Academic literature on the topic 'Trail of Tears'

ABSTRACT The purpose of this thesis was to explore the origins, formulation, course and outcome of the Intergovernmental Committee for Political Refugees meeting (better known as the Evian Conference) of July 1938. Special emphasis was placed on contemporary and later historical assessments of this assembly which represented the first international cooperative attempt to solve an acute refugee crisis. A general review followed by a more detailed evaluation was made of existing official and un-official accounts of the meeting utilizing both public records, private diaries, books, newspapers, journals and other periodicals for the period of January 1, 1938 through December 31, 1939. This data was supplemented by later recollections of conference participants as well as post-Holocaust historical scholarship. Various appraisals have been made of the motivations behind the summit and its ultimate success or failure. Franklin Roosevelt has particularly come under criticism by scholars who believed that his Administration had "abandoned" the Jews to their fate. The President's supporters, on the other hand, declared that FDR did everything possible given the existing political, economic and social conditions of the late 1930's. It is my conclusion that although Roosevelt may have been sympathetic to the plight of Central European Jewish refugees their resettlement and ultimate destiny merited a lower priority given his focus upon rebuilding the national economy and defense. The President clearly recognized the looming threat of Nazi Germany and Imperial Japan but was unwilling to expend political capital on an issue that faced domestic and political opposition. I further maintain that the conference was set up to fail while providing propaganda value for the participating democracies. The hypocritical rhetoric and actions of the delegates and the ineffectiveness of the conference's sole creation, the Intergovernmental Committee for Political Refugees, was clearly recognized by Nazi Germany and ultimately influenced its anti-Jewish policies. Thus, it is not a coincidence that the pogrom of November 1938, Kristallnacht, occurred only four months later. The avoidance of dealing with the Jewish refugee problem was further highlighted in the futile Wagner-Rogers Bill of 1939, the Hennings bill of 1940 and especially the Bermuda Conference of 1943, a time in which the details of mass murder of Jews and other groups was already well known within official circles. Further work needs to be done on the diverse responses of the Jewish community both within the United States and abroad to the peril facing their co-religionists.

The purpose of this dissertation was to compare and contrast the origins, formulation, course, and outcome of three major American immigration schemes to provide haven for German Jewish and non-Aryan refugees and British children: The Intergovernmental Committee for Political Refugees (better known as the Evian Conference), and particularly the German Refugee Children’s Bill (also labeled as the Wagner-Rogers Bill) and the Hennings Bill. The Evian Conference, called for by President Franklin D. Roosevelt in the aftermath of the Anschluss, the German annexation of Austria, sought to create a global solution to the problem of forced migration. The Wagner-Rogers Bill, influenced by the November 1938 nationwide pogrom of Kristallnacht and the British Kindertransport, a project to resettle Jewish and Christian children from the Reich into the United Kingdom, attempted, by legislative means, to allow the entry of ten thousand children outside of the annual German and Austrian quotas in 1939 and 1940. The Henning Bill endeavored to rescue British children from the perils of aerial warfare in 1940. This measure necessitated the amendment of the Neutrality Act of 1939, which prohibited American shipping from entering war zones. It has been argued that the Evian Conference was, at its core, a publicity ploy, designed to express sympathy for persecuted German minorities, while avoiding any political cost or acceptance of impoverished refugees. The Wagner-Rogers Bill failed as a result of the interplay of multiple factors that included: lack of presidential backing; the economic throes of the Great Depression; fear of aliens; anti-Semitism; growing isolationism and resistance to continued immigration, and a disunited and fractious Jewish community that sought to avoid stimulation of domestic prejudice and more restrictive immigration policies. A key component was a critical misreading of the bill’s sponsors of public compassion for Hitler’s victims; sentiments that did not translate into a willingness to accept Jewish refugees. The Henning Bill, which FDR endorsed with strict qualifications, demonstrated preferences for particular ethnic groups; specifically, British Christian children. In contrast with the Wagner-Rogers Bill, this legislation rapidly made its way through Congress and into law. Its failure lay in the inability to acquire guarantees of safe passage through contested waters by the warring powers. A general review followed by a more detailed examination was made of existing official and un-official sources, employing public records, private diaries, books, newspapers, journals, and other periodicals for the critical period of January 1, 1938 through December 31, 1940. Various historiographical appraisals have been made of the actions of Roosevelt, his administration, Congress, the Jewish community, and general public, and these opinions have generated markedly divergent opinions. Some have alleged that FDR and his administration, particularly the Department of State, abandoned the Jews to their fate while others assert that, in the context of the time, he did everything that was potentially achievable. Debate has also been waged over wide-ranging accusations of inaction, apathy, prejudice, and complicity involving official sources, the general public, and American Jewry. I argue that any assessment of responsibility for failure to attempt rescue can be laid at the feet of many actors in this existential drama of life and death.

