Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

Racial Bias Beliefs Related to COVID-19 Among Asian Americans, Native Hawaiians, and Pacific Islanders: Findings From the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS)

BACKGROUND

During the COVID-19 pandemic, there have been increased reports of racial biases against Asian American and Native Hawaiian and Pacific Islander individuals. However, the extent to which different Asian American and Native Hawaiian and Pacific Islander groups perceive and experience (firsthand or as a witness to such experiences) how COVID-19 has negatively affected people of their race has not received much attention.

OBJECTIVE

This study used data from the COVID-19 Effects on the Mental and Physical Health of Asian Americans and Pacific Islanders Survey Study (COMPASS), a nationwide, multilingual survey, to empirically examine COVID-19-related racial bias beliefs among Asian American and Native Hawaiian and Pacific Islander individuals and the factors associated with these beliefs.

METHODS

COMPASS participants were Asian American and Native Hawaiian and Pacific Islander adults who were able to speak English, Chinese (Cantonese or Mandarin), Korean, Samoan, or Vietnamese and who resided in the United States during the time of the survey (October 2020 to May 2021). Participants completed the survey on the web, via phone, or in person. The Coronavirus Racial Bias Scale (CRBS) was used to assess COVID-19-related racial bias beliefs toward Asian American and Native Hawaiian and Pacific Islander individuals. Participants were asked to rate the degree to which they agreed with 9 statements on a 5-point Likert scale (ie, 1=strongly disagree to 5=strongly agree). Multivariable linear regression was used to examine the associations between demographic, health, and COVID-19-related characteristics and perceived racial bias.

RESULTS

A total of 5068 participants completed the survey (mean age 45.4, SD 16.4 years; range 18-97 years). Overall, 73.97% (3749/5068) agreed or strongly agreed with ≥1 COVID-19-related racial bias belief in the past 6 months (during the COVID-19 pandemic). Across the 9 racial bias beliefs, participants scored an average of 2.59 (SD 0.96, range 1-5). Adjusted analyses revealed that compared with Asian Indians, those who were ethnic Chinese, Filipino, Hmong, Japanese, Korean, Vietnamese, and other or multicultural had significantly higher mean CRBS scores, whereas no significant differences were found among Native Hawaiian and Pacific Islander individuals. Nonheterosexual participants had statistically significant and higher mean CRBS scores than heterosexual participants. Compared with participants aged ≥60 years, those who were younger (aged <30, 30-39, 40-49, and 50-59 years) had significantly higher mean CRBS scores. US-born participants had significantly higher mean CRBS scores than foreign-born participants, whereas those with limited English proficiency (relative to those reporting no limitation) had lower mean CRBS scores.

CONCLUSIONS

Many COMPASS participants reported racial bias beliefs because of the COVID-19 pandemic. Relevant sociodemographic contexts and pre-existing and COVID-19-specific factors across individual, community, and society levels were associated with the perceived racial bias of being Asian during the pandemic. The findings underscore the importance of addressing the burden of racial bias on Asian American and Native Hawaiian and Pacific Islander communities among other COVID-19-related sequelae.

Disparities in Opioid Prescribing for Long-Term Chronic and Short-Term Acute Pain: Findings from the 2019 National Health Interview Survey

The CDC cautioned against prescribing opioids for long-term chronic pain because opioid use disorder (OUD) risk was greater compared to short-term use for acute pain. The study objective was to describe rates and characteristics of respondents prescribed opioids for long-term chronic and short-term acute pain. National Health Interview Survey respondents for 2019 aged 18 years and over were examined (n = 31,997). Bivariate and multivariable models demonstrated opioid use for long-term and acute pain relative to sociodemographic characteristics. About 12.3% of US adults took opioids in the last 12 months, and among those with chronic pain who had been prescribed opioids in the last 3 months, over half took opioids every day. The odds of taking opioids for long-term chronic pain decreased with increasing income and increased with advancing age. Opioid prescribing diverged from CDC recommendations. Less affluent older adults may be at increased risk for OUD.

