Challenges with healthcare workforce diversity and access

Patient–clinician cultural concordance can promote positive clinical outcomes, demonstrating that a diverse healthcare epidemiology, infection prevention, and antimicrobial stewardship workforce is essential to mitigate health inequities and serve diverse populations. ^{Reference Shen, Peterson and Costas-Muñiz41} Black, Hispanic/Latino, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander individuals are underrepresented as trainees and practicing physicians in the United States relative to their census demographics. ^{Reference Cichon, Green, Hilker and Inclusion42–Reference Rogo, Holland and Fassiotto45} Furthermore, individuals with these minoritized racial and ethnic identities are underrepresented in leadership positions, ^{Reference Marcelin, Manne-Goehler and Silver44} have fewer speaking opportunities at national conferences, ^{Reference Marcelin, Khazanchi and Lyden46,Reference Wiley, Kalu and Lyden47} and experience lower pay. ^{Reference Marcelin, Bares and Fadul48} Intentional efforts to address leadership and speaking opportunities for women have led to improvements in gender equity ^{Reference Marcelin, Manne-Goehler and Silver44,Reference Marcelin, Khazanchi and Lyden46,Reference Aberg, Blankson, Marrazzo and Adimora49} ; however, gaps remain related to pay ^{Reference Marcelin, Bares and Fadul48} and promotion. ^{Reference Manne-Goehler, Krakower, Marcelin, Salles, Del Rio and Stead50–Reference Stead, Manne-Goehler and Blackshear52}

Many of these gaps reported for physicians undoubtedly exist for other healthcare team members such as pharmacists, infection preventionists, advanced practice clinicians, etc; however, data from these professional groups are sparse. ^{Reference Abdul-Mutakabbir, Arya and Butler53–Reference Bissell, Johnston and Smith56} Furthermore, there is a dearth of data describing the contribution and impacts of infectious disease healthcare workers from lesbian, gay, bisexual, transgender, queer and nonbinary gender (LGBTQ+) communities or healthcare workers with disabilities. To address these gaps, medical societies can commit to identifying and mitigating these workforce inequities through coordinated strategies, ^{Reference Marcelin, Khazanchi and Lyden46,Reference Wiley, Kalu and Lyden47} ranging from intentional recruitment to retention and recognition. Concurrent with existing efforts to inspire interest in infectious diseases (ID), pathway programs (starting as early as elementary school) can expose young learners to ID careers, and their development and execution should be intentional to ensure that individuals from backgrounds historically excluded have access to these career opportunities. ^{Reference Rogo, Holland and Fassiotto57}

Ensuring an adequate workforce serving rural and community hospitals is also necessary. Patients in smaller community hospitals, particularly in the Southeastern United States, were disproportionately affected by CDI, catheter-associated urinary tract infections (CAUTIs), and CLABSIs during the height of the COVID-19 pandemic. ^{Reference Advani, Sickbert-Bennett and Moehring58} Children living in rural counties (compared to children living in urban counties) have increased rates of inappropriate antibiotic use. ^{Reference Dantuluri, Bruce and Edwards59} To address these geographic differences in HAIs and antibiotic prescribing quality, improving access to ID expertise (local or telehealth) is warranted to serve smaller rural community hospitals. ^{Reference Livorsi, Abdel-Massih and Crnich60} Academic healthcare facilities are often overrepresented in research, limiting the generalization of published data, with inadvertent exclusion of rural populations. In a survey assessing collection of SDOH data as a routine part of HAI surveillance in US-based hospitals, 7 (27%) of 26 responding facilities represented community hospitals and only 4 (16%) included public and federal hospitals. ^{Reference McGrath, Logan and Deloney10} Furthermore, of the responding facilities, only 1 (4%) of 26 responding facilities were from Western states (11 were from Southern states), which likely influenced the inclusion of indigenous persons living in Western states in these studies. Only 8 (30%) of 27 facilities collected SDOH patient variables and, of these 8 facilities, 7 (88%) were academic centers. ^{Reference McGrath, Logan and Deloney10} More than 70% of US hospitals have <200 beds, and many of these facilities serve communities in need and those from minoritized communities. ^{Reference Mena Lora, Echeverria and Lindsey11,Reference Stenehjem, Hyun and Septimus61}

