuse, and parasitic infestations further complicate the dermatologic health of this population. Teledermatology has emerged as a promising tool to enhance access to dermatologic care, showing significant improvements in clinical outcomes and accessibility, especially in underserved urban settings. However, challenges remain, such as the digital divide affecting the elderly and low-income populations, which could potentially exacerbate disparities. Addressing the dermatologic needs of the homeless population requires a multifaceted approach. Teledermatology offers a viable solution to improve care access and efficiency, but additional efforts are necessary to ensure inclusivity and avoid further marginalization. Volunteer-driven multidisciplinary clinics also play a crucial role in providing care, though they face challenges in continuity and resource availability. Future strategies should focus on integrating teledermatology with other supportive services to create a comprehensive care model for this underserved population.

Eliciting patient past experiences of healthcare discrimination as a potential pathway to reduce health disparities: A qualitative study of primary care staff.

OBJECTIVE: To understand whether and how primary care providers and staff elicit patients' past experiences of healthcare discrimination when providing care. DATA SOURCES/STUDY SETTING: Twenty qualitative semi-structured interviews were conducted with healthcare staff in primary care roles to inform future interventions to integrate data about past experiences of healthcare discrimination into clinical care. STUDY DESIGN: Qualitative study. DATA COLLECTION/EXTRACTION METHODS: Data were collected via semi-structured qualitative interviews between December 2018 and January 2019, with health care staff in primary care roles at a hospital-based clinic within an urban safety-net health system that serves a patient population with significant racial, ethnic, and linguistic diversity. PRINCIPAL FINDINGS: Providers did not routinely, or in a structured way, elicit information about past experiences of healthcare discrimination. Some providers believed that information about healthcare discrimination experiences could allow them to be more aware of and responsive to their patients' needs and to establish more trusting relationships. Others did not deem it appropriate or useful to elicit such information and were concerned about challenges in collecting and effectively using such data. CONCLUSIONS: While providers see value in eliciting past experiences of discrimination, directly and systematically discussing such experiences with patients during a primary care encounter is challenging for them. Collecting this information in primary care settings will likely require implementation of multilevel systematic data collection strategies. Findings presented here can help identify clinic-level opportunities to do so.

fRAP 2.0: a community engagement method applied to cervical cancer disparities among Hispanic women.

focused Rapid Assessment Process (fRAP) 2.0 is a community engagement approach combining geospatial mapping with rapid qualitative assessment in cyclical fashion within communities to capture multifactorial and multilevel features impacting primary care problems. fRAP 2.0 offers primary care researchers a methodology framework for exploring complex community features that impact primary healthcare delivery and outcomes. The fRAP 2.0 study design expands the fRAP from a sequential design to a cyclical process of geospatial mapping and rapid qualitative assessment in search of modifiable contextual factors. Research participants are stakeholders from various socioecological levels whose perspectives inform study outcomes that they may use to then become the agents of change for the very problems they helped explore. Here, we present a proof-of-concept study for fRAP 2.0 examining disparities in cervical cancer mortality rates among Hispanic women in Texas. The primary outcomes of interest are features at the community level, medical health system level and regional government policy levels that offer opportunities for collaborative interventions to improve cervical cancer outcomes. In this study, geospatial mapping of county and ZIP code-level variables impacting postdiagnosis cervical cancer care at community, medical and policy levels were created using publicly available data and then overlaid with maps created with Texas Cancer Registry data for cervical cancer cases in three of the largest population counties. Geographically disparate areas were then qualitatively explored using participant observation and ethnographic field work, alongside 39 key informant interviews. Roundtable discussion groups and stakeholder engagement existed at every phase of the study. Applying the fRAP 2.0 method, we created an action-oriented roadmap of next steps to improve cervical cancer care disparities in the three Texas counties with emphasis on the high disparity county. We identified local change targets for advocacy and the results helped convene a stakeholder group that continues to actively create on-the-ground change in the high-disparity county to improve cervical cancer outcomes for Hispanic women.

Perspectives from cystinosis: access to healthcare may be a confounding factor for variant classification.

Genetic variability persists across diverse populations, and it may impact the characterization of heritable diseases in different ancestral groups. Cystinosis is a metabolic disease caused by pathogenic variants in the CTNS gene causing the cellular accumulation of cystine. We attempted to assess the currently poorly characterized prevalence of cystinosis by employing a population genetics methodology. However, we encountered a significant challenge due to genetic variations across different populations, and the consideration of potential disparities in access to healthcare made our results inconclusive. Pathogenic CTNS variants were identified in a representative global population cohort using The Human Gene Mutation Database (HGMD) and the 1000 Genomes (1 KG) database. The c.124G>A (p.Val42Ile) variant was reported to be pathogenic based on an observation in the white population presenting with atypical phenotypes, but it would be reclassified as benign in the African ancestral group if applying the ACMG allele frequency guideline due to its high allele frequency specifically in this population. Inclusion or exclusion of this c.124G>A (p.Val42Ile) variant results in a significant change in estimated disease prevalence, which can impact the diagnosis and treatment of affected patients with a broad range of phenotypic presentations. This observation led us to postulate that pathogenic manifestations of the disease may be underdiagnosed due to variable expressivity and systemic inequities in access to care, specifically in the African subpopulation. We call for a more cautious and inclusive approach to achieve more equitable care across diverse populations.