Planning a Collection of Virtual Patients to Train Clinical Reasoning: A Blueprint Representative of the European Population

Background: Virtual patients (VPs) are a suitable method for students to train their clinical reasoning abilities. We describe a process of developing a blueprint for a diverse and realistic VP collection (prior to VP creation) that facilitates deliberate practice of clinical reasoning and meets educational requirements of medical schools. Methods: An international and interdisciplinary partnership of five European countries developed a blueprint for a collection of 200 VPs in four steps: (1) Defining the criteria (e.g., key symptoms, age, sex) and categorizing them into disease-, patient-, encounter- and learner-related, (2) Identifying data sources for assessing the representativeness of the collection, (3) Populating the blueprint, and (4) Refining and reaching consensus. Results: The blueprint is publicly available and covers 29 key symptoms and 176 final diagnoses including the most prevalent medical conditions in Europe. Moreover, our analyses showed that the blueprint appears to be representative of the European population. Conclusions: The development of the blueprint required a stepwise approach, which can be replicated for the creation of other VP or case collections. We consider the blueprint an appropriate starting point for the actual creation of the VPs, but constant updating and refining is needed.

Treatment gaps, 1-year readmission and mortality following myocardial infarction by diabetes status, sex and socioeconomic disadvantage

AIMS

We evaluated variation in treatment for, and outcomes following, myocardial infarction (MI) by diabetes status, sex and socioeconomic disadvantage.

METHODS

We included all people aged ≥30 years who were discharged alive from hospital following MI between 1 July 2012 and 30 June 2017 in Victoria, Australia (n=43 272). We assessed receipt of inpatient procedures and discharge dispensing of cardioprotective medications for each admission, as well as 1-year all-cause, cardiovascular, and MI readmission rates and 1-year all-cause mortality.

RESULTS

Risk of all-cause (HR: 1.22 (1.19-1.26)), cardiovascular (1.29 (1.25-1.34)), MI (1.52 (1.43-1.62)) and heart failure readmission (1.62 (1.50-1.75)) and mortality (1.18 (1.11-1.26)) were higher in people with diabetes. Males and people in more disadvantaged areas were at increased risk of readmission and mortality following MI. People with diabetes (vs without) were more likely to receive coronary artery bypass grafting (CABG) but less likely to receive percutaneous coronary intervention (PCI) during, or within 30 days of, their index admission. Females were less likely to receive either (eg, 87% of males with a STEMI received PCI or CABG vs 70% of females), and people in more disadvantaged areas were less likely to receive PCI. People with diabetes, males and people in more disadvantaged areas were more likely to be dispensed cardioprotective medications at or within 90 days of discharge.

CONCLUSIONS

Following an MI, people with diabetes and males had poorer outcomes but received more intensive cardiovascular treatments. However, socioeconomic disadvantage was associated with both less intensive inpatient treatment and poorer outcomes.

Validation of rule-based algorithms to determine colorectal, breast, and cervical cancer screening status using electronic health record data from an urban healthcare system in New York City

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Cancer screening adherence can be estimated using electronic health record data.

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Screening algorithms had high sensitivity and specificity compared to manual review.

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Validation of screening algorithms can be performed using de-identified data.

