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Article ; Online: 183 Advancing Structural and Systematic Equity in Epidemiological Analyses of Large Datasets

Martha L. Carvour

Journal of Clinical and Translational Science, Vol 6, Pp 24-

2022 Volume 25

Abstract: OBJECTIVES/GOALS: Health inequities represent complex structural and systematic processes that lead to disparate outcomes for populations or subgroups within populations. This project aims to improve the available structural and systematic approaches to ... ...

Abstract	OBJECTIVES/GOALS: Health inequities represent complex structural and systematic processes that lead to disparate outcomes for populations or subgroups within populations. This project aims to improve the available structural and systematic approaches to the study of such inequities at the population level. METHODS/STUDY POPULATION: Using examples from diabetes research, two critical factors that may impact the validity or utility of health equity models will be examined; and proposed methodological approaches to offsetting potentially resulting biases will be offered. The factors include: (1) inequitably missing and misclassified data in large datasets and (2) the presumed positioning of socially constructed variables such as race, ethnicity, and gender within modeled structural and systematic mechanisms. This examination intersects theories and praxis in epidemiological modeling and health equity promotion with the goal of advancing rigorous, equity-focused epidemiological methods. RESULTS/ANTICIPATED RESULTS: Inequitably missing and misclassified data are generally expected to obscure inequities. Treatment of missing or misclassified data as informative measures of inequity is expected to partially offset this bias. The implicitly modeled components of socially constructed variables are expected to be non-uniform across structural and systematic mechanisms of inequity. Models that apply these variables as informatively heterogeneous constructs, using multi-phase analyses to test modeling assumptions and to assess intersectionality, may provide better context about the mechanisms by which inequity has been distributed and, perhaps, by which equity may be achieved. DISCUSSION/SIGNIFICANCE: Equitable epidemiological methods are essential to the advancement of evidence-based health equity on the population level. Potential structural or systematic inequities in large-scale datasets and traditional data analyses should be thoughtfully reviewed through a health equity lens.
Keywords	Medicine ; R
Subject code	360
Language	English
Publishing date	2022-04-01T00:00:00Z
Publisher	Cambridge University Press
Document type	Article ; Online
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Article ; Online: A Scoping Review of Wearable Technologies for Use in Individuals With Intellectual Disabilities and Diabetic Peripheral Neuropathy.

Barsotti, Ercole / Goodman, Bailey / Samuelson, Riley / Carvour, Martha L

Journal of diabetes science and technology

2024 , Page(s) 19322968241231279

Abstract: Background: Individuals with intellectual disabilities (IDs) are at risk of diabetes mellitus (DM) and diabetic peripheral neuropathy (DPN), which can lead to foot ulcers and lower-extremity amputations. However, cognitive differences and communication ... ...

Abstract	Background: Individuals with intellectual disabilities (IDs) are at risk of diabetes mellitus (DM) and diabetic peripheral neuropathy (DPN), which can lead to foot ulcers and lower-extremity amputations. However, cognitive differences and communication barriers may impede some methods for screening and prevention of DPN. Wearable and mobile technologies-such as smartphone apps and pressure-sensitive insoles-could help to offset these barriers, yet little is known about the effectiveness of these technologies among individuals with ID. Methods: We conducted a scoping review of the databases Embase, PubMed, and Web of Science using search terms for DM, DPN, ID, and technology to diagnose or monitor DPN. Finding a lack of research in this area, we broadened our search terms to include any literature on technology to diagnose or monitor DPN and then applied these findings within the context of ID. Results: We identified 88 articles; 43 of 88 (48.9%) articles were concerned with gait mechanics or foot pressures. No articles explicitly included individuals with ID as the target population, although three articles involved individuals with other cognitive impairments (two among patients with a history of stroke, one among patients with hemodialysis-related cognitive changes). Conclusions: Individuals with ID are not represented in studies using technology to diagnose or monitor DPN. This is a concern given the risk of DM complications among patients with ID and the potential for added benefit of such technologies to reduce barriers to screening and prevention. More studies should investigate how wearable devices can be used among patients with ID.
Language	English
Publishing date	2024-03-04
Publishing country	United States
Document type	Journal Article ; Review
ISSN	1932-2968
ISSN (online)	1932-2968
DOI	10.1177/19322968241231279
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Article ; Online: Retrospective review of intermittent and continuous infusion vancomycin for methicillin-resistant Staphylococcus aureus bacteremia.

