The majority of adults with outpatient visits to a large urban health care system did not use the patient portal, and initiation of use was lower for racial and ethnic minorities, persons of lower socioeconomic status, and those without neighborhood broadband internet access. These results suggest the emergence of a digital divide in patient portal use. Given the scale of investment in patient portals and other internet-dependent health information technologies, efforts are urgently needed to address this growing inequality.

Numerous factors impact patients’ health beyond traditional clinical characteristics. We evaluated the association of risk factors in kidney transplant patients’ communities with outcomes prior to transplantation. The primary exposure variable was a community risk score(range 0–40) derived from multiple databases and defined by factors including prevalence of comorbidities, access and quality of healthcare, self-reported physical and mental health and socioeconomic status for each US county. We merged data with the Scientific Registry of Transplant Recipients(SRTR) and utilized risk-adjusted models to evaluate effects of community risk for adult candidates listed 2004–2010(n=209,198). Patients in highest-risk communities were associated with increased mortality(Adjusted Hazard Ratio[AHR]=1.22,1.16–1.28), decreased likelihood of living donor transplantation(Adjusted Odds Ratio[AOR]=0.90,0.85–0.94), increased waitlist removal for health deterioration(AHR=1.36,1.22–1.51), decreased likelihood of preemptive-listing(AOR=0.85,0.81–0.88), increased likelihood of inactive listing(AOR=1.49,1.43–1.55) and increased likelihood of listing for expanded criteria donor kidneys(AHR=1.19,1.15–1.24). Associations persisted with adjustment for rural-urban location; furthermore the independent effects of rural-urban location were largely eliminated with adjustment for community risk. Average community risk varied widely by region and transplant center(median=21, range 5–37). Community risks are powerful factors associated with processes of care and outcomes for transplant candidates and may be important considerations for developing effective interventions and measuring quality of care of transplant centers.

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Background The gap between the supply of organs available for transplantation and demand is growing, especially among ethnic groups. Objective To evaluate the effect of a video designed to address concerns of ethnic groups about organ donation. Design Cluster randomized, controlled trial. Randomization was performed by using a random-number table with centralized allocation concealment. Participants and investigators assessing outcomes were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00870506) Setting Twelve branches of the Ohio Bureau of Motor Vehicles in northeastern Ohio. Participants 952 participants aged 15 to 66 years. Intervention Video (intervention; n = 443) or usual Bureau of Motor Vehicles license practices (control; n = 509). Measurements The primary outcome was the proportion of participants who provided consent for organ donation on a newly acquired driver’s license, learner’s permit, or state identification card. Secondary outcomes included willingness to make a living kidney donation to a family member in need and personal beliefs about donation. Results More participants who viewed the video consented to donate organs than control participants (84% vs. 72%; difference, 12 percentage points [95% CI, 6 to 17 percentage points]). The video was effective among black participants (76% vs. 54%; difference, 22 percentage points [CI, 9 to 35 percentage points]) and white participants (88% vs. 77%; difference, 11 percentage points [CI, 5 to 15 percentage points]). At the end of the trial, fewer intervention than control participants reported having insufficient information about organ donation (34% vs. 44%; difference, −10 percentage points [CI, −16 to −4 percentage points]), wanting to be buried with all of their organs (14% vs. 25%; difference, −11 percentage points [CI, −16 to −6 percentage points]), and having conflicts with organ donation (7% vs. 11%; difference, −4 percentage points [CI, −8 to −2 percentage points]). Limitation How the observed increases in consent to donate organs might translate into a greater organ supply in the region is unclear. Conclusion Exposure to a brief video addressing concerns that ethnic groups have about organ donation just before obtaining a license, permit, or identification card increased consent to donate organs among white and black participants. Primary Funding Source National Institutes of Health and the Robert Wood Johnson Foundation.

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Objective-Family communication is important for delivering high quality end-of-life care in the ICU, yet little research has been conducted to describe and evaluate clinician-family communication with non-English speaking family members. We assessed clinician-family communication during ICU family conferences involving interpreters and compared it to conferences without interpreters.Design-Cross-sectional descriptive study.Setting-Family conferences in the ICU's of four hospitals during which discussions about withdrawing life support or delivery of bad news were likely to occur.Participants-70 family members from 10 interpreted conferences and 214 family members from 51 non-interpreted conferences. Nine different physicians led interpreted conferences and 36 different physicians led non-interpreted conferences.Measurements-All 61 conferences were audiotaped. We measured the duration of time that families, interpreters, and clinicians spoke during the conference and we tallied the number of supportive statements issued by clinicians in each conference.Results-The mean conference time was 26.3 ± 13 minutes for interpreted and 32±15 minutes for non-interpreted conferences (p=0.25). The duration of clinician speech was 10.9 ± 5.8 minutes for interpreted conferences and 19.6 ± 10.2 minutes for non-interpreted conferences (p=0.001). The amount of clinician speech as a proportion of total speech time was 42.7% in interpreted conferences and 60.5% in non-interpreted conferences (p=0.004). Interpreter speech accounted for 7.9 ± 4.4 minutes and 32% of speech in interpreter conferences. Interpreted conferences contained fewer clinician statements providing support for families, including valuing families' input (p=0.01), easing emotional burdens (p<0.01), and active listening (p<0.01).Conclusions-This study suggests that families with non-English speaking members may be at increased risk of receiving less information about their loved one's critical illness as well as less NIH Public Access Author ManuscriptCrit Care Med. Author manuscript; available in PMC 2010 January 1.

Rationale: One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care. Objectives: To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status. Methods: Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate. Measurements and Main Results: From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55-0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0-11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46-13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12-7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01-1.33). Patients in managed care systems had 14.3% (95% CI, 11.5-17.2) fewer procedures in intensive care, but were also less likely to receive ''potentially ineffective'' care. Differences in unmeasured confounding factors may contribute to these findings. Conclusions: Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.

School-based health education is a promising approach for improving organ donation rates, but little is known about its efficacy among ethnically diverse youth. The impact of a classroom intervention was examined in a multicultural high school population where students' ethnicities were 45% African American, 30% Asian American, and 33% Caucasian (allowing for multiracial choices). A baseline survey was administered to all health classes within 2 weeks prior to intervention. On the intervention day, classes randomly assigned to the intervention group received an educational session, followed by a second survey; in control classes, the second survey was taken before the educational session. At baseline, non-Caucasian ethnicity and male gender were each associated with lower levels of willingness to donate. Following the intervention, students in the intervention group demonstrated a significant increase in knowledge scores (p<0.001), as well as positive movement of opinion regarding willingness to donate (p<0.0001). Most importantly, the positive changes in opinion occurred independently of ethnicity and gender, in spite of these both being negative predictors of opinion at baseline. These results demonstrate that even a single classroom exposure can impact knowledge levels, correct misinformation, and effect opinion change on organ donation among an ethnically diverse adolescent population.