Thesis (M.A.)--East Tennessee State University, 2003.
Title from electronic submission form. ETSU ETD database URN: etd-0607103-161102. Includes bibliographical references. Also available via Internet at the UMI web site.

Health disparities and substance misuse are increasingly prevalent, costly, and deadly in Indian Country. Although women historically held positions of influence in pre-colonial Tribal societies and shared in optimum health, their current health is relegated to some of the worst outcomes across all racial groups in the United States. Women of the Choctaw Nation of Oklahoma (CNO) have some of the highest prevalence estimates in physical inactivity and excessive drinking in the United States. Building on the Indigenous Stress Coping model of indigenous health, “Our Vision of Health for Future Generations” explores the intersection of a historical event, the Trail of Tears, and its lasting impact on the contemporary health outcomes in tribal members. This inquiry is positioned within the Yappallí Choctaw Road to Health project that explores these broader issues. This culturally-centered study explores proximal and settings-based/intermediary motivations of twenty-three women who completed the Yappallí project, walked the Trail of Tears, and developed a holitobit ibbak fohki “sacred giving” community health event. Analysis was conducted using the Listening Guide method, that highlighted the contrapuntal voices of embodiment, motivation, challenges, and transformation. Participants shared stories in relation to both their individual health concerns (proximal), and deep love and commitment for the health of their family, community and for future generations (intermediary). This study provides another framework for the development of indigenized research, by using in-depth interviews, haklo “listen deeply” as a form of indigenous storywork that is centering of the experiences of marginalized people, and reflexivity as anukfilli “Deep Reflection”.

This study compares a physiotherapy exercise regime with a control treatment for the physiotherapy management of patients with massive, irreparable rotator cuff tears of the shoulder. Following ethical approval and informed consent, eligible patients with radiologically confirmed massive rotator cuff tears were recruited to the investigation. The study design was a randomised placebo controlled trial of 60 patients evaluating the change from baseline to three months, six months and twelve months in the shoulder function of patients randomised into either an intervention arm (exercise, advice, pain relief and ultrasound) or a control group (advice, pain relief and ultrasound). Randomisation using group designation in sealed envelopes took place after the baseline assessment. The primary outcome measure was the Oxford shoulder score. Secondary outcome measures included Short Form 36, the Measure Yourself Medical Outcome Profile and measures of range of shoulder movement.

AbstractAnxiety and pain control has been an inherent part of the oral and maxillofacial surgeon’s (OMS’s) armamentarium. In the United States, achieving competency in anesthesia is an integral part of oral and maxillofacial surgery (OMS) training curriculum. Further, OMS’s maintain the highest of standards in their practice of anesthesia outside the operating theaters. OMS-anesthesia-team model emphasizes patient safety. This requires rigorous training and meticulous standards of practice, not only by the surgeons but by the entire supporting team of office personnel. The American Association of Oral Maxillofacial Surgeons (AAOMS) endorses several critical steps in promoting the safety of this model in OMS offices. Periodic review of parameters of care, mandated training for office team and a peer review for office anesthesia evaluation of fellow OMSs are some of the critical components. AAOMS has a simulation based training to train teams in the provision of safe anesthesia in a low risk environment. Emphasis on appropriate patient selection, impeccable advanced anesthesia monitoring, and periodic strong didactic and skills based training supports the OMS-anesthesia-team in being a valid, safe practice model of anxiety and pain control in an outpatient setting.