Although cancer screening has greatly reduced colorectal cancer, breast cancer, and cervical cancer morbidity and mortality over the last few decades, adherence to cancer screening guidelines remains inconsistent, particularly among certain demographic groups. This study aims to validate a rule-based algorithm to determine adherence to cancer screening. A novel screening algorithm was applied to electronic health record (EHR) from an urban healthcare system in New York City to automatically determine adherence to national cancer screening guidelines for patients deemed eligible for screening. First, a subset of patients was randomly selected from the EHR and their data were exported in a de-identified manner for manual review of screening adherence by two teams of human reviewers. Interrater reliability for manual review was calculated using Cohen’s Kappa and found to be high in all instances. The sensitivity and specificity of the algorithm was calculated by comparing the algorithm to the final manual dataset. When assessing cancer screening adherence, the algorithm performed with a high sensitivity (79%, 70%, 80%) and specificity (92%, 99%, 97%) for colorectal cancer, breast cancer, and cervical cancer screenings, respectively. This study validates an algorithm that can effectively determine patient adherence to colorectal cancer, breast cancer, and cervical cancer screening guidelines. This design improves upon previous methods of algorithm validation by using computerized extraction of essential components of patients’ EHRs and by using de-identified data for manual review. Use of the described algorithm could allow for more precise and efficient allocation of public health resources to improve cancer screening rates.

A Comparative Case Study Analysis of Cultural Competence Training at 15 U.S. Medical Schools

PURPOSE

Twenty years have passed since the Liaison Committee on Medical Education (LCME) mandated cultural competence training at U.S. medical schools. There remain multiple challenges to implementation of this training, including curricular constraints, varying interpretations of cultural competence, and evidence supporting the efficacy of such training. This study explored how medical schools have worked to implement cultural competence training.

METHOD

Fifteen regionally diverse public and private U.S. medical schools participated in the study. In 2012-2014, the authors conducted 125 interviews with 52 administrators, 51 faculty or staff members, and 22 third- and fourth-year medical students, along with 29 focus groups with an additional 196 medical students. Interviews were recorded, transcribed, and imported into NVivo 10 software for qualitative data analysis. Queries captured topics related to students' preparedness to work with diverse patients, engagement with sociocultural issues, and general perception of preclinical and clinical curricula.

RESULTS

Three thematic areas emerged regarding cultural competence training: formal curriculum, conditions of teaching, and institutional commitment. At the formal curricular level, schools offered a range of courses collectively emphasizing communication skills, patient-centered care, and community-based projects. Conditions of teaching emphasized integration of cultural competence into the preclinical years and reflection on the delivery of content. At the institutional level, commitment to institutional diversity, development of programs, and degree of prioritization of cultural competence varied.

CONCLUSIONS

There is variation in how medical schools approach cultural competence. Among the 15 participating schools, longitudinal and experiential learning emerged as important, highlighting the needs beyond mere integration of cultural competence content into the formal curriculum. To determine efficacy of cultural competence programming, it is critical to conduct systematic assessment to identify and address gaps. While LCME standards have transformed aspects of medical education, further research is needed to clarify evidence-based, effective approaches to this training.

Barriers to Evidence-Based Treatment of Serious Burns: The Impact of Implicit Bias on Clinician Perceptions of Patient Adherence

The underlying assumption of modern evidence-based practice is that treatment decisions made by healthcare providers are based solely on the best available scientific data. However, the connection between evidence informed care guidelines and the provision of care remains ambiguous. In reality, a number of contextual and nonclinical factors can also play a role, among which is the implicit bias that affects the way in which we approach or treat others based on irrelevant, individual characteristics despite conscious efforts to treat everyone equally. Influenced by the social and demographic characteristics of patients, this bias and its associated perceptions have been shown to affect clinical decision making and access to care across multiple conditions and settings. This summary article offers an introduction to how the phenomenon of implicit bias can impact on treatment compliance in multiple care contexts, its potential presence and impact in burns care and describes some of the strategies which offer possible solutions to reducing the disconnect between the conscious attempts to deliver equitable care and the discrepancies in care delivery that remain.

Race and Gender-Based Perceptions of Older Adults: Will the Youth Lead the Way?

BACKGROUND

Older individuals encounter the greatest racial/gender biases. It is unknown whether younger generations, who often lead culture shifts, have racial and gender biases against older populations.

METHODS

Using Amazon's Mechanical Turk's crowdsourcing, we identified how an individual's race and gender are associated with perceptions of individuals aged mid-60s. Participants were asked to rate photograph appearances on Likert Scale (1-10). Interactions between participant and photograph race and gender were assessed with mixed effects models. Delta represents rating differences (positive value higher rating for Whites or women, negative value higher rating for African-Americans or men).

