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The Influence of Race, Cultural, and Psychosocial Factors on Disparities in Processes and Outcomes of Care for Spinal Cord Injury Larissa Myaskovsky, PhD.

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Presentation on theme: "The Influence of Race, Cultural, and Psychosocial Factors on Disparities in Processes and Outcomes of Care for Spinal Cord Injury Larissa Myaskovsky, PhD."— Presentation transcript:

1 The Influence of Race, Cultural, and Psychosocial Factors on Disparities in Processes and Outcomes of Care for Spinal Cord Injury Larissa Myaskovsky, PhD Associate Professor of Medicine, Psychiatry and Clinical and Translational Science University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System

2 Collaborators and Research Team Michael L. Boninger, MD Kelly H. Burkitt, PhD Michael J. Fine, MD Shasha Gao, PhD David Gater, MD Sam Phillips, PhD Ann Spungen, PhD Galen Switzer, PhD Kellee Bornemann Jemy Delikat Devra Greenwald, MPH Jewel Moore Kel Morin Michelle Oyster, MS Debbie Wetzler

3 Funding Sources Department of Education − National Institute of Disability and Rehab Research (NIDRR) VA – CHERP Pilot Study – Rehabilitation Research and Development Division (VA RR&D)

4 Presentation Topics A health service research perspective Why are health services researchers interested in Spinal Cord Injury (SCI)? Brief epidemiology of SCI Race and culture in SCI Research findings (hot off the presses!)

5 Health Services Research Social Factors Financing Systems Organizational Structures and Processes Health Technologies Personal Behavior 1.Access to healthcare 2.Quality and cost of healthcare 3.Health and well-being

6 CHERP Model to Advance Health Equity Research Detecting Define health disparities Define vulnerable populations Measure disparities in vulnerable populations Consider selection effects and confounding factors Understanding Identify determinants of health disparities at the following levels: Patient/individual Provider Clinical encounter Healthcare system Reducing Intervene Evaluate Translate and disseminate Change policy First GenerationSecond GenerationThird Generation Kilbourne et al, Am J Public Health 2006

7 Conceptualizing Disparities in Health and Health Care Healthcare Disparities Processes of care Structure of care Health Disparities Medical Complications Mortality Functional status Quality of life Provider Knowledge Attitudes Communication Patient Demographics Biology/Genes Preferences System Accessibility Organization Quality Environment Geography Poverty Segregation Social norms

8 Why are Health Services Researchers Interested in Spinal Cord Injury? High incidence and prevalence rate – 12,000 new cases each year (incidence) – Prevalence of SCI in 2013 = 273,000 (range = 238,000 – 332,000) www.nscisc.uab.edu

9 Why are Health Services Researchers Interested in Spinal Cord Injury? High incidence and prevalence rate Changing demographics

10 SCI Demographics Over Time www.nscisc.uab.edu

11 Why are Health Services Researchers Interested in Spinal Cord Injury? High incidence and prevalence rate Changing demographics Exemplar of life-long, team-based, patient- focused care

12 Life-Long Care in Multiple Domains Functional Medical Complications Psychological Community Integration and Employment

13 Team-Based and Patient-Focused Care

14 Why are Health Services Researchers Interested in Spinal Cord Injury? High incidence and prevalence rate Changing demographics Exemplar of life-long patient-focused team- based care Multiple under-explored research foci – Measurement development – Psychological, social, and behavioral predictors of outcomes – Disparities in processes of care and patient outcomes

15 Disparities in SCI Racial and ethnic disparities in health and health-related quality of life (QOL) are well- documented Cultural factors health disparities – Perceived discrimination and racism – Healthcare system distrust – Health literacy – Communication with provider These factors may be especially critical in SCI care

16 Race and Culture in SCI

17 Study Goals Identify and compare race differences in cultural and psychosocial factors in Veterans and non- Veterans with SCI Investigate and compare race differences in wheelchair quality and quality of life (QOL): – Participation – Life satisfaction or satisfaction with service – Perceived health status Determine how demographic, medical, cultural and psychosocial factors are associated with racial disparities in wheelchair quality and QOL

18 Methods Design: Two cross-sectional multi-site studies using structured questionnaires Setting: Six National Spinal Cord Injury Model Systems centers (NSCIMS) and three VA Spinal Cord Injury centers (VA SCI) Eligibility criteria: – Age > 16 years – SCI with discernable neurological impairments – Use a power or manual wheelchair >1 year as primary means of mobility – Non-ambulatory except for exercise purposes

19 Independent Measures Demographics (e.g., race, gender, age) Medical factors (e.g., SCI level) Cultural factors – Experience of discrimination – Perceived racism – Healthcare system distrust – Health literacy – Communication with provider Psychosocial factors – Anxiety – Depression

20 Cultural Factors - Examples Experience of discrimination - “Treated with less courtesy than other people because of your race or ethnicity.” Perceived racism - “Doctors treat people from racial or ethnic minorities the same as white people.” Healthcare system distrust - “The health care system covers up its mistakes.” Communication with provider -“Sometimes, my doctors do not listen to me.”

21 Outcomes Wheelchair Quality - VA SCI participants only Craig Handicap Assessment and Reporting Technique Short Form (CHART-SF) - physical independence, cognitive independence, mobility, occupational functioning, social integration Satisfaction with Life Scale - NSCIMS Satisfaction with Service - VA SCI Perceived health status: – 2 items from the SF-36 - NSCIMS – Veterans SF-12 - VA SCI

22 Implications for 3 rd Generation Research Detecting Define health disparities Define vulnerable populations Measure disparities in vulnerable populations Consider selection effects and confounding factors Understanding Identify determinants of health disparities at the following levels: Patient/individual Provider Clinical encounter Healthcare system Reducing Intervene Evaluate Translate and disseminate Change policy First GenerationSecond GenerationThird Generation

23 Thank you! Contact information: Larissa Myaskovsky, PhD larissa.myaskovsky@va.gov 412-360-2241

24 References for Measures Bass PF, Wilson JF, Griffith CH. A shortened instrument for literacy screening. Journal of General Internal Medicine 2003;18:1036-8. Bird ST, Bogart LM. Perceived race-based and socioeconomic status (SES)-based discrimination in interactions with health care providers. Ethnicity and Disease 2001;11:554-63. Derogatis L, Spencer P. The Brief Symptom Inventory (BSI): Administration, Scoring, and Procedures Manual. Clinical Psychometric Research. Baltimore, MD; 1975. Diener E, Emmons R, Larsen R, Griffin S. The Satisfaction With Life Scale. J Pers Assess 1985;49(1):71-5. Flocke SA. Measuring attributes of primary care: Development of a new instrument. The Journal of Family Practice 1997;45(1):64-74. LaVeist TA, Nickerson KJ, Bowie JV. Attitudes about racism, medical mistrust, and satisfaction with care among African-American and White cardiac patients. Medical Care Research & Review 2000;57(Suppl 1):146-61. Shea JA, Micco E, Dean LT, McMurphy S, Schwartz J, Armstrong K. Development of a revised Healthcare System Distrust scale. Journal of General Internal Medicine 2008;23(6):727-32. Wallston KA, Stein MJ, Smith CA. Form C of the MHLC Scales: A Condition-Specific Measure of Locus of Control. Journal of Personality Assessment 1994;63(3):534-53. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: Manual and interpretation guide. Boston: The Health Institute, New England Medical Center; 1993. Whiteneck GG, Charlifue SW, Gerhart KA, Overholser JD, Richardson GN. Qunatifying handicap: A new measure of long-term rehabilitation outcomes. Arch Phys Med Rehabil 1992;73:519-26.


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