The U.S. faces growing and increasingly unsustainable health inequities, and the number of voices calling for substantive healthcare system reforms is growing.
The U.S. is often the first to introduce advanced preventive and therapeutic interventions. Yet, the dominant healthcare delivery models must be equipped to deploy them in communities experiencing harmful SDOH and health inequities.
The recent response to the Mpox epidemic provides valuable insights into future directions for addressing equitable healthcare.
After the first round of Mpox vaccinations showed patterns that were similarly inequitable as past rollouts of necessary prevention modalities (e.g., HIV pre-exposure prophylaxis [PrEP]), the CDC quickly changed its approach to meaningfully engage grass-roots community leaders in the design and implement of local vaccination campaigns.
The resulting approach focused on deploying decentralized, community-based, and culturally and contextually aligned service delivery models that better served those most affected by Mpox.
“We must re-think the way healthcare is delivered in this country, especially when, where, and how care is delivered to groups persistently burdened by harmful social determinants of health that perpetuate health inequities,” says Vincente Guilamo-Ramos, Dean of the Duke School of Nursing and lead author. “The financial and human costs of these inequities are already in the danger zone and cannot be sustained for much longer.”
The paper also highlights the need to design healthcare interventions that more comprehensively address harmful social determinants of health, drawing from an innovative framework developed by the Center for Latino and Family Health at Duke University, accessible at www.DUSONtrailblazer.com.
”Three decades of evidence have shown that nurse practitioners with full practice authority play a vital role in improving health outcomes, especially in underserved communities, Ramos observed in his remarks. Focusing on the connections between FPA, access to care, and health outcomes, the Dean presented his case to the state’s Joint Legislative Committee on Access to Healthcare and Medicaid Expansion at the North Carolina General Assembly and urged them to pass the SAVE Act to grant full practice authority for NPs providing primary care. Ramos, who is also the vice-chancellor of nursing affairs for Duke, was among eight experts presenting varied views on full practice authority.
“Full practice authority isn’t new. This isn’t innovative. We have 30 years of evidence from 24 states, D.C., and several US territories about the benefit of granting full practice authority to NPs.”
In speaking to the joint committee presided over by Sen. Joyce Krawiec, Ramos addressed the role that nurse practitioners have in transforming health care access and outcomes in North Carolina, including the opportunity to expand care in rural areas that face health care shortages. The joint committee is hearing from experts as they consider passing the SAVE Act, which was first introduced in 2021 to expand full practice authority for primary care NPs in North Carolina. A similar version of the SAVE Act has been introduced in previous legislative sessions, but no action was taken on the legislation.
Role of FPA in Access to Care and Health Outcomes
“Nurse practitioners should be able to practice at the highest level of their competencies, education, and licensing,” Ramos said. “Full practice authority isn’t new. This isn’t innovative. We have 30 years of evidence from 24 states, D.C., and several US territories about the benefit of granting full practice authority to NPs. This improves health outcomes and expands health care to underserved populations and will benefit the people of North Carolina.”
Across the state, 97 of 100 counties face a health professional shortage.
Ramos reflected on his role as dean of the top school of nursing in the state and the second-ranked school in the U.S., and the intense pride he has seeing Duke graduates strengthen their career opportunities with the education they gain at Duke. “The nurse practitioner workforce growth is faster in states with full practice laws than in states with restricted practice,” said Ramos, who is interested in attracting NPs to practice in the state.
Ramos observed that the first states to authorize full NP practice authority began doing so in 1994 — nearly three decades ago — and that, once passed, full NP practice authority has never been repealed. “Full practice authority for primary care NPs improves care access, improves care outcomes, and improves workforce supply,” said Ramos, who also addressed a systematic review of 33 studies that showed no evidence for better NP care outcomes in states with more practice restrictions.
NPs with FPA Increase Efficacy of a State’s Health Workforce
In addressing the critical nursing workforce shortages across the U.S., Ramos notes that NP workforce growth is faster in states with full practice laws compared to states with restricted practice. Across the U.S., during the COVID-19 pandemic, states issued temporary waivers of NP practice restrictions. “This enabled more time-responsive NP practice and care provision as well as a streamlined process for NP orders in the absence of physician signature requirements and an increased capacity of the health care workforce to respond to COVID-19,” Ramos said.
