Health Equity in Hospital Medicine: Foundations, Populations, and Action 3031449983, 9783031449987

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Health Equity in Hospital Medicine Foundations, Populations, and Action Dr. Sujatha Sankaran

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Health Equity in Hospital Medicine

Sujatha Sankaran

Health Equity in Hospital Medicine Foundations, Populations, and Action

Sujatha Sankaran Hospital Medicine University of California, San Francisco San Francisco, CA, USA

ISBN 978-3-031-44998-7    ISBN 978-3-031-44999-4 (eBook) https://doi.org/10.1007/978-3-031-44999-4 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

For the people who have helped me envision the world as I hope it to be— Vanitha and my parents for providing me with the canvas, Bobby for sketching the picture with me, and Maya, Kavi, and Hari, for filling it with color.

Contents

Part I Foundations of Health Equity 1

Introduction����������������������������������������������������������������������������������������������    3 1.1 Introduction��������������������������������������������������������������������������������������    3 1.2 What Is Health Equity?��������������������������������������������������������������������    6

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 History of Social Medicine����������������������������������������������������������������������    7 2.1 The History of Social Medicine��������������������������������������������������������    7

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 Social Determinants of Health and Social Needs Screening����������������   11 3.1 A Case����������������������������������������������������������������������������������������������   11 3.2 Social Determinants of Health and Social Needs Screening������������   11

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 Current State of Health Disparities in the United States ��������������������   17 4.1 A Case����������������������������������������������������������������������������������������������   17 4.2 Current State of Health Disparities in the United States������������������   17 4.3 Clinical Pearls ����������������������������������������������������������������������������������   20

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 Social Medicine and Hospital Medicine������������������������������������������������   21 5.1 A Case����������������������������������������������������������������������������������������������   21 5.2 Social Medicine and Hospital Medicine ������������������������������������������   21 5.3 Clinical Pearls ����������������������������������������������������������������������������������   29

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 Patient Safety, Quality Improvement and Health Equity��������������������   31 6.1 A Case����������������������������������������������������������������������������������������������   31 6.2 Patient Safety, Quality Improvement and Health Equity������������������   31 6.3 Clinical Pearls ����������������������������������������������������������������������������������   37

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 Care of Patients in Each Phase of Care ������������������������������������������������   39 7.1 A Case����������������������������������������������������������������������������������������������   39 7.2 Care of Patients in each Phase of Care ��������������������������������������������   39 7.3 Clinical Pearls ����������������������������������������������������������������������������������   41

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Part II Specific Populations 8

 Race in Hospital Medicine����������������������������������������������������������������������   45 8.1 A Case����������������������������������������������������������������������������������������������   45 8.2 Race in Hospital Medicine����������������������������������������������������������������   45 8.3 Clinical Pearls ����������������������������������������������������������������������������������   55

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 Limited English Proficiency and Immigration��������������������������������������   57 9.1 A Case����������������������������������������������������������������������������������������������   57 9.2 Limited English Proficiency and Immigration����������������������������������   57 9.3 Clinical Pearls ����������������������������������������������������������������������������������   61

10 The  Impact of Social Determinants of Health on Hospitalized Patients ������������������������������������������������������������������������������   63 10.1 A Case��������������������������������������������������������������������������������������������   63 10.2 The Impact of Social Determinants of Health on Hospitalized Patients����������������������������������������������������������������������   63 10.3 Clinical Pearls ��������������������������������������������������������������������������������   65 11 Sexual  Orientation, Gender Identity, and Hospital Care��������������������   67 11.1 A Case��������������������������������������������������������������������������������������������   67 11.2 Sexual Orientation, Gender Identity, and Hospital Care����������������   67 11.3 Clinical Pearls ��������������������������������������������������������������������������������   70 12 Substance  Use and Hospital Care����������������������������������������������������������   71 12.1 A Case��������������������������������������������������������������������������������������������   71 12.2 Substance Use and Hospital Care ��������������������������������������������������   71 12.3 Clinical Pearls ��������������������������������������������������������������������������������   74 13 Pain  Management and End of Life Care and Equity ��������������������������   75 13.1 A Case��������������������������������������������������������������������������������������������   75 13.2 Pain Management and End of Life Care and Equity����������������������   75 13.3 Clinical Pearls ��������������������������������������������������������������������������������   78 14 The Rural-Urban Divide ������������������������������������������������������������������������   79 14.1 A Clinical Case ������������������������������������������������������������������������������   79 14.2 The Rural-Urban Divide ����������������������������������������������������������������   79 14.3 Clinical Pearls ��������������������������������������������������������������������������������   81 15 Incarcerated  Patients in the Hospital����������������������������������������������������   83 15.1 A Case��������������������������������������������������������������������������������������������   83 15.2 Incarcerated Patients in the Hospital����������������������������������������������   83 15.3 Clinical Pearls ��������������������������������������������������������������������������������   85 16 Geriatric  Patients and Inpatient Health Equity������������������������������������   87 16.1 A Case��������������������������������������������������������������������������������������������   87 16.2 Geriatric Patients and Inpatient Health Equity ������������������������������   87 16.3 Clinical Pearls ��������������������������������������������������������������������������������   92

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17 Environmental  Health and Its Effects on Health Equity ��������������������   93 17.1 A Case��������������������������������������������������������������������������������������������   93 17.2 Environmental Health and Its Effects on Inpatient Health Equity����������������������������������������������������������������������������������   93 17.3 Clinical Pearls ��������������������������������������������������������������������������������   98 18 Disparities  in Technology Use for Hospitalized Patients����������������������   99 18.1 A Case��������������������������������������������������������������������������������������������   99 18.2 Disparities in Technology Use for Hospitalized Patients����������������   99 18.3 Clinical Pearls ��������������������������������������������������������������������������������  102 19 Interpersonal  Violence and Its Effect on Hospitalized Patients����������  103 19.1 A Case��������������������������������������������������������������������������������������������  103 19.2 Interpersonal Violence and Its Effect on Hospitalized Patients����������������������������������������������������������������������  103 19.3 Clinical Pearls ��������������������������������������������������������������������������������  111 20 The  Loneliness Epidemic and How It Affects Hospitalized Patients ������������������������������������������������������������������������������  113 20.1 A Case��������������������������������������������������������������������������������������������  113 20.2 The Loneliness Epidemic and How It Affects Hospitalized Patients��������������������������������������������������������������������������������������������  113 20.3 Clinical Pearls ��������������������������������������������������������������������������������  116 Part III Framework and Action 21 Financial  Argument for Providing Hospital-Based Screening and Interventions for Health-Related Social Needs������������������������������  121 21.1 A Case��������������������������������������������������������������������������������������������  121 21.2 Financial Argument for Providing Hospital-Based Screening and Interventions for Health-Related Social Needs������  121 21.3 Clinical Pearls ��������������������������������������������������������������������������������  124 22 The  Impact of Hospital Security Measures on the Provision of Equitable Care ������������������������������������������������������������������������������������  125 22.1 A Case��������������������������������������������������������������������������������������������  125 22.2 The Impact of Hospital Security Measures on the Provision of Equitable Care��������������������������������������������������������������������������������  125 22.3 Clinical Pearls ��������������������������������������������������������������������������������  128 23 Patient  Centered Care and Community Involvement in Hospital Care ��������������������������������������������������������������������������������������  129 23.1 A Case��������������������������������������������������������������������������������������������  129 23.2 Patient Centered Care and Community Involvement in Hospital Care������������������������������������������������������������������������������  129 23.3 Clinical Pearls ��������������������������������������������������������������������������������  133

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24 Framework  for the Future����������������������������������������������������������������������  135 24.1 Information Technology������������������������������������������������������������������  137 24.2 Education����������������������������������������������������������������������������������������  137 24.3 Facilitation��������������������������������������������������������������������������������������  139 24.4 Patient Activation����������������������������������������������������������������������������  140 24.5 Re-Imagining Care for Iysha and Bernard��������������������������������������  141 Index������������������������������������������������������������������������������������������������������������������  145

Part I

Foundations of Health Equity

Chapter 1

Introduction

1.1 Introduction Framed by stunning views of the city on the fifteenth floor of a large academic medical center in San Francisco, at opposite ends of the corridor, two patients lie in their hospital beds. The first patient is Iysha Simmons, 32-year-old woman with long waves of ebony hair held back in a bun, a grimace on her face, body curled into fetal position. Iysha was admitted with fevers, chills, rigors, dysuria, and severe pain in her low back, and found to have E coli sepsis from a urinary tract infection. She presented to a community urgent care clinic a week before hospital admission with dysuria and back pain, and was sent home with a prescription for the antibiotic trimethoprim-sulfamethaxazole and a small supply of oxycodone for pain. When Iysha found out from the pharmacy that the copay for the medications would be $50, she hesitated because she was running low on money after recently losing her job as a cashier at a convenience store that closed during the COVID-19 pandemic and was the single parent of three young kids. But, convinced by the excruciating abdominal and back pain she was experiencing, she paid for the medications. When Iysha got home, she started taking her medications, and found that the antibiotic and painkiller together were effective at significantly reducing her pain. Distracted by the many pressures in her life, including interviews for more retail jobs and caring for her young kids, she stopped taking the antibiotic when her symptoms subsided after just three doses. But her reprieve was short-lived, and gradually, her symptoms returned in full force. She didn’t have an established primary care doctor, and on a Saturday evening called her mother to come watch her kids, and took herself to the Emergency Department. In the ED, after waiting for 4  hours, she is seen by the clinical team. She is questioned about why she had failed to complete her course of antibiotics, and why she did not have a primary care physician. She identifies as Black, and is being cared for by doctors and nurses who for the most part don’t look

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_1

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like her. She feels intimidated, embarrassed, anxious about who will care for her kids if she is admitted to the hospital, sick from the pain that is boring into her abdomen and back, and tired from the stress that she is carrying that never seems to remit. She is told that she has an infection in her kidneys that has spread to her blood, and will need to be admitted to the hospital for intravenous antibiotics. Exhausted, she buries herself into the sheets on her bed. Across the hall, in another hospital bed, lies an 84-year-old man, Bernard Greco. Bernard was living independently until falling ill, but after 9 days in the hospital, is weak and unable to get out of bed without assistance. He had been living alone at home in a government-subsidized apartment 10 days ago when he began to experience episodes of lightheadedness and decreased appetite. At baseline, he was able to carry out all of his activities of daily living without any difficulty. When his niece checked in on him a week before admission, she found him lying in bed in his own feces, confused and disoriented. Alarmed, she called 911 and Bernard was brought to the hospital. In the Emergency Department, he was found to have a urinary tract infection with the bacteria Klebsiella that had spread to the blood. His blood pressure rapidly dropped, and he was admitted to a transitional care unit, where his vital signs would be monitored closely in case his blood pressure dropped again precipitously. He never required vasopressors to support his blood pressure, and with aggressive intravenous hydration and broad IV antibiotics, his mental status rapidly improved. His antibiotic regimen was narrowed, and he was transferred to the Acute Care of Elders, or ACE unit, a medical ward specialized in providing care for elderly patients, with a focus on minimizing medications, preventing delirium, and mobilizing and mentally stimulating patients as much as possible. Despite this care, Bernard remains debilitated. He is weak, still not eating a significant portion of his meals, and even sitting on the side of his bed requires great effort. He worked for many years, married but had no children, and he and his wife were able to buy an apartment in the Hayes Valley neighborhood of San Francisco many years ago. Bernard, the grandson of Italian Jewish immigrants, has lived in San Francisco for most of his life, owns an apartment, and has saved for retirement, but this savings is not enough to cover the exorbitant costs of a prolonged inpatient hospitalization, even with insurance coverage. After his wife died several years earlier, he has lived alone, independent but socially isolated. He finds it increasingly difficult to walk to his neighborhood grocery store every week. He lives in an increasingly gentrified neighborhood of San Francisco, and many of the smaller shops on his street have been converted to boutique clothing stores and hipster eateries. He walks to one of the few remaining corner stores to get groceries and sometimes plays chess with a friend across the street. His only local family is a niece who is able to occasionally check on him but is harried by her own work and family responsibilities and does not have the ability to play a more substantial role in his life. He will not be able to return home in the state that he is currently in, too debilitated to walk up the five stairs to even get to his front door. He has not prepared for this eventuality. It is only when he becomes ill that he begins to get a glimpse of a future that may not be independent. When he is hospitalized, he has trouble hearing what his clinical team

1.1 Introduction

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is saying to him, and does not understand what is happening. At nighttime, he becomes delirious and thinks that he is still at home in his bed. When bedside nurses come to check his vital signs, he screams, thinking that he is at home and they are intruders. Health equity, particularly in inpatient settings, has not traditionally been incorporated into patient care in an intentional manner. But it is impossible to take care of patients who are acutely ill without taking into consideration the social milieu to which they will return—whether the impoverished patient with diabetes will have the money to fill the insulin prescription that she is given, whether the unhoused patient with severe cellulitis will have a bed on which to elevate his infected leg, or whether the patient with a substance use disorder will return to the environment in which he is prone to use drugs. These are scenarios all health care workers consider implicitly when creating discharge plans for patients, but often do not name. This has gradually changed in the past couple of decades, and in May 2020, when George Floyd’s murder by police officers in Minneapolis laid bare the stark disparities in mortality rates between Black and Latinx patients and the rest of the population, the national spotlight was shone on this inequity. As in all other aspects of life in America, it was no longer possible to deny what health workers and patients already knew, that who a patient is—where they come from, what language they speak, what they look like, what their religious beliefs are, who they choose to marry or sleep with, what gender they identify with, their socioeconomic status, their race, their culture—determines the care they receive in the hospital. Hospital Medicine is a reasonably new field, born around the time when Drs. Bob Wachter and Lee Goldman coined the term “hospitalist” in 1996, and it is a field that has taken ownership of quality improvement and patient safety, predicated on the notion that merely providing direct patient care is not enough. It is only when we understand health system deficiencies and continually improve this care, as well as elucidate and follow the implicit and explicit frameworks that exist when providing this care that we will be successful. Hospital Medicine is thus the perfect field in which principles of equity should be explored and developed, and new paradigms created for ensuring that the health care provided to hospitalized patients is equitable. The two patients described here, Iysha Simmons and Bernard Greco both entered a large, quaternary care academic medical center with the diagnoses of sepsis due to a urinary tract infection. This is where their similarities ended. They were different ages, races, and genders, with vastly different life experiences. Yet is undeniable that the care they receive will be at least in part determined by Iysha’s race and Bernard’s age, their relative socioeconomic resources, and the support structures they have in their families and friends. How long they remain in the hospital, what treatment they receive, how they are treated by hospital staff, indeed, whether they live or die, will at least in part be dictated by who they are. This book is an exploration of these factors, and will describe an organizing framework for hospitalist providers as they attempt to provide equitable care to their patients. This is the crux of the work that we do as physicians—at its essence, we are people taking care of other people. And just like anyone else, we are susceptible to bias, assumptions, and

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subjectivity. By stepping back and learning how we can better understand the care that we provide and incorporating principles of equity into everything we do, we can learn to provide hospital medicine care that is truly equitable.

1.2 What Is Health Equity? Health equity is defined by the World Health Organization as “the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically, or by other means of stratification”.1 Simply put, health equity is the attempt to acknowledge the differing needs of people with differing life circumstances, to tailor care to suit those differences, and to mitigate the deleterious effects of those circumstances in the arena of health. In the cases described earlier, it is helping Iysha with the financial resources she may need to obtain the medications she needs to be healthy, and providing Bernard with assistance at home or at a care facility because of his lack of support. It is truly understanding what the needs of each patient are and how those needs impede care, and designing interventions that target those needs, rather than applying broad brush approaches to caring for all patients. As Paula Dressel from the Race Matters Institute has stated, “the route to achieving equity will not be accomplished through treating everyone equally. It will be achieved by treating everyone justly according to their circumstances.”2 These circumstances may include social determinants of health, social and environmental factors that predispose individuals to different health outcomes, such as economic status, access to education, social and cultural context, zip code and built environment, and access to health care facilities. Common social determinants of health that have a clear impact on health include poverty, literacy, racism, education, employment status, access to transportation, food availability, air and water pollution, and safe housing and neighborhoods. Other circumstances that predispose patients to health outcomes includes behavioral determinants of health, such as smoking, alcohol use, and other substance use. As the National Academy of Sciences has stated, “research shows that problems like poverty, unemployment, low educational attainment, inadequate housing, lack of public transportation, exposure to violence, and neighborhood deterioration (social or physical) shape health and contribute to health inequities”.3

  World Health Organization, https://www.who.int/health-topics/health-equity, accessed July 6, 2022. 2  Race Matters Institute, https://www.viablefuturescenter.org/racemattersinstitute/. 3  National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press. https://doi. org/10.17226/24624. 1

Chapter 2

History of Social Medicine

2.1 The History of Social Medicine Simply put, social determinants of health can be defined as all of the factors that influence a person’s health. This includes where a patient lives, what work they do, what their race and ethnic background are, their gender identity, their sexual orientation, their immigration status, their education level, their income, and any other circumstance of their life. The notion that health is determined by more than just the intentional actions of individuals can be traced to the early 1800s, when the industrial revolution brought about rapid industrialization and urbanization, leading to an increase in low-wage workers who often worked under poor working conditions, increasingly crowded living conditions that led to poor sanitation, and lack of safe housing. The effects of poverty and these unsafe living conditions in turn led to increases in communicable diseases in the United States and many European countries, drawing the attention of some in the health care field to the role that social circumstances play in health. At around this time in France, a group of reformist French physicians and hygienists conducted a series of surveys on the influence of living and working conditions on health.1 This dawning recognition that social factors influence health coincided with the social upheaval preceding the French Revolution, as the timing was ripe to re-think commonly-held beliefs and frameworks. The term “social medicine” was coined in 1848 by Dr. Jules Guerin shortly after the French Revolution as a call to action for physicians to create a new framework for health care that was inclusive of all.

 Rosen G.  The evolution of social medicine. In: Freeman HE, Levine S, Reeder LG, editors. Handbook of medical sociology. 2nd ed. Englewood Cliffs: Prentice-Hall; 1972. pp.  30–60. [Google Scholar]. 1

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2  History of Social Medicine

Concurrently, in Germany, Rudolf Virchow, a prominent German physician whose work was seminal in the fields of Pathology and Social Medicine, started to write and speak about the role that social conditions play in health. His report on typhus provided a comprehensive study on a typhus outbreak, delineating the many complex social factors that had led to the outbreak. In this report, Virchow wrote “If medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find the diseases of the populace traceable to defects in society?”2 Virchow promoted the notion that advocating for changes in social circumstances that would improve health is an essential component of health care delivery. Virchow and his colleagues introduced three fundamental principles of the budding new field of social medicine3: 1. The health of a population is a matter of direct social concern 2. Social and economic conditions have an effect on health, and should be studied as factors that influence health’ 3. The field of medicine should adopt both clinical and social measures to promote health and combat disease. In the 1900s, Dr. Salvador Allende, a proponent of recognizing the importance of social factors in determining health brought concepts of social medicine to Latin America.4 Allende would later become president of Chile. In 1948, the World Health Organization, which had been formed after World War II as a reaction to the myriad humanitarian and public health issues unmasked by the war, created a constitution that adopted the definition of health as “a state of complete physical, mental, and social well-being.”5 It was around this time that the medical establishment in the United States also began to recognize the importance of social factors in determining health. However, increasing tensions between the United States and USSR led to increasing suspicion of the American public towards centralized approaches to health care delivery as “social medicine” was conflated with “socialized medicine.” The American approach to health care delivery was individualistic and innovation-­ driven, rather than communal and public health-oriented. Thinking around public health in the US began to evolve again in the 1960s with increased numbers of academic papers on social medicine that elucidated the vital role that social factors play in determining health outcomes. In addition, there were programmatic advancements in low- and middle-income countries in the 1960s which emphasized the vital role of social factors in health. Programs that employed community health workers to deliver care in remote and resource-denied regions were increasingly common in Asian and Latin American countries, and literature began to emerge exhibiting the utility of these approaches for improving health.  Virchow writing.  Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Public Health. 2001;91(10):1592–1601. [PMC free article] [PubMed] [Google Scholar]. 4  Waitzkin H, Iriart C, Estrada A, Lamadrid S. Social medicine then and now: lessons from Latin America. Am J Public Health. 2001;91(10):1592−601. https://doi.org/10.2105/ajph.91.10.1592. PMID: 11574316; PMCID: PMC1446835. 5  WHO info. 2 3

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In September 1978, the World Health Organization and UNICEF sponsored the International Conference on Primary Health Care in Alma-Ata, Kazakhstan. At this conference, the Director-General of the World Health Organization announced a focus on primary health care as the cornerstone of effective health care. In 1984, the US Secretary of Health and Human Services Margaret Heckler commissioned an investigation on health disparities, and issued a report that documented “persistent and distressing disparity” across different demographic groups.6 The Taskforce ­determined that there were excess deaths observed in minority populations in over 40 disease categories and disparities in disease prevalence, hospital admission rates, physician visits, and self-assessed health status.7 The Office of Minority Health was created in 1987 by the Department of Health and Human Services in response to the Taskforce Report with the express goal of developing programs and policies that would address the disparity. In 1999, Congress asked for an annual National Health Care Disparities Report which was commissioned by the Institution of Medicine as the report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care”. This report found that there were disparities in the burden of diseases and services provided when different racial and ethnic groups were compared.8 It is important to note that the disparities cited in this report persisted even when controlling for differences in access and socioeconomic differences. Since the publication of this landmark report, research has focused on quantification of disparities and their causes, and analyzing interventions to decrease disparities. However, it was only in 2002, when the WHO formed the Commission on Macroeconomics and Health and the financial benefits of focusing on social factors in determining health were better elucidated, that more specific goals to improve primary health care were adopted by the WHO. In 2003, the social determinants of health that were prioritized by the WHO included food insecurity, transportation difficulties, lack of social support, unemployment, social isolation, early life stress, and addiction.9 In 2008, the WHO went a step further and published “Closing the Gap in a Generation”, which took an in-depth look at how health equity could be achieved worldwide.10 This report linked economic development goals to achieving health equity and took the holistic view that health care was impacted by myriad  https://scholar.google.com/scholar_lookup?title=Report+of+the+Secretary%27s+Task+Force+R eport+on+Black+and+Minority+Health+Volume+I:+Executive+Summary&author=Margaret+M +Heckler&publication_year=1985&. 7  https://scholar.google.com/scholar_lookup?title=Report+of+the+Secretary%27s+Task+Force+R eport+on+Black+and+Minority+Health+Volume+I:+Executive+Summary&author=Margaret+M +Heckler&publication_year=1985&. 8  https://scholar.google.com/scholar_lookup?title=Unequal+Treatment:+Confronting+racial+and +ethnic+disparities+in+health+care&publication_year=2002&. 9  Wilkinson, Richard; Marmot, Michael, eds. (2003). The Social Determinants of Health: The Solid Facts (PDF) (2nd ed.). World Health Organization Europe. ISBN 978-92-890-1371-0. 10  Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (PDF). World Health Organization. ISBN 978-92-4-156370-3. Retrieved 2013-03-27. Pg 2. 6

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factors. In particular, two focuses on social determinants of health were adopted— focus on the daily circumstances that determine health for individuals and communities, such as employment, physical living circumstances, health care access, and focus on the social safety net, and the larger economic factors that drive health, such as economic disparities, political upheaval, lack of resources, and imbalances in power. In 2010, the Affordable Care Act (ACA) was passed in the United States, and one of the main goals of the legislation was to make policy changes that impact health. One example of this was the granting of Community Transformation Grants to community organizations to help change the larger factors that drive health. Some of the fundamental policy aims of the ACA were to improve insurance coverage and affordability of care, improve data collection on sociodemographic characteristics of patient populations, diversify the health care workforce, and open more community health centers. In 2011, the World Conference on Social Determinants of Health was convened, and the Rio Political Declaration on Social Determinants of Health was created. This declaration was a call for adopting global policies to combat social inequity.11 The murder of George Floyd by police in 2020 in the midst of the highly visible disparities in disease burden among racial and ethnic minorities during the COVID-19 pandemic highlighted the need for further whole-of health-care and whole-of-society interventions to change policy in order to provide more effective health care across sociodemographic groups, provide public health education across populations, and increase diversity in the health care workforce.

 The World Health Organization, World Conference on Social Determinants of Health, Rio Political Declaration on Social Determinants of Health (21 October 2011), available from https:// www.who.int/sdhconference/declaration. 11

Chapter 3

Social Determinants of Health and Social Needs Screening

3.1 A Case Mrs. Wilson is an 82-year-old woman with a history of hypertension and diabetes who has been living alone since her husband died a year ago. She has had progressive difficulty buying groceries because of inability to manage her finances and difficulty walking to the store as she previously had been. She has a niece who checks on her periodically and notes that her house has become increasingly disorganized and that she is becoming socially isolated. Her niece finds her at home one day, after she has fallen while getting out of the bathroom, and brings her to the Emergency Department, where she is found to have a hip fracture and admitted to the hospital. During her admission assessment, the nurse conducts a verbal survey assessing her health-related social needs. She screens positive for a number of social needs, including financial insecurity, transportation difficulty, and social isolation, driven by her age and lack of social support.

3.2 Social Determinants of Health and Social Needs Screening Social determinants of health, according to the World Health Organization are “the nonmedical factors that influence health outcomes.”1 These include the proximal factors that affect health, such as living circumstances, food availability, housing status, gender identity, age, race, insurance coverage, and socioeconomic status, as well as larger driving forces such as societal factors, economic policies, and political dynamics. Independent of whether a country overall is low-, middle-, or  https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.

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high-­income, a patient’s individual socioeconomic status impacts their health status. “Health-related social needs” is a term that is used to describe the downstream effects of the social determinants of health on patients. While social determinants of health describe the larger environment that determines health, health-related social needs describe the immediate factors that influence a patient’s ability to be healthy. The paradigm of our health system focuses on individual patients whose biological illnesses can be prevented and treated, but there is also broad acknowledgment among the medical community that health is determined by social, in addition to biological factors. In many cases, the illness that is experienced by the patient is a distal effect of more proximal factors. For example, individuals who live in certain zip codes may have poor access to healthy foods, higher rates of poverty that lead to inability to obtain necessary medications, poor transportation options making health facilities difficult to access, high rates of air pollution that lead to increased rates of cardiac and pulmonary diseases, and lack of a health facility within reasonable proximity, leading to inability to access emergency medical care. While the biological disease facing the patient may be the immediate cause of their illness, the larger disease is in the social structure itself, leading to a context in which accessing care becomes prohibitively difficult. If this paradigm is accepted, improving population health becomes as important as improving individual health. There are a multitude of examples of how social factors influence health both domestically and abroad. As many low- and middle-income countries have experienced economic growth, they have also seen a transition from infectious diseases as primary causes of death and illness to non-communicable diseases driving morbidity and mortality. Non-communicable diseases, which include heart disease, strokes, and cancer, according to the World Health Organization, have two larger driving factors, modifiable behavioral factors and metabolic factors. Behavioral factors include tobacco use, salt intake, alcohol use, and lack of physical activity, while metabolic factors include diabetes, overweight, hypertension, and hyperlipidemia.2 It is worth noting that there is a distinction between behavioral determinants of health and social determinants of health. Health-related behaviors often occur because of larger social drivers, but themselves are not social determinants of health. For example, alcohol and tobacco use are more common in regions where there is more access to these substances, such as increased density of liquor stores and decreased taxes on tobacco and alcohol.3 The rise of non-communicable disease rates in low- and middle-income countries which correlates to increasing economic development and wealth shows how socioeconomic factors play a vital role in determining health. In these societies, despite an increase in overall wealth that occurs with economic development, it is the more impoverished segments of the population that have worse outcomes due to non-communicable diseases, largely due to decreased access to safe living environments, medical care, and healthy food.

 https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases.  https://www.sciencedirect.com/science/article/pii/S0091743521004941.

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In turn, high rates of non-communicable diseases lead to loss of income and higher rates of poverty, perpetuating a cycle of illness and poverty.4 There is also ample evidence that racism and racial disparities have direct biological linkages to poor health outcomes. This relationship has been particularly well-illustrated in the obstetrics literature, which has demonstrated that African American newborn babies are more likely than newborn babies from other racial groups to be delivered prematurely, have low birth weights, and die within the first year of life.5 These outcomes are hypothesized to be due to multiple factors, including health disparities, barriers to access, and allostatic load. Allostatic load is burden that social stressors play on individuals, leading to adverse health outcomes such as coronary arterial disease, obesity, inflammatory disorders, cognitive impairment, autoimmune disorders, diabetes, and depression.67 The prevalence of diseases differs based on socioeconomic and demographic differences. These disparities had once been hypothesized to be due to biological factors, but numerous studies have shown that environment plays a large role in these disparities. For example, the prevalence of heart disease and diabetes is two to five times higher in African Americans than in Caribbean populations of African origin.8 This points to environmental causes for differences in disease prevalence rates. The Center for Interdisciplinary Health Disparities Research at the University of Chicago (CIHDR) has created a comprehensive model of the system through which upstream societal factors influence health outcomes. This model emphasizes the upstream influences as causative in all levels of the downstream effects on patients.9 One poignant illustration of the complex interplay between public policy, individual behaviors, and health occurred in the United States during the COVID-19 pandemic. Food insecurity rates had been declining in the United States before the  Global Burden of Disease Collaborative Network, Global Burden of Disease Study 2019 (GBD 2019) Results (2020, Institute for Health Metrics and Evaluation – IHME) https://vizhub.healthdata.org/gbd-results/. 5  Giscombé CL, Lobel M.  Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy. Psychol Bull. 2005 Sep;131(5):662–83. doi: 10.1037/0033-2909.131.5.662. PMID: 16187853; PMCID: PMC7451246. 6  Williams DR. Stress and the Mental Health of Populations of Color: Advancing Our Understanding of Race-related Stressors. J Health Soc Behav. 2018 Dec;59(4):466–485. doi: 10.1177/0022146518814251. PMID: 30484715; PMCID: PMC6532404. 7  Djuric Z, Bird CE, Furumoto-Dawson A, Rauscher GH, Ruffin MT 4th, Stowe RP, Tucker KL, Masi CM.  Biomarkers of Psychological Stress in Health Disparities Research. Open Biomark J. 2008 Jan 1;1:7–19. doi: 10.2174/1875318300801010007. PMID: 20305736; PMCID: PMC2841407. 8  Cruickshank JK, Mbanya JC, Wilks R, Balkau B, McFarlane-Anderson N, Forrester T.  Sick genes, sick individuals or sick populations with chronic disease? The emergence of diabetes and high blood pressure in African-origin populations. Int J Epidemiol. 2001;30(1):111–117. 9  Gehlert S, Sohmer D, Sacks T, Mininger C, McClintock M, Olopade O. Targeting health disparities: a model linking upstream determinants to downstream interventions. Health Aff (Millwood). 2008 Mar-Apr;27(2):339–49. doi: 10.1377/hlthaff.27.2.339. PMID: 18332488; PMCID: PMC2494954. 4

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pandemic and had reached a 20-year low in 2019. However, in March of 2020, the onset of the COVID-19 pandemic led the World Health Organization to declare a state of emergency, and many national and local governments followed this with stay-at-home orders. These orders led to a sharp decrease in food access, and the rates of food insecurity skyrocketed, with an increase to 17 million Americans who were food insecure in 2020.10 This increase in food insecurity led to worsened health outcomes, particularly in already marginalized patient populations. The presence of social determinants of health correlate with one another and impact overall behaviors that are both detrimental and beneficial to health. In the United States, the “Healthy People 2030” framework was adopted as a mechanism for guiding providers to address social determinants of health as part of overall care.11 The Healthy People reports began in 1979, when Surgeon General Julius Richmond issued a report entitled “Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention.” This report provided a blueprint for adopting strategies for population-level health care improvement. Since 1980, a new healthy people report has been released every 10 years, with goals and strategies for health promotion that build on those of the previous report. Healthy People 2030 has outlined the following foundational principles12: • The health and well-being of all people and communities is essential to a thriving, equitable society. • Promoting health and well-being and preventing disease are linked efforts that encompass physical, mental, and social health dimensions. • Investing to achieve the full potential for health and well-being for all provides valuable benefits to society. • Achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy. • Healthy physical, social, and economic environments strengthen the potential to achieve health and well-being. • Promoting and achieving health and well-being nationwide is a shared responsibility that is distributed across the national, state, tribal, and community levels, including the public, private, and not-for-profit sectors. • Working to attain the full potential for health and well-being of the population is a component of decision-making and policy formulation across all sectors.