Inclusive cultures must be developed and fostered during health professions training and patient care, ^{Reference Flores, Tan and Bryant43,Reference Rogo, Holland and Fassiotto45,Reference Essien, Agbafe and Norris62} as well as through intentional assembly of healthcare epidemiology–infection prevention–antimicrobial stewardship teams to include intersectional identities. Unconscious or implicit bias describes “associations or attitudes that reflexively alter our perceptions, thereby affecting behavior, interactions, and decision making,” ^{Reference Marcelin, Siraj, Victor, Kotadia and Maldonado63} and can contribute to inequities in antimicrobial stewardship. In one study, female antimicrobial stewardship pharmacists were less likely to have their antibiotic recommendations accepted by prescribing clinicians than male antimicrobial stewardship pharmacists. ^{Reference Vaughn, Giesler and Mashrah14} Approaches to counter unconscious bias are multidimensional; however, at the core they operate in conjunction with methods to increase diversity, equity, and inclusion, which includes diversifying the healthcare workforce. ^{Reference Marcelin, Manne-Goehler and Silver44,Reference Marcelin, Siraj, Victor, Kotadia and Maldonado63}

The case for supporting equity, diversity, inclusion, and access in the antimicrobial stewardship and infection prevention workforce is multifaceted. In addition to greater opportunity for clinician–patient concordant relationships, some data have demonstrated that diverse teams function better and are more successful in research. ^{Reference Miller and Del Carmen Triana64} Diverse teams produced more innovative research and published in higher-impact journals, which may allow for an increase in the dissemination of the innovative findings. ^{Reference Yang, Tian, Woodruff, Jones and Uzzi65} Importantly, addressing healthcare workforce inequities contributes directly to improved patient care. ^{Reference Snyder, Upton, Hassett, Lee, Nouri and Dill66}

Challenges with availability and quality of data

Medical research typically captures demographic information on sex, age, race, and ethnicity, but addressing inequities is rarely the objective, which prompted a call to expand the literature evaluating inequities in HAI incidence. ^{Reference Kim, Kabbani and Dube17,Reference Chen, Khazanchi, Bearman and Marcelin67,Reference Evans and Wiley68} In a scoping review of health-equity antibiotic prescribing studies, only 23% of studies reported a specific equity objective, whereas 48% of the included studies reported patient or prescriber characteristics. ^{Reference Kim, Kabbani and Dube17} Among studies reporting any health equity markers, people from racial and ethnic minoritized groups were less likely to receive antibiotics overall ^{Reference Wattles, Jawad and Feygin15,Reference Gerber, Prasad and Localio69} or were less likely to receive firstline antibiotic treatment. ^{Reference Wurcel, Essien and Ortiz70} Further disparities were observed based on geographic location, with higher antibiotic prescribing in southern regions ^{Reference Goodman, Baghdadi and Magder71} and rural areas. ^{Reference Dantuluri, Bruce and Edwards59} Additionally, socioeconomic status also influenced equitable prescribing; privately insured people were more likely to receive antibiotics compared with the uninsured. ^{Reference Hersh, Shapiro, Pavia and Shah72} Despite these disparities, research regarding potential drivers (or upstream causes) of observed disparities is lacking. ^{Reference Kim, Kabbani and Dube17}

