Perioperative medicine training resources: U1M3 Patient culture and diversity

Abstract
Aim: To describe disparities in post-operative mortality experienced by Indigenous Māori compared to non-Indigenous New Zealanders.

Methods: We completed a national study of all those undergoing a surgical procedure between 2005 and 2017 in New Zealand. We examined 30-day and 90-day post-operative mortality for all surgical specialties and by common procedures. We compared age-standardised rates between ethnic groups (Māori, Pacific, Asian, European, MELAA/Other) and calculated hazard ratios (HRs) using Cox proportional hazards regression modelling adjusted for age, sex, deprivation, rurality, comorbidity, ASA score, anaesthetic type, procedure risk and procedure specialty.

Results: From nearly 3.9 million surgical procedures (876,976 acute, 2,990,726 elective/waiting list), we observed ethnic disparities in post-operative mortality across procedures, with the largest disparities occurring between Māori and Europeans. Māori had higher rates of 30- and 90-day post-operative mortality across most broad procedure categories, with the disparity between Māori and Europeans strongest for elective/waiting list procedures (eg, elective/waiting list musculoskeletal procedures, 30-day mortality: adj. HR 1.93, 95% CI 1.56-2.39).

Conclusions: The disparities we observed are likely driven by a combination of healthcare system, process and clinical team factors, and we have presented the key mechanisms within these factors.

Abstract
Background: In the context of an effective consumer engagement framework, there is potential for health-care delivery to be safer. Consumers from culturally and linguistically diverse (CALD) backgrounds may experience several barriers when trying to engage about their health care, and they are not acknowledged sufficiently in contemporary strategies to facilitate patient engagement.

Methods: Four focus group discussions were facilitated by bilingual fieldworkers in Arabic, Mandarin, Turkish and Dari in a district of Sydney, Australia that has a high proportion of CALD consumers. Each group included 5-7 health-care consumers who, using a topic guide, discussed their experiences of barriers and facilitators when engaging with health-care services in Australia. Thematic analysis was undertaken to identify, analyse and report patterns in the data.

Results: In all, 24 consumers participated. Six inter-related themes emerged: navigating the health system; seeking meaningful interpretation; understanding and managing expectations; respectful professional care; accessing services; and feeling unsafe.

Conclusions: The incorporation of strategies such as professional interpreters and migrant health workers may go some way to addressing the needs of culturally or linguistically diverse consumers and facilitate communication, but do not sufficiently address the range of barriers to consumer engagement identified in this work. Understanding consumer experience in the context of the complex factors that may be associated with poor engagement and poor outcomes such as health literacy, cultural, educational and linguistic background, and health-care setting or condition, may contribute to better understanding about how to deliver quality health care to these patients.

Abstract
Background: Australia's healthcare system is complex and fragmented which can create challenges in healthcare, particularly in rural and remote areas. Aboriginal people experience inequalities in healthcare treatment and outcomes. This study aimed to investigate barriers and enablers to accessing healthcare services for Aboriginal people living in regional and remote Australia.

Methods: Semi-structured interviews were conducted with healthcare delivery staff and stakeholders recruited through snowball sampling. Three communities were selected for their high proportion of Aboriginal people and diverse regional and remote locations. Thematic analysis identified barriers and enablers.

Results: Thirty-one interviews were conducted in the three communities (n = 5 coastal, n = 13 remote, and n = 13 border) and six themes identified: (1) Improved coordination of healthcare services; (2) Better communication between services and patients; (3) Trust in services and cultural safety; (4) Importance of prioritizing health services by Aboriginal people; (5) Importance of reliable, affordable and sustainable services; (6) Distance and transport availability. These themes were often present as both barriers and enablers to healthcare access for Aboriginal people. They were also present across the healthcare system and within all three communities.

Conclusions: This study describes a pathway to better healthcare outcomes for Aboriginal Australians by providing insights into ways to improve access.

Background: Awareness of the specific needs of LGBTQI cancer patients has led to calls for inclusivity, cultural competence, cultural safety and cultural humility in cancer care. Examination of oncology healthcare professionals' (HCP) perspectives is central to identifying barriers and facilitators to inclusive LGBTQI cancer care.

Study aim: This study examined oncology HCPs perspectives in relation to LGBTQI cancer care, and the implications of HCP perspectives and practices for LGBTQI patients and their caregivers.

Method: 357 oncology HCPs in nursing (40%), medical (24%), allied health (19%) and leadership (11%) positions took part in a survey; 48 HCPs completed an interview. 430 LGBTQI patients, representing a range of tumor types, sexual and gender identities, age and intersex status, and 132 carers completed a survey, and 104 LGBTQI patients and 31 carers undertook an interview. Data were analysed using thematic discourse analysis.