 Gundersen C, Hake M, Dewey A, Engelhard E. Food Insecurity during COVID-19. Appl Econ Perspect Policy. 2021 Mar;43(1):153–161. doi: 10.1002/aepp.13100. Epub 2020 Oct 12. PMID: 33042509; PMCID: PMC7537061. 11  https://health.gov/healthypeople/about/healthy-people-2030-framework. 12  https://health.gov/healthypeople/about/healthy-people-2030-framework. 10

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Healthy People 2030 in turn outlined these specific actions13 to carry out the larger principles outlined above: • Attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death. • Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. • Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all. • Promote healthy development, healthy behaviors, and well-being across all life stages. • Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. In turn, Healthy People 2030 encouraged nations and societies to take on the following specific actions in order to intervene on social determinants of health14: • Set national goals and measurable objectives to guide evidence-based policies, programs, and other actions to improve health and well-being. • Provide accurate, timely, and accessible data that can drive targeted actions to address regions and populations that have poor health or are at high risk for poor health. • Foster impact through public and private efforts to improve health and well-­ being for people of all ages and the communities in which they live. • Provide tools for the public, programs, policymakers, and others to evaluate progress toward improving health and well-being. • Share and support the implementation of evidence-based programs and policies that are replicable, scalable, and sustainable. • Report biennially on progress throughout the decade from 2020 to 2030. • Stimulate research and innovation toward meeting Healthy People 2030 goals and highlight critical research, data, and evaluation needs. • Facilitate the development and availability of affordable means of health promotion, disease prevention, and treatment. As social determinants of health have become increasingly recognized as important drivers of overall health, the United States government Centers for Medicare and Medicaid Services in January of 2021 issued a roadmap for addressing Social Determinants of Health in the Medicaid and Children’s Health Insurance Programs. As CMS administrator Seema Varma stated, “the evidence is clear: social determinants of health, such as access to stable housing or gainful employment, may not be strictly medical, but they nevertheless have a profound impact on people’s

13 14

 https://health.gov/healthypeople/about/healthy-people-2030-framework.  https://health.gov/healthypeople/about/healthy-people-2030-framework.

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wellbeing.”15 The roadmap emphasized the benefits that address social determinants of health and are covered by the law. These benefits include housing-related services, non-medical transportation, community integration, social supports, and case management.16 –– A complex interplay between health-related social needs, social determinants of health, and individual characteristics drives each patient’s health status. –– Screening for health-related needs in clinical practice is both vital for ensuring high-quality care and becoming a regulatory requirement. –– Downstream pathways for addressing health-related social needs in clinical practice should be implemented through referral systems and robust community linkages to hospitals.

 https://www.cms.gov/newsroom/press-releases/cms-issues-new-roadmap-states-address-socialdeterminants-health-improve-outcomes-­­lower-costs. 16  https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf. 15

Chapter 4

Current State of Health Disparities in the United States

4.1 A Case Mr. Samuels is a 57-year-old man with a history of diabetes, hypertension, and end-­ stage renal disease on hemodialysis, who is admitted to the hospital with fevers, malaise, and pain at the site of his tunneled hemodialysis catheter site. He is found to have an infected catheter site and is scheduled for removal of the catheter. He identifies as Black, and has experienced numerous disparities in the management of his kidney disease, including delayed identification of his chronic kidney disease, delayed referral to a nephrologist once his kidney disease was identified, and delayed listing for a kidney transplant. Now he experiences frequent hospitalizations from complications of his end stage kidney disease.

4.2 Current State of Health Disparities in the United States Disparities are defined as health differences arising from social, economic, and/or economic disadvantage primarily experienced by people and communities that are defined by characteristics such as racial or ethnic identity, immigration status, gender identity, zip code, or disability status. Certain diseases are more prevalent in different segments of the population, and interventions to decrease disparities must take into consideration these different patterns of disease prevalence.1

 U.S. Department of Health and Human Services The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet] Section IV: Advisory Committee findings and recommendations [cited 2010 January 6] Available from: http://www.healthypeople. gov/sites/default/files/PhaseI_0.pdf. 1

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Five highly prevalent groups of diseases that illustrate differing morbidity and mortality based on disparities are diabetes, malignancy, renal disease, cardiovascular disease, and mental illness. Diabetes rates are higher in Latinx, Black and Native American/Alaskan Native patients as compared to White patients. In addition, of those patients with diabetes, non-White patients have a higher risk of complications such as amputations and end-stage renal disease, and higher mortality rates when compared to White patients.2 Race, ethnicity, socioeconomic status, zip code, and gender all play a role in cancer disparities. There is evidence that Black patients receive fewer diagnostic evaluations, fewer referrals to specialty care, less follow­up for abnormalities, and are more likely to die from cancer compared to other racial groups.3 In addition, patients with lower socioeconomic status and less education have higher incidence and mortality rates from cancer than patients with higher socioeconomic status and more education.4 End stage renal disease is kidney failure requiring hemodialysis or kidney transplantation, and in the United States, the patients at highest risk are individuals with diabetes, hypertension, or a family history of kidney disease. Patients with lower socioeconomic status have a higher incidence of chronic kidney disease, increased rates of progression to end stage renal disease requiring dialysis or transplantation, higher rates of inadequate dialysis, and decreased access to kidney transplants.5 Patients who are from a racial or ethnic minority group have higher rates of diabetes and hypertension, and thus higher rates of developing end stage renal disease if they have a predisposing factor.6 Though there are higher rates of CKD and ESRD in racial and ethnic minority groups, there are few exceptions to this scenario. Older adults who are racial and ethnic minorities have higher adjusted survival rates when compared to White patients.7 In addition, Black patients with ESRD who are on dialysis have lower mortality rates than White patients with ESRD who are receiving dialysis.8 Cardiovascular disease, which includes coronary artery disease and stroke, is the leading cause of death in the United States. Black adults have a higher risk of  Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. US Department of Health and Human Services; Atlanta, GA: 2014. 3  American Cancer Society. Cancer Facts & Figures 2015. American Cancer Society; Atlanta: 2015. 4  American Cancer Society. Cancer Facts & Figures 2015. American Cancer Society; Atlanta: 2015. 5  Patzer RE, McClellan WM. Influence of race, ethnicity and socioeconomic status on kidney disease. Nat Rev Nephrol. 2012;8:533–541. 6  U.S. Renal Data System. USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Bethesda, MD: 2011. 7  Palmer Alves T, Lewis J. Racial differences in chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States: a social and economic dilemma. Clin Nephrol. 2010;74(Suppl 1):S72–7. 8  Palmer Alves T, Lewis J. Racial differences in chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States: a social and economic dilemma. Clin Nephrol. 2010;74(Suppl 1):S72–7. 2

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developing strokes and a higher risk of death from stroke as compared to White adults in the US.9 There a number of demographic linkages to cardiovascular disease and risk factors for cardiovascular disease. Cardiovascular risk factors including tobacco use disorder, overweight and obesity, hypertension, hyperlipidemia, diabetes mellitus, excessive alcohol use, and physical inactivity are more likely in patients who have lower socioeconomic status, lower educational attainment, live in the Southeastern US, or come from a racial or ethnic minority group.10 Mental health disorders, including schizophrenia, major depressive disorder, and anxiety, are strongly linked to social determinants of health such as housing status. Approximately a quarter of adults with unstable housing have a mental health disorder, and a similar percentage of prisoners have a history of mental illness.11 In addition, there is a large rate of overlap between mental illness and substance use disorders. There is evidence that patients from racial and ethnic minority groups including Black patients, Latinx patients, and Asian American and Pacific Islander patients have lower rates of treatment for mental health illnesses.12 There is evidence that patients from racial and ethnic minority groups have higher rates of undiagnosed mental illness potentially due to cultural reasons, language barriers, and implicit bias.13 Historically, researchers have noted that there exists a “Hispanic paradox”, or “Latino paradox” that despite disparities in access and care, Latinx patients have lower mortality rates when compared to White patients, and patients from other racial and ethnic minority groups. The CDC’s 2015 Vital Signs report quantified this difference as a 24% lower risk of mortality, and lower risk for nine of the 15 leading causes of death in the US as compared to White patients.14 However, this report also noted that Latinx patients have a higher prevalence of obesity, and higher rates of death from diabetes, liver disease, and homicide.15 It is unclear why this paradox exists, with a number of theories proposed, including the theory that a disproportionate number of healthy Latinx individuals migrate to the US, the hypothesis that cohesive family networks provide a protective influence, and the observation that many Latinx individuals return to their countries of origin when they become older,  Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322. 10  Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322. 11  Substance Abuse and Mental Health Services Administration . Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings. Substance Abuse and Mental Health Services Administration; Rockville, MD: 2014. (NSDUH Series H-49). HHS Publication No. (SMA) 14-4887. 12  Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1993;50(2):85–94. 13  American Psychological Association Health Care Reform: Disparities in Mental Health Status and Mental Health Care. 2015. 14  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60945-X/fulltext. 15  https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60945-X/fulltext. 9

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decreasing overall mortality rates.16 However, the COVID-19 pandemic disproportionately affected Latinx patients, leading to rapid diminishment of the Hispanic paradox.17 In 2020, the COVID-19 pandemic exhibited the stark disparities between different racial and ethnic groups in rates of transmission, morbidity, and mortality from COVID-19. Studies have shown that rates of COVID-19 positivity and admissions to the ICU of COVID-19 patients were higher in African American, Latinx and Asian American and Pacific Islander populations compared to White patients.18 Theories for why these patient populations have higher rates of COVID-19 prevalence and morbidity when compared to White patients include overrepresentation of these racial and ethnic minority groups in essential jobs that in turn increase potential exposure to COVID-19, and higher coexistence of comorbidities such as hypertension and obesity which lead to worse outcomes. There is a correlation between increased deprivation and increased mortality in COVID-19 patients, but in Asian American patients a paradoxical correlation also was noted between increased median income and mortality rates, possibly due to large percentages of Asian American individuals who work in health care settings.19 There is also an association between lack of a primary care doctor and increased rates of COVID-19 positivity in Latinx patients.20 In addition, there exists a correlation between lack of health insurance and COVID-19 positivity among patients who identify as African American.21 Thus, racial and ethnic minorities experienced disproportionate morbidity and mortality from the COVID-19 pandemic, likely due to multiple causes, including predisposing comorbidities, poor preventive health care access, high likelihood of working in a health profession, and lack of health insurance.

4.3 Clinical Pearls –– It is important to recognize that systemic disparities affect individual patients in insidious ways based on race and other individual characteristics. –– Clinical care should be patient-centered and acknowledge the role that disparities have played in each individual patient’s trajectory when they present with acute illnesses in the hospital.

 Ranzini L, Ribble JC, Keddie AM (2001). “Understanding the Hispanic paradox”. Ethn Dis. 11 (3): 496–518. PMID 11572416. 17  https://academic.oup.com/psychsocgerontology/article/76/3/e81/5902962. 18  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785980#zoi210960r85. 19  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785980#zoi210960r92. 20  Oh H, Trinh MP, Vang C, Becerra D. Addressing barriers to primary care access for Latinos in the US: an agent-based model. J Soc Social Work and Res. 2020;11(2):165–184. doi:https://doi. org/10.1086/708616. Google Scholar Crossref. 21  Artiga S, Hill L, Orgera K, Damico A.  Health coverage by race and ethnicity, 2010–2019. KFF.  July 16, 2021. Accessed October 11, 2021. https://www.kff.org/racial-equity-and-healthpolicy/issue-brief/health-coverage-by-race-and-ethnicity/. 16

Chapter 5

Social Medicine and Hospital Medicine

5.1 A Case Mr. Ramirez is a 73-year-old man admitted to the hospital with fevers, chills, and cough and is found to have community-acquired pneumonia. On admission, he is noted to be unhoused, and living on the streets. He receives intermittent care from a local community clinic that is a federally-qualified health center, and has visited other hospitals in the area for acute illnesses including previous pneumonias, and COPD exacerbations. When he is seen by the admitting hospital medicine physician, the list of medications in the electronic medical record is outdated, and reflects a hospitalization more than one year ago without reflecting changes to his medications made in the past year at the community clinic and at an outside hospital. The hospital social worker spends time contacting his outpatient case manager to gain collateral social history, and his attending hospitalist contacts outside hospitals and the community clinic for an updated medication list. Mr. Ramirez is deeply distrustful of the health care system and tells the hospitalist that he is tired repeating the same medical history over and over again.

5.2 Social Medicine and Hospital Medicine The hospitalist model was introduced in the mid 1990s as a mechanism for providing high quality, efficient care without the pressures that primary care providers traditionally experienced splitting their time between outpatient and inpatient locations. The term was coined by Dr. Bob Wachter and Dr. Lee Goldman in 1996, and the field of hospital medicine has become the fastest-growing specialty in the United States, with a focus on providing high quality care to medicine inpatients as well as

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inpatient care and comanagement care in a number of other medical specialties.1 Early hospital medicine practice was characterized by high rates of patients who did not have primary care physicians who could see them in the hospital, leading to a hospitalist patient population with a disproportionately heavy burden of social needs. In addition, hospital medicine has been a leading field in the development of institutional quality improvement initiatives, in turn producing opportunities for improving care for patients with social needs.2 As the hospitalist movement has aged, hospitalists have also been increasingly focused on helping to alleviate financial and efficiency burdens, such as overcrowded emergency departments and poor hospital throughput. This has again afforded an opportunity to focus on vulnerable populations who have slower than average hospital throughput, as it has been shown that there is an inverse relationship between community social vulnerability indices and hospital financial performance.3 There is evidence that hospitalists care for more underserved patient populations but with higher patient satisfaction scores than are seen with primary care providers who see their hospitalized patients.4 There is some variation among hospitals themselves in their ability to provide equitable care to all patient populations. The US News and World Report has been ranking health systems with its “Best Hospitals” ranking since 1990, and in 2022, added four measures for health equity in acknowledgment that the quality of a health system is determined by the ability to provide equitable as well as excellent care. Per the US News and World Report, “the focus of [the new measures] is the health of vulnerable patient populations who have historically been underserved or marginalized in the healthcare system due to socioeconomic risk factors, particularly race, ethnicity, or economic status.”5 The four measures that the US News and World Report adopted for 2022-2023 are: 1. racial disparities in unplanned readmission rates 2. charity care for uninsured patients 3. community residents who accessed care at this hospital 4. preventive care for black residents in the community For the first metric, racial disparities in readmission rates are compared between Black and White patient populations. The second metric looks at the percentage of total costs spent on care for uninsured patients and how that compares to the percentage of uninsured patients in the whole community. The third measure evaluates access by comparing the percentage of non-White patients who receive elective procedures at the hospital to the percentage of White patients who receive elective  https://www.nejm.org/doi/full/10.1056/nejm199608153350713.  https://www.chcf.org/wp-content/uploads/2017/12/PDF-RiseHospitalistCalifornia.pdf. 3  https://www.healthfinancejournal.com/index.php/johcf/article/view/271. 4  https://journals.sagepub.com/doi/pdf/10.1177/106286060101600505?casa_token=k5GdWoNhH 6MAAAAA:vmYBVf7R8sg2pNrLAlFBpcwFnNnwnsKrkLaxTGd4nVhklFu heY-­G_9XjFbVPGijJQ8xiSoFKVoqn. 5  https://health.usnews.com/media/best-hospitals/Best-Hospitals-Health-Equity-2022-23. 1 2

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procedures, and the fourth measure examines the percentage of potentially preventable illnesses acquired by Black patients in the hospital to rates for White patients. In addition to disparities in patient care, there are lower percentages of hospital medicine physicians who belong to underrepresented groups as compared to the percentage of underrepresented groups in the overall population of the US.6 To compound this underrepresentation of minority groups in medicine, there is data that non-White faculty are in fewer positions of power and have lower promotion rates in academic settings.7 Hospitalists at multiple institutions have called for culture change and progress in three specific areas—(1) recruitment and retention of underrepresented minorities in medicine, (2) scholarship, mentorship, and sponsorship of underrepresented minorities in medicine, and (3) improved community engagement and partnership to provide more equitable care.8 In 2021, a group of academic hospitalists created a framework analogous to the commonly-used quality improvement framework of PDSA (Plan-Do-Study-Act), the framework TEAM (Target-Engage-Assess-Modify)9 (Fig. 5.1). Hospitals present an important opportunity to address health inequities, yet there is data to suggest that only around a quarter of hospitals in the US screen for the five basic health-related social needs, food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence.10 To close this gap, in 2022, the United States Centers for Medicare and Medicaid Services announce that they were implementing three health-equity measures in the Hospital Inpatient Quality Reporting program. This incorporation of health equity measures into quality reporting is a starting point for prioritizing health equity in hospital settings. The CMS measures are: 1. Evaluation of hospitals on five domains: strategic commitment to health equity, collection of data around health-related social needs, analysis of health equity data, quality improvement work that is focused on disparities, and leadership involvement in health equity initiatives. 2. Reporting of the percentage of adult patients who are screened for the five primary health-related social needs (food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence) 3. Reporting of the percentage of adult patients who screen positive for the five primary health-related social needs (food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence).

 https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019.  https://www.aamc.org/data-reports/workforce/interactive-data/fostering-diversity-and-inclusion. 8  https://www.the-hospitalist.org/hospitalist/article/246417/diversity-medicine/ embedding-diversity-equity-inclusion-and-justice/2/. 9  https://www.the-hospitalist.org/hospitalist/article/246417/diversity-medicine/ embedding-diversity-equity-inclusion-and-justice/2/. 10  Fraze TK, Brewster AL, Lewis VA, Beidler LB, Murray GF, Colla CH. Prevalence of screening for food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence by US physician practices and hospitals. JAMA Netw Open. 2019;2(9):e1911514. 6 7

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Fig. 5.1  Summary of T.E.A.M. PDSA cycle for diversity, equity and inclusion. Adapted from a framework created by Andrew Delapenha, Eileen Barrett, Flora Kisuule, and Shannon K. Martin in article “Embedding diversity, equity, inclusion, and justice in hospital medicine, a road map for success”

In 2023, CMS requires hospitals to implement the first measure to be implemented, and the second and third measures should be implemented by 2024.11 The Joint Commission also incorporated health equity into its requirements in 2022, for implementation by 2023. These requirements include six new elements of performance for acute care and critical access hospitals12: 1. The hospital will establish a leader or leaders who will lead efforts to reduce health disparities for the institution. 2. The hospital will screen for health-related social needs and provide patients with information and resources when they screen positive for any of the needs (access  Food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. 12  https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_disparities_ july2022-­6-­20-2022.pdf. 11

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Table 5.1  Social needs screening tools

to transportation, difficulty paying for prescriptions, education/literacy, food insecurity, housing insecurity). 3. The hospital will stratify quality data according to sociodemographic characteristics. 4. The hospital will create a written action plan to address at least one identified health disparity. 5. The hospital will provide annual updates to its leadership, providers, and staff regarding work that is being performed to address health disparities. As hospitals develop mechanisms for addressing these new regulatory requirements, they must consider the most feasible and effective ways to implement both screening and interventions. Now that CMS and the Joint Commission have established the “what”, hospitals must determine the “how”. Among the questions that hospitals have to answer are what screening tools to utilize, how to collect data, and how to incorporate screening and referrals into the pre-existing electronic medical record. In addition, hospitals have to determine how to obtain both population-level data as well as individual patient-level data. The Social Interventions Research and Evaluation Network has investigated the most common currently used screening tools (Table  5.1).13 Domains collected include childcare access and affordability, civic engagement, whether the patient has caregiver responsibilities, clothing availability, disabilities, experience of discrimination, education level, employment status, financial strain, food insecurity, health care access and affordability, housing instability, housing quality, immigrant or refugee status, incarceration status, income 13

 https://sirenetwork.ucsf.edu/tools-resources/resources/screening-tools-comparison.

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level, literacy, guardianship status, social support and isolation, transportation availability, veteran status, workplace status, health-related behaviors, stress level, neighborhood status, desire for assistance, and presence of interpersonal violence. Table 5.1 shows some commonly used screening instruments. There are a number of commonly used tools to screen for health-related social needs, but very little standardization and evidence to guide which tools are most effective in which settings, a problem that has been identified by academic experts as well as electronic health record companies.14 There does not exist consensus on the domains that should be included in social needs screening, and the measures that should be used to assess each domain. In addition, very few screening instruments include questions assessing support and resilience, which can predict the effect that a positive screen may actually have on individual patients. Among the common domains assessed for in many of the screening instruments are housing insecurity, financial compromise, transportation needs, food insecurity, and interpersonal violence. As hospitals determine which tools to use, they must also consider how to implement screening in busy clinical settings. There is legitimate concern that screening for social needs may not result in an improvement in outcomes. Two large studies examining health system adoption of social needs screening did not show any changes in outcomes, including emergency room visits, hospitalizations, referrals to community resources, or resolution of social needs.15 This lack of benefit may be due to inadequate linkages to community organizations and difficulty implementing robust screening mechanisms in busy settings where patients present with other acute needs. There is also potential for harm given the sensitive nature of the information collected, particularly when screening is conducted by untrained personnel. Discussion of sensitive and private aspects of people’s lives, including immigration status, history of trauma and violence, and custody issues can re-traumatize patients, and lead to legal consequences and deportation.16 It can also lead to frustration among patients, particularly if the screening sets up expectations for assistance that aren’t fulfilled. Incorporation of this screening into pre-existing surveys or already-­ used admission or discharge workflows may decrease the screening burden for frontline staff. Use of technology may help mitigate this burden. For example, the

 Freij M, Dullabh P, Lewis S, Smith SR, Hovey L, Dhopeshwarkar R. Incorporating social determinants of health in electronic health records: qualitative study of current practices among top vendors. JMIR Med Inform. 2019;7:e13849. 15  Schickedanz A, Sharp A, Hu YR. Impact of social needs navigation on utilization among high utilizers in a large integrated health system: a quasi-experimental study. J Gen Intern Med. 2019;34:2382–9. https://doi.org/10.1007/s11606-019-05123-2.31228054; Wu AW, Weston CM, Ibe CA.  The Baltimore Community-Based Organizations Neighborhood Network: Enhancing Capacity Together (CONNECT) cluster RCT.  Am J Prev Med. 2019;57:e31-41. https://doi. org/10.1016/j.amepre.2019.03.013.31248746. 16  It’s about trust: low-income parents’ perspectives on how pediatricians can screen for social determinants of health: united hospital fund/public agenda; 2019. 14

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Fig. 5.2  Social departments of health inventory. Adapted from Epic Systems EMR. Accessed 4 March 2023

use of chatbots for social needs screening in an ED setting proved feasible, acceptable, and effective in one study.17 As social needs screening is incorporated into the inpatient workflow, hospitals must determine the best ways to document this screening and referrals into the electronic health record (EHR). EHR companies have introduced modules into their platforms to document social needs screening and referrals. Electronic medical record company Epic Systems has created a “Social Determinants of Health Wheel” (Fig. 5.2) that documents both behavioral and social determinants of health, including alcohol use, tobacco use, substance use, food insecurity, housing status, transportation needs, financial resource strain, intimate partner violence, physical activity, stress, social connections, and depression. In contrast, the electronic medical record company Cerner has developed “Cerner determinants of health”, which includes screening tools and a dashboard that incorporates social needs screening and geographical data that clinicians can access for each patient.18 However, studies have shown that there are low levels of physician awareness of social needs screening, and that awareness of screening is greatest among physicians who practice in community health centers, are aware of other EHR tools, or who practice in systems where reimbursement relies on public financing.19  https://www.thieme-connect.com/products/ejournals/abstract/10.1055/a-2035-5342.  https://www.cerner.com/newsroom/innovative-cerner-solution-addresses-socialdeterminants-of-health. 19  Iott BE, Pantell MS, Adler-Milstein J, Gottlieb LM. Physician awareness of social determinants of health documentation capability in the electronic health record. J Am Med Inf Assoc 2022;29(12):2110–6. https://doi.org/10.1093/jamia/ocac154. 17

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The Gravity Project, a national collaborative focused on providing standards for social determinants of health data collection, has recommended linkage of social determinants of health to existing coding systems such as the International Classification of Diseases, 10th revision (ICD-10), Systematized Nomenclature of Medicine (SNOMED), and Logical Observation Identifiers Names and Codes (LOINC).20 Screening for social needs has been shown to reduce stigma regarding addressing social needs during clinical visits21 but is obviously not sufficient on its own. Workflows need to be developed to incorporate screening and referral to resources when needs are identified. These referrals may simply be lists of community resources or more formal linkages to community-based organizations, based on the patient’s need and the community connections of the institution. Involvement of the multi-disciplinary team is vital in this work, such that hospital case managers, social workers, community health workers, nurses, and physicians all work together to identify social needs and refer patients to resources. A study in 2022 showed that community health workers in hospital settings who helped connect patients to outpatient resources and provided follow-up with them for one month following hospital discharge had lower rates of 30-day readmissions and decreased rates of missed outpatient visits.22 It is essential for hospitals to create strong linkages with community-based organizations, government agencies, and primary care practices to ensure that robust linkages to community resources are established, and that efforts are not duplicative. Examples of platforms that connect community-based organizations to hospitals include commercial platforms such as Findhelp, Unite Us, and WellSky. Some state governments have also chosen to create platforms to enable referrals to community organizations. Measures that require social needs screening without including interventions for those who screen positive will have an unclear impact on populations in need. Further iterations of CMS and Joint Commission measures may also require resource linkages and other interventions. Allowing health systems to use the phenotype of their specific patient population to invest in the resources that they most need and providing value-based payment models that take into consideration equity metrics and reimburse accordingly would go further in providing care for patients who screen positive for health-related social needs.

 https://thegravityproject.net/.  https://www.nejm.org/doi/full/10.1056/NEJMp2211648. 22  https://www.nejm.org/doi/full/10.1056/NEJMp2211648. 20 21

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5.3 Clinical Pearls –– Many electronic medical records used in hospital settings have the capability to document social needs screening in discrete fields, so providers who work at hospitals that do not already have a system for documenting social needs can do this themselves using these electronic tools. –– CMS and Joint Commission are beginning to require social determinants of health screening for all hospitalized patients, and hospital-based providers can advocate with their hospital leadership to create systems for capturing this information in order to meet this requirement and better address the needs of patients. –– In future years, regulatory organizations may also require referral to resources addressing social needs on discharge, so providers can advocate with their health system leadership to implement these processes proactively.

Chapter 6

Patient Safety, Quality Improvement and Health Equity

6.1 A Case A case is presented at an academic hospital medicine program morbidity and mortality conference. The case describes a 47-year-old man with a history of alcoholic liver disease and cirrhosis who was being treated for decompensated cirrhosis and began to experience acute progressive worsening abdominal pain, rising lactate levels, and hypotension. He was found to have a bowel perforation that went undiagnosed for more than 24 hours, and despite surgical intervention and aggressive vasopressor support, he died. Upon review of the case, the chief resident discovers that in the days preceding the discovery of the bowel perforation, there is no documentation of interpreter use though the patient only speaks Tagalog. The subjective portion of the progress note states “no complaints” and the abdominal exam is documented as “non-tender” without any documentation of interpreter use. The chief resident considers whether inadequate ability to understand the patient’s symptoms led to delayed diagnosis of the bowel perforation.

