Search

In the United States, undocumented residents face unique barriers to healthcare access that render them disproportionately dependent on the emergency department (ED) for care. Consequently, ED providers are integral to the health of this vulnerable population. Yet special considerations, both clinical and social, generally fall outside the purview of the emergency medicine curriculum. This paper serves as a primer on caring for undocumented patients in the ED, includes a conceptual framework for immigration as a social determinant of health, reviews unique clinical considerations, and finally suggests a blueprint for immigration-informed emergency care. [ABSTRACT FROM AUTHOR]

The first baby has successfully been born by uterus transplantation (UTx) in the United States and the procedure is swiftly becoming a viable clinical option for patients with uterine factor infertility (UFI). This raises a practical ethical question: should health insurers finance UTx and what issues should they consider in coming to this decision? The article lays forth some of the factors that shape the decision over whether to finance UTx in the United States, including what procedures must be covered, whether UTx is more like organ transplantation or infertility treatment (which are treated differently in the United States), and the benefits and alternatives of the procedure. Then, the article explores arguments around why UTx should be financed, or at least considered along with other important medical needs. The paper argues that UTx ought to be considered along with other competing claims for healthcare services. In countries that generously cover other infertility services, it may logically follow that medical services that enable gestation should be insured when the healthcare system covers services to conceive. In the United States, however, many groups have long suffered inadequate access to medical care, in the context of infertility and more broadly. U.S. healthcare may need to be made more widely equitable, before covering UTx is seen as financially or politically possible. [ABSTRACT FROM AUTHOR]

Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

Background: Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches?Methods: We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches.Results: We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender.Conclusions: Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes. [ABSTRACT FROM AUTHOR]

The Department of Veterans Affairs (VA) has been at the vanguard of information technology (IT) and use of comprehensive electronic health records. Despite the widespread use of health IT in the VA, there are still a variety of key questions that need to be answered in order to maximize the utility of IT to improve patient access to quality services. This paper summarizes the potential of IT to enhance healthcare access, key gaps in current evidence linking IT and access, and methodologic challenges for related research. We also highlight four key issues to be addressed when implementing and evaluating the impact of IT interventions on improving access to quality care: 1) Understanding broader needs/perceptions of the Veteran population and their caregivers regarding use of IT to access healthcare services and related information. 2) Understanding individual provider/clinician needs/perceptions regarding use of IT for patient access to healthcare. 3) System/Organizational issues within the VA and other organizations related to the use of IT to improve access. 4) IT integration and information flow with non-VA entities. While the VA is used as an example, the issues are salient for healthcare systems that are beginning to take advantage of IT solutions. [ABSTRACT FROM AUTHOR]

This paper examines the geographic accessibility of tertiary health services for the rural population of Idaho. Utilizing the two most commonly used rurality definitions, we determined the spatial distribution of the rural and urban residents in Idaho. The distance to each of the tertiary healthcare facility was calculated using Geographic Information Systems (GIS). Our analysis showed a large disparity between rural and urban geographic access to tertiary healthcare and revealed that there are significant variations in the disparity depending on the rural definition used. Thus there is a need to deploy strategies to enhance rural access and to construct rurality measures that capture the local heterogeneity, given that rurality designations impact the interpretation of access problems, and the funding eligibility for healthcare programs. [ABSTRACT FROM AUTHOR]

This paper proposes a national program to restructure local public health services in the United States which are still characterized by an excessive number of very small health units. It reviews past proposals to correct this situation, and recommends specific programmatic, organizational and financial measures to strengthen the public health infrastructure and achieve an effective national network of federal, state and local public health agencies. [ABSTRACT FROM AUTHOR]

This paper examines the uses of some health status indices in measuring equity of access to medical care. Empirical examples are provided using data from national surveys of the U.S. population conducted from 1964 through 1976. A simple indicator, mean number of physician visits, suggests that between 1963 and 1976 the poor improved their position relative to the rest of the population and, indeed, currently enjoy the highest level of access. However, a second measure, the use-disability ratio indicates that the poor may still receive less care relative to their need. A third measure, the symptoms-response ratio suggests how norms of appropriate behavior might be incorporated into an access measure. [ABSTRACT FROM AUTHOR]

The article discusses the study on problems posed by language barriers. The authors of this paper turn to a series of papers testing innovative solutions. A pair of interpreters in a hospital ward service has been embedded. A study also compares the use of interpreters to language concordant interactions.

Background: Indigenous peoples in developed countries have reduced life expectancies, particularly from chronic diseases. The lack of access to and take up of palliative care services of Indigenous peoples is an ongoing concern. Objectives: To examine and learn from published studies on provision of culturally safe palliative care service delivery to Indigenous people in Australia, New Zealand (NZ), Canada and the United States of America (USA); and to compare Indigenous peoples' preferences, needs, opportunities and barriers to palliative care. Methods: A comprehensive search of multiple databases was undertaken. Articles were included if they were published in English from 2000 onwards and related to palliative care service delivery for Indigenous populations; papers could use quantitative or qualitative approaches. Common themes were identified using thematic synthesis. Studies were evaluated using Daly's hierarchy of evidence-for-practice in qualitative research. Results: Of 522 articles screened, 39 were eligible for inclusion. Despite diversity in Indigenous peoples' experiences across countries, some commonalities were noted in the preferences for palliative care of Indigenous people: to die close to or at home; involvement of family; and the integration of cultural practices. Barriers identified included inaccessibility, affordability, lack of awareness of services, perceptions of palliative care, and inappropriate services. Identified models attempted to address these gaps by adopting the following strategies: community engagement and ownership; flexibility in approach; continuing education and training; a whole-of-service approach; and local partnerships among multiple agencies. Better engagement with Indigenous clients, an increase in number of palliative care patients, improved outcomes, and understanding about palliative care by patients and their families were identified as positive achievements. Conclusions: The results provide a comprehensive overview of identified effective practices with regards to palliative care delivered to Indigenous populations to guide future program developments in this field. Further research is required to explore the palliative care needs and experiences of Indigenous people living in urban areas. [ABSTRACT FROM AUTHOR]