Health Services and Health Equity Research*

Date/Time: Sunday, September 10, 2023 - 3:30 PM – 5:00 PM
Track: Cross-Cutting Special Interest Group (SIG)
Room: Salon C-D (5th Floor)
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Chair: Sahar Zafar, MD, MBBS, MSc

Co-Chair: Neha Dangayach, MD

Health services research (HSR) is a rapidly growing area of research within Neurology. HSR focuses on developing evidence-based solutions to increase access and equity in healthcare, delivering high quality and cost-efficient care, and ultimately improving outcomes across the patient journey. 1) There is increasing recognition of racial and ethnic inequalities in the delivery of neurologic care, and an urgent need to address these disparities. 2) These inequities have been further amplified by the COVID-19 pandemic. 3) This SIG focuses on the application of different HSR approaches to improve the quality and value of neurologic care, education and research The SIG will provide an overview on the development and clinical implementation of quality measures that have been shown to improve patient care across a spectrum of neurologic diseases. 4) The SIG will also review disparities in neurologic research, academia and best practices to overcome these disparities. Increasing awareness, formal curricula that incorporate unconscious bias, allyship training for trainees and faculty. 5) diversity councils, evidence-based practices to improve recruitment and retention of diverse populations in clinical trials and training artificial algorithms on data from diverse populations have the potential to address disparities in clinical care, research and education.

Learning Objectives:

  • Define health services research approaches to improve the quality of neurologic care and address healthcare disparities.
  • Discuss the role of clinical and community partnerships in improving delivery of neurologic care.
  • Demonstrate the utility of big data/AI in evaluating patient outcomes, healthcare safety and efficiency.

Disparities in Research: Recruitment and Funding

Speaker: Adam de Havenon, MD, MS

In this session, we will focus on disparities in the recruitment and retention of subjects in clinical research, focusing mainly on social determinants of health. We will also discuss disparities in research funding for both medical conditions that predominantly affect underrepresented groups and funding for investigators from underrepresented groups as well as research staff. The intent is to understand disparities throughout the lifecycle of research, from funding decisions to the retention of vulnerable subjects.

Disparities in Education: Curricula and Representation

Speaker: Rebecca Matthews, MD

This presentation will explore disparities in graduate medical education and ways to improve diversity and to support underrepresented minorities in medicine.

Disparities in Clinical Care: Access, Outcomes and Best Practices

Speaker: Altaf Saadi, MD, MSc

This presentation will provide a framework for approaching disparities in clinical care, relevant literature, and best practices for mitigating these disparities.

Recruiting and Retaining a Diverse Neurology Workforce: The Pipeline from 2011 to 2022

Oral Abstract Presenter: George Ghaly, BA, New York Medical College

Background: The 2006-2013 medical expenditure panel survey revealed that despite being disproportionately impacted by many neurological disorders, Black and Hispanic patients respectively were 30% and 40% less likely to see an outpatient neurologist when compared to White patients. Black and Hispanic individuals comprise 13.4% and 18.3% of the general population respectively, but only 8.7% and 11.3%, respectively, of US medical students. Physicians from demographics underrepresented in medicine (URiM) are more likely to work in underserved communities and contribute diverse perspectives from varied experiences to the medical community. In this study, we explore trends of racial and ethnic diversity among US Neurology residents, focusing on URiM as defined by the Licensing Committee on Medical Education (LCME). Methods: A quantitative analysis of Accreditation Council for Graduate Medical Education (ACGME) publicly available GME Data Resource Book from 2011 to 2022. Demographic data including race, ethnicity, and gender of US neurology residents were extracted. A Chi-Square test was utilized with the observed ACGME data and expected values were calculated using the 2010 census data for years 2011 to 2019 and the 2020 US census data for 2020 onward. Microsoft Excel was used for data collection and analysis. Results: The percentage of Hispanics, African-Americans, and Native Americans in US neurology residency programs were analyzed. A Chi-square analysis demonstrated significant underrepresentation of Black, Hispanic, and Native Americans (p<.000001) in US neurology training programs. Furthermore, trend analysis demonstrated that although there has been an increased number of neurology residents nationwide, there has been no significant change in the percentage of URiM entering the field of neurology. Summary of all years analyzed demonstrated the demographics of adult neurology residents in training to be 6.04 % Hispanic (1754/29035), 3.55% Black (1031/29035) and 0.15% Native American (46/29035). Conclusion: Although there has been increased emphasis on diversifying the field of neurology and increasing access to care in underserved communities, the pipeline of neurology residents has not shown any significant increase in the percentage of URiM neurologists in training. The medical and neurology community must prioritize strategies for diversifying the pipeline of US Neurology residents to reflect the patient population of the US. Such steps include promoting the pipeline of URiM entering medical school, neurology residency and neurology fellowship programs. It is essential to ensure early and sustained exposure of URiM youth to the neurosciences via career awareness, mentorship and access to research and education opportunities.