Recent studies have evaluated disparities related to multidrug resistance, infection prevention efforts and outbreak response, HAIs, and specific conditions, including candidemia, CDI, and COVID-19. ^{Reference Brown, Henderson, Ruegsegger, Moody and van Duin4–Reference Lee, Zhou, Ortiz-Gratacos, Al Isso, Tan and Abdul-Mutakabbir8,Reference Prochaska, Caballero, Fabre and Milstone12,Reference Schrodt, Hart, Calanan, McLees, Perz and Perkins13,Reference Zlotorzynska, Chea and Eure16,Reference McGrath, Bettinger and Stimpson35,Reference O’Halloran, Holstein and Cummings73} Data regarding health inequities in inpatient antibiotic prescribing are very limited. Kim et al ^{Reference Kim, Kabbani and Dube17} reported that 55 (90%) of 61 articles in their scoping review described outpatient settings and only 1 (1.6%) was from the acute-care setting. Their review also noted very few stewardship intervention studies, only 4 (6.6%) of 61 studies. ^{Reference Kim, Kabbani and Dube17} Considering that patients who are uninsured and underinsured often do not have access to outpatient clinics and may use the emergency department or hospital as their only form of healthcare, the lack of published data in the inpatient setting is a significant limitation in the consideration of health inequities in antibiotic prescribing.

As researchers evaluate these disparities, even within what many consider to be basic demographic variables, they must be aware of how they are collecting the information and what methodologic biases may be introduced. For example, age is quantifiable, but age stratification (eg, who are considered “older adults”) and how disparities in infection incidence and antimicrobial use affect various age categories are all important considerations for researchers. Accurate identification of sex, race, and ethnicity is also key for both clinicians and researchers. Gender identity and biological sex are different constructs, and knowledge of both are necessary not only to provide high-level medical care but also to perform quality research, especially when disparities might exist among different groups. ⁷⁴ Clinicians and researchers also tend to make assumptions about race and ethnicity that may not align with their patients’ and study participants’ self-identified race and ethnicity, especially when these characteristics are limited to finite categories. ^{Reference Agawu, Chaiyachati, Radack, Duncan and Ellison75} Such assumptions can affect the care these patients receive if clinicians’ implicit racial biases translate into decision making either consciously or subconsciously and can in turn affect study analyses on racial disparities in infectious diseases. Race and ethnicity are sociopolitical, not biological constructs; therefore, they should not be used in clinical practice to make inferences about physiologic function. Care should be taken in research to understand structural barriers causing racialized disparities rather than assigning race itself as a risk factor. ^{Reference Cerdeña, Plaisime and Tsai76–Reference Boyd, Lindo, Weeks and McLemore79}

Finally, some SDOH variables are often not collected or are overlooked in medical research, such as disability status and housing or food insecurity. The charge to incorporate such variables into medical research extends beyond the individual clinician and researcher. Regulatory and government agencies should consider these when determining standard metrics for reportable infectious diseases and conditions. The National Healthcare Safety Network (NHSN) captures HAI and antimicrobial use data from acute and postacute care facilities. ⁸⁰ HAI case reporters can include race and ethnicity data, but the field is optional. The antimicrobial use module captures only aggregate facility-level or unit-level information. Although this information may be helpful to assess facility-level interventions, analysis of disparities in care or prescribing based on age, gender, race, or ethnicity cannot be performed.

Individuals

A starting point for clinicians is an urgent commitment to creating a culture of equity and inclusion in healthcare spaces (Fig. 1). To create environments that provide patients and staff with what they need to succeed through a lens of equity, thorough assessments of individual practices should be conducted to determine areas of greatest need. For example, Fortin-Leung et al ^{Reference Fortin-Leung and Wiley81} raised questions about the paucity of race and ethnicity data built into antimicrobial stewardship programs. Acknowledging that patient-level characteristics from birth to death can affect antimicrobial prescribing, use, and administration, they suggested that prescribers could seek to understand how cultural differences along racial, ethnic or gender lines affect nonprescription antibiotic use, medication adherence, and drive differences in prescribing behavior.

Because SDOH may have varying impacts on patient health, healthcare personnel should intentionally seek out education on the impact of SDOH and SES on patient health. ^{Reference Brown, Henderson, Ruegsegger, Moody and van Duin4} Healthcare professionals remain the most trusted sources of health information in our current era of declining health literacy and access to high-quality health information. Staying appropriately informed can help clinicians maintain this trust and properly advocate for patients. Patient advocacy may be strengthened by recruiting and retaining a diverse workforce. Through mentorship and sponsorship for people from different backgrounds, healthcare personnel can prioritize support for successful career advancement.