RESULTS

Among 1563 participants (mean 35 years ± 12), both non-Hispanic White (WP) and all Other race/ethnicity (OP) participants perceived African-American photos as more trustworthy [Delta WP -0.60(95%CI-0.83, - 0.37); Delta OP - 0.51(- 0.74,-0.28), interaction p = 0.06], more attractive [Delta non-Hispanic White participants - 0.63(- 0.97, - 0.29); Delta Other race/ethnicity participants - 0.40 (- 0.74, - 0.28), interaction p < 0.001], healthier [Delta WP -0.31(- 0.53, - 0.08); Delta OP -0.24(- 0.45, -0.03), interaction p = 1.00], and less threatening than White photos [Delta WP 0.79(0.36,1.22); Delta OP 0.60(0.17,1.03), interaction p < 0.001]. Compared with OP, WP perceived African-American photos more favorably for intelligence (interaction p < 0.001). Both genders perceived photos of women as more trustworthy [Delta Women Participants (WmP) 0.50(0.27,0.73); Delta Men Participants(MnP) 0.31(0.08,0.54); interaction p < 0.001] and men as more threatening [Delta WmP -0.84(-1.27, -0.41), Delta MnP - 0.77(- 1.20, - 0.34), interaction p = 0.93]. Compared with MnP, WmP perceived photos of women as happier and more attractive than men (interaction p < 0.001). Compared with WmP, MnP perceived men as healthier than women (interaction p < 0.001).

CONCLUSIONS

Among a young generation, older African-Americans were perceived more favorably than Whites. Gender perceptions followed gender norms. This suggests a decline in implicit bias against older minorities, but gender biases persist. Future work should investigate whether similar patterns are observed in healthcare.

Low socioeconomic status relates to asthma and wheeze, especially in women

Low socioeconomic status (SES) has been associated with asthma and wheezing. Occupational group, educational level and income are commonly used indicators for SES, but no single indicator can illustrate the entire complexity of SES. The aim was to investigate how different indicators of SES associate with current asthma, allergic and nonallergic, and asthmatic wheeze. In 2016, a random sample of the population aged 20-79 years in Northern Sweden were invited to a postal questionnaire survey, with 58% participating (n=6854). The survey data were linked to the national Integrated Database for Labour Market Research by Statistics Sweden for the previous calendar year, 2015. Included SES indicators were occupation, educational level and income. Manual workers had increased risk for asthmatic wheeze, and manual workers in service for current asthma, especially allergic asthma. Primary school education associated with nonallergic asthma, whereas it tended to be inversely associated with allergic asthma. Low income was associated with asthmatic wheeze. Overall, the findings were more prominent among women, and interaction analyses between sex and income revealed that women, but not men, with low income had an increased risk both for asthmatic wheeze and current asthma, especially allergic asthma. To summarise, the different indicators of socioeconomic status illustrated various aspects of associations between low SES and asthma and wheeze, and the most prominent associations were found among women.

Development and implementation of an LGBT initiative at a health sciences library: the first eighteen months

Background

The University of Louisville School of Medicine is the pilot site for the eQuality project, an initiative to integrate training for providing care to lesbian, gay, bisexual, and transgender (LGBT) patients into the standard medical school curriculum. Inspired by and in support of this School of Medicine initiative, Kornhauser Health Sciences Library staff have developing our own initiative. Because of past and current lack of competent provider training and the resulting need for patients to be knowledgeable self-advocates, however, our initiative was broadened to include the goal of providing LGBT individuals in our communities—both on campus and in the broader public—with the resources and tools that they need to access information about their own health.

Case Presentation

This paper describes the development of that twofold initiative and the tangible methods used in its implementation, including collection development, interdepartmental collaboration, electronic resource guide creation, and community engagement through outreach.

