A Rubric to Center Equity in Obstetrics and Gynecology Research.

The Steering Committee for the Obstetrics & Gynecology special edition titled "Racism in Reproductive Health: Lighting a Path to Health Equity" formed a working group to create an equity rubric. The goal was to provide a tool to help researchers systematically center health equity as they conceptualize, design, analyze, interpret, and evaluate research in obstetrics and gynecology. This commentary reviews the rationale, iterative process, and literature guiding the creation of the equity rubric.

Veno-venous Extracorporeal Membrane Oxygenation for COVID-19: A Call For System-Wide Checks to Ensure Equitable Delivery For All.

Extracorporeal membrane oxygenation (ECMO) has emerged in the COVID-19 pandemic as a potentially beneficial yet scare resource for treating critically ill patients, with variable allocation across the United States. The existing literature has not addressed barriers patients may face in access to ECMO as a result of healthcare inequity. We present a novel patient-centered framework of ECMO access, providing evidence for potential bias and opportunities to mitigate this bias at every stage between a marginalized patient's initial presentation to treatment with ECMO. While equitable access to ECMO support is a global challenge, this piece focuses primarily on patients in the United States with severe COVID-19-associated ARDS to draw from current literature on VV-ECMO for ARDS and does not address issues that affect ECMO access on a more international scale.

Use of Race in Pediatric Clinical Practice Guidelines: A Systematic Review.

Importance: National clinical practice guidelines (CPGs) guide medical practice. The use of race in CPGs has the potential to positively or negatively affect structural racism and health inequities. Objective: To review the use of race in published pediatric CPGs. Evidence Review: A literature search of PubMed, Medscape, Emergency Care Research Institute Guidelines Trust, and MetaLib.gov was performed for English-language clinical guidelines addressing patients younger than 19 years of age from January 1, 2016, to April 30, 2021. The study team systematically identified and evaluated all articles that used race and ethnicity terms and then used a critical race theory framework to classify each use according to the potential to either positively or negatively affect structural racism and racial inequities in health care. Findings: Of 414 identified pediatric clinical practice guidelines, 126 (30%) met criteria for full review because of the use of race or ethnicity terms and 288 (70%) did not use race or ethnicity terms. The use of a race term occurred 175 times in either background, clinical recommendations, or future directions. A use of race with a potential negative effect occurred 87 times (49.7%) across 73 CPGs and a positive effect 50 times (28.6%) across 45 CPGs. Conclusions and Relevance: In this systematic review of US-based pediatric CPGs, race was frequently used in ways that could negatively affect health care inequities. Many opportunities exist for national medical organizations to improve the use of race in CPGs to positively affect health care, particularly for racial and ethnic minoritized communities.

The Case for Health Reparations.

The disproportionate impact of COVID-19 on racially marginalized communities has again raised the issue of what justice in healthcare looks like. Indeed, it is impossible to analyze the meaning of the word justice in the medical context without first discussing the central role of racism in the American scientific and healthcare systems. In summary, we argue that physicians and scientists were the architects and imagination of the racial taxonomy and oppressive machinations upon which this country was founded. This oppressive racial taxonomy reinforced and outlined the myth of biological superiority, which laid the foundation for the political, economic, and systemic power of Whiteness. Therefore, in order to achieve universal racial justice, the nation must first address science and medicine's historical role in scaffolding the structure of racism we bear witness of today. To achieve this objective, one of the first steps, we believe, is for there to be health reparations. More specifically, health reparations should be a central part of establishing racial justice in the United States and not relegated to a secondary status. While other scholars have focused on ways to alleviate healthcare inequities, few have addressed the need for health reparations and the forms they might take. This piece offers the ethical grounds for health reparations and various justice-focused solutions.

Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short.

A professional and moral medical education should equip trainees with the knowledge and skills necessary to effectively advance health equity. In this Perspective, we argue that critical theoretical frameworks should be taught to physicians so they can interrogate structural sources of racial inequities and achieve this goal. We begin by elucidating the shortcomings in the pedagogic approaches contemporary Biomedical and Social Determinants of Health (SDOH) curricula use in their discussion of health disparities. In particular, current medical pedagogy lacks self-reflexivity; encodes social identities like race and gender as essential risk factors; neglects to examine root causes of health inequity; and fails to teach learners how to challenge injustice. In contrast, we argue that Critical Race Theory (CRT) is a theoretical framework uniquely adept at addressing these concerns. It offers needed interdisciplinary perspectives that teach learners how to abolish biological racism; leverage historical contexts of oppression to inform interventions; center the scholarship of the marginalized; and understand the institutional mechanisms and ubiquity of racism. In sum, CRT does what biomedical and SDOH curricula cannot: rigorously teach physician trainees how to combat health inequity. In this essay, we demonstrate how the theoretical paradigms operationalized in discussions of health injustice affect the ability of learners to confront health inequity. We expound on CRT tenets, discuss their application to medical pedagogy, and provide an in-depth case study to ground our major argument that theory matters. We introduce MedCRT: a CRT-based framework for medical education, and advocate for its implementation into physician training.

Calculating estimated glomerular filtration rate without the race correction factor: Observations at a large academic medical system.

BACKGROUND AND AIMS: Creatinine-based MDRD and CKD-EPI equations include a race correction factor, which results in higher eGFR in Black patients. We evaluated the impact on our patient population upon adoption of the CKD-EPI equation and the removal of the race correction factor from the equation. MATERIALS AND METHODS: Retrospective analysis of blood creatinine results and respective eGFR values calculated by the MDRD or CKD-EPI equation without the race correction factor (CKD-EPINoRace) in a large academic medical system over a 20.5-month period. RESULTS: In our population, when changing from MDRD to CKD-EPINoRace, we observed that 3.5% of all patients were reclassified to categorically have worse kidney function. However, we also observed fewer patients overall with eGFR below 60 mL/min/1.73 m2. Around 60 and 20 mL/min/1.73 m2, 2.96% and 0.16% of all patients > 65 years of age were reclassified, as were 4.29% and 0.03% of all Black patients, respectively. When calculated with CKD-EPINoRace, median eGFR was not meaningfully different between Black and non-Black patients (p = 0.02). CONCLUSIONS: Changing from MDRD to CKD-EPINoRace could lead to a lower referral rate to nephrology. The distributions of creatinine and eGFR calculated with CKD-EPINoRace were not meaningfully different in Black and non-Black patients.