Gilliam, Diari / Acosta, Dominic / Carvour, Martha L / Walraven, Carla

European journal of clinical pharmacology

2023 Volume 80, Issue 1, Page(s) 75–81

Abstract: Purpose: Vancomycin is commonly administered as an intermittent infusion (IIV), although vancomycin's stability at room temperature permits administration continuously over 24 h (CIV). At our institution, CIV has been the preferred infusion method for ... ...

Abstract	Purpose: Vancomycin is commonly administered as an intermittent infusion (IIV), although vancomycin's stability at room temperature permits administration continuously over 24 h (CIV). At our institution, CIV has been the preferred infusion method for over 20 years due to ease of administration and simplicity of therapeutic drug monitoring. The purpose of this study was to examine the outcomes associated with IIV compared to CIV. Methods: This was a retrospective study of patients who received vancomycin for MRSA bacteremia. The primary outcomes were the time to therapeutic goal and frequency of adverse drug reactions on IIV compared to CIV. Secondary outcomes evaluated all-cause readmission, relapse, and mortality 30 days after completion of therapy. Results: Sixty-three patients were included. Significantly fewer patients were able to achieve a therapeutic goal on IIV compared to CIV (52.4% vs. 82.5%, p < 0.01). Patients on IIV took 3.6 days, on average, to reach the target goal, compared to 1.9 days when patients were switched to CIV (95% confidence interval, 0.48-3.04, p < 0.01). Six patients experienced adverse events on IIV, and 15 patients experienced adverse events on CIV (IIV 9.5%, CIV 23.8%, p = 0.035). One patient experienced relapse of infection, and six patients (9.5%) were readmitted 30 days after completion of therapy. There were no deaths in the cohort. Conclusion: For MRSA bacteremia, CIV enabled patients to achieve the AUC/MIC goal significantly faster than when patients received IIV. Furthermore, patients who were unable to achieve a therapeutic trough on IIV became therapeutic once switched to CIV.
MeSH term(s)	Humans ; Vancomycin ; Methicillin-Resistant Staphylococcus aureus ; Anti-Bacterial Agents/adverse effects ; Retrospective Studies ; Staphylococcal Infections/drug therapy ; Bacteremia/drug therapy ; Recurrence ; Microbial Sensitivity Tests ; Treatment Outcome
Chemical Substances	Vancomycin (6Q205EH1VU) ; Anti-Bacterial Agents
Language	English
Publishing date	2023-10-28
Publishing country	Germany
Document type	Journal Article
ZDB-ID	121960-1
ISSN	1432-1041 ; 0031-6970
ISSN (online)	1432-1041
ISSN	0031-6970
DOI	10.1007/s00228-023-03585-2
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Article ; Online: Physician Wellness: the Ethics of Studying Ourselves.

Ramirez, Natalie C / Carvour, Martha L

Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry

2019 Volume 43, Issue 4, Page(s) 405–406

MeSH term(s)	Burnout, Professional/prevention & control ; Burnout, Professional/psychology ; Ethics, Research ; Humans ; Job Satisfaction ; Physicians/psychology ; Research Subjects
Language	English
Publishing date	2019-02-20
Publishing country	United States
Document type	Letter
ZDB-ID	1045331-3
ISSN	1545-7230 ; 1042-9670
ISSN (online)	1545-7230
ISSN	1042-9670
DOI	10.1007/s40596-019-01034-w
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Article ; Online: Visualizing complex healthcare disparities: proof of concept for representing a cyclical continuum of care model for a retrospective cohort of patients with musculoskeletal infections.

Carvour, Martha L / Chiu, Allyssa / Page, Kimberly

BMC musculoskeletal disorders

2021 Volume 22, Issue 1, Page(s) 465

Abstract: Background: Care continuum models (also known as care cascade models) are used by researchers and health system planners to identify potential gaps or disparities in healthcare, but these models have limited applications to complex or chronic clinical ... ...