6.2 Patient Safety, Quality Improvement and Health Equity Hospital Medicine has been a national leader in the development of systems for quality improvement and patient safety in inpatient settings. The birth of the quality improvement and patient safety movement arguably occurred with the publication of the Institute of Medicine (IOM, now National Academies of Science, Engineering, and Medicine, or NASEM) report To Err Is Human in 2000 and Crossing the Quality Chasm in 2001, but in reality, recognition of the role that safety plays in medical care long preceded this report, and was inculcated into the field of Medicine with

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Hippocrates’ early notions of primum no nocere (first, to do no harm).1 The IOM’s report Crossing the Quality Chasm defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” and identified six aims of health care systems, the provision of safe, effective, patient-­ centered, timely, efficient, and equitable care.2 The aim around equitable care notes that the quality of health care provided to patients should not be impacted by individual characteristics such as age, gender, race, ethnicity, socioeconomic status, or geographic location. Thus, principles of equity were embedded very early in the development of the modern quality improvement and patient safety movement. However, there has yet to be complete realization of this sixth aim that the IOM identified. In 1966, Avedis Donabedian described a systematic approach to analyzing health systems by dividing analysis of the quality of health systems into three components: structure, process, and outcome. Structure refers to the actual physical delivery of care, for example, in a hospital, while process refers to the element of health care delivery in these settings, and outcomes refer to the effects of those structures and process on the patient. This model for quality improvement examines each of these aspects for errors and quality. Another patient safety model adopts a systems-based model of error analysis popularized by James Reason, a British psychologist, and described as the “Swiss cheese model.” In this model, for an error to slip through to the patient, multiple layers of system failures need to occur and align.3 Neither of these patient safety models identify the role that demographic characteristics and systemic inequity may play in impacting clinical outcomes and patient safety events. Figure 6.1 shows a modification of the “Swiss Cheese Model” impacted by inequity. The first legislative recognition of the role that social circumstances play in determining health in the US occurred in 1965 with the passage of legislation that established the Medicare and Medicaid programs as part of the Social Security Act.4 Title XVIII of the Social Security Act was entitled “Health Insurance for the Aged and Disabled,” known as Medicare, and Title XIX of the Social Security Act established Medicaid as a solution to the inadequate medical care that public assistance at the time was providing. Through Medicare, Americans over the age of 65 could receive hospital insurance known as part A and could also opt-in for voluntary medical insurance known as part B. Congress chose to regulate Medicare with various requirements related to credentialing, staffing, and utilization review. These

 Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001. https://pubmed.ncbi.nlm.nih.gov/25077248/. 2  Institute of Medicine (IOM). Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press; 2001. https://pubmed.ncbi.nlm.nih.gov/25077248/. 3  Perneger TV. The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res 2005;5:71. 4  Center for Medicare and Medicaid Services. Title XVIII of the Social Security Act, in Title 42. Center for Medicare and Medicaid Services, Editor; 1965. 1

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Fig. 6.1  Illustration of James reason’s “Swiss Cheese Model” of patient. This framework depicts how affect patient 1 but not patient 2 based on individual characteristics

utilization review efforts were early attempts to identify gaps, though they lacked mechanisms to improve care based on identified gaps.5 These utilization review committees later evolved into “experimental medical care review organizations” meant to assess the quality of care that was provided. Eventually these organizations evolved further into Medicare’s Professional Standards Review Organizations. Over time, these organizations evolved into Peer Review Organizations, and later became Quality Improvement Organizations under the Centers for Medicare and Medicaid Services. The primary function of these different organizations was to provide a framework for ensuring that the care that Medicare was providing to primarily elderly and low-income patients was high-­ quality and safe. Among the tasks assigned to these organizations is validation of the assignments of diagnosis-related groups, reduction of readmission rates and unnecessary admissions, and reduction of mortality and complication rates. Another vital structure that was created to ensure high quality and safe patient care is the Joint Commission, started in 1951 as the Joint Commission on Accreditation of Hospitals and dedicated to ensuring that health care organizations maintain quality standards consistent with current evidence-based practice. In 1989, the Agency for Health Care Policy and Research, renamed as the Agency for Healthcare Research and Quality, was formulated in order to investigate clinical effectiveness and treatment outcomes in the context of practice guidelines. Finally, in 1990, the National Committee for Quality Assurance (NCQA) was established in order to improve health care quality through accreditation and data collection. While each of these structures was not created specifically to improve the care of marginalized populations, this infrastructure for quality improvement and patient safety has been utilized and studied extensively for Medicare and Medicaid patients.6  Chassin MR, Loeb JM.  The ongoing quality improvement journey: next stop, high reliability. Health Aff. 2011;30:559–68. https://doi.org/10.1377/hlthaff.2011.0076. 6  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702754/#CR9. 5

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In 2006, the Physician Quality Reporting Initiative (PQRI) was developed and provided incentive payments for Medicare providers who meet certain quality measures. Another important event in the provision of high-quality and safe care in the US was the passage of the Patient Protection and Affordable Care Act in 2010. This legislation was aimed at improving quality of care, decreasing costs of care, and expanding access to care. One of the provisions of this law was to create the PatientCentered Outcomes Research Institute, a non-profit research organization centered on studying how high-quality care can be provided with a focus on how patient characteristics impact care. Another important provision of this law was the creation of Accountable Care Organizations that provided more coordinated care for Medicare patients with a focus on meeting predefined process and outcome measures in five different domains of quality improvement, patient experience, care coordination, patient safety, preventive health, and at-risk population/frail elderly health.7 Thus these organizations implicitly accept that tailoring of care for population-­based characteristics such as age, is essential for providing high-quality care. It is inescapable that the frameworks used in quality improvement and patient safety overlap greatly with the frameworks used for promoting health equity, including the fundamental concept of moving away from individual health care provider blame towards a network of systems that catch harm before it reaches the patient.8 Figure 6.2 illustrates the overlap between these different frameworks. While quality improvement structures certainly have the potential to improve care for all patients, there is little data on how health disparities manifest in the fields of quality improvement and patient safety.9 There is data that suggests that incident reporting systems that rely on voluntary reporting may inadequately detect patient safety issues in underserved populations.10 Some combination of voluntary and automated reporting may help mitigate this potential bias. In addition, as the workforce becomes more diverse and equity is embedded more deeply into health care organizations, this bias may recede. Social determinants of health that lead to unsafe care must also be included in analysis of patient safety events. For example, if a patient’s lack of secure housing on discharge leads to a readmission, this is a patient safety event that was driven by a social determinant of health. Similarly, if a patient is discharged home and has a fall that may have been prevented by more robust social supports, it is appropriate to identify lack of social support at home as the cause of the patient safety event. Dr. Marshall Chin in 2020 formulated a framework for advancing health equity that was twofold—(1) organizational change to ensure that all levels of leadership,  38. US Congress. H.R. 6331 (110th): Medicare Improvements for Patients and Providers Act of 2008. Available at: http://www.govtrack.us/congress/bills/110/hr6331. 8  10. Sivashanker K, Gandhi TK.  Advancing equity and safety together. N Engl J Med. 2020;382:301–3. 9  Chauhan A, Walton M, Manias E, et al. The safety of health care for ethnic minority patients: a systematic review. Int J Equity Health 2020;19:118. 10  Schulson LB, Novack V, Folcarelli PH. Inpatient patient safety events in vulnerable populations: a retrospective cohort study. BMJ Qual Saf. 2021;30:372–9. 7

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Fig. 6.2  Spheres of overlap between quality improvement, health equity, and patient safety

front-line staff, and clinicians are invested in the goal of promoting health equity, and (2) tailored system-level work consistent with principles of quality improvement to identify disparities, understand the driving factors, and develop interventions that address the causes of the disparities. A major component of this framework is engagement of every level of the inpatient workforce to deliver equitable care. This will require each segment of the healthcare workforce to reimagine care delivery with principles of equity incorporated.11 Diversity and cultural humility training is important but without system changes cannot lead to meaningful change as staff cannot implement change in a fundamentally inequitable system. Conversely, systems level work without education and buy-in from all the clinical staff cannot be carried out effectively. What might a truly equitable system of quality improvement and patient safety look like? Health equity would be a fundamental component of every aspect of quality improvement and patient safety. Outcomes would be analyzed with demographic stratification. Every quality metric and safety goal would be tailored to impact different demographic groups. Metrics around patient communication and strategies to improve communication would be modified to meet the needs of all demographic groups. Quality outcomes would be chosen and tailored for patients from all demographic slices of the population. All staff would reimagine the structures of how they work and the effects that they strive to have based on the principle of providing high quality care to all patients. The entire health care organization 11

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8627426/#R17.

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would be infused with principles of equity, with health equity training and support essential components of all programs. Strategy, financial planning, operations, and human resources will all function within a framework of equity. The impact that social needs have on care will be taken into account in all efforts to improve health equity. Incremental change must be embraced in this approach, as small changes will later lead to larger changes, and eventually to sweeping restructuring of entrenched health system structures. While general efforts of quality improvement may help improve quality of care for marginalized patients, approaches that are truly tailored for each specific population are more effective than general initiatives that impact everyone.12 In some cases, systems that are built to improve care for everyone may be mainly accessed by populations who already have power and privilege, while marginalized populations experience barriers to access. In addition, simply working in a safety net organization where the majority of patients are racial or ethnic minorities does not equate to providing equitable care. Adequate representation from community members in the form of patient-family advisory committees or community advisory boards with members from all segments of the community is vital to improving health equity. It is essential to bring diverse lived experiences into clinical spaces as systems are built to provide high-quality care to all patients. Approaches that actually tailor care based on demographics are needed even in settings where there is a predominance of marginalized populations. One example is Medicare’s Hospital Readmissions Reduction Program, which was created to decrease readmission rates for all patients but ended up decreasing Medicare payments to safety-net hospitals by 1–3% and increasing readmission rates for Black patients in these hospitals.13 It was only when Medicare’s Hospital Readmissions Reduction Program stratified patients as Medicare alone versus Medicare and Medicaid as a surrogate measure for determining which hospitals were more impoverished than others, that hospitals could be grouped with other hospitals with similar levels of poverty when determining if quality metrics were being met. Hospitals with higher degrees of poverty had more difficulty achieving quality metrics because of the impact of health-related social needs, and this needed to be taken into consideration when determining reimbursement. As policy surrounding health care quality improvement and patient safety continues to evolve, it is essential that stakeholders advocate for policies that prioritize health equity and measures to improve population health in order to engrain principles of equity into the quality and safety infrastructure of the US.

 Fisher TL, Burnet DL, Huang ES, et al. Cultural leverage: interventions using culture to narrow racial disparities in health care. Med Care Res Rev 2007;64:243–82. 13  Chaiyachati KH, Qi M, Werner RM.  Changes to racial disparities in readmission rates after Medicare’s hospital readmissions reduction program within safety-net and non-safety-net hospitals. JAMA Netw Open 2018;1:e18415. 12

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6.3 Clinical Pearls –– When health systems decide which quality improvement initiatives to initiate, initiatives that advance health equity should be prioritized. –– Root cause analysis and patient safety events should be examined using a health equity lens to fully understand what role inequitable processes and structures played in the event and how to prevent this from occurring in the future. –– Quality improvement metrics should take into consideration demographic characteristics of groups when setting targets.

Chapter 7

Care of Patients in Each Phase of Care

7.1 A Case Mr. Hobson is a 29-year-old male with a history of methamphetamine use disorder, housing instability, depression, anxiety, and hypertension who presented to the Emergency Department after being found naked and confused at a public bus stop. He is found to be intoxicated with methamphetamines in the Emergency Department, and after his methamphetamine levels drop in his system, becomes fully oriented and appropriate. His blood pressure is slightly elevated but he is otherwise doing well. When his Emergency Department physician fills out the discharge paperwork, the patient states that he is unhoused and will have to go back to the streets. He also states that he uses methamphetamines to stay awake on the streets because he is worried that his belongings will be stolen if he falls asleep. He says that he will probably use methamphetamines if he goes back to the streets. He declines to go to a shelter because “I usually get jumped there.” Worried about discharging Mr. Hobson to an unsafe situation, the emergency physician calls the hospitalist for admission as a “social admit.” When questioned by the hospitalist about whether the admission is appropriate, the emergency physician states, “well, he also has hypertension.”

7.2 Care of Patients in each Phase of Care The care of patients is affected profoundly by their phase of care. On the outpatient side, long term social needs are often addressed, but in emergency and inpatient settings, acute medical issues often take precedence, and social barriers are only addressed as discharge nears. This can lead to missed opportunities to holistically care for the many determinants that have led patients to their acute illness. Social © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_7

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circumstances such as income level, housing status, immigration status, language proficiency, sexual orientation, gender identity, substance use, and race all impact the trajectory of hospitalization and ideally must be addressed throughout the hospitalization rather than just on discharge. Data shows that rates of hospitalization are higher in patients with lower socioeconomic statuses, and length of stays are higher for patients in poverty. Factors such as lack of social support, unstable housing, poverty, and uninsured and underinsured status can all lead to prolonged hospitalizations and delay discharge. In addition, as home health services and skilled nursing facilities have become more prevalent, there has been increased opportunity for patients to recuperate at home rather than stay in the hospital until fully recovered. However, these opportunities have not been realized by all segments of the population. Individuals without insurance coverage of home health services or rehab facilities, or those lacking family support or the means to hire help at home have not been able to receive post-acute care at the same rates as patients with more means and resources, resulting in disparities. In the emergency department, patients who cannot be safely discharged home because of social circumstances such as unstable housing, financial insecurity, or social isolation are sometimes admitted to the hospital before a safe discharge plan can be created. Other patients may be admitted for an acute illness, but their social circumstances later play a part in the trajectory of their hospitalization and discharge. Patients who do not have a primary care provider and have not seen a provider regularly may have illnesses that have gone undiagnosed, which can complicate their hospitalization. The social circumstances of patients, such as lack of social support, insecure housing, and interpersonal violence at home may lead to repeated visits to the Emergency Department or frequent hospitalizations. Inability to obtain medications because of financial instability may lead to worsening of chronic medical conditions. Overcrowded living conditions at home may lead to higher rates of infectious diseases. Employment in occupations that require strenuous physical labor or exposure to industrial chemicals can impact acute medical conditions that patients may develop. All of these social factors may influence the experience and trajectory of patients in the hospital. It is vital that hospitalists make use of interpreters or interpretation devices for all hospitalized patients who have limited English proficiency. During admission, careful discussion of social determinants of health and health-related social needs is essential. Substance use history, living situation, financial resource availability, food security, socioeconomic status, immigration status, interpersonal violence, employment status, sexual orientation and gender identity, transportation needs, and social isolation should be included in every admission assessment. Understanding the context at home is important not only for understanding the factors that have led the patient to become acutely ill, it will also set the groundwork for creating safe discharge plans after the acute illness has resolved. Attention should be given to how social circumstances are impacting every aspect of care, including food and medicine availability, access to age-appropriate preventive care, and social stability. The ability of patients to advocate for themselves should be assessed during hospitalization, and patients should be educated on how to self-advocate if needed.

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As discharge nears, providers should explore whether there is a safe discharge plan for the patient. The ability to obtain and store needed medications should be factored into discharge planning, and ensuring that streamlined follow-up in an accessible location is available should be prioritized. Hospitalists should partner with hospital-based case management and social worker teams to ensure that health-­ related social needs are addressed before discharge. Discharge follow-up and medications are particularly important and should be addressed in a patient-centered manner. Options for discharge should be addressed early with the patient, family, and case management or social work team. In some cases, patients may not have support at home and may lack the ability to care for themselves at home. In these cases, other options for post-acute placement should be explored, such as skilled nursing facilities, acute rehabilitation units, and medical respite. Accessibility to these institutions may be based on insurance status and financial means. Multidisciplinary teams should be engaged to help create a feasible discharge plan. It is vital to engage patients fully in decision-making regarding their discharge planning. There is data that physicians are less likely to engage patients from lower socioeconomic statuses in their own clinical care.1 Patients must be vital partners in order to receive equitable care and to ensure adherence to care plans. Hospitalization is a moment of great vulnerability for patients, and hospitalists should use this moment to advance the trajectory of the patient’s overall care, bolster social support structures, connect to vital resources, provide information to allow for shared decision making, and explore goals of care and advanced care planning. Patients with health-­related social needs often have had negative interactions with the health care apparatus and government systems in general due to systemic bias, and hospitalization offers an opportunity to reset that paradigm. Though the tendency in inpatient medicine is to focus on acute problems, taking a broader view that encompasses the entirety of a patient’s situation can improve care tremendously.

7.3 Clinical Pearls –– Provide careful, patient-centered care with special attention to admission and discharge, which can be points of vulnerability for hospitalized patients. –– Obtain comprehensive and careful social histories on all patients, using interpreters when patients have limited English proficiency. –– Use patient-centered communication and shared decision-making to help patients transition safely from each phase of care.

 Care of Vulnerable Populations.

1

Part II

Specific Populations

Chapter 8

Race in Hospital Medicine

8.1 A Case Ms. Imara is a 31-year-old woman with Sickle Cell Disease who is admitted to the hospital with an acute pain crisis likely provoked by a recent upper respiratory infection. She has a hematologist she follows with regularly and a pain protocol that she uses during her acute pain crises. She is placed on her pain protocol in the Emergency Department, but when she arrives in the ward, the daytime hospitalist becomes alarmed at the high doses of opioids prescribed, and decreases the oral morphine equivalents by half. Ms. Imara notes a sharp exacerbation in her pain and tells her nurse, who calls the hospitalist to come to bedside. When he arrives, the hospitalist tells Ms. Imara that he decreased the dosages of pain medications because “I know you have a high tolerance to pain meds and we don’t want you to get addicted.” Ms. Imara replies to the hospitalist, “you just don’t want to give me pain meds because I’m Black. I’m not an addict.”

8.2 Race in Hospital Medicine There is clear evidence of racial disparities in the quality and quantity of care that individuals in the US receive, with patients who identify with non-White racial groups having higher rates of morbidity and mortality than their White counterparts. There are a number of complex factors that mediate these differences, including decreased access to care, deeply racist systems that pose barriers to care, and socioeconomic mediators such as poverty, food insecurity, and housing insecurity. Racism can be defined as the extensive social structures that the dominant group has put into place based on the social construct of race in order to categorize individuals into social hierarchies that lead to the disempowerment and devaluation of specific © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_8

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groups.1 Rather than discrete acts that specific bad actors are responsible for, racism is deeply engrained in the structures that provide health care to individuals. In fact, even when there are no longer bad actors who are performing explicitly racist acts, racist systems can persist and lead to harm. There is data that shows that Black and Latino individuals receive hospital care that is less likely to adhere to evidence-based standards when compared to White patients, even when insurance coverage and income are controlled for. There are many examples of this. Patients who come from a racial or ethnic minority group are less likely to receive kidney transplants when needed, adequate pain management, appropriate cardiovascular care, and evidence-based cancer and stroke treatment.2 There is also higher likelihood of a shortage of physicians in areas that have high percentages of racial and ethnic minorities. This is driven largely by the closure of public hospitals, and the movement of non-profit hospitals from areas with high percentages of racial minorities to communities that are predominantly White. Multiple studies have shown that hospitals with higher percentages of racial minorities have higher rates of closing or discontinuing clinical services.3 When hospitals that serve diverse populations close, associated primary care practices often also close, leading to exacerbation of physician shortages in areas that have high rates of racial and ethnic minorities. There has been a false belief propagated by academics, physicians, and slave owners historically that Blacks and Whites have biological differences such as thicker skin, less sensitive nervous systems, and resistance to pain and injury. These false beliefs led to the myth that Black bodies would be able to withstand surgical pain with little anesthesia or be subjected to physical punishment without much pain. These false beliefs led to the testing of numerous chemicals on Black soldiers during World War II as well as the Tuskegee study.4 The Tuskegee study occurred between 1932 and 1972, when the Centers for Disease Control and Prevention performed extensive study of approximately 400 Black men without their consent. This shameful study did not provide informed consent or appropriate treatment and is responsible for generations of mistrust in the health care system by Black Americans. The patients were enrolled in a study run by Tuskegee University, where 600 male patients were enrolled, and 399 were found to have syphilis. The patients who tested positive were never informed of their syphilis diagnosis, and they were treated with a variety of ineffective treatments or placebo throughout the study. Even after 1947, when penicillin became widely available as the evidence-based treatment for  Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105–25. 2  Agency for Healthcare Research and Quality. 2019 national healthcare quality and disparities report. Rockville: AHRQ; 2020 Dec [last updated 2021 Jun; cited 2021 Dec 10]. Available from: https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.html. 3  Ko M, Needleman J, Derose KP, Laugesen MJ, Ponce NA. Residential segregation and the survival of U.S. urban public hospitals. Med Care Res Rev. 2014;71(3):243–60. Crossref, Medline, Google Scholar. 4  https://www.pnas.org/doi/full/10.1073/pnas.1516047113#core-r20. 1

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syphilis and the CDC was promoting widespread treatment, participants in the Tuskegee study were not treated for syphilis. The men were initially told that the study would be six months in length, but it actually lasted forty years, until a leak to the press led to its discontinuation by the CDC.  In the meantime, 128 enrolled patients had died from syphilis or complications related to syphilis, 40 of the patients' wives were infected with syphilis, and 19 children were born with congenital syphilis. In 1997, then US President Bill Clinton apologized to the participants in the Tuskegee study for the unethical actions of the American government. Another population that has suffered from systemic bias is the Native American population in the United States. The fraught historical and legal context of the relationship between Native Americans and the US government has led to deep health inequities. The legal relationship between Native American tribes and the US government dates back to the eighteenth century. The initial relationship between Native American tribes and the US government was framed in Article I, Section 8 of the United States Constitution, which grants Congress the right “to regulate commerce…with the Indian tribes.” The ensuing relationship between the US government and the Native American population has been called a “trust” relationship, whereby the government protects tribal lands, resources, rights, and health care in exchange for the land acquired by the US government. Two Supreme Court cases, Cherokee Nation v. Georgia, and Worcester v. Georgia reinforced this relationship between the federal government and Native American tribes as self-governing with the federal government taking on the responsibility of ensuring that state governments don’t interfere with tribal nations.5 In the late 1800s, a series of assimilation policies resulted in further marginalization of the Native American population. With expansion of the United States into the West, the government forced Native Americans to move to reservations. The US government launched a series of policies aimed at assimilating Native Americans into the general population, including reallotment of group plots of Native American land into individual plots and the opening of a system of Native American boarding schools that banned Native American cultural, religious, and medical practices. This combination of forcing Native Americans on to reservations and banning traditional healing practices led to an increase in infectious diseases in this population due to poor ventilation, overcrowding, malnutrition, and loss of collective knowledge about health. The health status of the Native American population worsened. In 1934, the Indian Reorganization Act was passed as an attempt to promote economic self-determination in the Native American population, but it was followed by the termination policies of the 1950s which resulted in the forced relocation of Native Americans from their lands to urban settings and ending of the “trust relationship”. In 1975, the Indian Self-Determination Education Assistance Act passed, giving Native American populations the right to enter in a self-determination and self-­ government contract with the US government if they so desired. However, the

 https://www.ncbi.nlm.nih.gov/books/NBK425854/.

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historical health inequities that already existed among tribal populations have led to persistent health disparities.6 Two pieces of legislation, the Snyder Act of 1921, and the Indian Health Care Improvement Act of 1976 gave legislative authority for the creation of the Indian Health Service to provide health care for the Native American population. The Indian Health Service is currently under the Department of Health and Human Services and is required to provide health care to federally recognized tribes. Individuals who are of Native American descent, members of a federally recognized tribe, enrolled in a tribe, or have a certificate of origin and live on a reservation or near a reservation are all generally eligible to receive health services from an Indian Health Service resource, including either federally or tribally operated resources or an urban health center. Disparities persist in health care for the Native American population at least partially due to inadequate health care spending (Figure 5), with per capita spending for Native American health care being approximately one third of the national per capita spending for health.7 In addition, the Native American population is deeply impoverished with lower median household incomes than most other racial or ethnic minority populations in the US. There are high rates of unemployment in this population, low rates of educational attainment, and low rates of home ownership. One in ten Native American households do not have access to clean water, and there are high rates of overcrowding in Native American households. Native Americans living in urban settings have better access to health care resources than populations living in rural settings, leading to higher death rates in Native individuals in rural areas as compared to urban areas. There are also high rates of intimate partner violence, interpersonal violence, and interactions with the criminal justice system among Native American populations. All of these factors lead to significant health disparities between this population and the general population. 8 In addition, high rates of depression, anxiety, and substance use disorders add to the high levels of illness among Native Americans.

 https://www.ncbi.nlm.nih.gov/books/NBK425854/.  National Congress of American Indians, 2016. 8  Campbell et al. 2001. 6 7

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2009–2010 Indian health expenditures per capita compared with other federal health care expenditures per capita

The COVID-19 pandemic is a case study in how health disparities adversely affect hospitalized Native Americans patients. In November of 2021, it was noted that Native Americans and Alaska Native individuals were three times as likely to be hospitalized from COVID-19 and two times as likely to die from COVID-19 when compared to non-Hispanic White patients. This increased risk of morbidity and mortality from COVID-19 is likely due to higher rates of comorbid conditions such as COPD, asthma, tobacco use, diabetes, and cardiovascular disease in Native American and Alaska native populations. In addition, preventive measures were difficult in this population due to overcrowding and limited remote work options. The historical inequities that have characterized care of Native Americans have led to uniformly worse outcomes in this patient population as compared to other demographic groups during the COVID-19 pandemic. One study in Mississippi showed that high rates of comorbidities, low rates of education, low rates of federal funding, and high rates of poverty among the Native American and Alaska Native population led to higher mortality rates in these populations as compared to White, Black, and Latinx individuals.9 While there are a complex array of reasons for the health disparities among Native American populations, underfunding by the US government remains a vital causative factor. Funding to the Indian Health Service (IHS) has not increased in proportion to medical inflation. A federal report in 2022 noted that the nearly $7 billion IHS budget funded less than half of what was needed for patient care. In addition to chronic underfunding, the care that Native American patients receive often is not informed by their cultural and spiritual belief systems, and studies have  https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2790506.

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shown that care of Native American patients that is informed by their spiritual and cultural beliefs engenders more trust and higher rates of patient satisfaction, particularly among elderly patients.10 The largest minority group in the United States is the Latinx population. “Latinx” is a term that denotes someone of Latin American descent and encompasses all genders, as opposed to the gendered terms “Latino” and “Latina.” We use this term for the most part in this book. Other common terms are “Hispanic”, denoting anyone of Spanish or Latin American descent, and Chicano/Chicana, male and female terms for individuals of Mexican descent. The Latinx population is extremely diverse because it refers to individuals from many different countries and regions, and broad generalizations about the health of this population tend to be simplistic and reductionist. However, it is possible to describe general trends of this population with regard to hospitalization and health care. The leading cause of death in the Latinx population is cancer, followed by cardiovascular disease, and unintentional injuries. There are a number of barriers to health in this population, including language and cultural barriers, disparities related to social determinants of health, rising rates of obesity and diabetes, and a relatively small percentage of Latinx health care providers. Obesity rates are very high in the Latinx population, with approximately 42.5% of the Latinx population meeting the criteria for obesity. In addition, the rates of obesity among Latinx youth are 21.9%, higher than any other subset of youth in the US population. The Latinx population exhibits significant heterogeneity in terms of obesity rates depending on country of origin, and there is a consistent gap between obesity rates of foreign-born and US-born Latinx individuals, with US born individuals having higher obesity rates. In all groups, women have higher obesity rates than their male counterparts. The root causes of high obesity rates in this population are multifactorial, and include low-cost availability of calorie-dense, low-nutrient, and high-sugar foods, genetic susceptibility to glucose intolerance, and low rates of health care provider engagement with Latinx patients to promote lifestyle modifications for healthful living.11 Other drivers of health inequities include socioeconomic status, employment status, and foreign-born or undocumented status. The median household income of Latinx individuals is lower than the non-Latinx White population, and poverty rates are higher in this population, with 23.65% of Latinx individuals living below the poverty level in 2014 as compared to 14.8% of the general population. In adults who are older than 65, Latinx individuals have the highest poverty rate of approximately 20% as compared to the general population which has a poverty rate of approximately 10%. Inequities in the Latinx population are more pronounced in women, who are at higher risk of intimate partner violence when compared to women in the general population. There are differences between first generation Latinx immigrants and second and third generation Latinx immigrants, such that the rates of overweight and obesity are higher in the latter two groups as compared to the first  https://www.ncbi.nlm.nih.gov/books/NBK425854/.  Alemán JO, Almandoz JP, Frias JP, Galindo RJ. Obesity among Latinx people in the United States: A review. Obesity (Silver Spring). 2023;31(2):329−337. https://doi.org/10.1002/oby.23638. PMID: 36695058; PMCID: PMC9937439. 10 11

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group. In general, the tightknit families that provide social, emotional, and financial support in many Latinx families are thought to be protective against disabling diseases.12 Migrant seasonal farm workers are another patient population with unique health challenges. A recent study showed that approximately 68% of these individuals were born in Mexico, more than three-quarters are male, and 59% are married (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3397370/). They have an average age of 36 years. The work that this group pursues tends to be highly mobile and often includes agricultural occupational health hazards such as the use of pesticides and long periods of time outside in the sun. This patient population thus has high rates of heat exposure, musculoskeletal injuries, damage to the eye and skin mucosa, and depression. Often social determinants of health play a role, including food insecurity, cultural barriers, and limited English language proficiency. Another group of the Latinx workforce are undocumented immigrant workers, individuals who are here for work from other countries but do not have legal papers to authorize their stay. While undocumented immigrant workers of many different racial backgrounds live in the US, the highest percentage of these workers are Latinx. These workers often play vital occupational roles, and the majority of Latinx undocumented workers, 53%, are from Mexico. They are often employed in jobs that are physically high-risk and may have limited or no health insurance.13 There is a phenomenon among the Latinx population known as the “Hispanic Mortality Paradox”, which refers to the fact that Latinx populations have lower all-­ cause mortality rates when compared to individuals from similar socioeconomic groups. There is a corresponding “Latina Birth Outcome Paradox”, a lower rate of maternal and perinatal outcomes among Latina mothers as compared to mothers with similar socioeconomic statuses. It has been proposed that these paradoxes are due to self-selected healthier populations choosing to migrate to the US, Latinx populations choosing to return to their countries of origin when they age, and potential protective benefits of tight social networks.14 The US health care system has been structured in a way that provides an advantage to the racial group in power, White individuals, and disadvantages to racial and ethnic minorities. During the COVID-19 pandemic in 2020 in the United States, the stress test of a global pandemic laid bare these inequitable systems, and patients who identified as Black, Latino, Native American and Alaska Native, and Asian American Pacific Islander were noted to suffer from higher rates of hospitalizations and death as compared to the majority White population.15 Access to care is impeded in racial and ethnic minorities in the US, largely mediated by health insurance  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809877/.  https://pubmed.ncbi.nlm.nih.gov/21745706/. 14  https://pubmed.ncbi.nlm.nih.gov/25246267/. 15  Centers for Disease Control and Prevention. Risk for COVID-19 infection, hospitalization, and death by race/ethnicity. Atlanta: CDC 2021 Jul 16 [cited 2021 Dec 10]. Available from: https:// www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-­ by-race-ethnicity.html. 12 13