Conclusions

Outcomes of the initiative to date will also be discussed, along with plans for further development.

Disparities in Access to Revascularization: Evidence from New York

Purpose: To quantify and compare citywide disparities in the performance of coronary revascularization procedures in New York residents diagnosed with ischemic heart disease (IHD) by the characteristics of the patients and their neighborhood of residence in 2000–2002 and 2011–2013.

Methods: We identify the number of hospitalizations for patients with diagnoses of IHD and/or congestive heart failure (CHF) and the number of revascularization procedures performed on the population 45 years and older, relying on hospital administrative data for New York City, by area of residence, from the Statewide Planning and Research Cooperative System (SPARCS). We conduct multiple logistic regressions to analyze the factors associated with revascularization for hospitalized patients admitted with IHD and CHF over the two time periods.

Results: Despite any decline in population health status, both the age-adjusted rates of inpatient hospital discharges for acute myocardial infarction, for IHD and for CHF, decreased as did the rates of revascularization procedures. Racial and ethnic disparities were much smaller in the later period than those documented earlier. However, there were persistent gender, insurance status, and neighborhood-level disparities in the treatment of heart disease.

Conclusions: With the declines in rates of heart disease, our findings point to the need for more clinical and population-based research to improve the understanding of why race/ethnicity, gender, insurance status, and neighborhood-level disparities persist in the treatment of heart disease.

The dynamics of poverty, educational attainment, and the children of the disadvantaged entering medical school

Approximately one-third of the US population lives at or near the poverty line; however, this group makes up less than 7% of the incoming medical students. In the United Kingdom, the ratio of those of the highest social stratum is 30 times greater than those of the lowest to receive admission to medical school. In an effort to address health disparities and improve patient care, the authors argue that significant barriers must be overcome for the children of the disadvantaged to gain admission to medical school. Poverty is intergenerational and multidimensional. Familial wealth affects opportunities and educational attainment, starting when children are young and compounding as they get older. In addition, structural and other barriers exist to these students pursuing higher education, such as the realities of financial aid and the shadow of debt. Yet the medical education community can take steps to better support the children of the disadvantaged throughout their education, so they are able to reach medical school. If educators value the viewpoints and life experiences of diverse students enriching the learning environment, they must acknowledge the unique contributions that the children of the disadvantaged bring and work to increase their representation in medical schools and the physician workforce. We describe who the disadvantaged are contrasted with the metrics used by medical school admissions to identify them. The consequences of multiple facets of poverty on educational attainment are explored, including its interaction with other social identities, inter-generational impacts, and the importance of wealth versus annual income. Structural barriers to admission are reviewed. Given the multi-dimensional and cumulative nature of poverty, we conclude that absent significant and sustained intervention, medical school applicants from disadvantaged backgrounds will remain few and workforce issues affecting the care patients receive will not be resolved. The role of physicians and medical schools and advocating for necessary societal changes to alleviate this dynamic are highlighted.

Explicit bias among fourth-year medical students

The aim of this study was to analyze themes related to explicit bias in patient-doctor relationships among fourth-year medical students. Class cohorts between 2013 and 2016 taking an online elective, "Self and Culture," submitted reflections about explicit bias. Thematic analysis was conducted on 283 student submissions totaling 849 entries until saturation. Themes included explicit bias toward patients with obesity, those who smoked, those from low-socioeconomic conditions, and, to a lesser extent, race/ethnicity. Themes related to the patient-doctor relationship included a negative impact on the relationship itself, trust, treatment of the patient, and patient experience. Themes related to making a positive impact included seeking positive treatment of the patient, understanding patients' circumstances rather than making assumptions, partnering with the patient, and education. Furthermore, researchers noted external versus internal attribution of the bias. Some students used neutral language to explain explicit biases, whereas fewer used internal attribution language. Results demonstrated that this type of reflection promoted personal insight, and faculty members should be trained to ensure successful crucial conversations about the impact of assumptions and biases on patient treatment, care plans, and health disparities. Finally, the curriculum should be intentional, providing experiences with marginalized populations to develop cultural humility and empathy.