Results: Three HCP subject positions - ways of thinking and behaving in relation to the self and LGBTQI patients - were identified:'Inclusive and reflective' practitioners characterized LGBTQI patients as potentially vulnerable and offered inclusive care, drawing on an affirmative construction of LGBTQI health. This resulted in LGBTQI patients and their carers feeling safe and respected, willing to disclose sexual orientation and gender identity (SOGI) status, and satisfied with cancer care. 'Egalitarian practitioners' drew on discourses of ethical responsibility, positioning themselves as treating all patients the same, not seeing the relevance of SOGI information. This was associated with absence of LGBTQI-specific information, patient and carer anxiety about disclosure of SOGI, feelings of invisibility, and dissatisfaction with healthcare. 'Anti-inclusive' practitioners' expressed open hostility and prejudice towards LGBTQI patients, reflecting a cultural discourse of homophobia and transphobia. This was associated with patient and carer distress, feelings of negative judgement, and exclusion of same-gender partners.

Conclusion: Derogatory views and descriptions of LGBTQI patients, and cis-normative practices need to be challenged, to ensure that HCPs offer inclusive and affirmative care. Building HCP's communicative competence to work with LGBTQI patients needs to become an essential part of basic training and ongoing professional development. Visible indicators of LGBTQI inclusivity are essential, alongside targeted resources and information for LGBTQI people.

Abstract
Background

There are health disparities in many countries between First Nations and non– First Nations populations. In Australia, the Aboriginal and Torres Strait Islander population have several risk factors and are more likely to experience higher rates of post-operative morbidity complications and mortality.

Purpose

To develop a culturally appropriate pre-surgery screening tool, administered by phone, to check health and wellness, identify relevant factors and support Aboriginal and Torres Strait Islander patients to ensure they are appropriately prepared to undertake surgery. The screening tool aims to reduce rates of patient-initiated cancellations of surgery and gain a greater understanding of factors contributing to patient-initiated cancellations of Aboriginal and Torres Strait Islander patients.

Methods

This quality improvement project uses the Model for Improvement methodology and integrates ‘Plan, Do, Study, Act’ (PDSA) cycles to implement, assess and improve the intervention. The rate of Aboriginal and Torres Strait Islander patient-initiated surgical cancellations was measured for an Australian tertiary referral hospital.

Results

The six-month phase after implementation demonstrated a decreased mean rate (0.078 to 0.060) of Aboriginal and Torres Strait Islander patient-initiated cancellations. Responses were thematically analysed to identify contributing factors for surgical cancellations.

Conclusions

Implementing a culturally appropriate pre-surgery screening tool, developed by suitably qualified staff, positively advocated for Aboriginal and Torres Strait Islander patient’s health and wellbeing.

Implications

This study is highly generalisable as the setting has similar key performance indicators and operational governance to many other hospitals treating Aboriginal and Torres Strait Islander patients nationwide.

Choosing Wisely is an international campaign that promotes a culture where low value and inappropriate clinical interventions are avoided, and patients and health professionals have well- informed conversations about treatment options, leading to better decisions and outcomes.

Abstract
Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) patients face challenging health care disparities. However, due to restrictions in reporting and collection of sexual orientation and gender identity (SOGI) demographic data, comprehensive studies of surgical disparities in the LGBTQ+ population are limited. This review aims to summarize the existing literature describing surgical disparities in LGBTQ+ patients and to identify areas of surgical care in which further studies are warranted. This review addresses the literature in infectious diseases, substance use disorders, bariatrics, cardiovascular medicine, oncology, and laryngology as relevant to surgical practice. Understanding the current landscape of knowledge in LGBTQ+ surgical disparities and the areas where gaps in research exist will help the surgeon to create a framework of practice to provide more equitable care to LGBTQ+ patients.

Abstract
With increasing frequency, patients are being asked to make complex decisions about cancer screening, prevention, and treatment. These decisions are fraught with emotion and cognitive difficulty simultaneously. Many Americans have low numeracy skills making the cognitive demands even greater whenever, as is often the case, patients are presented with risk statistics and asked to make comparisons between the risks and benefits of multiple options and to make informed medical decisions. In this commentary, we highlight 10 methods that have been empirically shown to improve patients' understanding of risk and benefit information and/or their decision making. The methods range from presenting absolute risks using frequencies (rather than presenting relative risks) to using a risk format that clarifies how treatment changes risks from preexisting baseline levels to using plain language. We then provide recommendations for how health-care providers and health educators can best to communicate this complex medical information to patients, including using plain language, pictographs, and absolute risks instead of relative risks.

Abstract
Objective: This paper aims to synthesise the broader perspectives of Māori patients and their whānau (extended family, family group) of their treatment within the public health system. Our research question was 'What are the experiences of Māori in the public health and/or hospital system in Aotearoa New Zealand?'

Methods: A systematic search using PRISMA protocols and reflexive typology organised around the categories of Māori, public healthcare and qualitative research identified 14 papers that covered all three categories. We undertook a qualitative metasynthesis on these papers using a critical community psychology approach.

Results: Māori patients and whānau from the included papers mention both barriers and facilitators to health. We categorised barriers as organisational structures, staff interactions and practical considerations. Facilitators were categorised as the provision of whānau support in the form of practical assistance, emotional care and health system navigation.

Conclusions: For many Māori, the existing public health system is experienced as hostile and alienating. Whānau members provide support to mitigate this, but it comes as a cost to whānau. Implications for public health: Public health providers must find ways to ensure that Māori consistently experience positive, high-quality healthcare interactions that support Māori ways of being.