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inequities. Racial identity is directly associated with lack of health insurance, and non-­White individuals are more likely to be uninsured or underinsured than their White counterparts. In order to fully understand the dynamics that have led to inequitable care based on race in the US, it is important to examine the history of structural racism as it relates to health care in the US. Historically, legislation that has built the public health infrastructure of the US has been impeded by implicit and explicit racism. In 1946, the federal government enacted the Hill-Burton act to promote construction of public hospitals and long-­ term care facilities but allowed for separate facilities to be built based on race, and did not mandate integration. Early federal programs aimed at providing health care to marginalized and impoverished populations had a history of underfunding and the decision of whether to participate in such programs was often relegated to the states, leading to states with large percentages of Black patients sometimes failing to participate. Racial and ethnic minority populations were often segregated in occupations that provided service, domestic, and agricultural work, and were excluded from unionization, leading to low and stagnant wages and allowing employers to exploit these populations. The National Labor Relations Act of 1935, for example, legislation that offered protections for workers and provided benefits such as health insurance, did not impact many racial and ethnic minorities because it excluded service, domestic, and agricultural workers. When Medicare and Medicaid were enacted in order to care for vulnerable elderly and low-income individuals, it became apparent that the decisions on whether Medicare and Medicaid funding would be provided was a very important tool for both promoting and withholding equitable care. In these early days, the Department of Health And Human Services Office for Civil Rights worked extensively to racially integrate hospitals, despite the economic and social forces that were promoting segregation and inequity. Medicare has perpetuated racial inequity by turning a blind eye to organizations such as nursing facilities which receive Medicare funding but deny services to members of different racial and ethnic minority groups. Medicaid has also given states tremendous flexibility to limit eligibility or underfund their programs, perpetuating inequity. The funding structure of health care in the US has been a vehicle for embedding racism and has limited access of racial and ethnic minorities to high quality care. Health insurance in the US is financed through employer-based systems, federal funding, and state funding. The Patient Protection and Affordable Care Act (ACA) instituted reforms aimed at decreasing inequities, such as providing federal subsidies for low-income individuals, providing coverage for individuals who do not have employer-sponsored insurance, and abolishing exclusions of patients with pre-­ existing conditions. In 2019, studies showed that 66% of White workers were covered by employee-sponsored insurance, as opposed to 47% of Black individuals, 43% of Latino individuals, and 37% of American Indian and Alaska native individuals.16 In addition, Black and Latino individuals are around 1.5 and 2.5 times more

 Employer-sponsored coverage rates for the nonelderly by race/ethnicity. San Francisco: KFF; 2019 [cited 2021 Dec 10]. 16

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likely to be uninsured than their White counterparts.17 When racial and ethnic minority patients are insured, they are more likely than White patients to have poor or incomplete coverage that leaves them with higher out-of-pocket expenses than they would receive if they bought insurance through the ACA exchanges. One other mechanism that the ACA has used to expand health coverage is Medicaid expansion, covering all adults below the age of sixty-five whose incomes are 138% or lower of the federal poverty level. However, due to resistance from many state governments to implementing Medicaid expansion, there has been uneven adoption of Medicaid coverage at the state level. In states that have fully expanded Medicaid, there has been a drop in rates of uninsurance among Black and Latinx patients. For example, in Louisiana, the uninsurance rate among eligible Black people was noted to drop by 14.7% after Medicaid expansion.18 However, the Supreme Court decided in National Federation of Independent Business vs. Sebelius that Medicaid expansion is optional. As a result, a number of states have opted out of Medicaid expansion with the effect that a number of Southern states with high percentages of Black and Latinx residents have failed to adopt Medicaid and have correspondingly high uninsured rates. The individuals who are likely to have a Medicaid coverage gap, where their income is not low enough for Medicaid but too low to buy private insurance, disproportionately live in Southern states that did not expand Medicaid. Black patients are twice as likely as White and Latino patients to have a Medicaid coverage gap, and 60% of those individuals in the coverage gap are people of color.19 In addition, some states have imposed work requirements on Medicaid coverage, a requirement that has reinforced the notion that the poor are lazy and perhaps influenced by racist assumptions that the “urban poor”, code for Black individuals, need work imposed on them externally. Indeed, analyses have shown that the percentage of Black individuals who would be subject to these work requirements would be higher than the percentage of Black individuals in these states. While the ACA did expand coverage, it also exacerbated inequities, such that the coverage gaps that remain due to lack of private insurance are disproportionately borne by racial and ethnic minorities. Value-based payment models such as pay-for-­ performance, accountable care organizations, bundled payments, and patient-­ centered medical homes exacerbate inequities because the incentives they provide are more readily earned for White affluent patient populations than for impoverished racial and ethnic minority populations. The reason for this is likely because these programs do not take into account the role that social determinants of health play in affecting care. It can be harder for providers who care for these marginalized  Artiga S, Hill L, Orgera K, Damico A. Health coverage by race and ethnicity, 2010–2019. San Francisco: Henry J. Kaiser Family Foundation; 2021. 18  Baumgartner JC, Collins SR, Radley DC. Racial and ethnic inequities in health care coverage and access, 2013–2019. New  York: Commonwealth Fund; 2021. Available from: https://www. commonwealthfund.org/publications/issue-briefs/2021/jun/racial-ethnic-inequities-healthcare-coverage-access-2013-2019. 19  Cross-Call J. Medicaid expansion has helped narrow racial disparities in health coverage and access to care. Washington: Center on Budget and Policy Priorities; 2020. 17

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populations to achieve quality metrics because of entrenched historical inequities, and clinics who care for these populations can be further disadvantaged by receiving lower reimbursement rates due to their inability to meet performance targets. While safety net hospitals often attract extremely dedicated staff, they also often have lower patient communication scores, higher lengths of stay, and higher rates of readmission. They also often are underfunded. This confluence of factors can result in lower-quality care for the racial and ethnic minorities who visit these hospitals. Tax benefits to employers for providing health insurance are not linked to equity measures, such that there is no governmental financial incentive for employers to provide health insurance to marginalized populations. Similarly, Medicaid provides reimbursement to hospitals who provide a disproportionate percentage of care to uninsured patients but these reimbursement rates have been very low, prompting a slew of lawsuits, including one in California claiming that low Medicaid reimbursement rates amount to discrimination against the growing Latinx population.20 Race-based medicine is another source of racism embedded in the health care system. Race-based medicine is the general principle that there exist health care conditions that differ in the ways that they manifest in patients of different racial and ethnic groups. However, there is little correlation between racial make-up and genetics, and many of the assertions about race-based differences have no evidence to support them. Examples of the assertions that have been made about race-based differences include effectiveness of diuretics over ACE inhibitors for blood pressure control in patients who are Black, higher muscle mass in Black patients, differing lung function test standards, and higher tolerance to pain in certain racial and ethnic minorities such as Black patients. There is no data supporting these claims, yet they have been propagated for decades. Race has also been identified as a causative agent in promoting disease, as opposed to a construct accompanied by systemic biases that together may make one racial group more likely to experience a particular disease than another racial group. Many providers are taught to link certain races with certain diseases, such as sarcoidosis and hypertension to Black patients, and Cystic Fibrosis to White patients. Estimated GFR and Pulmonary Function tests in Black patients are other examples of implementation of race-based care. Estimated GFR is assessed using a correction in Black patients that can lead to higher GFR rates, sometimes masking kidney failure and potentially delaying dialysis or transplant. In 2021, the American Society of Nephrology and National Kidney Foundation Task Force recommended that equations for calculating the GFR of patients should not include a race coefficient, an adjustment based on Black race. In addition, in 2022, the Organ Procurement and Transplant Network mandated that all transplant centers use race-neutral GFR equations to estimate kidney function, and that Black patients who had been waiting

 Mexican American Legal Defense and Education Fund [Internet]. Los Angeles: MALDEF. Press release, Advocates file lawsuit alleging California’s separate and unequal Medi-Cal system violates the rights of millions; 2017. 20

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for renal transplant but were disadvantaged by use of the race-based equation would advance further on the transplant list to decrease wait time for their transplants.21 Other areas where race-based care is used includes diabetes screening in Asian patients with lower body-mass index than White patients, fracture risk based on race, pediatric UTI diagnosis, and dosing of the medication Eltrombopag in East Asian patients. While some of these differences may actually exist, it is important to re-examine each assertion and determine whether it is race that is the determining factor or racist structures that have led to these differences. It is also important to rethink the practice of describing patients using racial descriptors in the medical record. The goal is not to ignore race, but to rather think about the sociopolitical basis of these differences rather than the unproven biological basis. These are just some of the ways that racism affects care in the US, and more research is needed to further elucidate the structural effects of racism on care.22

8.3 Clinical Pearls –– Be mindful that the legacy of racist systems both past and present impacts every patient. –– Even when individual providers feel that they are not biased and hold no racial animus, biased systems can lead to inequitable care, particularly for Black and Latinx patients, but also for any patients of color. –– There is little evidence supporting the use of race-based medicine, where different targets and cutoffs for clinical and laboratory indicators are set for individuals of different races, and this practice of tailoring care based on race should be re-examined.

21 22

 https://jamanetwork.com/journals/jama/fullarticle/2802102.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544456/.

Chapter 9

Limited English Proficiency and Immigration

9.1 A Case Mr. Nguyen is a 76-year-old Vietnamese refugee who has limited proficiency in English and is admitted to the hospital with productive cough, dyspnea, and subacute fatigue in the setting of a positive Quantiferon Gold test for tuberculosis. His chest imaging shows granulomatous disease and he is being admitted for evaluation of suspected active pulmonary tuberculosis. The physician team comes in the room to explain the results of the chest imaging and the patient speaks in limited English and acquiesces to the plan but does not fully grasp what is explained to him.

9.2 Limited English Proficiency and Immigration An essential component of high-quality hospital care is ensuring optimal patient experience. Of the NASEM (formerly IOM) six aims for high quality care, ensuring high-quality patient experience is included. Patient experience includes the overall experience for a hospitalized patient which by its nature has multiple facets. Did the physicians listen to the patient? Did the nurses seem responsive to requests? Was pain well controlled? How was the recovery process? Underlying all of these issues is the need for consistent, transparent communication. Hospitals throughout the US have patients with varying levels of English proficiency, which can by its nature impair communication when staff do not speak the patient’s language. Limited English proficiency patients fall into a number of categories—some of these patients are recent immigrants who are actively learning English but are currently unable to communicate effectively in English. Others may have some English language proficiency but are not comfortable having nuanced discussions about complex medical issues in English. Still others may be visitors to the US with no English proficiency © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_9

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and no expectation for encounters at health care facilities during their visit. According to the 2010 census, approximately 9% of patients in the United States had limited English proficiency.1 However, other studies have shown that more than 60 million people in the U.S.A. speak a language other than English at home, and that of these individuals, 42% report that they speak English less than “very well”, suggesting that the actual numbers of limited English proficiency patients in the US is much higher than what was documented in the census. There are many barriers when immigrants and refugees attempt to access health care in the United States. Language discordance, cultural differences, and difficulty navigating unfamiliar systems are among the barriers that can negatively impact the health care experience of immigrants and refugees. Language discordance is often the most visible barrier to care that immigrants and refugees face. The most common primary languages in the US other than English is Spanish, and there are significant percentages of patients whose primary language is not English in different regions of the US (Fig. 9.1). Notably, in some cases, the language that is available via translation at the health care institution may not be the patient’s first language, for example, for patients whose primary language is an indigenous dialect but who also speak Spanish as a second language. Lack of understanding by the clinical team that the patient is actually communicating in their second language can further impair communication. Studies have shown that in addition to impairment of patient communication and experience, comprehension of health care encounters, and adherence to prescribed courses of treatment, health outcomes can be adversely affected in limited English proficiency patients. There is data that length of hospital stay is prolonged in patients with limited English proficiency, and that unplanned readmission rates are higher in this population, but the data is not consistent across settings. Large metanalyses have shown that there is no association between language proficiency and mortality or complication rates.2

Fig. 9.1  Primary Language Distribution in the U.S.A. (Adapted from https://en.wikipedia.org/ wiki/Languages_of_the_United_States#/media/File:Languages_cp-­02.svg)

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5860946/#R16.  https://link.springer.com/article/10.1007/s11606-021-07348-6#ref-CR23.

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In the year 2000, the US Health and Human Services Office of Minority Health created National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, known as National CLAS standards, which elucidate barriers to care for limited English proficiency patients. The use of professional interpreters has been studied extensively and has been noted to decrease communication errors, increase general understanding of medical care, and improve outcomes in patients who have limited English proficiency. However, data illustrates that professional medical interpreters are not used consistently in hospitalized settings. Data regarding use of interpreters in hospital settings widely varies depending on the hospital and the percentage of limited English proficiency patients, and in some studies is as low as 18%, while in other settings being as high as 46%.3 This data is limited by the difficulty collecting this data—often interpreter use is not consistently documented in the medical record. Factors involved in whether a professional interpreter is used include not only the availability of interpreters, but also the patient’s perception of their own ability to communicate in English, whether the patient believes that their provider is capable of communicating in the patient’s primary language, complexity of the planned communication, and trust in the interpreter. The existence of streamlined services for accessing interpreters in the hospital setting can facilitate interpreter use. Preferred language and whether a patient would like an interpreter used do not always correspond to degree of language proficiency. In addition to language proficiency, cultural discordance between patients and the clinicians who care from them can create barriers to receiving care. The cultural mores of different societies differ based on region and can affect how patients view goals of clinical care and desires for treatment. In addition, the ways in which patients want to receive communication may differ based on their cultural background. Even hospitals with diverse staff cannot feasibly have staff from every culture, so there exist the possibility of misunderstanding and provision of care that is not culturally informed. There are many components to a successful hospitalization for patients, including appropriate medical management, clear communication, robust discharge linkages, and compassionate and responsive team members. These components may be disrupted by cultural and language barriers. Community health workers or health navigators who help facilitate elements of hospitalization may provide a mechanism for ensuring that patient expectations are met and that all of the components for successful hospitalization are addressed. One study described a community health worker intervention that helped patients create individually tailored action plans to achieve their goals for hospitalization. After 2 weeks of the intervention, there was found to be improvement in rates of discharge follow-up with primary care, improvement in discharge communication, increased patient satisfaction, and reduced readmission rates.4 Other studies have shown that a health navigator role for indigenous

 https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3823-1#ref-CR25.  https://pubmed.ncbi.nlm.nih.gov/24515422/.

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peoples across different settings in Canada and the US can help patients navigate the health care system and reduce both systemic and personal barriers to care while acknowledging the political and cultural social context.5 Health navigators and community health workers in inpatient settings are being increasingly recognized as important mechanisms for improving care of diverse populations. Prior to hospitalization, immigrant patients face a number of barriers that can impact their care. This includes factors linked to social determinants of health, such as poor insurance coverage, limited access to preventive and primary care, language and cultural barriers, transportation difficulties, and work schedules that do not allow for doctors visits. In addition, undocumented immigrants may fear exposure to legal authorities. All of these factors lead to immigrant patients presenting later to the hospital with uncontrolled medical illnesses, and may lead to more severe sequelae. During the COVID-19 pandemic, many individuals with respiratory symptoms reported continuing to work because of economic pressures and fear that they may lose their jobs.6 In addition, immigrant patients may have trouble adhering to post-hospitalization care and appointments, further worsening their health status. Policies pertaining to immigration can have a meaningful impact on hospitalized immigrant patients. Policies in which local and state governments partner with the federal government to provide immigration enforcement can negatively impact undocumented immigrant patients, while policies that allow state and local governments to protect undocumented immigrants can be very beneficial for hospitalized patients. For example, the designation of hospitals as “protected” from immigration enforcement can help ensure the safety of patients during hospitalization, and increase the comfort level of patients who are seeking hospital care. Another area that affects undocumented immigrants is limited access to public programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP). In addition, state laws that restrict individuals who do not have social security numbers from obtaining drivers licenses make it difficult for these individuals to access services due to lack of legal identification, in addition to creating transportation barriers that can in turn exacerbate the health impairment of these patients. Emergency Medicaid allows patients to access hospital care and will generally cover the costs of hospitalization. This can be helpful for immigrant patients with limited resources who have serious illnesses requiring hospitalization. However, other benefits such as primary care and home health services are not covered by emergency Medicaid. This system of covering hospital-based services but not covering primary care has led to a situation in which high-cost acute interventions are provided but less expensive preventive care is not covered, exacerbating health disparities and increasing cost. In addition, whether undocumented immigrants receive Medicaid coverage depends on the state. Some states provide insurance coverage

 https://journals.sagepub.com/doi/10.1177/08445621211066765.  https://shmpublications.onlinelibrary.wiley.com/doi/full/10.1002/jhm.12792#jhm12792bib-0009. 5

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for children and pregnant persons independent of immigration status. In California, the state Medicaid program includes some segments of the undocumented immigrant population.7

9.3 Clinical Pearls –– An interpreter, either in-person, via video, or via telephone should be used for every hospitalized patient with limited English proficiency. –– Certified medical interpreters should be used for interpretation in lieu of the patient’s friends or family members unless the patient strongly advocates otherwise. –– Immigration status and cultural differences are important driving factors of care in addition to language proficiency, and it is important to create a safe and inclusive environment informed by cultural differences without concern for law enforcement involvement.

 https://shmpublications.onlinelibrary.wiley.com/doi/full/10.1002/jhm.12792.

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Chapter 10

The Impact of Social Determinants of Health on Hospitalized Patients

10.1 A Case Mr. Banderas is a 24 year old Latinx male with a history of Type II diabetes mellitus who is admitted with hyperglycemia to greater than 400 mg/dL. He is placed on an insulin drip and transitioned to a subcutaneous insulin regimen, with good blood glucose control. On the day of discharge, the diabetes nurse provides discharge teaching to ensure that Mr. Banderas knows how to self-administer insulin and how to adhere to a carbohydrate-controlled diet. During his visit with the diabetes educator, Mr. Banderas states that he has not been taking insulin because he cannot afford it and has had trouble storing it because he is unhoused and does not have access to a fridge. His outpatient primary care doctor prescribed other oral diabetes medications but he has also been unable to afford these medications. “Sometimes I have to choose between my insulin and my next meal” he says.

10.2 The Impact of Social Determinants of Health on Hospitalized Patients It is known that social determinants of health play a role in overall health status and impact the level of acuity with which patients present to the hospital as well as their ability to access follow-up and preventive care after discharge. But it is also true that social determinants of health play a role in determining whether a patient is likely to be hospitalized at all. One study in 2021 showed that hospitalized patients had higher rates of social isolation, poor educational attainment, food insecurity, lack of community support, and economic instability as compared to their counterparts

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without impact from social determinants of health.1 In general, studies have shown a relationship between sociodemographic characteristics in patients with multiple medical problems and use of ED and inpatient services, with higher age, lower income, lower educational attainment, and more negative self-perception of health status all correlating with increased use of acute care services. Other studies have shown that food insecurity, social isolation, and low educational attainment increase an individual’s risk of hospitalization, with overall risk of hospitalization increasing as the burden of social determinants of health increases. This clustering of social determinants of health may heighten the adverse health effects on certain subsets of the population, indicating a need for comprehensive approaches to intervene on social determinants of health.2 Social determinants of health also have been shown to have an impact on readmission rates, with another study in 2021 showing a dose-response relationship between health-related social needs and rates of readmission. Individuals with housing insecurity, lack of family support, lack of psychosocial support, employment instability, and lower socioeconomic status were more likely than patients without these health-related social needed to be readmitted to the hospital within 30, 60, and 90  days of hospital discharge. This rate of readmission increased as number of health-related social needs increased, and this relationship persisted even after controlling for sex, payer, comorbidities, functional limitations, and hospital characteristics.3 A study in 2022 looking at the “Accountable Health Communities Model”, a system for screening community-dwelling individuals for health-related social needs in both community and Emergency Department settings showed that patients who screened positive for these needs were more likely to utilize the ED for care. The health-related social needs analyzed in that study were housing instability, difficulty paying utility bills, food insecurity, transportation, and interpersonal safety. It was found that the ED was an effective location for capturing more patients with these needs because patients with multiple health-related social needs often utilize the Emergency Department as their primary source of care.4 There is also evidence that multiple health-related social needs lead to even more financial instability when patients are ill and hospitalized, such that patients who are already vulnerable to adverse health effects due to their social determinants of health are rendered even more financially insecure due to illness and hospitalization.5 People experiencing homelessness with coexisting mental illness are among the most vulnerable populations from a health perspective. Studies that have examined the rates of acute non-psychiatric hospitalization in people experiencing homelessness have shown that patients experiencing homelessness with and

 https://link.springer.com/article/10.1007/s11606-021-07067-y.  https://link.springer.com/article/10.1186/s12913-020-06032-5. 3  https://link.springer.com/article/10.1007/s11606-021-06646-3. 4  https://link.springer.com/article/10.1007/s11606-022-07403-w. 5  https://link.springer.com/article/10.1186/s13690-022-00987-z. 1 2

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without concurrent mental illness have higher rates of health care utilization than the general population, with people experiencing homelessness with concurrent mental illness having the highest utilization of Emergency Department and inpatient hospitalization.6 In order to implement changes that have a lasting impact on reducing health disparities, interventions that includes multiple approaches at the individual, community, health system, and governmental levels are needed. Examples of such approaches are the hiring of patient navigators or advocates to provide community-­ based interventions for meal delivery and social isolation, integration of social determinants of health screening and linkages in primary care and hospital settings, and policy changes that make resources more widely available for patients with health-related social needs.

10.3 Clinical Pearls –– If your patient screens positive for one health-related social need, they are likely to also have other health-related social needs that need to be addressed. –– If they exist in your health system, enroll your patients who are high utilizers of emergency and inpatient care into programs that address social needs as these programs help decrease readmission rates and decrease length of stay.

 https://link.springer.com/article/10.1186/s12913-021-06562-6.

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Chapter 11

Sexual Orientation, Gender Identity, and Hospital Care

11.1 A Case Mr. Thune is a 42 year-old transgender male who is hospitalized for treatment of pyelonephritis. He is placed on intravenous antibiotics, hydrated with intravenous fluids, and given pain management with acetaminophen. He has been taking weekly subcutaneous testosterone for several years but the admitting hospitalist holds androgen treatment because of concern that testosterone would decrease the immune system’s ability to fight infection.

11.2 Sexual Orientation, Gender Identity, and Hospital Care Lesbian, Gay, Bisexual and Trans individuals are often included together as a group subject to common stressors and experiences, connoted as LGBT. A more inclusive moniker that encompasses the range of gender identities that exist is LGBTIA+, including intersex and asexual populations. Sexual orientation and gender identity data is increasingly being collected by hospitals at the urging of the Joint Commission. Patients who are lesbian, gay, or bisexual as a group have higher rates of mental health diagnoses such as a depression and anxiety, and substance use disorders than the heterosexual population. Lesbian and bisexual women have a higher prevalence of osteoporosis, overweight/obesity, and colon, liver, breast, ovarian, or cervical cancer when compared to the entire population. Gay and bisexual men have higher HIV transmission rates, higher rates of sexually transmitted infections, higher rates of viral hepatitis, and higher rates of anal, prostate, testicular and colon cancers.1  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8624572/.

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Lesbian, gay, and bisexual individuals have differing health needs at different stages of their lives. At younger ages, they at are risk for harm from experiencing family rejection, engaging in risky sexual behaviors, anxiety, depression, and substance use. As they age, they are less likely to have children than the general population, and so are at risk for social isolation. Discrimination and bias may also make them less likely to receive preventive care. LGBT+ individuals with intersectional identities such as racial and ethnic minorities and individuals in poverty are more likely to experience health disparities. Bisexual men and women have a higher rate of mental health diagnoses compared to lesbian and gay individuals. It is important to recognize these epidemiological characteristics while still avoiding assumptions, as LGBT+ individuals have reported stereotyping during health care encounters because of their expressed sexual orientation or gender identity.2 Transgender individuals experience an incongruence between their sex assigned at birth and their gender identity, while cisgender individuals experience alignment between their sex assigned at birth and their gender identity. Transgender individuals may identify as male, female, both, or neither, and the term transgender encompasses a spectrum of gender identities. Some transgender individuals seek gender-affirming clinical interventions including hormonal therapies and gender-­ affirming surgeries. Transgender individuals in the US experience health inequities due to social determinants of health, including higher rates of living below the poverty line and homelessness than the general population, higher rates of sexual and physical assaults as compared to the general population, and rates of unemployment that are three times higher than the rest of the population. Within health care, they often experience bias and discrimination, leading to care that is not patient-centered or appropriate. Transgender individuals have higher rates of clinical depression, anxiety, substance use, and suicide than the rest of the population. Transgender individuals have a 40% lifetime suicide attempt rate, as compared to 4.6% in the overall US population. Transgender health was named a national priority in the federal government’s Healthy People 2020 in 2010 due to the health inequities this population faces.3 In addition to high rates of depression and anxiety, somatization, tobacco use, alcohol use, and other substance use, transgender male to female individuals carry a disproportionate burden of HIV infection, with rates as high as 20% of that population.4 Gender affirming approaches that acknowledge and affirm each individual’s gender identity are essential for improving transgender health. Gender affirmation has been identified as an essential element of patient-centered health care for trans individuals. The gender-affirming approach recognizes, acknowledges, and supports the gender identity and expression of each individual. This approach includes social dimensions, with correct names and pronouns used by the clinical team and

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8624572/, doi/10.1377/hlthaff.2017.0277. 3  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502664/. 4  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4802845/. 2

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administration, medical dimensions, such as gender-affirming medications and surgeries, psychological dimensions which address internalized negative beliefs trans individuals may harbor about themselves, and legal dimensions, with legal name and gender changes.5 At health care encounters, patients who identify as transgender experience a number of barriers. Beginning during registration or intake, admitting staff and the electronic health record may document gender identity in a binary manner and use sex and gender interchangeably, resulting in confusion for the patient as to whether they should report their sex or gender identity. While transgender patients often travel long distances in their search for outpatient physicians who are knowledgeable about cross-sex hormones and gender affirming medical procedures, transgender patients who are hospitalized with acute or emergent illnesses often do not choose their hospitals and may not have access to clinical teams who are well-­ versed in transgender health. There can be issues regarding hospital rooms for transgender patients when their gender identify is different than the gender tagged in their medical record. Once transgender patients are hospitalized, their cross-sex hormonal therapy is sometimes held because of lack of awareness from the hospital provider as to the purpose of the therapy and concerns regarding how it might interact with the patient’s presenting diagnosis. Another issue is access to care. Because of fears of biased care, transgender patients report avoiding and delaying care, which may lead to clinical presentations in the hospital later in the course of illnesses. In addition, intersectional identities can play a role, and transgender people of color have reported higher rates of discrimination when they access emergency care when compared to White transgender patients.6 Transgender patients who have substance use disorders report increased discrimination compared to other patients with substance use disorders when accessing substance use resources. In one study, Latino trans adults were two to four times more likely to experience discrimination when accessing social services as compared to White trans adults, while bisexual and queer transgender adults were 5 and 3.5 times more likely, respectively, to report experiencing discriminatory treatment at a drug treatment center than heterosexual transgender patients.7 Another issue that transgender patients often face is that insurance companies do not pay for medically necessary procedures that are not aligned with the gender stated on their insurance policy, even if those procedures are indicated from a clinical perspective. In addition, patients who receive gender-­ affirming procedures may not receive insurance coverage for those procedures.8 Transgender patients have a number of health needs, including potential cross-­ sex hormone use, gender-affirming surgical interventions, and mental health needs arising from high rates of depression, anxiety, and post-traumatic stress disorder

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667985/.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502664/#R47. 7  https://pubmed.ncbi.nlm.nih.gov/28447917/. 8  https://pubmed.ncbi.nlm.nih.gov/26243380/. 5 6

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often caused or exacerbated by the stigma they face for being transgender. Given all of these needs, comprehensive trans health care delivered by care teams who are knowledgeable and compassionate are essential, and hospital-based teams should make every effort to incorporate outpatient care teams into inpatient management. There is very little formalized training or education of physicians and other clinical staff on transgender health, both in medical and nursing school curricula, and also via continuing education. In one study, medical students and medical residents reported significant less comfort with providing hormonal therapy to transgender patients when compared to treatment of other patient populations.9 Centralized health care delivery structures that coordinate and consolidate care for transgender patients may be a mechanism for ensuring multidisciplinary care and clinical expertise for transgender care in one setting. However, centralized transgender care may also require traveling long distances for patients who do not live near a center, while more decentralized care allows for local and accessible care, but may be staffed by clinicians may not have as much proficiency in transgender health.10 Generally, it is important to maintain a gender-expansive view of hospitalized transgender patients, to provide gender-affirming clinical care, and to recognize that while the transgender population has high rates of various illnesses as compared to the general population, not all trans patients have gender dysphoria and it is important to tailor care to each individual’s needs.

11.3 Clinical Pearls –– Recognize that lesbian, gay, and bisexual patients have higher rates of certain clinical conditions and provide patient-centered care that is informed by the patient’s sexual orientation without making assumptions. –– Use gender affirming approaches that recognize, acknowledge, and support the gender identity and expression of each patient. –– Gender affirmation includes using correct names and pronouns, offering gender-­ affirming medications and surgeries, maintaining updated registration with correct pronouns and gender identities listed, and referring appropriate patients to mental health resources.

 https://pubmed.ncbi.nlm.nih.gov/23425656/.  https://www.frontiersin.org/articles/10.3389/fendo.2021.717914/full.

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Chapter 12

Substance Use and Hospital Care

12.1 A Case Ms. Tabrizchi is a 23-year-old woman with opioid use disorder who presents to a community hospital with cellulitis of her left upper extremity in the setting of injecting Fentanyl into that arm. She is given intravenous antibiotics, fluids, and acetaminophen. During the first night of her admission, she experiences diaphoresis, restlessness, anxiety, and muscle cramps. She asks for pain medications, and the overnight hospitalist gives her ibuprofen, with little relief. When she continues to experience severe symptoms, the nurse calls the hospitalist again for management of her symptoms. The hospitalist says “the ibuprofen should help her pain. She just wants narcotics because she’s an addict.”