Racial/Gender Biases in Student Clinical Decision-Making: a Mixed-Method Study of Medical School Attributes Associated with Lower Incidence of Biases

BACKGROUND

Accumulating evidence suggests that clinician racial/gender decision-making biases in some instances contribute to health disparities. Previous work has produced evidence of such biases in medical students.

OBJECTIVE

To identify contextual attributes in medical schools associated on average with low levels of racial/gender clinical decision-making biases.

DESIGN

A mixed-method design using comparison case studies of 15 medical schools selected based on results of a previous survey of student decision-making bias: 7 schools whose students collectively had, and 8 schools whose students had not shown evidence of such biases.

PARTICIPANTS

Purposively sampled faculty, staff, underrepresented minority medical students, and clinical-level medical students at each school.

MAIN MEASURES

Quantitative descriptive data and qualitative interview and focus group data assessing 32 school attributes theorized in the literature to be associated with formation of decision-making and biases. We used a mixed-method analytic design with standard qualitative analysis and fuzzy set qualitative comparative analysis.

KEY RESULTS

Across the 15 schools, a total of 104 faculty, administrators and staff and 21 students participated in individual interviews, and 196 students participated in 29 focus groups. While no single attribute or group of attributes distinguished the two clusters of schools, analysis showed some contextual attributes were seen more commonly in schools whose students had not demonstrated biases: longitudinal reflective small group sessions; non-accusatory approach to training in diversity; longitudinal, integrated diversity curriculum; admissions priorities and action steps toward a diverse student body; and school service orientation to the community.

CONCLUSIONS

We identified several potentially modifiable elements of the training environment that are more common in schools whose students do not show evidence of racial and gender biases.

Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study

Although health provider racial/ethnic bias has the potential to influence health outcomes and inequities, research within health education and training contexts remains limited. This paper reports findings from an anonymous web-based study examining racial/ethnic bias amongst final year medical students in Aotearoa/New Zealand. Data from 302 students (34% of all eligible final year medical students) were collected in two waves in 2014 and 2015 as part of the Bias and Decision Making in Medicine (BDMM) study. Two chronic disease vignettes, two implicit bias measures, and measures of explicit bias were used to assess racial/ethnic bias towards New Zealand European and Māori (indigenous) peoples. Medical students demonstrated implicit pro-New Zealand European racial/ethnic bias on average, and bias towards viewing New Zealand European patients as more compliant relative to Māori. Explicit pro-New Zealand European racial/ethnic bias was less evident, but apparent for measures of ethnic preference, relative warmth, and beliefs about the compliance and competence of Māori patients relative to New Zealand European patients. In addition, racial/ethnic bias appeared to be associated with some measures of medical student beliefs about individual patients by ethnicity when responding to a mental health vignette. Patterning of racial/ethnic bias by student characteristics was not consistent, with the exception of some associations between student ethnicity, socioeconomic background, and racial/ethnic bias. This is the first study of its kind with a health professional population in Aotearoa/New Zealand, representing an important contribution to further understanding and addressing current health inequities between Māori and New Zealand European populations.

Priority and prejudice: does low socioeconomic status bias waiting time for endoscopy? A blinded, randomized survey

INTRODUCTION

An unwanted socioeconomic health gap is observed in Western countries with easily accessible, government-financed health care systems. Survival rates from several malignancies differ between socioeconomic clusters and the disparities remain after adjusting for major co-morbidities and health related behavior. The possibility of biased conduct among health care workers has been proposed as a contributing factor, but evidence is sparse.

METHODS

A blinded, randomized online questionnaire survey was conducted among specialists in gastroenterology in Norway. Each respondent was asked to give priority for colonoscopy to three different referrals. By randomized sequence, half the referrals contained a discreet piece of information indicating low socioeconomic status (SES). The SES information given was focused on known low-status clusters in Norway, namely the morbidly obese and receivers of disability pensions.