Ramos observes that the reliance of nurses in this manner during a pandemic and health care crisis demonstrates the clinical, scientific, and relational expertise that support nurse influence in improving health outcomes, and it demonstrates the confidence that the health care systems and public have in nurses, who have been considered the most trusted and most ethical profession for more than 20 years.
In conclusion, Ramos pointed out to the committee that:
NP practice restrictions contribute to inadequate care access and primary care workforce shortages, particularly in rural areas.
NP practice restrictions can be a barrier to improving health outcomes and reducing health outcomes and reducing health-related economic costs.
NP practice restrictions requirements can lead to an unsafe and fragile care model, including risks such as the possibility of immediate NP loss of ability to care for patients if a physician can no longer provide supervision for any reason, including moving, retiring, and so on.
NP practice restrictions weaken health workforce responsiveness to emergencies.
Physician supervision agreements can contribute to unnecessary and excessive costs.
The SAVE Act (House Bill 277/Senate Bill 249) did not receive a committee hearing during the 2021 legislative long session. However, following the conclusion of the committee’s work later this spring, the bill could move forward when the legislature returns for the 2022 short session on May 18, 2022.
Three Duke University School of Nursing researchers and their collaborators were recently awarded new funding for pilot projects — all centered around reducing health inequities and improving patient care.
This year’s pilot program required that faculty members submit proposals that incorporate at least one of the following racial justice themes:
Dismantling structures that perpetuate racism;
Advancing solutions that ensure health equity in marginalized populations;
Multilevel approaches to addressing social contributors to health;
Methods that improve the participant experience and address racial equity in data collection, analysis, and reporting.
The School’s Center for Nursing Research (CNR) is pleased to announce this year’s grants address the clinical context of sickle cell disease (SCD) management and associated health disparities for adults in Sierra Leone; improve our understanding of the pediatric urobiome, particularly in underserved populations; and acquire large datasets that will allow Duke researchers access to variables needed to improve understanding of health disparities.
Since 2017, the pilot program has encouraged researchers to investigate relevant and innovative ideas that promote health equity and address the School’s Research Areas of Excellence: data science, health innovation, population health and precision health. The goal of the program is to encourage team science and endorse scientific inquiry that positions investigators to be competitive for extramural research funding. The program is administered by the CNR and funded through a generous award from A. Eugene Washington, M.D., M.P.H., M.Sc., chancellor for health affairs, Duke University, and president and CEO, Duke University Health System.
“It was important for the CNR to invest in pilot research that addresses health equity and racial justice so that we are well-positioned to contribute to the future of nursing science,” said Christin Daniels, assistant dean for research development. “This year’s topics tackle a wide variety of pressing challenges – locally and globally, and we’re thrilled to support our researchers’ endeavors toward solving big problems. This pilot program is made possible by our volunteer reviewers, and we’d like to thank them for their collegiality and service. We’d also like to thank Chancellor Washington for the generous award that allows us to offer this program.”
Extending SCD Management: Adapting Management Recommendations to Sierra Leonean Context
Ibemere serves as the principal investigator for her study entitled “Extending Sickle Cell Disease (SCD) Management: Adapting Management Recommendations to Sierra Leonean Context.” She is collaborating with Paula Tanabe, PhD, MSN, MPH, RN, FAEN, FAAN, vice dean, research, and Laurel Chadwick Professor of Nursing, Nirmish Shah, MD, associate professor of medicine, and Cheedy Jaja, PhD, assistant dean for global engagement, University of South Florida.
Evidence-based guidelines exist for sickle cell management, but they do not currently account for the unique perspectives of sub-Saharan populations, who have the greatest prevalence of SCD. Approximately 75 percent of those born with SCD are born in sub-Saharan Africa, and 50 to 90 percent will die before the age of 5. The estimated life expectancy for adults with SCD in Sierra Leone is 20 to 30 years shorter than in high-resourced settings. To reduce the inequitable access to a clinical model for SCD management, the project team will assess clinician and community member knowledge of the National Heart, Lung, and Blood Institute SCD recommendations and evaluate existing SCD management algorithms (e.g. SCD toolbox) for the clinical context in Sierra Leone.
The chasms between SCD outcomes in low-income settings contrasted with those in high-resource settings are linked to systematic decisions and structural barriers which impede workforce development and patient access to care. If left unaddressed, researchers expect continued poor health outcomes for individuals living with SCD in sub-Saharan Africa. Guided by the culture-centered approach, this study will engage Sierra Leonean colleagues, elevating the voices of historically marginalized and minoritized populations while investing in the clinical improvement of SCD disease management within this specific cultural context.