12.2 Substance Use and Hospital Care Patients with substance use disorders often face barriers to care when they are hospitalized. Because of the adverse sequelae from drug use, patients with substance use disorders have high rates of comorbidities such as infections, and hospitalization can often be prolonged by withdrawal from substances, psychiatric comorbidities, and social instability. Stigma can be defined as negative beliefs and stereotypes associated with certain segments of the population and can impede care. There is evidence that stigma towards patients with substance use disorders negatively impacts care of hospitalized patients.1

 https://www.sciencedirect.com/science/article/abs/pii/S0740547221004347?casa_token= BVOgocmsrWUAAAAA:3Q6kFgoD5SElUS1m8Upbq3JBcqBErNHoX5z4PnJAKblIWqoVL1H Y1pp7e90siPt6vQdkXy84MQ. 1

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Some ways in which stigma can manifest includes separation of addiction care from other clinical care, use of stigmatizing language when discussing patients with substance use disorders, framing of addiction as a choice, and punitive policies for patients with substance use disorders. Because of stigma, patients may be denied treatment for withdrawal or management of their substance use disorder. Their illness may be categorized as “volitional”, and therefore not worthy of treatment. As Nora Volkow, director or the National Institute of Drug Abuse, has stated, “People who are addicted to drugs sometimes lie or steal and can behave aggressively, especially when experiencing withdrawal or intoxication-triggered paranoia. These behaviors are transgressions of social norms that make it hard even for their loved ones to show them compassion, so it is easy to see why strangers or health care workers may be rejecting or unsympathetic.”2 When a patient who is actively using drugs is admitted to the hospital, they are predisposed to certain comorbidities and complications as a result of their substance use. This can include withdrawal from the substance, intoxication, or adverse sequelae of the substance use itself. In patients with opioid use disorder, opioid withdrawal often becomes apparent in the first 24 hours of their hospitalization, and can manifest as agitation, tremors, body pains, diarrhea, and malaise. These patients, simply put, feel terrible if their withdrawal is not identified and treated. Identification of opioid withdrawal can occur with the use of the Clinical Opiate Withdrawal Score, or COWS, which looks for signs and symptoms of opioid withdrawal, and categorizes the withdrawal as mild, moderate, and severe (Fig. 12.1). Similarly, patients who have alcohol use disorder can present with signs of alcohol withdrawal within 24–72 hours of their last alcoholic drink. This withdrawal can manifest with tremors, agitation, altered mental status, and seizures. Both opioid and alcohol withdrawal can be managed with pharmacotherapy if properly identified, and both can cause significant harm if not identified. However, there is data that patients do not receive adequate management of opioid withdrawal in the hospital, and in one study, only 10–20% of patients with alcohol withdrawal were treated for their withdrawal.3 When patients are not treated for withdrawal, they not only are at risk for complications, they also are at higher risk of leaving the hospital against medical advice. These patient-directed discharges can cause tremendous harm as patients do not receive the essential clinical care they need. In addition, patients who visit the same health system repeatedly may be labeled as “non-­compliant” or “drug-seeking”, and the stigma can further negatively impact their care. Studies have assessed the reasons patients with substance use disorders give for leaving acute care hospitals against medical advice, and common reasons for these patientdirected discharges include untreated withdrawal, ongoing craving to use drugs, uncontrolled acute and chronic pain, hospital policies that do not allow patients to leave the wards intermittently, and stigma that they feel they experience in the hospital.4  https://www.nejm.org/doi/full/10.1056/NEJMp1917360.  https://www.aafp.org/pubs/afp/issues/2004/0315/p1443.html. 4  https://www.tandfonline.com/doi/full/10.1080/08897077.2019.1671942 2 3

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Fig. 12.1  Clinical Opiate Withdrawal Scale. (Adapted from https://nida.nih.gov/sites/default/files/ ClinicalOpiateWithdrawalScale.pdf on July 29, 2023)

There is evidence that patients with substance use disorders who are from marginalized racial or ethnic groups receive inferior care when compared to White patients. In patients with opioid use disorder (OUD), studies have shown that fewer Black and Latinx patients are linked to outpatient treatment on hospital discharge as compared to White patients.5 In patients who are treated for opioid use disorder, White patients are more likely to receive buprenorphine, while Black and Latinx patients are more likely to receive methadone.6 Historically, the development of methadone administration programs occurred in response to increasing crime rates in the US in the 1960s to address concerns of the White population about inner city crime, and targeted urban Black populations. In contrast, increased access to buprenorphine and the DEA-X program, which allowed providers with a special waiver on their DEA license to prescribe buprenorphine in the outpatient setting, was developed as a response to increasing opioid use disorder rates in the suburban and predominantly White population. In 2022, the DEA-X waiver requirement was rescinded, and any provider with a current DEA registration that includes Schedule III authority can now prescribe buprenorphine. While both methadone and buprenorphine are FDA-approved for opioid use disorder and are evidence-based approaches to treatment of OUD, buprenorphine prescription can occur through licensed outpatient providers, whereas methadone  https://www.sciencedirect.com/science/article/pii/S0740547221004177#coi0005.  https://www.tandfonline.com/doi/full/10.1080/08897077.2022.2074601.

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requires patients to visit a licensed facility daily. These visits to opioid treatment programs for methadone administration can interfere with a patient’s ability to maintain work and can expose patients to the influences and individuals that predispose them to drug use. A cross-sectional study of more than 3000 counties in the US in 2016 showed that there were more methadone treatment facilities per capita in highly segregated Black neighborhoods, and more buprenorphine treatment facilities per capita in highly segregated White neighborhoods.7 There is also a correlation between poverty and methadone use, with a negative correlation between poverty and buprenorphine use, indicating that patients who are from a lower socioeconomic status are less likely to be prescribed buprenorphine and more likely to be prescribed methadone for treatment of OUD. In the past several years, there has also been a concerning increase in rates of OUD in elderly patients, most pronounced in elderly Black patients. Rates of opioid overdose have increased in all groups in recent years, particularly during the early years of the COVID-19 pandemic, 2020–2022, but have increased most dramatically in the Black population. In addition, there has been an increase in hospitalizations related to alcohol use disorder in patients in the baby boomer cohort, born between 1946 and 1964, particularly from Black and Native American populations. Overall in the US, data shows that the highest rates of substance use disorders are in Native American and Alaska native populations, followed by White populations. This data exhibits how substance use and substance use-related hospitalization is affecting vulnerable populations, and how this effect is felt differently in patients who live in poverty, are from certain racial and ethnic groups, or who are older.8

12.3 Clinical Pearls –– When you suspect that a patient may have a substance use disorder, use the DSM-IV criteria to diagnose the patient. –– Avoid stigmatizing language such as “substance abuse”, “junkee”, “addict”, or “drug-seeking”. –– All patients with substance use disorders should be offered FDA-approved pharmacotherapy when admitted to the hospital, and linkages to outpatient treatment on discharge.

 Goedel WC, Shapiro A, Cerdá M, Tsai JW, Hadland SE, Marshall BD. Association of racial/ethnic segregation with treatment capacity for opioid use disorder in counties in the United States. JAMA Netw Open. 2020;3(4):e203711. 8  https://journals.sagepub.com/doi/pdf/10.1177/11782218221116733. 7

Chapter 13

Pain Management and End of Life Care and Equity

13.1 A Case Mrs. Delgado is an 89-year-old Latinx woman with a history of severe COPD, hypertension, and coronary artery disease who was admitted to the hospital with a COPD exacerbation. She is in significant respiratory distress, with dyspnea and acute on chronic retention of carbon dioxide, leading to an arterial blood gas that shows respiratory acidosis. As the night progresses, her oxygen levels drop and her carbon dioxide levels increase, resulting in worsening respiratory acidosis. Her durable power of attorney is listed as her granddaughter, who is at bedside. The overnight hospitalist asks Mrs. Delgado’s granddaughter whether BiPAP/CPAP, or intubation are within her goals of care. Mrs. Delgado does not have an advanced care directive, and in the past has said to her granddaughter, “I don’t want to be a vegetable and when the time comes, I’ll be ready to go.” Her granddaughter is unsure of whether her grandmother would have wanted BiPAP.

13.2 Pain Management and End of Life Care and Equity There is an abundance of research exhibiting disparities in pain management in patients who are racial and ethnic minorities in the US. In particular, multiple studies have shown differences in the way opioid pain medications are prescribed to Black patients when compared to their White counterparts. Research has shown that Black patients are less likely to receive opioid medications for pain control than White patients, and when they do receive these meds, they are given at lower doses for the same pain score as White patients in emergency, inpatient and outpatient settings.1  https://www.pnas.org/doi/full/10.1073/pnas.1516047113.

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There is also data of this disparity between Latinx and White patients, with Latinx patients being less likely to receive opioids and given fewer opioids than White patients for the same reported pain score. There are countless studies that replicate this disparity across a variety of settings. For example, one study found that only 35% of patients from a racial minority group received appropriate prescriptions for pain management compared to 50% of nonminority patients. Another study examining pain management among patients with metastatic or recurrent cancer found that only 35% of racial minority patients received appropriate prescriptions as established by the World Health Organization guidelines compared with 50% of nonminority patients.2 One study in 2021 looked at different health systems and noted consistent disparities in opioid prescribing across institutions. Standards around the use of opioid medications for pain management are complex. While opioids are not recommended for long term non-cancer pain, their use is accepted for acute or emergent use in the setting of illness or injury. High doses of opioids increase risk of overdose and death, and clinicians are often tasked with determining the balance between safety and pain management. This balance has been shown to be achieved with more pain medications for White patients when compared to Black and Brown patients. The reason for this disparity may at least in part stem from incorrect, racist assumptions around pain tolerance in Black patients. The larger context of these beliefs stems from racist assumptions around race-based medicine and the incorrect belief in the existence of biological differences based on race. Studies have shown that some physicians believe that Black individuals experience less pain than White individuals. The root cause of this racist belief is unclear, but some analysis has shown that this may be due to the incorrect assumption that Black patients have thicker skin or are physically and mentally stronger than White individuals from natural selection due to enduring the hardships of enslavement. There is evidence that physicians who hold these false assumptions are less likely to prescribe appropriate pain medications for Black patients. These racist beliefs as well as coexisting implicit bias may lead to poor pain management in this population. Several studies have shown an association between patients perceiving biased care and inadequate pain management, suggesting that prescribing patterns for pain management may be dictated by bias.3 Disparities also exist in the care given to patients palliatively and at the end of life. Studies have shown that the quality of care at the end of life or after a life-­threatening diagnosis that is given to a patient varies based on race, ethnicity, sexual orientation, and socioeconomic status.4 Palliative care, the field of medicine that focuses on alleviating pain and improving comfort associated with a serious  CS Cleeland, R Gonin, L Baez, P Loehrer, KJ Pandya, Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med 127, 813–816 (1997). 3  Hoffman KM, Trawalter S, Axt JR, Oliver MN.  Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Blacks and Whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–4301. doi:https://doi.org/10.1073/pnas.1516047113. 4  https://generations.asaging.org/health-equity-palliative-and-end-life-care. 2

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medical diagnosis, has been shown to improve quality of life for patients and family members. Studies have shown that hospitals that serve more racial minority patients are less likely to offer palliative care services than hospitals that serve fewer racial minorities.5 This disparity is heightened for patients when there is an intersectional identity such as lower socioeconomic status or LGBTQ+ status. Hospice care, where patients with terminal diagnoses experience a shift in their care to more explicitly focus on comfort and less on disease eradication, is generally offered to patients who have 6 months or less to live. Black patients have a significantly lower likelihood of accessing hospice when compared to White patients, and are rather more likely to experience aggressive interventions such as ICU care and invasive procedures such as intubation when compared to their White counterparts.6 This difference may be due to deep-seated distrust of a medical system that has historically mistreated Black patients and that continues to deliver inadequate care, leading to the fear among Black patients that the system will prematurely or inappropriately deliver care that is life-limiting. These disparities exist for a wide variety of life-limiting diagnoses including cancer care, trauma, kidney disease, and other medical illnesses.7 There is evidence that physicians do not offer thorough discussions around diagnosis, prognosis, management options, and end-of-life options to Black patients, which can lead to care that is not patient-centered and that delays appropriate management.8 Palliative care and hospice disparities are components of a larger disparity in care of patients with advanced illness. Patients from racial minority groups report more pain, greater financial concern, heightened caregiver burden, and overall worse family-reported experiences with death than individuals from racial majority groups in the US.9 In addition to racial disparities, there exist disparities in palliative care access in low income individuals. Specifically, patients with fewer financial resources have less access to hospice, and more limited ability to obtain medications that ease suffering. Some states in the United States do not offer hospice benefits for Medicaid patients and limit the number of prescriptions patients on Medicaid can receive, sometimes making it difficult to manage pain and other end-of-life symptoms. LGBTQ+ patients also have noted barriers to receiving end-of-life care. A study in 2021 showed that 43% of hospice professionals observed discriminatory behavior towards LGBTQ+ patients.10 Likely due to this context of discrimination, in another study, 80% of LGBTQ+ older adults chose to conceal their sexual orientation when entering a long-term care facility, and many of the individuals who chose to age at home expressed concern over allowing caregivers into their homes.11 In addition, if they are entering a hospice that has a religious affiliation, some LGBTQ+ individuals  Cole et al. (2019).  Ornstein (2020), Perry et al. (2021). 7  Diefeldt, Knopf, & Jackson (2021). 8  Perry et al. (2021). 9  Wachterman and Sommers (2006, 2021) 10  Candrian and Cloyes (2021). 11  SAGE (2019). 5 6

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worry that they will be discriminated against and do not disclose their sexual orientation.12 There is also concern among LGBTQ+ individuals that their partners may be excluded from decision-making.13 Closing the gap on these disparities can be achieved with provider and nursing education, initiatives to improve advanced care planning in all populations, and improving access to hospice and palliative care resources in neglected hospitals and communities.

13.3 Clinical Pearls –– Be aware that there is evidence that patients of color, particularly patients who identify as Black or Latinx, receive inadequate pain management when admitted to the hospital. –– Deliver patient-centered care and manage pain appropriately. –– Encourage all patients to complete advanced care planning while hospitalized.

12 13

 LGBT foundation (2022).  Candrian and Cloyes (2021).

Chapter 14

The Rural-Urban Divide

14.1 A Clinical Case Mr. Mar is a 78-year-old man who is admitted to a rural 24-bed hospital with 1 day of melena and worsening fatigue. His hemoglobin is 6. He receives packed red blood cell transfusion with some symptomatic improvement, but his melena continues. There are no gastroenterologists who are able to perform endoscopy at the hospital where he is admitted, so he must be transferred to the closest hospital where these procedures are performed, 90 miles away. When a bed is available at the outside hospital, he is prepared for transport, but has another large episode of melena, and his blood pressure drops to 70/40. He is given blood and placed on vasopressors but is deemed too unstable for transport, so he remains at the rural hospital for the time being.

14.2 The Rural-Urban Divide The topic of health equity often conjures up images of densely populated inner-city hospitals with a variety of cultures, languages, and socioeconomic statuses represented, but the reality is that rural hospitals in the US also may provide deeply inequitable care. With physicians and medical facilities often concentrated in densely populated settings, rural regions often exhibit a paucity of subspecialty access, equipment shortages, and overall clinician shortages because of difficulty recruiting clinicians to rural and under resourced settings. These issues are often compounded by issues that exist in more resourced settings such as racial inequity and care of patients with limited language proficiency. Rural hospital medicine physicians are often asked to expand the scope of their practice compared to hospitalist physicians in urban settings. This includes ability to care for ICU-level patients in © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_14

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settings that may lack subspecialist intensivist care and ability to care for broad subsets of populations such as patients with substance use disorders and geriatric patients without subspecialty support. Approximately 20% of Americans live in rural areas, and these individuals have a higher burden of chronic diseases and more limited access to health care resources than individuals living in urban settings. Critical access hospitals are hospitals that provide care to remote rural or critically under-resourced populations and constitute over two-thirds of rural hospitals. The data on whether rural hospitals deliver the same care as urban hospitals is mixed. Some studies have shown increased mortality in Medicare patients with acute myocardial infarctions, congestive heart failure, and pneumonia treated at critical access hospitals when compared to patients treated at non-critical access hospitals, as well as an increase in overall mortality in Medicare patients at critical access hospitals compared to non-critical access hospitals. Other studies have shown no differences in surgical mortality in Medicare patients at critical access hospitals.1 A large study of approximately ten million people from 2008 and 2013 showed that urban counties with large metro areas of more than one million people had a larger decline in hospital mortality compared to patients from rural counties which were centered around cities of between ten thousand and fifty thousand people. It was found that the rural populations had a greater percentage of patients with five or more chronic diseases and there was a large income disparity between rural and urban patients. Only one fatal diagnosis was more likely to result in death for urban versus rural patients, sepsis, and the diagnoses in rural patients that were most likely to result in death were lung cancer, renal failure, and intracranial hemorrhage. Patients with Medicare, commercial insurance, and Medicaid in rural regions were more likely to die than patients with these insurances in urban regions, and this disparity was greatest in patients with Medicaid. All told, in 2013 the probability of rural patients dying in the hospital was approximately 10% higher than for urban patients, with rural Medicaid patients experiencing the brunt of this disparity.2 The cause of this disparity is likely multifactorial. There may be quality gaps in hospital care for rural patients, as well as known subspecialty shortages. There is evidence that patients from rural areas are more frequently bypassing rural facilities and going straight to urban facilities in higher rates than in the past. It is also possible that rural patients who have diagnoses that lend poor chance of survival are not being transferred to urban hospitals while rural patients who have conditions treatable with procedures or subspecialty care available at only urban centers are being transferred, inflating the population at rural hospitals with untreatable or incurable conditions. The known shortage of primary care in rural areas may also lead to decreased preventive care interventions, resulting in sicker patient populations with higher mortality rates. This may be augmented by higher rates of  https://www.jabfm.org/content/30/6/816.short. Ibrahim et al. 2  https://www.jabfm.org/content/30/6/816.short. Ibrahim et al. 1

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detrimental health-­related behaviors such as tobacco use and unhealthy eating in rural populations as compared to urban populations. A framework of managing hospitalized patients in rural regions can be helpful to provide high-quality care to this population. The guiding principles of this framework include: –– Maintenance of a clear guideline for hospitalist scope of practice in rural settings. This includes very specific boundaries to the care that can and will be provided in the rural setting and transparency with on-site clinicians about these ­expectations. Transfer to a higher level of care for subspecialty care should only occur when treatment options at the rural facility have been exhausted. –– Subspecialty access must be prioritized and there must be broad awareness among hospitalists when there is no access to subspecialty support. For example, if there is no capability to perform endoscopies/colonoscopies on-site, teams must be aware of this limitation to allow for effective case planning. With the advent of increased telemedicine capacity accelerated by the COVID pandemic, there are opportunities for innovative approaches to incorporating telemedicinebased subspecialty communication. –– There must be robust pathways for transfer to other facilities when clinical needs cannot be met at the rural site. Many times, there is logistical difficulty transferring patients to other settings due to bed shortages and confusion about scope of practice. Agreements with other facilities are essential to avoid real time difficulties in transferring patients.

14.3 Clinical Pearls –– Know the scope of practice at the rural hospitals at which you work and be aware of where the closest centers for subspecialty care are located. –– Advocate with your hospital leadership for streamlined pathways for transfer of patients whose care requires resources that are not available at your site.

Chapter 15

Incarcerated Patients in the Hospital

15.1 A Case Mr. Toland is a 64-year-old male who is transferred from a correctional facility for chest pain in the setting of systolic blood pressures in the 200s. He is stabilized with an anti-hypertensive regimen, and myocardial infarction is ruled out. His blood pressure remains elevated, and he stays in the hospital for titration of his anti-­ hypertensive medication regimen. Two correctional officers are stationed outside of his room, and he is shackled to the hospital bed. The hospitalist physician thinks that he will be ready to be discharged the next day, but is unsure what to tell the patient about follow-up plans since he will be going back to the correctional facility.

15.2 Incarcerated Patients in the Hospital Individuals who are incarcerated may be hospitalized if they experience an acute medical illness needing hospital-level care. Patients may be incarcerated in jails, correctional facilities while they are awaiting adjudication of a crime or serving sentences less than a year, or in prisons, correctional facilities for patients with sentences greater than a year. There is data that individuals who are incarcerated have increased risk of chronic diseases including cardiovascular disease, hypertension, diabetes, kidney disease, HIV, and hepatitis as compared to the rest of the population.1 It is estimated that approximately 80% of released inmates have chronic diseases, psychiatric disorders, or substance use disorders, but only between 15% and 25% report seeing a doctor in their first year after release from a correctional facility (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069256/). Health care delivery  https://link.springer.com/article/10.1007/s40719-022-00231-7#ref-CR68.

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in the jails can be inconsistent and is not subject to standards for oversight. Incarcerated individuals are also subject to interpersonal violence and self-harm. One study showed that around half of incarcerated patients with surgical conditions had experienced trauma.2 In addition, there are high rates of general debility in terms of difficulties with ambulation, poor vision, hearing impairment, cognitive disorders, poor self-care, and the inability to live independently.3 There are also a number of other adverse health effects from incarceration, including increases in all-cause mortality after prison release, and the inability to access work, financial resources, housing, and health care. When patients are released from correctional facilities, their rates of hospital admission for acute medical conditions are higher than the general population. One study showed that among Medicare patients, approximately 1  in 70 individuals released from a correctional facility are hospitalized for an acute condition within 7 days of release from the facility, while 1 in 12 individuals released from prison are hospitalized within 90 days of release.4 This is likely due to the fact that access to health care is constitutionally required while inmates are in correctional facilities but this is no longer the case once they are released, and this population has a heavy burden of health-related social needs, including poverty, housing insecurity, unemployment, transportation needs, and food insecurity, leading to difficulty accessing health care resources for preventive and primary care and necessitating the use of emergency and inpatient care. Most inmates are not discharged on medications or with referrals to substance use treatment or mental health resources. Once released, inmates must arrange to start seeing primary care physicians on their own, and in the majority of states, their Medicaid and Medicare outpatient coverage is terminated while imprisoned so they must reinstate insurance before they can establish care with a primary care physician. This difficulty accessing primary care likely contributes to the high rate of hospitalization among inmates in the first year after their release from a correctional facility. Epidemiologically, the population of inmates tends to be predominantly younger men, but this demographic has been shifting with a documented increase in the aging prisoner population. As this aging continues, the rates of chronic disease among this population also grows. Black, indigenous, and people of color are over-­ represented in the incarcerated population, worsening disparities for this population.5 Data shows that hospitalized inmates have higher rates of ambulatory care-sensitive conditions, medical illnesses for which early intervention can prevent disease progression, when compared to the rest of the population. These diseases include conditions such as uncontrolled diabetes mellitus, COPD, asthma, hypertension, heart failure, pneumonia, UTI, and perforated appendix, and likely

 https://www.east.org/content/documents/2022_east_abstracts_sci_papers.pdf.  https://www.rti.org/publication/drug-use-dependence-and-abuse-among-state-prisonersand-jail-inmates-2007-2009. 4  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069256/. 5  https://link.springer.com/article/10.1007/s11606-021-07222-5. 2 3

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represents the cumulative effect of untreated and undertreated chronic conditions in this population. Other possible explanations are that inmates who are treated with medications while at correctional facilities are not able to receive these medications when they are released and therefore decline, or perhaps the treatment they receive while imprisoned is substandard, leading to proliferation of sequelae of untreated diseases. Patients who are hospitalized after release from correctional facilities most often are hospitalized for decompensated psychiatric disease or substance use-­ related issues. Studies have shown that there is quite a bit of variation in terms of how hospitalists care for inmates when they are admitted to the hospital. There is uncertainty about whether correctional officers should be asked to leave the room and whether shackles should be removed. The lack of clear clinical guidelines and paucity of hospital policies in this area often lead to disparate practices by different hospitalists based on their own experience and comfort level. Studies have also shown that there is a shortage of knowledge among inpatient physicians on how to communicate discharge plans to both patients and correctional facilities. While inpatient physicians often express the belief that inmates should receive equitable care, there is widespread uncertainty about how best to achieve this goal.6 Centers for Medicare and Medicaid Services (CMS) standards mandate that restraints that are the least restrictive are used for restraining patients who may be agitated during hospitalization, but CMS does not maintain any national standards with regard to shackling of inmates who are hospitalized. There are some restrictions on shackling pregnant individuals per national and state law, but there are no analogous restrictions or regulation of the shackling of non-pregnant inmates who are hospitalized. It is vital to maintain open and clear communication with incarcerated patients, involve family members in care discussions if desired by the patients, and engage with the correctional facility to ensure appropriate transitions in care. If shackling of patients or presence of officers inside the room is hindering care, it is appropriate for the hospitalist to attempt to limit these interventions as allowed by hospital policy. The removal of shackles is appropriate in cases where it is medical necessary. Ensuring linkages to post-hospitalization care through the correctional facility is vital. Providing truly patient-centered care and engaging the patient in decision-­ making are the cornerstones of caring for incarcerated patients in the hospital, an incredibly vulnerable patient population.

15.3 Clinical Pearls –– Provide patient-centered care and communicate clearly and openly about both the events of hospitalization and plans for care after discharge.

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787594/.

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–– If a patient’s shackles are interfering with their care, ask for shackles to be removed within the hospital policy. –– If the presence of a security officer in the room with the patient is hindering care, it is appropriate to ask for that officer to step outside of the room if allowed by hospital policy.

Chapter 16

Geriatric Patients and Inpatient Health Equity

16.1 A Case Mr. Novak is a 92-year-old male who lives alone and is admitted to the hospital after his grandson finds him lying on the floor. He tripped on a rug in his home and was unable to get up to call for help. He is admitted with rhabdomyolysis and a hip fracture and receives hydration and surgical repair of his hip fracture. He is placed on a post-op pain regimen that includes oxycodone as needed for severe pain. His family is unable to visit him in the hospital because of busy work schedules and long distances between the hospital and their homes. On postop day #2 at 9 PM, Mr. Novak begins to hallucinate and the hospitalist is called to bedside. When she arrives at bedside, the hospitalist notes that Mr. Novak is upset and confused, talking about having dinner with family members who have passed away. He has recently received a dose of oxycodone. In addition, the hospitalist notes that Mr. Novak has not had a bowel movement since surgery and that the previous day he had slept all day and was awake all night.

16.2 Geriatric Patients and Inpatient Health Equity In the United States, approximately 40% of hospitalized patients are over the age of 65, though they make up just 16% of the overall American population.1 These older adults are at risk for a number of complications during hospitalization. This increased risk of complications during hospitalization in older patients is due to their overall higher burden of comorbidities when compared to younger patients, and the health-related social needs that many older adults already face,  https://www.statnews.com/2018/11/16/hospitals-downplay-elder-care/.

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including poverty, lack of robust health insurance coverage, social isolation, food insecurity, and baseline debility. Complications include increased risk of delirium as compared to younger patients, increased risk of hospital acquired infections, and lack of support at home. For some older patients, hospitalization is the vulnerable moment that leads to a trajectory of overall functional decline. In some cases, an acute hospitalization may lead to patients no longer being able to live independently or the beginning of a spiral into poverty secondary to medical bills. In addition, hospitalization can act as a catalyst for changes in goals of care and advanced care planning. While ideally, advanced care planning discussions should occur at the primary care doctor’s office before patients become ill and not hastily occur at the bedside in the setting of a catastrophic event, in reality, many decisions about goals of care occur in the setting of an acute event. Some studies have shown that 30% to 40% of older adults who are hospitalized lose the ability to perform 1–2 activities of daily living at discharge when compared to their level of functioning two weeks before discharge.2 This can occur even in patients who are admitted with a medical diagnosis and do not have any pre-existing mobility problems. When older adults are hospitalized, clinicians should pay particular attention to four different domains: medications, mobility, cognition, and advanced care planning. It is well known that polypharmacy, the prescribing of multiple medications that sometimes have interactions and cumulative side effects, is a common cause of impairment and increased morbidity in older adults. With aging, patients are often not able to metabolize medications in the same manner as younger patients due to decreases in glomerular filtration rate that occur as patients age. Dose reduction of medications is important, but not always performed. In addition, common side effects and interactions between different medications can be augmented in older adults, producing deleterious effects. Careful consideration of medication regimens should take place when older adults are hospitalized. Table 16.1 lists commonly prescribed categories of fall-inducing and delirium-risk inducing medications. The second domain that clinicians should address for all hospitalized elderly patients is mobility. Bedrest can be detrimental to patients and result in deconditioning and muscle loss. Orders to keep patients on bedrest should be avoided, unless there is a specific contraindication to mobilization such as a fracture or other orthopedic diagnosis. For most hospitalized elderly patients, early and consistent mobilization is essential to prevent prolonged hospitalization and other complications. Many of the interventions that are performed in the hospital lead to impairment in mobility. The “tethering” of patients to intravenous lines, Foley catheters, telemetry boxes, and sequential compression devices all present barriers to mobility. As patients fail to mobilize, they undergo muscle loss, leading to significant deconditioning. Inpatients can often be mobilized by bedside nurses and do not necessarily need physical therapy consultation unless there are complex needs or specific orthopedic contraindications that need to be navigated. There are legitimate

 https://acpinternist.org/archives/2016/06/geriatrics.htm.

2

16.2  Geriatric Patients and Inpatient Health Equity Table 16.1  Commonly prescribed categories of fall-inducing and delirium risk-inducing medications

Medication class Anticonvulsants Anticholinergics Antidepressants Anxiolytics Antispasmodics Antiparkinsonian agents Anesthesia Corticosteroids Digoxin Antihistamines Antipsychotics H2 blockers Sedative hypnotics Opioids Muscle relaxants Antihypertensive agents Anticoagulants Benzodiazepenes

89 Adverse side effect Delirium, falls Delirium, falls Delirium, falls Delirium, falls Delirium, falls Delirium, falls Delirium, falls Delirium Delirium Delirium, falls Delirium, falls Delirium Delirium, falls Delirium, falls Delirium, falls Falls Falls Delirium, falls

concerns around falling in older adults, particularly given the increased fracture risk of many elderly patients due to osteopenia and osteoporosis and the significant morbidity and mortality associated with hip fractures in older adults. It is therefore important to safely mobilize patients with assistance from bedside staff and assistive devices as needed. Fear of a patient falling should not keep them tethered to their bed. Bedside staff should be available to mobilize patients, with physical therapy available when there are complex mobility needs. Though these measures may be expensive for health systems, it is even more expensive when a patient stays in the hospital longer than necessary because of a failure to mobilize and the resulting deconditioning and complications. The third domain that hospitalists who care for older adults should focus on is mentation. Delirium, which often occurs in older hospitalized adults, is a fluctuating disturbance in consciousness and cognition.3 Delirium can manifest both as hypoactive delirium, characterized by withdrawn affect, decreased appetite, apathy, and increased lethargy, or as hyperactive delirium characterized by confusion, agitation, and sometimes aggressive behavior. The hyperactive form of delirium, though commonly recognized, only occurs in 25% of patients, while the hypoactive form can occur in 75% of patients and is easily missed. Delirium can follow diurnal patterns and is more likely to occur during night time. Patients who are delirious are often disoriented and delirious states are characterized by inattention. All hospitalized patients should be evaluated daily for delirium using validated scoring systems such

 https://dl.uswr.ac.ir/bitstream/Hannan/138215/1/9781118127926.pdf.