Organizational

Healthcare systems and facility leadership are responsible for creating a culture of equity in their institutions. ⁸² Steps to be taken at institutions include the following: (1) assessing whether care delivery is equitable; (2) prioritizing quality improvement interventions that address differential care delivery; (3) providing high-quality health equity and implicit bias training for healthcare professionals; (4) leveraging data for individual-level clinician feedback on health equity measures; and (5) making public statements of goals and actions to improve equity, in addition to internal commitments (Fig. 1). For example, during the COVID-19 pandemic, infectious disease, and antimicrobial stewardship leadership at one hospital recognized that access to monoclonal antibody infusion for COVID-19 management was inequitable. They leveraged an emergency department fast-track location and existing staff to make the treatment available for an underserved community. ^{Reference Mena Lora, Echeverria and Lindsey11}

Sustainable measures to mitigate disparities require accountability. Public and private institutions, including societies dedicated to healthcare epidemiology and antibiotic stewardship, have made public declarations of diversity equity and inclusion commitments. ^83,84 Yet, without high-quality data collection and publicized data reviews, accountability may not be feasible for health systems. ^{Reference McGrath, Logan and Deloney10} Additionally, the validity of SDOH, race, and ethnicity data entered into the electronic health record (EHR) have often been called into question, creating challenges for collecting and interpreting HAI inequity data. ^{Reference Agawu, Chaiyachati, Radack, Duncan and Ellison75} However, interventions to correct these patterns might have limited impact in the absence of data validity tools for EHR systems to capture accurate data points. Despite these challenges, healthcare institutions can still develop anchor missions focused on addressing inequities for their local communities. For example, a Chicago-based health system crafted a multipronged framework that named racism and poverty as targeted causes of inequities. They embarked on a health equity mission to invest locally, collaborated with their surrounding community across all care spectrums, and they developed performance improvement plans to improve their patient outcomes. ^{Reference Ansell, Oliver-Hightower, Goodman, Lateef and Johnson85} The level of commitment to equity may not be replicable for every institution, but we recommend that institutions identify and tackle a singular equity mission that is achievable and feasible within an established timeline. Healthcare system and facility leadership should be purposeful in recruiting a diverse and skilled workforce in healthcare epidemiology, infection prevention, and antimicrobial stewardship. Institutions can frequently conduct equity reviews and proactively correct identified deficiencies.

Public health systems

Public health engagement at the federal, state, and local levels is needed to address health inequities (Fig. 1). National, state, and community policies, structural inequities, and differential access to reliable information sources are important factors. The COVID-19 pandemic revealed the need for future public health initiatives to address systematic inequalities that can perpetuate and lead to differences in population and individual outcomes. ^{Reference Li, Cai, Mao, Cheng and Temkin-Greener9} Action steps for public health include the following: (1) requiring surveillance and research activities that include health equity objectives and capture the needed data to support decision making and implementation science to address inequities; (2) providing necessary analytic resources to help characterize health inequities at the national, community, healthcare system, and facility levels to provide a compass for where action is needed; (3) communicating health information effectively to a variety of different audiences and health literacy levels; (4) facilitating access to subject matter expertise in healthcare epidemiology, infection prevention, antibiotic stewardship in health departments across the country; and (5) incorporating a health equity lens into guidance and policies for healthcare epidemiology, infection prevention, and antibiotic stewardship implementation. Regulatory and accreditation partners, such as The Joint Commission, can facilitate policy change. For example, in 2023 new health equity standards were released by The Joint Commission to establish a new baseline of equitable delivery of healthcare. ⁸⁶

In conclusion, inequities in healthcare occur at every resource level. Steps to advance health equity should be considered at every level, whether a well-resourced health system or a rural critical-access hospital. Advancing health equity includes delivery of safe and equitable patient care and recruiting individuals with diverse backgrounds to healthcare epidemiology, infection prevention, and antimicrobial stewardship career paths.