RESULTS

There were 107 respondents giving a response rate of 67%. A lower priority was consistently given to the referrals containing information on low SES, but the difference only reached statistical significance (p = .018) for one of the referrals.

CONCLUSION

Information on low SES may influence how referrals for endoscopy are prioritized.

Socio-economic status influences the likelihood of undergoing surgical treatment for pancreatic cancer in the Netherlands

Surgical resection offers the only prospect of cure in pancreatic cancer patients. The probability of undergoing surgery is determined by several factors. The influence of socio-economic status (SES) on surgical treatment and survival was investigated in the Netherlands, a country with a widely accessible healthcare system.

METHODS

Data on all patients with non-metastasised pancreatic cancer between 2005-2013 were analysed in the Eindhoven Cancer Registry (ECR). SES was categorized as low, intermediate or high. The influence of SES on the likelihood for surgery was assessed by multivariable logistic regression analyses. The influence on overall survival was analysed by multivariable Cox regression analyses.

RESULTS

698 M₀-patients were included, of whom 276 underwent surgery. Patients with low and intermediate SES were less likely to undergo surgery (32% vs 37%) than high-SES patients (48%) (p = 0.002; low SES: OR0.63, 95%CI [0.40-0.98]; intermediate SES: OR0.62, 95%CI [0.42-0.92]). Survival did not differ between SES groups (low SES: HR1.05 95%CI [0.85-1.30]; intermediate SES: HR1.11, 95%CI [0.91-1.35]), p = 0.181. SES in pancreatic cancer patients determined the likelihood for surgery. However, SES had no influence on survival. It is important to provide more insights in the causes of these inequalities to minimalize the effects of SES in pancreatic cancer care.

Development and testing of study tools and methods to examine ethnic bias and clinical decision-making among medical students in New Zealand: The Bias and Decision-Making in Medicine (BDMM) study

BACKGROUND

Health provider racial/ethnic bias and its relationship to clinical decision-making is an emerging area of research focus in understanding and addressing ethnic health inequities. Examining potential racial/ethnic bias among medical students may provide important information to inform medical education and training. This paper describes the development, pretesting and piloting of study content, tools and processes for an online study of racial/ethnic bias (comparing Māori and New Zealand European) and clinical decision-making among final year medical students in New Zealand (NZ).

METHODS

The study was developed, pretested and piloted using a staged process (eight stages within five phases). Phase 1 included three stages: 1) scoping and conceptual framework development; 2) literature review and identification of potential measures and items; and, 3) development and adaptation of study content. Three main components were identified to assess different aspects of racial/ethnic bias: (1) implicit racial/ethnic bias using NZ-specific Implicit Association Tests (IATs); (2) explicit racial/ethnic bias using direct questions; and, (3) clinical decision-making, using chronic disease vignettes. Phase 2 (stage 4) comprised expert review and refinement. Formal pretesting (Phase 3) included construct testing using sorting and rating tasks (stage 5) and cognitive interviewing (stage 6). Phase 4 (stage 7) involved content revision and building of the web-based study, followed by pilot testing in Phase 5 (stage 8).

RESULTS

Materials identified for potential inclusion performed well in construct testing among six participants. This assisted in the prioritisation and selection of measures that worked best in the New Zealand context and aligned with constructs of interest. Findings from the cognitive interviewing (nine participants) on the clarity, meaning, and acceptability of measures led to changes in the final wording of items and ordering of questions. Piloting (18 participants) confirmed the overall functionality of the web-based questionnaire, with a few minor revisions made to the final study.

CONCLUSIONS

Robust processes are required in the development of study content to assess racial/ethnic bias in order to optimise the validity of specific measures, ensure acceptability and minimise potential problems. This paper has utility for other researchers in this area by informing potential development approaches and identifying possible measurement tools.