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as the “Mini-Cog” brief assessment tool, a screening tool that tests memory, attention, and executive function. The diagnosis of delirium can be made using the “Confusion Assessment Method”, or “CAM” tool. A modified version of this tool, the CAM-­ICU is used for critically ill patients. As patients get older, the risk of both mild cognitive impairment and more significant cognitive disorders increases. The most significant risk factor for delirium is baseline cognitive impairment, and patients with pre-existing impairment in cognition have a higher risk of delirium in the hospital than those who do not have these baseline characteristics. In addition, patients with depression, prior stroke, or prior transient ischemic attack have increased risk of developing delirium in the hospital. Risk of delirium also increases with impaired baseline functional status, such as inability to carry out activities of daily living. Assessing a patient’s baseline functional status is important both for quantifying their risk of delirium, as well as for beginning the post-discharge planning process by understanding their larger social context. When an older patient is diagnosed with delirium, it is also important to do a thorough medical evaluation, including assessment of laboratory values that may reveal an underlying infection or metabolic abnormality. Hospitalists should learn to distinguish between dementia, depression, and delirium, which may have overlapping symptoms during hospitalization. Thorough analysis of the medications that are being given to patients should take place during hospitalization, as studies have shown that just three new medications in older patients can increase the risk of delirium threefold. Medications that are known to increase delirium risk in older adults include anticholinergic medications, benzodiazepines, and opioids. Anticholinergic medications include antihistamines such as diphenhydramine, H1 blockers such as loratadine, H2 blockers such as ranitidine, tricyclic antidepressants such as amitriptyline, and antispasmodics such as oxybutynin. These medications should be avoided, if possible. Benzodiazepines such as lorazepam and diazepam should also be avoided, though if a patient is on these medications chronically, the benzodiazepine should not be abruptly discontinued, as benzodiazepine withdrawal can also lead to delirium. Opioids are often used to treat significant pain, but can precipitate delirium in elderly patients, so should be used with caution. Paradoxically, uncontrolled pain can also lead to delirium, so it is important to exercise care to avoid both undertreating and over-medicating pain in elderly hospitalized patients. Other medications such as steroids can also precipitate delirium in hospitalized patients and should be used with caution. Delirium, once identified, can be treated by managing the underlying cause, such as infection, metabolic abnormalities, or medication effects. Other interventions that address delirium and should be carried out include frequent re-orientation, addressing sensory deficits such as visual and hearing impairment, ensuring that patients receive adequate sleep, making sure that patients are not constipated and are euvolemic, and removal of any catheters or intravenous lines that may be impairing patients. Patients who are at risk for delirium should be proactively identified and precipitating factors should be minimized. When older patients in the hospital are experiencing hyperactive delirium, antipsychotic medications can be used to

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calm them down after non-medication approaches have been exhausted. These nonmedication approaches include redirection, engagement of caregivers and family members to help re-orient the patient, conversation with patients in their preferred language for limited English proficiency patients, and removal of any precipitating factors as described earlier. If all of these measures have been taken but patients are still agitated and need further management, antipsychotic medications can be administered either orally, sublingually, intramuscularly, or in severe cases, intravenously. These medications include olanzapine, quetiapine, and haloperidol. There is evidence that antipsychotics given for prolonged periods of time increase mortality in older patients.4 These agents should therefore be used judiciously and only in urgent situations where non-medical approaches have not been successful. The fourth domain that hospital-based physicians should focus on when caring for older adults is advanced care planning. Advanced care planning is a general term that encompasses goals of care discussions, as well as more fundamental conversations with older adults about how they wish to live as they age. While ideally these discussions would occur in a relaxed outpatient setting rather than in the setting of a life-threatening illness, many times they do occur in the hospital precipitated by an acute event. Hospitalists should be comfortable with addressing the larger social context of patients who are older and be able to engage in discussions around what these patients want for their lives as they age. This includes discussion of whether patients hope to live independently as they age, their goals and interests, their support systems, and what they expect or plan to do if they lose independence. A complete and thorough understanding of the social context of older patients is essentials when having these discussions. After a general discussion occurs, hospitalists should focus on more immediate considerations around hospitalization. In fact, in many cases, discussion of immediate decisions surrounding acute care occur first, and act as an opening to then delve into larger questions about how older patients wish to live. Specifically, older patients may need to make decisions about whether they would like aggressive interventions to be performed during hospitalizations, including resuscitation, electrical shocking, intubation, placement of central catheters, and artificial feeding. These decisions are often informed by the larger goals that patients have for their lives, and can lead to more general discussions about their goals for living as they age. Thorough discussion of these issues is essential to ensuring that the wishes of older hospitalized patients are truly being taken into consideration, and respected. Another issue that commonly comes up for patients who are older during hospitalization is their support system and who they would like to make decisions for them during hospitalization if they are incapacitated and cannot make decisions for themselves. It is important for hospital medicine physicians to assess the capacity of patients to make decisions about their care, and if the hospitalist assesses that the patient has capacity, he or she should have explicit and clear discussions with the patient about who they would like to act as their durable power of attorney to make

 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2203833.

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medical decisions in case they lose the capacity to make such decisions. It is important that this information is discussed and documented early in hospitalization. If the patient does not have decision-making capacity, a surrogate decision-maker needs to be found. Often hospital case managers and social workers can assist with this process. It is also important that hospitalists consider intersectional identities when treating older adults. Patients who, for example come from other cultures may have different beliefs systems and practices that may play a role when they make decisions about surrogate decision makers. Some individuals may choose to defer entirely to family members even when they have capacity to make decisions themselves, while others may choose to keep their medical diagnoses and decisions private. Patients should not be stereotyped because of their culture or religion of origin, but rather very clear and explicit discussions should occur between patients and providers about what their belief systems are and who they would want engaged in decision making regarding their care. In addition, as is discussed elsewhere, when treating patients who are LGBTQ+, assumptions should not be made about who the surrogate decision maker will be, but rather patients should be asked in a clear and non-judgmental manner who they would like to make their decisions for them if a surrogate is needed.

16.3 Clinical Pearls –– Hospitalists should be aware that elderly patients are a vulnerable patient population with specific needs. –– When caring for elderly patients, take care to prioritize mobility, minimize medications when able, prevent and manage delirium, and discuss advanced care planning in a sensitive and comprehensive manner during hospitalization. –– Be aware of intersectional identities for elderly patients, and take into account culture, race, religion, sexual orientation, gender identity, language proficiency, and other characteristics when caring for these patients.

Chapter 17

Environmental Health and Its Effects on Health Equity

17.1 A Case Mr. Stanton is brought to the Emergency Department with worsening cough and trouble breathing over the past several days. On evaluation, he is assessed as having community acquired pneumonia and is admitted to the hospital for oxygen support and antibiotics. Throughout his hospital course, Mr. Stanton’s infection improves with intravenous antibiotics, but he is persistently short of breath. He receives further chest imaging, which reveals interstitial pulmonary infiltrates. A detailed social and occupational history is taken, and it is noted that he has had heavy exposure to dust and pesticides for the past twenty-five years due to his work as a farmer.

17.2 Environmental Health and Its Effects on Inpatient Health Equity Environmental and occupational health is a vital component of hospital-based care and environmental exposures disproportionately affect racial and ethnic minorities, as well as individuals from lower socioeconomic backgrounds in the United States. Providing equitable care requires knowledge and interventions that focus on the role that environmental and occupational exposures play in determining health. There is an intimate relationship between where people live, the work they perform, and the environment they are exposed to in determining health outcomes. Hospitalizations are affected by these many overlapping factors. Individuals with fewer financial resources may be employed in fields that involve more exposure to environmental toxins. In addition, racial and ethnic minorities, immigrants, and individuals from lower socioeconomic statuses are more likely to live in zip codes that are subject to

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Table 17.1  Occupational exposures to unhealthy substances Occupation exposure Contact with animals

Work setting Farms, zoos, work with lab animals, veterinarians, leisure

Working outdoors

Agriculture, forestry, gardening, construction, lawn care Handling Kitchens, food foodstuffs manufacturing, food preparation Contact with Childcare workers, people school workers, residential care facilities, community care Contact with Health care workers, blood or other lab workers, body fluids housekeeping, hospitality workers Handling waste Building and or contaminated maintenance workers, material retail workers, construction Travelling abroad

Travelers

Biological agent Borrelia, tick-borne illness, Brucella, other zoonotic agents, E. coli, parasites Borrelia, Legionella, Staphylococcus, Tetanus

Salmonella, Rotavirus, E. coli, Hepatitis A

Adverse health effects Enteric diseases, brucellosis, allergies, asthma, skin rashes, borreliosis, scabies Borreliosis, meningitis, legionella pneumonia, respiratory tract and skin diseases Foodborne infections

Parasites, childhood illnesses such as chicken pox, mumps, measles, rubella, bacteria, rotavirus, influenza Bloodborne pathogens such as HIV, Hepatitis B, C

Diarrhea, parasitic infections, drug-resistant infections, influenza, TB, giardiasis

Viruses affecting the GI system, E. coli, salmonella, Hepatitis A, B, C, Legionella, HIV, endotoxins, mold Mycobacterium, E. coli, Hepatitis A, B, C, Vibrio cholerae, parasites

Diarrhea, asthma, bloodborne infections, skin and eye irritation, skin rashes

TB, HIV/AIDS, Hepatitis B, C

TB, tropical diseases, infections from food or water, parasitic diseases, mosquito- or tick-borne illnesses, zoonotic diseases

toxic exposures, and to engage in professions that expose them to environmental and occupational risk.1,2 Table 17.1 summarizes some of these occupations and exposures. Examples of professions that often involve exposure to environmental toxins include housekeeping, which may subject employees to inhalational injury due to cleaning agents, construction and other physically intense professions, which may subject patients to outdoor heat or cold exposure as well as fall and injury risk, factory employment, which may increase risk of repetitive stress injury, and industrial work, which may include exposure to paints, chemicals, and other toxins that adversely affect health.

 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32345-0/ fulltext?ref=prendi-il-controllo-della-tua-salute. 2  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198680/. 1

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Farmworkers, who are often immigrants or migrant workers, are subject to much harm from environmental causes, including pesticide, dust, and heat exposure. In addition, certain health care professions such as nursing aides and paid caregivers may have a considerable amount of close patient interaction, leading to exposure to infectious diseases. Increased risk based on occupation was seen during the COVID-19 pandemic, when individuals from lower socioeconomic status levels, Black and Latinx individuals, and immigrants were more likely to work in frontline professions that exposed them to increase risk of COVID-19 infection.3 These groups were shown to have increased mortality during the COVID-19 pandemic due to a confluence of these occupational exposures, and the effect of other social determinants of health. Occupational exposures are augmented by environmental exposures based on where individuals live. Patients who are racial and ethnic minorities or are from lower socioeconomic strata are more likely to live in zip codes with harmful environmental exposures.4 In 2016, the World Health Organization estimated that 24% of global deaths could be attributed to environmental causes.5 Environmental exposures encompass a range of phenomena, including air pollution, water and soil pollution, toxins in the food that is consumed or in substances applied topically to the body, and the effects of climate change on health. Air pollution can be stationary, such as industrial toxins produced by factories, or mobile, such as heavily-trafficked highways. There have been a number of studies examining the effect that environmental exposures have on rates of hospitalizations for acute illnesses. These studies have showed that exposure to both stationary and mobile air pollution lead to increased rates of hospitalization for asthma exacerbations and other exacerbations of respiratory illnesses. There is also an increase in stroke mortality among individuals who have been exposed to air pollution.6 In addition, studies that have examined the relationship between hospitalizations from diabetes and exposure to persistent organic pollutants (POPs) have showed increased rates of hospitalization from diabetes in populations with close proximity to sites that have high levels of POPs, an effect that is augmented for Black and elderly individuals.7,8 There is also data that rates of certain types of cancer are increased in populations with exposure to pesticide- and fertilizer-producing plants, as well as some nuclear power plants. These cancers include leukemias, lung,  https://www.oecd.org/coronavirus/policy-responses/the-unequal-impact-of-covid-19-a-spotlight-onfrontline-workers-migrants-and-racial-ethnic-­minorities-f36e931e/. 4  https://www.acpjournals.org/doi/10.7326/M22-1864. 5  World Health Organization. Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks. Overview. 13 September 2018. Accessed at www.who.int/publications/i/item/9789241565196 on 1 August 2022. 6  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3222489/. 7  Kouznetsova M, Huang X, Ma J, Lessner L, Carpenter DO. Increased rate of hospitalization for diabetes and residential proximity of hazardous waste sites. 8  Environ Health Perspect. 2007;115(1):75–79. 3

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pancreas, and stomach cancers, Non-Hodgkin’s lymphoma, and melanoma. Other studies have shown that proximity to stationary and mobile sources of air pollution, refineries, nuclear power plants, and hazardous waste sites are associated with increased risk of asthma, respiratory disease, heart disease, non-Hodgkin’s lymphoma, end stage renal disease, and adult leukemia. Increased risk of hospitalizations due to environmental exposures occur on a population level, and this effect may not be seen for every individual.9 The environmental effects of climate change and the warming planet are disproportionately impacting individuals from lower socioeconomic statuses as well as people in low- and middle-income countries. Climate disasters, including wildfires and flooding lead to a number of health-related conditions, result in political instability, produce unsafe living conditions, perpetuate homelessness, and may be directly responsible for increased rates of hospitalization. As the climate warms, food insecurity will likely worsen, and the rates of catastrophic environmental events such as wildfires and flooding are predicted to increase. When this happens, there is likely to be migration from one region of the United States to another, which could exacerbate poverty, homelessness, and other health-related social needs. While hospitalizations primarily address acute conditions, it is impossible to ignore the role that environmental exposures are having on hospitalized individuals. There has already been evidence of the effect that climate change is having on health in the United States. During 2018–2022, wildfires in the Western United States led to an increase in rates of hospitalization for respiratory illnesses, cardiovascular disease and other inhalational-related urgent medical conditions due to wildfire exposure,10 with more detrimental effects seen in women and individuals over the age of 65.11 Climate change also has led to increased rates of dust storms. Dust carries both particulate matter that can damage the lungs, as well as infectious agents, such as coccidiomycosis in the Western US, leading to infectious outbreaks. Climate change also has been linked to heat waves, increases in flooding, a rise in allergy rates, and increase in rates of tickborne illnesses such as Lyme disease.12 Another area of environmental exposure that has been studied is indoor air pollution. Indoor air pollution has been identified as an important cause of cardiovascular disease and pulmonary disease, and is defined as the pollutants and toxins that are produced inside homes due to stoves and heating systems. This toxicity can be increased when using certain types of cookstoves and heating systems, including

 Morris MS, Knorr RS. Adult leukemia and proximity-based surrogates for exposure to Pilgrim plant’s nuclear emissions. Arch Environ Health. 1996;51(4):266–274, Wilkinson P, Thakrar B, Shaddick G, et al. Cancer incidence and mortality around the Pan Britannica Industries pesticide factory, Waltham Abbey. Occup Environ Med. 1997;54(2):101–107. 10  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9076366/. 11  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5860049/. 12  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191619/. 9

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wood-burning and gas burning stoves. These methods for cooking and heating homes are more common in individuals who live in resource-poor areas.13,14 Studies examining the attitudes of hospital medicine physicians regarding environmental health have revealed that hospitalists generally believe that environmental health is an important consideration for the health of their patients as well as the health of the overall community, but that they feel that they have a significant gap in knowledge as to how to address environmental health concerns. Hospitalists also identify hospitals themselves as a source of environmental waste and pollution, but again, as a group, are unclear on how to address these issues.15 The American College of Physicians in November 2022 put forth a series of recommendations for tackling environmental health in the context of the enormous effect that the warming planet is having on health. These recommendations, summarized in Fig. 17.1, include calls to limit global temperature rise to 1.5 °C above preindustrial levels, funding of federal agencies and legislation that support environmental health, action to protect the public from harmful environmental exposures, enforcement of stringent air quality standards to decrease pollutants, and action to implement environmental justice measures that protect people of color, low-income individuals, and marginalized populations.16 When a patient is hospitalized, it is essential that the healthcare provider obtains a thorough social history, including history of occupational and environmental exposures. This rich history can be a vital tool for understanding the proximate causes of the patient’s acute medical illness. Often injuries to the cardiopulmonary system and the development of malignancies involve multiple insults and

Fig. 17.1  Summary of ACP recommendations to mitigate the effects of climate change on health. (Adapted from https://www.acpjournals.org/doi/10.7326/M22-­1864)  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888569/.  https://www.sciencedirect.com/science/article/pii/S0160412019340917. 15  https://pubmed.ncbi.nlm.nih.gov/37039588/. 16  https://www.acpjournals.org/doi/10.7326/M22-1864. 13 14

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understanding the cumulative impact of indoor air pollution, occupational exposures, air pollution, and other exposures can lend a more detailed and nuanced view of the multiple causes that interact with one another and the patient’s own biological factors to produce illness. Environmental and occupational health may seem outside the scope of hospitalist practice. However, when treating the patient in the hospital bed in front of them, it is important to contextualize the illness in the larger social, economic, and environmental situation. Hospitalists must also consider engagement at the advocacy level to ensure that sources of environmental toxins are not built near under-resourced communities, as has historically occurred. Through advocacy, education and compassionate treatment of individuals, hospitalists can have an impact on environmental and occupational health.

17.3 Clinical Pearls –– Detailed occupational and environmental histories should be obtained on all patients to fully characterize where patients live and work. –– Patients who are racial or ethnic minorities, live in zip codes where there is poverty, and have other health-related social needs are all more likely to have exposures to environmental and occupational toxins, and thorough occupational and environmental histories should be obtained from these populations.

Chapter 18

Disparities in Technology Use for Hospitalized Patients

18.1 A Case Mrs. Tang is admitted to her rural community hospital with fatigue, shortness of breath, and severe anemia in the setting of multiple episodes of melenic stools. She is given a blood transfusion and admitted to the hospital for further management. Unfortunately, there is no gastroenterologist support at the remote rural hospital where she is admitted and the closest hospital with subspecialty support currently does not have any bed availability and also expresses concerns that she may not be stable enough for transfer given her active melena and the three hour transport time. The hospitalist makes use of a remote gastroenterology e-consult service, and a GI physician sees the patient remotely over a mobile tablet system. Consultation advice is given and the patient is stabilized and transferred to the other hospital when a bed is available.

18.2 Disparities in Technology Use for Hospitalized Patients The use of mobile technology for hospital care was irrevocably affected by the COVID-19 pandemic in 2020. During the pandemic, because of the public health orders around isolation, outpatient clinical care began to occur largely over mobile electronic devices, and even after the public health orders were lifted, patients often continued to be seen over telehealth. The implications of the COVID-19 pandemic for hospital-based services have been less clear. Hospital-based care in many instances could not be transitioned to telehealth because of the importance of in-­ person physical examination and evaluation and frequent need for procedures when managing hospitalized patients. In addition, during the COVID-19 pandemic, family members and friends were often not allowed to visit their loved ones in the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_18

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hospital, necessitating the use of mobile devices for patients to communicate with family members remotely. This system of communication using mobile devices in some cases continued even as the rates of COVID-19 decreased and visitor restrictions were loosened. In addition, consultations that do not require direct in-person care are still often being conducted via telehealth. The use of telehealth technology in hospital medicine has evolved greatly secondary to the COVID-19 pandemic. As we examine the evolution of telehealth in the United States, it is apparent that there are four applications for telehealth in hospital settings that have emerged in the aftermath of the COVID-19 pandemic. These approaches include the use of telehealth for patient education and activation, telehealth-facilitated subspecialty consultation, post discharge follow-up via telehealth, and the use of telehealth to create hospitalist teams that enhance the quality of care delivered to patients. The first application of telehealth for facilitating inpatient hospital care is the use of mobile technology for patient education and activation. Patient education can be facilitated by the use of mobile training modules or online patient educational platforms that can be accessed from the hospital room.1 In addition to education, patients can learn to advocate for their own care through mobile patient care tools that facilitate easier communication between patients and their care teams during hospitalization, and mobile tools for patient advocacy that may link patients to patient relations teams or inpatient health advocates who can help them ensure that their voices are incorporated into the care that they receive. This use of mobile technology while patients are in the hospital as a mechanism for more fully engaging them in their care in addition to directly educating them about their illnesses and teaching them management strategies is one vital use of mobile technology for inpatients. The second potential application of telehealth approaches for improving inpatient care involves the engagement of subspecialty consultation via mobile devices. This mobile technology allows providers who are not in-house educate patients on specialty areas, such as a diabetes educator who provides telehealth consultation or a psychologist who provides a mental health intervention while patients are in the hospital. This use of mobile technology is important because care can be delivered to settings that are typically under resourced, resulting in improved health equity. For example, as previously discussed, one of the major challenges of rural hospitals is lack of subspecialty expertise and access. Using telehealth mechanisms for engaging subspecialty providers for consultation can be vital to improving the quality of care in such remote and under-staffed settings. The third application of telehealth to hospital-based care is the use of virtual hospitalist models. Through these models, tele-hospitalists partner with in-person hospitalists to allow for more comprehensive inpatient care delivery in settings where there is a shortage of providers. This system was used by one hospital during the COVID-19 pandemic in New York City. During the pandemic, this hospital used a tele-hospitalist model that paired an in-person hospitalist with a telehospitalist to

 https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2314-0.

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enhance the quality of care provided, and to allow providers who could not see patients in-person help enhance the quality of patient care.2 Such novel approaches may help bridge the gap in care, particularly in rural and disadvantaged communities with shortages of healthcare providers. Another application of mobile technology that can be used to enhance patient care is the use of post discharge follow up through telemedicine consultation. These telehealth visits with patients after hospital discharge can help patients who have health related social needs that prevent them from accessing in-person post-­ discharge follow-up by providing this follow-up via telemedicine. This post-­ discharge follow-up can be performed by nurse practitioners, physicians, healthcare assistants, social workers, community navigators, and other members of the healthcare team to provide seamless follow-up for patients after hospital discharge. This system can improve the equity of care delivery by allowing patients who have health-related social needs that prevent them from visiting their physician after hospital discharge to receive this follow-up care via telemedicine. In addition, given that the providers providing post-discharge follow up to these patients already know the specifics of their hospitalization, there may be an opportunity to improve the quality of transitions care from the hospital setting to the primary care physician office. There is evidence that post-discharge telehealth follow-up can decrease rates of 30-day readmissions to the hospital.3 While these approaches have potential for improving health equity, we must also consider their potential for worsening disparities in care. We know that mobile technology is not globally accessible to all patients. Patients with health-related social needs are less likely to have access to Internet services and mobile phone access.4 Those who do have Internet access may not have robust connectivity and areas of the country that are remote, isolated and poor are less likely to have internet connectivity.5 By creating services that use telehealth resources without also investing in improving electronic access in underserved communities, we run the risk of diverting resources to more privileged communities at the expense of under-­ resourced communities. This does not mean that we should close the door on telehealth approaches as a tool for improving health equity. It simply means that we must advocate for improved accessibility and connectivity in concert with the development of telehealth approaches for hospitalized patients. Approaches that incorporate inpatient technology for teleconsultation, tele-hospitalist rounding, and patient education can all take place regardless of socioeconomic status and may improve equity as under-resourced rural hospitals gain access to resources they might not otherwise have. Telehealth approaches provide an excellent opportunity to improve care and help improve health equity in hospital settings.  https://link.springer.com/article/10.1007/s11606-021-06675-y.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10202267/. 4  https://www.nature.com/articles/s41746-021-00413-8. 5  https://scholar.google.com/scholar_lookup?journal=Appl+Econ+Perspect+Policy&title=Revisiti ng+the+digital+divide+in+the+COVID-19+era&author=J+Lai&author=NO+Widmar&volume=4 3&publication_year=2021&pages=458-464&doi=10.1002/aepp.13104&.

2

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18.3 Clinical Pearls –– Hospitalists should help develop programs to use mobile technology at their institutions, including the use of mobile technology for patient education, subspecialty consultation when needed, and post-discharge follow-up. –– Special attention should be paid to populations who already have health-related social needs and care should be taken to not exacerbate existing health care disparities through the use of mobile technology. –– Hospital-based physicians should advocate for more robust connectivity and accessibility to mobile devices.

Chapter 19

Interpersonal Violence and Its Effect on Hospitalized Patients

19.1 A Case Mrs. Barton is admitted to the hospital with abdominal pain of unclear etiology. She has visited the Emergency Department four times in the past 6 weeks with vague non-specific complaints and minor injuries. She has a history of anxiety and depression, and the hospitalist taking care of her notices that she appears restless and worried, particularly when her husband is in the room. On further discussion, the hospitalist learns that Mrs. Barton recently moved from a different city, and has no friends, family, or support system in her current city of residence. She does not work outside the home and defers to her husband for most financial decisions. The hospitalist screens her for intimate partner violence and presence of a firearm in the home.

19.2 Interpersonal Violence and Its Effect on Hospitalized Patients It is impossible to care for hospitalized patients in the United States without acknowledging and incorporating interventions for the interpersonal violence that is rampant in American society today. This includes intimate partner violence, assault, homicide, suicide, and firearm-related violence. The rate of injury and deaths from firearms is higher in the United States than in any other country in the world, with death rates five times higher in the US compared to countries with the second- and third-highest rates of firearm violence. More than 45,000 people died in the United

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States in 2020 due to firearms, with greater than half of these deaths occurring due to suicide, and more than 40% occurring due to homicide.1,2 Assessment of a patient’s risk of violence is an essential component of the in-­ depth social histories that hospitalists obtain from patients. When patients are hospitalized for medical illnesses, firearm violence may not be directly involved. However, hospitalization is an important time for hospitalists to screen for the threat of violence that patients face and assess the availability of a firearm in the home as part of the larger social context of the patient’s health. Approximately 60% of firearm deaths in the US each year are due to suicide, and conversely, each year approximately half of all suicides occur using firearms. Experts have suggested that interventions that focus on decreasing access to firearms and other lethal methods should be culturally informed and engage both health systems and firearm owners outside of clinical settings.3 There is a prominent linkage between race and the types of firearm violence that individuals experience. Examination of the racial breakdown of firearm violence shows demographic differences based on race. In Native American and Alaska Native individuals, the rate of homicides is disproportionately higher than the rate of homicides in all other racial groups, except for Black individuals. Approximately half of homicides in Native American and Alaska native individuals involve a firearm, and among homicides involving Native American and Alaska Native women, more than half involve intimate partner violence.4 There is evidence that firearm violence disproportionately affects Black communities, with homicide being the leading cause of death in Black males between the ages of 15 and 34 years of age, and the majority of these deaths involving firearms. In 2020, the rate of firearm death was 26.6 per 100,000 in Black individuals, compared to 2.2 per 100,000  in White individuals. Individuals who identify as Black are more likely to experience gun violence that results in homicide, whereas patients who are White are more likely to experience gun violence that results in suicide.5 In addition, Black individuals have higher rates of morbidity and mortality when they come into contact with law enforcement in the community and in custody, and more comprehensive data collection is needed to fully understand the causes and potential interventions.6

 https://www.commonwealthfund.org/publications/2023/apr/health-costs-gun-violence-how-uscompares-other-countries. 2  https://jamanetwork.com/journals/jama/fullarticle/2796714. 3  Betz ME, Thomas AC, Simonetti JA.  Firearms, suicide, and approaches for prevention. JAMA. Published September 27, 2022. doi: https://doi.org/10.1001/jama.2022.16663. 4   McPherson L.  Homicides involving American Indian and Alaska Native individuals. JAMA. Published September 27, 2022. doi: https://doi.org/10.1001/jama.2022.14817. 5  https://jamanetwork.com/journals/jama/fullarticle/2796714. 6  Mitchell RA Jr, Aronson JD. Violence and the carceral state. JAMA. Published September 27, 2022. doi: https://doi.org/10.1001/jama.2022.17144. 1

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The Society of Hospital Medicine has called for gun control measures to be pursued as a public health intervention. As they stated in 2022, “hospitalists practice hospital medicine, a medical specialty dedicated to the delivery of comprehensive medical care to hospitalized patients. We see effects of gun violence firsthand when victims receive care in the hospital, we experience it directly when we no longer feel safe in our workplace due to the prevalence of violence in the clinical setting, and we feel it as community members when our hometowns experience these tragedies.”7 Hospitalists can screen patients by inquiring about whether they have a firearm in their home as a basic measure to identify patients who may be at increased risk of firearm-related violence. However, patients may not be used to being asked this question, particularly if they are admitted with an acute medical problem unrelated to violence. These questions may cause a rift in the patient-physician relationship and patients may be suspicious that this questioning is politically motivated. It is important for the hospitalist to assess each patient individually and determine whether asking questions about firearms in the home may jeopardize the physician-­ patient relationship. Explaining to the patient that this question is asked of all individuals who are hospitalized, and including this screening as part of a larger social history are strategies to ask these questions in a sensitive manner. It is also important to emphasize that hospitalist physicians do not have the authority to confiscate weapons, but rather ask these questions as a mechanism for improving safety. Patients who screen positive for presence of a firearm in the home should also be assessed for use of safety measures to secure the firearm, and when such measures are not being taken, should be educated to use safe storage methods, store ammunition in a separate, securely locked location, and use a firearm safety device such as a trigger lock or cable lock. Universal screening of patients for risk of firearm violence in clinical settings is an effective mechanism for identifying individuals at risk for experiencing firearm violence early and proactively.8 One major barrier to implementation of measures to reduce rates of firearm-­ related violence is the limited availability of data infrastructure to collect metrics. This barrier is at least partly due to the Dickey amendment, a 1996 provision to the 1997 US omnibus spending bill that states that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”9 This amendment has prevented robust research into the causes of firearm violence and stopped analysis of interventions to prevent further violent events. Researchers have proposed the development of a comprehensive system with data infrastructure to collect and make accessible reliable information on the epidemiology of firearm injuries and deaths as a starting point for developing effective interventions.10  https://www.hospitalmedicine.org/news-publications/press-releases/society-ofhospital-medicine-issues-statement-in-response-to-gun-violence/. 8  h t t p s : / / j o u r n a l s . l w w. c o m / a o s o p e n / f u l l t ex t / 2 0 2 2 / 0 3 0 0 0 / u n ive r s a l _ s c r e e n i n g _ for_firearm_injury_risk_could.8.aspx. 9  104th Congress. “Public Law 104–208” (PDF). 10  Kaufman EJ, Delgado MK. The epidemiology of firearm injuries in the US. JAMA. Published September 27, 2022. doi: https://doi.org/10.1001/jama.2022.16894. 7

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In addition to data collection and clinical interventions to identify at-risk patients, it is clear that legislative and regulatory actions need to take place to decrease access to firearms. Proposed legislation limits concealed carrying of firearms, decreases access to firearms by children, intensifies regulation of the process of owning a firearm, and attempts to exclude individuals at high risk of firearm-related violence from owning a firearm. Other proposed strategies include restraining orders against individuals who have a history of serious domestic violence, removal of firearms from individuals who own a firearm but subsequently are prohibited from possessing firearms due to felony conviction, imposing waiting periods on gun ownership, and implementing universal background checks. In addition, more firearm-related research is needed to gain a deeper understanding of the inciting factors for firearm violence and implement robust whole-of-society interventions to mitigate these factors.11 Another form of interpersonal violence that affects hospitalized patients is domestic or intimate partner violence (IPV). Intimate partner violence can be defined as violence that occurs between individuals in an intimate relationship. This relationship does not have to be between sexual or romantic partners, but can occur between any two individuals who have a close relationship. There are no scholarly distinctions between intimate partner violence and domestic violence, but the term intimate partner violence tends to be used for more narrow interactions within a partnership, while domestic violence generally refers to a broader swath of domestic interactions. Importantly, intimate partner violence and domestic violence do not only include direct physical violence, but also include any controlling behavior meant to exert power over an individual against that individual’s consent. Among those at increased risk of experiencing intimate partner violence are women, individuals from lower socioeconomic status groups, individuals between the ages of 26 and 30, and individuals with a history of childhood mistreatment.12 Approximately 21% of women in North America experience intimate partner violence. Intimate partner violence is associated with a host of symptoms, including chronic pain, and gastrointestinal, gynecological, and cardiovascular complaints, in addition to injuries due to violence. Patients often will have repeated visits to health care settings but may exhibit anxiety during clinician encounters. European studies have shown that the majority of individuals experiencing intimate partner violence turn to health systems and hospitals in particular for help.13 However, there is evidence that very few patients are actually asked about their history of intimate partner violence, with one Austrian study showing that only 4.4% of patients had been asked about domestic violence in a hospital setting, though 73.9% of individuals in that study stated that they would have liked to have been asked about domestic

 https://jamanetwork.com/journals/jama/fullarticle/2796714.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719257/. 13  FRA (2014). Violence against women: A European survey. Vienna: European Union Agency for Fundamental Rights. [Google Scholar]. 11 12

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violence and more than two-thirds stated that they would have liked to have been asked by a physician.14 Literature from US hospitals also shows very low rates of screening. One study that examined screening rates for IPV in the literature from 1992 to 2005 showed that between 3% and 41% of physicians reported screening for IPV, and that clinicians who are female, younger, have received training and education on screening, and are nurses as opposed to physicians are more likely to screen patients in practice.15 Screening is also more likely to occur if the electronic medical record facilitates or triggers a screen, and if there are in-person prompts such as posters or signs reminding providers to screen. There are a number of screening instruments for IPV. Six screening tools that have been found to be highly accurate in screening for intimate partner violence include the Hurt, Insult, Threaten, and Scream (HITS) instrument, the Ongoing Violence Assessment Tool (OVAT), the Slapped, Threatened, and Throw (STaT) instrument, the Humiliation, Afraid, Rape, Kick (HARK) instrument, the Women Abuse Screening Tool (WAST), and the Partner Violence Screen (PVS).16 Table 19.1 summarizes these validated screening instruments used to screen for intimate partner violence.