Abstract The objective of this paper is to develop a methodology to better understand behavioral empathy in the design process for the purpose of addressing user needs. To accomplish this, content analysis was conducted on undergraduate student assignments that documented group projects designing a consumer product. Using qualitative data analysis, the assignments and presentations were coded for their levels of behavioral empathy, using a scale that applied psychology and design theories. The Interpersonal Reactivity Index was administered to the students to assess their trait empathy. Results from these two analyses showed little connection between levels of behavioral empathy and self-assessed trait empathy of the student groups. The student assignments did reveal empathic waves that demonstrated comprehension and application of expressed user needs, evidenced by ascending and descending the empathy scale. These results indicate that is it not trait empathy that leads to empathic design, but rather applied empathy in the design process; developing internal empathy is not sufficient if it does not effectively translate user needs to technical requirements in the final design.

A study to determine the optimal insertion point of the latissimus dorsi muscle for treatment of rotator cuff tears using in-silico biomechanical models. A cadaver trial was used to validate the simulation results. The optimal area for insertion for improving glenohumeral rotation throughout a range of flexion was found to be the center of the greater tuberosity.

Abstract The Railway industry is facing a productivity issue as is often publicised with regular delays in rolling stock projects [1]. Plus, there is a growing need for innovation in remote services and management that have become the new normal during the COVID-19 pandemic. It drives a need for better Systems Engineering (SE) methods which include increased automation and dependence between systems and system performance, increasing number of disparate specialist engineering teams. [2] The aim of this paper is to develop an adaptable model which expresses the operational behavior of a train system in different railway environments, this model will be quickly and accurately configured to a specific environment to define the needs for a specific passenger service mission. Preventing late changes (cost and time-saving) by generating the right system requirements at the very early design phase through agile Model-Based Systems Engineering (MBSE) approach is the key benefit. Another goal includes increased productivity by minimizing unnecessary manual transcription of concepts when coordinating the work of large teams. This Generic* functional model of a Rolling Stock system can be configured to define specific products for an operator or Original Equipment Manufacturer (OEM).

In this paper an application of software agents is described, aimed at supporting students working on team projects in the online situation. Online teamwork is problematical for a number of reasons, such as getting acquainted with team members, communications between members and knowing what progress has been made on the project. Software agents have the ability to monitor progress and offer advice by operating in the background to act autonomously when the need arises. An agent prototype has been developed to perform a limited set of functions to support students, and the results of a trial carried out using teams working on projects are discussed.

Rolling stock, particularly of freight railroads, is currently maintained using regular preventative and corrective maintenance schedules. This maintenance approach recommends sets of inspections and maintenance procedures based on the average expected wear and tear across their inventory. In practice, however, this approach to scheduling preventative maintenance is not always effective. When scheduled too soon, it results in a loss of operating revenue, whereas when it is scheduled too late, equipment failure could lead to costly and disastrous derailments. Instead, proactive maintenance scheduling based on Big Data Analytics (BDA) could be utilized to replace traditional scheduling, resulting in optimized maintenance cycles for higher train safety, availability, and reliability. BDA could also be used to discover patterns and relationships that lead to train failures, identify manufacturer reliability concerns, and help validate the effectiveness of operational improvements. In this work, we introduce a train inventory simulation platform that enables the modelling of different train components such as wheels, brakes, axles, and bearings. The simulator accounts for the wear and tear in each component and generates a comprehensive data set suitable for BDA that can be used to evaluate the effectiveness of different BDA approaches in discerning patterns and extracting knowledge from the data. It provides the basis for showing that BDA algorithms such as Random Forest [9] and Linear Regression can be utilized to create models for proactive train maintenance scheduling. We also show the capability of BDA to detect hidden patterns and to predict failure of train components with high accuracy.

Abstract Teams in engineering design tackle problems that exceed the abilities of individuals. Improved understanding of how personality traits influence human behaviors and interaction may help create new methods and tools to support design teams. This paper seeks to understand how the Locus of Control (LOC) personality trait influences designer behaviors and team performance. A designer experiment studies 12 participant pairs controlled for categorical LOC pairing factors (internal-internal, external-external, and internal-external). Each design team completes six simplified cooperative parameter design tasks to minimize completion time, yielding 72 total data points. Regression analysis shows LOC pairing affects team efficiency in agreement with literature outside engineering design: diverse LOC traits reduce design efficiency while similarity increases team effectiveness. Results contribute to an explanatory hypothesis that LOC pairing influences designer behaviors related to action effectiveness which, subsequently, affects team performance outcomes.