Evidence-Based Implementation of Free Phenytoin and Free Valproate Therapeutic Drug Monitoring to Reduce Costs and Improve Patient Care at the University of Texas Medical Branch

Oral Abstract Presenter: Hannah Lu, BSA, University of Texas

Background: Excessive laboratory testing is estimated to occur in 30%-50% of all hospitalized patients in the US. Phenytoin and valproate are commonly prescribed anticonvulsants and must be monitored to ensure adequate seizure control while avoiding toxicity. Total serum drug levels have been shown to vary in patients with differing comorbities and are thus less reliable in clinical practice. Reducing the number of total levels ordered would significantly decrease healthcare costs while improving patient care. A quality improvement (QI) assessment performed by the UTMB Neurology department in 2019 revealed total levels made up the majority of tests ordered institutionally. Consequently, educational interventions were implemented throughout the Neurology department to promote testing of free levels only. This current QI project aimed to quantify the change in number of free vs. total levels ordered and assess for adverse outcomes post-intervention. Methods: Our data was collected retrospectively from patients with phenytoin or valproate laboratory tests (729 total) performed at UTMB who were at a UTMB hospital or UTMB clinic from 4/1/2022 to 10/30/2022. We analyzed frequencies of tested phenytoin total (PT), phenytoin free (PF), bundled PT+PF, valproate total (VT), valproate free (VF), bundled VT+VF to determine changes in tests ordered after educational intervention. We also assessed whether therapeutic indices aligned in cases where both total and free levels were ordered. Results: We found 84.6% of valproate and 77.7% of phenytoin labs ordered post-intervention were solo free levels compared to 11-12% of labs ordered pre-intervention. Therapeutic indices did not align in 34.0% of cases when total and free levels were ordered. Additionally, no negative impact was observed from ordering only free levels appreciated by the fact no follow-up orders of total levels were required to determine dosage adjustments. Conclusions: Previously, solo free level tests composed only 11-12% of all lab orders. After implementation of evidence-based phenytoin and valproate monitoring at UTMB facilities, percentages of solo free levels ordered significantly increased to 81.2% of labs ordered. Total serum labs and associated downstream costs have considerably decreased by more than 50% while quality of patient care improved by decreasing unnecessary workups. Additionally, the lack of equivalency in therapeutic indices between free and total levels emphasizes the inefficacy of ordering total levels. Future steps include implementation of similar educational interventions across UTMB and eventually the nation to alleviate excessive and gratuitous ancillary testing.

Disparities in Access to and Experience with Technology and Teleconferencing in MCI Subjects

Oral Abstract Presenter: Abhinav Bhamidipati, BS, University of Pennsylvania

Introduction: Usage of teleconferencing technology in clinical and research settings has become more prevalent in the COVID-19 era with a corresponding increase in disparities in access to and confidence in using technology (Shahid et al. 2020). This abstract aims to identify disparities in digital literacy amongst older adult populations with aMCI. Methods: Data from a screening questionnaire as part of the NIH funded, multi-site Memories2 clinical research study was used for analysis. Amnestic mild cognitive impairment (MCI) status was determined with a neuropsychological battery using standard criteria. Subjects who passed the initial medical and MCI screening were given the questionnaire to gauge access to and comfortability with using teleconferencing. Subjects were given the opportunity to participate in a 15-minute troubleshooting session to increase comfortability with using teleconferencing technology. Results: Data from 399 participants from the University of Pennsylvania site were analyzed. The average age was 65.4 years (SD=7.0), 65% of subjects were female, and 44% of subjects were black. Black persons were significantly less likely to have access to a computer (77.4%) and a smartphone or tablet (75.1%) than Non-Black persons (90.5% and 88.3%, respectively) (p<0.001). Black persons were significantly less likely to have used teleconferencing before (70.6%) compared to Non-Black persons (91.9%) (p<0.001). A troubleshooting session to address challenges with digital literacy was offered to all subjects, and was completed by 204 participants. After the session, the average self-reported confidence in teleconferencing technology increased from 7.6/10 to 8.6/10 (10 = “Extremely Confident”; 1 = “Total lack of confidence”). Participants’ access to technological devices was also associated with their comfort level using technology (Pearson r = 0.23; p < 0.0001). Conclusion: Overall, the majority of participants appeared to have access to technology and felt comfortable using it. Confidence in ability to use technology increased after a troubleshooting session, suggesting that comfort levels can be improved with even a brief, 15-minute supervised support session. This is also an indication that the less access one has to technology, the less comfortable they are likely to be with using technology for health care/medical research. Future research should explore how variation in socioeconomic status affects digital technology accessibility and consequently, confidence in utilizing telehealth applications.