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719257/#cit0016.  Stayton, Catherine D., and Mary M. Duncan. “Mutable Influences on Intimate Partner Abuse in Health Care Settings: A Synthesis of the Literature.” Trauma, Violence, and Abuse Vol. 6 No. 4, Oct. 2005. Accessed 30 October 2012 from http://tva.sagepub.com.ezproxyhhs.nihlibrary.nih.gov/ content/6/4/271.full.pdf+html. 16  Nelson, Heidi D., Christina Bougatsos, and Ian Blazina. “Screening Women for Intimate Partner Violence: A Systematic Review to Update the 2004 U.S.  Preventive Services Task Force Recommendation.” Annals of Internal Medicine. Vol. 156 No. 11 June 2012. Accessed 4 November 2012 from http://www.uspreventiveservicestaskforce.org/uspstf12/ipvelder/ipvelderart.pdf. 14 15

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Table 19.1  Validated screening instruments for intimate partner violence Screening instrument HITS (Hurt, Insult, Threaten, and Scream)

STaT

Description Four questions: in the past 12 months, did your partner:  – Hurt  – Insult  – Threaten  – Scream at you? Each answer gets one point “Have you ever been in a relationship where your partner has pushed or slapped you?” “Have you ever been in a relationship where your partner threatened you with violence?” and “Have you ever been in a relationship where your partner has thrown, broken or punched things?” (positive response gets 1 point each)

Definition of positive screen Greater than 1 point

Sensitivity/specificity Sensitivity: 30–100% Specificity: 86–99%

1–3, with each score conferring different sensitivity/ specificity

Sensitivity for lifetime IPV is 96% for score equal to or greater than 1, 89% for score equal to or greater than 2, and 64% for score equal to 3 Corresponding specificity is 75%, 100%, and 100% respectively

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Table 19.1 (continued) Screening instrument WAST (Woman Abuse Screening Tool)

Definition of Description positive screen Eight questions: 13 points or 1. In general, how would you higher describe your relationship?  – A lot of tension (3 points)  – Some tension (2 points)  – No tension (1 point) 2. Do you and your partner work out arguments with:  – Great difficulty (3 points)  – Some difficulty (2 points)  – No difficulty (1 point) 3. Do arguments ever result in you feeling down or bad about yourself?  – Often (3 points)  – Sometimes (2 points)  – Never (1 point) 4. Do arguments ever result in hitting, kicking or pushing?  – Often (3 points)  – Sometimes (2 points)  – Never (1 point) 5. Do you ever feel frightened by what your partner says or does?  – Often (3 points)  – Sometimes (2 points)  – Never (1 point) 6. Has your partner ever abused you physically?  – Often (3 points)  – Sometimes (2 points)  – Never (1 point) 7. Has your partner ever abused you emotionally?  – Often (3 points)  – Sometimes (2 points)  – Never (1 point) 8. Has your partner ever abused you sexually?  – Often (3 points)  – Sometimes (2 points)  – Never (1 point)

Sensitivity/specificity Sensitivity: 47% Specificity: 96%

(continued)

19  Interpersonal Violence and Its Effect on Hospitalized Patients

110 Table 19.1 (continued) Screening instrument PVS

HARK

Description 1. Have you been hit, kicked, punched, or otherwise hurt by someone in the past year? If so, by whom? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is making you feel unsafe now? H—HUMILIATION Within the last year, have you been humiliated or emotionally abused in other ways by your partner or your ex-partner? A—AFRAID Within the last year, have you been afraid of your partner or ex-partner? R—RAPE Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner? K—KICK Within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?

Definition of positive screen Greater than one positive response

Sensitivity/specificity Sensitivity: 35–71%

Specificity: 80–94%

Greater than or equal to 1 positive response

Sensitivity: 81% Specificity: 95%

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19.3 Clinical Pearls –– Firearm violence is a major cause of death and injury in the United States, and hospitalization offers a unique opportunity to screen for presence of a firearm in the home. –– The epidemiology of firearm violence reveals racial patterns, and providing interventions to decrease firearm violence is an essential component of health equity. –– There are few validated approaches for screening for firearm violence during hospitalization, but this should not stop hospitalists from screening patients and offering simple safety measures when appropriate. –– Hospitalists should screen patients for intimate partner violence using a validated tool and refer patients who screen positive in a sensitive, confidential manner.

Chapter 20

The Loneliness Epidemic and How It Affects Hospitalized Patients

20.1 A Case Mrs. Rao is a 79-year-old woman who is admitted to the hospital after experiencing a fall at home. She is an immigrant from India and currently lives with her daughter. She is a widow and initially came to the United States to help care for her grandchildren. She does not speak English fluently and communicates most effectively in her native language of Gujarati. Her daughter and son-in-law work during the day and her grandchildren are in school so she spends her days alone at home. She reports crippling loneliness at home during the day. She feels isolated from her Gujarati community, does not feel comfortable leaving the house because she does not understand English and is afraid that she may get lost, and misses the social connections from her home. Her feelings of loneliness and isolation were exacerbated during the COVID-19 pandemic when she was unable to travel, and did not leave the house for several months for fear of contracting the virus. She expresses deep regret that she has been unable to visit her close family in India for several years.

20.2 The Loneliness Epidemic and How It Affects Hospitalized Patients In recent years, it has become increasingly apparent that social isolation and loneliness result in a great deal of morbidity and mortality. Social isolation can be defined as the lack of social connections and support, whereas loneliness is a subjective state characterized by the perception of being alone. These distinctions are important because an individual may have a great deal of social support and connection, but still feel loneliness. Loneliness has been linked to a number of disease states, including cardiovascular disease, strokes, hypertension, depression, anxiety, and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_20

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cognitive disorders. Studies have shown that loneliness has health effects equivalent to smoking fifteen cigarettes daily and has a greater effect on mortality than drinking six alcoholic drinks daily, obesity, physical activity, or air pollution.1 Regardless of cause, multiple studies have shown that loneliness increases the risk of premature death by 26%, while social isolation increases premature mortality by 29%. Conversely, social connection increases odds of survival by approximately 50%.2 Loneliness is widespread in the United States, and in one survey in 2022, only 39% of Americans stated that they felt very connected to others.3 There are three components of social connection that have been described—structure, function, and quality. The structure of social connection refers to the number and frequency of social connections, while function refers to the ability that individuals have to receive support from these connections, and quality describes the positive or meaningful nature of the connections themselves. In order for individuals to feel truly connected, they must have adequate fulfilment of all three of these components of connection.4 Social isolation and loneliness have been problems globally as well as in the United States specifically for quite some time, but were exacerbated during the COVID-19 pandemic in 2020. During that time, public health isolation orders led to imposed social isolation on many individuals, leading to an increase in rates of loneliness. In 2021, one in four Americans reported feeling less close to their families due to the pandemic, while one in five Americans reported feeling closer to their families, suggesting that the pandemic exacerbated pre-existing patterns of family dynamics.5 Rates of social isolation, and loneliness are highest among individuals who live alone, have disabilities, experience financial needs, have baseline physical or mental health disorders, or are adults at the younger or older extremes of age.6 Some of the issues around increasing social isolation are linked to the advent of mobile technology and use of social media. Particularly during the COVID-19 pandemic, there was an acceleration in the use of mobile technologies as a tool for communication and interaction, as many individuals worked and went to school from home. During this period, there was an increase in social isolation and impairment in the development of meaningful relationships. In addition, the increase in use of social media has been shown to increase the emphasis on quantity of social

 https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf.  Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227–237. 3  Gallup Inc., Meta. The State of Social Connections. Washington D.C.: Gallup Inc.,; 2022. 4  Holt-Lunstad J.  Social Connection as a Public Health Issue: The Evidence and a Systemic Framework for Prioritizing the “Social” in Social Determinants of Health. Annual Review of Public Health. 2022;43(1):193–213. 5  McClain C, Vogels E, Perrin A, Sechopoulos S, Rainie L. The Internet and the Pandemic. Pew Research Center; 2021. 6  https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf. 1 2

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interactions as opposed to quality. The quality of social interactions is reported to be higher with in-person rather than remote interactions.7 Though patients are admitted with an acute medical illness during hospitalization, often loneliness and social isolation lurk behind the presenting diagnosis. When hospitalists are obtaining comprehensive medical histories from patients and are attempting to understand the totality of their life experience as factors that influence their health and outcomes, they should also pay attention to the social support structures that patients have and screen for loneliness and social isolation as significant drivers of morbidity and mortality. Though loneliness has been recognized relatively recently as a driving factor for increased morbidity and mortality, and may not be directly related to the reason the patient is hospitalized, it is imperative that hospitalists screen for loneliness and provide interventions for patients who screen positive. In 2023 the Surgeon General of the United States Vivek Murthy issued a report stating that loneliness is an epidemic and needs to be treated as such. Among the recommendations that Dr. Murthy made include increased public health infrastructure and investment in community organizations as tools for improving the ability of individuals to find social support in their communities.8 In addition, the development of infrastructure around transportation can facilitate community connections between individuals, and regulation of social media, particularly for younger people can help physicians make recommendations to patients about how to moderate their social media use, emphasizing the value of prioritizing in-person connection to online connections. There is literature among young people and adolescents that social media can increase rates of depression and anxiety, and lead to increased social isolation.9 However, it must be noted that for some marginalized individuals, such as transgender youth, social media and online connections allow them access to a larger subset of individuals who are more likely to understand their particular life experiences. On an individual level, as hospital medicine physicians identify loneliness, they can work with their social worker and case management team members to refer patients to community organizations that may help provide social support. In patients with pre-existing physical debility in addition to loneliness, helping to bolster social support can have multiple positive benefits. In some cases, patients may benefit both physically and emotionally from having help in the home to carry out activities of daily living. Programs that provide health care workers, health navigators, social work assistants, advocates, or other services that cross inpatient and outpatient settings can help bolster connections to community resources and decrease rates of loneliness. In patients who have more online interactions than in-­ person interactions, hospitalists should focus on providing patients with guidelines

 Misra S, Cheng L, Genevie J, Yuan M.  The iPhone Effect: The Quality of In-Person Social Interactions in the Presence of Mobile Devices. Environment and Behavior. 2014;48(2):275–298. 8  https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf. 9  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392374/. 7

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Fig. 20.1  Surgeon General’s Six Pillars to Combat Loneliness. (Adapted from https://www.hhs. gov/sites/default/files/surgeon-­general-­social-­connection-­advisory.pdf)

for safe use of social media and encourage in-person interactions in addition to online interactions. Institutional investment in community organizations will help bolster the ability of inpatient providers to connect patients to resources for developing more meaningful social connections. The US Surgeon General report on loneliness calls for six pillars of intervention to combat the epidemic of loneliness in the United States (Fig. 20.1). These pillars are to (1) strengthen social infrastructure in local communities, (2) enact pro-connection public policies, (3) mobilize the health sector, (4) reform digital environments, (5) deepen clinical knowledge of loneliness and social isolation, and (6) cultivate a culture of connection.10 In the hospital, loneliness among patients can coexist with a number of other health-related social needs. These needs cumulatively can affect the length of hospital admission, risk of re-admission, and complications that occur during hospitalization. There have been studies that have looked at the effect of loneliness on the brain that have showed that the regions of the brain that are activated when a patient is feeling lonely overlap with those activated when a patient is in physical pain. It is vital to address this loneliness just as a hospitalist addresses physical pain.

20.3 Clinical Pearls –– Loneliness causes a tremendous amount of morbidity and mortality in the United States, and must be addressed by hospitalists.

10

 https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf.

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–– Hospitalists should distinguish between loneliness and social isolation, as both independently predict risk of morbidity and mortality in hospitalized patients. –– Hospitalists should screen for loneliness and work with the multidisciplinary team to bolster community connections and provide resources to patients who are socially isolated and experiencing loneliness.

Part III

Framework and Action

Chapter 21

Financial Argument for Providing Hospital-Based Screening and Interventions for Health-Related Social Needs

21.1 A Case Ms. Stoker is a 63-year-old woman with chronic lower extremity ulcers, hypertension, peripheral vascular disease, and mild cognitive impairment. She has very little social support and has been experiencing homelessness intermittently for the past several years. She is admitted to the hospital with cellulitis of her right lower extremity. She receives intravenous antibiotics with improvement in her infection, and her antibiotics are transitioned to oral administration. However, though she uses a wheelchair, she has become increasingly debilitated due to the infection and there is concern that she would have difficulty caring for herself outside of the hospital. The hospital physical therapist sees the patient and recommends short-term rehabilitation in a skilled nursing facility, but despite referrals to multiple skilled nursing facilities, she is not accepted at any facility because her Medicaid insurance would give very poor reimbursement to the facilities for her care. The local medical respite facility is full and does not have a bed for her. She stays in the hospital, waiting for a facility to accept her, or for her debility to improve sufficiently for her to be discharged back to the streets.

21.2 Financial Argument for Providing Hospital-Based Screening and Interventions for Health-Related Social Needs In addition to ensuring the provision of high-quality care for all hospitalized patients, addressing health-related social needs can decrease the overall costs of caring for hospitalized patients with social needs. There is evidence that addressing social needs during hospitalization in patients who have been identified as “high © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_21

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utilizers”—patients who use the health system a disproportionately greater amount of time compared to others—can in turn decrease future health care utilization, thereby decreasing costs to the health system.1 There is a lopsided funding distribution between acute care and preventive care interventions. In one analysis, it was shown that greater than 95% of health care costs come from acute care issues though 40% of acute care conditions are caused by upstream modifiable causes.2 Unhealthy lifestyle choices, behaviors, and exposures can in turn lead to acute illnesses that need treatment. Reducing the rate of preventable hospital admissions in low-income neighborhoods to that of higher income neighborhoods would prevent 500,000 hospital admissions per year. This prevention is a fraction of the cost of acute care interventions. The Accountable Health Care Communities initiative was an effort by the Centers for Medicare and Medicaid to determine whether addressing health-related social needs does indeed decrease costs. In this five-year initiative, five social needs were addressed: food insecurity, housing instability, interpersonal violence, transportation needs, and utility needs. More than one million patients were included in this intervention from 2017 to 2021. Patients were enrolled who had at least one health-­ related social need and had at least two ED visits in the prior 12 months. Enrolled patients received navigation to social services that addressed their health-related social needs. Fee-for-service Medicare patients who were offered this service were noted to have an 8% reduction in ED use and a 9% reduction in unnecessary ED visits, primarily consisting of visits that involved social needs that could have been addressed in primary care settings. Medicaid patients offered this service experienced a 3% reduction in ED use. Medicaid patients who had more than one health-­ related social need, and Medicare fee-for-service patients who were non-White or identified as Latinx received greater benefits from the service.3This study gave a glimpse of how addressing health-related social needs can have downstream effects on acute illnesses and lower overall costs for the health system. One of the reasons why this investment in preventive care hasn’t historically been made in the US health care system is misaligned financial incentives—the body that provides the preventive care for patients is not always the same body that benefits from decreased costs due to avoidance of intensive medical interventions. Other reasons include the lack of immediate cost reductions from preventive interventions, and the complexity of preventive interventions that are influenced by genetic predispositions, behavioral modification, and complex social circumstances. The cost of hospital care is influenced by a number of factors. When patients seek to receive care in the form of ED visits resulting in hospital admission, or whether their admission is planned by their outpatient surgeon or primary care physician, how long they stay in the hospital, known as the length of stay, and whether they require re-admission within a month after discharge all play a large role in cost.

 https://link.springer.com/article/10.1007/s11606-019-05123-2.  https://www.nejm.org/doi/10.1056/NEJMp1512532. 3  https://innovation.cms.gov/innovation-models/ahcm. 1 2

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Increased ED and planned admissions, increased length of stay, and increased numbers of readmissions all can lead to increases in the cost of care and decrease value when those increased days are not necessary to provide high-quality and safe clinical care. Planned admissions are usually driven by the health care provider or team, but high ED visit rates often point to the failure of primary care systems to provide access to high quality care. Higher lengths of stay and readmission rates can also be related to health systems failures to create safe discharge plans for patients. ED visits, length of stay, and readmission rates are all impacted by health-related social needs. Some examples include the lack of insurance resources that allow for short term skilled nursing facility stays for continuing care and rehabilitation before patients are able to go home, the lack of safe recovery spaces for patients with housing instability, interpersonal violence at home that precludes discharge, and a shortage of home health resources to allow for safe living at home. The lack of a robust social safety net often leaves hospital-based clinicians with a bitter choice between keeping patients in the hospital when they no longer have clinical needs and increasing the drain on already over-burdened health system or discharging patients who have health-related social needs to unsafe living situations. Most hospitals have case managers and clinical social workers who help connect patients to resources they need prior to discharge, but this process is piecemeal and often inadequate, leading to both inadequate coverage of needs and `clinical burnout as hospital-based teams provide piecemeal solutions that are inadequate in the context of larger systemic problems. One approach to providing care where reimbursement is aligned with clinical quality is value-based care. Value-based care is a health care reimbursement system whereby clinical providers are reimbursed based on clinical outcomes rather than the quantity of care that they deliver. The principle behind value-based care is that rather than incentivizing providers to order more tests or schedule more interventions, the priority shifts to providing positive clinical outcomes. Unfortunately, there is evidence that value-based care can actually exacerbate health inequities. Historically marginalized patients may have characteristics that make it more difficult to control costs and achieve quality metrics than the rest of the population. There is evidence that value-­based care has been adopted more widely in affluent communities with high percentages of White patients, and less frequently in communities with high percentage of low-income, uninsured, or disabled individuals because there is no requirement or mandate to provide value-based care.4 This lack of mandated use of value-based systems can lead to cherry-picking of patients who are more likely to achieve targets because of limited comorbidities or lack of health-related social needs. Mandating all communities to participate in these systems could mitigate this effect. If mandates are used, however, care must be taken to ensure that the reporting requirements and infrastructure required for implementation do not adversely impact safety net hospitals. Another approach is to give incentives for value-based participation to rural and safety net hospitals that are

 https://jamanetwork.com/journals/jama/fullarticle/2795498.

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less likely to implement value-based systems. One likely contributor to the exacerbation of inequity through value-based care is the reality that health-related social needs often lead to more costly care for patients. For example, patients with housing instability or underinsurance leading to less access to skilled nursing facility or other post-acute discharge care may have prolonged lengths of stay in the hospital. Inability to access primary care may result in higher readmission rates or increased ED visits. These increased costs often mean that these patients who are enrolled in value-based systems will not meet spending targets, and the health system is penalized. One approach to remedying this problem is to set higher payment targets based on social needs. When quality metrics are decided upon in value-based systems, they must take into account health-related social needs. Understanding baseline metrics and finding metrics that account for historical inequities is key. When performance targets are decided upon, the comparator group should include only similar patient populations and health systems, rather than including patient populations with baseline different characteristics. An effort should be made to set metric thresholds that take into account the baseline state of the population, so that improvement is prioritized without setting unachievable goals. In addition, incentives could be granted to encourage health systems that consist of larger percentages of marginalized populations to adopt value-based systems. Currently value-based payment systems are exacerbating inequity, but thoughtful revision of value-based payment goals and the mechanisms to achieve those goals could help reverse this trend and actually improve health equity for hospitalized patients.

21.3 Clinical Pearls –– Expect that individuals with health-related social needs will utilize more hospital resources than individuals without these needs, and that this is not a deficiency of the patient or clinical team, but rather a defect of the health system as whole. –– Advocate at the health system, county, state, and national level to strengthen the social safety net in your region to better provide resources for patients with health-related social needs.

Chapter 22

The Impact of Hospital Security Measures on the Provision of Equitable Care

22.1 A Case Mr. Delgado is a 29-year-old man with a history of depression, anxiety, and alcohol use disorder who was admitted with cellulitis of his right upper extremity. During hospitalization, he went into alcohol withdrawal and became increasingly agitated. He was placed by the attending hospitalist on a CIWA-directed benzodiazepine regimen, but still was increasingly agitated and jumped out of bed, ran towards the nursing station, and started yelling loudly. The bedside nurse called the attending hospitalist and called a “Code Grey”, indicating a behavioral emergency. Hospital security arrived at bedside at the same time as the attending physician. The security staff escorted the patient back to his room while the attending hospitalist assessed the patient.

22.2 The Impact of Hospital Security Measures on the Provision of Equitable Care One of the imperatives of hospitals is to provide care that is safe, as well as high-­ quality. That safety encompasses not only direct patient safety, but also the safety of the institution itself. Hospital-based security systems face the challenge of providing safety in settings where the paradigm is based on healing, not security. Many health systems have created security departments that use policing techniques to provide safety. These tactics, however, also reinforce the systemic bias that exists within policing systems, which can compound already inequitable and biased systems within medicine. It has been shown that Black patients and their visitors are

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more likely to be subject to requests for security presence than White patients and visitors.1 Physicians and nurses may respond in a way that criminalizes emotional expression in Black or Latinx patients while appeasing this behavior in White patients when confronted with emotions expressed in ways that differ from common White expressions of emotion or cultural norms of acceptable behavior. Examples include more intense or visible expressions of sadness or anger in some racial and ethnic groups towards a family member’s illness. There exists tension between ensuring the safety of patients and staff while preserving patients’ rights and voices, as well as being respectful of cultural and racial differences. Hospitals often employ private security companies and may not have transparency and accountability to how they handle difficult cases. In some cases, the training of these security staff is not transparent, and there are concerns that security staff are not being taught anti-racist and trauma-informed methods of intervention. There is evidence that armed and uniformed officers in a health system may cause psychological distress to patients, particularly if they have a history of negative interactions with police outside the hospital.2 This negative effect can be mitigated by training all hospital staff in trauma-informed care and de-escalation, as well as adoption of support teams that can help de-escalate tense and emotional situations without needing security involvement. A culture that reserves security involvement for only the most extreme of situations can reframe the hospital as a place for healing, not enforcement. In addition, patients who use substances or have a substance use disorder should be given very clear information about what their rights are and should not be subject to room or belongings searches without clear notification and cause. Given the stigma surrounding substance use, framing substance use disorders as a policing problem rather than a health problem leads to lower rates of treatment for substance use disorders. Historically, the US has expanded the criminal legal system tremendously in the last fifty years, with police involvement activated for emergencies such as drug overdoses and psychiatric emergencies that may be better addressed by social services or health services involvement. The legacy of slavery has been transformed into systemic bias towards Black Americans, which is apparent in the legal justice system. Though Black Americans constitute only 13% of the population, they constitute 40% of the prison population. While there certainly has been a trend towards increased policing of all public spaces, including hospitals in the US over the past few decades, data from the last ten years has also shown an increase in violence directed at hospital workers. Violence against hospital workers has gradually been increasing since 2012, from the rate of 4 per 10,000 full-time equivalents to 5.9 per 10,000 full-time equivalents in 2021. Given this increase, various regulatory organizations have recommended development of comprehensive systems for security at hospitals. There is data that

 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2783642.  https://jamanetwork.com/journals/jamapediatrics/fullarticle/2783642#ped210025r12.

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hospital security personnel have a high likelihood of being assaulted in the workplace as they work to decrease violence in hospitals.3 When considering whether and how hospital-based security staff should be armed, and whether lethal or nonlethal weapons should be made available to them, it is important to balance the needs of hospital-based security staff to protect themselves with the well-being of patients and staff members. Analysis of a large number of hospitals of different sizes has shown that most security policies are centered on preventing workplace violence. The system that most hospitals use is a security warning code to alert staff when there is a violent event, as well as unit-specific policies for addressing these events. Common codes include codes for a missing or abducted infant or child, active shooter, aggressive or combative individual, and elopement. Units that are most likely to have a security policy are emergency departments, inpatient psychiatry units, newborn nurseries, and pediatric units. Around one third of hospitals in one study had metal detectors installed, usually in the emergency department entrance. Seventy-two percent of hospitals had security personnel employed by the hospital, while around 21% of hospitals had police officers present. Public hospitals were more likely to have police officers present, and 12% of hospitals used undercover security. Almost three quarters of hospitals have continuous security presence in the emergency department. The vast majority of security personnel are required to have training that was either held by the hospital itself or an outside entity. Many hospitals also require non-security staff to receive workplace violence training. Eighty-eight percent of hospitals in this study had security personnel who were allowed to handcuff, while 64% were allowed to restrain patients, and around half had authority to arrest or issue citations to visitors. The most common weapon or tool used by hospital security were handcuffs, followed by batons, pepper spray, TASERs, and K9 units. Weapon availability was greater in health systems that had police present. Surveys of hospital personnel asking how to improve hospital-based security practices have been conducted and suggestions include improvement of training, implementation of training for all personnel, increases in numbers of security personnel and nursing staffing, increased support from hospital administration in addressing workplace violence and relevant policies, and control of hospital visitors. It has also been suggested that security systems need to be integrated into the hospital, rather than work separately or in silos. Hospital staff have cited decreased staffing and lack of services to provide treatment for patients with mental illness or substance use disorders as reasons for escalating violence in emergency departments. This data shows that concerns over workplace violence have led to increased presence of police or security staff in hospitals. These security personnel receive widely varying training, depending on their setting, and often do not receive training on trauma-informed care practices. Hospital staff are concerned about their safety, and express sometimes feeling unsupported by hospital leadership. The use of

 https://link.springer.com/article/10.1007/s40719-022-00231-7 Pompeii et  al., 2013; Pompeii et al., 2015. 3

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traditional security methods and stricter policing practices may also lead to bias and inequity, as more reactive approaches to hospital disruptions are used. Hospital-­ based de-escalation teams that include mental health support, addiction consult, pain management support, and social work support can help diffuse tense situations in the hospital. The use of unbiased trauma-informed care training for all personnel and hospital de-escalation teams, and the integration of security staff into clinical care teams that follow the paradigm of caring for patients, rather than policing them, are all potentially powerful approaches to halting the increasing police presence in hospitals.

22.3 Clinical Pearls –– Use trauma-informed care practices that prioritize understanding why a patient is becoming agitated and treat the underlying cause rather than calling security. –– Reserve escalation to security for situations that cannot be controlled with trauma-informed approaches. –– Work to integrate security into your hospital staff and help create a de-escalation team if your hospital doesn’t already have one.

Chapter 23

Patient Centered Care and Community Involvement in Hospital Care

23.1 A Case Mrs. Loggins is admitted to the hospital with cellulitis and feels that her medical team uses medical jargon and does not explain her diagnosis and treatment adequately. Her major goal is to leave the hospital by the weekend to attend her son’s high school graduation, but her hospitalist attending keeps talking to her about her high white blood cell count and says that she cannot leave the hospital until that number comes down. She is frustrated and does not feel like her voice is being heard. On hospital discharge, Ms. Loggins does not fully understand the medical terminology on her discharge paperwork. After leaving the hospital, she receives a communication soliciting members for the hospital’s Patient and Family Advisory Council. Motivated by the negative experiences she had during her own hospital care, Ms. Loggins joins the group. Over the next several months, Ms. Loggins helps create educational tools for hospital-based physicians and nurses on patient-­centered communication and designs discharge paperwork that is readable and easy to understand.