St. Croix is home to a variety of threatened and endangered (T&E) species that are at risk for predation by the invasive red-tailed boa (Boa constrictor), such as the St. Croix ground lizard (Amevia polyps), the ground-nesting least tern (Sterna antillarum), and the hawksbill sea turtle (Eretmochelys imbricata). Genetic analysis determined the original red-tailed boa population on St. Croix sourced from a single female released by a pet owner and its range expands every year. Presently, the main population of red-tailed boa is established on the west end of St. Croix and extends as far east as Salt River. One individual was found in Salt River Marina and additional sightings have occurred in Salt River Bay National Historical Park and Ecological Preserve (SARI) more recently. This inventory aims to search for red-tailed boas in two focal areas that park staff are actively restoring. The park will use information from this inventory to develop a boa removal program and protect sensitive native species like the ground-nesting least tern, the St. Croix ground lizard and the hawksbill sea turtle nests and increase the success of restoration. Snakes are cryptic species, often occurring in low density, and utilize complex habitat patterns. To increase the likelihood of detecting red-tailed boa, the Maryland/Delaware/D.C. Wildlife Services detector dog handling team partnered with the USDA-APHIS National Detector Dog Training Center to train and develop detector dogs to assist in determining the presence/absence of red-tailed boa for this project. Canines were trained to locate red-tailed boa and indicate its presence to the handler via barking three times near the identified target. Two dog detector teams traveled to Salt River Bay National Park (SARI) in St. Croix to conduct surveys for red-tailed boa in habitats likely to contain red-tailed boa in June 2023. Habitat varied throughout the surveys. Close to the bay, mangrove forests dominated and, as elevation increased, transects took place in almost exclusively dry tropical shrub forest. Each transect was surveyed by one dog team. The canine teams had no red-tailed boa detections within SARI. Canines showed proficiency at surveying for red-tailed boa populations in SARI. Given the proximity of confirmed detections to SARI, it is likely red-tailed boa will be in the park in the future, if they are not already. Additional surveys, whether by humans, canines, or both, are recommended in areas of the park that have not been previously surveyed.

Cruise AL534/2 is part of a multi-disciplinary research initiative as part of the JPI Oceans project HOTMIC and sought to investigate the origin, transport and fate of plastic debris from estuaries to the oceanic garbage patches. The main focus of the cruise was on the horizontal transfer of plastic debris from major European rivers into shelf regions and on the processes that mediate this transport. Stations were originally chosen to target the outflows of major European rivers along the western Europe coast between Malaga (Spain) and Kiel (Germany), although some modifications were made in response to inclement weather. In total, 16 stations were sampled along the cruise track. The sampling scheme was similar for most stations, and included: 1) a CTD cast to collect water column salinity and temperature profiles, and discrete samples between surface and seafloor, 2) sediment sampling with Van Veen grab and mini-multi corer (mini-MUC), 3) suspended particle and plankton sampling using a towed Bongo net and vertical WP3 net, and 4) surface neusten sampling using a catamaran trawl. At a subset of stations with deep water, suspended particles were collected using in situ pumps deployed on a cable. During transit between stations, surface water samples were collected from the ship’s underway seawater supply, and during calm weather, floating litter was counted by visual survey teams. The samples and data collected on cruise AL534/2 will be used to determine the: (1) abundance of plastic debris in surface waters, as well as the composition of polymer types, originating in major European estuaries and transported through coastal waters, (2) abundance and composition of microplastics (MP) in the water column at different depths from the sea surface to the seafloor including the sediment, (3) abundance and composition of plastic debris in pelagic and benthic organisms (invertebrates), (4) abundance and identity of biofoulers (bacteria, protozoans and metazoans) on the surface of plastic debris from different water depths, (5) identification of chemical compounds (“additives”) in the plastic debris and in water samples.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.