Abstract	Background: Care continuum models (also known as care cascade models) are used by researchers and health system planners to identify potential gaps or disparities in healthcare, but these models have limited applications to complex or chronic clinical conditions. Cyclical continuum models that integrate more complex clinical information and that are displayed using circular data visualization tools may help to overcome these limitations. We performed proof-of-concept cyclical continuum modeling for one such group of conditions-musculoskeletal infections-and assessed for racial and ethnic disparities across the complex care process related to these infections. Methods: Cyclical continuum modeling was performed in a diverse, retrospective cohort of 1648 patients with musculoskeletal infections, including osteomyelitis, septic arthritis, and/or infectious myositis, in the University of New Mexico Health System. Logistic regression was used to estimate the relative odds of each element or outcome of care in the continuum. Results were visualized using circularized, map-like images depicting the continuum of care. Results: Racial and ethnic disparities differed at various phases in the care process. Hispanic/Latinx patients had evidence of healthcare disparities across the continuum, including diabetes mellitus [odds ratio (OR) 2.04, 95% confidence interval (CI): 1.61, 2.60 compared to a white non-Hispanic reference category]; osteomyelitis (OR 1.28, 95% CI: 1.01, 1.63); and amputation (OR 1.48; 95% CI: 1.10, 2.00). Native American patients had evidence of disparities early in the continuum (diabetes mellitus OR 3.59, 95% CI: 2.63, 4.89; peripheral vascular disease OR 2.50; 95% CI: 1.45, 4.30; osteomyelitis OR 1.43; 95% CI: 1.05, 1.95) yet lower odds of later-stage complications (amputation OR 1.02; 95% CI: 0.69, 1.52). African American/Black non-Hispanic patients had higher odds of primary risk factors (diabetes mellitus OR 2.70; 95% CI: 1.41, 5.19; peripheral vascular disease OR 4.96; 95% CI: 2.06, 11.94) and later-stage outcomes (amputation OR 2.74; 95% CI: 1.38, 5.45) but not intervening, secondary risk factors (osteomyelitis OR 0.79; 95% CI: 0.42, 1.48). Conclusions: By identifying different structural and clinical barriers to care that may be experienced by groups of patients interacting with the healthcare system, cyclical continuum modeling may be useful for the study of healthcare disparities.
MeSH term(s)	Continuity of Patient Care ; Ethnic Groups ; European Continental Ancestry Group ; Healthcare Disparities ; Humans ; Mexico ; Retrospective Studies ; United States
Language	English
Publishing date	2021-05-21
Publishing country	England
Document type	Journal Article
ISSN	1471-2474
ISSN (online)	1471-2474
DOI	10.1186/s12891-021-04358-7
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Article ; Online: Epidemiological approaches to multivariable models of health inequity: A study of race, rurality, and occupation during the COVID-19 pandemic.

Zadeh, Hannah / Curran, Michaela / Del Castillo, Nicole / Morales, Carol / Dukes, Kimberly / Martinez, Denise / Salinas, Jorge L / Bryant, Rachel / Bojang, Matida / Carvour, Martha L

Annals of epidemiology

2024 Volume 94, Page(s) 42–48

Abstract: Purpose: Methods for assessing the structural mechanisms of health inequity are not well established. This study applies a phased approach to modeling racial, occupational, and rural disparities on the county level.: Methods: Rural counties with ... ...