23.2 Patient Centered Care and Community Involvement in Hospital Care Patient-centered care has been defined as “health care that establishes a partnership among practitioners, patients, and their families…to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and

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support they need to make decisions and participate in their own care.”1 Patient-­ centered care is an essential component of health equity, and hospital-based physicians should incorporate a patient-centered approach into the care that they provide in order to deliver truly equitable care. Patient-centered care models call for hospital medicine physicians to center patients in the care that they receive and to fully partner with patients when providing care. This requires physicians to focus on what patients truly value, and to reframe the role of the physician as facilitator and guide, rather than leader. The report that the Institute of Medicine (now NASEM) issued in 2001, “Crossing the Quality Chasm” includes patient-centeredness as one element necessary for the transformation of American health care quality.2 The US Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consortium, funded by the Agency for Healthcare Research and Quality, has created hospital-based patient experience surveys as a mechanism for evaluating patient experience in the hospital. Hospital systems and patients should work together to design care that centers the values, goals, and priorities of patients, using quantitative and qualitative survey data as a guide. Health care systems are often designed to accommodate the needs of physicians and staff rather than patients. The experience of illness—not just understanding pathophysiology but understanding what it feels like to actually be the individual in the hospital bed—is a perspective only the patient can provide. Studies that have examined patients’ hopes and expectations for care explicitly have shown that patients value coordination and integration of care, information delivery, physical comfort, emotional support including alleviation of fear and anxiety, engagement of family and friends, improvement of access, and smooth transitions ensuring continuity of care.3 While there is overlap between these patient-focused goals and the objectives of the clinical team, patients have a set of priorities that are distinct from clinicians. There is data that trust in hospital-based clinical teams is essential for decreasing the anxiety of patients, enhancing their care experience, and improving clinical outcomes. When outpatient physicians express their trust in the hospital-based physicians who will be caring for their patient, this decreases the patient’s anxiety and results in higher quality clinical care overall.4

 Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patient’s eyes: understanding and promoting patient-centered care. San Francisco, CA: Jossey-Bass; 1993. [Google Scholar]. 2  Institute of Medicine (US) Committee on Quality of Health Care in America . Crossing the quality chasm: a new health system for the twenty-first century. Washington (DC): National Academies Press (US); 2001. [Google Scholar]. 3  Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patient’s eyes: understanding and promoting patient-centered care. San Francisco, CA: Jossey-Bass; 1993. [Google Scholar]. 4  Flugelman MY, Jaffe R, Luria G, Yagil D. Trust in the referring physician reduces anxiety in an integrated community-to-hospital care system. Isr J Health Policy Res. 2020;9(1):7. doi: 10.1186/ s13584-020-00365-6. [PMC free article] [PubMed] [CrossRef] [Google Scholar]. 1

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However, there is also data that physicians and patients have different priorities and perceptions of care. One study of 33 US family physicians and more than 500 of their patients showed that physicians and patients were in agreement on the patient’s health status less than 40% of the time.5 Much of this discrepancy was due to the tendency of physicians to prioritize disease control and modification, while patients prioritized subjective perceptions of well-being and quality of life. In ­addition to improving the personal interactions that patients and hospitalist physicians have, it is also important to create systems that support patient-centered care. However, many of these measures undertaken by health systems focus on technological interventions that may not be accessible to all patient populations, such as improving accessibility to laboratory and radiology results through online patient portals and mobile devices. While these interventions to give patients better access to their data benefit many patients, they can also worsen disparities for inpatients with health-related social needs who do not have access to technology. Patient-­ facing educational materials that are used in the hospital and on discharge should also evaluated to ensure that they do not contain medical jargon and are at an appropriate literacy level. Many organizations have systematized structures to incorporate input from diverse patients, families, and community partners into these educational materials. Interventions used by various organizations to improve patient-centered care have been catalogued and analyzed. The types of interventions employed to improve the patient-centeredness of care include a change in practice or care process, training of staff, change in the way services are designed or delivered, and the use of patient-­ centered staff roles. This includes three broad categories: staff-related

Fig. 23.1  Tools for patient-centered care

 Elder NC, Imhoff R, Chubinski J, Jacobson CJ, Jr., Pallerla H, Saric P, Rotenberg V, Vonder Meulen MB, Leonard AC, Carrozza M, Regan S. Congruence of patient self-rating of health with family physician ratings. J Am Board Fam Med. 2017;30(2):196–204. doi: 10.3122/ jabfm.2017.02.160243. 5

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interventions, patient and family-related interventions, and environment-related interventions. Staff-related interventions may involve training staff, creating individualized care plans, and improvement of bedside communication, while patient and family-level interventions may engage patients in care planning and provide patients with tools for communication, and environment-related interventions involve changing the design of the hospital ward.6 Fig.  23.1 summarizes various tools for achieving patient-­centered care. Engagement of communities in addition to individual patients in care delivery is essential. Individuals who are hospitalized belong to families and communities that often play a tremendous role in informing the care that they receive. A patient’s cultural belief systems, religious practices, ethical values, food habits, and social norms are dictated to a large extent by the communities from which they come. Notably, patients often belong to more than one community, and the values that they hold may be overlapping or contradictory. Truly incorporating the perspective of these communities and engaging community members in care are essential components of building more equitable health systems. One mechanism for community engagement is the creation of patient family advisory councils (PFACs), and community advisory and activation boards. These structures give patients, family members, and community members tools for implementing changes in the care that they receive. Patient family advisory councils are committees that consist of patients, family members of patients, and other community stakeholders and advise on health systems improvement, whereas community advisory and activation boards may involve specific initiatives or research. The goal of these groups is to improve the quality, safety, and patient experience for inpatients. It is important to ensure that PFACs consist of a diverse range of individuals. One cross-sectional study in 2020 showed that members of a pediatric health system’s PFAC contained disproportionately low numbers of Black individuals, and few inidividuals from lower socioeconomic backgrounds. Intentional efforts must be made to establish racial, ethnic, economic, and cultural diversity on PFACs.7 Partnerships between community stakeholders and health systems can lead to transformative improvement in care and increase the reach of health systems. One study examining the drivers of community involvement at academic health centers described five primary causative factors: the perception of the public, population health focus, community requests for involvement, competition for community sites, and financial concerns. These factors that come from external pressures are compounded by internal dynamics of the organization that can also influence whether the community is engaged in care.8 These internal dynamics can include lack of leadership buy-in for community engagement, absence of structures or processes for community involvement, leadership culture that does not emphasize the importance of community engagement, and financial constraints. Despite the

 https://www.sciencedirect.com/science/article/pii/S0020748923000305#t0010.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8573511/. 8  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6538435/. 6 7

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internal and external challenges to incorporating community perspectives into care, it is essential to engage both patients and communities in order to provide truly equitable care.

23.3 Clinical Pearls –– Hospitalists should center patients in the hospital care that they provide in order to truly understand the goals and priorities of patients during hospitalization. –– Care should be taken to ensure that approaches to provide patient-centered care should not overly rely on technological approaches that may exacerbate disparities. –– Diverse community members should be engaged in care on a system level in order to ensure that diverse community perspectives help shape the care that patients receive in the hospital.

Chapter 24

Framework for the Future

In this book, we have described the profound impact that social circumstances play on patients who are admitted to the hospital. Hospital care is impacted by the totality of a patient’s life experience, and it is vital for hospital-based providers to engage with patients about the totality of their experiences in order to provide comprehensive hospital-based care. While focusing on the individual in front of them, it is also important for hospitalists to take into consideration the health system in which they are cared for and larger principles of population health. Each patient is and should be treated as a unique individual, but the health system and larger population-level factors that have led the patient to the hospital bed should also be analyzed, deconstructed and taken into consideration. At the health system level this includes ensuring that appropriate inpatient resources that address  the overall social and demographic characteristics of individuals are available to patients who are admitted to the hospital. These resources include in-person interpreters, social workers, case managers, health navigators, health advocates, chaplains, substance use counselors, and other staff with expertise in caring for patients from diverse, social and economic backgrounds. Hospital systems should also work to create networks for building robust transitions in care. This includes health navigators who bridge inpatient and outpatient settings, transitions clinics and systems for communication that allow for improved documentation, and improvement in warm handoffs as patients leave the hospital and re-enter the community. Additionally, hospital systems should work to ensure that they have robust linkages to skilled nursing facilities, assisted living facilities, board-and-care facilities, and other community-based organizations that work to care for patients in the community. Hospitals should use governmental and commercial support to create systems that provide a safety net for the most vulnerable populations, including resources for patients experiencing homelessness, medical respite facilities, substance use treatment facilities, and resources for mental health treatment. Hospitals should maintain relationships with organizations that support transgender individuals and that help patients from immigrant and refugee communities adjust to living © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4_24

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in the United States. All of these measures should not be thought of as outside the purview of hospital care, but rather should be embedded as essential components of the care that is provided to patients before, during, and after hospitalization. Care transitions programs that incorporate technology can sometimes be helpful but access to technological resources should not be assumed as vulnerable populations may not have access to mobile devices or have connectivity for telehealth. For individuals who do have this access, post-discharge phone call programs, post-discharge telehealth programs, and other related post-discharge follow-up can help patients thrive in the community after they are discharged from the hospital. In addition to hospital systems improvement and enhancement to deliver equitable care, health care organizations should develop population health-based approaches to delivering care around hospitalization. These approaches includes data analysis of population factors and metrics around patients’ hospitalizations. Other population-­ level data includes analysis of length of stay, readmission rates, quality metrics such as rates of hospital acquired infections, rates of falls, and rates of adverse outcomes stratified for specific populations. The stratification should include consideration of race, gender identity, sexual orientation, country of origin, language proficiency, immigration status, income level, zip code, and other factors related to their social and demographic status. We have presented a detailed description of the many complex factors that produce inequities in American hospital care. What are ways to dismantle these inequities? How can we provide truly equitable care for all? In order to achieve these goals, we present a framework that incorporates four essential domains. These domains are: 1. 2. 3. 4.

Information Technology (IT) Education Facilitation Patient activation

Using these four components to guide change, health systems must address the barriers in inpatient care that inequities promote. These inequities, as described in the preceding pages, include lower rates of advanced care planning in certain racial and ethnic minority groups, poor pain management in Black and Latinx patients, stigma associated with substance use disorders, limited English proficiency patients not receiving care in the languages that they understand, lack of sensitivity and evidence-­ based treatment related to sexual orientation and gender identity, stigmatizing language used in communication and documentation, and the sacrificing of basic patient rights due to hospital security policies. Health systems need to recognize the complex interplay that exists between history, culture, and the personal characteristics of each individual while still following evidence-based guidelines. This includes discontinuing race-based clinical management that has no basis in evidence.

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24.1 Information Technology Information technology systems are the cornerstone of equitable hospital care delivery. Clinical outcomes must be stratified by demographics, electronic hospital-based screening should take place for all social determinants of health and health-related social needs, and electronic referral mechanisms need to be implemented for inpatients to be referred directly to social resources on discharge from the hospital. This screening should not be nursing-driven, but rather completed by a workforce of health assistants or community health workers who are recruited to meet these specific needs, allowing nurses to practice at the top of their licenses. Merely having IT systems is not enough to implement change, but stratifying data to focus on the ways in which social circumstances impact health is the first step to gain a deeper understanding of barriers to care and is an essential step before change can be made. Information technology infrastructure built to ensure patient health equity should include electronic medical record systems that allow for collection of data around social determinants of health. This includes data around rates of screening for food insecurity, housing instability, financial difficulties, socioeconomic strain, immigrant status, zip code, sexual orientation, gender identity, substance use, and other related social and demographic factors. It should also include electronic referral systems with community-based organizations that provide social services for patients after hospital discharge. In addition, there should be data collection at individual, health system, and population levels. This data should include demographic data, health outcomes data, rates of screening and intervention, and trends over time. Institutions should benchmark themselves in comparison to other organizations as they do for others quality metrics. The electronic medical record should also include mechanisms for improving financial reimbursement of health-related social needs screening and interventions. Institutions should take advantage of state and national government financial incentives for improving care for patients with social needs. One example of this funding is California bridge funding for expanding buprenorphine treatment of opioid use disorder in California hospitals with heavy burdens of opioid use disorder. Electronic medical records should be used to maximize these  kinds of financial incentives. Data collection on individual, health system, and population levels should drive improvement initiatives around health-related social needs in order to achieve health equity.

24.2 Education Another vital component of any system to achieve health equity is multidisciplinary education that includes on-the-ground anti-racism training as well as didactics and space for self-reflection and introspection. Broad comprehensive education at multidisciplinary levels is essential for improving hospital health equity. This education

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should start at the medical and nursing student level and include teaching on the impact that social determinants of health have on the care of hospitalized patients. This curriculum should begin with didactics, but should also be infused into the clinical curriculum as students learn to care for patients with social needs in the hospital. Currently, very few physician training programs and medical schools provide concrete coursework on evidence-based interventions for patients with social needs. There is a paucity of literature and courses in this area, particularly for physicians, with nursing programs providing slightly more emphasis on social aspects of care than medical programs. In order to truly provide equitable care, socially-relevant medicine needs to be taught not as an elective or extra course, but as a vital component of teaching for all clinicians. Students should also be educated about the importance of multidisciplinary teams in providing comprehensive and equitable care during hospitalization. The role of case managers, social workers, health navigators, and other essential team members should be emphasized throughout medical education. As medical students progress through their training they should understand care as a multidimensional process that requires a diversity of healthcare workers to provide. Early exposure to medicine that incorporates social factors and role models who practice socially-­ conscious medicine will help ensure that future leaders in health care are focused on providing equitable care. During residency, young physicians should be taught that the care that they provide must encompass social, as well as clinical factors, and they should learn in a practical manner the ways in which socially informed care can take place even in busy clinical settings. Emphasis should be placed on screening for social factors, referring and providing interventions that are social as well as clinical, and working hard to provide seamless transitions care. In addition, many residency programs now incorporate quality improvement and patient safety into their curricula. Health equity in hospital settings should be approached from a quality improvement lens as residents are taught how to improve systems-based care. Residents can be the strongest advocates for their patients, and they should be taught how to be effective advocates and how to teach patients to advocate for themselves. Residents should undertake quality improvement initiatives that incorporate goals around achieving hospital health equity, and should be engaged in work that improves patient safety for this population. In addition to medical students and residents, physicians in practice should receive continuing education related to providing equitable care to all patients. Hospitals should adopt policies incorporating health equity education into their credentialing requirements and physicians should be encouraged to receive continuing medical education on topics related to health equity. The major academic hospitalist programs should incorporate health equity- related topics into their continuing medical education courses and evidence-based approaches for providing equitable care should be particularly emphasized. With all of these domains of education, a new generation of hospital-based physicians who provide care that is holistic and informed by principles of health equity will materialize.

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24.3 Facilitation Facilitation of inpatient care through health care workers has been proven to be a successful tool for the improvement of quality of hospital care and has been shown to strengthen transitions in care at discharge. Facilitators may be interpreters, health care navigators, cultural navigators, and health advocates. Some of these individuals will be trained as interpreters, social workers or social work assistants, while others may be trained as health care navigators, community health workers, substance use navigators, peer counselors, case managers, and community liaisons. Most importantly, these individuals serve as a bridge for patients and families between their rich out-of-hospital lives that include religious and spiritual life, community organizations, and family and friend networks, and their care team during hospitalization. These facilitators can help ensure that social needs and cultural beliefs are incorporated into care in a systematic manner. One of the most important ways in which health equity can be improved for hospitalized patients is through the use of facilitators. Facilitation in a general sense in hospital settings is the use of techniques that provide patients with assistance to receive the care that they need. Hospital systems by their nature are complex and can be confusing, and facilitators can help patients navigate this complexity. Facilitation is an important tool for closing health equity gaps among hospitalized patients. Facilitators are any individuals in the hospital hired to improve patients’ quality of care and ability to access the patient care resources they may need to get better. The role of such facilitators is to identify gaps both during hospital care, and as the patient transitions to the outpatient setting, to help create interventions to fill those gaps. The underlying assumption with the use of facilitators is that secondary to social situations such as economic deprivation, food insecurity, housing instability, sexual orientation, gender identity, cultural background, and other social factors discussed in this book, some patients are at a disadvantage and lack the ability to navigate health systems in order to receive high-quality care. There are a number of vulnerable periods in the hospitalization of a patient. During admission, patients are often acutely ill and dealing with a great deal of uncertainty around their diagnosis and management options, and a tremendous amount of information from their lives needs to be communicated to the clinical team. During hospitalization, as the clinical trajectory of patients evolves, and as patients may undergo worsening in their clinical status, they may have to make a number of critical decisions about their care and are subject to a great deal of vulnerability. Lastly, when patients are ready for hospital discharge, the process of transitioning the care that they received in a closely monitored hospital setting to a community setting can sometimes be daunting and overwhelming for patients. It can be also be difficult for hospital-based providers to adequately communicate the complexity of a hospital admission to outpatient providers using current health systems tools. Appraoches that are used include sending discharge summaries and medication lists to primary care doctors and attempting to adequately communicate to outpatient providers the trajectory of complex and lengthy hospitalizations over the telephone or through

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health information systems. These systems are sometimes are inefficient and ineffective, leading to a great deal of vulnerability. Patients who have pre-existing health-related social needs are subject to even more vulnerability during admission, acute hospitalization, and hospital discharge. Facilitators can help at these meaningful junctures, in order to help patients navigate patients these situations. As was discussed previously, the Joint Commission and Centers for Medicare and Medicaid are now mandating that social determinants of health screening should take place for all patients when they are in the hospital. Health facilitators in the hospital can help screen patients for social determinants of health, identify health related social needs, and link patients to pre-existing systems and target interventions to address these identified needs. Community health workers and advocates can help elevate the patient’s perspective to the clinical team, and ensure that the patient’s voice is truly being incorporated into their care. Social workers and social work assistants also are vital facilitators of care, as they try to understand the overall context for the patient’s hospitalization, link to community resources and ensure that patients receive post discharge resources after they leave the hospital. Interpreters and cultural navigators also act as facilitators by helping to improve communication between the patient and teams, and provide a richer context for the patient’s illness. Community advocates who help facilitate care longitudinally from the community setting to the inpatient setting back to the community setting again after discharge can have a powerful window into the many driving factors that determine care for patients. Hospitals should adopt systems for facilitating care through the roles described in order to provide equitable care in hospital settings.

24.4 Patient Activation Another essential component of any health system that provides equitable hospital care is patient activation and self-advocacy. There should be mechanisms in place to ensure that patients are supported to advocate for themselves and that their voices are elevated in the system. This includes robust patient relations and health advocacy departments that not only give patients a recourse when they have problems with their care, but also provide an avenue for addressing system-based issues that they encounter during hospitalization. The positive effect of giving patients the tools to successfully advocate for themselves will not only be seen during hospitalization, it will also have an impact on the way patients manage future encounters with health care systems. Patient activation can be distinguished from facilitation in that activation places an emphasis on teaching patients to advocate for themselves to receive excellent hospital care. Engagement of patients in their own care is essential and paternalistic models of medicine in which healthcare providers dictate care rather than participating in shared decision making are no longer recommended. Patient activation consists of truly engaging patients in the care that they are receiving so that they have ownership over their own health and well-being, feel that their own priorities

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and health goals matter, and that their voices are truly heard as they receive care. Facilitators in hospital settings can help promote patient activation. Patients who have historically been marginalized, either due to lack of power or privilege, or secondary to characteristics, such as race, ethnicity, gender, identity, or sexual orientation, socioeconomic, status, or immigrant status, may not feel that they have the ability to advocate for their own care. These individuals may feel as though they need to adapt to the existing healthcare system rather than identifying their needs and asking the health system to accommodate them. In order to achieve true health equity in the hospital, healthcare systems need to focus on patient activation as a key priority during hospitalization. In addition to assistance from individual facilitators, formal structures should be built in order to engage patients in care, such as patient relations department that outreach to patients about their experience, patient surveys and real time assessments of patient experience. These tools can help patients express their needs in real time or provide feedback after they leave the hospital through patient communication services such as hospital-administered surveys. HCAHPS scores are patient communication scores that hospitals throughout the United States calculate based on survey data, and these scores are generally collected from patients after discharge from the hospital. This survey data can help quantify patient satisfaction and identify gaps in perceptions of patient care by patients. Patient activation may not be an area of focus for many hospitals, yet truly engaging patients in care is vital to improve the quality of care, and the benefits of this focus will be seen across the continuum as patients learn to become active partners in their care. In addition, through the use of community advisory boards and patient family advisory councils, patients can engage more broadly to help improve the health systems in their communities, in addition to engaging in their own clinical care.

24.5 Re-Imagining Care for Iysha and Bernard In the first chapter of this book, we introduced two patients whose social situations played a vital role in the care that they were receiving during hospitalization. How could their care be re-imagined if it was framed by the principles of equity that we have discussed in this book? Iysha Simmons, the young woman with sepsis from an E. Coli urinary tract infection had landed in the hospital largely due to incomplete outpatient treatment of her UTI, which was driven by her inability to complete the medication course in the setting of multiple life stressors and poor financial resources to pay for the medicine. There are many conceivable ways that her hospitalization could have been prevented altogether—a stronger social safety net, better resources for medication subsidies, larger system-based efforts to decrease the cost of medications all could have kept Iysha in treatment at home. Completing her initial course of antibiotics would have decreased the chance of the infection worsening and spreading. More taxing than the cost of medication, however, was her larger economic and social situation—limited childcare support, and the need to attend job

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interviews in the setting of losing her job due to economic forces related to the COVID-19 pandemic—these are factors that only larger economic, governmental, and social changes can fix. However, even when she was admitted to the hospital, there were ways in which her care could have been more equitable. In the Emergency Department, the physician did not delve into the social circumstances that had led to her discontinuation of her antibiotics, but rather honed in on her personal responsibility for failing to complete her course of antibiotics. He questioned her for lack of a primary care physician, disregarding the larger dynamics that have made it difficult to find primary care physicians in many markets, particularly for individuals who are also facing social and economic pressures. As a Black American, Iysha has been subject to systemic bias and likely does not fully trust a health care system that has not been responsive to her needs. Rather than expecting her to simply adhere to the treatment course prescribed, the admitting physician should have provided patient-centered care that really focused on the many factors that brought her to the Emergency Department. He could have made an attempt to truly understand what had brought her there, and more importantly, helped her create a plan to prevent this from happening again, including establishing a warm linkage to primary care, educating her on the consequences of failing to complete antibiotics, and linking her to child care and safety net resources through the clinical social worker in the hospital. Perhaps most importantly, he could have prompted patient activation by partnering with her and teaching her to advocate for herself in a proactive manner. These skills would help define her interactions with the health care system as she continues to face medical and social challenges in the future. Bernard’s story was also described in the first chapter. He is elderly and has been living independently until a fall debilitated him to the extent that he is unlikely to be able to live alone again. If he had financial resources, he could benefit from living at an assisted-living facility, a board-and-care, or other setting where he could receive additional assistance to safely ambulate, carry out his activities of daily living, and manage his medication regimen. Without financial resources and adequate social support, Bernard may qualify for some home health assistance from the government, but this is unlikely to cover more than a few hours each week, leaving him alone and vulnerable to further falls and worsening debility. He may qualify for placement in a short-term skilled nursing facility, but without sufficient financial resources, he will eventually need to cope with living at home with the piecemeal home services he is able to assemble. While hospitalized, the nurses and physicians often do not use pocket-talkers or other devices to help him hear what they are saying. He does not understand what is happening. And without a family member at bedside to advocate for him, he has very little ability to describe the extent of the help he may need at home or make decisions about whether he wants to go to a short-term skilled nursing facility for rehabilitation. How might Bernard’s care look different? The clinicians who care for him may prioritize patient-centered care and communication by always using a pocket-talker or other device that amplifies their voices when they talk to him. His team can also engage multidisciplinary partners such as social work and the

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chaplaincy to help provide him with more holistic care and to more deeply understand his life outside the hospital, including religious or spiritual beliefs and goals of care. If he is at a hospital that has invested in bedside patient advocates or navigators, engaging this service will allow his voice to be elevated in the health system so his needs are truly met. Social determinants of health screening may expose other areas of need, such as food insecurity and transportation needs, so he can be given linkages to resources that provide food and provide transportation to medical visits. He may also be linked to resources that address his social isolation, such as community classes and groups for elderly people. These multiple systems together may help Bernard not only improve his overall level of functioning and sense of well-­ being, they may prevent future hospitalizations. Iysha and Bernard are two real patients whose health, illness, and very survival depend on a confluence of individual and social factors. They are a microcosm of all of us. Our health is determined by our personal, ancestral, and social histories in addition to our genetic and clinical constitutions. The art of hospital medicine—care of people in the depths of sickness who are often at the most vulnerable moment of their lives—is to incorporate all that each individual encompasses into the care that we provide them, including their cultures of origin, their racial backgrounds, whom they identify with, the communities from which they come, whom they love, whether and whom they worship, and how they choose to live. To do this, we must embrace patients for all of who they are, and fully center them in the care that we provide. It is only when we do this that we will provide truly equitable care.

Index

A Accountable Health Care Communities, 122 Accountable Health Communities Model, 64 Acute Care of Elders, 4 Affordable Care Act (ACA), 10 Agency for Healthcare Research and Quality, 33 Allostatic load, 13 American approach, 8 C Care of patients, 39 clinical pearls, 41 discharge planning, 41 emergency department, 40 interpretation devices, 40 safe discharge plan, 41 Center for Interdisciplinary Health Disparities Research (CIHDR), 13 Cerner determinants of health, 27 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consortium, 130 COVID-19 pandemic, 3, 10, 13–14, 49, 51, 114 Crossing the Quality Chasm, 32, 130 Cystic fibrosis, 54 D Dickey amendment, 105 Disparities in technology

clinical pearls, 102 health equity, 101 hospital-based care, 100 mobile technology, 99, 101 subspecialty consultation, 100 telehealth technology, 100 E Environmental and occupational health, 93 climate disasters, 96 clinical pearls, 98 dust storms, 96 history of, 97 hospital medicine physicians, 97 hospitalizations, 93 non-Hodgkin’s lymphoma, 96 occupational exposures, 95 persistent organic pollutants (POPs), 95 F Financial argument, 121 clinical pearls, 124 high utilizers, 121–122 hospital care cost, 122 Medicaid patients, 122 quality metrics, 124 readmission rates, 123 reimbursement, 123 value-based systems, 123

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Sankaran, Health Equity in Hospital Medicine, https://doi.org/10.1007/978-3-031-44999-4

145

146 G Geriatric patients and inpatient health equity, 87–92 anticholinergic medications, 90 CAM-ICU tool, 90 catastrophic event, 88 clinical pearls, 92 delirium, 90 hospital-based physicians, 91 hospitalization, 87, 91 intersectional identities, 92 mentation, 89 orthopedic diagnosis, 88 H Health disparities cardiovascular disease, 18 clinical pearls, 20 COVID-19 pandemic, 20 definition, 17 end stage renal disease, 18 mental health disorders, 19 Health equity, 5 Black and Latinx patients, 5 definition, 6 Health Insurance for the Aged and Disabled, 32 Health-related social needs, 12 Health system, 12 Healthy People reports, 14 Healthy People 2020, 68 Healthy People 2030, 15 Hispanic Mortality Paradox, 51 Hispanic paradox, 19 Holistic view, 9 Hospital-based security systems, 125 armed and uniformed officers, 126 clinical pearls, 128 hospital administration, 127 hospital workers, 126 metal detectors, 127 physicians and nurses, 126 police involvement, 126 workplace violence, 127 Hospital care, 135 care transitions programs, 136 community-based organizations, 135 education, 137, 138 facilitation of inpatient care, 139, 140 information technology systems, 137 patient activation, 140, 141 re-imagined care, 141–143

Index Hospital Inpatient Quality Reporting program, 23 Hospitalist model, 21 clinical pearls, 29 CMS measures, 23 electronic health record (EHR), 27 hospitalist movement, 22 non-White faculty, 23 racial disparities, 22 requirements, 24 screening, 26 social needs, 28 US News and World Report, 22 Hospitalization, 41 Hospital Medicine, 5 I Incarcerated patients, 83–85 Indian Health Service (IHS), 49 Indian Reorganization Act, 47 individual and social factors, 143 International Classification of Diseases, 10th revision (ICD-10), 28 Interpersonal violence, 103 Black individuals, 104 clinical interventions, 106 clinical pearls, 111 clinician encounters, 106 data collection, 106 firearm violence, 104 hospitalists, 105 intimate partner violence (IPV), 106 medical specialty, 105 patient’s risk, 104 screening instruments, 107 Intimate partner violence, 106 J Joint Commission, 24 L Language discordance, 58 Latino paradox, 19 Limited English proficiency clinical pearls, 61 community health workers, 59 cultural discordance, 59 emergency Medicaid, 60 health outcomes, 58 immigrant patients, 60

Index overview, 57 professional medical interpreters, 59 undocumented immigrants, 60 Loneliness epidemic, 113–116 M Medical community, 12 Medicare and Medicaid programs, 32 Medicare’s Hospital Readmissions Reduction Program, 36 N National CLAS standards, 59 National Committee for Quality Assurance (NCQA), 33 National Federation of Independent Business vs. Sebelius, 53 National Health Care Disparities Report, 9 National labor Relations Act, 52 Native American population, 47 Non-communicable diseases, 12 Non-Hodgkin’s lymphoma, 96 P Pain management, 75 clinical pearls, 78 disparities, 76 hospice care, 77 LGBTQ+ patients, 77 opioid medications, 76 palliative care, 77 Patient-centered care, 129 clinical pearls, 133 community stakeholders, 132 engagement of communities, 132 hopes and expectations, 130 PFACs, 132 types of, 131 Patient family advisory councils (PFACs), 132 Patient Protection and Affordable Care Act, 52 Physician Quality Reporting Initiative (PQRI), 34 Plan-Do-Study-Act (PDSA), 23 Pulmonary function tests, 54 Q Quality improvement and patient safety, 31 clinical pearls, 37

147 community advisory boards, 36 diversity and cultural humility training, 35 equitable system, 35 health disparities, 34 IOM’s report, 32 utilization review committees, 33 R Racism Alaska Native population, 49 Black and Latino individuals, 46 clinical pearls, 55 definition, 45 diabetes screening, 55 IHS budget funded, 49 Latinx population, 50, 51 Native Americans, 47 race-based medicine, 54 and racial disparities, 13 socioeconomic status, 50 tax benefits, 54 Tuskegee study, 46 value-based payment models, 53 Rural-urban divide, 79 bypassing rural facilities, 80 clinical pearls, 81 fatal diagnosis, 80 guiding principles, 81 inequity and language proficiency, 79 medicare patients, 80 S Self-Determination Education Assistance Act, 47 Sexual orientation and gender identity data, 67 centralized health care delivery, 70 clinical pearls, 70 cross-sex hormones, 69 gender affirmation, 68 intersectional identities, 69 lesbian and bisexual women, 67 LGBT+ individuals, 68 transgender individuals, 68 Snyder Act, 48 Social determinants of health, 6, 11, 14, 15 definition, 7 homelessness, 64 hospitalized patients, 63 readmission rates, 64

148 Social Interventions Research and Evaluation Network, 25 Social isolation, 113–115 Social medicine academic papers, 8 fundamental principles, 8 history of, 7 persistent and distressing disparity, 9 Social Security Act, 32 Stigma, 71 Substance use disorders, 71 clinical pearls, 74 comorbidities and complications, 72 drug-seeking, 72 methadone and buprenorphine, 73 opioid overdose, 74 opioid use disorder (OUD), 73 stigma, 72 Supplemental Nutrition Assistance Program (SNAP), 60

Index Swiss cheese model, 32 Systematized Nomenclature of Medicine (SNOMED), 28 T Target-Engage-Assess-Modify (TEAM), 23 Taskforce Report, 9 U US News and World Report, 22 V Vital Signs report, 19 W World Health Organization (WHO), 9