These findings will inform the development of a SCD care management model rooted in evidence-based practice for providers, and the preliminary data will help inform the development of a future NIH R21 submission.
Stability of the Pediatric Urinary Microbiome
Principal investigator Kelly will lead the study entitled “Stability of the Pediatric Urinary Microbiome” along with her collaborators Lisa Karstens, PhD, assistant professor, Oregon Health and Science University, and Tatyana Sysoeva, PhD, assistant professor of microbiology, The University of Alabama in Huntsville.
Urinary tract infections (UTIs) are the most common outpatient infections in the U.S. and are among the most serious bacterial infections encountered by pediatricians. In children, UTIs can result in life-long health consequences including renal scarring, hypertension, renal insufficiency, and pregnancy complications, such as preeclampsia and preterm birth. Antimicrobial resistance of urinary pathogens that cause UTIs is increasing, yet antibiotics remain the standard treatment for UTIs in children. Antibiotic use increases resistance and may change the child’s microbiome. There is a pressing need to develop non-antibiotic therapeutics for UTI treatment, especially in children.
UTIs are more common in Latinx and white children. Inability to make frequent trips to a clinic for urine collection presents a barrier to care that is exacerbated in marginalized populations. At-home urine collection and storage would improve adherence and enhance the quality of the urobiome data.
This pilot study will utilize urine samples in children taken over the course of two months to determine the stability of the urinary microbiome in children and determine if at-home collection is viable, particularly in the Latinx population. The team will translate their study materials into Spanish and work with a community advisory board to ensure the Latinx community helps guide the research. The long-term goal of this study is to develop a predictive test that can identify children at increased risk of UTIs as well as a non-antibiotic intervention strategy. Kelly and team anticipate using the study data towards a future R01 grant submission.
National Representative Databases for Clinical Research
Myers will serve as the principal investigator of the study entitled “National Representative Databases for Clinical Research.” The research team includes Michael Cary, PhD, RN, Elizabeth C. Clipp Term Chair in Nursing and associate professor and Nancy Crego, PhD, RN, CCRN, CHSE, assistant professor, and Michael J. Smith, MD, professor of pediatrics, Bradley Hammill, DrPH, associate professor, and Gina-Maria Pomann, PhD, assistant professor, with the School of Medicine.
National administrative databases are rich sources of clinical information that may serve as the basis for a multitude of research projects. The School of Nursing and overall Duke community have limited access to such databases. In addition, the databases are not in formats that allow untrained analysts to perform appropriate analyses. This pilot project seeks to purchase the following data sources and convert data into user-friendly formats for Duke research utilization:
Kid’s Inpatient Database from Healthcare Cost and Utilization Project (HCUP)
National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Surveys
National Immunization Survey
National Inpatient Survey
National Emergency Department Sample Census Data and Area Health Resources Files
Myers and team will use this data to build the School of Nursing’s first data warehouse, Health e-Data. The data contained within the warehouse will significantly enhance our ability to access and study large-scale, national clinical data.
The warehouse will also advance our ability to address racial equity in data collection, analysis, and reporting. Incomplete race data is a serious and persistent problem that hampers progress. Fortunately, the HCUP databases have created multiple procedures to address this issue. They have identified standardized categories for race and ethnicity, developed novel imputation methods to reduce the impact of existing missing data on disparities research, and linked zip code-level information (e.g., racial distribution, income, education, and poverty level) from the U.S. Census to address socioeconomic status data. They now also include data examining social determinants of health . As such, the creation of the Health e-Data warehouse will allow researchers to examine racial disparities more robustly and rigorously.
Ibemere serves as the principal investigator for her study entitled “Extending Sickle Cell Disease (SCD) Management: Adapting Management Recommendations to Sierra Leonean Context.” She is collaborating with 
Principal investigator Kelly will lead the study entitled “Stability of the Pediatric Urinary Microbiome” along with her collaborators Lisa Karstens, PhD, assistant professor, Oregon Health and Science University, and Tatyana Sysoeva, PhD, assistant professor of microbiology, The University of 
Myers will serve as the principal investigator of the study entitled “National Representative Databases for Clinical Research.” The research team includes