Publications by authors named "Emily C Cleveland Manchanda"

10 Publications

  • Page 1 of 1

Racial Equity in Crisis Standards of Care-Reassuring Data or Reason for Concern?

JAMA Netw Open 2021 03 1;4(3):e214527. Epub 2021 Mar 1.

Department of Emergency Medicine, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.4527DOI Listing
March 2021

Heart Failure Admission Service Triage (H-FAST) Study: Racialized Differences in Perceived Patient Self-Advocacy as a Driver of Admission Inequities.

Cureus 2021 Feb 16;13(2):e13381. Epub 2021 Feb 16.

Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.

Background Racial inequities in mortality and readmission for heart failure (HF) are well documented. Inequitable access to specialized cardiology care during admissions may contribute to inequity, and the drivers of this inequity are poorly understood. Methodology This prospective observational study explored proposed drivers of racial inequities in cardiology admissions among Black, Latinx, and white adults presenting to the emergency department (ED) with symptoms of HF. Surveys of ED providers examined perceptions of patient self-advocacy, outreach to other clinicians (e.g., outpatient cardiologist), diagnostic uncertainty, and other active co-morbid conditions. Service census, bed availability, prior admission service, and other structural factors were explored through the electronic medical record. Results Complete data were available for 61/135 patients admitted with HF during the study period, which halted early due to coronavirus disease 2019. No significant differences emerged in admission to cardiology versus medicine based on age, sex, insurance status, education level, or perceived race/ethnicity. White patients were perceived as advocating for admission to cardiology more frequently (18.9 vs. 5.6%) and more strenuously than Black patients (p = 0.097). ED clinicians more often reported having spoken with the patient's outpatient cardiologist for whites than for Black or Latinx patients (24.3 vs. 16.7%, p = 0.069). Conclusions Theorized drivers of racial inequities in admission service did not reach statistical significance, possibly due to underpowering, the Hawthorne effect, or clinician behavior change based on knowledge of previously identified inequities. The observed trend towards racial differences in coordination of care between ED and outpatient providers, as well as in either actual or perceived self-advocacy by patients, may be as-yet undemonstrated components of structural racism driving HF care inequities.
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http://dx.doi.org/10.7759/cureus.13381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891794PMC
February 2021

Tackling Gender and Racial Bias in Academic Emergency Medicine: The Perceived Role of Implicit Bias in Faculty Development.

Cureus 2020 Nov 4;12(11):e11325. Epub 2020 Nov 4.

Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA.

Background Gender and racial disparities in academic medicine have recently garnered much attention. Implicit Association Tests (IATs) offer a validated means of evaluating unconscious associations and preferences. This study examines the perceived role of implicit bias in faculty development in academic emergency medicine (EM). Methods EM faculty at a large urban academic medical center were invited to independently participate in a self-reflection assessment in preparation for a faculty retreat session discussing diversity, equity, and inclusion. Participants completed two IATs designed to examine gender associations (gender IAT) and race preferences (race IAT) followed by a short anonymous survey where IAT scores were recorded. The survey also captured demographic information and perceptions about the impact of gender and racial biases in faculty development. Results Forty faculty members (66%) completed the survey; 70% were male and 80% white. The majority (59%) reported gender IAT results indicating automatic male-sciences and female-liberal arts associations. Nearly half (45%) reported race IAT results indicating an automatic preference for white people. More than 70% of males reported that faculty recruitment, development, and promotion decisions were 'never' or 'seldom' affected by gender bias, while more than 80% reported racial bias 'never' or 'seldom' affects these decisions. Female faculty more frequently perceived adverse effects of unconscious gender and race biases. Conclusion Our group of academic physicians reported IAT results showing different levels of implicit bias compared to the general population. Female faculty may be both more aware of and more susceptible to the adverse effects of unconscious biases. Further study is needed to determine both the extent to which unconscious biases affect the academic workplace, as well as ways in which such unintentional forms of discrimination can be eliminated. Unconscious biases are not unique to EM. Intentional efforts to increase self-awareness of these 'blind spots' may help mitigate their impact and foster a more diverse and inclusive healthcare environment.
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http://dx.doi.org/10.7759/cureus.11325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717082PMC
November 2020

Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19.

J Racial Ethn Health Disparities 2020 Aug 13. Epub 2020 Aug 13.

Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: Crisis Standards of Care (CSC) provide a framework for the fair allocation of scarce resources during emergencies. The novel coronavirus disease (COVID-19) has disproportionately affected Black and Latinx populations in the USA. No literature exists comparing state-level CSC. It is unknown how equitably CSC would allocate resources.

Methods: The authors identified all publicly available state-level CSC through online searches and communication with state governments. Publicly available CSC were systematically reviewed for content including ethical framework and prioritization strategy.

Results: CSC were identified for 29 states. Ethical principles were explicitly stated in 23 (79.3%). Equity was listed as a guiding ethical principle in 15 (51.7%); 19 (65.5%) said decisions should not factor in race, ethnicity, disability, and other identity-based factors. Ten states (34.4%) allowed for consideration of societal value, which could lead to prioritization of health care workers and other essential personnel. Twenty-one (72.4%) CSC provided a specific strategy for prioritizing patients for critical care resources, e.g., ventilators. All incorporated Sequential Organ Failure Assessment scores; 15 (71.4%) of these specific CSC considered comorbid conditions (e.g., cardiac disease, renal failure, malignancy) in resource allocation decisions.