Abstract	Purpose: Methods for assessing the structural mechanisms of health inequity are not well established. This study applies a phased approach to modeling racial, occupational, and rural disparities on the county level. Methods: Rural counties with disparately high rates of COVID-19 incidence or mortality were randomly paired with in-state control counties with the same rural-urban continuum code. Analysis was restricted to the first six months of the pandemic to represent the baseline structural reserves for each county and reduce biases related to the disruption of these reserves over time. Conditional logistic regression was applied in two phases-first, to examine the demographic distribution of disparities and then, to examine the relationships between these disparities and county-level social and structural reserves. Results: In over 200 rural county pairs (205 for incidence, 209 for mortality), disparities were associated with structural variables representing economic factors, healthcare infrastructure, and local industry. Modeling results were sensitive to assumptions about the relationships between race and other social and structural variables measured at the county level, particularly in models intended to reflect effect modification or mediation. Conclusions: Multivariable modeling of health disparities should reflect the social and structural mechanisms of inequity and anticipate interventions that can advance equity.
Language	English
Publishing date	2024-04-19
Publishing country	United States
Document type	Journal Article
ZDB-ID	1074355-8
ISSN	1873-2585 ; 1047-2797
ISSN (online)	1873-2585
ISSN	1047-2797
DOI	10.1016/j.annepidem.2024.04.008
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Article ; Online: Diabetes care in the pandemic era in the Midwestern USA: a semi-structured interview study of the patient perspective.

Gonzalez Bravo, Carolina / Sabree, Shakoora A / Dukes, Kimberly / Adeagbo, Morolake J / Edwards, Sarai / Wainwright, Kasey / Schaeffer, Sienna E / Villa, Aneli / Wilks, Aloha D / Carvour, Martha L

BMJ open

2024 Volume 14, Issue 3, Page(s) e081417

Abstract: Objectives: To understand patients' experiences with diabetes care during the COVID-19 pandemic, with an emphasis on rural, medically underserved, and/or minoritised racial and ethnic groups in the Midwestern USA.: Design: Community-engaged, semi- ... ...

Abstract	Objectives: To understand patients' experiences with diabetes care during the COVID-19 pandemic, with an emphasis on rural, medically underserved, and/or minoritised racial and ethnic groups in the Midwestern USA. Design: Community-engaged, semi-structured interviews were conducted by medical student researchers trained in qualitative interviewing. Transcripts were prepared and coded in the language in which the interview was conducted (English or Spanish). Thematic analysis was conducted, and data saturation was achieved. Setting: The study was conducted in communities in Eastern and Western Iowa. Participants: Adults with diabetes (n=20) who were fluent in conversational English or Spanish were interviewed. One-third of participants were residents of areas designated as federal primary healthcare professional shortage areas and/or medically underserved areas, and more than half were recruited from medical clinics that offer care at no cost. Results: Themes across both English and Spanish transcripts included: (1) perspectives of diabetes, care providers and care management; (2) challenges and barriers affecting diabetes care; and (3) participant feedback and recommendations. Participants reported major constraints related to provider availability, costs of care, access to nutrition counselling and mental health concerns associated with diabetes care during the pandemic. Participants also reported a lack of shared decision-making regarding some aspects of care, including amputation. Finally, participants recognised systems-level challenges that affected both patients and providers and expressed a preference for proactive collaboration with healthcare teams. Conclusions: These findings support enhanced engagement of rural, medically underserved and minoritised groups as stakeholders in diabetes care, diabetes research and diabetes provider education.
MeSH term(s)	Adult ; Humans ; Pandemics ; Diabetes Mellitus ; Medically Underserved Area ; Health Personnel ; Qualitative Research
Language	English
Publishing date	2024-03-08
Publishing country	England
Document type	Journal Article
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-081417
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Article: A Cyclical Approach to Continuum Modeling: A Conceptual Model of Diabetic Foot Care.

Carvour, Martha L / Chiu, Allyssa

Frontiers in public health

2017 Volume 5, Page(s) 337

Abstract: Cascade" or "continuum" models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. ...