Objectives. To examine the evidence on whether and how healthcare algorithms (including algorithm-informed decision tools) exacerbate, perpetuate, or reduce racial and ethnic disparities in access to healthcare, quality of care, and health outcomes, and examine strategies that mitigate racial and ethnic bias in the development and use of algorithms. Data sources. We searched published and grey literature for relevant studies published between January 2011 and February 2023. Based on expert guidance, we determined that earlier articles are unlikely to reflect current algorithms. We also hand-searched reference lists of relevant studies and reviewed suggestions from experts and stakeholders. Review methods. Searches identified 11,500 unique records. Using predefined criteria and dual review, we screened and selected studies to assess one or both Key Questions (KQs): (1) the effect of algorithms on racial and ethnic disparities in health and healthcare outcomes and (2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms. Outcomes of interest included access to healthcare, quality of care, and health outcomes. We assessed studies’ methodologic risk of bias (ROB) using the ROBINS-I tool and piloted an appraisal supplement to assess racial and ethnic equity-related ROB. We completed a narrative synthesis and cataloged study characteristics and outcome data. We also examined four Contextual Questions (CQs) designed to explore the context and capture insights on practical aspects of potential algorithmic bias. CQ 1 examines the problem’s scope within healthcare. CQ 2 describes recently emerging standards and guidance on how racial and ethnic bias can be prevented or mitigated during algorithm development and deployment. CQ 3 explores stakeholder awareness and perspectives about the interaction of algorithms and racial and ethnic disparities in health and healthcare. We addressed these CQs through supplemental literature reviews and conversations with experts and key stakeholders. For CQ 4, we conducted an in-depth analysis of a sample of six algorithms that have not been widely evaluated before in the published literature to better understand how their design and implementation might contribute to disparities. Results. Fifty-eight studies met inclusion criteria, of which three were included for both KQs. One study was a randomized controlled trial, and all others used cohort, pre-post, or modeling approaches. The studies included numerous types of clinical assessments: need for intensive care or high-risk care management; measurement of kidney or lung function; suitability for kidney or lung transplant; risk of cardiovascular disease, stroke, lung cancer, prostate cancer, postpartum depression, or opioid misuse; and warfarin dosing. We found evidence suggesting that algorithms may: (a) reduce disparities (i.e., revised Kidney Allocation System, prostate cancer screening tools); (b) perpetuate or exacerbate disparities (e.g., estimated glomerular filtration rate [eGFR] for kidney function measurement, cardiovascular disease risk assessments); and/or (c) have no effect on racial or ethnic disparities. Algorithms for which mitigation strategies were identified are included in KQ 2. We identified six types of strategies often used to mitigate the potential of algorithms to contribute to disparities: removing an input variable; replacing a variable; adding one or more variables; changing or diversifying the racial and ethnic composition of the patient population used to train or validate a model; creating separate algorithms or thresholds for different populations; and modifying the statistical or analytic techniques used by an algorithm. Most mitigation efforts improved proximal outcomes (e.g., algorithmic calibration) for targeted populations, but it is more challenging to infer or extrapolate effects on longer term outcomes, such as racial and ethnic disparities. The scope of racial and ethnic bias related to algorithms and their application is difficult to quantify, but it clearly extends across the spectrum of medicine. Regulatory, professional, and corporate stakeholders are undertaking numerous efforts to develop standards for algorithms, often emphasizing the need for transparency, accountability, and representativeness. Conclusions. Algorithms have been shown to potentially perpetuate, exacerbate, and sometimes reduce racial and ethnic disparities. Disparities were reduced when race and ethnicity were incorporated into an algorithm to intentionally tackle known racial and ethnic disparities in resource allocation (e.g., kidney transplant allocation) or disparities in care (e.g., prostate cancer screening that historically led to Black men receiving more low-yield biopsies). It is important to note that in such cases the rationale for using race and ethnicity was clearly delineated and did not conflate race and ethnicity with ancestry and/or genetic predisposition. However, when algorithms include race and ethnicity without clear rationale, they may perpetuate the incorrect notion that race is a biologic construct and contribute to disparities. Finally, some algorithms may reduce or perpetuate disparities without containing race and ethnicity as an input. Several modeling studies showed that applying algorithms out of context of original development (e.g., illness severity scores used for crisis standards of care) could perpetuate or exacerbate disparities. On the other hand, algorithms may also reduce disparities by standardizing care and reducing opportunities for implicit bias (e.g., Lung Allocation Score for lung transplantation). Several mitigation strategies have been shown to potentially reduce the contribution of algorithms to racial and ethnic disparities. Results of mitigation efforts are highly context specific, relating to unique combinations of algorithm, clinical condition, population, setting, and outcomes. Important future steps include increasing transparency in algorithm development and implementation, increasing diversity of research and leadership teams, engaging diverse patient and community groups in the development to implementation lifecycle, promoting stakeholder awareness (including patients) of potential algorithmic risk, and investing in further research to assess the real-world effect of algorithms on racial and ethnic disparities before widespread implementation.