Conclusion: There is wide variability in the existence and specificity of CSC across the USA. CSC may disproportionately impact disadvantaged populations due to inequities in comorbid condition prevalence, expected lifespan, and other effects of systemic racism.
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http://dx.doi.org/10.1007/s40615-020-00840-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425256PMC
August 2020

Patient and Community Organization Perspectives on Accessing Social Resources from the Emergency Department: A Qualitative Study.

West J Emerg Med 2020 Jun 24;21(4):964-973. Epub 2020 Jun 24.

Massachusetts General Hospital, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts.

Introduction: Social risks adversely affect health and are associated with increased healthcare utilization and costs. Emergency department (ED) patients have high rates of social risk; however, little is known about best practices for ED-based screening or linkage to community resources. We examined the perspectives of patients and community organizations regarding social risk screening and linkage from the ED.

Methods: Qualitative interviews were conducted with a purposive sample of ED patients and local community organization staff. Participants completed a brief demographic survey, health literacy assessment, and qualitative interview focused on barriers/facilitators to social risk screening in the ED, and ideas for screening and linkage interventions in the ED. Interviews were conducted in English or Spanish, recorded, transcribed, and coded. Themes were identified by consensus.

Results: We conducted 22 interviews with 16 patients and six community organization staff. Three categories of themes emerged. The first related to the importance of social risk screening in the ED. The second category encompassed challenges regarding screening and linkage, including fear, mistrust, transmission of accurate information, and time/resource constraints. The third category included suggestions for improvement and program development. Patients had varied preferences for verbal vs electronic strategies for screening. Community organization staff emphasized resource scarcity and multimodal communication strategies.

Conclusion: The development of flexible, multimodal, social risk screening tools, and the creation and maintenance of an accurate database of local resources, are strategies that may facilitate improved identification of social risk and successful linkage to available community resources.
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http://dx.doi.org/10.5811/westjem.2020.3.45932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390556PMC
June 2020

Best Practices for Lactation Support at Conferences and Standardized Testing Centers.

Obstet Gynecol 2020 Feb;135(2):475-478

Departments of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, and North Shore Medical Center, Salem, Massachusetts, and Columbia University Medical Center, New York, New York.

Breastfeeding has demonstrable benefits for children and their mothers; however, breastfeeding can be particularly difficult for women who return to the workplace in the months after a child's birth. The challenge of continuing to provide breast milk to an infant after a mother returns to work is evident in the day-to-day lives of health professionals who choose to do so and is reflected in the literature, which shows a marked reduction in breastfeeding rates corresponding to a woman's return to work. These barriers are even more apparent when travel is required for professional obligations or advancement, such as to attend or present at national conferences or to take standardized examinations at test centers. This article provides guidelines and practical advice for event organizers and testing centers to support a lactating mother's ability to provide for her child without compromising her professional career. In particular, we describe the physical requirements of lactation spaces, considerations for milk storage, ways to create a lactation-friendly environment, and unique considerations and accommodations for test takers and test centers. Supporting lactating health professionals should be seen as part of a larger endeavor to support gender equity, advance women in medicine, and integrate wellness and family into our professional lives.
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http://dx.doi.org/10.1097/AOG.0000000000003661DOI Listing
February 2020

Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.

Circ Heart Fail 2019 11 29;12(11):e006214. Epub 2019 Oct 29.

Division of Cardiovascular Medicine, and Department of Medicine (E.F..L.), Brigham and Women's Hospital, Boston, MA.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality.

Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84-0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72-0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race.

Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7183732PMC
November 2019

Dyspnea in an Otherwise Healthy 18-year-old: The Importance of Point-of-care Ultrasonography.

Clin Pract Cases Emerg Med 2019 Aug 1;3(3):271-274. Epub 2019 Jul 1.

Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.

A healthy 18-year-old male presented to the emergency department with chest pain, palpitations, and dyspnea. His exam was unremarkable; however, point-of-care ultrasound (POCUS) revealed right ventricular strain with a D-sign and enlarged right ventricle. He subsequently reported a history of factor V Leiden. His D-dimer was markedly elevated, and a computed tomography angiogram of the chest demonstrated submassive pulmonary embolism (PE). He was taken to the catheterization lab for directed thrombolysis and was discharged in good condition two days later. Factor V Leiden is the most common genetic cause of venous thromboembolism. POCUS can facilitate rapid diagnosis and risk stratification of patients with acute PE.
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http://dx.doi.org/10.5811/cpcem.2018.9.39218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682241PMC
August 2019

Putting the Gas in Gastrocnemius: Knee Pain in a 61-Year-Old Agoraphobic Man.

J Emerg Med 2019 Oct 26;57(4):e127-e129. Epub 2019 Jul 26.

Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jemermed.2019.05.038DOI Listing
October 2019