Abstract	"Cascade" or "continuum" models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. These models may be used to compare care across subgroups or populations and to identify and evaluate interventions intended to improve outcomes on the population level. Previous cascade or continuum models have been limited by several factors. These models are best suited to processes with stepwise outcomes-such as screening, diagnosis, and treatment-with a single defined outcome (e.g., treatment or cure) for each member of the population. However, continuum modeling is not well developed for complex processes with non-sequential or recurring steps or those without singular outcomes. As shown here using the example of diabetic foot care, the concept of continuum modeling may be re-envisioned with a cyclical approach. Cyclical continuum modeling may permit incorporation of non-sequential and recurring steps into a single continuum, while recognizing the presence of multiple desirable outcomes within the population. Cyclical models may simultaneously represent the distribution of clinical severity and clinical resource use across a population, thereby extending the benefits of traditional continuum models to complex processes for which population-based monitoring is desired. The models may also support communication with other stakeholders in the process of care, including health care providers and patients.
Language	English
Publishing date	2017-12-08
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2711781-9
ISSN	2296-2565
ISSN	2296-2565
DOI	10.3389/fpubh.2017.00337
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Article ; Online: Racial and ethnic disparities in surgical amputations following serious musculoskeletal infections in a diverse New Mexico cohort.

Carvour, Martha L / Chiu, Allyssa / Page, Kimberly

Journal of clinical and translational research

2019 Volume 5, Issue 1, Page(s) 25–32

Abstract: Background: Patients with serious musculoskeletal infections may encounter health disparities across multiple phases of prevention and treatment, including surgical intervention. The purpose of this study was to identify and compare the predictors of ... ...

Abstract	Background: Patients with serious musculoskeletal infections may encounter health disparities across multiple phases of prevention and treatment, including surgical intervention. The purpose of this study was to identify and compare the predictors of surgical intervention and surgical amputation among patients with septic arthritis, osteomyelitis, and infectious myositis in a diverse cohort of patients from New Mexico. Methods: A retrospective cohort from the University of New Mexico Health System was formed. Patients with septic arthritis, osteomyelitis, and/or infectious myositis who underwent surgical procedures or amputations were compared with those who did not, using predictive multivariable logistic regression modeling. The impact of diabetes mellitus (DM) as a predictor of surgical outcomes was evaluated. Results: DM was a predictor of both surgical procedures and amputations in a diverse cohort of patients (n = 1694). Diabetes was more common in American Indian/Alaskan Native (AI/AN) patients. However, Black non-Hispanic/African American and Hispanic patients were more likely to undergo amputations, compared to AI/AN patients, even after adjustment for diabetes severity. Conclusions: Racial and ethnic disparities in infection-related amputation may differ from those observed for diabetes or for general access to surgical management. Interventions intended to prevent or treat serious musculoskeletal infections should consider health disparities that differ across the clinical care process.
Language	English
Publishing date	2019-01-30
Publishing country	Singapore
Document type	Journal Article
ZDB-ID	3019815-X
ISSN	2424-810X ; 2382-6533
ISSN (online)	2424-810X
ISSN	2382-6533
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Article ; Online: A Cyclical Approach to Continuum Modeling

Martha L. Carvour / Allyssa Chiu

Frontiers in Public Health, Vol

A Conceptual Model of Diabetic Foot Care

2017 Volume 5

Abstract: Cascade” or “continuum” models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. ...

Abstract	“Cascade” or “continuum” models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. These models may be used to compare care across subgroups or populations and to identify and evaluate interventions intended to improve outcomes on the population level. Previous cascade or continuum models have been limited by several factors. These models are best suited to processes with stepwise outcomes—such as screening, diagnosis, and treatment—with a single defined outcome (e.g., treatment or cure) for each member of the population. However, continuum modeling is not well developed for complex processes with non-sequential or recurring steps or those without singular outcomes. As shown here using the example of diabetic foot care, the concept of continuum modeling may be re-envisioned with a cyclical approach. Cyclical continuum modeling may permit incorporation of non-sequential and recurring steps into a single continuum, while recognizing the presence of multiple desirable outcomes within the population. Cyclical models may simultaneously represent the distribution of clinical severity and clinical resource use across a population, thereby extending the benefits of traditional continuum models to complex processes for which population-based monitoring is desired. The models may also support communication with other stakeholders in the process of care, including health care providers and patients.
Keywords	continuum model ; cascade model ; population health ; diabetes ; limb salvage ; limb preservation ; Public aspects of medicine ; RA1-1270
Subject code	310
Language	English
Publishing date	2017-12-01T00:00:00Z
Publisher	Frontiers Media S.A.
Document type	Article ; Online
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